Use of Cigarettes and Other Tobacco Products Among Students Aged 13--15 Years --- Worldwide, 1999--2005

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The use of tobacco in any form is a major preventable cause of premature death and disease. Globally, nearly 5 million persons die every year from tobacco-related illnesses, with disproportionately higher mortality occurring in developing countries (1). The Global Youth Tobacco Survey (GYTS), initiated in 1999 by the World Health Organization (WHO), CDC, and the Canadian Public Health Association, is a school-based survey that includes questions on prevalence of cigarette and other tobacco use; attitudes toward tobacco; access to tobacco products; exposure to secondhand smoke, school curricula on tobacco, media, and advertising; and smoking cessation. This report presents estimates of self-reported cigarette and other tobacco-product use during 1999--2005 in 132 different countries and the Gaza Strip/West Bank. The data are aggregated within each of the six WHO regions. GYTS data indicate that nearly two of every 10 students reported currently using a tobacco product, with no statistically significant difference between the proportion of those reporting cigarette smoking (8.9%) and other tobacco use (11.2%). Use of tobacco by adolescents is a major public health problem in all six WHO regions. Worldwide, more countries need to develop, implement, and evaluate their tobacco-control programs to address the use of all types of tobacco products, especially among girls.

GYTS is a school-based survey that collects data from students aged 13--15 years by using a standardized methodology for constructing the sample frame, selecting participating schools and classes, and processing data. The survey uses a two-stage, cluster-sample design that produces representative samples of students attending public and private schools in grades associated with ages 13--15 years. At the first sampling stage, the probability of selecting a school is proportional to the number of students enrolled in the specified grades. At the second stage, individual classes in the designated grades for students aged 13--15 years within the selected schools are randomly selected. All students attending school in the selected classes on the day the survey was administered were eligible to participate. Data included in this report come from GYTS surveys conducted in 395 sites in 132 different countries and the Gaza Strip/West Bank during 1999--2005.* Nationally representative data were collected in 93 countries, and regionally representative data at the state, province/region, or city level were collected in 39 countries. In the 395 sites included in this study, 747,603 students in 9,900 schools completed the GYTS. Of the sites surveyed, 56.5% had school response rates of 100%, and 2.2% had school response rates below 80%. Approximately 40% of the sites had student response rates of nearly 90%, with 9.3% having student response rates less than 80%.

These analyses compared tobacco use, including current use of any tobacco products, current cigarette smoking, and current use of tobacco products other than cigarettes in the six WHO regions (Africa, Americas, Eastern Mediterranean, Europe, South-East Asia, and Western Pacific). Software for statistical analysis of correlated data was used to compute 95% confidence intervals. Two-tailed t tests were used to establish significant differences. Only significant differences (p<0.05) are reported. Regional aggregations were calculated as means weighted by the population of the sampling frame. In many cases, the sampling frame was youths aged 13--15 years in the country, but in areas where samples were drawn to be representative of a subnational population, estimates were weighted by the population of the city, state, or administrative region and included in the regional aggregation. Indicators in this report include current cigarette smoking status (defined as the percentage of students who reported that they had smoked a cigarette on >1 days during the preceding 30 days), current use of tobacco products other than cigarettes (defined as the percentage of students who reported that they had used another form of tobacco, including chewing tobacco, snuff, dip, cigars, cigarillos, little cigars, pipes, or shisha on >1 days during the preceding 30 days), and current use of any tobacco products (defined as the percentage of students who were either current cigarette smokers or current users of other tobacco products).

Nearly two in 10 students (17.3%) were currently using any form of tobacco (Table). Any tobacco use was highest in the American and European regions (22.2% and 19.8%, respectively) and lowest in the South-East Asian and Western Pacific regions (12.9% and 11.4%, respectively). Boys were significantly more likely than girls to currently use any tobacco products (i.e., cigarettes or tobacco products other than cigarettes) in the Eastern Mediterranean, South-East Asian, and Western Pacific regions. Approximately one of every 10 students (8.9%) currently smoked cigarettes. Current cigarette smoking was highest in the European and American regions (17.9% and 17.5%, respectively) and lowest in the South-East Asian, Eastern Mediterranean, and Western Pacific regions (4.3%, 5.0%, and 6.5%, respectively). Boys were significantly more likely than girls to smoke cigarettes in the African, South-East Asian, and Western Pacific regions.

Approximately one of every 10 students (11.2%) currently used tobacco products other than cigarettes (Table). Use of other tobacco products was highest in the South-East Asian and Eastern Mediterranean regions (13.3% and 12.9%, respectively) and lowest in the Western Pacific and European regions (6.4% and 8.1%, respectively). Boys were significantly more likely than girls to use other tobacco products overall and in the American and South-East Asian regions. Cigarette smoking was significantly higher than other tobacco use for girls in the Americas and for boys and girls in the European Region. Other tobacco use was significantly higher than cigarette smoking for boys and girls in the Eastern Mediterranean and South-East Asian regions.

Reported by: Y Mochizuki-Kobayashi, MD, PhD, Tobacco Free Initiative, Geneva, Switzerland; B Fishburn, MPP, Western Pacific Regional Office; J Baptiste, PhD, African Regional Office; F El-Awa, PhD, Eastern Mediterranean Regional Office; H Nikogosian, MD European Regional Office; A Peruga, MD, DrPh, Region of the Americas; K Rahman, PhD, South-East Asia Regional Office, World Health Organization. CW Warren, PhD, NR Jones, PhD, S Asma, DDS, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; LR McKnight, PhD, EIS Officer, CDC.

Editorial Note:

Before GYTS, few data existed on the use of tobacco products other than cigarettes among adolescents (2). GYTS provides data on overall tobacco use to assist countries in the development and implementation of tobacco-control programs. The findings in this report suggest that tobacco-control programs must address all forms of tobacco, not just cigarettes. GYTS data indicate no significant differences in the rates of current cigarette smoking and current use of other tobacco products overall and in the African and Western Pacific regions. In the Americas and Europe, cigarette smoking prevalence is higher than other tobacco use, whereas in the Eastern Mediterranean and South-East Asian regions, other tobacco use is more common than cigarette smoking.

The popularity of specific forms of tobacco other than cigarettes varies among WHO regions: in the Eastern Mediterranean, shisha (flavored tobacco smoked in hookah pipes) is prevalent (3); in South-East Asia, bidis, smokeless tobacco (i.e. betel quid, gutka, and creamy snuff), and shisha use are popular (4); in the Western Pacific, betel nut is chewed with tobacco (5); pipe, snuff, and rolled tobacco leaves are common in the African Region; and in the Americas and Europe, use of cigars and smokeless tobacco are used (6).

The similarity in prevalence of cigarette smoking and other tobacco products between boys and girls is a cause for concern. No significant differences were observed in current cigarette smoking by sex overall and in three of the six regions (Americas, Eastern Mediterranean, and Europe). In addition, no statistically significant differences by sex were observed in other tobacco use rates in four regions (Africa, Eastern Mediterranean, Europe, and Western Pacific). In contrast, available data for adults indicate that, globally, males have higher rates of smoking than females (6). In all six WHO regions, but especially in those where tobacco-use levels among boys and girls are similar, effective tobacco-control programs must be developed and implemented with special focus on girls.

The findings in this report are subject to at least four limitations. First, because GYTS is limited to students, it might not be representative of adolescents aged 13--15 years from participating countries. However, in most countries, the majority (82%) of children attend schools (7). Second, these data apply only to youths who were in school on the day of the survey and who completed the survey. Student response rates were high (approximately 40% of the sites had student response rates of approximately 90%), suggesting that bias attributable to absence or nonresponse is limited. Third, data are based on the self-report of students, who might underreport or overreport their use of tobacco. The extent of this bias cannot be determined from these data; however, responses to tobacco-related questions on surveys in the United States similar to GYTS have demonstrated good test-retest reliability (8). Finally, systematic data collection on the use of specific types of tobacco products other than cigarettes was not included in the core GYTS questionnaire. Many survey administrators added questions to the core survey regarding specific tobacco products used in their countries, so the lack of consistency across sites precludes systematic regional or global analyses.

The goal of WHO's 2006 World No Tobacco Day is to promote awareness of the harmful effects of tobacco in any form. The findings described in this report indicate the need to develop, implement, and evaluate effective, comprehensive tobacco-control programs, including evidence-based interventions for adolescents to decrease the burden of tobacco-related diseases. Tobacco-control measures should address both sexes, but focus on girls, and include all forms of tobacco to emphasize that use of any product containing tobacco seriously damages health.

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