Charles W. Warren

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

The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 13-15 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey. In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes.

Patterns of global tobacco use in young people and implications for future chronic disease burden in adults

BACKGROUND Tobacco use is a leading preventable risk factor for many chronic disorders, which are expected to account for an increasing share of the global disease burden. As part of the Global Youth Tobacco Survey (GYTS), we aimed to assess the effect of tobacco use by young people on global mortality. METHODS GYTS is a school-based survey of students aged 13-15 years. The survey was undertaken at 395 sites in 131 countries and the Gaza Strip and West Bank. We questioned students about current tobacco use, susceptibility to smoking among non-smokers, and exposure to secondhand smoke at home and in public places. FINDINGS The difference in current cigarette smoking between boys and girls is narrower than expected in many regions of the world. Use of tobacco products other than cigarettes by students is as high as cigarette smoking in many regions. Almost one in five never-smokers reported they were susceptible to smoking in the next year. Student exposure to secondhand smoke was high both at home (more than four in ten) and in public places (more than five in ten). Never-smokers were significantly less likely than current smokers to be exposed to secondhand smoke at home (prevalence 39.1% [95% CI 36.6-41.6] vs 72.8% [64.0-81.6]) and in public places (49.5% [46.7-52.3] vs 81.2% [74.2-88.2]). INTERPRETATION Our findings are troubling for the future of chronic disease and tobacco-related mortality. Reduction of tobacco consumption will require a redoubling of efforts to prevent initiation and promote cessation among the large proportion of young people who currently use tobacco. High exposure to secondhand smoke suggests a need for countries to pass strong and effective smoke-free policies.

Forced sexual intercourse and associated health-risk behaviors among female College students in the United States

This study analyzed data from the 1995 National College Health Risk Behavior Survey (NCHRBS) to assess the prevalence of lifetime rape among female college students and to examine the association between rape and health-risk behaviors. The NCHRBS used a mail questionnaire to assess health-risk behaviors among a nationally representative sample of undergraduate students. Twenty percent of female students reported ever having been forced to have sexual intercourse, most often during adolescence. When analyses controlled for demographic characteristics, female students who had ever been raped were significantly more likely than those who had not to report a wide range of health-risk behaviors. These results highlight a need to improve rape prevention and treatment programs for female adolescents.

Smoking initiation and smoking patterns among US college students.

The ages at which 18- to 24-year-old college students started smoking and its relationship to subsequent smoking were explored, using data from the 1995 National College Health Risk Behavior Survey. Most students (70%) had tried smoking; among those who had tried, 42% were current smokers, 19% were current frequent smokers, and 13% were current daily smokers. The majority (81%) who had ever smoked daily began doing so at age 18 years or younger, and 19% began smoking daily at age 19 years or older. Women were as likely as men to report ever having smoked a whole cigarette or ever having smoked daily. Most students (82%) who had ever smoked daily had tried to quit, but 3 in 4 were still smokers. Policies and programs designed to prevent the initiation of smoking and to help smokers quit are needed at both the high school and the college levels to reduce the proportion of young adults who smoke cigarettes.

Change in tobacco use among 13—15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey

Tobacco use is the leading preventable cause of death and disease in the world; yet little is known about the levels or patterns of youth tobacco use on a global basis. The purpose of this paper is to focus on change in youth tobacco use using data from 100 sites that have conducted repeat Global Youth Tobacco Surveys (GYTS). The GYTS is a school-based survey that collects data from students aged 13–15 years using a standardized methodology for constructing the sample frame, selecting schools and classes, and processing data. GYTS is conducted in school classes using self-administered anonymous data collection. The GYTS sample produces representative, independent, cross-sectional estimates for each sampling frame. Of the 100 sites surveyed, 61 reported no change over time in prevalence of cigarette smoking, likewise in 50 of the 97 sites with data on use of other tobacco products there was no change. However, 34 sites reported an increase in other tobacco use. This appears to be attributed to waterpipe, an emerging trend in tobacco use. Evidence was found supporting the idea that tobacco use among adolescent girls is likely increasing. The global tobacco control effort continues to face many challenges in reversing the tobacco epidemic. Few countries have implemented comprehensive tobacco control legislation laid out by the World Health Organization. The few countries that have adopted some of these proven policies can serve as examples in achieving positive results in curbing the tobacco epidemic. (Global Health Promotion, 2009; Supp (2): pp. 38–90)

Sexual behavior among U.S. high school students, 1990-1995

CONTEXT High rates of unintended pregnancy and sexually transmitted diseases (STDs), including HIV infection, among adolescents are major public health concerns that have created interest in trends in teenage sexual activity. METHODS Nationally representative data from Youth Risk Behavior Surveys conducted in 1990, 1991, 1993 and 1995 are used to examine levels of sexual experience, age at first intercourse, current sexual activity and condom use at last intercourse among students in grades 9-12. RESULTS The proportion of students who reported being sexually experienced remained at 53-54% from 1990 through 1995, while the percentage of sexually active students who used condoms at last intercourse rose from 46% to 54% between 1991 and 1995. Black students were more likely than white students to report being sexually experienced, being currently sexually active and having had four or more lifetime sexual partners; black students also reported a significantly younger age at first intercourse. Gender differences in sexual behavior were found more frequently among black students than among white or Hispanic students. CONCLUSIONS Although levels of sexual experience for high school students in the United States have not risen during the 1990s, a very high percentage of students continue to be at risk for unintended pregnancy and STDs, including HIV infection.

The use of condoms with other contraceptive methods among young men and women.

In a nationally representative sample of sexually experienced youths aged 14-22, 37% of young women and 52% of young men said the condom was the primary method used to prevent pregnancy at last intercourse; an additional 8% and 7%, respectively, said they used a condom at last intercourse; much of this represents dual use [corrected]. Condom use at last intercourse was reported by 25% of young men whose partner was using the pill. Significant independent predictors of condom use with the pill among men included younger age, black race, engaging in fewer nonsexual risk behaviors and having received instruction about HIV in school. Among young women, 21% of those relying on the pill reported also using a condom at last intercourse. For women, independent predictors of dual use included younger age, black race, older age at first sex, fewer nonsexual risk behaviors, having no partners in the previous three months and having talked to parents or other adult relatives about HIV.

An assessment of the effect of data collection setting on the prevalence of health risk behaviors among adolescents

PURPOSE To examine the effect of data collection setting on the prevalence of priority health risk behaviors among adolescents. METHODS Analyses were conducted using data from two national probability surveys of adolescents, the 1993 national school-based Youth Risk Behavior Survey (YRBS) and the 1992 household-based National Health Interview Survey (NHIS/YRBS). Forty-two items were worded identically on both surveys. RESULTS Thirty-nine of the 42 identically worded items (93%) showed that the YRBS produced estimates indicating higher risk than the NHIS. Twenty-four of these comparisons yielded statistically significant differences. The prevalence estimates affected most were those for behaviors that are either illegal or socially stigmatized. CONCLUSIONS School-based surveys produce higher prevalence estimates for adolescent health risk behaviors than do household-based surveys. Each has advantages and disadvantages, and both can play a role in assessing these behaviors.

Tobacco use and cessation counselling: cross-country. Data from the Global Health Professions Student Survey (GHPSS), 2005–7

Background: Brief intervention by a health professional can substantially increase smoking cessation rates among patients. However, few studies have collected information on tobacco use and training to provide cessation counselling among health professional students. Objective: To examine tobacco use prevalence and tobacco cessation training among students pursuing advanced degrees in health professions. Methods: The Global Health Professions Student Survey (GHPSS) has been conducted among third-year students attending dental, medical, nursing and pharmacy schools. The GHPSS was conducted in schools during regular lectures and class sessions. GHPSS follows an anonymous, self-administered format for data collection. Results: The GHPSS was completed by at least one of the four target disciplines in 31 countries between 2005 and 2007 for a total of 80 survey sites. In 47 of the 80 sites, over 20% of the students currently smoked cigarettes; and in 29 of 77 sites, over 10% of the students currently used other tobacco products. GHPSS data showed that the majority of health professional students recognised that they are role models in society, believed that they should receive training on counselling patients to quit using tobacco, but in 73 of 80 sites less than 40% of the students reported they received such training. Conclusions: Health professional schools, public health organisations and education officials should discourage tobacco use among health professionals and work together to design and implement programmes that train all health professionals in effective cessation counselling techniques. If the goal of the tobacco control community is to reduce substantially the use of tobacco products, then resources should be invested in improving the quality of education of health professionals with respect to tobacco control.

Age of initiating selected health-risk behaviors among high school students in the United States.

PURPOSE To estimate and compare the age of initiation of alcohol use, cigarette smoking, sexual intercourse, and marijuana use among female and male students in U.S. high schools. METHODS Using data from the 1991 and 1993 national school-based Youth Risk Behavior Surveys, life-table analysis was used to create hypothetical cohorts to estimate age of initiation of selected health-risk behaviors. The sample size was 12,272 in 1991 and 16,296 in 1993, with an overall response rate of 68% in 1991 and 70% in 1993. RESULTS Male students initiate each of these behaviors earlier than female students, but the pace of initiation for females accelerates so that by age 15 years the cumulative proportion of male and female students who have initiated these behaviors is similar. For both female and male students, the youngest cohort appears to initiate use of alcohol and sexual intercourse at earlier ages than older cohorts. Similarly, the younger cohorts of female students appear to initiate smoking cigarettes and using marijuana at earlier ages than older cohorts. CONCLUSIONS Many high school students are initiating alcohol use, cigarette smoking, sexual intercourse, and marijuana use at early ages. These data suggest a need for intensive intervention programs by middle/junior high school to motivate and prepare students to avoid these behaviors. Clinicians should begin screening and counseling for risk behaviors in early adolescence.