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Sri Lanka 2015 country report: global youth tobacco survey (GYTS)

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Global Youth Tobacco Survey (GYTS) Sri Lanka 2015, Country Report

Global Youth Tobacco Survey (GYTS) Sri Lanka 2015 Country Report

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Sri Lanka 2015 country report: global youth tobacco survey (GYTS)

1. Tobacco Use – statistics and numerical data. 2. Demography. 3. Surveys and Questionnaires. I. Sri Lanka ISBN 978-92-9022-522-5 (NLM classification: WM 290)

© World Health Organization 2016 All rights reserved. Requests for publications, or for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be obtained from SEARO Library, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: searolibrary@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. This publication does not necessarily represent the decisions or policies of the World Health Organization. Printed in India.

Acknowledgements Sri Lanka acknowledges the support of the World Health Organization’s Regional Office for South-East Asia (SEARO) and the United States Centers for Disease Control and Prevention (CDC) for providing technical and financial support to conduct the Global Youth Tobacco Survey (GYTS) 2015 in Sri Lanka and to develop and print this document. This report has been prepared by Dr A. Pubudu de Silva, Consultant Community Physician, National Intensive Care Surveillance (NICS) and a member of the Asian Collaboration for Excellence in Non Communicable Diseases (ASCEND); Dr Turlin Abenayake, Senior Medical Officer, National Authority on Tobacco and Alcohol (NATA); Dr Palitha Abeykoon, Chairman, NATA; Dr Palitha Mahipala, Director General of Health Services, Ministry of Health; Mr Hemantha Premathilaka, Additional Secretary (Education Quality Development), Ministry of Education; Dr Krishna Mohan Palipudi, Team Leader, Global Tobacco Surveillance System, CDC; Dr Dhirendra Narain Sinha, Regional Advisor, Surveillance (Tobacco Control), SEARO; Dr Jagdish Kaur. Regional Adviser (Tobacco Free Initiative), SEARO; and is based on the 2015 Global Youth Tobacco Survey (GYTS) findings in Sri Lanka. We acknowledge the contributions of Dr Lanka Dissanayake, World Health Organization Country Office (Sri Lanka); staff of SEARO; and staff from Global Tobacco Control Branch at CDC for their continuous technical guidance and valuable support throughout the GYTS implementation in Sri Lanka. We are also grateful to NATA (Mr P .W.P .W.K. Pallewaththa, Ms H.P .G. Nivarthana, Mr Geeth Pathum Subasinghe, Mr Buddhika Herath and Mr M.D. Kuruppuarachchi) and Network for Improving Critical care Systems and Training (NICST; Dr Manavi Deshani, Dr Vethanathan Sriraman, Dr M. Ramanan, Dr Adithi Weerasinghe and Dr Faisal Miskin) for the invaluable assistance provided during the survey.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

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Contributors Authors Dr A. Pubudu de Silva Dr Turlin Abeynayake Dr Palitha Abeykoon Dr Palitha Mahipala Mr Hemantha Premathilaka Dr Krishna Mohan Palipudi Dr Dhirendra Narain Sinha Dr Jagdish Kaur Editorial Committee Center for Disease Control Atlanta (Global Tobacco Control Branch) Dr Krishna Mohan Palipudi – Team Leader, Global Tobacco Surveillance System Ms Linda Anton – GYTS Coordinator Ministry of Education Sri Lanka Mr Hemantha Premathilaka – Additional Secretary (Educational Quality Development) Ministry of Health Sri Lanka Dr Palitha Mahipala – Director General of Health Services Dr Amal Harsha De Silva – Deputy Director General (Medical Services II) Dr Priyantha Athapattu – Director (Medical Services) and Head, National Intensive Care Surveillance Dr Pubudu de Silva – Consultant Community Physician, National Intensive Care Surveillance National Authority on Tobacco and Alcohol Dr Palitha Abeykoon – Chairman Dr Turlin Abeynayake – Senior Medical Officer Network for Improving Critical Care Systems and Training (NICST) Dr Rashan Haniffa – Director Ms Chathurani Sigera – Programme Officer World Health Organization South East Asia Regional Office Dr Thaksaphon Thamarangsi – Director, NCD and Environment Health Dr Dhirendra Narain Sinha – Former Regional Adviser, Surveillance, Tobacco Control Dr Jagdish Kaur – Regional Adviser (Tobacco Free Initiative) Mr Naveen Agarwal – Surveillance Management Associate, Noncommunicable and Tobacco Surveillance. Printed in August 2016

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Contents Acknowledgements.................................................................................................iii Contributors........................................................................................................... iv Contents.................................................................................................................. v List of Tables.......................................................................................................... vii Abbreviations........................................................................................................ viii Message from the Hon’ble Minister of Health,........................................................ ix Nutrition and Indigenous Medicine Message from the Regional Director, WHO South-East Asia Region......................... xi Executive Summary.............................................................................................. xiii Introduction.............................................................................................................1 Country Demographics....................................................................................1 WHO Framework Convention on Tobacco Control and MPOWER..................2 Purpose and Rationale.....................................................................................2 Current State of Policy.....................................................................................4 Other Tobacco Surveys....................................................................................4 Country-Specific Objectives............................................................................4

Methods..................................................................................................................5 Sampling, Sample Size and Study Population...................................................5 Data Collection and Variables..........................................................................6 Data Analysis...................................................................................................7

Results.....................................................................................................................9 Geographic and Sociodemographic Profile......................................................9

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Prevalence....................................................................................................10 Knowledge and Attitudes...............................................................................12 School Curriculum.........................................................................................12 Access and Availability...................................................................................13 Exposure to Secondhand Smoke....................................................................13

Cessation.......................................................................................................15 Media and Advertising...................................................................................15

Discussion.............................................................................................................17 Summary of Results.......................................................................................17 Comparison to Previous Tobacco Surveys......................................................19 Relevance to WHO FCTC/WHO MPOWER..................................................20

Conclusions...........................................................................................................23 Recommendations.................................................................................................25 References.............................................................................................................27 Annexes.................................................................................................................29 Annex1 - Questionnaire................................................................................31 Annex2 - Core GYTS indicators.....................................................................45 Annex3 - Fact Sheet – GYTS Sri Lanka 2015.................................................58

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

List of Tables Table 1. Distribution of selected schools by province............................................9 Table 2. Sociodemographic profile of students......................................................9 Table 3. Percent of students who use tobacco ...................................................10 Table 4. Percent of students who first tried using tobacco...................................11 at different age groups Table 5. Knowledge and attitude of students towards those who smoke..............12 Table 6. Students who received education on tobacco through school................12 curriculum Table 7. Accessibility of students for smoking......................................................13 Table 8. Exposure of students for secondhand smoking in the past 7 days .........13 Table 9. Students’ attitude on secondhand smoking...........................................14 Table 10. Students with family members who smoke............................................14 Table 11. Cessation information of students who smoke.......................................15 Table 12. Exposure of students on media advertising............................................15 Table 13. Exposure of students on tobacco company advertising..........................16 Table14. Comparisons of various tobacco use and tobacco control......................19 indicators of previous GYTS surveys in Sri Lanka from 1999 to 2015

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Abbreviations CDC CI FCTC GYTS NATA NCD OSH SE SEARO TFI WHO Centers for Disease Control and Prevention Confidence Interval Framework Convention on Tobacco Control Global Youth Tobacco Survey National Authority on Tobacco and Alcohol Noncommunicable disease Office on Smoking and Health Standard Error World Health Organization’s Regional Office for South-East Asia Tobacco Free Initiative World Health Organization

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Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Message from the Hon’ble Minister of Health, Nutrition and Indigenous Medicine I am pleased to learn about the publication of the Report of the Global Youth Tobacco Survey for 2015 in Sri Lanka. This latest Global Youth Tobacco Survey (GYTS) follows four other such surveys conducted in the country in 1999, 2003, 2007 and 2011 in an effort to track tobacco use among adolescents. We are aware of the vulnerability of this age group and need to keenly understand the knowledge and the behaviour patterns of this segment of youth in order to effectively plan our tobacco prevention and control programmes. The Government of the Democratic Socialist Republic of Sri Lanka made a number of very important policy decision regarding tobacco control in the past decade. The most important was the enactment of the National Authority on Tobacco and Alcohol (NATA Act) passed by the parliament unanimously in 2006. Another was the ratification of the world Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) in 2003. One of the most significant and far-reaching enactments has been the initiative of our current president H.E. Maithripala Sirisena to pass the law in 2015 requiring 80% pictorial warning to be placed on cigarette packets. I was privileged to steer this Bill through Parliament soon after our President assumed office. Sri Lanka’s ratification of the protocol to Eliminate Illicit Trade in Tobacco Products, we believe, will also help plug some of the loopholes that may exist in our current portfolio of tobaccorelated laws. The Government is now ready with the Draft Bill to introduce a number of amendment to the NATA Act. These will further bolster the Act’s provisions and facilitate its implementation.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

The GYTS is a school-based survey conducted among students aged 13-15 years. I am also very pleased to learn that there has been a significant reduction in the use of tobacco-based products among this vulnerable segment of youth and I commend all those who have strived hard and relentlessly to make this happen. But we need to work harder to ensure all the children born in this century are completely free from tobacco use and other substance abuse. On behalf of the Ministry of Health, Nutrition and Indigenous Medicine and the National Authority on Tobacco and Alcohol of Sri Lanka, I sincerely acknowledge the invaluable support of the World Health Organization and the contribution of partners such as the Ministry of Education and the Centres for Disease Control and Prevention (CDC), Atlanta, USA, as well as the researchers who were involved as principal investigators, staff and students of schools and others.

Dr. Rajitha Senarathna Minister of Health, Nutrition and Indigenous Medicine The Government of the Democratic Socialist Republic of Sri Lanka Colombo

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Message from the Regional Director, WHO South-East Asia Region Tobacco use is the most common preventable cause of premature death and disease worldwide. Currently, approximately 6 million people die each year due to tobacco-related illnesses; a figure expected to increase to more than 8 million a year by 2030. Nearly all tobacco use begins during youth and young adulthood. Tobacco contains nicotine, a highly addictive substance that causes many young people to progress from occasional to daily tobacco use over a period of time. Intensive marketing by the tobacco industry to a large extent is responsible for initiating tobacco use among young individuals. An efficient and systematic surveillance mechanism to monitor the epidemic is one of the essential components of a comprehensive tobacco control program. WHO Global Action Plan for Prevention and Control of NCDs calls for 30% relative reduction in the prevalence of current tobacco use among persons aged 15 years and above by 2025. Reducing tobacco use is also critical to achieving Sustainable Development Goals by 2030, with adherence to the WHO Framework Convention on Tobacco Control (FCTC) being one of the specific targets. The Global Youth Tobacco Survey (GYTS) is a school-based survey of students aged 13-15 years, designed as a standardized tool to collect data on tobacco use among youth in countries around the globe. Sri Lanka has completed multiple rounds of the GYTS since 1999. I am delighted to learn that the prevalence of tobacco use among the children in the study has shown a declining trend since the last GYTS in 2011. However, it is also necessary to be vigilant about the possible increase in the number of children adopting smokeless tobacco use.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

I congratulate Ministry of Health, Nutrition and Indigenous Medicine and the National Authority on Tobacco and Alcohol (NATA), Sri Lanka for conducting this survey. The WHO Regional office for South East Asia will continue to support and facilitate tobacco-related surveillance in Member States. The findings of the survey shall prove useful for policy and programme implications aimed at tobacco control, especially among the youth and to monitor implementation of WHO FCTC and MPOWER measures in Sri Lanka.

Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region

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Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Executive summary The Global Youth Tobacco Survey (GYTS) was developed by the Tobacco Free Initiative (TFI), the World Health Organization (WHO) and the Office on Smoking and Health (OSH) of the United States Centers for Disease Control and Prevention (CDC) in collaboration with a range of countries representing the six WHO regions to gather comprehensive tobacco prevention and control information on young people. The GYTS supports WHO MPOWER by monitoring country-specific data on key tobacco indicators, including prevalence, knowledge and behaviour. The GYTS is a school-based survey that uses a two-stage cluster sample design to produce representative samples of students in grades associated with the age group 13–15 years. During the first-stage sampling, a sampling frame was created for all eligible schools in Sri Lanka containing grades 8, 9 and 10 (Type IAB, Type IC and Type II). Within the sampling frame, 30 schools were selected with probability proportional to school enrollment size. The second sampling stage consisted of systematic equal probability sampling (with a random start) of classes from each school selected during the first stage. All classes in the selected grades were included in the sampling frame. All students in the selected classes were eligile to participate in the survey. A pre-tested, self-administered questionnaire was used to collect the data. The questionnaire contained 55 multiple-choice questions. The survey included 43 questions from the core questions and 12 from the optional questions. The questionnaire covered sociodemography, usage, knowledge and attitude, access and availability, secondhand smoking, cessation, media and advertising, and school curriculum regarding tobacco products. Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Colombo. The 2015 GYTS in Sri Lanka was conducted in 65 class rooms of 30 schools. A total of 1505 students participated, of which 1416 were ages 13 to 15 years (Male: 726, Female: 689, missing: 1). The school response rate was 100%, the class response rate was 100% and the student response rate was 81.9%. The overall response rate was 81.9%. SUDAAN, a software package for statistical analysis of complex survey data, was used to calculate weighted prevalence estimates and standard errors (SE) of the estimates (95% confidence intervals [CI] were calculated from the SEs).

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In Sri Lanka, 5.7% of students reported that they had smoked one or more cigarette(s) in their lifetime. Overall, 3.7% reported current tobacco use (at least once in the last 30 days). Approximately 1.5% reported currently smoking cigarettes, and 0.5% reported using tobacco other than cigarettes within the previous 30 days. In addition, 2.5% indicated that they were susceptible to start tobacco in future. Of the current smokers, 10.4%* usually smoke at a friend’s house and 20.5%* of current smokers buy cigarettes in a store or shop. Among the smokers, 76.9%* reported that they want to stop smoking, and 83.9%* tried to stop smoking within the past year. Regarding cessation attempts, 25.0%* of current smokers reported that they have received help from a programme or professional to stop smoking. From the participants, 13.4% lived in households where others smoked, and 35.7% were around others who smoked in enclosed public places. In their personal lives, 15.3% of students reported that they have one or more parents who smoke, and 14.8% report having close friends who smoke tobacco. In the past 30 days, 88.0 % saw anti-smoking media messages while 44.6% noticed tobacco advertisements or promotions at points of sale. 91.6%* of the current smokers reported that they noticed health warnings on cigarette packages in the past 30 days. Up to 2.9% reported that they have an object with a cigarette brand logo, and 2.0% have been offered one or more free cigarettes by a tobacco company representative. In the past year, 78.9% had been taught in class about the dangers of smoking. GYTS methodology provides an excellent framework for monitoring and guiding the implementation of school tobacco control programmes while making it compliant with the requirements of World Health Organization - Framework Convention on Tobacco Control (WHO-FCTC). There is a need to effectively enforce the existing laws banning tobacco use in public places. Public health activities should focus on actions to increase the awareness on secondhand smoking, especially at home settings and public places. Organizations which are involved in supporting youth interested in quitting require further capacity-building. A comprehensive health promotion strategy and effective and comprehensive tobacco cessation programmes need to be formulated to prevent tobacco use and assist school personnel and the general community in quitting. *Total number of participants in the denominator was less than 35 (n<35)

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Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Introduction

Tobacco use is the leading cause of preventable death worldwide. World Health Organization (WHO) attributes nearly 6 million deaths a year to tobacco use. This figure is expected to rise to more than 8 million deaths a year by 2030. The majority of people who are heavy smokers started the habit before 18 years of age . Initial exposure at a younger age is a documented risk factor for heavier tobacco use as an adult1-3. 1

The Global Youth Tobacco Survey (GYTS) was developed by the Tobacco Free Initiative (TFI), World Health Organization (WHO) and the Office on Smoking and Health (OSH) of the United States Centers for Disease Control and Prevention (CDC) in collaboration with a range of countries representing the six WHO regions to gather comprehensive tobacco prevention and control information on young people. The GYTS is a school-based survey that uses a two-stage cluster sample design to produce representative samples of students in grades associated with the age group 13–15 years. All classes in the selected grades were included in the sampling frame. All students in the selected classes were eligible to participate in the survey.

Country Demographics Sri Lanka is an island in the Indian Ocean with a population of approximately 20 million distributed over 65,610km2. It is a Member State of the WHO SEARO and is considered a lower-middle-income country. In 2011, the country reported a growth rate of 4.8% of GDP4. Although it is a lower-middle-income-country, it has better health and education indicators compared with similar developing countries. The literacy rate in the country is over 91.9% with female literacy rate of 90.8%5. The infant mortality rate is 9.9 per 1000 live births and the maternal mortality rate is 37.7 per 100 000 live births6.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

WHO Framework Convention on Tobacco Control and MPOWER In response to the globalization of the tobacco epidemic, the 191 Member States of the World Health Organization unanimously adopted the WHO Framework Convention on Tobacco Control (FCTC) at the Fifty-sixth World Health Assembly in May 2003. The FCTC is the world’s first public health treaty on tobacco control. It is the driving force behind, and blueprint for the global response to the pandemic of tobacco-induced deaths and diseases. The treaty embodies a coordinated, effective, and urgent action plan to curb tobacco consumption and lays out cost-effective tobacco control strategies for public policies such as banning direct and indirect tobacco advertising, increasing tobacco tax and price, promoting smoke-free public places and workplaces, displaying prominent health messages on tobacco packaging, and tobacco research, surveillance, and exchange of information. To help countries fulfill their WHO FCTC obligations, in 2008, WHO introduced MPOWER, a technical package of six evidence-based tobacco control measures that are proven to reduce tobacco use and save lives: •• •• •• •• •• •• Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion and sponsorship Raise taxes on tobacco

The GYTS supports WHO MPOWER by monitoring country-specific data on key tobacco indicators, including prevalence, knowledge and behaviour. The final questionnaire was translated into Sinhalese and Tamil and back-translated into English to check for accuracy.

Purpose and Rationale The purpose of participating in the GYTS is to enhance countries’ capacity to monitor youth tobacco consumption and tobacco use initiation, guide national tobacco prevention and control programmes, and facilitate comparison of tobacco-related data

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

at the national, regional, and global levels. Results from the GYTS are also useful for documenting changes in different variables of tobacco control measures for monitoring the implementation of different provisions of the tobacco control law and the relevant Articles of the WHO Framework Convention. The rationale for Sri Lanka’s participation in the GYTS includes the following: Sri Lanka has signed and ratified the WHO FCTC in 2004. GYTS and WHO FCTC have synergies on following articles of the convention7: •• •• •• •• •• •• •• Articles 8 – Protection from exposure to tobacco smoke Articles 11 – Packaging and labeling of tobacco products Article 12 – Education, communication, training and public awareness Article 13 – Tobacco advertising, promotion and sponsorship Article 16 – Sales to and by minors Article 20 – Research, surveillance and exchange of information Article 21 – Reporting and exchange of information

The incidence of diseases related to tobacco use is on the rise. Among the 10 leading causes of morbidity and mortality are ischaemic heart disease, diseases related to respiratory tract, neoplasms and cerebrovascular accidents6. Among the neoplasms, the leading cancer sites are the lip, oral cavity, pharynx and trachea, bronchus, lung6. The occurrence of neoplasms in above-mentioned sites are directly related to tobacco use. Noncommunicable diseases (NCDs) have become the leading cause of morbidity and mortality with tobacco use being the second biggest cause of all deaths and disabilities from NCDs9. The current smoking prevalence is 39% and 2.6% among adult males and females respectively9. Chewing tobacco is more common than smoking tobacco among women9. Over 20 000 people die due to tobacco-related illnesses annually in Sri Lanka9. Among the youth, prevalence of tobacco use over the last 10 years according to the GYTS in 1999 to 2011 demonstrated a reduction in the current cigarette smoking from 4.0% to 1.5% 10-13. During this period, the percentage of never smokers in this age group likely to initiate smoking also decreased, from 5.1% in 1999 to 3.4% in 201110-13. The GYTS survey in 2011 covered 90 schools around the island. This included 30 schools from each of the school categories (Type IAB, Type IC and Type II).

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

The current survey will also be helpful to reveal the immediate outcomes of National Authority on Tobacco and Alcohol (NATA) Act No. 27 of 2006, which regulates the sale, advertisement and usage of tobacco products 9. In Sri Lanka, smoking is banned in all public places other than restaurants and airport. The sale of tobacco products to minors is prohibited and unlike most other countries, NATA defines minors as those who are less than 21 years of age.

Current State of Policy Currently, in Sri Lanka, there is NATA Act No. 27 of 2006, which regulates the sale and advertisement of tobacco products and also smoking in public and work areas.

Other Tobacco Surveys The GYTS has previously been conducted in Sri Lanka in 1999, 2003, 2007 and 2011. In addition to the GYTS, the following surveys have been conducted in Sri Lanka: WHO-World Bank study on economics, which described the regional situation analysis on impact of tobacco; biannual surveys using the WHO STEP-wise approach; Global School Personal Survey; and Global Health Professional Survey.

Country-Specific Objectives The country-specific objectives are as follows: •• •• •• Reduce current cigarette use in Sri Lanka in students of 13 to 15 years from 1.5% in 2011 to1.0% in 2015. Reduce current user of other tobacco products other than cigarettes in Sri Lanka in students of 13 to 15 years from 10% in 2011 to 7.5% in 2015. Increase tobacco use cessation requirement in Sri Lanka in students of 13 to 15 years from 80.6% in 2011 to 85% in 2015.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Methods Sampling, sample size and study population

The 2015 Sri Lanka GYTS is a school-based survey that employed a two-stage cluster sample design to produce a national representative sample of students of 13 to 15 years. At the time of the survey, the majority of the youth in ages 13 to 15 years were in grades 8, 9 and 10. During the first-stage sampling, a sampling frame was created containing grades 8, 9 and 10. The description of the different types of government schools in Sri Lanka is as follows: •• •• •• •• Type IAB – Schools that have classes up to Advanced Level (Grade 13) Science Sections Type IC – Schools that have classes up to Advanced Level (Grade 13) but do not have Advanced Level Science Sections Type II – Schools that have classes only up to Ordinary Level (Grade 11) Type III – Schools that have classes only up to grade 8

Type III schools were excluded from the survey as these schools do not contain grades 9, 10 and 11. The study population includes youth who are 13 to 15 years old studying in grades 8, 9 or 10 in government schools. The target sample size was 1500 students in eligible grades with applicable nonresponse rate of 20%. The required number of schools was 30, considering 50 students from each school. There were a total of 972 schools in Type IAB; 1812 schools in Type IC; and 3583 schools in Type II. Within the sampling frame, 30 schools were selected with a probability proportional to school enrollment size. The second sampling stage consisted of systematic equal probability sampling (with a random start) of classes from each school selected during the first stage. Accordingly, 65 classes were selected for the survey. There were 21 classes from Type 1AB; 15 classes from Type IC; and 29 classes from Type II. All students in the selected classes were eligible to participate in the survey. A weighting factor was applied to each student

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

record to adjust for nonresponse and for the varying probabilities of selection. The weight used for estimation is given by: W = W1 * W2 * f1 * f2 * f3 * f4 W1 = the inverse of the probability of selecting the school W2 = the inverse of the probability of selecting the class within the school f1 = a school-level nonresponse adjustment factor calculated by school size category (small, medium, large) f2= a class adjustment factor calculated by school f3 = a student-level nonresponse adjustment factor calculated by class f4 = a post-stratification adjustment factor calculated by gender and grade The 2015 GYTS in Sri Lanka was conducted in 65 classrooms of 30 schools. A total of 1505 students participated, of which 1416 were ages 13 to 15 years (Male: 726, Female: 689, missing: 1). All participants with missing age are excluded. The school response rate was 100%, the class response rate was 100% and the student response rate was 81.9%. The overall response rate was 81.9%. SUDAAN, a software package for statistical analysis of complex survey data, was used to calculate weighted prevalence estimates and standard errors (SE) of the estimates (95% confidence intervals [CI] were calculated from the SEs).

Data collection and variables Data collection took place from mid-October 2015 to mid-November 2015, and was supported by two research assistants who were pre-intern medical officers (MBBS undergraduates who have just passed from the university and were waiting to start their internship). The research assistants were given training on the questionnaire and its administration. A self- administered questionnaire was used to collect the data. The data collection was conducted during the class sessions in the morning hours. The 2nd to 4th periods of the class room sessions were selected while the 1st period was purposefully avoided as late attendants to the class may be missed during the 1st period of the class sessions. The

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

English questionnaire was translated to Sinhalese and Tamil and then back-translated into English to check for accuracy. The translations and back translations were sent to CDC to compare with the original English questionnaire for accuracy. The questionnaires were pre-tested. The questionnaire contained 55 multiple-choice questions. The survey included 43 questions from the core questions and 12 from the optional questions. The questionnaire covered sociodemography, usage, knowledge and attitude, access and availability, secondhand smoking, cessation, media and advertising, and school curriculum regarding tobacco products. A copy of the questionnaire is included in Appendix 1. Permission from the Ministry of Education was granted by the Secretary, Ministry of Education, on the request of the Chairman, NATA, to conduct the survey in schools. Before the conduction of the survey, the Principals of the relevant schools were informed of the survey through NATA and the dates for the survey were informed. On the day of the survey, the research assistants visited the schools to conduct the survey. Informed consent was obtained from the school principal and relevant class teachers. Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Colombo, which was the only WHO accredited Ethics Review Committee in Sri Lanka. Survey procedures were designed to protect students’ privacy by allowing for anonymous and voluntary participation. The self-administered questionnaire was administered in the classroom. Students recorded their responses directly on an answer sheet that could be scanned by a computer.

Data analysis Frequency tables for each survey question are developed that show the number of cases, percentage, and the 95% confidence interval. Preferred tables are also developed highlighting the questions that are considered key tobacco control indicators from the GYTS. Indicators are in accordance with the WHO FCTC and MPOWER technical package.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Results

Geographic distribution of schools, classes and students Table 1. Distribution of selected schools by province Province Total schools Schools selected Classes selected Total students Students selected

IAB Central Eastern Northern North Central North Western Southern Western Uva Total 110 98 95 58 100 142 188 81 972

IC 317 167 112 135 258 179 216 251 177

II 473 363 305 241 514 451 395 523 318

IAB 0 1 2 1 3 0 2 3 0

IC 1 0 0 1 0 1 0 1 2 6

II 2 2 0 2 2 2 1 1 0 12

Number Total Number 8 7 4 10 10 8 6 8 5 66 121342 87267 60240 60757 110920 83614 114108 219418 62316 919982

Number 193 158 119 166 372 166 217 296 141 1828

Percentage % 0.16 0.18 0.20 0.27 0.34 0.20 0.19 0.13 0.23 0.20

Sabaragamuwa 100

1812 3583 12

Sociodemographic profile of students Table 2. Sociodemographic profile of students Sociodemography Number (n=1,416) Percentage %

Sex Male Female Missing Age** 13 Years 14 Year 461 481 34.1 33.9 726 689 1 50.2 49.8 -

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

15 Years Missing School grade Grade 8 Grade 9 Grade 10 Missing School type Type IAB Type IC Type II Missing * *All participants with missing age are excluded

474 00 448 500 468 15 788 443 597 00

32.0 33.9 35.4 30.8 43.1 24.2 32.7 -

Prevalence – Article 20 of WHO FCTC: Research, Surveillance and Exchange of Information Table 3. Percent of students who use tobacco Category Ever smoked cigarettes Current Any Tobacco Users Current Cigarette Smokers Current Smokeless Tobacco Users % (95% CI) Never Tobacco Users Susceptible to Start tobacco in the future % (95% CI)

% (95% CI)

Total Male Female

5.7 (3.5 – 9.0) 1.4 (0.6 – 3.5)

3.7 (2.1 – 6.4) 0.7 (0.3 – 1.4)

1.5 (0.8 – 2.7) 2.4 (1.2 – 4.7) 2.5 (1.6 – 3.9) 0.0 (0.0 – 0.0) 0.5 (0.3 – 1.0) 1.0 (0.4 – 2.7)

10.0 (5.9 – 16.4) 6.7 (3.6 – 12.0) 2.9 (1.5 – 5.5) 4.2 (2.0 – 8.9) 4.3 (2.6 – 7.0)

In Sri Lanka, ever tobacco users (smoked and/or smokeless) were 11.1% (males 17.4% and females 4.9%) while ever smokeless tobacco users were 6.6% (males 10.6% and females 2.6%). There were 5.7% of students reported smoking one or more cigarettes in their lifetime while the figure was 4.7% (males 7.3% and females 2.1%) for “ever” bidi users. Overall, 3.7% reported current tobacco use (at least once in the last 30 days), 1.7% (males 3.2% and females 0.2%) reported currently smoking tobacco, 1.5% reported currently smoking cigarettes, and 2.4% reported using smokeless tobacco in the last 30 days.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

In addition, 2.5% indicated that they were susceptible to start using tobacco in the future while 6.4% of never smokers think they might enjoy smoking a cigarette. Most (65.6%; males 66.6% and females 49.4%*) ever cigarette smokers first tried a cigarette when they were aged between 13 to 15 years. This was also true for bidi (63.7%; males 61.3% and females 100%*) and smokeless tobacco group (57.6%; males 57% and females 64.2%*). Table 4. Percent of students who first tried using tobacco at different age groups Age Category First tried cigarettes First tried bidi First tried smokeless tobacco

% (95% CI) Less than 12 years 12 or 13 years 14 or 15 years Total Male Female Total Male Female Total Male Female 34.4 (24.3 – 46.1) 33.3 (22.4 – 46.5) 50.6 (6.8 – 93.5)* 30.8 (15.5 – 51.8) 31.3 (15.7 – 52.8) 22.0 (2.9 – 72.9)* 34.8 (15.7 – 60.5) 35.3 (16.4 – 60.3) 27.4 (1.8 – 88.5)*

% (95% CI) 36.4 (22.5 – 52.9) 38.7 (24.8 – 54.7) 0.0 (0.0 – 0.0)* 42.7 (27.0 – 59.9) 42.2 (27.0 – 59.0) 50.4 (4.8 – 95.4)* 21.0 (7.8 – 45.2) 19.1 (8.0 – 39.2) 49.6 (4.6 – 95.2)*

% (95% CI) 42.4 (29.1 – 56.9) 43.0 (28.1 – 59.3) 35.8 (4.3 – 87.2)* 27.2 (17.6 – 39.5) 27.5 (18.5 – 38.8) 23.3 (1.7 – 84.6)* 30.4 (17.5 – 47.5) 29.5 (14.0 – 51.9) 40.9 (6.8 – 86.7)*

*Total number of participants in the denominator was less than 35 (n<35)

Among the current smokers, 28.9%* show signs of smoking dependency.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Knowledge and Attitudes – Article 12 of WHO FCTC: Education, Communication, Training and Public Awareness Table 5. Knowledge and attitude of students towards those who smoke Category Percent who think that smoking is difficult to quit once someone starts smoking Percent who think smoking helps people feel comfortable at parties/gatherings Percent who think others smoking is harmful to them

% (95% CI) Total Male Female 13.2 (11.1 – 15.6) 13.6 (10.1 – 18.1) 12.8 (8.4 – 19.0)

% (95% CI) 23.9 (18.8 – 29.9) 26.3 (20.9 – 32.5) 21.5 (14.2 – 31.1)

% (95% CI) 86.2 (81.8 – 89.7) 82.8 (75.8 – 88.1) 89.6 (83.9 – 93.5)

Students reported that 86.9% think smoking can be ceased once someone starts smoking tobacco.

School Curriculum – Article 12 of WHO FCTC: Education, communication, training and public awareness Table 6. Students who received education on tobacco through school curriculum Category Percent who had been taught in class during the past year about the dangers of tobacco use

(95% CI) Total Male Female 78.9 (71.8 –84.6) 76.3 (66.5 – 83.9) 81.5 (72.5 – 88.0)

In the past year, 78.9% had been taught in class about the dangers of smoking.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Access and Availability – Article 20 of WHO FCTC: Research, Surveillance and Exchange of Information Table 7. Accessibility of students for smoking Category Percent of current smokers who usually smoke at a friend’s house* Percent of current smokers who buy cigarettes in a store*

% (95% CI) Total Male 10.4 (2.8 – 319) 10.4 (2.8 – 319)

% (95% CI) 20.5 (6.7 – 48.3) 20.5 (6.7 – 48.3)

*Total number of participants in the denominator was less than 35 (n<35) **All figures are zero for females

Of current smokers, 10.4%* usually smoke at a friend’s house and 20.5%* of current smokers buy cigarettes in a store. None of them smoke at their own homes or school. Most (62.1%*) have bought cigarettes as individual sticks while 21.6%* bought tobacco and rolled their own. Among current cigarette smokers, 36.9%* were not prevented from buying cigarettes because of their age. The majority (51.1%*) of current cigarette smokers obtain the cigarettes from someone else.

Secondhand Smoke - Article 8 of WHO FCTC: Protection from Exposure to Tobacco Smoke Table 8. The exposure of students for secondhand smoking in the past 7 days Category Percent of youth exposed to tobacco smoke at home Percent of youth exposed Percent of youth exposed to tobacco smoke in to tobacco smoke in enclosed public places outdoor public places

% (95% CI) Total Male Female 13.4 (9.6 – 18.5) 13.9 (9.3 – 20.1) 13.0 (9.3 – 18.0)

% (95% CI) 35.7 (32.8 – 38.7) 39.6 (34.7 – 44.7) 31.7 (27.5 – 36.2)

% (95% CI) 34.6 (31.8 – 37.5) 37.4 (31.8 – 43.3) 31.7 (27.0 – 36.9)

From the participants, 13.4 % lived in households where others smoked, and 35.7 % were around others who smoked in enclosed public places, whereas 30.1% (36.6%

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

males and 23.6% females) have seen someone smoking inside the school building or outside on school property in the past 30 days. Table 9. Students’ attitude on secondhand smoking Category Percent who think smoking should be banned from enclosed public places Percent who think smoking should be banned from outdoor public places

(95% CI) Total Male Female 96.4 (95.2 – 97.3) 95.7 (93.7 – 97.1) 97.3 (95.6 – 98.4)

(95% CI) 93.3 (91.6 – 94.7) 91.9 (89.5 – 93.8) 94.8 (92.1 – 96.6)

Regarding environmental tobacco smoke, 96.4% thought that smoking should be banned from enclosed public places and 93.3 % thought it should be banned from outdoor public places. Table 10 Students with family members who smoke Category Percent who have one or more parents who smoke Percent who have close friends who smoke tobacco

(95% CI) Total Male Female 15.3 (12.2 – 18.9) 14.1 (10.3 – 19.1) 16.5 (13.6 – 19.8)

(95% CI) 14.8 (10.3-20.7) 22.6 (15.3-32.0) 6.9 (4.4-10.6)

In their personal lives, 15.3 % of students reported they have one or more parents who smoke.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Cessation – Article 14 of WHO FCTC: Demand Reduction Measures Concerning Tobacco Dependence and Cessation Table 11. Cessation information of students who smoke Category Percent of current Percent of current smokers who want to stop smokers who tried to stop smoking* smoking during the past year* Percent of current smokers who have received help from a programme or professional to stop smoking*

(95% CI) Total Male 76.9 (24.2 – 97.2) 76.9 (24.2 – 97.2)

(95% CI) 83.9 (42.8 – 97.3) 83.9 (42.8 – 97.3)

(95% CI) 25.0 (11.4 – 46.4) 25.0 (11.4 – 46.4)

*Total number of participants in the denominator was less than 35 (n<35) **All figures are zero for females

Of current smokers, 76.9%* reported that they want to stop smoking, and 83.9%* tried to stop smoking within the past year. Regarding cessation attempts, 25.0%* of current smokers report that they have received help from a programme or professional to stop smoking.

Media and Advertising – Article 13 of WHO FCTC: Tobacco Advertising, Promotion and Sponsorship Table 12. Exposure of students on media advertising Category Percent who saw anti-tobacco media messages in the past 30 days* Percent who saw anyone using tobacco on television, video or movies* Percent of youth who saw tobacco marketing at points of sale in the past 30 days* Percent current smokers who noticed health warnings on cigarette packages in the past 30 days*

% (95% CI) Total Male Female 88.0 (84.5 – 90.8) 88.5 (83.8 – 91.9) 87.6 (82.6 – 91.3)

% (95% CI) 83.1 (77.6-87.5) 85.0 (78.2-89.9) 81.2 (74.5-86.4)

% (95% CI) 44.6 (37.7 – 51.7) 47.5 (41.3 – 53.7) 41.6 (31.6 – 52.2)

% (95% CI) 91.6 (73.0 – 97.8) 96.2 (77.3 – 99.5) 0.0 (0.0 – 0.0)

*Total number of participants in the denominator was less than 35 (n<35)

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

In the past 30 days, 88.0% saw anti-tobacco media messages while 83.1% reported that they saw tobacco use on television, video or movies and 44.6% reported that they saw tobacco marketing at points of sale in the past 30 days. Among the current smokers, 61.7%* had thought about quitting smoking because of health warnings on cigarette packages while 37.3% of never smokers thought about not starting to smoke because of the health warnings on cigarette packages. Table 13. Exposure of students on tobacco company advertising Category Percent who have an object with a tobacco product brand logo Percent who were offered free tobacco product by a tobacco company representative

% (95% CI) Total Male Female 2.9 (1.8 – 4.5) 3.8 (2.2 – 6.6) 1.9 (1.1 – 3.6)

% (95% CI) 2.0 (1.2 – 3.5) 2.9 (1.7 – 4.9) 1.2 (0.4 – 3.4)

Up to 2.9% reported that they have an object with a tobacco brand logo, and 2.0% have been offered one or more free tobacco products by a tobacco company representative. Among never tobacco users, 5.5% owns something with a tobacco product brand logo/picture. Also 96.2% indicated that if one of their best friends’s offered a tobacco product they definitely will not use it.

*Total number of participants in the denominator was less than 35 (n<35)

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Discussion Summary of Results Prevalence, Cessation, and Addiction

In Sri Lanka, 3.7% used any type of tobacco product whereas 1.7% were tobacco smokers. Out of the current smokers, 83.9%* reported that they have tried to quit smoking during the previous year. However, 62.2% believed that it was definitely or probably not difficult to quit smoking once someone starts smoking. Out of the never tobacco users, 2.5% indicated that they were susceptible to begin smoking in the future.

Gender Differences A significant gender difference was observed in consumption of tobacco products (Table 3). Males were significantly more likely to have smoked one or more cigarettes and to be current smokers. The lower smoking rates observed among females can be attributed to the cultural factors discouraging females to use tobacco.

Harmful Effects of Smoking Harmful effects of smoking are well known and well documented. The tobacco epidemic kills 5.4 million people a year from lung cancer, heart disease and other illnesse.14 The younger the person is when he or she first tries smoking, the more likely he/she is to be regular smokers and the less likely to quit.15-19 Younger people are still unaware of the harmful effects of smoking. Schools are integral to educating youths about the dangers of tobacco use but in Sri Lanka, only 78.9% of youths surveyed had been taught in class about the dangers of smoking during the previous year. Strengthening education is a focus of the FCTC. Educators are specifically identified as important sources of information about the dangers of tobacco use for their students.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Public Awareness and Dangers of Smoking In Sri Lanka, a number of programmes have been initiated to raise awareness of the dangers of tobacco smoking. Many of these programmes directly target the youth. However, this information has been diffused with other contradicting messages, which portray positive images of smoking and using tobacco products, such as pro-cigarette advertisements in newspapers, magazines and billboards. In Sri Lanka, although 88.0% of youths reported seeing anti-smoking media messages in the previous 30 days, as many as 44.6% reported seeing tobacco marketing at points of sale in the past 30 days. As many as 2.9% of the students owned an item with a cigarette brand logo and 2.0% have been offered a free cigarette by tobacco company representative.

Regulations in Country to Control Tobacco Use in Youths In Sri Lanka, the National Authority on Tobacco and Alcohol Act No. 27of 2006 is in place to restrict the sale and use of tobacco products in youths. Despite having laws to control sale of tobacco products to youth, all of the students enrolled in this survey who used tobacco were under the age of 18. In addition, among the current cigarette users, 20.5%* indicated that they were able to buy their cigarettes from a store.

Secondhand Smoke In Sri Lanka, the National Authority on Tobacco and Alcohol Act No. 27of 2006 is in place to regulate tobacco smoking in public areas to prevent secondhand smoking. The results of this survey showed that 86.2% of youth surveyed believed that secondhand smoke could be harmful to them. Further, 96.4% believed that smoking should be banned from public places. It is important to educate youth on the dangers of tobacco use, particularly the risks associated with secondhand smoke.

*Total number of participants in the denominator was less than 35 (n<35)

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Comparison with Previous Tobacco Surveys Table14. Comparisons with various tobacco use and tobacco control indicators of previous GYTS surveys in Sri Lanka from 1999 to 2015 Questions 1999 % 2003 % 2007 % 2011 % 2015 %

(95% CI) Tobacco use Ever smoked cigarettes Current cigarette smokers Current use of other tobacco products Never smokers likely to initiate smoking in the next year Exposure to smoke One or more parents smoke Exposed to smoke in public places In favour of banning smoking in public places Media/Advertising Have an object with a cigarette brand logo Ever offered a free cigarette by a cigarette company representative Cessation Want to stop smoking now School During the past year taught in class about the dangers of smoking (59.3 – 66.0) (61.8 – 89.7) (8.9 – 12.3) (5.3 – 7.7) (47.8 – 53.8) (64.5 – 71.2) (9.4 – 15.4) (2.8 – 5.8) (6.1 – 8.4) (4.2 – 6.4)

(95% CI) 6.3 2.4 7.0 4.6

(95% CI) 5.1 1.2 8.6 (6.4 – 11.5) (2.4 – 5.6)

(95% CI) 6.5 1.5

(95% CI) 5.7 1.5 2.7 2.5 (1.6 – 3.9)

12.1 4.0 7.2 5.1

(4.6 – 8.5) (1.5 – 3.7) (5.4 – 8.9) (3.5 – 6.1)

(2.9 – 9.0) (0.5 – 2.9)

(4.9 – 8.6) (1.0 – 2.5) (8.5 – 11.6) (2.6 – 4.4)

(3.5 – 9.0) (0.8 – 2.7) (1.4 – 5.2)

10.0 3.4

3.7

50.8 67.9 91.4

(37.2 – 45.4) (64.9 – 71.4)

41.2 68.3 93.0

(25.6 – 34.5) (62.1 – 69.5) (83.1 – 91.5)

29.9 65.9 87.9

(26.7 – 30.8) (39.8 – 45.1)** (86.8 – 90.6)

28.7 42.5 88.9

(12.2 – 18.9) (32.8 – 38.7)** (95.2 – 97.3)

15.3 35.7 96.4

(88.6 – 93.6)

(90.9 – 94.7)

10.5 6.4

(9.3 – 12.9) (4.7 – 7.5)

11.0 5.9

(4.1 – 7.9) (1.7 – 5.0)

5.7 3.0

(3.8 – 5.5) (2.3 – 3.8)

4.6 2.9

(1.8 – 4.5) (1.2 – 3.5)

2.9 2.0

79.0

(49.1 – 89.1)

73.7

(56.8 – 88.9)

76.5

(55.9 –93.2)

80.6

(24.2 – 97.2)*

76.9

62.7

(75.8 – 83.3)

79.8

(67.1 – 77.8)

72.8

(66.2 – 72.8)

69.6

(71.8 –84.6)

78.9

*Total number of participants in the denominator was less than 35 (n<35) **Enclosed public places

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Relevance to WHO FCTC/WHO MPOWER The results of this GYTS are critical for gauging progress toward WHO FCTC and MPOWER implementation and adaption. Sri Lanka’s participation in GYTS addresses the first element of MPOWER (Monitor tobacco use and prevention policies), and also GYTS asks students a range of questions that spans many of the remaining elements of MPOWER. The resulting data are critical for measuring Sri Lanka’s progress towards fully implementing the elements of MPOWER among its youth. The information provided by GYTS can address several provisions of the FCTC that relate to the role of school personnel and the comprehensive school tobacco control policy.

Highlights •• Protecting people from tobacco smoke The GYTS data show that 35.7% of students are exposed to secondhand smoke because of people who smoked in enclosed public places, and 13.4% live in homes where others smoke in their presence. •• Offer help to quit tobacco use Results from GYTS show that students who currently smoke are interested in quitting. Of students who currently smoke: –– –– –– •• 76.9%* want to stop smoking. 83.9%* tried to stop smoking in the past year. 25.0%* have ever received help from a programme or professional to stop smoking.

Warn about the dangers of tobacco During the past year, 78.9% of students had been taught in class about the dangers of smoking.

••

Enforce bans on tobacco advertising, promotion, and sponsorship The GYTS data show that 88.0% of students saw anti-smoking media messages in the past 30 days. But, in the past 30 days, 44.6% saw tobacco

*Total number of participants in the denominator was less than 35 (n<35)

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

marketing at points of sale. Further, 2.9% of students have an object with a cigarette brand logo and 2.0% were offered free cigarettes by a tobacco company representative. Among the current smokers, 91.6%* had noticed health warnings on cigarette packages in the past 30 days while 56.5%* of them had thought about quitting smoking because of health warnings on cigarette packages while 37.3% of never smokers thought about not starting to smoke because of the health warnings on cigarette packages. •• Reduce the availability and accessibility for tobacco Among the current cigarette smokers, 20.5%* buy cigarettes directly from the store. •• Reduce the prevalence of tobacco use The GYTS data indicate 3.7% as tobacco users. While current smokers were 1.7%, current smokeless tobacco users were 2.4%. The never smokers susceptible to start smoking in the next year was 2.5%. GYTS methodology provides an excellent framework for monitoring and guiding the implementation of school tobacco control programmes and other comprehensive tobacco control strategies while making it compliant with the requirements of FCTC. The results of this survey will be disseminated broadly and ideally used to adopt and implement effective legislative measures for preventing and reducing tobacco consumption, nicotine addiction and exposure to tobacco smoke.

*Total number of participants in the denominator was less than 35 (n<35)

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Conclusions ••

Many youths have expressed willingness to quit tobacco smoking. Some have received help to quit smoking, but the staff in cassation programmes are not trained in any way to assist these students to achieve their objective. Perceived susceptibility to begin smoking in the next year seems to have declined a little compared with 2011 figures, but there are no active school-based programmes to prevent tobacco use among students. The data suggest an early age of initiation of cigarette usage among adolescents. Tobacco control education therefore needs to start at a very young age. However, very limited levels of tobacco-related issues are currently discussed in the formal school curriculum. Secondhand smoking continues to be a problem in spite of the strict legal measures that have been adopted. Adolescents are faced with the double burden of cigarette use and the use of other forms of tobacco products such as beetle chewing with tobacco. Direct accessibility to the sources is still available regardless of the laws to prevent the sale of tobacco products to minors. Students are being exposed to pro-smoking media campaigns. It is important to control this exposure. Despite the existence of much information on tobacco control, a significant information gap exists on tobacco use in this country.

••

•• •• •• •• ••

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Recommendations •• ••

Increase research on the rising use of tobacco products other than cigarettes among youths to understand this alarming new trend. Consider tobacco control policies on the influence of tobacco advertising, high smoking rates among adults (including those that serve as role models for young people), availability of affordable and easily accessible tobacco products, and unrestricted smoking in public places on the likelihood of children taking up tobacco use. Increase awareness and effective enforcement of existing tobacco control policies needs to be endured. For example, the law already in place on ban of sale of tobacco products to persons aged below 21 years needs to be disseminated further. Intensify awareness campaigns on the dangers of tobacco use. Institutionalize regular and sustained school-based programmes to prevent youth from initiating tobacco use. Develop appropriate anti-tobacco media strategies to reach out to youth both in urban and rural areas. Locate dedicated resources through development partners and other stakeholders to supplement limited government funding for tobacco control by the government. Build capacity of the health system for providing support for tobacco cessation, with focused policies for youth. Popularize life--course approach for tobacco control by encouraging integration into NCD programmes for synergistic effect. Rope in departments other than health into overall tobacco control strategies implementation.

••

•• •• •• ••

•• •• ••

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

References 1.

Fernandez E, Schiaffino A, La Vecchia C, Borras JM, Nebot M, Salto E, et al. Age at starting smoking and number of cigarettes smoked in Catalonia, Spain. Prev Med. 1999 Apr;28(4):361-6. D’Avanzo B, La Vecchia C, Negri E. Age at starting smoking and number of cigarettes smoked. Ann Epidemiol. 1994 Nov;4(6):455-9. United States Department of Health and Human Services.Preventing tobacco use among youth and young adults: a report of the surgeon general, 2012.. Washington, D.C.: Dept. of Education, 1995. News Release. National accounts estimates of Sri Lanka: 4th Quarter of 2015 and the whole year of 2015. Colombo: The Department of Census and Statistics, Ministry of National Policy and Economic Affairs, 2016. Central Bank of Sri Lanka. Economic and social statistics of Sri Lanka 2013. Colombo, 2013. Ministry of Health, Sri Lanka. Annual health bulletin 2013. Colombo, 2015. World Health Organization. WHO framework convention on tobacco control. Geneva, 2005. Ministry of Health, Sri Lanka. Cancer incidence data: Sri Lanka Year 2001-2005. Colombo: National Cancer Control Programme, 2009. Ministry of Healthcare and Nutrition, Sri Lanka. Brief profile on tobacco control in Sri Lanka. Colombo, 2009.

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5. 6. 7. 8. 9.

10. Gunasekara PW, Rahman K, Sinha DN, Warren CW, Lee J, Lea V, Asma S. Tobacco use among students aged 13-15 Years in Sri Lanka, 1999—2007. Morbidity and Mortality Weekly Review. 2008 May; 57(20):545-549.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

11. Gunasekara PW. Repot of the global youth tobacco survey (GYTS) and global school personnel survey (GSPS): Sri Lanka. New Delhi: World Health Organization Regional Office for South East Asia, 1999. 12. Gunasekara PW. Report on the results of the Global Youth Tobacco Survey (GYTS – Repeat), Sri Lanka 2003. New Delhi: World Health Organization Regional Office for South East Asia, 2003. 13. World Health Organization, Regional Office for South-East Asia. Global youth tobacco survey (GYTS) Sri Lanka 2011 (Ages 13-15). http://www.searo.who.int/ entity/noncommunicable_diseases/data/srl_gyts_fs_2011.pdf – accessed 9 August 2015. 14. World Health Organization. MPOWER: a policy package to reverse the tobacco epidemic. Geneva, 2008. 15. Khuder SA, Dayal HH, Mutgi AB. Age at smoking onset and its effect on smoking cessation. Addictive Behaviors. 1999;24(5):673–677. 16. D’Avanzo B, La Vecchia C, Negri E. Age at starting smoking and number of cigarettes smoked. Annals of Epidemiology. 1994;4(6):455–459. 17. Chen J, Millar WJ. Age of smoking initiation: implications for quitting. Health Reports. 1998;9(4):39–46. 18. Everett SA, Warren CW, Sharp D, Kann L, Husten CG, Crossett LS. Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students. Preventive Medicine. 1999;29(5):327–333. 19. Breslau N, Peterson EL. Smoking cessation in young adults: age at initiation of cigarette smoking and other suspected influences. American Journal of Public Health. 1996 February;86(2):214–220.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Annexes

Annex 1

Questionnaire Q1. How old are you? a. 11 years old or younger b. 12 years old c. 13 years old d. 14 years old e. 15 years old f. 16 years old g. 17 years old or older Q2. What is your sex? a. Male b. Female Q3. In what grade/form are you? a. Grade 8 b. Grade 9 c. Grade 10

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q4.

During an average week, how much money do you have that you can spend on yourself, however you want? a. I usually don’t have any spending money b. Less than Rs. 250/= c. Between Rs. 250/= to Rs. 500/= d. Between Rs. 501/= to Rs. 750/= e. Between Rs. 751/= to Rs. 1000/= f. Between Rs. 1001/= to Rs. 1500/= g. More than Rs. 1500/=

Q5.

Have you ever tried or experimented with cigarette smoking, even one or two puffs? a. Yes b. No

Q6.

How old were you when you first tried a cigarette? a. I have never tried smoking a cigarette b. 7 years old or younger c. 8 or 9 years old d. 10 or 11 years old e. 12 or 13 years old f. 14 or 15 years old g. 16 years old or older

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q7.

During the past 30 days, on how many days did you smoke cigarettes? a. 0 days b. 1 or 2 days c. 3 to 5 days d. 6 to 9 days e. 10 to 19 days f. 20 to 29 days g. All 30 days

Q8.

Please think about the days you smoked cigarettes during the past 30 days. How many cigarettes did you usually smoke per day? a. I did not smoke cigarettes during the past 30 days b. Less than 1 cigarette per day c. 1 cigarette per day d. 2 to 5 cigarettes per day e. 6 to 10 cigarettes per day f. 11 to 20 cigarettes per day g. More than 20 cigarettes per day

Q9.

Have you ever tried or experimented with any form of smoked tobacco products other than cigarettes (such as pipes, cigars, little cigars, cigarillos, water pipe, bidis)? a. Yes b. No

Q10. During the past 30 days, did you use any form of smoked tobacco products other than cigarettes (such as pipes, cigars, little cigars, cigarillos, water pipe, bidis)? a. Yes b. No

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q11. Do you ever smoke tobacco or feel like smoking tobacco first thing in the morning? a. I don’t smoke tobacco b. No, I don’t smoke tobacco or feel like smoking tobacco first thing in the morning c. Yes, I sometimes smoke tobacco or feel like smoking tobacco first thing in the morning d. Yes, I always smoke tobacco or feel like smoking tobacco first thing in the morning Q12. How soon after you smoke tobacco do you start to feel a strong desire to smoke again that is hard to ignore? a. I don’t smoke tobacco b. I never feel a strong desire to smoke again after smoking tobacco c. Within 60 minutes d. 1 to 2 hours e. More than 2 hours to 4 hours f. More than 4 hours but less than one full day g. 1 to 3 days h. 4 days or more Q13. Where do you usually smoke? (SELECT ONLY ONE RESPONSE) a. I do not smoke b. At home c. At school d. At work e. At friends’ houses f. At social events g. In public spaces (e.g. parks, shopping centers, street corners) h. Other

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q14. Have you ever tried or experimented with bidi smoking, even one or two puffs? a. Yes b. No Q15. How old were you when you first tried smoking a bidi? a. I have never tried smoking a bidi b. 7 years old or younger c. 8 or 9 years old d. 10 or 11 years old e. 12 or 13 years old f. 14 or 15 years old g. 16 years old or older Q16. Have you ever tried or experimented with any form of smokeless tobacco products (such as chewing tobacco, baabul, snuff, dip, tobacco with betel quid)? a. Yes b. No Q17. During the past 30 days, did you use any form of smokeless tobacco products (such as chewing tobacco, baabul, snuff, dip, tobacco with betel quid)? a. Yes b. No Q18. How old were you when you first tried using smokeless tobacco (such as chewing tobacco, baabul, snuff, dip, tobacco with betel quid)? a. I have never tried using smokeless tobacco b. 7 years old or younger c. 8 or 9 years old d. 10 or 11 years old e. 12 or 13 years old f. 14 or 15 years old g. 16 years old or older

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q19. During the past 30 days, on how many days did you use smokeless tobacco (such as chewing tobacco, baabul, snuff, dip, tobacco with betel quid)? a. 0 days b. 1 or 2 days c. 3 to 5 days d. 6 to 9 days e. 10 to 19 days f. 20 to 29 days g. All 30 days Q20. Do you want to stop smoking now? a. I have never smoked b. I don’t smoke now c. Yes d. No Q21. During the past 12 months, did you ever try to stop smoking? a. I have never smoked b. I did not smoke during the past 12 months c. Yes d. No Q22. Do you think you would be able to stop smoking if you wanted to? a. I have never smoked b. I don’t smoke now c. Yes d. No

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q23. Have you ever received help or advice to help you stop smoking? (SELECT ONLY ONE RESPONSE) a. I have never smoked b. Yes, from a program or professional c. Yes, from a friend d. Yes, from a family member e. Yes, from both programs or professionals and from friends or family members f. No Q24. How long ago did you stop smoking? a. I have never smoked b. I have not stopped smoking c. 1-3 months d. 4-11 months e. One year f. 2 years g. 3 years or longer Q25. What was the main reason you decided to stop smoking? (SELECT ONE RESPONSE ONLY) a. I have never smoked b. I have not stopped smoking c. To improve my health d. To save money e. Because my family does not like it f. Because my friends do not like it g. Other

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q26. During the past 7 days, on how many days has anyone smoked inside your home, in your presence? a. 0 days b. 1 to 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days Q27. During the past 7 days, on how many days has anyone smoked in your presence, inside any enclosed public place, other than your home (such as schools, shops, restaurants, shopping malls, movie theaters, buses, streetcars, trains, gyms, sports arenas, discos)? a. 0 days b. 1 to 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days Q28. During the past 7 days, on how many days has anyone smoked in your presence, at any outdoor public place (such as playgrounds, sidewalks, entrances to buildings, parks, beaches)? a. 0 days b. 1 to 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days Q29. During the past 30 days, did you see anyone smoke inside the school building or outside on school property? a. Yes b. No

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q30. Do you think the smoke from other people’s tobacco smoking is harmful to you? a. Definitely not b. Probably not c. Probably yes d. Definitely yes Q31. Are you in favor of banning smoking inside enclosed public places (such as schools, shops, restaurants, shopping malls, movie theaters, buses, streetcars, trains, gyms, sports arenas, discos)? a. Yes b. No Q32. Are you in favor of banning smoking at outdoor public places (such as playgrounds, sidewalks, entrances to buildings, parks, beaches)? a. Yes b. No Q33. The last time you smoked cigarettes during the past 30 days, how did you get them? (SELECT ONLY ONE RESPONSE) a. I did not smoke any cigarettes during the past 30 days b. I bought them in a store or shop c. I bought them from a street vendor d. I got them from someone else e. I got them some other way Q34. During the past 30 days, did anyone refuse to sell you cigarettes because of your age? a. I did not try to buy cigarettes during the past 30 days b. Yes, someone refused to sell me cigarettes because of my age c. No, my age did not keep me from buying cigarettes

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q35. The last time you bought cigarettes during the past 30 days, how did you buy them? a. I did not buy cigarettes during the past 30 days b. I bought them in a pack c. I bought individual sticks (singles) d. I bought them in a carton e. I bought them in rolls f. I bought tobacco and rolled my own

Q36. On average, how much do you think a pack of 20 cigarettes costs? a. Between Rs. 100/= to Rs. 200/= b. Between Rs. 201/= to Rs. 300/= c. Between Rs. 301/= to Rs. 400/= d. Between Rs. 401/= to Rs. 500/= e. Between Rs. 501/= to Rs. 600/= f. Between Rs. 601/= to Rs. 700/= g. Between Rs. 701/= to Rs. 800/= h. I don’t know Q37. During the past 30 days, did you see or hear any anti-tobacco media messages on television, radio, internet, billboards, posters, newspapers, magazines, or movies? a. Yes b. No Q38. During the past 30 days, did you see or hear any anti-tobacco messages at sports events, fairs, concerts, or community events, or social gatherings? a. I did not go to sports events, fairs, concerts, or community events, or social gatherings in the past 30 days

b. Yes c. No

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q39. During the past 30 days, did you see any health warnings on cigarette packages? a. Yes, but I didn’t think much of them b. Yes, and they led me to think about quitting smoking or not starting smoking c. No Q40. During the past 12 months, were you taught in any of your classes about the dangers of tobacco use? a. Yes b. No c. I don’t know Q41. During the past 30 days, did you see any people using tobacco on TV, in videos, or in movies? a. I did not watch TV, videos, or movies in the past 30 days b. Yes c. No Q42. During the past 30 days, did you see any advertisements or promotions for tobacco products at points of sale (such as stores, shops, kiosks, etc.)? a. I did not visit any points of sale in the past 30 days b. Yes c. No Q43. Would you ever use or wear something that has a tobacco company or tobacco product name or picture on it such as a lighter, t-shirt, hat, or sunglasses? a. Yes b. Maybe c. No

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q44. Do you have something (for example, t-shirt, pen, backpack) with a tobacco product brand logo on it? a. Yes b. No Q45. Has a person working for a tobacco company ever offered you a free tobacco product? a. Yes b. No Q46. If one of your best friends offered you a tobacco product, would you use it? a. Definitely not b. Probably not c. Probably yes d. Definitely yes Q47. At anytime during the next 12 months do you think you will use any form of tobacco? a. Definitely not b. Probably not c. Probably yes d. Definitely yes Q48. Once someone has started smoking tobacco, do you think it would be difficult for them to quit? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q49. Do you think smoking tobacco helps people feel more comfortable or less comfortable at celebrations, parties, or in other social gatherings? a. More comfortable b. Less comfortable c. No difference whether smoking or not Q50. Do you agree or disagree with the following: “I think I might enjoy smoking a cigarette.” a. I currently smoke cigarettes b. Strongly agree c. Agree d. Disagree e. Strongly disagree Q51. Do your parents smoke tobacco? a. None b. Both c. Father only d. Mother only e. Don’t know Q52. Do any of your closest friends smoke tobacco? a. None of them b. Some of them c. Most of them d. All of them

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Q53. Do you think smoking tobacco is harmful to your health? a. Definitely not b. Probably not c. Probably yes d. Definitely yes Q54. Do you think it is safe to smoke tobacco for only a year or two as long as you quit after that? a. Definitely not b. Probably not c. Probably yes d. Definitely yes Q55. During the past 12 months, were you taught in any of your classes about the effects of using tobacco like it makes your teeth yellow, causes wrinkles, or makes you smell bad? a. Yes b. No c. Not sure

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Annex 2

Core GYTS indicators The core GYTS indicators are described in detail in this chapter. This includes the indicators provided in the GYTS Fact Sheet Template and GYTS Country Report Template. The GYTS Fact Sheet is intended to provide an overview of the key findings and highlights of the survey for a broad audience. The GYTS Country Report provides an opportunity to examine the core indicators and other findings in more detail and to describe the results in the context of each country’s unique tobacco control environment. Tobacco use Ever tobacco users Ever tobacco smokers Indicator: Percentage of youth who ever smoked any tobacco products. Numerator: Number of respondents who tried or experimented with cigarette smoking or any smoked tobacco products other than cigarettes. Denominator: Total number of respondents. Ever cigarette smokers Indicator: Percentage of youth who ever smoked cigarettes. Numerator: Number of respondents who tried or experimented with cigarette smoking, even one or two puffs. Denominator: Total number of respondents.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Ever smokers of other products Indicator: Percentage of youth who ever smoked tobacco products other than cigarettes. Numerator: Number of respondents who tried or experimented with any smoked tobacco products other than cigarettes. Denominator: Total number of respondents. Ever smokeless tobacco users Indicator: Percentage of youth who ever used any smokeless tobacco products. Numerator: Number of respondents who tried or experimented with any smokeless tobacco products. Denominator: Total number of respondents. Ever tobacco users Indicator: Percentage of youth who ever used any tobacco products. Numerator: Number of respondents who tried or experimented with cigarettes or any other smoked tobacco products or any smokeless tobacco products. Denominator: Total number of respondents. Current tobacco smokers Indicator: Percentage of youth who currently smoke any tobacco products. Numerator: Number of respondents who smoked cigarettes or any other smoked tobacco products in the past 30 days. Denominator: Total number of respondents. Current cigarette smokers Indicator: Percentage of youth who currently smoke cigarettes. Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days. Denominator: Total number of respondents.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Frequent cigarette smokers Indicator: Percentage of youth who smoked cigarettes on 20 or more days of the past 30 days. Numerator: Number of respondents who smoked cigarettes on 20 or more days of the past 30 days. Denominator: Total number of respondents. Current smokers of other products Indicator: Percentage of youth who currently smoke tobacco products other than cigarettes. Numerator: Number of respondents who smoked tobacco products other than cigarettes during the past 30 days. Denominator: Total number of respondents. Current smokeless tobacco users Indicator: Percentage of youth who currently use smokeless tobacco products. Numerator: Number of respondents who used any smokeless tobacco products in the past 30 days. Denominator: Total number of respondents. Current tobacco users Indicator: Percentage of youth who currently use any tobacco products. Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days or smoked any tobacco products other than cigarettes in the past 30 days or used any smokeless tobacco products in the past 30 days. Denominator: Total number of respondents.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Susceptibility to future tobacco use Indicator: Percentage of never tobacco users who are susceptible to using tobacco in the future. Numerator: Number of respondents who have never used any tobacco products who answered: 1) ”Definitely Yes”, ”Probably Yes”, or ”Probably Not” to using tobacco if one of their best friends offered it to them, or 2) ”Definitely Yes”, ”Probably Yes”, or ”Probably Not” to using tobacco during the next 12 months. Denominator: Number of never tobacco users. Susceptibility to cigarette smoking Indicator: Percentage of never smokers who think they might enjoy smoking a cigarette. Numerator: Number of respondents who have never smoked tobacco who Strongly Agree or Agree with the statement “I think I might enjoy smoking a cigarette”. Denominator: Number of never smokers. Number of cigarettes smoked per day Indicator: Percentage of current cigarette smokers who usually smoke [less than 1; 1; 2 to 5; 6 to 10; 11 to 20; more than 20] cigarettes per day, on the days they smoke. Numerator: Number of current cigarette smokers who reported usually smoking [less than 1; 1; 2 to 5; 6 to 10; 11 to 20; more than 20] cigarettes per day on the days they smoked in the past 30 days. Denominator: Number of current cigarette smokers. Age at cigarette smoking initiation Indicator: Percentage of ever cigarette smokers who first tried a cigarette at the age of [7 or younger; 8 or 9; 10 or 11; 12 or 13; 14 or 15] years old. Numerator: Number of ever cigarette smokers who reported trying a cigarette at the age of [7 or younger; 8 or 9; 10 or 11; 12 or 13; 14 or 15] years old. Denominator: Number of ever cigarette smokers.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Smoking dependency Indicator: Percentage of current smokers who are showing signs of smoking dependence. Numerator: Number of current smokers who sometimes or always smoke or feel like smoking tobacco first thing in the morning OR start to feel a strong desire to smoke again within one full day after smoking. Denominator: Number of current smokers. Cessation Attempt to stop smoking in the past 12 months Indicator: Percentage of current smokers who tried to stop smoking during the past 12 months. Numerator: Number of current smokers who tried to stop smoking during the past 12 months. Denominator: Number of current smokers. Desire to stop smoking Indicator: Percentage of current smokers who want to stop smoking. Numerator: Number of current smokers who want to stop smoking now. Denominator: Number of current smokers. Ability to stop smoking Indicator: Percentage of current smokers who think they would be able to stop smoking. Numerator: Number of current smokers who think they would be able to stop smoking if they wanted to. Denominator: Number of current smokers. Received help to stop smoking Indicator: Percentage of current smokers who have received help/advice to stop smoking from a programme or professional.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Numerator: Number of current smokers who received any help/advice from a program or professional to help them stop smoking. Denominator: Number of current smokers. Secondhand smoke Exposure to secondhand smoke at home Indicator: Percentage of youth who were exposed to tobacco smoke at home in the past seven days. Numerator: Number of respondents who reported that smoking occurred in their presence inside their home on one or more days in the past seven days. Denominator: Total number of respondents. Exposure to secondhand smoke in enclosed public places Indicator: Percentage of youth who were exposed to tobacco smoke in enclosed public places in the past seven days. Numerator: Number of respondents who reported that smoking occurred in their presence in any enclosed public place other than their home (such as schools, shops, restaurants, shopping malls, and movie theatres) in the past seven days. Denominator: Total number of respondents. Exposure to secondhand smoke at outdoor public places Indicator: Percentage of youth who were exposed to tobacco smoke at outdoor public places in the past seven days. Numerator: Number of respondents who reported that smoking occurred in their presence at any outdoor public place other than their home (such as playgrounds, sidewalks, entrance of buildings, parks, and beaches) in the past seven days. Denominator: Total number of respondents. Exposure to secondhand smoke at school Indicator: Percentage of youth who saw anyone smoking inside the school building or outside on school property in the past 30 days.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Numerator: Number of respondents who saw someone smoke inside the school building or outside on school property during the past 30 days. Denominator: Total number of respondents. Access and availability Source for obtaining cigarettes Indicator: Percentage of current cigarette smokers who last obtained cigarettes from various sources in the past 30 days. Numerator: Number of current cigarette smokers who last obtained cigarettes by [purchasing from a store or shop; purchasing from a street vendor; purchasing from a kiosk; purchasing from a vending machine; getting them from someone else; getting them some other way]. Denominator: Number of current cigarette smokers. Obtaining cigarettes from a person-to-person retail purchase Indicator: Percentage of current cigarette smokers who last obtained cigarettes by purchasing them from a store, shop, street vendor, or kiosk in the past 30 days. Numerator: Number current cigarette smokers who last obtained cigarettes by purchasing them from a store, shop, street vendor, or kiosk in the past 30 days. Denominator: Number of current cigarette smokers. Minors’ access to purchasing cigarettes Indicator: Percentage of current cigarette smokers who were not prevented from buying cigarettes in the past 30 days because of their age. Numerator: Number of current cigarette smokers who were not prevented from buying cigarettes in the past 30 days because of their age. Denominator: Number of current cigarette smokers who tried to buy cigarettes in the past 30 days.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Unit of purchased cigarettes Indicator: Percentage of current cigarette smokers who last bought cigarettes as [individual sticks; packs, cartons; rolls; loose tobacco for hand-rolled cigarettes] in the past 30 days. Numerator: Number of current cigarette smokers who last purchased cigarettes as [individual sticks; packs, cartons; rolls; loose tobacco for hand-rolled cigarettes] in the past 30 days. Denominator: Number of current cigarette smokers. Purchasing cigarettes: Cost Indicator: Percentage of youth who estimate the cost of a pack of 20 cigarettes is [Range 1, Range 2, Range 3, etc.]. Numerator: Number of respondents who think, on average, a pack of 20 cigarettes costs [Range 1, Range 2, Range 3, etc.]. Denominator: Total number of respondents. Media: Anti-tobacco Awareness of anti-tobacco messages in the media Indicator: Percentage of youth who saw or heard any anti-tobacco messages in the media in the past 30 days. Numerator: Number of respondents who saw or heard any anti-tobacco messages in the media (e.g., television, radio, internet, billboards, posters, newspapers, magazines, or movies) in the past 30 days. Denominator: Total number of respondents. Awareness of anti-tobacco messages at sporting or community events (among the population) Indicator: Percentage of youth who saw or heard any anti-tobacco messages at sporting or other community events in the past 30 days.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Numerator: Number of respondents who saw or heard any anti-tobacco messages at sporting events, fairs, concerts, community events, or social gatherings in the past 30 days. Denominator: Total number of respondents. Awareness of anti-tobacco messages at sporting or community events (among those who attended events) Indicator: Percentage of youth who attended sporting or other community events in the past 30 days who saw or heard any anti-tobacco messages at the events. Numerator: Number of respondents who saw or heard any anti-tobacco messages at sporting events, fairs, concerts, community events, or social gatherings in the past 30 days. Denominator: Number of respondents who attended sporting or other community events in the past 30 days. Noticing health warnings on cigarette packages Indicator: Percentage of current smokers who noticed health warnings on cigarette packages in the past 30 days. Numerator: Number of current smokers who answered “Yes, but I didn’t think much of them” or ”Yes, and they led me to think about quitting smoking or not starting smoking” to seeing health warnings on cigarette packages in the past 30 days. Denominator: Number of current smokers. Thinking of quitting because of health warnings on cigarette packages (among all current smokers) Indicator: Percentage of current smokers who thought about quitting smoking in the past 30 days because of health warnings on cigarette packages. Numerator: Number of current smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about quitting smoking. Denominator: Number of current smokers.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Thinking of quitting because of health warnings on cigarette packages (among current smokers who noticed health warnings) Indicator: Percentage of current smokers who noticed health warnings on cigarette packages in the past 30 days, who thought about quitting smoking because of the health warnings. Numerator: Number of current smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about quitting smoking. Denominator: Number of current smokers who saw health warnings on cigarette packages in the past 30 days. Thinking of not starting smoking because of health warnings on cigarette packages Indicator: Percentage of never smokers who thought about not starting smoking in the past 30 days because of health warnings on cigarette packages. Numerator: Number of never smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about not starting smoking. Denominator: Number of never smokers who saw health warnings on cigarette packages in the past 30 days. Learning about dangers of tobacco use at school Indicator: Percentage of youth who were taught about the dangers of tobacco use in class during the past 12 months. Numerator: Number of respondents who were taught in any classes about the dangers of tobacco use during the past 12 months. Denominator: Total number of respondents. Media: Pro-tobacco Awareness of tobacco marketing at points of sale (among the population) Indicator: Percentage of youth who saw any tobacco marketing at points of sale in the past 30 days.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Numerator: Number of respondents who saw any advertisements or promotions for tobacco products at point of sale (such as stores, shops, kiosks, etc.) in the past 30 days. Denominator: Total number of respondents. Awareness of tobacco marketing at points of sale (among those who visited points of sale) Indicator: Percentage of youth who visited points of sale in the past 30 days who saw any tobacco marketing at the points of sale. Numerator: Number of respondents who saw any advertisements or promotions for tobacco products at point of sale (such as stores, shops, kiosks, etc.) in the past 30 days. Denominator: Number of respondents who visited points of sale in the past 30 days. Awareness of tobacco use on television, videos, or movies (among the population) Indicator: Percentage of youth who saw someone using tobacco on television, videos, or movies in the past 30 days. Numerator: Number of respondents who saw someone using tobacco on television, videos, or movies in the past 30 days. Denominator: Total number of respondents. Awareness of tobacco use on television, videos, or movies (among those who watched television, videos, or movies) Indicator: Percentage of youth who watched television, videos, or movies in the past 30 days who saw someone using tobacco on television, videos, or movies. Numerator: Number of respondents who saw someone using tobacco on television, videos, or movies in the past 30 days. Denominator: Number of respondents who watched television, videos, or movies in the past 30 days. Exposure to free tobacco promotion Indicator: Percentage of youth who were ever offered a free tobacco product from a tobacco company representative.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Numerator: Number of respondents who were ever offered a free tobacco product from a tobacco company representative. Denominator: Total number of respondents. Ownership of an object with a tobacco brand logo Indicator: Percentage of youth who have something with a tobacco product brand logo on it. Numerator: Number of respondents who have something (e.g., t-shirt, pen, backpack) with a tobacco product brand logo on it. Denominator: Total number of respondents. High receptivity to tobacco marketing Indicator: Percentage of youth who own something with a tobacco product brand logo or who might use or wear something that has a tobacco company or product name or picture on it. Numerator: Number of respondents who own something with a tobacco product brand logo on it or answered “Yes” or ”Maybe” to would they ever use or wear something that has a tobacco company or tobacco product name or picture on it (such as a lighter, t-shirt, hat, or sunglasses). Denominator: Number of never tobacco users. Knowledge and attitudes Belief about the addictiveness of smoking Indicator: Percentage of youth who definitely think that once someone starts smoking tobacco it is difficult to quit. Numerator: Number of respondents who answered ”Definitely Yes” to thinking it would be difficult to quit smoking tobacco once they started. Denominator: Total number of respondents.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Belief that smoking helps people feel comfortable at social gatherings Indicator: Percentage of youth who think that smoking tobacco helps people feel more comfortable at celebrations, parties, and social gatherings. Numerator: Number of respondents who think smoking tobacco helps people feel more comfortable at celebrations, parties or in other social gatherings. Denominator: Total number of respondents. Beliefs about the dangers of secondhand smoke Indicator: Percentage of youth who think other people’s tobacco smoking is harmful to them. Numerator: Number of respondents who answered “Definitely Yes” when asked if smoke from other people’s tobacco smoking is harmful to them. Denominator: Total number of respondents. Banning smoking in enclosed public places Indicator: Percentage of youth who are in favor of banning smoking in enclosed public places. Numerator: Number of respondents who favor banning smoking in enclosed public places (such as schools, shops, restaurants, shopping malls, and movie theatres). Denominator: Total number of respondents. Banning smoking at outdoor public places Indicator: Percentage of youth who are in favor of banning smoking at outdoor public places. Numerator: Number of respondents who favor banning smoking at outdoor public places (such as playgrounds, sidewalks, entrances to buildings, parks, and beaches). Denominator: Total number of respondents.

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Annex 3

Fact Sheet – GYTS Sri Lanka 2015 Results for youths aged 13-15 years TOBACCO USE Smoked tobacco Current tobacco smokers1 Current cigarette smokers 2 3 4

Overall (%)

Boys (%)

Girls (%)

1.7 1.5 0 0.5 6.8 5.7 7

3.2 2.9 0 0.8 10.9 10.0 3.4 4.2 10.6 6.7 17.4 4.3 7.8

0.2 0 0 0.2 2.7 1.4 1.5 0.5 2.6 0.7 4.9 1.0 5.2

Frequent cigarette smokers Ever tobacco smokers5 Ever cigarette smokers6

Current smokers of other tobacco

Ever smokers of other tobacco

2.5 2.4 6.6 3.7 11.1 2.5 6.4

Smokeless tobacco Current smokeless tobacco users8 Ever smokeless tobacco users Current tobacco users10 Ever tobacco users11 9

Tobacco use (smoked and/or smokeless)

Susceptibility Never tobacco users susceptible to tobacco use in the future12 Never smokers who thought they might enjoy smoking a cigarette13

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Results for youths aged 13-15 years SECONDHAND SMOKE Exposure to tobacco smoke at home† Exposure to tobacco smoke inside any enclosed public place† Exposure to tobacco smoke in any outdoor public place† Students who saw anyone smoking inside the school building or outside the school property†

Overall (%) 13.4 35.7 34.6 30.1

Boys (%) 13.9 39.6 37.4 36.6

Girls (%) 13.0 31.7 31.7 23.6

MEDIA Tobacco industry advertising Noticing tobacco advertisements or promotions at point of sale14 Students who saw anyone using tobacco on television, video or movies 15

44.6 83.1 2.0

47.5 85.0 2.0

41.6 81.2 1.2

Students who were ever offered a free cigarette from a tobacco company representative Students who own something with a tobacco brand logo on it

2.9

3.8

1.9

Anti-tobacco advertising Noticing anti-tobacco messages in the media†† Noticing anti-tobacco message at sporting or community events 16

88.0 57.9 78.9

88.5 59.0 76.3

87.6 56.3 81.5

Students who were taught in school about the dangers of tobacco use in the past 12 months

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

Results for youths aged 13-15 years KNOWLEDGE AND ATTITUDES Students who definitely thought it is difficult to quit once someone starts smoking tobacco Students who thought smoking tobacco helps people feel more comfortable at celebrations, parties, and social gatherings Students who definitely thought other people’s tobacco smoking is harmful to them Students who favor banning smoking inside enclosed public places Students who favor banning smoking at outdoor public places 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Overall (%) 13.2 23.9

Boys (%) 13.6 26.3

Girls (%) 12.8 21.5

86.2 96.4 93.3

82.8 95.7 91.9

89.6 97.3 94.8

Smoked tobacco anytime during the past 30 days. Smoked cigarettes anytime during the past 30 days. Smoked cigarettes on 20 or more days of the past 30 days. Smoked tobacco other than cigarettes or bidis anytime during the past 30 days. Ever smoke any tobacco, even one or two puffs. Ever smoked cigarettes, even one or two puffs. Ever smoked tobacco other than cigarettes, even one or two puffs. Used smokeless tobacco anytime during the past 30 days. Ever used smokeless tobacco Smoked tobacco and/or used smokeless tobacco anytime during the past 30 days. Ever smoked tobacco and/or used smokeless tobacco. Susceptible to future tobacco use includes those who answered “definitely yes”, “probably yes”, or “probably not” to using tobacco if one of their best friends offered it to them, or “definitely yes”, “probably yes”, or “probably not” to using tobacco during the next 12 months. Those answered “Agree” or “strongly agree” to the statement: “I think I might enjoy smoking cigarette”. Among those who visited a point of sale in the past 30 days. Among those watched television, video or movies in the past 30 days. Among those who attended sporting or community events in the past 30 days.

† During the past 7 days. †† During the past 30 days.

Acknowledgement: WHO sincerely acknowledges the contribution of researchers involved as principal investigators, schools and students and partners such as Centers for Disease Control and Prevention (CDC), Atlanta, USA, and others. For more information refer our Website http://www.searo.who.int/tobacco. For technical information, please contact: Dr Pubudu De Silva, Email: pubudu@nicslk.com; Mr Naveen Agarwal, Surveillance Management Associate, Email: agarwaln@who.int

Global Youth Tobacco Survey (GYTS), Sri Lanka Report, 2015

ISBN 978-92-9022-522-5

World Health House Indraprastha Estate, Mahatma Gandhi Marg, New Delhi-110002, India www.searo.who.int

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Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 30 septembre 2016

Source Organisation mondiale de la santé