Global Youth Tobacco Survey (GYTS), Bhutan Report, 2013

Global Youth Tobacco Survey (GYTS) Bhutan Report, 2013

WHO Library Cataloguing-in-Publication data World Health Organization, Regional Office for South-East Asia. Global youth tobacco survey (GYTS): Bhutan report 2013. 1. Tobacco Use – statistics and numerical data 3. Data Collection - methods 4. Marketing ISBN 978-92-9022-480-8 2. Demography I. Bhutan. (NLM classification: WM 290)

Suggested citation: World Health Organization, Regional Office for South-East Asia. Global Youth Tobacco Survey (GYTS): Bhutan report, 2013. New Delhi: WHO-SEARO, 2015.

© World Health Organization 2015 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 Bhutan acknowledges the technical and financial support of the World Health Organization (WHO) and the United States Centers for Disease Control and Prevention (CDC) for conducting this survey, and for developing and printing this document. The GYTS 2013 would not have been successful without the unwavering support of the Department of School Education, Ministry of Education. Special credit also goes to all the principals and school health coordinators of the selected schools for being so forthcoming during the process of the survey. The Comprehensive School Health Programme under the Heath Promotion Division also merits special mention for its active involvement in the conduct of the survey.

Disclaimer: The views expressed in this document are not necessarily those of the GYTS collaborating organizations. iii To l Y o ut h

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Contributors 1. Mr Tshering Gyeltshen, Communication Officer, Health Promotion Division under the Department of Public Health; 2. Dr Dhirendra N. Sinha, Regional Advisor, Surveillance (Tobacco Control), WHO, Regional Office for South-East Asia; 3. Dr Krishna Palipudi, CDC Atlanta; 4. Mr Naveen Agarwal, Data Analyst, WHO, Regional Office for SouthEast Asia.

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Contents Acknowledgements.........................................................................................iii List of tables and figures................................................................................. vii Acronyms.........................................................................................................x Regional Director’s message............................................................................xi Foreword....................................................................................................... xiii Executive summary......................................................................................... xv 1. Introduction.............................................................................................. 3 1.1 Country demographics.................................................................... 3

1.2 WHO Framework Convention on Tobacco Control and MPOWER.... 3 1.3 Purpose and rationale...................................................................... 4

1.4 Current state of policy..................................................................... 5 1.5 Other tobacco surveys..................................................................... 5 1.6 Country-specific objectives............................................................... 5 2. Methodology............................................................................................ 9 2.1 Questionnaire.................................................................................. 9 2.2 2.3 2.4 Sampling design.............................................................................. 9 Data collection................................................................................ 9 Data analysis................................................................................. 10

3. Results.................................................................................................... 13 3.1 Tobacco use.................................................................................. 13

3.2 Cessation...................................................................................... 16 3.3 Secondhand smoke....................................................................... 16 3.4 Access and availability................................................................... 16 v To l Y o ut h

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3.5 Media........................................................................................... 17 3.6 Knowledge and attitudes.............................................................. 18 4. Comparison with previous tobacco surveys............................................. 23 5. Discussion on relevance to the WHO FCTC and MPOWER policy package........................................................................................ 33 5.1 Monitor tobacco control among youth.......................................... 33 5.2 Protect people from tobacco smoke.............................................. 33 5.3 Offer help to quit tobacco use....................................................... 34 5.4 Warn about the dangers of tobacco.............................................. 34 5.5 Enforce bans on tobacco advertising, promotion and sponsorship................................................................................. 34 5.6 Access and availability of tobacco products....................................35 5.7 Relevance to the country............................................................... 35 6. Recommendations.................................................................................. 39 7. Bibliography............................................................................................ 41 Annexes 1. Global Youth Tobacco Survey (GYTS), Bhutan 2012–2013, questionnaire.......................................................... 42 2. Indicator definitions................................................................................ 61 3. Results of the Bhutan GYTS, 2013.......................................................... 76 4. Comparative tables................................................................................. 84 5. Factsheet GYTS – Bhutan 2013............................................................... 88

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List of tables and figures Tables Table 1: Sample sizes and response rates, by region (unweighted) – GYTS Bhutan, 2013 Table 2: Detailed tobacco use status among students 13–15 years old, by gender – GYTS Bhutan, 2013 Table 3: Cigarettes smoked per day among current cigarette smokers 13–15 years old, by gender– GYTS Bhutan, 2013 Table 4: Age at cigarette smoking initiation among ever cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Table 5: Current smokers 13–15 years old who showed signs of smoking dependence, by gender – GYTS Bhutan, 2013 Table 6: Smoking tobacco cessation indicators among current smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Table 7: Students 13–15 years old who were exposed to tobacco smoke during the past 30 days, by gender – GYTS Bhutan, 2013 Table 8: Source for obtaining cigarettes among cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Table 9: Current cigarette smokers 13–15 years old who were not prevented from buying cigarettes because of their age, by gender – GYTS Bhutan, 2013 Table 10: Unit of cigarette purchase among current cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Table 11: Estimated cost of cigarettes among students 13–15 years old, by gender and smoking status – GYTS Bhutan, 2013 Table 12: Noticed anti-tobacco information among students 13–15 years old, by gender – GYTS Bhutan, 2013 Table 13: Noticed health warnings on cigarette packages among current and never smokers 13–15 years old, by gender – GYTS Bhutan, 2013 vii To l Y o ut h

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Table 14: Noticed tobacco marketing among students 13–15 years old, by gender – GYTS Bhutan, 2013 Table 15: Ownership and receptivity to tobacco marketing among students 13–15 years old, by gender – GYTS Bhutan, 2013 Table 16: Knowledge and attitudes towards smoking cessation and social smoking among students 13–15 years old, by gender – GYTS Bhutan, 2013 Table 17: Knowledge and attitudes towards secondhand smoke among students 13–15 years old, by gender – GYTS Bhutan, 2013

Figures Figure 1: Ever tobacco use – GYTS Bhutan, 2013 Figure 2: Current use of tobacco products – GYTS Bhutan, 2013 Figure 3: Percentage of current cigarette smokers who smoke cigarettes per day by number of cigarettes per day – GYTS Bhutan, 2013 Figure 4: Percentage of ever cigarette smokers by age at which they first tried a cigarette – GYTS Bhutan, 2013 Figure 5: Percentage of current smokers who wanted to stop, tried to stop and received help to stop smoking – GYTS Bhutan, 2013 Figure 6: Percentage of youth who were exposed to secondhand smoke and their attitude towards secondhand smoke – GYTS Bhutan, 2013 Figure 7: Percentage of youth who saw or heard any anti-tobacco media message (in the past 30 days) – GYTS Bhutan, 2013 Figure 8: Percentage of smokers who noticed health warning on cigarette packages and thought of quitting because of the health warnings – GYTS Bhutan, 2013 Figure 9: Percentage of youth who were ever offered a free tobacco product and who had objects with brand logos of tobacco products, by gender – GYTS Bhutan, 2013 Figure 10: Attitude to and knowledge of secondhand smoking – GYTS Bhutan, 2013 viii To l Y o ut h

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Figure 11: Current tobacco users – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 12: Current smokeless tobacco users – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 13: Current cigarette smoking – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 14: Current use of other tobacco products – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 15: Never smokers susceptible to initiating cigarette smoking – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 16: Exposed to smoke from others at home during the week preceding survey – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 17: Exposed to smoke in public places during the week preceding survey – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 18: Favoured banning smoking in enclosed public places – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 19: Usually buy their cigarettes in a store or shop – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 20: Tobacco marketing – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 21: Anti-tobacco advertising – GYTS Bhutan 2004, 2006, 2009 and 2013 Figure 22: Knowledge and attitudes – GYTS Bhutan 2004, 2006, 2009 and 2013

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Acronyms CDC CI GATS GYTS HMIS MPOWER Centers for Disease Control and Prevention (United States) confidence interval Global Adult Tobacco Survey Global Youth Tobacco Survey health management information system a package of six evidence-based demand reduction measures: 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 Office on Smoking and Health (US) standard error secondhand smoke World Health Organization

OSH SE SHS WHO

WHO FCTC The World Health Organization Framework Convention on Tobacco Control

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Message The findings of the Global Youth Tobacco Survey (GYTS) show that exposure to secondhand smoke in homes and public places is decreasing. However surprisingly the access and availability of tobacco products has increased from 23.7% in 2009 to 50.5% in 2013 and prevalence of tobacco use has increased from around 10% in 2006 and 2009 to over 20% among youth aged 13–15 years in the country. Bhutan has banned production and sale of tobacco products in the country. This trend calls for strict enforcement of tobacco control laws banning sale of tobacco products. Bhutan must take the lead with other stakeholders in a cohesive effort to minimize the access and availability to tobacco products among the youth. GYTS findings also suggest that exposure to direct advertising in electronic media is decreasing but still high. Exposure to indirect advertisement does not show any change over the years. All partners in tobacco control must make coordinated efforts to decrease exposure to tobacco advertisement among the youth by stricter enforcement of their existing policies banning tobacco advertisements. Action by the Royal Government of Bhutan against the tobacco industry to prevent it from distributing free samples of tobacco products and objects with brand logo of tobacco products would go a long way to protect the people of Bhutan from the scourge of tobacco. Over 80% of smokers want to quit now and attempted to quit but did not have access to tobacco cessation support. WHO continues to work with Bhutan to establish tobacco cessation facilities at all levels. Experts from Bhutan have been trained to establish quit lines. And now, it is time to establish national quit lines.

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This report provides an opportunity to review the effects of public health policies and tobacco control interventions among the youth in Bhutan. WHO commends and supports Bhutan to continue in its tobacco control effort among adults and youth. In compliance with Article 21 of the WHO Framework Convention on Tobacco Control (WHO FCTC), Bhutan has been monitoring tobacco control among the youth using the standard protocol of the GYTS. The Government of Bhutan is committed to protecting their youth from the ill effects of tobacco on health.

Dr Poonam Khetrapal Singh Regional Director South-East Asia Region

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Foreword Tobacco consumption remains one of the public health concerns in Bhutan today. Diseases caused by tobacco have a profound impact on the quality of life of individuals, families, communities and countries. These diseases also have a direct impact on socioeconomic development. I am very pleased to release the Global Youth Tobacco Survey (GYTS) 2013 country report, as it provides a State-level view and suggests a road map for tobacco control in the country. I am informed that a series of GYTS were undertaken in the country and the findings over the years pose a very serious concern. I am particularly alarmed by the fact that the prevalence of tobacco use among students in the country has increased over the years and is among the highest in the Region. These findings and interpretations show that proactive and sustained tobacco control efforts are needed for our younger generations. As young people are susceptible to tobacco marketing and peer pressure, they need and deserve high-quality prevention, education, delivered in a way that they can willingly respond to in order to remain free from tobacco. Further, schoolgoing youth who already smoke and want to quit need cessation help that is appropriate to their specific needs. The findings of this GYTS also need to be widely disseminated to schools and relevant stakeholders across the country. Therefore, these data are crucial for planning, implementing and evaluating effective tobacco control and prevention measures. Lastly, I would like to thank all those who were involved in contributing to this document. I take this opportunity to thank the World Health Organization (WHO) and the Centers for Disease Control and Prevention,

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USA (CDC) in particular for helping us get through this important survey. I hope this document will take us a long way towards controlling tobacco use and enabling people to live healthier and happier lives without tobacco.

(Tandin Wangchuk) Minister Ministry of Health Royal Government of Bhutan

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Executive summary The Global Youth Tobacco Survey (GYTS) in Bhutan was conducted in 2013. A national-level representative sample of students in grades 7–9 was selected. The survey consisted of 25 sampled schools and random classes selected within the sampled schools. A total of 1378 students aged 13–15 years were surveyed with an overall response rate of 97.1%. The GYTS findings indicate that there has been a significant increase in the prevalence of current tobacco use among boys; from 28.6% in 2006 to 39.0% in 2013 and, among girls, from 12.4% in 2006 to 23.2% in 2013. This drastic increase is mainly because of a significant rise in the prevalence of current smokeless tobacco use among both boys and girls; from 14.5% in 2006 to 25.0% in 2013 (boys) and from 6% in 2006 to 18.9% in 2013 (girls). However, the good news is that exposure to secondhand smoke (SHS) has decreased both in homes and public places. Exposure to tobacco smoke among students aged 13–15 years in homes has reduced significantly from around 30% in 2004, 2006 and 2009 to 15.3% in 2013. Exposure to tobacco smoke in public places has reduced significantly, from over 50% in 2006 and 2009 to 42.8% in 2013. However, over half of the students (51.3%) were exposed to SHS inside and outside the school property in the past 30 days. The survey revealed that almost half of the students (49.1%) favoured banning smoking both in enclosed and outdoor public places. The majority (78.9%) of students definitely thought that other people’s tobacco smoking was harmful to them. To this effect, the already existing “tobacco-free schools” policy needs to be strengthened and implemented to improve the situation. Sale of tobacco products is strictly banned in principle in Bhutan; however, 54.5% of student smokers reported that they obtained tobacco products from a store, shop or street vendor. The GYTS showed that 81.8% of current smokers wanted to stop smoking (boys 87.4%; girls 65.9%) and 83.1% of current smokers had

tried to quit smoking (boys 82.1%; girls 85.8%). Only 25.3% of smokers received help/advice to stop smoking from a programme or professionals. This warrants provision of tobacco cessation support to them, which may be facilitated by providing training on tobacco cessation to health professionals/nurses/health workers/teacher counsellors and school health coordinators, and equip them with the requisite skills to assist students and others to quit tobacco use. Exposure to anti-tobacco messages on TV has significantly reduced, from 86.9% in 2009 to 74.0% in 2013. Exposure to anti-tobacco media messages at sporting and community events has significantly reduced from 71.9% in 2004, to 79.2% in 2006, 83.1% in 2009 to 59.3% in 2013. From the findings of the GYTS in 2004, 2006, 2009 and 2013, it seems that teaching students about the dangers of tobacco use in school has not improved. This suggests that communication on the ill effects of tobacco needs to be improved through appropriate channels of communication in Bhutan.

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1

Introduction

1. Introduction Tobacco use is the leading global cause of preventable death. WHO attributes nearly 6 million deaths a year to tobacco. This figure is expected to rise to more than 8 million deaths a year by 2030.1 Most people begin using tobacco before the age of 18 years.2 It is therefore important to monitor the initiation and use of tobacco among the youth. 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 present comprehensive tobacco prevention and control information on young people. The GYTS provides a global standard to systematically monitor youth tobacco use and track key tobacco control indicators. It is a nationally representative schoolbased survey of students aged 13–15 years, and uses a consistent and standard protocol across countries. It is intended to generate comparable data within and across countries.

1.1 Country demographics Bhutan is a Member State of the WHO South-East Asia Region and is considered a developing country. The population of Bhutan is about 0.7 million, with t h e majority (70%) of them living on subsistence farming. People in rural areas depend on agricultural farming and rearing livestock to sustain themselves. Bhutan transitioned from an absolute monarchy to a multiparty democracy in 2008. It democratically elected the first National Council in December 2007 and held the first general election in March 2008 for the National Assembly.

1.2 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 3 To l Y o ut h

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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 taxes and prices, promoting smoke-free public places and workplaces, displaying prominent health messages on tobacco packaging, and tobacco surveillance, research and exchange of information. To help countries fulfil 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: tt tt tt tt tt tt

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 the WHO MPOWER package by monitoring country-specific data on key tobacco indicators, including prevalence, knowledge and behaviour.

1.3 Purpose and rationale The GYTS enhances countries’ capacity to monitor consumption and initiation of tobacco use among the youth, guide national tobacco prevention and control programmes, and facilitate comparison of tobaccorelated data 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 FCTC. 4 To l Y o ut h

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There is scientific evidence that tobacco consumption will cut short more lives than other noncommunicable diseases. The youth have long been the target of tobacco companies, which regard them as tomorrow’s regular customers. No study h a s b e e n done or evidence recorded of deaths attributable to tobacco consumption in Bhutan. However, data from t h e health management information system (HMIS) show the number of deaths from ischaemic heart disease, chronic obstructive pulmonary disease, lower respiratory tract infections, and cancers of the trachea, bronchus and lung, which are likely to be related to tobacco use. The GYTS data would provide an important platform to base policy measures and guide suitable interventions and strategies for tobaccofree initiatives in Bhutan. It would also provide a baseline measure for monitoring and evaluating tobacco control programmes to assess progress towards achieving a reduction in the prevalence of tobacco use, as outlined in the Eleventh Five-Year Plan of Ministry of Health.

1.4 Current state of policy Bhutan was one of the earliest countries in the world to have put in place anti-tobacco measures in the first legal code, way back in the seventeenth century. Currently, tobacco control in Bhutan is guided by the Tobacco Control Act, 2010, which is in line with the WHO FCTC. Tobacco control rules and regulations were framed in 2011 for effective implementation of tobacco control in Bhutan.

1.5 Other tobacco surveys The GYTS was conducted in Bhutan in 2004, 2006 and 2009. In addition to the GYTS, the National Health Survey was conducted in 2013, in which tobacco-related components were included.

1.6 Country-specific objectives Objectives have been formulated in line with the Eleventh Five-Year Plan (2013–2018) document to reduce the prevalence of tobacco consumption: 5 To l Y o ut h

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(1) (2) (3) (4) (5)

Reduce the harmful effects of tobacco. Reduce the prevalence of tobacco use among adolescents and youth by 20%. Identify various cessation measures and establish cessation services in all district hospitals. Eliminate the illicit trade of tobacco and tobacco products in the country. Involve national, district and local governments in the implementation of tobacco control policies.

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2

Methodology

2. Methodology 2.1 Questionnaire The GYTS questionnaire contains 60 multiple-choice questions. The survey included 43 questions from the GYTS Standard Core Questionnaire, 15 selected optional questions, and two country-specific questions. The questionnaire was in English. The 2013 Bhutan questionnaire is provided in Annex 1.

2.2 Sampling design The 2013 Bhutan GYTS was a school-based survey, which employed a two-stage cluster sample design to produce a national-level representative sample of students aged 13–15 in grades 7–9. The sampling frame consisted of all lower secondary schools, middle secondary schools and higher secondary schools containing grades 7– 9. In the first stage, schools were selected with a probability proportional to school enrolment 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. The GYTS was conducted in 25 schools and 68 classrooms. A total of 2319 students participated in the GYTS. The grades that were sampled for the 2013 GYTS were 7, 8 and 9.

2.3 Data collection Data collection took place from 1 March 2013 to 30 June 2013, and was supported by four field staff. Survey procedures were designed to protect the students’ privacy by allowing for anonymous and voluntary participation. The questionnaire was self-administered in the classroom. Students recorded their responses directly on an answer sheet that could be scanned by a computer.

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2.4 Data analysis A weighting factor was applied to each student record to adjust for probability of selection, non- response and post-stratification adjustment to population estimates. 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). Frequency tables were developed for the survey questions that were considered key tobacco control indicators from the GYTS. The indicators were in accordance with the WHO FCTC and MPOWER technical package. Table 1 provides information on the sample size and response rate. For the 2013 Bhutan GYTS, 2319 questionnaires were completed in 25 schools. A total of 2319 students participated in the GYTS, of which 1378 were aged 13–15 years. The school response rate was 100%, the class response rate was 100%, and the student response rate was 97.1%. The overall response rate was 97.1%. Table 1: Sample sizes and response rates, by region (unweighted) – GYTS Bhutan, 2013 Total School level Number of sampled schools Number of participating schools School response rate (%) Class level Number of sampled classes Number of participating classes Class response rate (%) Student level Number of sampled Number of participating students Student response rate (%) Overall response rate (%) 10 T l Y o ut h 1

25 25 100% 68 68 100% 2388 2319 97.1% 97.1%

1

Overall response rate = school response rate x class response rate x student response rate

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3

Results

3. Results 3.1 Tobacco use Ever use Figure 1 shows that nearly half (48.1%) of the students had ever used any tobacco product in 2013. Ever use of tobacco among boys (58.6%) was significantly higher than among girls (39.5%). Ever use of smokeless tobacco products was reported by 35.7% of students (boys 40.0%; girls 32.2%). Figure 1: Ever tobacco use – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 48.1 46.2 30 20 10 0 Any tobacco product 58.6 39.5 43.2 Total Boys Girls

35.7

40.0

32.2

30.9

27.3

18.3

14.3

Smokeless tobacco product

Smoked any tobacco product

Smoked cigarettes

Smoked tobacco products other than cigarettes

Nearly one third (30.9%) of students had ever smoked any tobacco product. Boys (46.2%) were more likely to ever smoke any tobacco product than girls (18.3%). Ever smoking of cigarettes among students was reported by 27.3% of respondents. Boys (43.2%) were more likely to ever smoke cigarettes than girls (14.3%). 13 To l Y o ut h

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Tobacco products other than cigarettes had been ever smoked by 11.5% of students. Boys (18.1%) were significantly more likely than girls (6.0%) to ever smoke tobacco products other than cigarettes.

Current use Nearly one third (30.3%) of students were current users of any tobacco product. The prevalence of current use of any tobacco product among boys was significantly higher than among girls (39.0% and 23.2%, respectively). The current use of smokeless tobacco products was reported by 21.6% of students; however, there was no significant difference among boys and girls. Nearly one in five (16.5%) students currently smoked any tobacco product. There was a significant difference in the prevalence of current smoking among boys (26.3%) and girls (8.6%). The prevalence of current cigarette smoking was reported by 14.0% of students. More boys than girls currently smoked cigarettes (23.1% and 6.6%, respectively). There was a significant difference in the prevalence of cigarette smoking (14.0%) and prevalence of using any tobacco product other than cigarettes (24.3%) (Figure 2). Figure 2: Current use of tobacco products – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 30.3 39.0 23.2 16.5 26.3 8.6 14.0 23.1 24.3 29.0 20.3 20 10 0 14 To l Y o ut h

Total

Boys

Girls

21.6 25.0 18.9

6.6

5.5

Any tobacco product

Smokeless tobacco product

Smoked any tobacco product

Smoked cigarettes

Any tobacco Smoked tobacco products other products other than cigarettes than cigarettes

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Nearly half the boys (54.3%) and girls (49.6%) smoked less than 1 cigarette per day. Nearly one out of five (18.3%) boys and one out of three (31.7%) girls smoked 1 cigarette per day (Figure 3). Figure 3: Percentage of current cigarette smokers by number of cigarettes per day – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Less than 1

2.0 3.9 19.5

2.4 4.8 20.3

1.5 17.2

21.8

18.3

31.7

53.1

54.3

49.6

Total 1 cigarette 2 to 5 cigarettes

Boys 6 to 10 cigarettes

Girls More than 10 cigarettes

Among ever cigarette smokers, 21.4% had tried their first cigarette before the age of 10 years (boys 23.4%; girls (16.3%) (Figure 4). Figure 4: Percentage of ever cigarette smokers by age at which they first tried a cigarette – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 23.7 12.0 9.4 Total 7 years old or younger 12 or 13 years old

19.4

19.8

18.5

35.5

32.2

44.2

24.7 21.0 13.4 9.9 Boys 8 or 9 years old 14 or 15 years old 10 or 11 years old

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3.2 Cessation Nearly 4 in 5 (81.8%) current smokers wanted to stop smoking (boys 87.4%) and nearly the same proportion (83.1%) of current smokers had tried to quit smoking (boys 82.1%). One quarter of smokers (25.3%) had received help/advice to stop smoking from a programme or professionals (boys 23.9%; girls 29.1%) (Figure 5). Figure 5: Percentage of current smokers who wanted to stop, tried to stop and received help to stop smoking – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Wanted to stop smoking Tried to stop smoking during the past 12 months

Total

Boys

Girls

81.8

87.9

83.1 82.1

25.3 23.9 29.1 Had received help/advice to stop smoking from a programme or professional

3.3 Secondhand smoke In their homes, 15.3% of students were exposed to secondhand smoke (SHS) (16.3% boys; 14.4% girls). Nearly 2 in 5 (42.8%) students were exposed to SHS in enclosed public places and nearly half (46.6%) were exposed to SHS at outdoor public places. Over half of the students (51.3%) were exposed to SHS inside and outside school property (Figure 6).

3.4 Access and availability Among current cigarette smokers, 54.5% obtained cigarettes by buying them from a store, shop or street vendor. Among current cigarette smokers who bought cigarettes, 47.8% were not prevented from buying them because of their age. 16 To l Y o ut h

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Figure 6: Percentage of youth who were exposed to secondhand smoke and their attitude towards seconhand smoke – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 51.3 49.1 Boys 50.5 46.6 47.9 42.8 43.0 42.7 45.6 45.0 48.0 30 20 15.3 16.3 14.4 10 0 58.9 Total Boys Girls

Exposed to Exposed to Exposed to Saw someone In favour of banning secondhand smoke secondhand smoke secondhand smoke smoking inside the smoking in enclosed at home in enclosed public in outdoor public school building or public places places places outside on school property in the past 30 days

3.5 Media Anti-tobacco messages Nearly three fourth of the boys (72.7%) and girls (75.1%) saw or heard anti-tobacco media messages and nearly one third of boys (33.4%) and girls (32%) aged 13–15 years had been exposed to anti-tobacco media messages at sporting or other community events (Figure 7). Figure 7: Percentage of youth who saw or heard any anti-tobacco media message (in the past 30 days) – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 In the media

Total

Girls

74.0

72.7

75.1

32.6

33.4

32.0 17

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Among current smokers, nearly three fourths (73.9%) noticed health warnings on cigarette packages and one third (37.4%) thought of quitting smoking because of the health warnings (Figure 8). Figure 8: Percentage of smokers who noticed health warnings on cigarette packages and thought of quitting because of the health warnings – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Noticed health warnings on cigarette packages

Total

Boys

Girls

73.9

75.4

70.1 37.4 41.2

27.9

Thought about quitting smoking because of health warnings

Tobacco marketing Roughly 1 in 10 boys (11.9%) and girls (7.9%) had been offered free tobacco products by tobacco companies. Nearly 1 in 5 boys (18.6%) and 1 in 10 girls (10.2%) owned something with a tobacco product brand logo on it (Figure 9).

3.6 Knowledge and attitudes Nearly 4 in 5 boys (78.5%) and girls (79.2%) definitely thought that other people’s tobacco smoking was harmful to them. Roughly half of the boys (52.0%) and girls (46.7%) favoured banning smoking at enclosed public places (Figure 10).

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Figure 9: Percentage of youth who were ever offered a free tobacco product and who had objects with brand logos of tobacco products, by gender – GYTS Bhutan, 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 9.7 11.9 7.9 14.0 18.6 10.2 Total Boys Girls

Offered a free tobacco product

Owned something with a tobacco product brand logo

Figure 10: Attitude to and knowledge of secondhand smoking – Bhutan GYTS, 2013

100 90 80 70 Percentage 60 50 40 30 20 10 0 Definitely think other people’s tobacco smoking is harmful to them Are in favour of banning smoking at outdoor public places

Total

Boys

Girls

78.9

78.5

79.2 52.0

49.1

46.7

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4

Comparison with previous tobacco surveys

4. Comparison with previous tobacco surveys A significant increase in the prevalence of tobacco use was noticed both among boys (from 21.7% in 2004, to 28.6% in 2006, 27.6% in 2009 to 39.0% in 2013) and girls (from 11.9% in 2004, to 12.4% in 2006, 11.6% in 2009 to 23.2% in 2013) (Figure 11). Figure 11: Current tobacco users – GYTS Bhutan 2004, 2006, 2009 and 2013

100 90 80 70 Percentage 60 50 40 30 20 10 0 17.3 20.2 18.8 Total

2004

2006

2009

2013

39.0 30.3 21.7 28.6 27.6 11.9 12.4 11.6 Boys Girls

23.2

A significant increase in the prevalence of current smokeless tobacco use was noticed among both boys (from 10.0% in 2004, to 14.5% in 2006, 14.1% in 2009 to 25.0% in 2013) and girls (from 4.5% in 2004, to 6.0% in 2006, 5.3% in 2009 to 18.9% in 2013) (Figure 12). Current cigarette smoking was reported by 23.1% of boys and 6.6% of girls in 2013. No change in the prevalence of cigarette smoking was noticed both among boys and girls between the 2013 GYTS and earlier GYTS (Figure 13).

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Figure 12: Current smokeless tobacco users – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 7.4 10.0 9.4 Total

2004

2006

2009

2013

21.6 10.0

14.5 14.1 Boys

25.0 4.5 6.0 5.3 Girls

18.9

Figure 13: Current cigarette smoking – GYTS Bhutan 2004, 2006, 2009 and 2013

100 90 80 70 Percentage 60 50 40 30 20 10 0 10.1 12.1 12.4 Total

2004

2006

2009

2013

14.0

14.6 18.3 18.3 Boys

23.1 4.9 6.3 7.9 6.6 Girls

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A significant increase in the prevalence of current use of tobacco products other than cigarettes was noticed overall (from 14.2% in 2006, to 12% in 2009 to 24.3% in 2013); boys (from 19.7% in 2006, to 17.7% in 2009 to 29.0% in 2013) and girls (from 9.1% in 2006, to 7% in 2009 to 20.3% in 2013) (Figure 14). ur vey (G Y

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Figure 14: Current use of other tobacco products – GYTS Bhutan 2004, 2006, 2009 and 2013

100 90 80 70 Percentage 60 50 40 30 20 10 0 10.6 14.2 12.0 Total

2004

2006

2009

2013

24.3 11.3

19.7 17.7 Boys

29.0 9.9 9.1 7.0 Girls

20.3

The percentage of never smokers susceptible to initiating cigarette smoking in 2013 decreased from about 11% in 2004 and 2006 but was similar to the findings in 2009 (8.0% and 6.7%, respectively) (Figure 15). Figure 15: Never smokers susceptible to initiating cigarette smoking – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 10.9 11.0 8.0 6.7 Total

2004

2006

2009

2013

10.5 15.2 9.1 7.4 Boys

11.5 7.8 7.3 6.4 Girls

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There was a significant decrease in exposure to SHS at homes among all students (from 31.9% in 2006, to 29.5% in 2009 to 15.3% in 2013); boys (from 32.5% in 2006, to 29.2% in 2009 to 16.3% in 2013) and girls (from 31.1% in 2006, to 29.5% in 2009 to 14.4% in 2013) (Figure 16). Figure 16: Exposed to smoke from others at home during the week preceding survey – GYTS Bhutan 2004, 2006, 2009 and 2013

100 90 80 70 Percentage 60 50 40 30 20 10 0 29.2 31.9 29.5 15.3 Total Boys

2004

2006

2009

2013

30.7 32.5 29.2 16.3

27.0 31.1 29.5 Girls

14.4

There was also a significant decrease in exposure to SHS in public places, from 54.5% in 2006 to 59.4% in 2009 to 42.8% in 2013. This difference was noticed both for boys (from 57.8% in 2006 to 58.6% in 2009 to 43.0% in 2013) and girls (from 51.7% in 2006 to 59.7% in 2009 to 42.7% in 2013) (Figure 17). Nearly 20% of the students favoured banning smoking in enclosed public places in 2004, which increased significantly to around 50% in 2006 and since then there has been hardly any change in the overall attitude to banning smoking in enclosed public places between 2006, 2009 and 2013 (47.0% in 2006, 44.1% in 2009 and 49.1% in 2013) (Figure 18) Overall, the percentage of current smokers who bought cigarettes in stores increased significantly from 23.7% in 2009 to 50.5% in 2013 (among boys from 28.5% in 2009 to 53.4% in 2013, and among girls from 17.2% in 2009 to 42.8% in 2013) (Figure 19). 26 To l Y o ut h

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Figure 17: Exposed to smoke in public places during the week preceding survey – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Total Boys Girls

2004

2006

2009

2013

47.4

54.5

59.4 42.8 45.0

57.8 58.6 43.0

49.5 51.7

59.7 42.7

Note: from 2013 public place catergorized in two, i.e. “enclosed” and “outdoor”; figures are for “enclosed” public place.

Figure 18: Favoured banning smoking in enclosed public places – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 19.8 Total

2004

2006

2009

2013

47.0 44.1 49.1 21.7

49.6 45.4 50.5 17.9 Boys

45.0 42.9 48.0

Girls

Note: from 2013 public place catergorized in two, i.e. “enclosed” and “outdoor”; figures are for “enclosed” public place. 27 To l Y o ut h

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Figure 19: Usually buy their cigarettes in a store or shop – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 41.3 36.4 23.7 Total

2004

2006

2009

2013

50.5

49.2

53.4 40.6 28.5 17.2 Boys Girls

42.8

The number of students who noticed anyone using tobacco on TV, in videos or movies reduced significantly, from over 90% in 2004, 2006 and 2009 to around 80% in 2013 but remained high (Figure 20). Nearly 1 in 10 students were offered free samples of tobacco products and a similar proportion of students had some objects with the brand logo of a tobacco product in 2004, 2006, 2006, 2009 and 2013 (Figure 20). Figure 20: Tobacco marketing – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Noticed anyone using tobacco on TV, videos or movies

2004

2006

2009

2013

93.0 93.5

98.4 79.8

13.7 11.1

9.7

9.1 10.5 14.9 14.0 Owned something with a tobacco brand logo on it

Ever offered a free tobacco product from a tobacco company

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Exposure to anti-tobacco messages on TV significantly reduced from 86.9% in 2009 to 74.0% in 2013. Exposure to anti-tobacco media messages at sporting and community events significantly reduced from 71.9% in 2004, to 79.2% in 2006, 83.1% in 2009 and 59.3% in 2013 (Figure 21). Figure 21: Anti-tobacco advertising – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Message in media Message at sporting or community events Taught in school about the dangers of tobacco use

2004

2006

2009

2013

74.5

82.6

86.9 74.0 71.9 79.2

83.1 59.3 56.7 59.8 61.6 60.8

Students’ believe that SHS was harmful for them significantly increased from around 60% in 2004 and 2006 to 78.9% in 2013. The percentage of students who favoured a ban on smoking in public enclosed spaces increased from around 20% in 2004 to around 50% in 2006 and remained almost the same in 2009 and 2013 (Figure 22). Figure 22: Knowledge and attitudes – GYTS Bhutan 2004, 2006, 2009 and 2013 100 90 80 70 Percentage 60 50 40 30 20 10 0 Thought other people’s tobacco smoking is harmful to them

2004

2006

2009

2013

63.4

62.1

72.8

78.9 47.0 19.8 Favoured banning smoking inside enclosed public places

44.1

49.1

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5

Discussion on relevance to the WHO FCTC and MPOWER policy package

5. Discussion on relevance to the WHO FCTC and MPOWER policy package The results of this GYTS are critical for understanding the implementation of the WHO FCTC and MPOWER policy package in Bhutan.

5.1 Monitor tobacco control among youth Bhutan’s regular participation in the GYTS in 2004, 2006, 2009 and 2013 addresses the first element of MPOWER (Monitor tobacco use and prevention policies) package for youth. The GYTS asks students a range of questions that span many of the remaining elements of MPOWER and several provisions of the WHO FCTC, such as involving local communities/ local governments and different sectors, including formulation and implementation of a comprehensive school tobacco control policy.

Tobacco use It has been reported that the current use of smokeless tobacco and any tobacco product has increased from 9.4% in 2009 to 21.6% in 2013, and from 18.8% in 2009 to 30.3% in 2013, respectively, which is among the highest in the Region as well as globally. Although the sale of tobacco products has been banned in Bhutan since 2004, and the Tobacco Control Act, 2010 prohibits the manufacture, sale and distribution of tobacco products in the country, the increasing prevalence of overall tobacco use indicates that tobacco products remain highly accessible.

5.2 Protect people from tobacco smoke The Royal Government of Bhutan is committed to controlling tobacco use and implementing its smoking ban policy (Section 3 of the Tobacco Control Act, 2010), which has resulted in a significant decrease in exposure to tobacco smoke in homes as well as in public places. The survey results show that in 2013, 15.3% of the youth surveyed were exposed to smoke in their homes and 42.8% were exposed to SHS in enclosed public places. The survey also showed that 78.9% of students thought that SHS was 33 To l Y o ut h

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harmful to them. The Government needs to continue its efforts at further implementing the smoking ban policy and educating people about the harmful effects of SHS.

5.3 Offer help to quit tobacco use Overall, 81.8% of students who currently smoked cigarettes reported that they wanted to stop smoking and 83.1% of students had tried to stop smoking. Only 25.3% of current smokers had ever received help or advice to quit smoking from a programme or professionals. Hence, there is dire need to provide assistance to tobacco users who desire to quit. Bhutan needs to establish cost–effective tobacco cessation services. The WHO Regional Office for South-East Asia has provided assistance in training health professionals from Bhutan in tobacco cessation and assisted the Ministry of Health in understanding quitline services in Thailand.

5.4 Warn about the dangers of tobacco The Ministry of Health has been carrying out mass media campaigns and creating awareness through social and community mobilization on the health hazards of tobacco use. Both the print and broadcast media are used to disseminate anti-tobacco information. The Bhutan Narcotics Control Agency and the Ministry of Health collaborate to observe “World No Tobacco Day” every year with various theme-based activities in order to educate the public on tobacco use and its catastrophic health, social, economic and ecological consequences. The Ministry of Health also engages school youth in conducting educational activities on tobacco. In spite of these activities, exposure to anti-tobacco messages in the media has significantly decreased. During the past year, 60.8% of students had been taught in class about the dangers of tobacco use.

5.5 Enforce bans on tobacco advertising, promotion and sponsorship In the past 30 days, 80.0% of students had noticed anyone using tobacco in videos or movies. Further, 14.0% of students had an object with a cigarette brand logo on it, and 9.7% were offered free cigarettes by a 34 To l Y o ut h

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tobacco company representative. The Royal Government of Bhutan has banned advertisements in the national media and keeps a watch over this. Pro-tobacco advertisements might be coming from international TV channels. The tobacco industry continues its efforts at distributing free samples of tobacco products and objects with the brand logo of tobacco products. The Royal Government of Bhutan needs to take stern action against the tobacco industry and strictly implement the ban on direct and indirect advertisements.

5.6 Access and availability of tobacco products Despite a ban on the sale of tobacco products since 2004, illicit tobacco products are still available in Bhutan. The southern districts of Bhutan share a porous border with neighbouring India. This has made it very difficult to monitor the continuing illicit trade of tobacco products coming into Bhutan. The prevalence of tobacco use reported in the International Tobacco Control Bhutan report, 2009 and GYTS 2013 indicate that there is ongoing sale of tobacco products in the country.

5.7 Relevance to the country The GYTS methodology provides an excellent framework for monitoring and guiding the implementation of school tobacco control programmes, while making them compliant with the requirements of the WHO FCTC. The results of this survey will be disseminated widely and, ideally, used to adopt and implement effective legislative measures for preventing and reducing tobacco consumption, nicotine addiction, and exposure to tobacco smoke. Many of the students who participated in the survey wanted to quit tobacco use, but school health coordinators are not adequately trained in preventing tobacco consumption among students and there is a lack of cessation services in schools. The GYTS data provide a platform for initiating a continuous training programme for school health coordinators and tobacco cessation services in schools. The GYTS report provides evidence that the susceptibility to initiating tobacco use begins in schools at an early age; tobacco control education therefore needs to start at a very 35 To l Y o ut h

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young age. However, the coverage of issues related to the prevention of tobacco use is currently very limited in the formal school curriculum. The youth is faced with the double and dubious choice of smoking cigarettes and using other forms of tobacco products, such as chewing tobacco. This requires further in-depth study on the behaviour of the youth and enforcing strict rules and regulations.

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6

Recommendations

Recommendations In recognition of the findings of the GYTS 2013, Bhutan should consider rapidly implementing expanded comprehensive tobacco control measures across all levels. This will help to save lives, reduce illness, and reduce the economic burden associated with tobacco-related illnesses and lost productivity in future. The following interventions are recommended: tt

There is a dire need for implementing comprehensive tobacco control policies especially addressing the youth. Considering the progressively increasing trend of current use of tobacco products, especially smokeless tobacco products, from 2004 to 2013 (7.4% to 21.6%), the country should include and put in place a smokeless tobacco control programme in communities/schools, and not programmes limited to smoking only. In spite of a ban on sale of tobacco products in the country, over half of the students had bought tobacco products from stores. The Ministry of Health and all other stakeholders should work cohesively to minimize access to and availability of tobacco products to minors. In the present scenario, there is a great need to enforce the ban on sale of tobacco products. The Royal Government of Bhutan should take appropriate action against the tobacco industry and prevent it from distributing free samples of tobacco products and objects with brand logos of tobacco products. The Royal Government of Bhutan should further strengthen antitobacco mass media programmes through television, radio, sports and community events, as exposure to anti-tobacco advertisements have drastically reduced from 86.9% in 2009 to 74.0% in 2013. Although the prevalence of never tobacco users susceptible to tobacco use has decreased over the years (6.7%), tobacco control agencies should work to ensure that tobacco remains in the public consciousness by supporting anti-tobacco media campaigns and 39 To l Y o ut h

tt

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tt

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workshops undertaken by local, national and international civil society organizations. tt

Students who smoke expressed the desire to quit smoking (81.8%) and many had even attempted to quit (83.1%). Tobacco cessation training needs to be provided to health professionals/public health physicians/clinicians/nurses/teacher counsellors and school health coordinators to equip them with the skills to assist students. The prevalence of exposure to tobacco advertisements (persons seen using tobacco on TV, in videos or movies) has decreased from 98.4% in 2009 to 79.8% in 2013. However, it remains high. The law enforcement agency for tobacco control in Bhutan should strictly enforce the existing law that bans all forms of advertisement of tobacco products. In line with a comprehensive health promotion plan and strategy developed in Bhutan, the issue of increasing tobacco consumption among school youth needs to be highlighted in the annual school health coordinator’s training and parents’ meeting, so that an appropriate solution can be found to prevent tobacco use among the youth. Implementation of the ban on smoking in public places needs to be strengthened, although exposure to SHS in public places has decreased over the years. However, exposure of the youth to tobacco smoke remains high (42.8%). The existing “tobacco-free schools” policy needs to be strengthened and implemented.

tt

tt

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Bibliography 1. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva: World Health Organization; 2011 (http:// www.who.int/tobacco/global_report/ 2011/en/index.html), accessed 20 February 2015. Preventing tobacco use among youth and young adults: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2012 (http://www. surgeongeneral.gov/library/reports/ preventing-youth-tobacco- use/index. html), accessed 20 February 2015. Givel MS. History of Bhutan’s prohibition of cigarettes: implications for neo-prohibitionists and their critics. Int J Drug Policy. 2011;22(4):306–10. Glenn BA, Surani Z, Chawla N, Bastani R. Tobacco use among South Asians: results of a community–university collaborative study. Ethn Health. 2009;14(2):131–45. Brief profile of tobacco control in Bhutan. Thimphu: Royal Government of Bhutan; 2010 (http://www.searo.who.int/tobacco/documents/2010-pub1. pdf, accessed 20 February 2015). The International Tobacco Control Policy Evaluation Project: ITC Bhutan Project Report. Thimphu and Ontario: University of Waterloo, Ontario, Canada, and Ministry of Health, Thimphu, Bhutan; May 2011 (http://www.itcproject.org/files/Report_Publications/National_Report/ itcbhutanreportapr27v20web.pdf, accessed 20 February 2015).

2.

3. 4.

5.

6.

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Annex 1

Global Youth Tobacco Survey (GYTS), Bhutan 2012–2013, questionnaire Instructions tt tt

Please read each question carefully before answering it. Choose the answer that best describes what you believe and feel to be correct. Choose only one answer for each question. On the answer sheet, locate the circle that corresponds to your answer and fill it in completely with the pencil that was provided to you. Correctly fill in the bubbles:

tt tt

tt

tt



Like this:



If you have to change your answer, don’t worry, just erase it completely, without leaving marks.

Example: 24. Do you believe that fish live in water? a. Definitely yes b. Probably yes c. Probably not d. Definitely not 24. 

B

C

D

E

F

G

H

Introduction Thank you for participating in this survey. Before you start, please read the following information that will help to answer the questions. tt tt 42 To l Y o ut h

Some of the questions will ask about smoking cigarettes. Other questions may ask about smoking tobacco in general that includes cigarettes and other types of smoked tobacco products.

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tt

Other questions may ask about using smokeless tobacco,which is tobacco that is not smoked, but is sniffed through the nose, held in the mouth, or chewed. Finally, other questions may ask about any tobacco use or any tobacco products – this includes smoking cigarettes, smoking tobacco other than cigarettes, and using smokeless tobacco. Here is a chart that provides examples of various tobacco products: Any Tobacco Use Smoking Tobacco includes: - - - Cigarettes Manufactured cigarettes Other types of smoked tobacco: bidis - - - Smokeless Tobacco includes: Chewing tobacco (baba) Doma (betel nut without tobacco) Betel quid with tobacco

tt

tt

The first few questions ask for some background information about yourself. 1. 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 2. What is your sex? a. Male b. Female

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3.

In what class are you? a. 7 (Seven) b. 8 (Eight) c. 9 (Nine)

4.

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 Nu. 100 c. Nu.100–300 d. Nu. 301–500 e. Nu. 501–700 f. Nu. 701–1000 g. Nu. 1000 and above

The next questions ask about your use of tobacco. 5. Have you ever tried or experimented with cigarette smoking? a. Yes b. No 6. 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

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7.

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

8.

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 I 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

9.

Have you ever tried or experimented with any form of smoked tobacco products other than cigarettes (such as bidi)? a. Yes b. No

10. During the past 30 days, did you use any form of smoked tobacco products other than cigarettes (such as bidi)? a. Yes b. No 45 To l Y o ut h

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11. 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. 12. 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. Within 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 13. Have you ever tried or experimented with any form of smokeless tobacco products (such as baba)? a. Yes b. No 14. During the past 30 days, did you use any form of smokeless tobacco products (such as baba)? a. Yes b. No

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15. Have you ever tried or experimented with chewing doma (betel nut with lime and leaf)? a. Yes b. No 16. During the past 30 days, did you use chewing doma (betel nut with lime and leaf)? a. Yes b. No

The next questions ask about your feelings toward stopping smoking. 17. Do you want to stop smoking now? a. I have never smoked. b. I don’t smoke now. c. Yes d. No 18. During the past 12 months, did you ever try to stop smoking? a. I have never smoked. b. I don’t smoke now. c. Yes d. No 19. 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

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20. 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 programme or professional c. Yes, from a friend d. Yes, from a family member e. Yes, from both programmes or professionals and from friends or family members f. No

The next questions ask about your exposure to other people’s smoking. 21. During the past 7 days, on how many days has anyone smoked inside your home, in your presence? a. 0 days b. 1 or 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days 22. 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: school, shops, restaurants, shopping malls, movie theatres, offices)? a. 0 days b. 1 or 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days

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23. 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, Lhakhangs, festivals, sports, social gatherings, bus terminals, etc.)? a. 0 days b. 1 or 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days 24. During the past 30 days, did you see anyone smoke inside the school building or outside on school property? a. Yes b. No 25. 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 26. Are you in favour of banning smoking inside enclosed public places (such as: schools, shops, restaurants, shopping malls, movie theatres, offices, public transports, discotheques)? a. Yes b. No

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27. Are you in favour of banning smoking at outdoor public places (such as: playgrounds, sidewalks, entrances to buildings, parks, Lhakhangs, festivals, sports arenas, social gatherings, bus terminals, etc.)? a. Yes b. No

The next questions ask about getting cigarettes. 28. 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 bought them from other’s house. e. I bought them out of the country. f. I got them from someone else. g. I got them some other way. 29. 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. 30. 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. 50 To l Y o ut h

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31. On average, how much do you think a pack of 20 cigarettes costs? a. Less than Nu. 50 b. Nu. 51–100 c. Nu.100–150 d. Nu.151–200 e. Nu. 201–250 f. Nu. 251–300 g. Nu. 301–350 h. I don’t know.

The next questions ask about your knowledge of messages that are against using tobacco (might include cigarettes, other smoked tobacco and smokeless tobacco). 32. 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 33. During the past 30 days, did you see or hear any anti-tobacco messages at sports events, fairs, concerts, or community events, or social gathering? 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 34. During the past 30 days, did you see any health warnings on cigarette packages? a. Yes, but I didn’t think much of them. 51 To l Y o ut h

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b. Yes, and they led me to think about quitting smoke or not start smoking. c. No 35. 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.

The next questions ask about your knowledge of advertisements or promotions for tobacco (might include cigarettes, other smoked tobacco, and smokeless tobacco). 36. During the past 30 days, did you see any people using tobacco when you watched TV, videos, or movies? a. I did not watch TV, videos, or movies in the past 30 days. b. Yes c. No 37. During the past 30 days, did you see any advertisements or promotions for tobacco products at points of sale (such as shopping malls, shops, vegetable market, etc.)? a. I did not visit any points of sale in the past 30 days. b. Yes c. No 38. 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 52 To l Y o ut h

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39. Do you have something (for example, T-shirt, pen, backpack) with a tobacco product band logo on it? a. Yes b. No 40. Has a person working for a tobacco company ever offered you a free tobacco product? a. Yes b. No

The next questions ask about your attitudes and beliefs about using tobacco. 41. If one of your friends offered you a tobacco product, would you use it? a. Definitely not b. Probably not c. Probably yes d. Definitely yes 42. At any time 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 43. 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 l Y o ut h

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44. 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 45. 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

Smokeless tobacco module The next questions asked about smokeless tobacco. This includes chewing tobacco (such as baba, khaini/surti, panmasala with zarda or pan). 46. How old were you when you first tried using smokeless tobacco? 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

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47. Do you want to stop using smokeless tobacco now? a. I have never used smokeless tobacco. b. I don’t use smokeless tobacco now. c. Yes d. No 48. During the past 12 months, did you ever try to stop using smokeless tobacco? a. I have never used smokeless tobacco. b. I did not use smokeless tobacco during the past 12 months. c. Yes d. No 49. Do you think you would be able to stop using smokeless tobacco if you wanted to? a. I have never used smokeless tobacco. b. I don’t use smokeless tobacco now. c. Yes d. No 50. Have you ever received help or advice to stop using smokeless tobacco? (SELECT ONLY ONE RESPONSE) a. I have never used smokeless tobacco. b. Yes, from a programme or professional c. Yes, from a friend d. Yes, from a family member e. Yes, from both programmes or professionals and from friends or family members f. No

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51. The last time you used smokeless tobacco during the past 30 days, how did you get it? (SELECT ONLY ONE RESPONSE) a. I did not use smokeless tobacco during the past 30 days. b. I bought it in a store or shop. c. I bought it from a street vendor. d. I bought it from other’s house. e. I bought it from outside the country. f. I got it from someone else. g. I got it some other way. 52. During the past 30 days, did you see any health warnings on smokeless tobacco packages? a. Yes, but I didn’t think much of them. b. Yes, and they led me to think about quitting smokeless tobacco or not starting smokeless tobacco. c. No 53. If one of your best friends offered you smokeless tobacco, would you use it? a. Definitely not b. Probably not c. Probably yes d. Definitely yes 54. Once someone has started using smokeless tobacco, do you think it would be difficult for them to quit? a. Definitely not b. Probably not c. Probably yes d. Definitely yes 56 To l Y o ut h

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55. Do you think using smokeless 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 using smokeless tobacco or not 56. Do you agree or disagree with the following: “I think I might enjoy using smokeless tobacco.” a. I currently use smokeless tobacco. b. Strongly agree c. Agree d. Disagree e. Strongly disagree

List of optional questions Background information 57. Do your parents work? a. Father (stepfather or mother’s partner) only b. Mother (stepmother or father’s partner) only c. Both d. Neither e. Don’t know 58. What level of education did your father (stepfather or mother’s partner) complete? a. Did not study b. Primary c. Lower 57 To l Y o ut h

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d. Middle secondary e. Higher secondary f. Degree g. Masters h. Don’t know 59. What level of education did your mother (stepmother or father’s partner) complete? a. Did not study b. Primary c. Lower d. Middle secondary e. Higher secondary f. Degree g. Masters h. Don’t know 60. What do you think you will be doing when you finish high school? a. Continue education b. Look for job c. Vocational training d. Help parents e. Start business f. Enroll in a monk g. Farmer h. Don’t know

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School policy questionnaire 1. What is your primary position in this school? a. Principal b. Administrator c. Teacher d. School health services personnel (e.g.nurse) e. Clerical staff f. Other type of school personnel (______________________) 2. Does your school have a policy or rule specifically prohibiting tobacco use among students inside school buildings? a. Yes b. No c. I don’t know. 3. Does your school have a policy or rule specifically prohibiting tobacco use among students outside school buildings on school premises/property? a. Yes b. No c. I don’t know. 4. Does your school have a policy or rule specifically prohibiting tobacco use among school personnel inside school buildings? a. Yes b. No c. I don’t know.

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5.

Does your school have a policy or rule specifically prohibiting tobacco use among school personnel outside school buildings on school premises/property? a. Yes b. No c. I don’t know.

6.

How well does your school enforce any of its policies (or rules) on tobacco use among students? a. There is no policy or rule on tobacco use among students. b. Completely c. Partially d. Not at all

7.

How well does your school enforce any of its policies (or rules) on tobacco use among school personnel? a. There is no policy or rule on tobacco use among school personnel. b. Completely c. Partially d. Not at all

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Annex 2

Indicator definitions 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 product 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

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

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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 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 product 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 product Numerator: Number of respondents who used any smokeless tobacco product in the past 30 days Denominator: Total number of respondents

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Current tobacco users Indicator: Percentage of youth who currently use any tobacco product Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days or smoked any tobacco product other than cigarettes in the past 30 days or used any smokeless tobacco product in the past 30 days Denominator: Total number of respondents 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 product 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

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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 initiation of cigarette smoking 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 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 Denominator: Number of ever cigarette smokers 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

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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 Numerator: Number of current smokers who received any help/advice from a programme or professional to help them stop smoking Denominator: Number of current smokers

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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

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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 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 Obtained cigarettes through 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

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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 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

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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 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

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Noticed 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 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, and 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

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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 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

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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 73 To l Y o ut h

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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 had something with a tobacco product brand logo on it Numerator: Number of respondents who had 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 owned 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 owned 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

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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 Believe 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 favour of banning smoking in enclosed public places Numerator: Number of respondents who favour 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 favour of banning smoking at outdoor public places Numerator: Number of respondents who favour banning smoking at outdoor public places (such as playgrounds, sidewalks, entrances to buildings, parks, and beaches) Denominator: Total number of respondents 75 To l Y o ut h

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Annex 3

Results of the Bhutan GYTS, 2013 Table 2: Detailed tobacco use status among students 13–15 years old, by gender – GYTS Bhutan, 2013 Overall Boys Percentage (95% CI) Smoked tobacco Current tobacco smokers1 Current cigarette smokers2 Frequent cigarette smokers3 Current smokers of other tobacco4 Ever tobacco smokers5 Ever cigarette smokers6 Ever smokers of other tobacco7 Smokeless tobacco Current smokeless tobacco users8 Ever smokeless tobacco users9 Tobacco use Current tobacco users10 Ever tobacco users11 30.3 (26.2–34.7) 48.1 (43.2–53.0) 39.0 (33.7–44.5) 58.6 (52.9–64.0) 23.2 (19.0–28.0) 39.5 (34.1–45.2) 21.6 (18.5–25.2) 35.7 (31.0–40.8) 25.0 (21.7–28.6) 40.0 (34.5–45.7) 18.9 (14.6–24.1) 32.2 (26.9–38.1) 16.5 (13.9–19.5) 14.0 (11.8–16.4) 1.5 (0.9–2.4) 5.5 (4.2–7.0) 30.9 (27.2–34.8) 27.3 (23.8–31.2) 11.5 (9.5–13.8) 26.3 (21.6–31.6) 23.1 (19.0–27.6) 3.0 (1.7–5.2) 9.1 (6.6–12.3) 46.2 (40.0–52.5) 43.2 (37.4–49.1) 18.1 (14.4–22.6) 8.6 (7.0–10.6) 6.6 (4.8–9.0) 0.2 (0.0–1.1) 2.5 (1.6–3.8) 18.3 (14.9–22.2) 14.3 (10.8–18.8) 6.0 (4.1–8.5) Girls

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Overall

Boys Percentage (95% CI)

Girls

Susceptibility to tobacco use Never tobacco users susceptible to tobacco use in the future12 Never smokers who thought they might enjoy smoking a cigarette13 1 2

6.7 (5.4–8.3) 6.7 (5.2–8.7)

7.4 (5.0–10.8) 8.0 (5.1–12.3)

6.4 (4.9–8.2) 6.1 (4.3–8.6)

Smoked tobacco at any time during the past 30 days Smoked cigarettes at any time during the past 30 days 3 Smoked cigarettes on 20 or more days in the past 30 days 4 Smoked tobacco other than cigarettes any time during the past 30 days 5 Ever smoked any tobacco, even one or two puffs 6 Ever smoked cigarettes, even one or two puffs 7 Ever smoked tobacco other than cigarettes, even one or two puffs 8 Used smokeless tobacco any time during the past 30 days 9 Ever used smokeless tobacco 10 Smoked tobacco and/or used smokeless tobacco any time during the past 30 days 11 12

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 those who answered “Definitely yes”, “Probably yes”, or “Probably not” to using tobacco during the next 12 months 13 Those who answered “Agree” or “Strongly agree” to the statement: “I think I might enjoy smoking a cigarette.”

Table 3: Cigarettes smoked per day among current cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Number of cigarettes usually smoked1 Less than 1 per day 1 per day 2 to 5 per day 6 to 10 per day 11 to 20 per day More than 20 per day Total 1

Overall

Boys Percentage (95% CI)

Girls

53.1 (44.1–61.8) 21.8 (17.0–27.4) 19.5 (14.4–25.8) 3.9 (1.9–7.8) 0.6 (0.1–4.3) 1.2 (0.3–5.2) 100

54.3 (44.4–63.8) 18.3 (14.2–23.2) 20.3 (13.9–28.5) 4.8 (2.2–10.1) 0.8 (0.1–5.8) 1.6 (0.4–7.0) 100

49.6 (33.8–65.4) 31.7 (17.4–50.4) 17.2 (10.2–27.5) 1.5 (0.2–11.3) 0.0 0.0 100 l Y o ut h

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Table 4: Age at cigarette smoking initiation among ever cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Age when first tried a cigarette1 7 years old or younger 8 or 9 years old 10 or 11 years old 12 or 13 years old 14 or 15 years old Total 1

Overall

Boys Percentage (95% CI)

Girls

9.4 ( 6.0–14.6) 12.0 (8.4–16.7) 23.7 ( 20.4–27.3) 35.5 ( 29.2–42.4) 19.4 ( 13.9–26.5) 100

9.9 ( 5.5–17.3) 13.4 (9.1–19.4) 24.7 ( 20.7–29.1) 32.2 ( 25.2–40.1) 19.8 ( 13.7–27.7) 100

8.1 ( 4.5–14.1) 8.2 ( 4.8–13.6) 21.0 ( 12.8–32.6) 44.2 ( 38.9–49.6) 18.5 ( 11.6–28.2) 100

Among those that have ever tried a cigarette

Table 5: Current smokers 13–15 years old who showed signs of smoking dependence, by gender – GYTS Bhutan, 2013 Indicator Signs of smoking dependence1 1

Overall 52.9 (42.0–63.4)

Boys Percentage (95% CI) 49.6 (40.0–59.3)

Girls 62.5 (42.5–79.0)

Those who answered: they sometimes or always smoke tobacco or feel like smoking tobacco first thing in the morning, or they start to feel a strong desire to smoke again within one full day after smoking

Table 6: Smoking tobacco cessation indicators among current smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Tried to stop smoking in the past 12 months Wanted to stop smoking now Thought they would be able to stop smoking if they wanted to 78 T l Y o ut h

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Boys Percentage (95% CI)

Girls

83.1 (72.3–90.2) 81.8 (65.3–91.5) 83.8 (74.4–90.2) 25.3 (22.0–28.9)

82.1 (71.4–89.3) 87.4 (74.7–94.2) 87.3 (76.8–93.5) 23.9 (19.0–29.7)

– – – 29.1 (19.0–41.8)

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Table 7: Students 13–15 years old who were exposed to tobacco smoke during the past 30 days, by gender – GYTS Bhutan, 2013 Indicators Exposed to tobacco smoke at home Exposed to tobacco smoke inside any enclosed public place Exposed to tobacco smoke at any outdoor public place Saw anyone smoking inside the school building or outside on school property Overall Boys Percentage (95% CI) 15.3 (13.0–17.9) 42.8 (39.1–46.6) 46.6 (42.0–51.3) 51.3 (46.1–56.4) 16.3 (11.5–22.5) 43.0 (37.9–48.3) 47.9 (40.9–55.0) 58.9 (52.7–64.8) 14.4 (12.2–17.0) 42.7 (38.4–47.1) 45.6 (40.8–50.5) 45.0 (39.8–50.2) Girls

Table 8: Source for obtaining cigarettes among cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Purchased from a store or shop Purchased from a street vendor Got them from someone else Got them some other way Overall Boys Percentage (95% CI) 50.5 (43.0–58.1) 4.0 (1.5–10.1) 32.3 (24.8–40.7) 6.6 (3.1–13.6) 53.4 (45.6–61.0) 4.6 (1.6–12.3) 28.3 (22.5–35.0) 5.6 (2.5–12.1) 42.8 (27.4–59.8) 2.5 (0.3–18.2) 42.8 (25.7–61.8) 9.4 (3.7–21.9) Girls

Table 9: Current cigarette smokers 13–15 years old who were not prevented from buying cigarettes because of their age, by gender – GYTS Bhutan, 2013 Indicators Current cigarette smokers who were not prevented from buying cigarettes because of their age Overall Boys Percentage (95% CI) 47.8 (39.4–56.3) 47.4 (36.5–58.6) 48.7 (32.2–65.6) 79 To l Y o ut h

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Table 10: Unit of cigarette purchase among current cigarette smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Individual sticks Pack Carton Rolls Loose tobacco for hand-rolled cigarettes Overall Boys Percentage (95% CI) 53.1 (42.5–63.3) 29.0 (21.6–37.6) 3.4 (1.2–9.6) 7.6 (3.9–14.2) 7.0 (3.4–13.9) 53.9 (41.7–65.7) 29.2 (20.4–39.7) 2.4 (0.5–10.2) 5.9 (1.8–17.5) 8.6 (3.9–17.6) 50.7 (34.4–66.8) 28.5 (11.9–54.1) 6.0 (1.3–23.7) 12.0 (3.8–31.8) 2.8 (0.3–20.6) Girls

Table 11: Estimated cost of cigarettes among students 13–15 years old, by gender and smoking status – GYTS Bhutan, 2013 Cost of a pack (20 cigarettes)1 Less than Nu. 50 Nu. 50–100 Nu. 101–150 Nu. 151–200 Nu. 201–250 Nu. 251–300 Nu. 301–350 Total Overall Boys Percentage (95% CI) 24.2 (19.2–29.9 24.1 (18.6–30.6) 11.9 (9.1–15.5) 22.5 (17.6–28.2) 10.5 (7.2–15.1) 3.0 (1.8–4.9) 3.8 (2.4–6.2) 100 23.2 (15.9–32.5 24.3 (18.1–31.7) 12.5 (8.3–18.3) 22.8 (15.8–31.5) 11.8 (7.7–17.6) 1.7 (0.8–3.6) 3.9 (2.1–6.9) 100 25.5 (19.5–32.6 23.9 (17.5–31.7) 11.2 (9.4–13.3) 22.1 (18.0–26.8) 8.9 (4.8–15.9) 4.6 (2.1–9.8) 3.8 (1.8–7.8) 100 Girls

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Table 12: Noticed anti-tobacco information among students 13–15 years old, by gender – GYTS Indicators Noticed anti-tobacco messages in the media1 in the past 30 days2 Overall Boys Percentage (95% CI) 74.0 (70.4–77.2) 72.7 (67.2–77.5) 75.1 (71.7–78.2) Girls

Noticed anti-tobacco messages at sporting or community events Among all students in the past 30 days Among those who attended sporting or community events in the past 30 days Taught in school about the dangers of tobacco use in the past 12 months2 1 2

32.6 (30.1–35.3) 59.3 (55.4–63.0) 60.8 (55.9–65.4)

33.4 (29.1–38.0) 56.8 (49.7–63.5) 60.8 (53.6–67.7)

32.0 (28.7–35.5) 61.6 (55.9–67.0) 60.7 (56.4–64.9)

For example, television, radio, internet, billboards, posters, newspapers, magazines, movies Among all students aged 13–15 years old

Table 13: Noticed health warnings on cigarette packages among current and never smokers 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Current smokers who noticed health warnings on cigarette packages Thought about quitting smoking because of health warnings on cigarette packages (among current smokers) Thought about quitting smoking because of health warnings on cigarette packages (among current smokers who noticed health warnings) Never smokers who thought about not starting smoking because of health warnings on cigarette packages Overall Boys Percentage (95% CI) 73.9 (68.5–78.6) 75.4 (68.9–81.0) 70.1 (61.8–77.3) Girls

37.4 (31.6–43.6)

41.2 (33.3–49.6)

27.9 (18.9–39.1)

50.6 (43.8–57.4)

54.7 (45.7–63.3)

39.9 (27.8–53.3)

29.7 (25.2–34.7)

34.0 (25.8–43.3)

27.4 (23.4–31.9)

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Table 14: Noticed tobacco marketing among students 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Overall Boys Percentage (95% CI) Girls

Noticed tobacco advertisements or promotions at points of sale Among all students in the past 30 days Among those who visited a point of sale in the past 30 days 31.2 (26.5–36.3) 43.6 (37.9–49.6) 33.5 (27.6–39.9) 46.4 (39.8–53.1) 29.4 (23.7–35.7) 41.3 (33.4–49.7)

Noticed anyone using tobacco on television, videos, or movies Among all students in the past 30 days Among those who watched television, videos, or movies in the past 30 days Ever offered a free tobacco product from a tobacco company representative 70.0 (67.0–72.9) 79.8 (77.3–82.1) 9.7 (8.1–11.6) 70.0 (67.0–72.9) 79.0 (74.9–82.5) 11.9 (8.7–16.0) 71.7 (67.8–75.4) 80.5 (77.3–83.4) 7.9 (6.5–9.6)

Table 15: Ownership and receptivity to tobacco marketing among students 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Students who1… Owned something with a tobacco brand logo on it2 Owned something with a tobacco brand logo on it or might in the future 1

Overall

Boys Percentage (95% CI)

Girls

14.0 (12.0 –16.3) 36.9 (31.9 –42.1)

33.5 (27.6–39.9) 38.7 (32.9–44.8)

29.4 (23.7–35.7) 35.8 (29.8–42.3)

Never smokers who might use or wear something that has a tobacco company or product name or picture on it. For example, a T-shirt, pen, backpack

2

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Table 16: Knowledge and attitudes towards smoking cessation and social smoking among students 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Students who… Definitely thought it is difficult to quit once someone starts smoking tobacco Thought smoking tobacco helps people feel more comfortable at celebrations, parties and social gatherings 46.6 (42.3–51.0) 45.2 (40.3–50.3) 47.8 (42.6–53.1) Overall Boys Percentage (95% CI) Girls

13.4 (11.7–15.5)

17.4 (14.4–21.1)

10.2 (7.9–12.9)

Table 17: Knowledge and attitudes towards secondhand smoke among students 13–15 years old, by gender – GYTS Bhutan, 2013 Indicators Definitely thought other people’s tobacco smoking is harmful to them Favoured banning smoking inside enclosed public places Favoured banning smoking at outdoor public places Overall Boys Percentage (95% CI) 78.9 (75.3 - 82.1) 49.1 (43.2 - 55.1) 49.1 (43.5 - 54.7) 78.5 (72.4 - 83.6) 50.5 (42.8 - 58.1) 52.0 (44.8 - 59.1) 79.2 (75.1 - 82.9) 48.0 (41.7 - 54.5) 46.7 (39.4 - 54.1) Girls

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Annex 4

Comparative tables 2004 Boys Percentage (95% CI) Tobacco use Girls Overall Boys Girls Overall Boys Girls 2006 2009 Overall 2013 Boys Girls

Bhutan Report, 2013 2.1 (1.0– 4.3) 0.2 (0.0– 1.9) 0.6 (0.3– 1.3) 1.0 (0.3– 3.0) 0.2 (0.0– 2.0) 2.1 (1.1– 3.8) 3.3 (1.9– 5.6) 1.2 (0.4– 3.2) 1.5 (0.9– 2.4) 3.0 (1.7– 5.2) 10.0 (6.0–16.2) NA NA NA NA 4.5 (2.8– 7.4) 10.0 14.5 6.0 (8.0–12.5) (10.0–20.5) (4.3– 8.3) NA

Comparison of indicators from Bhutan GYTS 2004, 2006, 2009 and 2013

Prevalence

Overall

Smoked tobacco 12.1 18.3 6.3 12.4 18.3 7.9 14.0 23.1 6.6 (9.6–15.2) (13.8–23.8) (4.1– 9.6) (10.0–15.3) (13.9–23.7) (6.0–10.4) (11.8–16.4) (19.0–27.6) (4.8– 9.0) 0.2 (0.0– 1.1)

Current cigarette smokers

10.1 14.6 4.9 (7.7–13.1) (10.3–20.2) (3.2– 7.4)

Frequent cigarette smokers

1.2 (0.7– 2.0)

Ever cigarette smokers

19.3 25.4 12.6 22.0 33.0 12.2 22.2 33.3 14.0 27.3 43.2 14.3 (15.4–23.9) (18.6–33.8) (9.2–16.9) (18.3–26.2) (26.0–40.8) (9.3–15.7) (19.2–25.7) (27.3–40.0) (11.5–16.9) (23.8–31.2) (37.4–49.1) (10.8–18.8)

Smokeless tobacco 9.4 14.1 5.3 21.6 25.0 18.9 (7.3–12.1) (10.7–18.3) (3.4– 8.2) (18.5–25.2) (21.7–28.6) (14.6–24.1) 14.0 17.7 10.7 35.7 40.0 32.2 (11.5–17.0) (13.8–22.5) (8.1–13.9) (31.0–40.8) (34.5–45.7) (26.9–38.1)

Current smokeless tobacco users

7.4 (5.2–10.6)

Ever smokeless tobacco users

NA

Tobacco use

Current tobacco users

17.3 21.7 11.9 20.2 28.6 12.4 18.8 27.6 11.6 30.3 39.0 23.2 (13.2–22.3) (15.5–29.4) (8.1–17.3) (17.3–23.4) (23.2–34.7) (9.6–15.8) (15.8–22.2) (22.9–32.8) (8.9–15.0) (26.2–34.7) (33.7–44.5) (19.0–28.0)

2004 Boys Percentage (95% CI) Girls Overall Boys Girls Overall Boys Girls Overall Boys Girls

2006

2009

2013

Prevalence

Overall

Susceptibility 10.5 (7.2–15.2) 11.5 (8.5–15.3) 11.0 15.2 7.8 (8.4–14.1) (11.1–20.6) (4.9–12.2) 8.0 (5.9–10.6) 9.1 (5.5–14.5) 7.3 (5.3–10.0) 6.7 (5.4– 8.3) 7.4 (5.0–10.8) 6.4 (4.9– 8.2)

Never tobacco users susceptible to tobacco use Cessation

10.9 (9.2–13.0)

Tried to stop smoking in the past 12 months§

81.8 80.4 80.3 85.4 82.7 88.9 84.1 83.2 84.2 83.1 82.1 85.8 (69.9–89.7) (59.4–92.0)* (51.5–94.0)* (72.4–92.9) (70.2–90.7) (65.4–97.1)* (71.6–91.8) (65.2–92.9) (65.1–93.8) (72.3–90.2) (71.4–89.3) (63.5–95.5)*

Want to stop smoking now§ 100* 88.1 91.2 83.8 77.1 76.4 (77.5–94.0) (73.4–97.5) (60.7–94.6)* (63.7–86.6) (59.2–87.8)

87.0 87.1 90.1 91.7 89.1 96.4 79.1 79.5 76.9 81.8 87.4 65.9 (69.7–95.1) (66.7–95.8)* (47.3–98.9)* (81.0–96.7) (76.6–95.3) (73.6–99.6)* (63.6–89.2) (62.7–90.0) (55.9–89.7)* (65.3–91.5) (74.7–94.2) (34.2–87.8)* 75.8 (47.0– 91.7)* 83.8 87.3 74.0 (74.4–90.2) (76.8–93.5) (56.2–86.3)*

Thought they would be able to stop§ Secondhand smoke

84.4 80.2 (71.0–92.3) (67.8–88.6)*

Exposed to tobacco smoke at home

29.2 30.7 27.0 31.9 32.5 31.1 29.5 29.2 29.5 15.3 16.3 14.4 (25.2–33.5) (24.4–37.7) (22.9–31.6) (29.0–35.1) (26.9–38.5) (28.0–34.5) (25.9–33.4) (24.3–34.6) (25.1–34.3) (13.0–17.9) (11.5–22.5) (12.2–17.0)

Exposed to tobacco smoke inside any enclosed public place†

47.4 45.0 49.5 54.5 57.8 51.7 59.4 58.6 59.7 42.8 43.0 42.7 (40.7–54.3) (35.1–55.4) (42.5–56.6) (47.2–61.6) (49.4–65.8) (43.8–59.6) (54.5–64.0) (54.1–63.0) (53.7–65.4) (39.1–46.6) (37.9–48.3) (38.4–47.1)

Access and availability 49.2 11.7 36.4 40.6 30.2 23.7 28.5 17.2 54.5 58.0 45.3

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Buying them from a store (29.3–54.4) (32.4–66.1) (3.9–29.9)* (24.8–49.8) (28.0–54.4) (11.8–58.3)* (16.4–33.0) (17.2–43.3) (9.7–28.8) (46.5–62.4) (49.9–65.6) (29.5–62.1)

41.3

Not prevented from 71.3 72.2 40.3 59.2 59.7 64.2 53.4 48.3 64.3 47.8 47.4 48.7 buying cigarettes because (42.9–89.1)* (42.0–90.3)* (2.2–95.3)* (42.2–74.2) (42.8–74.5)* (37.9–84.1)* (35.4–70.6)* (26.1–71.3)* (28.1–89.2)* (39.4–56.3) (36.5–58.6) (32.2–65.6) of their age

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2004 Boys Percentage (95% CI) Media Girls Overall Boys Girls Overall Boys Girls Overall Boys

2006

2009

2013 Girls

Bhutan Report, 2013 11.1 (8.0–15.1) NA NA 10.5 (8.7–12.6) 11.9 (8.4–16.7) 14.1 (9.9–19.6) 8.6 (6.1–12.1) NA 9.7 (8.1–11.6) 11.9 (8.7–16.0) 8.0 (4.1–14.7) 10.2 (7.5–13.8)

Prevalence

Overall

Tobacco industry advertising

Noticed anyone using tobacco on television, videos, or movies

93.0 93.7 92.9 93.5 91.9 94.9 98.4 98.9 98.2 79.8 79.0 80.5 (89.9–95.2) (89.2–96.4) (89.3–95.4) (89.7–96.0) (85.0–95.7) (92.0–96.8) (96.2–99.3) (96.2–99.7) (94.8–99.4) (77.3–82.1) (74.9–82.5) (77.3–83.4)

Ever offered a free tobacco product from a tobacco company§§

13.7 14.0 12.9 (11.4–16.5) (11.0–17.7) (9.5–17.3)

7.9 (6.5– 9.6)

Owned something with a tobacco brand logo on it

9.1 (6.6–12.6)

9.2 14.9 17.7 12.5 14.0 18.6 10.2 (7.0–11.9) (11.5–18.9) (12.8–23.8) (8.6–17.8) (12.0–16.3) (15.7–21.9) (7.9–13.0)

Anti-tobacco advertising

Anti-tobacco messages in the media

74.5 71.9 76.5 82.6 83.7 81.6 86.9 85.2 88.3 74.0 72.7 75.1 (69.2–79.3) (62.3–79.8) (66.1–84.5) (76.4–87.4) (77.4–88.5) (74.2–87.2) (83.4–89.8) (80.0–89.3) (82.2–92.5) (70.4–77.2) (67.2–77.5) (71.7–78.2)

Anti-tobacco messages 71.9 72.3 71.0 79.2 78.0 79.6 83.1 84.4 82.1 59.3 56.8 61.6 at sporting or community (64.8–78.2) (62.9–80.1) (61.2–79.1) (72.3–84.8) (70.3–84.1) (72.3–85.3) (79.8–86.0) (75.5–90.5) (76.5–86.6) (55.4–63.0) (49.7–63.5) (55.9–67.0) events

Taught in school about the dangers of tobacco use

56.7 57.9 55.6 59.8 59.9 59.2 61.6 63.8 60.9 60.8 60.8 60.7 (49.5–63.5) (50.3–65.1) (46.6–64.2) (52.7–66.5) (51.7–67.7) (52.5–65.5) (55.8–67.1) (56.6–70.4) (54.9–66.7) (55.9–65.4) (53.6–67.7) (56.4–64.9)

2004 Boys Percentage (95% CI) Knowledge and attitudes Girls Overall Boys Girls Overall Boys Girls Overall Boys Girls

2006

2009

2013

Prevalence

Overall

Definitely thought other 63.4 61.9 64.3 62.1 64.6 60.5 72.8 73.5 72.4 78.9 78.5 79.2 people's tobacco smoking (57.7–68.8) (52.5–70.6) (59.0–69.3) (55.3–68.4) (57.4–71.1) (52.3–68.2) (67.4–77.7) (66.7–79.4) (66.3–77.7) (75.3–82.1) (72.4–83.6) (75.1–82.9) is harmful to them

Favoured banning smok19.8 21.7 17.9 47.0 49.6 45.0 44.1 45.4 42.9 49.1 50.5 48.0 ing inside enclosed public (12.5–29.9) (13.9–32.2) (10.8–28.3) (37.2–57.1) (39.7–59.7) (34.9–55.6) (35.5–53.1) (37.4–53.7) (33.0–53.4) (43.2–55.1) (42.8–58.1) (41.7–54.5) places†

* Cell size is less than 35 NA: Indicator was not included in survey § Among current cigarette users/2013 among current smoked tobacco users † Enclosed or outdoor public places/2013 Enclosed public places §§ Cigarette brand/2013 tobacco brand

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Annex 5

Factsheet GYTS –Bhutan 2013

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9 789290 224808