Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project.

Theme Papers Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project Charles W. Warren,1 Leanne Riley,2 Samira Asma,3 Michael P. Eriksen,4 Lawrence Green,5 Curtis Blanton,6 Cliff Loo,6 Scott Batchelor,6 & Derek Yach7 The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 13–15 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey. In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes. Keywords: tobacco; smoking, epidemiology; tobacco use disorder, epidemiology; smoking cessation; adolescence; schools; data collection, methods; cluster analysis; questionnaires. Voir page 875 le re´sume´ en franc¸ais. En la pa´gina 875 figura un resumen en espan˜ol. Introduction Tobacco use is one of the chief preventable causes of death in the world. The World Health Organization (WHO) attributes some 4 million deaths a year to tobacco, a figure which is expected to rise to 8.4 million deaths a year by 2020 (1). By that time, 70% of these deaths will be occurring in the developing countries. Studies in the developed countries show that most people begin using tobacco before the age of 18 years (2, 3). Recent trends indicate an earlier age of initiation and rising smoking prevalence rates among children and adolescents. If these patterns continue, tobacco use will result in the deaths of 250 million of the people who are children and adolescents today, many of them in the developing countries (4). In recent years, WHO (5), UNICEF (6), the Group of Eight (G8) Ministers of the Environment (7), the Ministers Responsible for Youth (8), and many national health agencies have called for concerted action against tobacco use by young people (9). Yet, information on tobacco use among young people is not available for most developing countries. To help fill in this data gap, WHO — through its Tobacco Free Initiative (TFI) — and the Office on Smoking and Health (OSH) in the Centers for Disease Control and Prevention (CDC) in the USA developed the Global Youth Tobacco Survey (GYTS), in consultation with countries in the six WHO regions. Assessing tobacco use by youth through the GYTS forms an important part of the global tobacco surveillance system. This article describes the design and develop- ment of the GYTS, a project for international surveillance and comparisons of tobacco use, which is intended to enhance the capacity of countries to monitor tobacco use among youth, and to guide the 1 Distinguished Fellow/Statistician, Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333, USA (email wcw1@cdc.gov). Correspondence should be addressed to this author. 2 Scientist, Tobacco Free Initiative, World Health Organization, Geneva, Switzerland. 3 Senior Service Fellow/Visiting Scientist, Office on Smoking and Health, CDC, Atlanta, GA, USA. 4 Director, Office on Smoking and Health, CDC, Atlanta, GA, USA. 5 Distinguished Fellow, Office on Smoking and Health, CDC, Atlanta, GA, USA. 6 Statistician, Office on Smoking and Health, CDC, Atlanta, GA, USA. 7 Executive Director, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva, Switzerland. Ref. No. 00-0703 Special Theme – Tobacco 868 # World Health Organization 2000 Bulletin of the World Health Organization, 2000, 78 (7) implementation and evaluation of tobacco preven- tion and control programmes. Reported below are the early results of the GYTS obtained from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela and Zimbabwe. Study design and methods As one of the first steps, TFI and OSH worked with tobacco control experts from China, Fiji, Jordan, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe to plan the design and implementation of an initial baseline assessment of tobacco use among youth in at least one country from each WHO region. The GYTS was thus created with the following design. . The surveys in individual countries would be school-based because they are inexpensive, can be done in a short time frame, and require only limited field staff. . The surveys would focus on school grades associated with students aged 13–15 years (at least 80%of young people in this age group are still either in regular schools or in vocational/technical schools). . The questionnaire would have a ‘‘core’’ component whichwouldprovide essential data for comparisons between countries and regions, while allowing ‘‘optional’’ questions on specific issues according to the needs of individual countries. The GYTS core questions deal with tobacco use and related knowledge and attitudes, access to tobacco pro- ducts, media and advertising exposure to tobacco, tobacco use as a subject in the school curriculum, smoking cessation, and environmental tobacco smoke. Most of the core questions were included in a ‘‘cognitive lab test’’ completed in 1999 (10) and, in addition, were pilot-tested in each country. In the spring of 1999, the GYTS was conducted in Barbados, China, Jordan, the Russian Federation (Moscow), Sri Lanka, Ukraine (Kiev), and Venezuela. Subsequently, five other countries completed the survey — Costa Rica, Fiji, Poland, South Africa, and Zimbabwe.Representatives fromeightmore countries were trained in1999 to implement their surveys in2000 — Brazil, Chile, Colombia, Dominican Republic, India, Mexico, Philippines, and Singapore. Because of the demand, TFI and OSH are working to conduct surveys in an additional 20–30 countries in the year 2000. WHO and the CDC are thus committed to developing a global tobacco surveillance system with GYTS as one of the primary components. Sampling methods The GYTS school-based surveys employ two-stage cluster sample designs within each country, state or city (depending on the scope of the country’s survey). The first stage consists of sampling schools with probability of selection proportional to the school enrolment size. The second stage consists of randomly selecting classes from the eligible grades within each chosen school. All students in the selected classes are eligible to participate in the survey. A weighting factor was applied to each student record to adjust for non-responses and for the varying probabilities of selection. SUDAAN, a software package for statistical analysis of correlated data, was used to compute 95% confidence intervals (11). Differences between prevalence estimates were considered statistically significant if the 95% con- fidence intervals did not overlap. Data collection Survey coordinators were trained in groups of countries that were conducting the GYTS to ensure that the survey protocol and procedures for admin- istration would be identical across the countries. Survey procedures were designed to protect the students’ privacy by allowing for anonymous and voluntary participation. The students completed the self-administered questionnaire in their classrooms, recording their responses directly on a machine- readable answer sheet. The core questionnaire contained 57 multiple-choice questions, with each country adding further questions to meet individual needs. Country-level parental permission procedures were followed before the survey was conducted. Results The results compare the extent of tobacco use among students aged 13–15 years across 12 countries. Gender-specific data are not shown in the Tables, but are reported in the text. School and student response rates for the GYTS were impressively high (Table 1). The school response rate ranged from 100% in Tianjin Province of China, Costa Rica, Ukraine (Kiev), and Zimbabwe to 76.9% in South Africa. The student response rate ranged from 99.7% in Venezuela to 81.4% in Ukraine (Kiev). The overall response rate (school rate 6 student rate) ranged from 96.8% in Tianjin Province of China to 65.7% in South Africa. Prevalence Students who had ever smoked cigarettes ranged from a high of nearly 70% in Ukraine (Kiev), Poland (urban), and the Russian Federation (Moscow) to a low of approximately 15% in Shandong Province of China, and Sri Lanka (median: 24.2%) (Table 2). Boys were significantly more likely than girls to have ever smoked cigarettes, except in Barbados, Venezuela, and Zimbabwe. Current cigarette smoking (i.e. had smoked on one or more days during the 30 days preceding the survey) showed a median of 8.7% and ranged from one-third of students (33%) in Ukraine (Kiev) and the Russian Federation (Moscow), nearly 30% in Poland (urban), nearly 20% in Costa Rica, Jordan, Global Youth Tobacco Survey 869Bulletin of the World Health Organization, 2000, 78 (7) Table 1. Study sample sizes and response rates among schools and students — Global Youth Tobacco Survey, 1999 Country No. of No. of Response No. of No. of Response Response schools in schools rate by students students rate by rate: the sample participating schools (%) selected participating students (%) overall (%) Barbados 19 18 94.7 1712 1647 96.2 91.1 China Chongqing 49 48 98.0 4096 3794 92.6 84.9 Guangqing 49 49 100 2989 2893 96.8 92.1 Shandong 48 45 93.8 2935 2882 98.2 90.7 Tianjin 49 44 89.8 2549 2409 94.5 96.8 Costa Rica 62 62 100 5114 4623 90.4 90.4 Fiji 51 44 86.3 1850 1629 88.1 75.9 Jordan 100 91 91.0 4244 3912 92.2 83.9 Poland urban 65 57 87.7 1875 1,567 83.6 73.3 rural 65 60 92.3 1980 1,642 82.9 76.5 Russian Federation Moscow 100 99 99.0 4755 4091 86.0 85.2 South Africa 160 123 76.9 7074 6,045 85.5 65.7 Sri Lanka 98 84 85.7 3253 2,896 89.0 76.3 Ukraine Kiev 100 100 100 5104 4156 81.4 81.4 Venezuela 103 96 93.2 3779 3767 99.7 92.9 Zimbabwe Harare 24 24 100 1080 896 83.0 83.0 Manicaland 33 33 100 1514 1358 89.7 89.7 Table 2. Percentage prevalence of tobacco use among students aged 13–15 years — Global Youth Tobacco Survey, 1999 Country Smoked cigarettes, Current usea Smoked cigarettes even one or two puffs first before age Cigarettes Other tobacco Any tobacco of 10 yearsb products product Barbados 34.7 (± 6.1)c 10.8 (± 4.0) 9.0 (± 2.2) 16.9 (± 3.9) 25.0 (± 4.3) China Chongqing 30.1 (± 3.8) 6.3 (± 1.5) 9.6 (± 1.4) 14.6 (± 2.3) 39.2 (± 5.1) Guandong 21.6 (± 1.7) 4.5 (± 1.0) 6.7 (± 1.0) 10.3 (± 1.2) 37.7 (± 4.9) Shandong 16.2 (± 4.0) 2.4 (± 0.9) 6.9 (± 1.6) 8.6 (± 1.7) 20.5 (± 7.7) Tianjin 21.6 (± 2.5) 5.7 (± 1.6) 4.9 (± 1.1) 9.7 (± 1.7) 27.3 (± 3.8) Costa Rica 44.4 (± 2.8) 17.8 (± 2.1) 6.4 (± 0.9) 20.8 (± 2.0) 10.9 (± 1.5) Fiji 32.8 (± 5.6) 10.4 (± 3.4) 7.9 (± 2.2) 15.1 (± 3.8) 21.6 (± 5.0) Jordan 34.3 (± 4.0) 16.6 (± 2.9) 11.2 (± 2.2) 20.6 (± 3.2) 26.1 (± 3.5) Poland urban 69.8 (± 3.3) 29.3 (± 3.9) 13.1 (± 2.7) 34.1 (± 3.8) 26.6 (± 3.3) rural 58.7 (± 4.2) 16.9 (± 2.5) 6.2 (± 1.4) 20.0 (± 2.6) 37.3 (± 3.8) Russian Federation Moscow 67.2 (± 2.7) 33.4 (± 2.8) 10.7 (± 1.3) 35.1 (± 2.5) 22.0 (± 1.9) South Africa 44.2 (± 6.0) 17.6 (± 2.5) 11.8 (± 3.4) 24.3 (± 3.0) 19.9 (± 3.2) Sri Lanka 12.1 (± 2.9) 4.0 (± 1.4) 7.2 (± 1.1) 9.9 (± 1.5) 25.4 (± 8.7) Ukraine Kiev 73.6 (± 2.7) 33.9 (± 3.1) 6.8 (± 1.2) 34.6 (± 2.9) 26.6 (± 2.5) Venezuela 21.9 (± 3.2) 7.4 (± 1.7) 8.7 (± 1.5) 14.8 (± 2.3) 12.1 (± 3.7) Zimbabwe Harare 26.5 (± 5.6) 10.7 (± 3.4) 9.5 (±3.4) 18.0 (± 5.0) 27.3 (± 7.2) Manicaland 20.4 (± 4.7) 10.0 (± 3.7) 13.2 (± 4.5) 18.5 (± 4.9) 31.2 (± 12.8) a Smoked cigarettes or used other tobacco products on 51 of the 30 days preceding the survey. b First whole cigarette. c Figures in parentheses are 95% confidence intervals. Special Theme – Tobacco 870 Bulletin of the World Health Organization, 2000, 78 (7) Poland (rural), and South Africa, to 10% or less in the other countries (Table 2). Boys in China, Jordan, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev) were significantly more likely than girls to smoke cigarettes currently. With a median of 8.9%, current use of tobacco products other than cigarettes ranged from approxi- mately 10% in Barbados, Chongqing Province of China, Jordan, Poland (urban), the Russian Federa- tion (Moscow), South Africa, Venezuela, and Zimbabwe, 7% in Guangdong and Shandong Provinces of China, Costa Rica, Fiji, Poland (rural), Ukraine (Kiev), and Sri Lanka, to less than 5% in Tianjin Province of China (Table 2). Boys in Fiji, Jordan, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev) were significantly more likely than girls to use other tobacco products. Current use of any tobacco product (cigarette smoking or use of other tobacco products) had a median of 15.9% and ranged from a high of 35% in the Russian Federation (Moscow), Ukraine (Kiev), and Poland (urban), 15–20% in Barbados, Chongqing Province of China, Costa Rica, Jordan, Poland (rural), South Africa, Venezuela, and Zimbabwe, to less than 10% in Guangdong, Shandong, and Tianjin Pro- vinces of China, and Sri Lanka (Table 2). Boys in China, Fiji, Jordan, the Russian Federation (Moscow), and Sri Lanka were significantly more likely than girls to currently use any tobacco product. The highest prevalence of early initiation of cigarette smoking was in Chongqing and Guang- dong Provinces of China, Poland (rural), and Manicaland in Zimbabwe, where nearly one-third (33%) of the students who ever smoked cigarettes started smoking before the age of 10 years (Table 2). The median for all countries was 26.4%. Over one- fifth of 13–15-year-old students began smoking before 10 years in Barbados, Fiji, Jordan, Poland (rural), Shandong and Tianjin Provinces of China, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), and Zimbabwe (Harare). Initiation of smoking before 10 years was lowest in Venezuela (12.1%) and Costa Rica (10.9%). In the Russian Federation (Moscow) and Ukraine (Kiev), boys were significantly more likely than girls to begin smoking before 10 years of age. Access Studentswho currently smokewere askedwhere they usually smoked (Table 3). In their homewas themost likely location for smoking among students in Barbados and China (over 40%), followed by Jordan (33%), and Venezuela and Zimbabwe (over 25%) (median: 30.5%). In the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev), public places were identified as the most likely place where students smoked. In Poland (urban and rural), ‘‘social events’’ were identified as the most likely venue where the students smoked. Girls in China, Fiji, Jordan, and Venezuela were significantly more likely than boys to smoke at home. In every country, the most likely means of obtaining cigarettes by students who currently smoke was to purchase them in a store (Table 3). Nearly two- thirds of the surveyed students in the Russian Federation (Moscow) purchased cigarettes in a store, compared with about one-half in Guangdong Province of China, Poland (urban), South Africa, Venezuela, andHarare in Zimbabwe (median: 38.5%). Between 30% and 40% of students purchased their cigarettes in a store in Chongqing and Tianjin Provinces of China, Costa Rica, Fiji, Jordan, Poland (rural), Sri Lanka, Ukraine (Kiev), and Manicaland in Zimbabwe; and less than 20% in Barbados and Shandong Province of China. In every country, except for Sri Lanka, the majority of students who currently smoke and buy their cigarettes in a store were not refused their purchase because they were under age (median: 75.3%) (Table 3). Cessation The core questionnaire asked current smokers if they wanted to stop smoking cigarettes now (Table 4). In every country, except Barbados and Jordan, over one-half of the surveyed 13–15-year-old smokers expressed a desire to stop smoking now (median: 68.0%). The desire to stop smoking was especially high (near 90%) in Shandong and Tianjin Provinces of China wheremany of the students started smoking at an early age. The desire to stop smoking was similar Table 3. Percentage of students aged 13–15 years who usually smoked cigarettes at home and bought them in a store — Global Youth Tobacco Survey, 1999 Country Smokes usually Cigarettes bought Cigarettes not at home in a store refused in a store (%) (%) because of being under-age (%) Barbados 41.2 (± 7.5)a 18.1 (± 8.4) 70.6 (± 9.1) China Chongqing 49.6 (± 11.2) 33.7 (± 9.8) 73.1 (± 10.3) Guandong 41.0 (± 11.3) 52.8 (± 10.2) 92.1 (± 4.2) Shandong 43.4 (± 6.8) 14.1 (± 8.8) 75.2 (± 14.5) Tianjin 56.5 (± 8.1) 32.9 (± 13.6) 87.5 (± 5.2) Costa Rica 16.9 (± 3.3) 31.7 (± 4.8) 61.0 (± 5.5) Fiji 14.5 (± 7.2) 34.7 (± 9.2) 69.0 (± 5.4) Jordan 33.1 (± 9.1) 33.8 (± 7.5) 67.9 (± 7.5) Poland urban 8.7 (± 2.7) 53.4 (± 4.5) 67.8 (± 5.2) rural 10.6 (± 4.4) 38.5 (± 6.4) 62.2 (± 5.5) Russian Federation Moscow 4.8 (± 1.3) 62.8 (± 3.7) 78.5 (± 3.9) South Africa 18.8 (± 4.2) 54.8 (± 6.8) 65.4 (± 8.1) Sri Lanka 10.0 (± 5.4) 42.1 (± 17.7) 40.7 (± 8.2) Ukraine Kiev 6.7 (± 1.9) 38.5 (± 4.1) 90.9 (± 2.3) Venezuela 27.8 (± 6.7) 46.2 (± 9.0) 77.0 (± 7.0) Zimbabwe Harare 25.2 (± 12.2) 47.6 (± 8.4) 75.3 (± 7.7) Manicaland 26.0 (± 10.7) 37.7 (± 13.3) 58.6 (± 15.1) a Figures in parentheses are 95% confidence intervals. Global Youth Tobacco Survey 871Bulletin of the World Health Organization, 2000, 78 (7) for boys and girls in every country, except Ukraine (Kiev) where more boys than girls wanted to stop. In every country, except Sri Lanka, Ukraine (Kiev), and Zimbabwe, approximately two-thirds of current smokers had tried to stop smoking during the 12 months preceding the survey (median: 63.4%) (Table 4). Media and advertising Anti-tobacco messages were not widely seen by students in these countries either as media messages or at sporting or other events during the 30 days preceding the survey (Table 5). In most countries, only 20–25% of students had seen an anti-smoking message during the 30 days preceding the survey (median: 19.2% for media and 25.6% at sports events). In contrast, in most countries, over two- thirds of students saw advertisements promoting cigarettes on billboards (median: 69.3%), in news- papers and magazines (median: 67.9%), and at public events (median: 67.7%), or saw cigarette brand names at such events (median: 78.3%). In Fiji, Jordan, Poland (urban and rural), the Russian Federation (Moscow), and Ukraine (Kiev), over one in five students owned an object with a cigarette brand logo on it (median: 14.0%) (Table 5). In the other countries, less than 15% of students had a brand logo item. The percentage of students who reported that they had been offered free cigarettes by a representative of a tobacco company was relatively high, with a median of 7.2% (Table 5). This practice was most likely in Jordan (24.8%), the Russian Federation (Moscow) (16.7%), South Africa (15.2%), and in Manicaland in Zimbabwe (14.5%). Environmental tobacco smoke The percentage of students who lived in a home where others smoked ranged from over 67% in Jordan and Poland (urban and rural), to 22.5% in Barbados (median 49.0%) (Table 6). In China, Fiji, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev), approximately one-half of the students were exposed to cigarette smoking from others in their home. In South Africa and Venezuela, over 40% of students were exposed to other people smoking at home. In every country, at least 40% of students were exposed to cigarette smoking by other people in places away from their homes (median: 56.5%) (Table 6). Boys in China, Fiji, Jordan, Sri Lanka, and Ukraine (Kiev) were more likely than girls to be exposed to smoke from others. In the Russian Federation (Moscow), South Africa, Ukraine (Kiev), and Zimbabwe, only approxi- mately one-half of the students ‘‘definitely’’ thought that smoke from others was harmful to them (Table 6). In all the other countries, over two-thirds of the students thought smoke from others was harmful to them (median: 69.7%). Except in Zimbabwe, the majority of students thought that smoking should be banned from public places (median: 67.8%). Approximately 9 out of 10 students in Costa Rica (84.2%), Sri Lanka (91.4%) and Venezuela (87.3%) thought that smoking should be banned in public places. School curriculum The percentage of students who reported having been taught in school about the dangers of tobacco use varied from over 70% in China to approximately 33% in Barbados, Costa Rica, the Russian Federation (Moscow), South Africa, and Harare in Zimbabwe (median: 53.5%) (Table 7). Those who reported having been taught the ‘‘reasons not to smoke’’ or were taught about the ‘‘effects of tobacco use’’ was much lower. Overall, less than one-half of the students reported having been taught about the effects of tobacco use (median: 35.2%). Discussion The GYTS was initiated by WHO and CDC as a means of providing baseline data to selected countries participating in a project on youth and tobacco funded by the United Nations Foundation for International Partnerships (UNFIP) project on youth and tobacco. The findings of the GYTS in these countries and the growing need for data on youth and tobacco led other countries to ask for assistance in conducting their own surveys.WHOandCDC are therefore now Table 4. Percentage of students aged 13–15 years who wanted to stop and unsuccessfully tried to stop cigarette smoking — Global Youth Tobacco Survey, 1999 Country Desire to stop Tried to stop Barbados 43.4 (± 15.3)a 63.5 (± 6.6) China Chongqing 72.4 (± 6.8) 63.2 (± 12.6) Guandong 62.5 (± 12.8) 62.6 (± 10.6) Shandong 86.9 (± 13.6) 78.8 (± 15.3) Tianjin 86.9 (± 6.3) 68.2 (± 8.4) Costa Rica 57.8 (± 5.3) 63.0 (± 5.3) Fiji 78.0 (± 8.3) 78.9 (± 12.0) Jordan 40.4 (± 5.9) 78.3 (± 5.7) Poland urban 74.6 (± 5.7) 73.3 (± 3.8) rural 79.5 (± 4.4) 79.1 (± 6.6) Russian Federation Moscow 69.2 (± 3.7) 76.1 (± 3.0) South Africa 69.1 (± 7.3) 74.6 (± 5.5) Sri Lanka 79.0 (± 13.6) 42.9 (± 15.4) Ukraine Kiev 51.3 (± 3.1) 56.4 (± 4.0) Venezuela 69.8 (± 10.8) 68.4 (± 10.7) Zimbabwe Harare 66.7 (± 17.7) 43.4 (± 20.0) Manicaland 64.6 (± 8.9) 54.0 (± 19.3) a Figures in parentheses are 95% confidence intervals. Special Theme – Tobacco 872 Bulletin of the World Health Organization, 2000, 78 (7) mounting a multi-agency, international collaborative effort to provide this assistance. The data available on tobacco use by youth and related problems is weak, except in a few developed countries. Global monitoring of the tobacco epi- demic and comparisons between countries require a degree of standardization of core concepts and definitions, and of the methodology of data collec- tion. Until now, no survey instrument had been designed or consistently applied to meet these conditions. The GYTS has several strengths in this regard: it is both standardized and adaptable to the needs of each country; it is relatively simple and inexpensive to administer; and the data gathered are processed and returned to countries within a short time-frame. The GYTS surveillance system will also enhance the capacity of countries to design, imple- ment, and evaluate their own tobacco control and prevention programmes by following a standard format. It offers a unique tool for improving the information base on tobacco use among young people, which will support medium-term and long- term programming and advocacy actions for youth- targeted tobacco control. The GYTS will serve in evaluating the success of national programmes and the WHO Framework Convention for Tobacco Control (FCTC) (12), especially in the protection of children and adolescents. Conclusions . The percentage of young people using any tobacco product ranges from a high of 33% to a low of about 10%. Cigarette use is extremely high in two Eastern European urban areas —Moscow and Kiev, where more than one-third of young people aged between 13 and 15 years currently smoke cigarettes. This high prevalence in such a young age group portends a lifetime of addiction for a large number of people, half of whomwill die prematurely of tobacco-related diseases. . In most countries, boys are more likely than girls to use tobacco. Where this tendency is reversed, wemay bewitnessing the success of advertising by the tobacco industry in making cigarettes fashion- able. . One-fifth ormore of young people begin smoking cigarettes before the age of 10 years. This is of concern, since the younger they start to smoke, the more likely they are to become addicted, or become heavy smokers, or die from tobacco- related diseases. Table 5. Percentage of students aged 13–15 years who were exposed to anti- and pro-smoking advertising — Global Youth Tobacco Survey, 1999 Country Saw anti- Saw anti- Saw ads for Saw ads for Saw brand Saw ads for Had some Cigarettes smoking smoking cigarettes on cigarettes in names at a cigarettes at object with offered free messages on messages at billboards newspapers/ sports events sports event a cigarette by tobacco the media sporting and (%) magazines or on TV (%) brand logo company (%) other events (%) (%) (%) on it (%) (%) Barbados 22.8 (± 2.3)a 47.0 (± 4.3) 69.3 (± 3.6) 69.1 (± 3.9) 86.5 (± 2.0) 48.9 (± 3.7) 14.7 (± 2.2) 7.3 (± 1.6) China Chongqing 17.7 (± 2.5) 19.5 (± 2.3) 67.5 (± 3.7) 44.7 (± 2.9) 57.7 (± 2.5) 63.9 (± 3.3) 12.2 (± 1.6) 7.0 (± 1.3) Guandong 13.4 (± 1.7) 9.5 (± 1.2) 75.7 (± 2.0) 48.6 (± 2.9) 67.0 (± 1.8) 71.5 (± 2.9) 18.9 (± 2.0) 5.3 (± 1.2) Shandong 18.6 (± 2.7) 19.2 (± 2.5) 50.3 (± 2.2) 31.6 (± 2.4) 45.6 (± 3.1) 44.3 (± 2.3) 7.4 (± 1.1) 2.5 (± 1.2) Tianjin 12.8 (± 1.6) 15.5 (± 2.0) 60.4 (± 4.4) 35.1 (± 3.8) 46.8 (± 3.1) 48.4 (± 2.8) 6.7 (± 1.3) 2.5 (± 1.1) Costa Rica 25.2 (± 1.3) 50.4 (± 2.4) 91.9 (± 1.4) 85.5 (± 1.7) 92.3 (± 1.1) NA 13.1 (± 1.3) 7.2 (± 1.0) Fiji 12.5 (± 3.7) 16.5 (± 2.6) 78.3 (± 3.1) 81.2 (± 3.7) 93.2 (± 1.9) 84.2 (± 3.5) 20.5 (± 2.6) 10.8 (± 2.5) Jordan 19.1 (± 2.1) 25.2 (± 3.1) 64.6 (± 2.5) 59.1 (± 2.3) 72.3 (± 2.2) 63.0 (± 3.2) 30.5 (± 2.5) 24.8 (± 2.9) Poland urban 35.4 (± 2.7) 18.0 (± 2.2) 89.3 (± 2.8) 91.0 (± 3.5) 87.6 (± 2.9) 82.8 (± 1.9) 30.0 (± 2.0) NA rural 42.5 (± 1.4) 20.5 (± 3.1) 83.9 (± 3.2) 89.1 (± 3.1) 88.0 (± 3.4) 79.1 (± 2.8) 20.5 (± 1.9) NA Russian Federation Moscow 25.2 (± 1.7) 41.2 (± 2.7) 94.9 (± 0.8) 77.0 (± 1.5) 89.5 (± 1.3) 79.3 (± 1.5) 22.9 (± 1.9) 16.7 (± 1.9) South Africa 20.2 (± 2.8) 22.4 (± 3.7) 76.4 (± 4.6) 80.7 (± 3.9) 83.8 (± 3.6) 78.3 (± 5.3) 14.5 (± 3.0) 15.2 (± 4.4) Sri Lanka 9.6 (± 1.7) 15.0 (± 2.3) 81.0 (± 2.1) 83.4 (± 1.9) 87.0 (± 2.4) 84.8 (± 2.2) 10.5 (± 1.7) 6.4 (± 1.1) Ukraine Kiev 21.2 (± 2.0) 26.0 (± 1.9) NA 87.8 (± 1.3) 90.9 (± 1.1) 83.8 (± 1.6) 25.0 (± 1.7) 6.6 (± 1.0) Venezuela 19.7 (± 2.2) 27.8 (± 2.6) 80.2 (± 2.0) 80.4 (± 2.0) 81.0 (± 2.4) 76.3 (± 2.5) 14.9 (± 1.9) 10.2 (± 1.1) Zimbabwe Harare 19.3 (± 3.6) 26.7 (± 4.9) 76.6 (± 5.3) 74.7 (± 4.9) 83.3 (± 3.7) 74.1 (± 5.8) 10.0 (± 1.7) 8.7 (± 3.7) Manicaland 30.3 (± 6.1) 36.2 (± 6.6) 64.6 (± 5.1) 66.7 (± 4.0) 75.5 (± 5.7) 62.2 (± 6.2) 13.2 (± 2.6) 14.5 (± 3.4) NA - Not available, question was not asked. a Figures in parentheses are 95% confidence intervals. Global Youth Tobacco Survey 873Bulletin of the World Health Organization, 2000, 78 (7) . Young people usually smoke at home— except in Moscow and Kiev where there is no restriction on smoking. Smoking in the home adds to the burden of secondary exposure of other persons and provides an unfortunate role model for younger siblings. . Young people who wish to buy cigarettes in stores are very rarely refused purchase if they are under age. Even where laws exist which restrict the sale of cigarettes to young people, these laws are seldom enforced. . The majority of young people currently smoking want to stop smoking and over two-thirds have tried to stop. The traditional focus of youth prevention programmes has been on preventing the start of tobacco use. Few have offered cessation programmes to those who may already be smoking. Programmes and interventions targeting young people therefore need to expand their focus to include both preventing starting and offering tailored youth cessation programmes. . Across the countries, anti-tobacco advertising is rare. Conversely, in most countries the majority of young people report having seen advertisements for cigarettes from a variety of media outlets (billboards, newspapers, magazines, etc.). Thus, the influence of advertising by the tobacco industry is pronounced in most populations. Until legislation provides for labelling of tobacco products and support for counter-advertising, children and adolescents are seeing and hearing only pro-tobacco messages in the media. . On the other hand, in most countries the majority of young people have been taught in school about the dangers of smoking. The present survey does not provide details about the content or quality of the curriculum, the preparation of the teachers on this topic, or the number or duration of the lessons taught. . Exposure of young people to environmental tobacco smoke is very high in all countries. The majority of young people definitely think that smoke from others is harmful to them. Also, the majority of young people feel smoking should be banned from public places. The environment in which most young people live therefore is contrary to their desire for freedom from exposure to tobacco smoke. n Acknowledgements The agencies contributing to the surveys, besides those within each country, included the United Nations Foundation for International Partnerships (UNFIP), the United Nations Children’s Fund (UNICEF), the US National Cancer Institute (NCI), and the Canadian Public Health Association (CPHA). The Research Coordinators in the 12 countries described in the present study were A. Daniels (Barbados), Jiang-ping Sun (China), M. Shreim (Jordan), P.W. Gunasekera (Sri Lanka), K. Krasovsky Table 6. Percentage of students aged 13–15 years who were exposed to tobacco smoke in the home and other places — Global Youth Tobacco Survey, 1999 Country % of others % exposed to % who % who think who smoke smoke from definitely smoking should in the student’s persons in think smoke be banned home other places from others is in public harmful to them places Barbados 22.5 (± 4.8)a 51.3 (± 3.9) 63.7 (± 4.1) 79.4 (± 2.6) China Chongqing 56.8 (± 3.7) 59.6 (± 3.2) 81.3 (± 1.6) 55.7 (± 2.7) Guandong 49.4 (± 2.8) 48.4 (± 2.8) 80.2 (± 1.7) 64.3 (± 2.1) Shandong 48.9 (± 3.8) 42.9 (± 2.7) 79.6 (± 2.6) 63.1 (± 2.1) Tianjin 59.1 (± 3.1) 52.6 (± 3.2) 81.4 (± 1.8) 68.7 (± 2.3) Costa Rica 32.8 (± 1.7) 55.7 (± 2.1) 73.5 (± 1.9) 84.2 (± 1.8) Fiji 49.4 (± 4.8) 68.6 (± 3.4) 57.2 (± 5.4 ) 54.0 (± 8.2) Jordan 67.4 (± 2.4) 61.3 (± 2.9) 75.0 (± 2.3) 78.3 (± 2.1) Poland urban 68.6 (± 2.4) 72.1 (± 3.0) 66.2 (± 2.0) 76.5 (± 2.0) rural 67.9 (± 3.1) 62.3 (± 2.9) 61.8 (± 3.1) 84.6 (± 2.8) Russian Federation Moscow 55.3 (± 2.2) 72.5 (± 2.1) 51.0 (± 2.6) 71.0 (± 2.1) South Africa 43.6 (± 4.6) 56.1 (± 8.0) 57.3 (± 7.5) 53.4 (± 9.1) Sri Lanka 55.9 (± 3.4) 67.9 (± 3.3) 74.7 (± 2.5) 91.4 (± 2.4) Ukraine Kiev 49.0 (± 2.4) 71.8 (± 1.8) 49.4 (± 2.6) 66.9 (± 2.7) Venezuela 43.5 (± 2.2) 47.8 (± 2.9) 64.6 (± 2.4) 87.3 (± 1.5) Zimbabwe Harare 36.2 (± 5.0) 62.4 (± 5.0) 45.3 (±6.2) 43.2 (± 11.1) Manicaland 35.0 (± 6.0) 51.6 (± 6.4) 31.0 (± 6.3) 31.6 (± 8.1) a Figures in parentheses are 95% confidence limits. Table 7. Percentage of students aged 13–15 years who were taught the facts about tobacco smoking during the past school year — Global Youth Tobacco Survey, 1999 Country Dangers of Reasons for Effects of smoking taught not smoking tobacco use in class (%) discussed in taught in class (%) class (%) Barbados 32.0 (± 8.7)a 22.8 (± 4.6) 29.2 (± 8.9) China Chongqing 78.6 (± 2.8) 39.8 (± 3.4) 48.0 (± 3.4) Guandong 83.0 (± 3.1) 35.5 (± 2.7) 57.3 (± 2.9) Shandong 71.7 (± 2.6) 35.5 (± 3.4) 41.3 (± 3.7) Tianjin 75.9 (± 3.4) 35.4 (± 2.9) 43.2 (± 3.8) Costa Rica 39.4 (± 3.8) 32.9 (± 3.1) 37.8 (± 3.1) Fiji 64.1 (± 5.7) 44.8 (± 5.6) 56.1 (± 6.1) Jordan 52.5 (± 3.9) 49.2 (± 2.8) 49.7 (± 2.7) Poland urban 48.3 (± 4.1) 42.5 (± 3.4) 39.2 (± 3.2) rural 53.4 (± 3.7) 44.8 (± 4.3) 41.5 (± 4.1) Russian Federation Moscow 35.6 (± 4.0) 23.0 (± 2.6) 32.3 (± 3.5) South Africa 38.7 (± 4.8) 29.4 (± 4.3) 41.7 (± 4.3) Sri Lanka 62.7 (± 3.2) 34.5 (± 2.7) 53.8 (± 2.9) Ukraine Kiev 54.4 (± 5.1) 37.8 (± 4.8) 48.0 (± 4.2) Venezuela 42.1 (± 5.0) 30.3 (± 2.7) 49.8 (± 4.7) Zimbabwe Harare 34.1 (± 5.9) 26.7 (± 5.7) 33.3 (± 6.2) Manicaland 51.6 (± 5.7) 34.9 (± 5.5) 50.8 (± 5.1) a Figures in parentheses are 95% confidence limits. Special Theme – Tobacco 874 Bulletin of the World Health Organization, 2000, 78 (7) (Kiev, Ukraine), R. Granero (Venezuela), K.V. Vyshinsky (Moscow, Russian Federation), I. Movono (Fiji), K. Przewozniak (Poland), D. Swart (South Africa), J. Bejarano (Costa Rica), and the Blair Research Group (Zimbabwe). Special support for the GYTS was also provided by the following A. Demine (Moscow, Russian Federation), N. Herrera (Venezuela), P. Reddy (South Africa), and W. Zatonski (Poland). Re´sume´ Le tabac chez les jeunes : surveillance du projet d’enqueˆte mondiale sur le tabagisme chez les jeunes Le tabagisme est l’une des principales causes de de´ce`s e´vitables dans le monde. L’Organisation mondiale de la Sante´ lui attribue pre`s de 4 millions de de´ce`s par an, un chiffre qui devrait passer a` 8,4 millions d’ici 2020. A ce moment-la`, 70 % de ces de´ce`s se produiront dans les pays en de´veloppement. La plupart des gens commen- cent a` fumer avant l’aˆge de 18 ans. Les tendances observe´es re´cemment vont dans le sens d’un accroisse- ment des taux de pre´valence du tabagisme chez les enfants et les adolescents, qui commencent a` fumer plus toˆt. L’enqueˆte mondiale sur le tabagisme chez les jeunes a e´te´ e´labore´e par l’initiative Pour un monde sans tabac de l’OMS et par l’Office on Smoking and Health des Centers for Disease Control and Prevention (CDC) des Etats-Unis d’Ame´rique, afin d’analyser le tabagisme chez les jeunes de pays du monde entier au moyen d’une me´thodologie et d’un questionnaire de base communs. Cette enqueˆte est re´alise´e dans les e´coles et fait appel a` un e´chantillonnage a` deux degre´s, afin d’obtenir des donne´es repre´sentatives de ce qu’est le tabagisme chez des e´le`ves de 13 a` 15 ans. Dans un premier temps, on re´alise un choix probabiliste des e´coles et, dans un second temps, on choisit de fac¸on ale´atoire les classes dans lesquelles on va enqueˆter au sein des e´coles participantes. Tous les e´le`ves des classes choisies peuvent participer a` l’enqueˆte. Cet article de´crit le principe et la mise au point de cette enqueˆte et rapporte les re´sultats obtenus dans 12 pays : Afrique du Sud, Barbade, Chine, Costa Rica, Fe´de´ration de Russie (Moscou), Fidji, Jordanie, Pologne, Sri Lanka, Ukraine (Kiev), Venezuela et Zimbabwe. Les re´sultats montrent que le tabagisme chez les jeunes s’e´tage entre un maximum de 33 % et un minimum de 10 %. La plupart des fumeurs actuels souhaitent arreˆter de fumer, mais tre`s peu d’entre eux ont de´ja` suivi un programme pour y parvenir. Dans la plupart des pays, la majorite´ des jeunes indiquent avoir vu des publicite´s pour les cigarettes dans les me´dias. La publicite´ antitabac est rare, mais la majorite´ des jeunes ont appris a` l’e´cole quels e´taient les dangers du tabac. L’exposition au tabagisme ambiant est tre`s importante dans tous les pays. Les re´sultats de l’enqueˆte re´alise´e dans ces 12 pays et la ne´cessite´ croissante de disposer de donne´es sur le tabac chez les jeunes ont conduit d’autres pays a` demander de l’aide pour effectuer leurs propres enqueˆtes. L’OMS/TFI et les CDC sont donc maintenant en train de mettre en place avec plusieurs autres organisations un important effort international concerte´ pour fournir cette aide. Le syste`me de surveillance de ce type d’enqueˆte vise a` renforcer la capacite´ des pays a` concevoir, a` mettre en œuvre et a` e´valuer des programmes de pre´vention et de lutte antitabac en suivant un mode`le commun/ standard. Ce type d’enqueˆte constitue donc un moyen important d’e´valuer les succe`s remporte´s par les programmes nationaux et la convention-cadre OMS pour la lutte antitabac re´cemment lance´e, surtout pour ce qui est prote´ger les enfants et les adolescents. Resumen El consumo de tabaco entre los jo´venes: informe de vigilancia de la Encuesta Mundial sobre el Tabaco y los Jo´venes El consumo de tabaco es una de las principales causas prevenibles de defuncio´n en el mundo. La Organizacio´n Mundial de la Salud (OMS) atribuye al tabaco unos 4 millones de defunciones anuales, cifra que segu´n las previsiones habra´ aumentado a 8,4 millones anuales para 2020. En esa fecha el 70% de tales defunciones se producira´n en los paı´ses en desarrollo. La mayor parte de la gente empieza a consumir tabaco antes de los 18 an˜os. Las u´ltimas tendencias muestran un aumento de las tasas de prevalencia de tabaquismo entre los nin˜os y adolescentes y un comienzo ma´s precoz del ha´bito. La Encuesta Mundial sobre el Tabaco y los Jo´venes (GYTS) fue desarrollada por la Iniciativa «Liberarse del tabaco» (ILT) de la OMS y por la Oficina de Tabaco y Salud de los Centros de Control y Prevencio´n de Enfermedades de los Estados Unidos (CDC), a fin de analizar la evolucio´n del consumo del tabaco entre los jo´venes en paı´ses de todo el mundo, usando para ello una metodologı´a comu´n y un cuestionario ba´sico. La GYTS es una encuesta escolar que emplea un me´todo de muestreo en dos etapas para obtener datos representa- tivos sobre el ha´bito de fumar entre los alumnos de 13 a 15 an˜os de edad. En la primera fase se hace una seleccio´n probabilista de las escuelas, y en la segunda se seleccionan aleatoriamente clases de las escuelas participantes. Todos los estudiantes de las clases seleccionadas son incluibles en la encuesta. En el presente artı´culo se describen el disen˜o y el desarrollo de la GYTS y se notifican los resultados de las Global Youth Tobacco Survey 875Bulletin of the World Health Organization, 2000, 78 (7) encuestas llevadas a cabo en 12 paı´ses: Barbados, China, Costa Rica, Federacio´n de Rusia (Moscu´), Fiji, Jordania, Polonia, Sri Lanka, Suda´frica, Ucrania (Kiev), Venezuela y Zimbabwe. Los resultados muestran que el consumo de tabaco se situ´a entre un ma´ximo del 33% y un mı´nimo del 10%. La mayorı´a de los fumadores actuales desean dejar de fumar, pero son muy pocos los que han asistido en alguna ocasio´n a un programa de deshabituacio´n. En la mayorı´a de los paı´ses la mayor parte de los jo´venes declaran que han visto anuncios de cigarrillos en los medios de comunicacio´n. La publicidad contra el tabaco rara vez se menciona, pero a la mayorı´a de los jo´venes se les ha informado en la escuela sobre los peligros del ha´bito de fumar. La exposicio´n a humo de tabaco ambiental era muy elevada en todos los paı´ses. Los resultados obtenidos por la GYTS en estos 12 paı´ses y la creciente necesidad de datos sobre la juventud y el tabaco ha llevado a otros paı´ses a pedir ayuda para realizar sus propias encuestas. En conse- cuencia, OMS/ILT y los CDC esta´n impulsando una ene´rgica iniciativa de colaboracio´n internacional mul- tiorganismos para proporcionar esa ayuda. El sistema de vigilancia de la GYTS tiene como objetivo aumentar la capacidad de los paı´ses para disen˜ar, aplicar y evaluar programas de prevencio´n y control del tabaquismo con arreglo a un formato comu´n/ esta´ndar. La GYTS constituye por tanto un instrumento importante para evaluar el e´xito de los programas nacionales y del recientemente iniciado Convenio Marco de la OMS para la Lucha Antitaba´quica, sobre todo en lo que respecta a proteger a los nin˜os y los adolescentes. References 1. 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