Tobacco Questions for Surveys of Youth (TQS-Youth) A Subset of Key Questions from the Global Youth Tobacco Survey (GYTS)
Tobacco Questions for Surveys of Youth (TQS-Youth) A Subset of Key Questions from the Global Youth Tobacco Survey (GYTS) iv Tobacco questions for surveys of youth (TQS-Youth): a subset of key questions from the Global Youth Tobacco Survey (GYTS) ISBN 978-92-4-151557-3 © World Health Organization 2019 Some rights reserved. This work is available under the Creative Commons Attribution-Non Commercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The contributors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the Centers for Disease Control and Prevention (CDC). Printed in the United States of America. vContents Section Page Global Tobacco Surveillance System vii Preface 1 1. Why Use Standardized Questions in Tobacco Surveys? 3 2. Overview of the Youth Tobacco Questions 5 3. Tobacco Use Prevalence 10 4. Cessation 14 5. Exposure to Secondhand Smoke 16 6. Cigarette Accessibility 19 7. Anti-Tobacco Information 21 8. Tobacco Advertising and Promotions 24 9. Electronic Cigarettes 26 10. Analysis of Tobacco Questions 28 Appendix A: GYTS Overview 34 Appendix B: Question Mapping to GYTS 36 Acknowledgments 37 Contact Information 38 vi Tables Table 2-1. Measuring Tobacco Use Prevalence 6 Table 2-2. Measuring Key Aspects of Tobacco Surveillance 7 Table 10-1. Detailed tobacco use status, overall and by gender 28 Table 10-2. Age at cigarette smoking initiation among ever cigarette smokers, overall and by gender 29 Table 10-3. Smoking tobacco cessation indicators among current smokers, overall and by gender 29 Table 10-4. Exposure to secondhand smoking, overall and by gender 30 Table 10-5. Current cigarette smokers who were not prevented from buying cigarettes because of their age, overall and by gender 30 Table 10-6. Unit of cigarette purchase among current cigarette smokers, overall and by gender 31 Table 10-7. Noticing anti-tobacco information, overall and by gender 31 Table 10-8. Noticing health warnings on cigarette packages among current and never cigarette smokers, overall and by gender 32 Table 10-9. Exposure to tobacco marketing, overall and by gender 32 Table 10-10. Awareness, ever use, and current use of electronic cigarettes, overall and by gender 33 vii In 1998, the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and partners initiated the Global Tobacco Surveillance System (GTSS) to assist countries in establishing tobacco control surveillance and monitoring programs. Current active components of GTSS include the Global Youth Tobacco Survey (GYTS) (a school-based survey), the Global Adult Tobacco Survey (GATS) (a household survey), and Tobacco Questions for Surveys (TQS) (a standard set of questions on tobacco use that can be incorporated into any adult survey). These components provide a consistent framework for surveillance including standard sampling procedures, core questionnaire items, training in field procedures, data analysis, and consistent reporting across all participating countries. The latest component of GTSS is the Tobacco Questions for Surveys of Youth (TQS-Youth). TQS-Youth has been developed to provide a standard set of survey questions on tobacco use for youth surveys in order to improve survey comparability over time and harmonize questions across global surveillance and monitoring efforts. GTSS enhances the role of government and the nongovernmental sector(s) in surveillance, monitoring of tobacco use and key tobacco control indicators, and policy and program interventions. The synergy between countries passing tobacco control laws, regulations or decrees, ratifying and complying with the WHO Framework Convention on Tobacco Control, and conducting GTSS surveys offers opportunities to develop, implement, and evaluate comprehensive tobacco control policies. GTSS reflects ongoing efforts to establish tobacco control surveillance and monitoring programs to track trends over time in tobacco-related knowledge, attitudes, behaviors and environmental influences. Global Tobacco Surveillance System viii 1Preface Given the global acceptance and success of the Tobacco Questions for Surveys (TQS), GTSS partners developed a version to use in youth surveys. TQS is a subset of key survey questions from the Global Adult Tobacco Survey (GATS) to be used in adult surveys that want to include questions on tobacco. The TQS questions can be used as a standalone survey but are most often integrated in existing surveys (e.g., multi-risk factor surveys, national health surveys). This document Tobacco Questions for Surveys of Youth (TQS-Youth) has been prepared for youth surveys that want to include questions on tobacco. If national and sub-national surveys use the questions and response categories in this guide, this could help to improve survey comparability over time and harmonize them with international tobacco surveillance and monitoring activities. The survey questions in this guide are from the Global Youth Tobacco Survey (GYTS) questionnaire. GYTS was developed to provide a global standard protocol for consistent monitoring of tobacco use among youth who attend school. It is a school-based survey providing nationally representative data for youth in grades associated with the ages 13 to 15 years. GYTS uses a standard and consistent core questionnaire, sample design, and data collection procedures that were created by experts from developed and developing countries. The survey produces estimates on tobacco use (smoking and smokeless), exposure to secondhand smoke, tobacco use cessation, access and availability to tobacco, awareness of anti-tobacco information, and exposure to tobacco marketing. GYTS is intended to assist countries to design, implement and evaluate tobacco control and prevention programs targeting youth. A detailed overview of GYTS can be found in Appendix A. The questions in this guide are mapped to the GYTS Core Questionnaire in Appendix B. In order to maintain consistency and comparability in monitoring tobacco use among youth globally and keep-up with the ever changing tobacco control landscape, it is critical that a standard set of survey questions on tobacco use be implemented across various surveys. To address possible gaps in youth tobacco surveillance, GTSS partners have created this Tobacco Questions for Surveys of Youth (TQS-Youth) booklet that includes a subset of key survey questions from the GYTS. Surveys can select indicators and corresponding questions from this list to include based on their particular focus or priority, or incorporate the complete set if appropriate. 2This guide: » Explains why it is important to adopt a standard set of tobacco questions in surveys. » Introduces a set of questions on tobacco and the corresponding analysis indicators including: • Tobacco use prevalence questions, which are essential for monitoring tobacco use rates. • Additional questions covering key aspects of tobacco control policies. » Explains how survey data from the questions are used to estimate key tobacco indicators. 31. Why Use Standardized Questions in Tobacco Surveys? 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. 1. WHO Report on the Global Tobacco Epidemic, 2017: Monitoring Tobacco Use and Prevention Policies, ISBN 978-92-4-151282-4. Tobacco use is a major preventable cause of premature death and disease worldwide. Approximately seven million people die each year due to tobacco-related illnesses – a figure expected to increase to more than eight million a year by 20301. Unless the current trend is changed, the vast majority of these deaths are projected to occur in the developing world. The WHO Framework Convention on Tobacco Control (WHO FCTC) was developed in response to the globalization of the tobacco epidemic. The WHO FCTC and its guidelines provide the foundation for countries to implement and manage tobacco control, and set the baseline for reducing both demand for and supply of tobacco. To assist countries in meeting the WHO FCTC requirements, WHO introduced MPOWER, a technical package of selected demand reduction measures contained in the WHO FCTC. (Further information about WHO’s Tobacco Free Initiative can be found at www. who.int/tobacco). As described in Article 20 (Research, surveillance, and exchange of information) and Article 21 (Reporting and exchange of information) of the WHO FCTC, an efficient and systematic surveillance mechanism to monitor the tobacco epidemic is an essential component of comprehensive tobacco control. In order to maintain consistency and comparability in monitoring tobacco use, a standard set of tobacco use survey questions could be implemented across various surveillance activities. The GATS and GYTS were developed to meet this need by generating comparable data within and across countries. The TQS and TQS-Youth provide standardized tobacco questions for integration into other existing surveys for continuous surveillance and/or when it is not feasible for countries to conduct GATS or GYTS. 4The TQS and TQS-Youth survey questions can become the worldwide standard for core tobacco use questions, greatly enhancing the capacity of all stakeholders for monitoring tobacco use and tobacco control interventions. With the expanded use of these standardized questions, the pool of reliable data could increase, potentially leading to quality estimates at country, regional and global levels. Using these data will be important to help reduce tobacco use among youth, which will ultimately contribute to the attainment of the United Nations’ Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages). 5The 21 survey questions in this guide assess key aspects of youth tobacco use surveillance. The questions are not exhaustive, but serve as a key set to include in youth surveys. Surveys can select particular questions and corresponding analysis indicators from this set or incorporate all of the questions, if suitable. This structure was developed so that the surveys could pick and choose from the various analysis indicators and questions based on their needs and tobacco control situations if they are unable to add all of the questions. There are five key questions that measure tobacco use prevalence. These questions are the highest priority measures and it is critical that these questions be included in all surveys that measure youth tobacco use. Thus, for surveys with only a few question spots available, these questions could be incorporated. Table 2-1 below provides a summary description of these five questions and corresponding analysis indicators. 2. Overview of the Youth Tobacco Questions The five tobacco use prevalence questions should be included in all surveys that measure tobacco use. Surveys can then select additional questions covering key topics as appropriate. 6The other 16 questions in this guide cover additional key topics related to tobacco control policies including cessation, secondhand smoke (SHS) exposure, cigarette accessibility, anti-tobacco information, tobacco marketing, and electronic cigarettes. Table 2-2 provides a summary description of these questions and corresponding analysis indicators. Note that for surveys that want to include some or all of these questions, the five tobacco use prevalence questions (Q1-Q5 discussed above) need to be included as well, for proper survey administration and analysis indicator construction. Table 2-1. Measuring Tobacco Use Prevalence Tobacco Topic Indicator Name and Description To ba cc o U se Q1. Ever cigarette smoking Q2. Age at cigarette smoking initiation Q3. Current cigarette smoking Q4. Current other tobacco smoking Q5. Current smokeless tobacco use Ever Cigarette Smokers Percentage of youth who ever smoked a cigarette. Age at Cigarette Smoking Initiation Percentage of youth who first tried a cigarette at the age of [7 or younger; 8 or 9; 10 or 11; 12 or 13; 14 or 15] years old. Current Tobacco Smokers Percentage of youth who currently smoke any tobacco products. Current Cigarette Smokers Percentage of youth who currently smoke cigarettes. Frequent Cigarette Smokers Percentage of youth who smoked cigarettes on 20 or more days of the past 30 days. Current Smokers of Other Products Percentage of youth who currently smoke tobacco products other than cigarettes. Current Smokeless Tobacco Users Percentage of youth who currently use smokeless tobacco products. Current Tobacco Users Percentage of youth who currently use any tobacco products. 7Table 2-2. Measuring Key Aspects of Tobacco Surveillance Tobacco Topic Indicator Name and Description Ce ss at io n Q6. Attempts to quit smoking Attempt to Stop Smoking in the Past 12 Months Percentage of current smokers who tried to stop smoking during the past 12 months. Q7. Receiving advice to quit smoking Received Help to Stop Smoking Percentage of current smokers who have ever received help/advice to stop smoking from a program or professional. Se co nd ha nd Sm ok e Q8. SHS exposure inside the home Exposure to Secondhand Smoke Inside the Home Percentage of youth who were exposed to tobacco smoke inside the home in the past 7 days. Q9. SHS exposure inside public places Exposure to Secondhand Smoke in Enclosed Public Places Percentage of youth who were exposed to tobacco smoke inside enclosed public places in the past 7 days. Q10. SHS exposure at school Exposure to Secondhand Smoke at School Percentage of youth who saw anyone smoking inside the school building or outside on school property in the past 30 days. Ac ce ss ib ili ty Q11. Access to purchasing cigarettes Minors’ Access to Purchasing Cigarettes Percentage of current cigarette smokers who were not prevented from buying cigarettes in the past 30 days because of their age. Q12. Unit of cigarette purchase Unit of Purchased Cigarettes Percentage of current cigarette smokers who last bought cigarettes as [individual sticks; packs, cartons; loose tobacco for hand-rolled cigarettes] in the past 30 days. 8An ti- To ba cc o I nf or m at io n Q13. Anti-tobacco messages in the media Awareness of Anti-Tobacco Messages in the Media Percentage of youth who saw or heard any anti-tobacco messages in the media in the past 30 days. Q14. Cigarette pack health warnings Noticing Health Warnings on Cigarette Packages Percentage of current cigarette smokers who noticed health warnings on cigarette packages in the past 30 days. Thinking of Quitting Because of Health Warnings on Cigarette Packages (Among All Current Cigarette Smokers) Percentage of current cigarette smokers who thought about quitting smoking in the past 30 days because of health warnings on cigarette packages. Thinking of Quitting Because of Health Warnings on Cigarette Packages (Among Current Cigarette Smokers who Noticed Health Warnings) Percentage of current cigarette smokers who noticed health warnings on cigarette packages in the past 30 days, who thought about quitting smoking because of the health warnings. Thinking of Not Starting Smoking Because of Health Warnings on Cigarette Packages Percentage of never cigarette smokers who thought about not starting smoking in the past 30 days because of health warnings on cigarette packages. Q15. Learning about dangers of tobacco use at school Learning About Dangers of Tobacco Use at School Percentage of youth who were taught about the dangers of tobacco use in class during the past 12 months. To ba cc o A dv er tis in g & Pr om ot io ns Q16. Tobacco marketing at points of sale Awareness of Tobacco Marketing at Points of Sale (Among the Target Population) Percentage of youth who saw any tobacco marketing at points of sale in the past 30 days. Awareness of Tobacco Marketing at Points of Sale (Among Those who Visited Points of Sale) Percentage of youth who visited points of sale in the past 30 days who saw any tobacco marketing at the points of sale. Q17. Owning items with tobacco brand logos Ownership of an Object with a Tobacco Brand Logo Percentage of youth who have something with a tobacco product brand logo on it. Q18. Free tobacco promotion Exposure to Free Tobacco Promotion Percentage of youth who were ever offered a free tobacco product from a tobacco company representative. 9All of the TQS-Youth questions are described in detail in the subsequent sections. This includes: question wording, response options, purpose of including question, and construction of analysis indicators. The last section of this guide provides example tables for reporting the indicators. Note that the format of the questions and corresponding details are specific to GYTS. GYTS is a self-administered paper questionnaire that does not include any skip patterns and provides a set of possible responses for each question that are mutually exclusive and exhaustive. Because there are no skip patterns in GYTS, editing rules are sometimes applied for inconsistent answers. (GYTS documentation on editing rules can be provided by CDC.) The survey questions in this guide can be adapted for other survey modes of administration (e.g., interviewer administered). For example, skip logic instructions can be added for surveys that use them, which would negate the need for including the ‘not applicable’ type of response options. In addition, while GYTS is typically administered to 13 to 15 year old students, these questions can be administered to youth outside of this age range (e.g., 12 to 17 year olds). E- cig ar et te s Q19. Awareness of electronic cigarettes Ever Heard of Electronic Cigarettes: Percentage of youth who have ever heard of electronic cigarettes. Q20. Current use of electronic cigarettes Current Electronic Cigarette Users: Percentage of youth who currently use electronic cigarettes. Q21. Ever use of electronic cigarettes Ever Electronic Cigarette Users: Percentage of youth who ever used an electronic cigarette. 10 3. Tobacco Use Prevalence The highest priority indicators are constructed from the five questions used to assess the prevalence of tobacco use. Q1 measures ever use of cigarettes and Q2 measures age of initiation of cigarette smoking. Questions 3 through 5 measure current use of: cigarettes (Q3), other smoked tobacco (Q4), and smokeless tobacco (Q5). It is imperative that these questions be included in any youth survey that wants to examine basic tobacco use prevalence rates. Q1. Ever Cigarette Smoking Have you ever tried or experimented with cigarette smoking, even one or two puffs? a. Yes b. No Purpose Determines whether respondents ever smoked a cigarette. Indicator Ever Cigarette Smokers: Percentage of youth who ever smoked a cigarette. Numerator: Number of respondents who tried or experimented with cigarette smoking, even one or two puffs. Denominator: Total number of respondents to the question. 11 Q2. Age at Cigarette Smoking Initiation 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 Purpose Determines age at cigarette smoking initiation. Notes The age categories can be adjusted depending on the age of the survey respondents. Indicator Age at Cigarette Smoking Initiation: Percentage of ever cigarette smokers who first tried a cigarette at the age of [7 or younger; 8 or 9; 10 or 11; 12 or 13; 14 or 15] years old. Numerator: Number of ever cigarette smokers who reported trying a cigarette at the age of [7 or younger; 8 or 9; 10 or 11; 12 or 13; 14 or 15] years old. Denominator: Number of ever cigarette smokers. (The analysis of this question should be restricted to Ever Cigarette Smokers, as previously defined. Q2=a responses should be excluded from the denominator.) 12 Q3. Current Cigarette Smoking 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 Q4. Current Other Tobacco Smoking During the past 30 days, did you use any form of smoked tobacco products other than cigarettes, (such as FILL APPROPRIATE COUNTRY EXAMPLES)? a. Yes b. No Q5. Current Smokeless Tobacco Use During the past 30 days, did you use any form of smokeless tobacco products (such as FILL APPROPRIATE COUNTRY EXAMPLES)? a. Yes b. No 13 Purpose These three questions determine the current tobacco use status of the respondents. Notes Appropriate examples of other smoked tobacco products and smokeless tobacco products should be included for the specific country. Additional questions measuring specific other smoked tobacco products can be included if deemed important (e.g., measuring prevalence of waterpipe tobacco smoking). Indicator 1 Current Tobacco Smokers: Percentage of youth who currently smoke any tobacco products. Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days (Q3=b through g) or any other smoked tobacco products in the past 30 days (Q4=a). Denominator: Total number of respondents to the questions. Indicator 2 Current Cigarette Smokers: Percentage of youth who currently smoke cigarettes. Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days (Q3=b through g). Denominator: Total number of respondents to the question. Indicator 3 Frequent Cigarette Smokers: 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 (Q3=f or g). Denominator: Total number of respondents to the question. Indicator 4 Current Smokers of Other Products: Percentage of youth who currently smoke tobacco products other than cigarettes. Numerator: Number of respondents who smoked tobacco products other than cigarettes during the past 30 days (Q4=a). Denominator: Total number of respondents to the question. Indicator 5 Current Smokeless Tobacco Users: Percentage of youth who currently use smokeless tobacco products. Numerator: Number of respondents who used any smokeless tobacco products in the past 30 days (Q5=a). Denominator: Total number of respondents to the question. Indicator 6 Current Tobacco Users: Percentage of youth who currently use any tobacco products. Numerator: Number of respondents who smoked cigarettes on 1 or more days in the past 30 days (Q3=b through g) or smoked any tobacco products other than cigarettes in the past 30 days (Q4=a) or used any smokeless tobacco products in the past 30 days (Q5=a). Denominator: Total number of respondents to the questions. 14 4. Cessation Two concepts are measured with these questions: 1) Attempt of current tobacco smokers to quit (Q6), and 2) Receiving help/advice to quit (Q7). Q6. Attempts to Quit Smoking During the past 12 months, did you ever try to stop smoking? a. I have never smoked b. I did not smoke during the past 12 months c. Yes d. No Purpose Determines if current tobacco smokers have tried to quit in the last 12 months. Indicator Attempt to Stop Smoking in the Past 12 Months: Percentage of current tobacco smokers who tried to stop smoking during the past 12 months. Numerator: Number of current tobacco smokers who tried to stop smoking during the past 12 months (Q6=c). Denominator: Number of current tobacco smokers. (The analysis of this question should be restricted to Current Tobacco Smokers, as previously defined. Q6=a or b responses should be excluded from the denominator.) 15 Q7. Receiving Advice to Quit Smoking Have you ever received help or advice to help you stop smoking? [SELECT ONLY ONE RESPONSE] a. I have never smoked b. Yes, from a program or professional c. Yes, from a friend d. Yes, from a family member e. Yes, from both programs or professionals and from friends or family members f. No Purpose Determines whether respondents received help or advice to stop smoking tobacco. Indicator Received Help to Stop Smoking: Percentage of current tobacco smokers who have ever received help/ advice to stop smoking from a program or professional. Numerator: Number of current tobacco smokers who received any help/advice from a program or professional to help them stop smoking (Q7=b or e). Denominator: Number of current tobacco smokers. (The analysis of this question should be restricted to Current Tobacco Smokers, as previously defined. Q7=a responses should be excluded from the denominator.) 16 5. Exposure to Secondhand Smoke These questions measure secondhand smoke (SHS) exposure inside the home (Q8), inside enclosed public places (Q9), and at school (Q10). Q8. SHS Exposure Inside the Home During the past 7 days, on how many days has anyone smoked inside your home, in your presence? a. 0 days b. 1 to 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days Purpose Determines whether respondents were exposed to secondhand smoke inside their homes. Indicator Exposure to Secondhand Smoke Inside the Home: Percentage of youth who were exposed to tobacco smoke inside the home in the past 7 days. Numerator: Number of respondents who reported that smoking occurred in their presence inside their home on 1 or more days in the past 7 days (Q8=b through e). Denominator: Total number of respondents to the question. 17 Q9. SHS Exposure Inside Public Places 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 FILL APPROPRIATE COUNTRY EXAMPLES: school, shops, restaurants, shopping malls, movie theaters)? a. 0 days b. 1 to 2 days c. 3 to 4 days d. 5 to 6 days e. 7 days Purpose Determines whether respondents were exposed to secondhand smoke inside enclosed public places. Notes Appropriate examples of enclosed public places should be included for the specific country. Indicator Exposure to Secondhand Smoke in Enclosed Public Places: Percentage of youth who were exposed to tobacco smoke inside enclosed public places in the past 7 days. Numerator: Number of respondents who reported that smoking occurred in their presence inside any enclosed public place other than their home (such as schools, shops, restaurants, shopping malls, and movie theaters) in the past 7 days (Q9=b through e). Denominator: Total number of respondents to the question. 18 Q10. SHS Exposure at School During the past 30 days, did you see anyone smoke inside the school building or outside on school property? a. Yes b. No Purpose Determines whether smoking occurred at school. Notes This question assumes the respondent attends school as this GYTS question is from a school-based survey. For general population surveys, an additional response category (or skip logic routing) may be added to indicate if the respondent does not attend school. Indicator Exposure to Secondhand Smoke at School: 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 to the question. 19 6. Cigarette Accessibility These questions measure whether youth were able to purchase cigarettes regardless of their age (Q11) and the unit (e.g., individual sticks, packs) of cigarette purchase (Q12). Q11. Access to Purchasing Cigarettes 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 Purpose Determines if respondents were prevented from purchasing cigarettes because of their age. Notes If applicable for a country, another similar question could be included for other types of tobacco products (e.g., smokeless tobacco). Indicator Minors’ Access to Purchasing Cigarettes: 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 (Q11=c). Denominator: Number of current cigarette smokers who tried to buy cigarettes in the past 30 days. (The analysis of this question should be restricted to Current Cigarette Smokers, as previously defined. Q11=a responses should be excluded from the denominator.) 20 Q12. Unit of Cigarette Purchase 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 tobacco and rolled my own Purpose Determines the unit of the last cigarette purchase. Notes The units can be adjusted for the specific country. If applicable for a country, another similar question could be included for other types of tobacco products (e.g., smokeless tobacco). Indicator Unit of Purchased Cigarettes: Percentage of current cigarette smokers who last bought cigarettes as [individual sticks; packs, cartons; 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; loose tobacco for hand-rolled cigarettes] in the past 30 days. Denominator: Number of current cigarette smokers who bought cigarettes during the past 30 days. (The analysis of this question should be restricted to Current Cigarette Smokers, as previously defined. Q12=a responses should be excluded from the denominator.) 21 7. Anti-Tobacco Information There are three important measures that are included in this section: 1) Awareness of anti- tobacco messages in the media (Q13), 2) Noticing health warnings on cigarette packs and the effects of the warnings (Q14), and 3) Learning about the dangers of tobacco use at school (Q15). Q13. Anti-Tobacco Messages in the Media 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 Purpose Determines if respondents noticed, in the past 30 days, any information in the media against using tobacco (cigarettes, other smoked tobacco, or smokeless tobacco). Indicator Awareness of Anti-Tobacco Messages in the Media: 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 (Q13=a). Denominator: Total number of respondents to the question. 22 Q14. Cigarette Pack Health Warnings During the past 30 days, did you see any health warnings on cigarette packages? a. Yes, but I didn’t think much of them b. Yes, and they led me to think about quitting smoking or not starting smoking c. No Purpose Determines if respondents noticed health warnings on cigarette packages in the past 30 days and if the health warnings had any influence on thinking about quitting or not starting smoking. Notes If applicable for a country, another similar question could be included for other types of tobacco products (e.g., smokeless tobacco). Indicator 1 Noticing Health Warnings on Cigarette Packages: Percentage of current cigarette smokers who noticed health warnings on cigarette packages in the past 30 days. Numerator: Number of current cigarette 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 (Q14=a or b). Denominator: Number of current cigarette smokers. (The analysis of this question should be restricted to Current Cigarette Smokers, as previously defined.) Indicator 2 Thinking of Quitting Because of Health Warnings on Cigarette Packages (Among All Current Cigarette Smokers): Percentage of current cigarette smokers who thought about quitting smoking in the past 30 days because of health warnings on cigarette packages. Numerator: Number of current cigarette smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about quitting smoking (Q14=b). Denominator: Number of current cigarette smokers. (The analysis of this question should be restricted to Current Cigarette Smokers, as previously defined.) Indicator 3 Thinking of Quitting Because of Health Warnings on Cigarette Packages (Among Current Cigarette Smokers who Noticed Health Warnings): Percentage of current cigarette smokers who noticed health warnings on cigarette packages in the past 30 days, who thought about quitting smoking because of the health warnings. Numerator: Number of current cigarette smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about quitting smoking (Q14=b). Denominator: Number of current cigarette smokers who noticed health warnings on cigarette packages in the past 30 days. (The analysis of this question should be restricted to Current Cigarette Smokers, as previously defined. Q14=c responses should be excluded from the denominator.) Indicator 4 Thinking of Not Starting Smoking Because of Health Warnings on Cigarette Packages: Percentage of never cigarette smokers who thought about not starting smoking in the past 30 days because of health warnings on cigarette packages. Numerator: Number of never cigarette smokers who reported that seeing health warnings on cigarette packages in the past 30 days led them to think about not starting smoking (Q14=b). Denominator: Number of never cigarette smokers who saw health warnings on cigarette packages in the past 30 days. (The analysis of this question should be restricted to never cigarette smokers: Q1=b. Q14=c responses should be excluded from the denominator.) 23 Q15. Learning About Dangers of Tobacco Use at School 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 Purpose Determines if the respondents were taught about the dangers of tobacco use (cigarettes, other smoked tobacco, or smokeless tobacco) in school. Indicator Learning About Dangers of Tobacco Use at School: 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 (Q15=a). Denominator: Total number of respondents to the question. (“I don’t know” responses should be included in the denominator.) 24 8. Tobacco Advertising and Promotions These questions measure exposure to tobacco marketing at points of sale (Q16), ownership of something with a tobacco brand logo (Q17), and whether youth were ever offered a free tobacco product from a tobacco company representative (Q18). Q16. Tobacco Marketing at Points of Sale During the past 30 days, did you see any advertisements or promotions for tobacco products at points of sale (such as FILL APPROPRIATE COUNTRY EXAMPLES: stores, shops, kiosk)? a. I did not visit any points of sale in the past 30 days b. Yes c. No Purpose Determines if the respondents have, in the past 30 days, seen advertisements or promotions for tobacco products (cigarettes, other smoked tobacco, or smokeless tobacco) at points of sale. Notes Appropriate examples of points of sale should be included for the specific country. Indicator 1 Awareness of Tobacco Marketing at Points of Sale (Among the Target Population): 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 (Q16=b). Denominator: Total number of respondents to the question. Indicator 2 Awareness of Tobacco Marketing at Points of Sale (Among Those who Visited Points of Sale): 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 points of sale (such as stores, shops, kiosks, etc.) in the past 30 days (Q16=b). Denominator: Number of respondents who visited points of sale in the past 30 days. (Q16=a responses should be excluded from the denominator.) 25 Q17. Owning Items with Tobacco Brand Logos Do you have something (for example, t-shirt, pen, backpack) with a tobacco product brand logo on it? a. Yes b. No Purpose Determines if the respondents own something that has a tobacco product (cigarette, other smoked tobacco, or smokeless tobacco) brand logo on it. Indicator Ownership of an Object with a Tobacco Brand Logo: Percentage of youth who have something with a tobacco product brand logo on it. Numerator: Number of respondents who have something (e.g., t-shirt, pen, backpack) with a tobacco product brand logo on it (Q17=a). Denominator: Total number of respondents to the question. Q18. Free Tobacco Promotion Has a person working for a tobacco company ever offered you a free tobacco product? a. Yes b. No Purpose Determines if the respondents have ever been offered a free tobacco product (cigarette, other smoked tobacco, or smokeless tobacco) from someone who works for a tobacco company. Indicator Exposure to Free Tobacco Promotion: Percentage of youth who were ever offered a free tobacco product from a tobacco company representative. Numerator: Number of respondents who were ever offered a free tobacco product from a tobacco company representative (Q18=a). Denominator: Total number of respondents to the question. 26 9. Electronic Cigarettes These questions measure awareness (Q19), current use (Q20), and ever use (Q21) of electronic cigarettes. Q19. Awareness of Electronic Cigarettes Electronic cigarettes, or e-cigarettes, are electronic devices that usually contain a nicotine-based liquid that is vaporized and inhaled. You may also know them as vape-pens, hookah-pens, electronic hookahs (e-hookahs), electronic cigars (e-cigars), electronic pipes (e-pipes), or e-vaporizers. Some look like cigarettes and others look like pens or small pipes. These are battery-powered devices that produce vapor instead of smoke. Before today, had you ever heard of electronic cigarettes or e-cigarettes? a. Yes b. No Purpose Determines if respondents have ever heard of electronic cigarettes. Indicator Ever Heard of Electronic Cigarettes: Percentage of youth who have ever heard of electronic cigarettes. Numerator: Number of respondents who have heard of electronic cigarettes. Denominator: Total number of respondents to the question. 27 Q20. Current Use of Electronic Cigarettes During the past 30 days, on how many days did you use electronic 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 Purpose Determines if respondents currently use electronic cigarettes. Indicator Current Electronic Cigarette Users: Percentage of youth who currently use electronic cigarettes. Numerator: Number of respondents who used electronic cigarettes on 1 or more days in the past 30 days (Q20=b through g). Denominator: Total number of respondents to the question. Q21. Ever Use of Electronic Cigarettes In total, on how many days have you used an electronic cigarette or e-cigarette in your entire life? a. 0 days b. 1 day c. 2 to 10 days d. 11 to 20 days e. 21 to 50 days f. 51 to 100 days g. More than 100 days Purpose Determines if respondents ever used electronic cigarettes. Indicator Ever Electronic Cigarette Users: Percentage of youth who ever used an electronic cigarette. Numerator: Number of respondents who used electronic cigarettes on 1 or more days in their lifetime (Q21=b through g). Denominator: Total number of respondents to the question. 28 10. Analysis of Tobacco Questions This section provides examples of table shells that serve as a guide for data analysis of the questions. Note that these example tables are specific for GYTS, where the estimates are reported for youth aged 13 to 15 and gender is reported as the key demographic variable. Analysis tables should be adjusted for the specific survey’s design and needs. Tobacco Use Prevalence Table 10-1. Detailed tobacco use status, overall and by gender Overall Boys Girls Percentage (95% CI*) Smoked Tobacco Current tobacco smokers1 Current cigarette smokers2 Frequent cigarette smokers3 Current smokers of other tobacco4 Ever cigarette smokers5 Smokeless Tobacco Current smokeless tobacco users6 Tobacco Use Current tobacco users7 1Smoked tobacco anytime during the past 30 days. 2 Smoked cigarettes anytime during the past 30 days. 3 Smoked cigarettes on 20 or more days of the past 30 days. 4 Smoked tobacco other than cigarettes anytime during the past 30 days. 5 Ever smoked cigarettes, even one or two puffs. 6 Used smokeless tobacco anytime during the past 30 days. 7 Smoked cigarettes and/or other smoked tobacco, and/or used smokeless tobacco anytime during the past 30 days. * 95% Confidence Interval 29 Cessation Table 10-3. Smoking tobacco cessation indicators among current smokers, overall and by gender Table 10-2. Age at cigarette smoking initiation among ever cigarette smokers, overall and by gender Overall Boys Girls Percentage (95% CI*) Current smokers who... Tried to stop smoking in the past 12 months Have ever received help/advice from a program or professional to stop smoking Age when first trying a cigarette1 Overall Boys Girls Percentage (95% CI*) 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 100 100 100 1Among those that have ever tried a cigarette. * 95% Confidence Interval * 95% Confidence Interval 30 Table 10-4. Exposure to secondhand smoking, overall and by gender Table 10-5. Current cigarette smokers who were not prevented from buying cigarettes because of their age, overall and by gender Overall Boys Girls Percentage (95% CI*) Exposed to tobacco smoke inside the home in the past 7 days Exposed to tobacco smoke inside any enclosed public place in the past 7 days Saw anyone smoking inside the school building or outside on school property in the past 30 days Overall Boys Girls Percentage (95% CI*) Current cigarette smokers who were not prevented from buying cigarettes because of their age1 * 95% Confidence Interval 1 Among those who tried to buy cigarettes during the past 30 days. * 95% Confidence Interval Exposure to Secondhand Smoke Cigarette Accessibility 31 Table 10-7. Noticing anti-tobacco information, overall and by gender Table 10-6. Unit of cigarette purchase among current cigarette smokers, overall and by gender Overall Boys Girls Percentage (95% CI*) Noticed anti-tobacco messages in the media1 in the past 30 days Taught in school about the dangers of tobacco use in the past 12 months Unit of purchase1 Overall Boys Girls Percentage (95% CI*) Individual sticks Pack Carton Loose tobacco for hand-rolled cigarettes Total 100 100 100 1 For example, television, radio, internet, billboards, posters, newspapers, magazines, movies. * 95% Confidence Interval 1 Based on the last purchase, among those who bought cigarettes during the past 30 days. * 95% Confidence Interval Anti-Tobacco Information 32 Table 10-8. Noticing health warnings on cigarette packages among current and never cigarette smokers, overall and by gender Overall Boys Girls Percentage (95% CI*) Current cigarette smokers who noticed health warnings on cigarette packages1 Thought about quitting smoking because of health warnings on cigarette packages1 Among current cigarette smokers Among current cigarette smokers who noticed health warnings Never cigarette smokers who thought about not starting smoking because of health warnings on cigarette packages1,2 1 During the past 30 days. 2 Among never cigarette smokers who noticed health warnings on cigarette packages in the past 30 days. * 95% Confidence Interval Table 10-9. Exposure to tobacco marketing, overall and by gender Overall Boys Girls Percentage (95% CI*) Noticed tobacco advertisements or promotions at points of sale Among all youth in the past 30 days Among those who visited a point of sale in the past 30 days Students who owned something with a tobacco brand logo on it1 Ever offered a free tobacco product from a tobacco company representative 1 For example, a t-shirt, pen, backpack. * 95% Confidence Interval Tobacco Advertising and Promotions 33 Table 10-10. Awareness, ever use, and current use of electronic cigarettes, overall and by gender Overall Boys Girls Percentage (95% CI*) Ever heard of electronic cigarettes Ever used an electronic cigarette1 Current electronic cigarette users2 1 Used an electronic cigarette on 1 or more days in lifetime. 2 Used an electronic cigarette anytime during the past 30 days. * 95% Confidence Interval Electronic Cigarettes 34 Background In 1998-1999, the Global Youth Tobacco Survey (GYTS) was developed to begin a process for standardized global youth monitoring with the intent to generate internationally comparable data. GYTS is the global standard to systematically monitor youth tobacco use and track key tobacco control indicators. In 2012, the protocol was revised for the first time since its launch to include developments in tobacco control policies and ensure national representation of the surveys as the standard. GYTS is a nationally representative school-based survey of students 13–15 years of age, using a consistent and standard protocol across countries. GYTS estimates indirectly measure the impact of tobacco control and prevention strategies. Corresponding to the MPOWER policy package strategies, GYTS assists countries by monitoring selected demand-related articles of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) — a global health treaty. As of publication of this document, GYTS has been conducted in over 187 countries and sites with 149 completing a second round; 114 completing a third round; and 38 completing a fourth round. Over 120 countries (WHO member and non-member states) have been trained using the 2012 revised protocol. Questionnaire The following topics are covered in the GYTS questionnaire: » Background characteristics » Tobacco smoking » Smokeless tobacco » Cessation » Secondhand smoke » Knowledge and attitudes » Media » School education Appendix A: GYTS Overview 35 Data are collected confidentially using a paper-based, self-administered questionnaire. Students complete the questionnaire in a classroom setting. There are no skip patterns in the questionnaire so all students are requested to answer every question. This is done so that students will complete the questionnaire at approximately the same time to help ensure confidentiality of the answers (e.g., those who currently smoke would have to answer more questions than those who do not.) Sample Design GYTS is a nationally representative school-based survey of students in grades associated with 13 to 15 years of age and is designed to produce cross-sectional estimates for each country. It uses a global standardized methodology that includes a two-stage sample design with schools selected with a probability proportional to enrollment size. The classes within selected schools are chosen randomly and all students in selected classes are eligible to participate in the survey. The sample for each GYTS survey should be designed to obtain completed questionnaires from at least 1,500 students with roughly half the sample respondents being boys and the other half being girls. These minimum sample sizes will generate nationally representative estimates that meet the expected precision requirements of the GYTS. Key Partner Organizations and Roles Partners include national governments (Ministries of Health, Ministries of Education, etc.) and institutions, the World Health Organization (WHO), and the United States Centers for Disease Control and Prevention (CDC). WHO provides global, regional and in-country leadership as well as resource and program support; CDC, a WHO Collaborating Center for Global Tobacco Control, provides technical assistance for implementation of the surveillance system and data analysis and reporting. Globally, CDC supports GYTS financially. In Africa, GYTS is partially funded by the CDC Foundation with grants from Bloomberg Philanthropies’ Bloomberg Initiative to Reduce Tobacco Use and the Bill & Melinda Gates Foundation. Many countries have provided co- funding or in-kind support. Further information about GYTS can be found at: CDC: https://nccd.cdc.gov/GTSSDataSurveyResources/Ancillary/Documentation. aspx?SUID=1&DOCT=1 WHO: www.who.int/tobacco/surveillance/gyts 36 Appendix B: Question Mapping to GYTS The tobacco questions in this guide are taken from the GYTS Core Questionnaire. Reference to the GYTS Core Questionnaire numbering is provided below. Question Number Reference to GYTS Q# Description Q1 C5 Ever cigarette smoking Q2 C6 Age at cigarette smoking initiation Q3 C7 Current cigarette smoking Q4 C10 Current other tobacco smoking Q5 C14 Current smokeless tobacco use Q6 C16 Attempts to quit smoking Q7 C18 Receiving advice to quit smoking Q8 C19 Secondhand smoke exposure inside the home Q9 C20 Secondhand smoke exposure inside public places Q10 C22 Secondhand smoke exposure at school Q11 C27 Access to purchasing cigarettes Q12 C28 Unit of cigarette purchase Q13 C30 Anti-tobacco messages in the media Q14 C32 Cigarette pack health warnings Q15 C33 Learning about dangers of tobacco use at school Q16 C35 Tobacco marketing at points of sale Q17 C37 Owning items with tobacco brand logos Q18 C38 Free tobacco promotion Q19 E1 Awareness of electronic cigarettes Q20 E2 Current use of electronic cigarettes Q21 E3 Ever use of electronic cigarettes 37 Acknowledgments GYTS partners wish to acknowledge the contributions made by several collaborators in researching and developing the proposed set of key tobacco questions, including the following members of the TQS-Youth Working Group: Gary Giovino (University at Buffalo, State University of New York), Prakash Gupta (Healis – Sekhsaria Institute for Public Health), Candace Kirksey Jones (RTI International) and Jeremy Morton (CDC Foundation). Financial support provided by the Bloomberg Initiative to Reduce Tobacco Use through the CDC Foundation with a grant from Bloomberg Philanthropies is gratefully acknowledged along with the contributions made by Jeremy Morton (CDC Foundation) who wrote and organized the initial draft of the booklet. In addition, special thanks are extended to WHO, CDC, and the CDC Foundation for assistance with reviewing, editing, preparing the layout design, and printing. GYTS Collaborating Organizations: » U.S. Centers for Disease Control and Prevention (CDC) » CDC Foundation » RTI International » World Health Organization (WHO) 38 Contact Information The Tobacco Questions for Surveys of Youth booklet is available for download from CDC’s website at: https://www.cdc.gov/tobacco/global/ or WHO’s website at: http://www.who.int/tobacco/surveillance For more information, contact GTSSINFO@cdc.gov