Exploring Worldwide Youth Attitudes and Behaviors Toward Tobacco Use and Control Sreenivas Phanikumar Veeranki East Tennessee State University

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______

A dissertation

presented to

the faculty of the Department of Biostatistics and Epidemiology

East Tennessee State University

In partial fulfillment

of the requirements for the degree of

Doctor of Public Health with concentration in Epidemiology

______

Sreenivas Phanikumar Veeranki

August 2012

______

James L. Anderson, MD, PhD, MPH

Hadii M. Mamudu, PhD, MPA

Shimin Zheng, PhD

Key Words: Smoking, Youth, Smoke-free Policy, Susceptibility, Environmental Tobacco Smoke, Global Youth Tobacco Survey

ABSTRACT

Advancing Global Tobacco Control: Exploring Worldwide Youth Attitudes and Behaviors toward Tobacco Use and Control

Sreenivas Phanikumar Veeranki

Tobacco use continues to be the leading cause of preventable death in the world. The disproportionate increase in tobacco use in low- and middle-income countries needs immediate attention. Many smokers begin smoking as adolescents and are most likely to become permanent smokers. Moreover, youth are highly targeted by tobacco industry strategies. However, a gap exists in literature to understand worldwide youth tobacco use and control. The purpose of this study is to 1) identify factors that influence never-smoking youths‟ smoking susceptibility, 2) explore characteristics that influence youth exposure to environmental tobacco smoke (ETS) and

3) to delineate key determinants of youth support for smoke-free policies (SFPs).

Data related to worldwide youth tobacco use was obtained from the Global Youth Tobacco

Survey for the years 1999-2008. Simple and multiple logistic regression analyses were conducted, after the sample was weighted for design effect, nonresponse patterns and poststratification. Unadjusted and adjusted odds ratios along with 95% confidence intervals were reported.

Around 14% of never-smoking youth were susceptible to smoking worldwide. Around 40% and

50% youth were exposed to ETS inside and outside the home respectively, and 78% supported

SPFs globally. Parental and peer smoking was strongly associated with smoking susceptibility in

never-smoking youth [AOR 2.63, 95% CI 2.43 to 2.84], and youth exposure to ETS inside [AOR

5.09, 95% CI 4.84 to 5.35] and outside [AOR 2.51, 95% CI 2.39 to 2.63] the home, while anti- smoking school education was negatively associated. Youth having knowledge about smoking harm [AOR 2.37, 95% CI 2.22 to 2.54] supported SFPs, while youth exposed to tobacco industry promotion [AOR 0.83, 95% CI 0.78 to 0.89] did not support.

The study highlighted a number of modifiable factors that can be used for augmenting global tobacco control in youth. Well-executed anti-smoking campaigns, parental and peer education, inclusion of anti-tobacco education in school curricula, comprehensive SFPs, and comprehensive ban on tobacco industry strategies are important approaches to prevent tobacco use and advance global tobacco control in youth.

DEDICATION

I dedicate this work to my dearest uncle, Late Konakalla Babu Rajendra Prasad, who had always been an inspiration to me.

ACKNOWLEDGEMENTS

Many debts have been incurred to people who have inspired and supported me during the span of 12 years of career in medicine and public health.

First, I would like to thank my dissertation committee members, Dr. James Anderson, Dr.

Hadii Mamudu, and Dr. Zheng, for their guidance, patience, and support. A special thanks to my mentor, Dr. Hadii Mamudu, for his knowledge, guidance, encouragement, and support. His very best “thoughtful criticisms” and “constant new ideas” have always encouraged me to explore and learn new things. I would like to thank my academic committee, Dr. James Anderson, Dr.

Deborah Slawson, and Dr. Keshang Wang, for their guidance and support.

Institutionally, I would like to express my gratitude to the College of Public Health for providing my financial assistance through Graduate Research Assistantship to accomplish my doctoral studies. My very special thanks go out to Dr. Robert Pack for admitting me into the

DrPH program and Dr. Amal Khoury for her guidance while making important judgments. I am very thankful to other faculty members in the college. I would also like to personally thank

Rickie Carter and Carolyn Castoc for catering all my administrative needs.. Special thanks to my

“Tobacco Policy Research” team members for their continuous encouragement. Finally, I would like to thank Dr. Randy Wykoff, Dean of the College of Public Health, for fostering an excellent research environment.

Personally, I would like to thank my family and friends for their continuous support throughout my career. I would like to thank my parents- Dr. PanduRanga Rao Veeranki and

Amala Veeranki; my sister and her family- Bhavani Veeranki, Bheema Vadlamuri, and Aditi

Vadlamuri, and my in-laws – Anil Konakalla and Jayasree Konakalla for their continuous

support and encouragement. Finally, my special thanks to my wife Padmini Konakalla, who is good-humored and tolerated my more attention to research and less attention towards her. Last but not the least; I would express my appreciation to all my friends in the college (many names to be mentioned here) for their support and encouragement.

CONTENTS

Page

ABSTRACT ...... 2

DEDICATION ...... 5

ACKNOWLEDGEMENTS ...... 6

LIST OF TABLES……………………………………………………………………………...... 11

LIST OF FIGURES…………………………………………………………………………...…..13

ACRONYMS AND ABBREVIATIONS ...... 14

Chapter

1. INTRODUCTION ...... 15

Research Study Aims ...... 19

Tobacco: Origin, History, and Health ...... 21

Environmental Tobacco Smoke: History and Health ...... 26

Tobacco Control: Monitoring and Surveillance ...... 34

Global Tobacco Surveillance System ...... 36

Global Youth Tobacco Survey ...... 42

Theoretical Framework of the Research Study ...... 54

2. UNDERSTANDING WORLDWIDE YOUTH SUSCEPTIBILITY TO SMOKING: AN

ANALYSIS OF THE GLOBAL YOUTH TOBACCO SURVEY...... 59

Abstract ...... 60

Introduction ...... 62

Methods ...... 66

Results ...... 73

Discussion ...... 77

Conclusion ...... 81

Funding ...... 82

Competing Interests ...... 82

Contributions ...... 82

References ...... 83

3. PREVALENCE AND DETERMINANTS OF WORLDWIDE YOUTH EXPOSURE TO

ENVIRONMENTAL TOBACCO SMOKE ...... 93

Abstract ...... 94

Introduction ...... 96

Methods ...... 98

Results ...... 104

Discussion ...... 110

Conclusion ...... 113

Funding ...... 113

Competing Interests ...... 113

Contributions ...... 114

References ...... 115

4. SUPPORT FOR SMOKE-FREE POLICY AMONG SCHOOL-GOING ADOLESCENTS

(11-17 YEARS) GLOBALLY ...... 126

Abstract ...... 127

Introduction ...... 129

Methods ...... 130

Results ...... 137

Discussion ...... 142

Conclusion ...... 146

Funding ...... 147

Competing Interests ...... 147

Contributions ...... 147

References ...... 148

5. CONCLUSION ...... 158

REFERENCES ...... 162

APPENDIXES ...... 176

Appendix A: Human Subjects Protection ...... 176

Appendix B: Global Youth Tobacco Survey Questionnaire, 2008 ...... 177

VITA ...... 194

LIST OF TABLES

Table Page

1.1: Major Reports that Address Exposure to Environmental Tobacco Smoke and Its

Adverse Effects………………………………………………………………………….….29

1.2: Global Tobacco Surveillance System, Surveys and Objectives…………………...………..37

1.3: GTSS Partners and Their Roles……………………………………………………………..40

1.4: Global Youth Tobacco Survey in WHO Africa, by Year, 1999- 2008……………………..45

1.5: Global Youth Tobacco Survey in WHO Eastern Mediterranean Region, by Year,

1999- 2008………………………………………………………………………………….47

1.6: Global Youth Tobacco Survey in WHO European Region, by Year, 1999- 2008…………48

1.7: Global Youth Tobacco Survey in WHO Region of the Americas, by Year,

1999- 2008 …………………………………………………………………………………50

1.8: Global Youth Tobacco Survey in WHO South-east Asia Region, by Year,

1999- 2008………………………………………………………………………………….52

1.9: Global Youth Tobacco Survey in WHO Western Pacific Region, by Year, 1999- 2008 …..53

2.1: Study Measures, Survey Items with Responses from Global Youth Tobacco Survey

(GYTS)……………………………………………………………………………………...68

2.2: Susceptibility to Smoking Among Never-Smoking Youth by WHO region,

Global Youth Tobacco Survey, 1999-2008…………………………………………………73

2.3: Descriptive Characteristics of Never-Smoking Youth Globally, Global Youth

Tobacco Survey, 1999-2008 (n=495,492)………………………………………………….74

2.4: Bivariate Analysis of Factors Associated with Susceptibility to Smoking Among

Never-Smoking Youth, Global Youth Tobacco Survey, 1999-2008 (n=495,492)………....75

2.5: Multivariate Analysis of Factors Associated with Susceptibility to Smoking

Among Youth, Global Youth Tobacco Survey, 1999-2008 (n=495,492)…………………77

3.1: Study Measures, Survey Items with Responses from Global Youth Tobacco

Survey (GYTS)…………………………………………………………………………...100

3.2: Youth Exposure to Environmental Tobacco Smoke (ETS) by WHO region,

Global Youth Tobacco Survey, 1999-2008………………………………………………104

3.3: Descriptive Characteristics of Youth Globally, Global Youth Tobacco Survey,

1999-2008 (n=728,929) …………………………………………………………………..105

3.4: Bivariate Analysis of Factors Associated with Worldwide Youth Exposure to

Environmental Tobacco Smoke (ETS), Global Youth Tobacco Survey,

1999-2008 (n=728,929)…………………………………………………………………..107

3.5: Multivariate Analysis of Factors Associated with Worldwide Youth Exposure to

Environmental Tobacco Smoke (ETS), Global Youth Tobacco Survey,

1999-2008 (n=728,929)…………………………………………………………………..109

4.1: Study Measures, Survey Items with Responses from Global Youth Tobacco

Survey (GYTS)…………………………………………………………………………...134

4.2: Youth Support for SFP by Region, Global Youth Tobacco Survey, 1999-2008 …………..138

4.3: Descriptive Characteristics of Youth in Developing Countries, Global Youth

Tobacco Survey, 1999-2008 (n=752,824)………………………………………………..139

4.4: Bivariate Analysis of Factors Associated with Youth (11-17 Years) Support for

Smoke-Free Policies, Global Youth Tobacco Survey, 1999-2008 (n=752,824)………...140

4.5: Multivariate Analysis of Factors Associated with Youth Support for Smoke-Free

Policies, Global Youth Tobacco Survey, 1999-2008 (n=752,824)……………………….142

LIST OF FIGURES

Figure Page

1.1: Global Tobacco Surveillance System, Partnerships, and Collaborations at Global,

Regional, and National level, School-based surveys…………………………………….....39

1.2: Global Tobacco Surveillance System (GTSS) Plan………………………………………...42

1.3: Principles of Global Youth Tobacco Survey………………………………………………..43

1.4: Theoretical framework………………………………………………………………………58

ACRONYMS AND ABBREVIATIONS

CA California

CDC Centers for Disease Control and Prevention

CPHA Canadian Public Health Association

D.C. District of Columbia

EPA Environmental Protection Agency

ETS Environmental Tobacco Smoke

FCTC Framework Convention on Tobacco Control

GTSS Global Tobacco Surveillance System

GYTS Global Youth Tobacco Survey

IARC International Agency for Research on Cancer

SHS Secondhand Smoke

SFP Smoke-free Policy

TFI Tobacco Free Institute

USDHEW U.S. Department of Health, Education and Welfare

USDHHS United States Department of Health and Human Services

USPHS United States Public Health Service

WHO World Health Organization

WHA World Health Assembly

YTS Youth Tobacco Survey

CHAPTER 1

INTRODUCTION

Tobacco use, which includes smoked and smokeless tobacco products and exposure to secondhand smoke (SHS), continues to be the leading preventable cause of mortality and morbidity in the world (Jha & Chaloupka, 2000) (World Health Organization., Research for

International Tobacco Control., & ebrary Inc., 2008b). As of 2011 tobacco use and tobacco- related illnesses contributes to six million deaths annually (World Health Organization et al.,

2008b; World Health Organization., Research for International Tobacco Control., & ebrary Inc.,

2011). If the trends persist and no urgent action taken, it is estimated that by 2030 tobacco use will contribute to eight million deaths annually with 80% of these deaths in the low- and middle- income countries (LMICs) and about a billion or more deaths by the end of the 21st century

(Mathers & Loncar, 2006; Murray & Lopez, 1997; World Health Organization et al., 2008a).

Currently there are about 1.6 billion smokers and around one third to one half (390 to 650 million) will be die due to tobacco use unless any action is taken (Guindon & Boisclair, 2003;

Mathers & Loncar, 2006).

Traditionally, noncommunicable diseases (NCDs) are proportionally higher in high- income countries (HICs) compared to the developing nations. However, with rapid globalization

(including tobacco industry marketing and promotions), unplanned urbanization, and increasing westernized lifestyle, there has been a shift in burden of NCDs to LMICs, where most of the world‟s population resides. It has been reported that around 80% of the deaths due to NCDs occur in the LMICs (Alwan et al., 2010). In 2010 the World Health Organization (WHO) released a report on NCDs, "Global Status Report on non-communicable diseases", which stated that a large percentage of NCDs were preventable through reduction of four main behavioral risk

factors, namely tobacco use1, harmful use of alcohol, physical inactivity, and unhealthy diet

("WHO maps noncommunicable disease trends in all countries: country profiles on noncommunicable disease trends in 193 countries," 2011; "WHO warns of inadequate noncommunicable disease prevention," 1996).

The shift in the burden of NCDs to LMICs was due to a shift in the burden of tobacco use to these LMICs. It was found that the cigarette consumption has increased drastically from 1.1 billion in 1970 to 3.4 billion sticks in 2000 in LMICs, as compared to 1.5 billion in the developed world in 2000 (Guindon & Boisclair, 2003). In addition, the per capita cigarette consumption has increased from 712 in 1970 to 1,041 in 2000 in the LMICs. Therefore, tobacco use has now become an increasingly “a developing country problem” (Cairney, Studlar, &

Mamudu, 2012). As stated above, by 2030, about 80% of tobacco-related deaths will occur in the

LMICs. This is because of the long latent period for tobacco-attributable diseases that has resulted in the increased morbidity and mortality rates occurring since the 1990s in the LMICs

(Ezzati et al., 2006; Lopez, Mathers, Ezzati, Jamison, & Murray, 2006).

In conjunction with the shift in burden of adult tobacco use in the LMICs, it was found that there has been a disproportionate increase in tobacco use in LMICs among youth aged 11-17 years and young adults aged 18-25 years. In 2006 it has been estimated that 82,000 to 99,000 young people start smoking daily (Tanski, Prokhorov, & Klein, 2004; Warner & Mackay, 2006), many of whom were below 20 years of age and reside in LMICs whose citizens annual income was less than $760 ("Curbing the epidemic: governments and the economics of tobacco control.

The World Bank," 1999). In 1999 the WHO reported that 700 million children around the world

1 The terms “tobacco use” and “smoking” have been used interchangeably in this dissertation. However, “tobacco use” includes smoked and smokeless tobacco products and exposure to secondhand smoke.

were exposed to SHS, of which more than 200 million below 20 years age will die prematurely due to tobacco-related diseases (Peto, Imperial Cancer Research Fund (Great Britain)).

Therefore, tobacco, stated as “the LMICs problem”, is also called as “pediatric disease” because most people begin smoking as adolescents or young adults and are more likely to become dependent on nicotine in future ("Curbing the epidemic: governments and the economics of tobacco control. The World Bank," 1999).

With the rising burden of tobacco use in youth worldwide and tobacco dependence stated as a “pediatric disease”, it is important to identify some of the reasons and health effects of tobacco use in youth. Some of the reasons for increased risk of tobacco use in youth are: 1) higher breathing rates in children and adolescents, 2) their limited ability to avoid smoking environments leading to excessive exposure to SHS, 3) the early stages of development of their respiratory, immune, and nervous systems, 4) Cultural norms and traditions, 5) Easy accessibility, pricing, and sale of single cigarettes to adolescents, 5) parents and peers tobacco use behavior, and 6) tobacco industry advertising, marketing, and promotional strategies to lure adolescents to smoke cigarettes so that they transform to permanent smokers in future

(Winickoff et al., 2005). Tobacco use, especially exposure to SHS, has also been attributed to many short-term and longer-term health effects among youth. The short-term health effects include pneumonia, asthmatic exacerbations, otitis media, sudden infant death syndrome (SIDS), and colic. The longer-term health effects include pulmonary dysfunction, dental caries, cardiovascular diseases, and cancer.

The Surgeon General‟s Report released by the United States (U.S.) Department of Health and Human Services in 2012 addresses the prevention of tobacco use among youth and young adults ("U.S. Department of Health and Human Services," 2012). This is the second U.S.

Surgeon General‟s Report published exclusively to address tobacco use among youth- 17 years after the publication of the first report in in 1994. The 1994 U.S. Surgeon General Report concluded that most people will never start smoking if they can refrain from smoking before the age of 18 years. It also documented the process of nicotine addiction in youth and highlighted that tobacco was a gateway for many illicit drugs usage. Moreover, it identified tobacco industry advertising, marketing, and promotional strategies as potential agents in increasing the risk, and community-wide efforts as successful public health interventions in reducing the risk of tobacco use among youth. However, since 1994 there has been substantial research conducted on tobacco use in youth, especially in relation to understanding the prevention and the dynamics of tobacco use cessation ("Preventing tobacco use among young people. A report of the Surgeon General.

Executive summary," 1994). Moreover, many updates and new data in the Healthy People 2000,

2010, subsequent U.S. Surgeon General reports, in National Cancer Institute (NCI) monographs, in Cochrane Collaboration reviews, thousands of peer-reviewed publications, book chapters, databases, and reports have been added to the scientific literature to understand tobacco use and control in youth. Therefore, the 2012 report, a follow-up to the 1994 report, incorporates all the new scientific literature related to tobacco use and control in youth for the past seventeen years and provides information about the key strategies for tobacco control in youth, which are discussed in the next paragraph.

The 2012 U.S. Surgeon General report presented detailed information about the causes and consequences of tobacco use among youth, with particular attention focused on social, environmental, tobacco industry marketing, and advertising characteristics that encourage adolescents to smoke cigarettes and/or use other tobacco products. Many causes were determined to be responsible for tobacco use among youth. The most important ones include tobacco

industry marketing strategies to encourage never smokers to initiate and sustain tobacco use, the period of „adolescence‟ during which adolescents are highly susceptible to starting tobacco use, and social norms and smoke-free policies (SFPs) protecting the youth. Some potential solutions identified to decrease the burden of tobacco use among the youth include comprehensive SFPs to limit youth exposure to SHS, anti-smoking education to help the youth choose healthy behaviors, limiting tobacco industry marketing and promotional strategies, raising cigarette prices, and enforcing laws that prohibit sale of tobacco products to children.

While the 2012 U.S. Surgeon Report fills the gap in scientific literature in tobacco control in youth in the U.S. (HIC), there has been a major gap to address youth tobacco control globally, especially in LMICs where more than 80% of the world‟s smoking population resides.

Therefore, the main overall goal of this research study is to identify youth characteristics that are related to tobacco use and control globally. The results of this research have the potential to help prevent tobacco use in the youth and to reduce the overall burden of tobacco use worldwide.

Three specific research aims have been identified to accomplish this main research goal, which are presented in detail below.

Research Study Aims

Research Study Aim # 1

To determine the extent and identify key factors that influence susceptibility2 to smoking among never-smoking youth aged 11-17 years globally during the years 1999-2008, inclusive.

2 Susceptibility to smoking is defined as the lack of firm decision against smoking

Research Study Aim # 2

To determine the prevalence and factors associated with worldwide youth aged 11-17 years, exposure to environmental tobacco smoke (ETS) both inside and outside the home during the years 1999-2008, inclusive.

Research Study Aim # 3

To estimate prevalence and explore factors responsible for worldwide youth aged 11-17 years, support for SFPs during the years 1999-2008, inclusive.

The next three chapters- chapters 2, 3, and 4, present detailed discussion of the three specific research aims. These three chapters explain tobacco use and control in youth in a sequential manner. Chapter 2 presents details about susceptibility to smoking among youth who had never smoked before. This research study is important because it paves the way for early intervention efforts in the initiation phase of the adolescents‟ cigarette learning behavior and prevents never-smoking youth to initiate cigarette smoking. Chapter 3 provides detailed assessment of worldwide youth exposure to ETS inside and outside the home. This research study is important because it provides evidence for the definite need for development and implementation of comprehensive SFPs globally. Finally, Chapter 4 presents the solution to the problem, i.e., youth support for SFPs globally. Prior to discussing chapters 2, 3, 4, it is important to understand the broader background information related to tobacco and environmental tobacco smoke (ETS) and their adverse health effects on individuals. The next sections of this chapter will discuss details about the following tobacco-related topics: 1) origin, history, and relation to

health, 2) the history and health impact of ETS, 3) monitoring and surveillance of tobacco control activities, 4) the Global Tobacco Surveillance System (GTSS), 5) the Global Youth

Tobacco Survey (GYTS) from which the study is obtained, and 6) the theoretical framework that integrates all broad concepts and contexts used in this research.

Tobacco: Origin, History, and Health

Tobacco, derived from the native plants Nicotiana tabacum and Nicotiana rustica of the

Americas, was discovered about 18,000 years ago when explorers migrated across the Straight

Land Bridge from Asia and Europe to the American continents (Musk & de Klerk, 2003). Gately

(2001) described the ancient origins of tobacco and its subsequent insinuation into modern society through the action of explorers (Gately, 2001).

Tobacco has been cultivated by the indigenous peoples of the Americas and Cuba since about 5000-3000 BC for medicinal, religious, and social purposes. The later migration to and colonization of the American continents and Cuba by explorers resulted in tobacco becoming a commodity of success and pleasure. In 1492 the crew members of Christopher Columbus‟s ship became the first known Europeans to smoke tobacco. The medicinal purposes attributed to

Nicotiana by the American natives were the reason that its seeds were taken to Spain and

Portugal for cultivation. A major irony was that the claimed medicinal properties of Nicotiana to cure and prevent cancer resulted in tobacco being used in the form of snuff by healthy people, who then became addicted. From Spain, tobacco spread to Great Britain, to the remaining

European nations, and then to the rest of the world. Many provinces and nations eventually began to cultivate its own tobacco because it was expensive and because of its claimed cancer

prevention medical property. Important milestones in the evolving history of tobacco include the actions of Christopher Columbus and his crew, the cultivation of tobacco by Spain and Portugal for its claimed medicinal properties, Sir Francis Drake- bringing tobacco to Great Britain in the

1560s, Queen Elizabeth I‟s actions associating tobacco use with royalty and with royal endorsement, and King James I of England prophetically describing the use of tobacco as „a custom loathsome to the eye, hateful to the nose, harmful to the brain, stinking fume thereof nearest resembling the horrible stygian smoke of the pit that is bottomless‟ (Gately, 2001).

In his book, Gately (2001) described tobacco as a „coveted commodity‟ that transformed the world economy and trigged revolutions resulting in the birth of nations and the end of empires (Gately, 2001). He chronicled the epic history of human‟s fascination with tobacco from its unclear origins among ancient civilizations to its rise to worldwide fame and its besieged state today. He argued that tobacco was „”the driving force behind the development of global trade, the foundation of the Dutch mercantile empire, the fulcrum of the African slave trade, and the financial basis for our victory in the American Revolution”. As a result, tobacco has been described as „a tragic accident of history‟ because of its devastating health and economic impacts on individuals, societies, countries, and entire globe (Gately, 2001; Glantz, 1996; Winstanley M,

1995).

It has taken a long time to accumulate the scientific evidence or proof of King James I‟s assertion regarding the harmful effects of tobacco smoking. However, indisputable evidence that cigarette smoking and tobacco is the leading cause of death in HICs has existed for more than half a century (Musk & de Klerk, 2003). The major milestone in evidence supporting the adverse health effects of smoking occurred in 1950 when 16 retrospective studies were published, 4 of them associated smoking with an increased risk of lung cancer (Doll & Hill, 1950; Levin,

Goldstein, & Gerhardt, 1950; Schrek, Baker, Ballard, & Dolgoff, 1950; Wynder & Graham,

1950), 2 of them examined the effects of smoking on women‟s health (Clark, 1950; Trampuz,

1950), 2 of them investigated the link between smoking and vascular disorders (Jarlov, 1950;

Rapaprot, Frank, & Massell, 1950), 1 that looked at smoking and the risk of cardiac disease

(Levy, 1950; Sinclair-Smith et al., 1950), 1 that examined the association of tobacco use and risk of oral cancers (Mills & Porter, 1950), 1 that examined smoking and pituitary endocrine disorders (Sinclair-Smith et al., 1950), and 1 that studied the association of smoking and gastric ulcers (Hodges & Gilmour, 1950).

Established evidence shows reports or studies prior to 1950 that examined the harmful effects of tobacco use were consistently ignored (Davey Smith & Egger, 2005). In 1930s and

1940s the German epidemiologists, who were considered the most advanced in the world during that time, recognized tobacco as a cause for cancer and many health conditions. Germany‟s Nazi medical elite strongly supported tobacco-related health research and were credited to be the first health professionals to recognize tobacco both for its addictive nature and hazardous nature to cause lung cancer (Proctor, 1997). The anti-smoking campaign during the Nazi regime encompassed smoking bans in public spaces, tobacco advertising bans, tobacco ration restrictions for women, and support for research linking tobacco use to lung cancer (Proctor,

1996). However, the political climate and the post-World War II loss of Germany lead to the silence of the World‟s first and most aggressive anti-tobacco science (Proctor, 1996, 1997,

2001). In pre-1950 a popular hypothesis attributed lung cancer and its mortality to widespread tarring of roads and exhaust from motor vehicles and not from smoking (Thun, 2005). However, four major studies provided strong evidence that this hypothesis was incorrect and that lung cancer and its mortality was due to smoking and not from roads tar or motor vehicles‟ exhaust.

These four major studies were: 1) Schönherr‟s study in 1928 that provided evidence that lung cancer in nonsmoking wives of smokers was caused by passive smoke inhalation (Schonherr,

1928), 2) Fritz Linckint‟s synthetic review on time trends in lung cancer and smoking, ecological associations between cigarette smoking and lung cancer, autopsy series, biological studies, experimental animal studies and clinical reports in 1935 (Lickint, 1935), 3) Franz Müller‟s case- control study on lung cancer in 1939, where smoking habits of lung cancer patients were compared with those of other patients (Lickint, 1939), and finally, 4) Scahirer and Schöniger‟s population-based study in 1943, where population and hospital control groups were used to analyze the health effects of people quitting smoking and comparing the results with previous data to ensure consistency (Schairer & Schoniger, 2001; Schairer E, 1943).

After the strong evidence presented in 1950 about the association between smoking and lung cancer, the first longitudinal study was conducted in the year 1954 to study the association between lung cancer deaths and the number of cigarettes smoked (Hammond & Horn, 1954).

The study included 187,783 men followed for an average period of 44 months. It was found that there was an excess of 1,783 deaths due to smoking alone, with mortality ratios higher among those men who smoked the largest number of packs per day. The first official public statement that “cigarette smoking causes lung cancer” was issued by the United States (U.S.) Public Health

Service in 1957 (United States. Surgeon General's Advisory Committee on Smoking and Health.,

1964). This was followed by a similar statement by the Royal College of Physicians and

Surgeons in 1962 (Evans, 1962). The U.S. Surgeon General commission has reached the same conclusion with the statement that “cigarette smoking was a serious hazard to health and is related to illness and death from lung cancer, chronic broncho-pulmonary disease, cardiovascular disease and other diseases”. (United States. Office on Smoking and Health. & United States.

Surgeon-General's Office., 1979; United States. Public Health Service. et al., 1967; United

States. Public Health Service. Office of the Surgeon General. & United States. Office on

Smoking and Health., 1980; United States. Surgeon General's Advisory Committee on Smoking and Health., 1964). Similar investigations conducted in Australia and England re-emphasized the association between lung cancer and cigarette smoking (Doll, Peto, Wheatley, Gray, &

Sutherland, 1994; Peto, 1994; Winstanley M, 1995). In 1969 in Australia, a country with less than 20 million inhabitants, it was found that tobacco use killed 19,000 smokers and 2,400 nonsmokers. Similarly, in England, it was found that one regular smoker in two died from a smoking-attributable diseases prematurely (Peto et al., 1994). In conclusion, the studies conducted following the initial statement by the U.S. Public Health Service in 1957 found similar association between lung cancer and smoking among different sub-populations, race/ethnic groups and in different nations.

As of 2012 numerous reports by many organizations such as the International Agency for

Cancer (IARC), WHO, U.S. Public Health Service (USPHS), U.S. Department of Health and

Human Services (USDHHS), United Kingdom Royal College of Physicians, educational institutions and agencies, and individual researchers have identified tobacco use (smoked and smokeless tobacco products and exposure to SHS) as a major cause of chronic obstructive lung disease (COPD), lung cancer, heart disease, stroke, vascular disorders, Raynaud‟s disease, peptic ulcer disease, inflammatory bowel disease, cancers of oral cavity, esophagus, stomach, pancreas, gall bladder, anus, kidney, vulva, cervix, and others. Other adverse health effects that have been reported include impaired fertility (impotence) in males and females, premature aging (wrinkles) of the skin, snoring, abortion and ectopic pregnancy, cataracts and increased complications of surgery, wound healing, diabetes, and hypertension (United States. Public Health Service. Office

of the Surgeon General., 2010; United States. Public Health Service. Office of the Surgeon

General., Centers for Disease Control and Prevention (U.S.), National Center for Chronic

Disease Prevention and Health Promotion (U.S.), & United States. Office on Smoking and

Health., 2001; United States. Public Health Service. Office of the Surgeon General., Koop, &

United States. Office on Smoking and Health., 1986; United States. Public Health Service.

Office of the Surgeon General. & National Center for Chronic Disease Prevention and Health

Promotion (U.S.), 2004; Winstanley M, 1995).

Environmental Tobacco Smoke: History and Health

In addition to smoked cigarettes and smokeless tobacco products, tobacco use also includes exposure to environmental tobacco smoke (ETS). Exposure to ETS has serious health consequences because it contains more than 4,000 chemicals, of which 100 are considered toxic and 70 are toxigenic ("IARC Monographs on the Evaluation of Carcinogenic Risks to Humans.

Tobacco Smoke and Involuntary Smoking," 2004; "Preventing tobacco use among young people.

A report of the Surgeon General. Executive summary," 1994; World Health Organization. et al.,

2008b).

Anecdotes and unsubstantiated reports on the health impact of ETS existed for years, but it was not until the publication of the famous epidemiological study by Takeshi Hirayama in

1981 that ETS was identified as a significant health problem. The study demonstrated the risk of lung cancer increased among nonsmoking Japanese women whose husbands smoked compared to those nonsmoking women whose husbands did not smoke. This increased risk has been attributed to exposure to ETS (Hirayama, 1981, 2000). At about the same time, Trichopoulos et

al. from Greece conducted a case-control study and published similar results (Trichopoulos,

Kalandidi, Sparros, & MacMahon, 1981). In this study 41 women with lung cancer (cases) and

163 other hospital patients (controls) were questioned about their personal smoking patterns as well as their husbands‟ habits (Trichopoulos et al., 1981). Forty of the cases and 149 of the controls were nonsmokers. Among these nonsmoking women, lung cancer was 2.4 times more likely (Relative Risk = 2.4) for those whose husband smoked less than one pack of cigarettes per day and 3.4 times (Relative Risk = 3.4) more for those whose husband smoked more than one pack per day as compared to those whose husband did not smoke. The results of this study received wide public attention because of the relationship between exposure to ETS and the adverse health effects in nonsmoking female residents of Athens. However, the harmful health effects of ETS in children due to familial smoking behavior had been demonstrated even earlier during the 1970s (Colley, 1974; Colley, Holland, & Corkhill, 1974; Harlap & Davies, 1974;

Leeder, Corkhill, Irwig, Holland, & Colley, 1976).

Comparable to the 1950s era in regard to tobacco use, the 1970s were considered as a significant milestone for focusing on ETS as a health risk. Passive smoking/ SHS/ involuntary smoking/ ETS was addressed for the first time in the 1972 U.S. Surgeon General‟s Report- “The

Health Consequences of Smoking” (National Clearinghouse for Smoking and Health., United

States Public Health Service. Office of the Surgeon General., & United States. Health Services and Mental Health Administration., 1972), which was only 8 years after the publication of the first U.S. Surgeon General report in 1964 (United States. Surgeon General's Advisory Committee on Smoking and Health., 1964). Some of the salient features of the 1972 U.S. Surgeon General

Report included a definition of ETS/ SHS: a mixture of side stream smoke given off by a smoldering cigarette and mainstream smoke exhaled by a smoker, examination of the high levels

of cigarette smoke components due to smoking in enclosed spaces, and the adverse health effects of carbon monoxide in ETS. The report concluded that “an atmosphere contaminated with tobacco smoke can contribute to the discomfort of many individuals” (National Clearinghouse for Smoking and Health et al., 1972).

As stated above, the 1970s were an important milestone in the understanding of the health effects of the ETS. However, it was as early as 1928 that the health effects of the ETS were first studied. Schönherr from Chemnitz (1982) found an increased risk of lung cancer in nonsmoking wives of smokers that was attributed to inhalation of passive smoke from their husbands‟ tobacco use (Schonherr, 1928). Therefore, though consistently ignored, it is important to recognize the first early reports about the adverse health effects of ETS and its association with lung cancer on the evolving history of ETS.

Since the 1970s exposure to ETS has been gaining importance as a recognized risk factor and demands immediate attention. The major reports that addressed exposure to ETS and its adverse effects are highlighted in Table 1.1.

Table 1.1:

Major Reports that Address Exposure to Environmental Tobacco Smoke and Its Adverse Effects

Year Agency Title of report Salient features 1972 USDHEW ^, The Health Consequences of Smoking “ an atmosphere contaminated with tobacco smoke can Washington, D.C. 1972 contribute to the discomfort of many individuals” (pg.7) 1975 USDHEW, Chapter 4 (Involuntary Smoking) “smoking” is “involuntary” Washington, D.C. The Health Consequences of Smoking “the exposure occurs as an unavoidable consequence of 1975 breathing in a smoke-filled environment” (pg.87) 1979 USDHEW, Chapter – Involuntary Smoking “ attention to involuntary smoking is of recent vintage, Washington, D.C. Smoking and Health: A Report of the and only limited information regarding the health effects Surgeon General of such exposure upon the nonsmoker is available” (pg.11-35) 1982 USDHEW, The Health Consequences of Smoking Three epidemiological studies published on involuntary Washington, D.C. - Cancer: A Report of the Surgeon smoking and lung cancer. This report addresses General methodological difficulties inherent in these studies.

“Although the currently available evidence is not sufficient to conclude that passive or involuntary smoking causes lung cancer in nonsmokers, the evidence raises concern about a possible serious public health problem” pg. 251 1984 USDHEW, Chapter 7- Passive Smoking “Parental smoking and respiratory effects on children” Washington, D.C. The Health Consequences of Smoking - Chronic Obstructive Lung Disease: A “Measurement of ETS using biomarkers” Report of the Surgeon General 1986 USDHEW, The Health Consequences of “Involuntary smoking caused lung cancer with more Washington, D.C. Involuntary Smoking: A Report of the adverse effects on nonsmokers and children” Surgeon General

Table 1.1 (continued)

1986 International Agency IARC Monograph 38 “Passive smoking gives rise to smoke risk of cancer” for Research on Cancer Monographs on the Evaluation of the pg.314 (IARC), Lyon, France Carcinogenic Risk of Chemicals to Humans: Tobacco Smoking 1986 National Research Environmental Tobacco Smoke: “Involuntary smoking increases the incidence of lung Council, Washington, Measuring Exposures and Assessing cancer in nonsmokers” D.C. Health Effects “Secondhand smoke exposures from parental smoking to increased risks for respiratory symptoms and infections and to a slightly diminished rate of lung growth” 1992 U.S Environmental Respiratory Health Effects of Passive “secondhand smoke is a Group A carcinogen” Protection Agency Smoking: Lung Cancer and Other (EPA), Washington, Disorders D.C. 1994 USDHEW, Preventing Tobacco Use Among “Exposure to ETS in young people” Washington, D.C. Young People: A Report of the Surgeon General

1997 National Health and The Health Effects of Passive Smoking “ETS is a combination of poisonous gases, liquids and Medical Research breathable particles that are harmful to health, particularly Council, Canberra, that of children” Australia 1997 California EPA , Health Effects of Exposure to “Estimated the annual excess deaths in the U.S. Sacramento, CA Environmental Tobacco Smoke attributable to secondhand smoke” 1998 Scientific Committee on Report of the Scientific Committee on “Exposure to secondhand tobacco smoke causes Tobacco and Health, Tobacco and Health lung cancer and heart disease in adult non-smokers and a London, United variety of conditions including respiratory disease, cot Kingdom death and middle ear disease in children”

Table 1.1 (continued)

1998 USDHEW, Tobacco Use Among U.S. “Exposure to ETS among racial/ethnic groups” Washington, D.C. Racial/Ethnic Minority Groups: A Report of the Surgeon General

1999 World Health International Consultation on “Exposure to environmental tobacco smoke causes Organization, Geneva Environmental Tobacco Smoke (ETS) increased risks of several illnesses in children” Switzerland and Child Health. Consultation Report “Children do not choose this exposure. Their right to grow up in an environment free from tobacco smoke must be safeguarded through actions by national and local governments, voluntary bodies, community leaders, health workers, educators and parents”

“Reducing children‟s exposure to tobacco smoke requires a two-pronged strategy: reducing smoking in spaces where children live, play, and learn, and reducing overall tobacco consumption”

“Policies to protect children from tobacco smoke exposure should be implemented as part of comprehensive tobacco control programs”

“Young children‟s greatest exposure to tobacco smoke occurs at home” 2001 USDHEW, Women and Smoking: A Report of the “Exposure to ETS in women” Washington, D.C. Surgeon General

2004 IARC, Lyon, France IARC Monograph 83 “Exposure, human carcinogenicity, animal Tobacco Smoke and Involuntary carcinogenicity and evaluation of involuntary smoking” Smoking

Table 1.1 (continued)

2004 Scientific Committee on Report of the Scientific Committee on “knowledge of the hazardous nature of SHS has Tobacco and Health, Tobacco and Health consolidated over the last five years, and this evidence London, United strengthens earlier estimates of the size of the health Kingdom Secondhand Smoke: Review of risks” evidence since 1998 “No infant, child or adult should be exposed to SHS”

“SHS represents a substantial public health hazard” 2005 California EPA , Proposed Identification of “Evaluates the potential health impacts from exposures to Sacramento, CA Environmental Tobacco Smoke as a ETS” Toxic Air Contaminant

2006 USDHEW, The Health Consequences of “Many millions of Americans, both children and adults, Washington, D.C. Involuntary Exposure to Tobacco are still exposed to secondhand smoke in their homes and Smoke: A Report of the Surgeon workplaces” General “Secondhand smoke exposure causes disease and premature death in children and adults who do not smoke”

“Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children”

“No risk-free level of exposure to secondhand smoke”

“Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke.”

Table 1.1 (continued)

2007 USDHHS^^, Children and Secondhand Smoke “Reaffirms and strengthens the findings in the 1986 U.S. Washington, D.C. Exposure-Excerpts from The Health Surgeon General Report” Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General

2012 USDHHS, Washington, Preventing Tobacco Use Among Youth “Exposure to ETS among youth” D.C. and Young Adults: A Report of the Surgeon General ^USDHEW: U.S. Department of Health, Education and Welfare, ^^USDHHS: U.S. Department of Health and Human Services

As stated in the “Report of the Scientific Committee on Tobacco and Health”, exposure to ETS3 is a substantial public health hazard. As states earlier, exposure to ETS among youth demands more attention especially among youth due to their higher breathing rates, limited ability to avoid smoking environments and the early stages of development of their respiratory, immune, and nervous systems (Bearer, 1995a, 1995b; United States. Public Health Service.

Office of the Surgeon General, 2006). Among youth, exposure to ETS has been linked with acute upper and lower respiratory infections, pulmonary dysfunction, delayed lung growth, exacerbation of asthma, bronchitis, pneumonia, chronic cough and phlegm, middle ear infections, and premature death among both smokers and nonsmokers (United States. Public

Health Service. Office of the Surgeon General, 2006). Exposure to ETS and tobacco use among adolescents have been studied and reported in detail, both separately and combined, by various researchers and agencies at the local, state, and country level. However, there have been no studies or reports to address this issue on a global scale, especially in LMICs, where 80% of all smokers reside (World Health Organization et al., 2008a).

Tobacco Control: Monitoring and Surveillance

After the “pre-1950” and “1950s” eras of establishing the association between cigarette smoking and lung cancer and developing an understanding about the adverse health effects of tobacco use, it was only in “late 1990s” that a new era began focused on controlling tobacco use on a global scale. In July 1998, in response to the massive toll of death, sickness, and misery caused by the global tobacco epidemic and the need for a tobacco control work profile at the

3 ETS and secondhand smoke are used interchangeably in this dissertation. However, they are different as secondhand smoke captures “involuntary nature of the exposure” while ETS does not.

global level, the WHO established the Tobacco Free Initiative (TFI) to focus international attention, resources, and action on the global tobacco epidemic.

The WHO TFI‟s mission was –

“To reduce the global burden of disease and death caused by tobacco, thereby protecting present and future generations from the devastating health, social, environmental and economic consequences of tobacco use and exposure to tobacco smoke.“

Three major objectives of TFI were: 1) to promote the WHO Framework Convention on

Tobacco Control (WHO FCTC), the world‟s first international treaty negotiated by the WHO, and encourage countries to adhere to its principles and to support them in their efforts to implement tobacco control measures (Simpson, 2004), 2) to provide global policy leadership, and 3) to encourage mobilization at all levels of society to fight against the global tobacco epidemic. To supplement the WHO FCTC tobacco control measures, the WHO Regional Offices

(ROs) have developed and implemented tobacco control strategies with plans to address the growing tobacco epidemic in their respective regions. The WHO ROs identified the paucity of data as the major problem in addressing the growing tobacco epidemic. Consequently, all tobacco control efforts by these WHO ROs and their countries were directed to establishing surveillance efforts, which is consistent with the Article 20 of the WHO FCTC that addresses research, surveillance and communication of information related to global tobacco use

The Article 20 of the WHO FCTC states:

“The Parties shall establish, as appropriate, programmes for national, regional and global surveillance of the magnitude, patterns, determinants and consequences of tobacco consumption and exposure to tobacco smoke. Towards this end, the Parties should integrate tobacco surveillance programmes into national, regional and global tobacco surveillance programmes so that data are comparable and can be analyzed at the regional and international levels, as appropriate.”

During the same time of the 1990s as the above activities were taking place, other important events that played a major role in the development of the Global Tobacco Surveillance

System (GTSS) were the release of the 1) U.S. Surgeon General report to address tobacco use among youth (1994) ("Preventing tobacco use among young people. A report of the Surgeon

General. Executive summary," 1994), 2) tobacco Master Settlement Agreement (MSA) in

November 1998 (Luka, 1999; United States. General Accounting Office., 2001), and 3) the initiation of Youth Tobacco Survey (YTS) in Florida, U.S.A

Global Tobacco Surveillance System

In December 1998 a meeting was convened at the WHO headquarters in Geneva,

Switzerland to address the need for development of a surveillance system for tobacco use

[smoked and smokeless tobacco products and exposure to SHS] among adolescents (Warren,

Lee, et al., 2009). The meeting was attended by experts in tobacco control from the WHO, the

U.S. Center for Disease Control and Prevention (CDC), the Canadian Public Health Association

(CPHA), and country representatives from the six WHO regions. The highlights and conclusions of the meeting were discussed in detail by Warren et al. (Warren, Lee, et al., 2009).

Subsequently, they initiated and developed the GTSS to assist countries to establish, monitor, and evaluate tobacco use and tobacco control (Esteghamati et al., 2010; Saran et al., 2010;

Warren, Lee, et al., 2009). The GTSS was developed as a coordination effort of the WHO FCTC and National Tobacco Control Action Plans to assist respective countries in the development, implementation, and evaluation of tobacco control programs in all WHO member states. It is a flexible system that includes common data items and countries are allowed to add supplemental questions at their discretion. It uses common survey questionnaires, similar sampling procedures

for data collection, similar data cleaning, data management, and processing techniques for all countries. The GTSS collects data related to the surveillance of tobacco use through three school-based surveys and one household survey. The three school-based surveys are the Global

Youth Tobacco Survey (GYTS), the Global School Personnel Survey (GSPS), and the Global

Health Professions Student Survey (GHPSS). The Global Adult Tobacco Survey (GATS) is the only household survey and was included in the GTSS in 2006. The surveys of GTSS and their respective objectives are detailed in Table 1.2.

Table 1.2: Global Tobacco Surveillance System, Surveys and Objectives S. No GTSS Survey Objective

School-based Surveys

1 Global Youth Tobacco Survey Surveillance tobacco use among adolescents. (GYTS)

2 Global School Personnel Survey Collects information on tobacco use, (GSPS) knowledge and attitudes of school personnel toward tobacco use, existing tobacco control policies in policies and materials for implementing tobacco prevention efforts.

3 Global Health Professions Student Gathers information from health-profession Survey (GHPSS) students about their tobacco use and their role in tobacco control as cessation counselors cross-nationally.

Household Survey

4 Global Adult Tobacco Survey Surveillance of tobacco use among adults, aged 15 years and above. It collects information related to adults‟ tobacco use, exposure to second-hand smoke and their intention to quit smoking.

The philosophy of the Global Tobacco Surveillance System (GTSS) is-

“The WHOLE is greater than the SUM of the PARTS” which means, that interaction, collaboration, partnership, and co-operation of two or more organizations will produce an effect that is greater than the sum of individuals effects. The organizations in the GTSS collaborative group include the following: 1) global partners- WHO,

CDC, CPHA, 2) regional partners- six WHO regional offices and, 3) national partners- governments of countries in respective WHO regions (Figure 1.1). The specific roles or functions of these partners are detailed in Table 1.3.

Figure 1.1: Global Tobacco Surveillance System, Partnerships, and Collaborations at Global, Regional, and National level, School-based surveys

Table 1.3: GTSS Partners and Their Roles Partners Major roles Global partners World Health Organization  A global policy framework for implementation and use of GTSS surveillance data  Develop partnerships and collaborations  Data dissemination  Ensure capacity building  Political commitment U.S. Centers for Disease Control and  Financial and technical support for GTSS Prevention  Survey process and data coordinating center  Coordination with WHO regional offices and national governments. Canadian Public Health Association (CPHA) Financial and technical support to GTSS surveys conducted in Balkan region and other countries. John Hopkins School of Public Health a Technical expertise in validation of GATS questionnaire and data analysis Bloomberg Initiative b Development of GATS Financial and technical support to GATS Regional partners Six WHO regions  Plan, organize, operationalize and manage the surveys for their respective countries  Data dissemination center  Political commitment  Selection and training of research coordinators who administer the survey National partners National governments of countries  Resources for survey administration  Accomplish country‟s report in timely manner  Utilizing GTSS survey results for policy development and tobacco control programs  Implementation of WHO FCTC Associate partners c RTI International Data collection support (software and training) UNC Survey Research Unit Technical assistance in sample methodology a,b,c – Partners for household survey (GATS) only. RTI – Research Triangle Institute; UNC – University of North Carolina at Chappel hill [Adapted from Warren et al. (2009). Evolution of global tobacco surveillance system (GTSS) 1998-2008. Global Health Promotion..]

The training plan of the GTSS is outlined in Figure 1.2. It is comprised mainly of three phases of workshops for regional coordinators (RCs). RCs are those personnel who are appointed by the national governments or Ministries of Health of respective countries. During the Phase I- survey workshop, the RCs are provided training in questionnaire development, sample design and selection, field procedures, data collection and management, and developing the timeline for the survey and the budget required to conduct the survey. Regional workshops are conducted for

RCs involved with GYTS and GSPS and global workshops for those involved with GHPSS.

During the Phase II- analysis workshop, the RCs are provided training in data analysis, report writing and dissemination of results. The analysis workshop follows completion of the survey.

Phase III consists of the program workshop. The description of the GTSS training plan has been discussed in detail by Warren et al. (Warren, Lee, et al., 2009)

Figure 1.2: Global Tobacco Surveillance System (GTSS) Plan

Global Youth Tobacco Survey

The GYTS is one of the three school-based surveys developed by the GTSS. It was the first global tobacco-related survey developed by the GTSS in 1998 to monitor and surveillance tobacco use among youth worldwide. The major principles of GYTS are given in Figure 1.3.

 Multiple partnership, collaboration & governance  Standard methodology and protocol (4 C‟s) o Consistent o Comparable o Customizable o Cost-effective  Sustainability- repeating the survey every 4-5 years  Systematic framework related to questionnaire development, sample design, training, data collection, analysis, dissemination of results and evaluation  Enhance capacity of countries related to tobacco surveillance among youth  Guide policy development and national tobacco control programs implemented

Figure 1.3: Principles of Global Youth Tobacco Survey

Similar to GTSS, the training plan of the GYTS includes three workshops- survey, analysis, and program workshops. The first core questionnaire of the GYTS was developed in 1998 and the first training workshop (survey workshop) was conducted in March 1999 for eight countries

(Barbados, China, Jordan, Russian Federation, Sri Lanka, Ukraine, Venezuela, and Zimbabwe).

The second survey workshop was conducted for four more countries (Costa Rica, Fiji, Poland, and South Africa) in April 1999. The 12 countries completed the GYTS survey by August 1999 and attended the first analysis training workshop in September 1999 to learn to use Epi Info to analyze the data collected for youth tobacco use from the respective countries. In addition, the

RCs were also provided training in writing a country-level report and disseminating the results to guide national tobacco control programs and policies. Between 1999 and 2009, the GYTS has been administered in 171 countries. The GYTS survey methodology, core questionnaire and limitations have been discussed in detail in earlier studies (Warren, 2008; Warren, Jones,

Eriksen, & Asma, 2006; Warren et al., 2008; Warren, Lea, et al., 2009; Warren, Lee, et al., 2009;

Warren et al., 2000). The GYTS surveys that were conducted in countries between 1999 and

2008 have been outlined in Tables 1.4 through 1.9 by year and respective WHO regions.

Table 1.4: Global Youth Tobacco Survey in WHO Africa, by Year, 1999- 2008 GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 South South Africa South Africa Africa 2 Zimbabwe Zimbabwe Zimbabwe 3 Ghana Ghana 4 Malawi Malawi 5 Nigeria Nigeria 6 Burkina Burkina Faso Faso 7 Kenya Kenya 8 Mali Mali 9 Mauritania Mauritania 10 Niger Niger 11 Swaziland Swaziland 12 Togo Togo 13 Senegal Senegal 14 Botswana Botswana 15 Lesotho Lesotho 16 Mozambique Mozambique 17 Seychelles Seychelles 18 Uganda Uganda 19 Zambia Zambia 20 Cote d‟Ivoire 21 Ethiopia 22 Mauritius Mauritius 23 Tanzania Tanzania 24 Benin 25 Namibia 26 Congo

Table 1.4 (continued)

S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 27 Eritrea 28 Algeria 29 Comoros 30 Cape Verde 31 T chad 32 Gambia 33 Madagascar 34 Burundi 35 Central African Republic 36 Cameroon 37 Dem. Rep. of the Congo 38 Eq Guinea 39 Liberia 40 Rwanda 41 Sierra Leone 42 Guinea-Bissau

[Adapted from Warren et al. (2009). Evolution of global tobacco surveillance system (GTSS) 1998-2008. Global Health Promotion..]

Table 1.5: Global Youth Tobacco Survey in WHO Eastern Mediterranean Region, by Year, 1999- 2008 (Warren, Lee, et al., 2009) GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 Jordan Jordan Jordan 2 Gaza Gaza Strip Strip 3 West West Bank Bank 4 Egypt Egypt 5 Kuwait Kuwait 6 Lebanon Lebanon 7 Morocco Morocco 8 Saudi Saudi Arabia Arabia (regions) 9 Sudan Sudan 10 Tunisia Tunisia 12 Bahrain 13 United Arab United Arab Emirates Emirates 14 Syria Syria 15 Oman Oman 16 Iran Iran 17 Libya Libya 18 Djibouti 19 Pakistan Pakistan (regions) 20 Yemen Yemen 21 Afghanistan Qatar 22 Qatar Somalia 23 Somalia 24 Iraq Iraq (regions) 25 UNRWA 47

Table 1.6: Global Youth Tobacco Survey in WHO European Region, by Year, 1999- 2008 GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 Russian Russian Federation Federation 2 Poland Poland 3 Ukraine Ukraine 4 Lithuania Lithuania 5 Bulgaria Bulgaria 6 Czech Czech Republic Republic 7 Latvia Latvia 8 FYR Macedonia 9 Georgia Georgia 10 Estonia Estonia 12 Slovakia Slovakia 13 Hungary Hungary 14 Croatia Croatia 15 Bosnia and Bosnia and Herzegovina Herzegovina 16 Slovenia Slovenia 17 Turkey 18 Serbia Serbia 19 Belarus 20 Kazakhstan 21 Kyrgyzstan Kyrgyzstan 22 Moldova Moldova 23 Montenegro Montenegro 24 Albania 25 Armenia 26 Romania 27 Tajikistan

Table 1.6 (continued)

S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 28 Kosovo 29 Cyprus 30 Greece 31 Uzbekistan

[Adapted from Warren et al. (2009). Evolution of global tobacco surveillance system (GTSS) 1998-2008. Global Health Promotion..]

Table 1.7: Global Youth Tobacco Survey in WHO Region of the Americas, by Year, 1999- 2008 GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 Barbados Barbados Barbados 2 Costa Rica Costa Rica Costa Rica 3 Venezuela Venezuela Venezuela (regions) 4 Antigua and Antigua Barbuda and Barbuda 5 Bahamas Bahamas 6 Dominica Dominica 7 Grenada Grenada 8 Guyana Guyana 9 Montserrat 10 Suriname Suriname 12 Trinidad & Trinidad & Tobago Tobago 13 Argentina Argentina Argentina 14 Bolivia Bolivia Chile 15 Chile Chile 16 Mexico Mexico Mexico Mexico (regions) (regions) (regions) 17 Peru Peru Peru Peru (regions) 18 USA USA USA USA 19 Jamaica Jamaica 20 Cuba Cuba 21 Haiti Haiti 22 St Lucia St Lucia

Table 1.7 (continued)

S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 23 St Vincent & St Vincent & The The Grenadines Grenadines 24 US Virgin US Virgin Islands Islands 25 Uruguay Uruguay 26 British Virgin Islands 27 Colombia Colombia 28 Ecuador Ecuador 29 St Kitts & Nevis 30 Brazil Brazil Brazil Brazil Brazil (regions) (regions) (regions) (regions) 31 Panama Panama 32 Guatemala Guatemala 33 Belize Belize 34 Paraguay Paraguay 35 Honduras 36 Nicaragua 37 El Salvador 38 Dominican Republic 39 Puerto Rico

[Adapted from Warren et al. (2009). Evolution of global tobacco surveillance system (GTSS) 1998-2008. Global Health Promotion..]

Table 1.8: Global Youth Tobacco Survey in WHO South-east Asia Region, by Year, 1999- 2008 GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 Sri Lanka Sri Lanka Sri Lanka 2 India India India India India (regions) (regions) (regions) 3 Indonesia Indonesia 4 Myanmar Myanmar 5 Nepal Nepal 6 Maldives Maldives 7 Bangladesh Bangladesh 8 Bhutan Bhutan 9 Thailand 10 Timor Leste

[Adapted from Warren et al. (2009). Evolution of global tobacco surveillance system (GTSS) 1998-2008. Global Health Promotion..]

Table 1.9: Global Youth Tobacco Survey in WHO Western Pacific Region, by Year, 1999- 2008 (Warren, Lee, et al., 2009) GYTS conducted in respective country, by year S. 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 No 1 China China (regions) 2 Fiji Fiji 3 Northern Northern 4 Mariana Mariana Islands Islands 5 Palau Palau 6 Philippines Philippines Philippines 7 Singapore 8 Macau Macau 9 Guam 10 Cambodia 11 Cook Cook Islands Islands 12 Laos Laos 13 Vietnam Vietnam 14 Mongolia Mongolia 15 Malaysia 16 Taiwan Taiwan Taiwan 17 Republic of Republic of Korea Korea 18 American Samoa 19 Tuvalu 20 Papua Guinea 21 Samoa 22 Micronesia (Fed. States of) 23 Vanuatu 24 New Zealand New Zealand 53

Theoretical Framework of the Research Study

The theoretical framework for this research study has been detailed in Figure 1.4. This framework is an adaption of the socio-ecological model to examine the multiple effects, interactions, and interrelatedness of various elements influencing the health of adolescents

(Lupandin, 1989). This model has been used most in conflict communication, psychology, and field procedures (Oetzel & Ting-Toomey, 2006b). In the field of health, it is widely used in the context of health promotion, where understanding the socio-ecological perspective of an element helps the health professional remove barriers to healthy choices, promote personal well-being by creating the necessary conditions, understand the interconnectedness and interrelationships that exist across various elements, recognize the competing elements and interests, strengthen relationships, tailor public health efforts to those needed elements, and promote social justice.

Previous research studies have identified that focusing on one level (or element) often underestimates the results and effects of other contexts, which emphasizes the importance of this model (Klein & Kozlowski, 2000; Rousseau, 1997; Stokols, 1996).

The WHO defines individual health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity (Callahan, 1973). In this context the socio-ecological model has been used with adolescents to help understand various elements and how they interact with one another at the four levels in the model (Figure 1.4) to produce an ultimate effect on the health of an adolescent. The four levels at which these elements interact include the individual, the community, the country, and the global.

The health of adolescents is influenced by their personal attitudes, behaviors, perceptions, knowledge, exposure, and individual susceptibility. When considering tobacco use, adolescents‟ health is influenced by their tobacco use behavior, accessibility to tobacco products, attitudes

about tobacco use and policies, perceptions about those who smoke, exposure to media and counter-marketing, and knowledge about the harmful effects of smoking and second hand smoke.

The individual-level elements are influenced by the community-level contexts in which the individual resides. At this level the individual-level tobacco-related contexts of adolescents are influenced by parental (father alone, mother alone, and both of them) and peer smoking behavior, anti-smoking education at school, home, and through health professional, and exposure to environmental tobacco smoke.

The elements at the community-level where the adolescent resides are further nested within the country-level contexts. At this level both community and individual-levels elements are influenced by country-level tobacco control policies, programs, health systems infrastructure, and the scientific community.

Finally, the three individual-level, community-level and country-level contexts are incorporated within the global contextual level. The elements of the global context encompass the elements of the other three contexts and include various conventions and treaties (WHO

FCTC), Intergovernmental Organizations (IGOs, e.gs - WHO, World Bank, United Nations),

Nongovernmental Organizations (NGOs, e.gs - Framework Convention Alliance, International

Union Against Tobacco and Lung Diseases), the scientific community (the Global Tobacco

Control Epistemic Community), businesses (e.gs, Transnational Tobacco Companies, TTCs), philanthropists (e.gs, Melinda and Bill Gates Foundation, Michael Bloomberg) and research institutions (Research for International Tobacco Control, Canada, CDC) (Cruz, 2009; Lee, Ling,

& Glantz, 2012; Mamudu, Gonzalez, & Glantz, 2011; Mamudu & Studlar, 2009; Rice, 2009;

Slama, 2005; Warner, 2005)

The interaction or interrelatedness among the four different level contexts can be explained through two concepts. First, it is explained based on the nature of impact and resulting impact of one context on other, and second, based on the nature of the level effects between different levels that can be either top-down, bottom-up, or interactive effects.

The nature and result of impact are either 1) isomorphic, meaning that the impacts of different levels on one another are equal both in magnitude and direction resulting in an impact on only one level or 2) discontinuities, where an effect on one level produces an impact that is unequal in magnitude and opposite in direction resulting in an impact on one or more levels

(Oetzel & Ting-Toomey, 2006a). In this theoretical framework most of the interactions are discontinuities. For instance, tobacco control policies (country-level element) decrease both parental and peer smoking behavior but may or may not produce change in anti-smoking education resulting in an unequal magnitude in tobacco use status with decreased susceptibility in smoking and exposure to media marketing.

For the nature of level effects conceptual framework, most of the contextual factors involve interactive effects and are cyclical in nature. All contextual factors in all four context levels influence adolescents‟ health through interactive effects, which further influences the four contexts in an indirect manner. These interactive effects are interrelated and interdependent and occur simultaneously at multiple levels (Rousseau, 1997). McLeroy et al. has stated that the

“ecological perspective implies reciprocal causation between the individual and the environment” defining interactive effects as broad and necessary in many scenarios (economics,

social work, psychology, corporate ethics, health, risk communication, political conflict etc.)

(McLeroy, Bibeau, Steckler, & Glanz, 1988). In addition, all four levels influence the smoke-free nature of the environment that further affects adolescents‟ health. All direct interactions in the theoretical framework are bi-directional in nature.

Figure 1.4: Theoretical framework

CHAPTER 2

UNDERSTANDING WORLDWIDE YOUTH SUSCEPTIBILITY TO SMOKING: AN

ANALYSIS OF THE GLOBAL YOUTH TOBACCO SURVEY

Sreenivas P Veeranki 1, Hadii M Mamudu 2, James L Anderson1, Shimin Zheng1

1 Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State

University, Johnson City, TN 37604

2 Department of Health Services Management and Policy, College of Public Health, East

Tennessee State University, Johnson City, TN 37604

Address for correspondence:

Sreenivas P Veeranki

P O 12993

Johnson City, TN 37604

Phone: 412-378-3936

Email: [email protected]

[email protected]

Key words: Tobacco, youth, smoking susceptibility, Global Youth Tobacco Survey

Abstract

Objective:

To estimate the prevalence of susceptibility to smoking (the lack of firm decision against smoking) among never-smoking youth globally and identify the individual-level factors influencing it.

Methods:

Cross-sectional data for 164 countries was obtained from the Global Youth Tobacco Survey for the years 1999-2008. For countries surveyed more than once, the latest data were used.

Univariate, bivariate, and multiple logistic regression analysis were conducted, after the sample was weighted for design effect, nonresponse patterns, and poststratification. Unweighted and weighted counts and weighted percentages for univariate and bivariate models and unadjusted and adjusted odds ratios with respective confidence intervals for multivariate models were reported.

Results:

Around 14% of never-smoking youth were found to be susceptible to smoking worldwide, with variation across WHO4 regions (11.9% in Africa and 25.5% in Europe). Never-smoking youth who had either smoking parent(s) or peer(s) [AOR5 2.63, 95% CI6 2.43 to 2.84], were exposed to tobacco industry promotion [AOR 1.56, 95% CI 1.41 to 1.73], were exposed to secondhand smoke (SHS) outside the home [AOR 1.48, 95% CI 1.38 to 1.59] and inside the home [AOR

1.43, 95% CI 1.33 to 1.54] were strongly associated with susceptibility to smoking. In contrast,

4 WHO means World Health Organization 5 AOR means Adjusted Odds Ratio 6 CI means Confidence Interval 60

those who received anti-smoking education in schools [AOR 0.85, 95% CI 0.80 to 0.91] and who supported smoke-free policies (SFPs) [AOR 0.92, 95% CI 0.82 to 0.99] were inversely associated with susceptibility to smoking. An important finding is that never-smoking youth who were exposed to anti-smoking media messages and who were knowledgeable about the harmful effects of smoking and SHS were positively associated with susceptibility to smoking.

Conclusion:

The study identified a number of modifiable factors that can help prevent smoking initiation among never-smoking youth, providing strong support for the initiation of early public health prevention programs. Well-executed anti-smoking campaigns, health education programs targeting parents and peers, comprehensive SFPs, comprehensive ban on tobacco advertising, promotion, and marketing strategies, along with anti-smoking education in schools will prevent and/or reduce smoking susceptibility among never-smoking youth globally.

Introduction

Despite public health prevention efforts, tobacco use continues to be the leading preventable cause of deaths (1). In recent decades, it is observed that there is a slow and steady decrease in tobacco use in the developed nations, while at the same time there is a disproportionate increase in smoking rates in the developing countries (2). If current trends persist, it is expected that tobacco use will kill around eight million people worldwide annually by 2030 and a billion people or more by the end of 21st century (2). Moreover, it is predicted that

80% of these premature deaths will occur in the developing countries where tobacco use is very high with reported smoking prevalence among men in excess of 50% (1-3).

Cigarette smoking is a learned behavior that progresses through several stages: preparation, initiation, experimentation, regular smoking, and addiction (4, 5). The average age of smoking initiation is as early as 14 years, and progression to regular or daily smoking peaks during 15-16 years age (6-8). The concept of the preparation and initiation stages of smoking learned behavior were initially introduced more than 30 years ago (5), but did not receive significant recognition until 1994 with the United States (US) Surgeon General report on youth smoking (4, 9). Even today, this concept still receives little research attention in the developing countries. Understanding the preparatory and initiation stages of smoking learned behavior in detail will provide directions for tobacco control strategies and prevent many never-smoking adolescents to initiate smoking and become regular or replacement smokers in future. In this research study, we explore the prevalence of worldwide never-smoking youth susceptibility to smoking (the lack of firm decision against smoking) and also identify the key determinants that influence their smoking susceptibility utilizing data from the Global Youth Tobacco Survey

(GYTS).

Susceptibility to smoking, defined as the lack of firm decision against smoking, usually starts in the preparatory or initiation phases of smoking learned behavior. Pierce et al. conducted a longitudinal study of 4,500 adolescents to assess the predictive validity of smoking susceptibility and found that susceptibility to smoking was a stronger independent predictor of smoking experimentation than the familial relationships behavior (10). Similarly, Unger et al. investigated the predictive value of susceptibility to smoking for predicting smoking initiation among 687 seventh-grade nonsmokers and found that 1-2 years later susceptible teenagers were two to three times more likely to become regular smokers compared to non-susceptible teenagers

(11). Choi et al. analyzed longitudinal survey samples data from the United States and California with 7,960 and 3,376 adolescents respectively and identified that those adolescents susceptible to smoking increased the probability of future established smoking at all levels of previous smoking experience 7 (12). Huang et al. used data from a randomized controlled trial (n=1,995) (13) and

Jackson et al. from a prospective study (n= 788) (14) to conclude that smoking susceptibility was a stronger predictor for smoking initiation and experimentation than were parental and/or peer- smoking behavior. Additionally, susceptibility to smoking among never-smoking adolescents has been significantly associated with participation in tobacco promotion campaigns (15). A major concern related to susceptibility to smoking was its effect on adolescents‟ responsiveness to tobacco prevention programs. It was found that susceptibility to tobacco use among adolescents was inversely related to their responsiveness and compliance for tobacco prevention programs

(16-19). Therefore, tobacco prevention efforts should target never-smoking youth during the preparatory stage to prevent them from becoming susceptible to smoking (10).

7 Previous smoking experience was categorized into six levels: never smoker, puffer, non-recent experimenter, recent experimenter, non-recent established, and current established smoker. 63

As stated earlier, there has been a scarcity of scientific research evidence on the preparatory phase of cigarette learning behavior, especially in the developing countries. To date, there have been only three research studies that have focused exclusively on understanding smoking susceptibility among youth outside Canada or the United States (20-22). Ertas et al. used the GYTS data to examine prevalence and factors associated with tobacco use and stages of smoking, including susceptibility among Turkish youths (20). Similarly, Guindon et al. used the

GYTS data to estimate the extent of association between smoking susceptibility and context- difference and delineate the factors that influenced susceptibility to smoking among youth in

Cambodia, Laos, and Vietnam(21). Arillo-Santillan et al. used school surveys to identify the factors associated with susceptibility to smoking among Mexican youth in 10 cities (22).

Evaluating susceptibility to smoking among youth globally has an advantage because it provides opportunities for early intervention efforts that are not captured by traditional smoking experimentation or participation prevention measures (23-28). The GYTS, a component of

Global Tobacco Surveillance System (GTSS), was initiated in 1999 by the World Health

Organization (WHO), the United States Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) and has provided an opportunity to explore susceptibility to smoking among never-smoking youth globally (29-31).

Previous research studies have identified a number of characteristics that influence youth susceptibility to smoking. At an individual level, there is considerable evidence that susceptibility to smoking among youth is influenced by peers (20, 32-37), parents and/or family members (20, 32, 36, 38), co-workers (35), and/or school teachers (20) smoking behavior, smoking restrictions at home (37), positive attitudes towards smoking ban in public places and/or support for smoke-free policies (SFPs) (39), perceptions about smoking, and attitudes about

social consequences of smoking (40, 41). Other factors that have been found to influence smoking susceptibility among youth include exposure to tobacco advertisements, tobacco industry marketing and promotion activities (20, 32-34, 36, 42, 43), and knowledge about the harmful effects of smoking and secondhand smoke (SHS) exposure. The research findings regarding the relationship between smoking susceptibility and prevention programs are mixed

(44). Research has shown that perceived usefulness of school prevention programs and perceived helpfulness of anti-smoking information has been associated with decreased smoking susceptibility (44). However, Wiehe et al. reported that these school-based prevention programs did not have a long-term success in keeping youth from initiating smoking (45). In addition, it was found that youth attending schools with relatively high smoking rates among older students have an increased susceptibility to smoking (38). Similar to prevention programs, the relationship of gender and smoking susceptibility is unclear. Some research studies identified girls at an increased risk (34, 39, 41), and some found boys at an increased risk (20, 33, 43).

Other studies found no significant difference based on gender (13, 32, 36, 42). This research study is important because it explores the extent and factors associated with smoking susceptibility among never-smoking globally. The study findings will provide important information that will allow countries not only to tailor their efforts for early anti-smoking intervention measures targeting youth during the preparatory phase of smoking learned behavior but also encourage them to develop and implement comprehensive SFPs and comprehensive bans on tobacco industry promotion and marketing strategies.

Methods

In 1999, the WHO, CDC, and CPHA developed the Global Youth Tobacco Survey (GYTS) for surveillance of tobacco use among adolescents across countries using a common survey questionnaire and methodology. The GYTS employed a standardized and structured questionnaire with a 'core' set of 54 questions to explore prevalence and determinants of tobacco use in respective countries. Countries have the option to include additional questions specific to their cultural beliefs and norms and also to administer the survey in their own language. The original core questionnaire is translated into local languages and then back-translated to English to ensure accuracy (46).

In this research study, we used GYTS data related to tobacco use among youth for 164 countries for the years 1999-2008. The most recent survey was used for countries that have been surveyed more than once. The description and methodology of GYTS have been described in detail in earlier studies (30, 46, 47). Briefly, the GYTS was a school-based survey and employs a two- stage cluster sample design to collect representative data on tobacco use among school-going adolescents. During the first stage, clusters of schools proportional to the student enrollment size were selected, followed by random selection of classes in these schools during the second stage. The survey questionnaire was administered to all students in these selected classes. The school, class and student response rates were calculated respectively for each country.

Measures

Dependent variable.

The dependent variable, susceptibility to smoking among never-smoking youth, which is defined as lack of a firm decision against smoking and/or having never tried or experimented with cigarette smoking, even one or more puffs was obtained from the algorithm developed by

Pierce et al. (10). In this GYTS survey, smoking susceptibility is measured using the following questions that have a four-point ordinal scale for response (Definitely not, probably not, probably yes and definitely yes):

1) If one of your best friends offered you a cigarette, would you smoke it?

2) Do you think you will be smoking cigarettes five years from now?

3) At any time during the next 12 months do you think you will smoke a cigarette?

Those who answered “definitely not” to all three questions were considered non-susceptible and recoded as „0‟; all other students were considered susceptible to smoking and recoded as „1‟ for multiple logistic regression models (Table 2.1).

Table 2.1: Study Measures, Survey Items with Responses from Global Youth Tobacco Survey (GYTS)

Study Measure GYTS survey items GYTS item responses Dichotomized measure GYTS question used to obtain never- smoking youth Smoking status Have you ever tried or experimented with cigarette Yes Yes= Ever smoker smoking, even one or two puffs? No No= Never smoker Dependent Variable Susceptibility to smoking If one of your friends offered you a cigarette, would Definitely not No = 'Definitely not' you smoke it? Probably not for all three items At any time during the next 12 months do you think Probably yes Yes= any other you will smoke a cigarette? Definitely yes responses for any of Do you think you will be smoking cigarettes 5 years the three items from now? Independent Variables Exposure to secondhand During the past week, on how many days have 0 No= 0 days for both smoke (SHS) inside home people smoked in your home, in your presence? 1 to 2 items 3 to 4 Yes ≥ 1 day for both 5 to 6 items 7 Exposure to SHS outside During the past 7 days, on how many days have 0 No= 0 days for both home people smoked in your presence, in places other than 1 to 2 items in your home? 3 to 4 Yes ≥ 1 day for both 5 to 6 items 7

Table 2.1 (continued)

Parental or peer Parents Do your parents smoke? None No='none' or 'I don't smoking Both know' for both items Father only Yes= any other Mother only reasons for either None of them items Peers Do any of your closest friends smoke cigarettes? Some of them Most of them All of them Support for smoke-free Are you in favor of banning smoking in public places No No policy (SFP) (such as in restaurants, in buses, streetcars, and trains, Yes Yes in schools, on playgrounds, in gyms and sports arenas, in discos)? Knowledge about harmful Do you think cigarette smoking is harmful to your Definitely not No = 'Definitely not' effects of smoking and health? Probably not for both items SHS Do you think the smoke from other people's cigarettes Probably yes Yes= any other is harmful to you? Definitely yes responses for either item Exposure to anti-smoking During the past 30 days (one month), how many anti- None No= 'none/never' media messages smoking media messages (e.g. television, radio, A few response for both billboards, posters, newspapers, magazines, movies) A lot items have you seen? Yes= any other When you go to sports events, fairs, concerts, response for either community events, or social gatherings, how often do item you see anti-smoking messages? Tobacco industry Do you have something (t-shirt, pen, backpack, etc.) No No promotion with a cigarette brand logo on it? Yes Yes Has a (cigarette representative) ever offered you a free cigarette?

Table 2.1 (continued)

Anti-smoking During this school year, were you taught in any of your No No = 'No' or 'Not sure' school education classes about the dangers of smoking? Not sure for all three items During this school year, did you discuss in any of your classes Yes Yes = Yes for any of the reasons why people your age smoke? the three items During this school year, were you taught in any of your classes about the effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad? Dichotomization of GYTS survey responses based on method in Warren et al. (46)and Koh et al. (52) All responses were dichotomized. 'No' responses were coded as '0' and 'Yes' responses as '1' for multivariate model

Independent variables.

Of the 54 core questions in the GYTS survey instrument, 14 questions were chosen based on previous studies, to develop eight independent measures that influence smoking susceptibility among never-smoking youth (4, 48-51). The eight measures include 1) current smoking status, 2) exposure to SHS, 3) parental or peer smoking behavior, 4) attitudes toward SFPs, 5) knowledge about the harmful effects of smoking and SHS, 6) exposure to anti-smoking media messages, 7) tobacco industry promotional activities and items, and 8) anti-smoking education in schools. These variables were dichotomized based on methods developed by Warren et al. (46) and previously employed by Koh et al. (52). Students' age and gender were included as covariates (Table 2.1).

To estimate the smoking susceptibility among never-smoking youth, the data collected from

164 countries were weighted to adjust for design effect (selection of school and class levels), nonresponses (school, class, and student levels), and poststratification of the sample relative to the grade and sex distribution in the population. The methodology used for weighing the measures has been commonly used previously and described by the CDC in the help file of the GYTS. The weighted data produced a true population-based sample for the never-smoking youth in 164 countries from which it was obtained.

The weighting factor is given by the formula:

W = W1 * W2 * f1 * f2 *f3 *f4 where,

W1 = the inverse of the probability of selecting a school

W2 = the inverse of the probability of selecting a classroom within a school

f1 = a school-level nonresponse adjustment factor calculated by school size category (small,

medium, large)

f2 = a class-level nonresponse adjustment factor calculated for each school

f3 = a student-level nonresponse adjustment factor calculated by class

f4 = a post-stratification adjustment factor calculated by sex and grade

Data Analysis

The weighted data were analyzed sequentially in three steps- univariate, bivariate, and multivariate analyses. Univariate analysis of weighted data was conducted for country-specific frequencies and percentages to understand the prevalence of smoking susceptibility among never- smoking youth in 164 countries. Bivariate analysis was performed to establish relationships between the dependent variable and each of the eight independent measures that influenced smoking susceptibility among never-smoking youth. A final multiple logistic regression analysis was conducted to identify factors associated with smoking susceptibility among never-smoking youth.

The measures that were significant (p < 0.05) in the bivariate analysis were included in the multiple logistic regression models. Age and gender of student were included as covariates. Unadjusted and adjusted odds ratios along with the respective 95% confidence intervals were reported. All statistical analyses were weighted to reflect the likelihood of sampling a student based on his/her gender and grade within the population of school children in the same jurisdiction, accounting for nonresponse patterns (31). All statistical analyses were performed using SAS/STAT V.9.2 of the SAS System for

Results

From a total of 164 countries, we obtained data from 495,492 never-smoking school- going adolescents who responded to the three Global Youth Tobacco Survey (GYTS) questions,

„If one of your friends offered you a cigarette, would you smoke it?‟, „At any time during the next 12 months do you think you will smoke a cigarette?‟ and „Do you think you will be smoking cigarettes 5 years from now?‟. After weighting the measures, the data for this global analysis represented 66,535,748 never-smoking youth worldwide. Table 2.2 illustrates the percentages of never-smoking youth who were susceptible to smoking globally and by six WHO regions. It was found that 14.4% of never-smoking youth were susceptible to smoking globally, with 11.9% in Africa (least) and 25.5% in Europe (highest).

Table 2.2: Susceptibility to Smoking Among Never-Smoking Youth by WHO region, Global Youth Tobacco Survey, 1999-2008

WHO region Number Number Youth Never-smoking Susceptibility of of youth to smoking countries survey (%*) sites Sample Population Sample Population size size size size Global 164 331 717,741 87,775,644 495,492 66,535,748 14.4 Africa 42 63 167,109 9,281,394 134,933 7,284,506 11.9 Eastern 28 34 75,690 11,713,447 60,514 9,462,262 14.1 Mediterranean Europe 30 37 165,581 9,651,596 94,345 5,327,602 20.9 The Americas 35 117 211,627 11,823,121 132,254 7,054,446 25.5 Southeast 10 47 43,343 37,837,547 33,004 32,405,456 11.7 Asia Western 19 33 54,391 7,468,539 40,442 5,001,477 14.4 Pacific * weighted percentages

Table 2.3 presents sample (unweighted count) and population (weighted count) characteristics of never-smoking youth worldwide. Around 79% of never-smoking youth were in

ages 13-15 years with boys and girls distributed equally. Around 14% were susceptible to smoking and have either parents or peers smoking around them. While 89% were knowledgeable about the harmful effects of smoking and SHS, around 33% and 45% were exposed to SHS inside and outside home respectively. While around 60% were exposed to anti-smoking media messages, 9% youth received tobacco promotional items.

Table 2.3: Descriptive Characteristics of Never-Smoking Youth Globally, Global Youth Tobacco Survey, 1999-2008 (n=495,492)

Measures Unweighted Weighted Weighted count count percentage Exposure to SHS^ at home 186,288 21,989,503 33.0 Exposure to SHS outside home 238,343 29,663,582 44.6 Parental or peer smoking 71,272 9,506,735 14.3 Susceptibility to smoking 91,652 9,611,352 14.4 Knowledge about harmful effects of 439,722 59,155,278 88.9 smoking Exposure to counter marketing 301,502 39,879,691 59.9 Tobacco industry promotion 46,491 6,119,113 9.2 School anti-smoking education 256,310 34,660,185 50.1 Support for smoke-free policy 394,095 52,754,447 79.3 Age 11 years and younger 22,851 1,741,807 2.6 12 years 61,138 4,460,195 6.7 13 years 114,525 18,186,368 27.3 14 years 125,035 18,867,050 28.4 15 years 92,426 15,265,047 22.9 16 years 48,660 4,577,488 6.9 17 years and older 30,857 3,437,794 5.2 Gender Boys 221,774 32,677,787 49.1 Girls 273,718 33,857,961 50.1 ^SHS means secondhand smoke

Table 2.4 presents the bivariate analysis of factors associated with susceptibility to smoking among never-smoking youth worldwide. Of all eight individual measures considered, all but one (support for SFPs) was significantly associated with smoking susceptibility among

never-smoking youth. An interesting finding was that never-smoking youth who were knowledgeable about the harmful effects of smoking and SHS were highly susceptible to smoking (13.1%). It was also found that susceptibility to smoking among never-smoking youth peaked at 14 years, with boys (7.9%) slightly more susceptible than girls (6.5%).

Table 2.4: Bivariate Analysis of Factors Associated with Susceptibility to Smoking Among Never- Smoking Youth, Global Youth Tobacco Survey, 1999-2008 (n=495,492)

Measure Percentage Unweighted Weighted Percentage p yes* count count susceptible to value smoking Parental or peer 14.3 23,725 2,978,424 4.5 <.0001 smoking Exposure to SHS ^ at 33.0 45,553 4,675,761 7.0 <.0001 home Exposure to SHS^ 44.6 53,906 5,694,846 8.6 <.0001 outside home Support for smoke-free 79.3 72,935 7,619,488 11.5 0.9829 policy Knowledge about 88.9 83,639 8,693,277 13.1 0.0004 harmful effects of smoking Exposure to counter 59.9 57,523 6,209,655 9.3 <.0001 marketing Tobacco industry 9.2 11,088 1,261,074 1.9 <.0001 promotion School anti-smoking 50.1 47,099 4,698,432 7.1 <.0001 education Age ≤ 11 years 2.6 3,646 328,012 0.5 <.0001 12 years 6.7 10,931 787,084 1.2 13 years 27.3 22,387 2,331,182 3.5 14 years 28.4 24,667 2,688,484 4.0 15 years 22.9 17,412 2,243,044 3.4 16 years 6.9 8,077 669,877 1.0 ≥17 years 5.2 4,532 563,670 0.8 Gender Boys 49.1 43,895 5,255,761 7.9 <.0001 Girls 50.1 47,757 4,355,591 6.5 * See Table 2.1 for details of variable dichotomization (yes/no), ^ SHS means secondhand smoke

Table 2.5 presents the results of multiple logistic regression analysis to identify the factors associated with smoking susceptibility among never-smoking youth worldwide. Never- smoking youth who had either parent(s) or peer(s) smoking were most strongly associated with susceptibility to smoking [AOR8 2.63, 95% CI9 2.43 to 2.84], followed by self-reported receipt of tobacco industry promotional items [AOR 1.56, 95% CI 1.41 to 1.73], self-reported exposure to SHS outside home [AOR 1.48, 95% CI 1.38 to 1.59], and self-reported exposure to SHS inside home [AOR 1.43, 95% CI 1.33 to 1.54]. In contrast, never-smoking youth who received anti-smoking education in schools were 15% less likely to be susceptible to smoking [AOR 0.85,

95% CI 0.80 to 0.91], followed by those who supported SFPs [AOR 0.92, 95% CI 0.82 to 0.99].

Interestingly, never-smoking youth self-reported exposure to anti-smoking media messages

[AOR 1.17, 95% CI 1.09 to 1.24] and knowledge about the harmful effects of smoking and SHS

[AOR 1.13, 95% CI 1.01 to 1.26] were significantly (p<0.0001) associated with increased susceptibility to smoking compared to those who reported non-exposure to anti-smoking media messages and no knowledge about the harmful effects of smoking and SHS. With respect to gender, never smoking boys were 22% more susceptible to smoking than girls [AOR 1.22, 95%

CI 1.15 to 1.30].

8 AOR means Adjusted Odds Ratio 9 CI means Confidence Interval 76

Table 2.5: Multivariate Analysis of Factors Associated with Susceptibility to Smoking Among Youth, Global Youth Tobacco Survey, 1999-2008 (n=495,492)

Measure Unadjusted OR! Adjusted OR (95% CI~) (95% CI) Parental or peer smoking 3.47 (3.23, 3.72)*** 2.63 (2.43, 2.84)*** Exposure to SHS ^ at home 2.17 (2.04, 2.31)*** 1.43 (1.33, 1.54)*** Exposure to SHS ^ outside home 2.00 (1.88, 2.13)*** 1.48 (1.38, 1.59)*** Support for smoke-free policies 0.99 (0.93, 1.08) 0.92 (0.85, 0.99)* Knowledge about harmful effects of smoking 1.21 (1.10, 1.35)** 1.13 (1.01, 1.26)* Exposure to counter marketing 1.26 (1.18, 1.34)*** 1.17 (1.09, 1.24)*** Tobacco industry promotion 1.62 (1.47, 1.78)*** 1.56 (1.41, 1.73)*** School anti-smoking education 0.86 (0.81, 0.92)*** 0.85 (0.80, 0.91)*** Age 1.01 (0.99, 1.02) 0.99 (0.97, 1.01) Gender (boys vs. girls) 1.30 (1.22, 1.38)*** 1.22 (1.15, 1.30)*** ! OR means Odds Ratio, ~CI means Confidence Intervals, ^ SHS means secondhand smoke * p<0.05, ** p<0.01 *** p<0.001

Discussion

Tobacco use in the developed countries has stalled but continued to increase in the developing countries (2). Tobacco use is a “Pediatric Disease” as 80-90% of smokers begin as minors (4). Tobacco companies market and promote tobacco products to youth as replacement smokers (53, 54). We examined the susceptibility to smoking among never-smoking youth using the GYTS data from 164 countries. We found that 14% of never-smoking youth, with some variation across the six WHO regions were susceptible to cigarette smoking.

Using multivariate model we identified factors associated with susceptibility to smoking among never-smoking youth. In consistent with the existing literature, we found that adolescents who had either parents or peers smoking were more susceptible to smoking (20, 32-36, 38, 43).

Additionally, we found that never-smoking youth exposed to SHS inside and outside home were highly susceptible to smoking. This finding was important and consistent with existent studies because assessment of SHS exposure sensitivity index has been considered as a novel approach

to study the etiology of cigarette initiation and smoking learned behavior (55-57). Boys, as compared to girls were more susceptible to smoking, as found in earlier studies (58). This emphasized the importance of developing public health prevention programs targeting never- smoking boys to prevent them from initiating smoking. In contrast, our study found that anti- smoking education in schools and youth support for SFPs were inversely associated with smoking susceptibility. The associations between youth support for SFPs and decreased susceptibility to smoking emphasized the need for developing comprehensive SFPs to establish smoke-free environments and improve the health of people globally.

Consistent with earlier studies, we found that adolescents who were exposed to tobacco industry marketing strategies through distribution of promotional items were associated with an increased susceptibility to smoking (32, 43, 59-61). This finding supports the importance of the

2012 World No Tobacco Day theme - “Tobacco industry interference”, which is aimed at exposing and countering the tobacco industry‟s brazen and aggressive attempts to undermine tobacco control strategies (62). This finding has increased importance because earlier studies have provided evidence of a dose-response relationship between an increased smoking susceptibility index and increased tobacco use among never smokers (10, 32, 63, 64) when adolescents are more involved in tobacco promotion campaigns (36, 60, 65, 66). Although transnational tobacco companies (TTC) have stated their opposition to the sale of tobacco products to minors and their participation in tobacco promotional activities and campaigns, our study identified tobacco industry promotions as a major determinant of increased susceptibility to smoking among never-smoking youth. The tobacco industry promotions can be prevented primarily in two ways: 1) develop and implement comprehensive tobacco bans in respective countries and 2) stronger regulation of tobacco company practices. Developing comprehensive

bans on tobacco industry advertising, promotion, and sponsorship must be in accordance with

Article 13 of the WHO Framework Convention on Tobacco Control (FCTC) (67). Stronger regulation of tobacco company practices include prohibiting free samples, requiring warning labels on all tobacco products and promotional items in accordance with Articles 9,10, 11 of the

WHO FCTC (67, 68), implementing strong enforcement laws regarding the sale and distribution of tobacco products to minors, especially regulating the methods of distributing promotional items, including the use of mail to promote tobacco products.

Our study found that never-smoking adolescents who were exposed to anti-smoking messages in newspapers, television, radio, posters, billboards, magazines, and movies were strongly associated with susceptibility to smoking. While this finding is consistent with earlier studies (20, 33), it provides additional important evidence about the delivery and receptivity of anti-smoking messages. This association might be due to the role of Tobacco Transnational

Companies (TTCs) interference in the delivery of anti-smoking messages resulting in no effect for such messages on youth anti-tobacco attitudes and behaviors. A study conducted in Florida to understand the nature of anti-smoking campaigns by comparing American Legacy Foundation's

'truth' campaign and Philip Morris's 'Think. Don't Smoke' (TDS) campaign on youth's tobacco- related attitudes, beliefs, and intentions revealed that youth exposed to „truth‟ campaign have developed steady and positive attitudes with less intention to smoke, while youth exposed to

„TDS‟ campaign have developed attitudes and beliefs favorable to tobacco industry with increased intention to smoke (69-71). Hence, a well-executed anti-smoking campaign will not only develop anti-tobacco beliefs and attitudes but also decrease susceptibility to smoking.

Another important finding of this study is that never-smoking adolescents‟ knowledge about the harmful effects of smoking and SHS and its association with increased susceptibility to

smoking. While this finding is contrary to the existent literature (21, 72), it is important because school anti-smoking education that imparts knowledge about smoking harm along with dangers about smoking and reasons for people smoking decreases the likelihood of smoking susceptibility among never-smoking youth. This implies that knowledge about other smoking characteristics such as dangers of smoking and reasons for people smoking should be integrated while imparting knowledge to adolescents. Just conveying the harmful effects of smoking and

SHS alone is not sufficient. Future research studies should be conducted to further evaluate and explore this finding, for instance is this finding due to knowledge of the harmful effects of smoking and SHS alone or is there an influence of other factors that dominate adolescents‟ knowledge.

Strengths and weaknesses of the study

This study has several importance strengths. First, it is the first study to identify factors associated with smoking susceptibility among never-smoking youth on a global scale. Second, the methodological approach used sample weights and allows us to generalize the findings to all never-smoking youth population worldwide. Third, the standardization of the study and its broad scope allow comparisons across global regions of the world.

As is true of other studies, our study has weaknesses that merit discussion. First, the measure used to determine susceptibility to smoking among never-smoking youth that was developed by Pierce et al. (10) has not been validated globally. Second, 18 questions in the

GYTS „core‟ questionnaire were pooled into 10 measures (one dependent, eight independent and one measure to differentiate smoking status) (see Table 2.1) based on the existing literature (46,

52), which limits identifying differences in susceptibility when exposed to individual

components. For instance, smoking susceptibility differs when youth are exposed to different types of anti-smoking messages such as newspapers, posters, magazines, community gatherings, radio etc. Third, the GYTS is a school-based survey and presents only information about youth attending schools. Those who do not attend schools and those attending schools but absent on the day the survey was conducted were not captured. Also, the students‟ responses are subject to recall bias. Fourth, the GYTS is a cross-sectional study with no inferences about causality.

Finally, this study used only individual-level measures to understand smoking susceptibility among never-smoking youth, with country-level measures such as developing status of countries and presence or absence of national tobacco control plans at respective countries not included.

Future research studies should include such country-level measures to fully understand susceptibility to smoking among never-smoking youth globally.

Conclusion

This study found that on a worldwide basis 14% of youth who had never smoked were susceptible to initiate smoking. Parental or peer smoking, tobacco industry promotion and exposure to SHS were found to be important predictors of increased susceptibility to smoking among never-smoking youth. The study also demonstrates that GYTS data can be used to examine factors associated with smoking initiation, thereby addressing a major gap in the scientific literature. The study suggests that to reduce the increasing trend in tobacco use it requires addressing the problem of never-smoking youth susceptibility to smoking. This will require implementing policies and programs that limit youth exposure to adult smoking or modifying social norms about smoking and make cigarette smoking as socially unacceptable. In this case, developing well-executed anti-smoking campaigns, comprehensive SFPs,

comprehensive ban on tobacco industry advertising, promotion and marketing strategies with anti-smoking education in the schools are some of the important public health efforts that help prevent never-smoking youth worldwide from becoming susceptible to smoking.

Funding

The authors declare that no external funds were used to conduct this study.

Competing Interests

The authors have no competing interests to declare.

Contributions

SPV worked with HMM and JLA to conceptualize the idea and conducted the data analysis. SPV worked with HMM and SZ to interpret the results and wrote the initial draft of the manuscript.

All authors contributed to revision of the manuscript.

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CHAPTER 3

PREVALENCE AND DETERMINANTS OF WORLDWIDE YOUTH EXPOSURE TO

ENVIRONMENTAL TOBACCO SMOKE

Sreenivas P Veeranki 1, Hadii M Mamudu 2, James L Anderson1, Shimin Zheng1

1 Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State

University, Johnson City, TN 37604

2 Department of Health Services Management and Policy, College of Public Health, East

Tennessee State University, Johnson City, TN 37604

Address for correspondence:

Sreenivas P Veeranki

P O 12993

Johnson City, TN 37604

Phone: 412-378-3936

Email: [email protected]

[email protected]

Key words: Tobacco use and control, youth, environmental tobacco smoke, secondhand smoke,

Global Youth Tobacco Survey

Abstract

Objective:

To estimate the prevalence and identify factors associated with exposure to environmental tobacco smoke (ETS) among adolescents worldwide.

Methods:

Data for 728,929 school-going adolescents representing 89,179,528 youth aged 11-17 years for the years 1999-2008 were obtained from the Global Youth Tobacco Survey (GYTS). Sample characteristics (unweighted counts) and respective population characteristics (weighted counts and percentages) were reported. Multiple logistic regression analysis was used to identify key determinants of youth exposure to ETS both inside and outside the home. The independent measures used in this study include adolescents‟ knowledge about the harmful effects of smoking and secondhand smoke (SHS), smoking susceptibility, parental or peer smoking, and anti-smoking education at schools. Students‟ age and gender were included as covariates.

Results:

For adolescents worldwide, about 40% are exposed to ETS inside the home and 50% outside the home. Exposure to ETS is strongly positively associated with parental or peer smoking, followed by smoking susceptibility and knowledge about the harmful effects of smoking and SHS.

School-based anti-smoking education was negatively associated with youth exposure to ETS inside the home. Notable findings include that 77% youth support SFPs, a positive association between youth exposure to ETS and knowledge about the harmful effects of smoking and SHS, and higher exposure to ETS among females than males.

Conclusion:

Parental or peer smoking is the key determinant of youth exposure to ETS and provides strong support for voluntary smoking bans at homes. Anti-smoking education at schools reduces youth exposure to ETS inside the home; therefore, it is necessary to incorporate anti-smoking education in the school curricula. An interesting finding is that adolescents‟ who had knowledge about the harmful effects of smoking and SHS are associated with increased exposure to ETS both inside and outside the home. This provides evidence that adolescents may have developed a tolerance or resistance to programs or messages that impart such knowledge due to constant and continuous exposure to ETS from parents or peers.

Introduction

The first known report on second-hand smoke (SHS) and its harmful health effects were by Schönherr in 1928 who reported that lung cancer in the non-smoking wives of smokers was caused by passive smoke inhalation (1). However, it was not until the 1970s that scientific interest in SHS and its adverse health effects gained recognition as important, especially when exposure to SHS or passive smoking was linked to lung cancer in healthy non-smokers (2, 3). In the 1980s, scientific consensus (4, 5) on the adverse health effects of SHS begun to emerge through the reports of Trichopoulos et al. from Greece (6), Takeshi Hirayama from Japan (7),

Garfinkel from the United States (U.S.), and the U.S. Surgeon General Report (8). Since then, many studies have been conducted in different parts of the world and by different organizations such as the International Agency for Research on Cancer (IARC) which have provided evidence about the harmful effects of SHS and led to the realization that smokers were not only putting their own health at risk but also the health of others (9). SHS is a significant public health problem and a common indoor air pollutant in many regions, thus making it a worldwide environmental public health problem. Therefore, SHS is also referred to as Environmental

Tobacco Smoke (ETS). Public health advocates have focused their strategies on ETS (10, 11) and have developed and implemented comprehensive legislations to protect non-smokers from exposure to ETS in a variety of locations including indoor spaces, workplaces, and public places

(12-16). However, comprehensive legislations cover only an estimated 7% of the world‟s population, implying that a vast majority (93%) have no protection against exposure to ETS (17).

In 2009, the WHO estimated that exposure to ETS kills 600,000 people worldwide each year(17). The comprehensive assessments and reviews conducted by the IARC (18), the World

Health Organization (WHO)(19), the California Environmental Protection Agency (20), and the

U.S. Surgeon General (21) have reported associations between exposure to ETS and a wide variety of conditions including upper respiratory infections, bronchial diseases, coronary heart disease, vascular infections, periodontal disease, dementia, Parkinson‟s and Alzheimer‟s disease among adult non-smokers, lower respiratory infections, middle ear diseases, severe asthma, respiratory symptoms, sickle cell disease, delayed lung development, and increased risk for sudden infant death syndrome (21-36). In addition, besides the health effects, exposure to ETS has a psychological influence on adolescents‟ behavior, especially when ETS exposure occurs in their homes and in the cars in which they travel, and when they observe their parents, peers and others smoke (37, 38). The health problems attributed to ETS provides strong support of the need for investigation into youth exposure to ETS as adolescents constitute the most vulnerable group for tobacco industry marketing and promotional strategies. This need becomes more urgent when considering the fact that only 7% of the world‟s population is covered by comprehensive SFPs (17).

During the same time, in 2009, the 174 member countries that are parties to the WHO

Framework Convention on Tobacco Control (FCTC) did “recognize that scientific evidence has unequivocally established that exposure to tobacco smoke causes death, disease and disability” (39).

As there is no scientific evidence for safe level of exposure to ETS, the WHO recommends effective measures to protect non-smokers from exposure to ETS, as envisioned by Article 8 of the WHO

FCTC- “Protection from exposure to tobacco smoke”. The WHO report on the Global Tobacco

Epidemic in 2009 emphasized the need for countries to effectively implement Article 8 of the WHO

FCTC, which required elimination of smoking and tobacco smoke in all indoor public places, indoor workplaces, and public transport (17, 40).

Some country-specific and global prevalence studies (41-49) have reported on adolescents‟ exposure to ETS. The Global Tobacco Surveillance System (GTSS) collaborative Group (50)

published three articles related to youth exposure to ETS globally (48, 50). In 2002, the GTSS collaborative group published a special report using the Global Youth Tobacco Survey (GYTS) data for the years 1999-2001 and reported that 48.9% and 60.9% of youth were exposed to SHS inside and outside the home (50). In 2006, a research paper was published using the GYTS data for the years 1999-2005, and it reported that 43.9% and 55.8% youth were exposed to SHS inside and outside the home (48). In 2007, a report was published using the GYTS data for the years 2000-2007 and found that 46.8% and 47.8% of never smokers were exposed to SHS inside and outside the home (47). However, our study provides not only global prevalence but also the first detailed assessment evaluating for possible determinants of adolescents10 (aged11-17 years) exposure to ETS worldwide. In this study, we used the GYTS (51), a school-based survey that is designed to monitor tobacco use among adolescents worldwide by collecting information related their exposure to ETS inside and outside the home along with other factors that are identified to influence ETS exposure.

Understanding the magnitude and determinants of adolescents‟ exposure to ETS worldwide will provide guidance to policy makers and public health advocates as they plan preventive strategies for comprehensive smoke-free legislations.

Methods

Data Collection

The GYTS survey was used to obtain information about tobacco use among youth aged 11 through 17 years from 164 countries. For countries surveyed more than once, we obtained information from the most recent surveys. The GYTS followed a standard methodology and protocol in survey preparation and administration, data collection and processing, and reporting the

10 The word “adolescents” and “youth” have been used interchangeably in this manuscript. 98

results (52, 53). The survey was administered using a standard and structured questionnaire consisting of a „core‟ set of 54 questions to collect information on prevalence and determinants of tobacco use among youth. The countries have the option to add supplemental questions to the „core‟ set while preparing the country-specific surveys. Moreover, the surveys were translated to the respective local or non-English language in order to fit the local language and cultural beliefs.

However, the questionnaires have to be back-translated to English to ensure accuracy across all survey sites (53). In addition to questionnaire development and administration, the GYTS survey followed a standard protocol and sampling design while selecting the samples. The sampling design has been described in detail in earlier research studies (50, 53, 54). Briefly, the GYTS used a two- stage cluster sampling design, where cluster of schools proportional to the student enrollment size were selected during the first stage. During the second stage, classes from the selected clusters of schools were randomly chosen and all students from these classes were considered eligible to participate in the survey. Response rates for the selected schools, classes, and students were determined for every country administering the survey.

Measures

Dependent variable.

The dependent variable exposure to ETS among youth was assessed using two questions, youth exposure to ETS inside the home, “During the past week, on how many days have people smoked in your home, in your presence?” and exposure to ETS outside home, “During the past 7 days, on how many days have people smoked in your presence, in places other than in your home?”

For both questions, the responses were recoded as “no” if the students answered „0‟, and “yes” if the students responded with responses anything from 1 through 7 days (Table 3.1).

Table 3.1: Study Measures, Survey Items with Responses from Global Youth Tobacco Survey (GYTS) Study Measure GYTS survey items GYTS item responses Dichotomized measure Dependent Variable Exposure to Inside the During the past week, on how many days 0 No = 0 ETS home have people smoked in your home, in 1 to 2 Yes ≥ 1 day your presence? 3 to 4 Outside 5 to 6 the home During the past 7 days, on how many 7 days have people smoked in your presence, in places other than in your home? Independent Variables Parental or Parents Do your parents smoke? None No='none' or 'I don't peer smoking Both know' for both items Father only Yes= any other reasons Mother only for either items I don't know Peers Do any of your closest friends smoke None of them cigarettes? Some of them Most of them All of them Susceptibility to smoking If one of your friends offered you a Definitely not No = 'Definitely not' for cigarette, would you smoke it? Probably not all three items At any time during the next 12 months do Probably yes Yes= any other you think you will smoke a cigarette? Definitely yes responses for any of the Do you think you will be smoking three items cigarettes 5 years from now?

100

Table 3.1 (continued)

Knowledge about the Do you think cigarette smoking is harmful to your health? Definitely No = 'Definitely not' harmful effects of smoking Do you think the smoke from other people's cigarettes is harmful not for both items and SHS to you? Probably Yes= any other not responses for either Probably item yes Definitely yes School anti-smoking During this school year, were you taught in any of your classes No No = 'No' or 'Not education about the dangers of smoking? Not sure sure' for all three During this school year, did you discuss in any of your classes the Yes items reasons why people your age smoke? Yes = Yes for any of During this school year, were you taught in any of your classes the three items about the effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad? Dichotomization of GYTS survey responses based on method in Warren et al.(53) and Koh et al. (57) All responses were dichotomized. 'No' responses were coded as '0' and 'Yes' responses as '1' for multivariate model

101

Independent variables.

Ten questions from the „core‟ set of 54 questions were identified as those characteristics that influence youth exposure to ETS. Based on extant literature and earlier research studies (53, 55-58), these 10 questions were further grouped to develop four measures that might influence the dependent variable. These four measures are: 1) parental or peer smoking, 4) adolescents‟ susceptibility to smoking, 5) knowledge about the harmful effects of smoking and SHS, and 8) anti- smoking education at schools (Table 3.1). These independent variables were dichotomized for multiple regression models based on methods previously developed by Warren et al. (53). Age and gender of students participating in the survey were included as covariates.

As described earlier, the GYTS was a two-stage cluster sampling design where the samples were collected in proportion to the student enrollment size. To estimate the overall youth exposure to ETS on a global basis inside and outside the home, the data were weighted to adjust for design effect (selection of school and class levels), nonresponses (school, class, and student levels), and poststratification of the sample relative to the grade and sex distribution in the population. This methodology of weighting measures has been described in detail in earlier studies (50, 57) and also reported in the help file of GYTS by the United States Centers for Disease Control and Prevention

(CDC). Weighting of data was done to adjust the sample so that it would be a true representation of the population, and therefore population-based. This allows for generalizability of results to youth across the respective countries.

The weighting factor is given by the formula:

W = W1 * W2 * f1 * f2 *f3 *f4 where,

W1 = the inverse of the probability of selecting a school

102

W2 = the inverse of the probability of selecting a classroom within a school

f1 = a school-level nonresponse adjustment factor calculated by school size category (small,

medium, large)

f2 = a class-level nonresponse adjustment factor calculated for each school

f3 = a student-level nonresponse adjustment factor calculated by class

f4 = a post-stratification adjustment factor calculated by sex and grade

Data Analysis

Descriptive analysis included frequencies and percentages for the sample (unweighted counts) and population characteristics (weighted counts and percentages). Inferential statistics included univariate, bivariate, and multivariate analyses. Univariate analysis consisted of determining frequencies and percentages of youth exposure to ETS, both inside and outside the home separately for the aggregated data for 164 countries. The data were adjusted for survey design effects (primary sampling unit and stratum) and final weight. Bivariate logistic regression analysis to identify associations between youth exposure to ETS and the four independent measures was conducted. Multiple logistic regression models were conducted to determine the above associations, after adjusting for effects of other measures. As stated earlier, students‟ age and gender were added as covariates in the final regression models. Odds ratios with corresponding 95% confidence intervals were reported. p values less than 0.05 were considered statistically significant. The statistical analyses and regression models were weighted to reflect the probability of sampling a student based on his/her grade and gender within the sample school population in the same jurisdiction. The statistical analyses in this research study were conducted using SAS/STAT V.9.2 analytical software of the SAS System for Windows © 2011 SAS Institute Inc. Cary, NC, USA.

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Results

The prevalence of ETS exposure among youth is shown in Table 3.2, which shows the overall global prevalence as well as for six WHO regions. Around 39% of youth were exposed to

ETS inside the home globally with the highest exposure in the Europe (77.5%) and the lowest in the

Southeast Asian countries (30.3%). Around 50% of youth were exposed to ETS outside the home globally with the highest exposure in the Western Pacific region (63.3%) and the lowest in the

Southeast Asia (44.8%) region. It was found that youth in the Southeast Asian countries, as compared to other WHO regions, had lower exposure to ETS both inside and outside the home.

Table 3.2: Youth Exposure to Environmental Tobacco Smoke (ETS) by WHO region, Global Youth Tobacco Survey, 1999-2008

WHO region Number Number Sample Youth Exposure Exposure to of of survey size population to ETS at ETS outside countries sites home home (%) (%) Global 164 331 728,929 89,179,528 39.2 49.5 Africa 42 63 170,503 9,496,785 28.2 45.2 Eastern 28 34 76,997 11,968,747 39.5 45.9 Mediterranean Europe 30 37 168,010 9,791,910 77.5 60.9 The Americas 35 117 214,151 12,003,441 37.9 53.5 Southeast Asia 10 47 43,766 38,328,860 30.3 44.8 Western 19 33 55,502 7,589,786 50.0 63.3 Pacific

Table 3.3 presents the characteristics of youth worldwide, both for the sample

(unweighted counts) and population (weighted counts and percentages). About 76% of youth were 13-15 years of age, 52% were males, and only 9.6% currently smoked cigarettes. Around a quarter of youth population were susceptible to smoking and one-fifth of them have either

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parents or peers who smoked. Only half of them received anti-smoking school education, and more than three-quarters adolescents supported the SFP.

Table 3.3: Descriptive Characteristics of Youth Globally, Global Youth Tobacco Survey, 1999-2008 (n=728,929)

Measures Unweighted Weighted Weighted count count percentage Parental or peer smoking 162,805 18,456,868 20.7 Exposure to ETS^ inside home 321,859 34,965,063 39.2 Exposure to ETS outside home 393,557 44,165,610 49.5 Susceptibility to smoking 220,319 21,174,401 23.7 Knowledge about harmful effects of 650,601 79,274,403 88.9 smoking and SHS School anti-smoking education 372,603 46,152,928 51.8 Age 11 years and younger 31,742 2,702,211 3.1 12 years 78,547 6,050,113 6.8 13 years 153,865 22,200,062 24.9 14 years 184,404 24,461,524 27.4 15 years 149,006 20,792,056 23.3 16 years 81,650 7,679,180 8.6 17 years and older 49,715 5,294,381 5.9 Gender Males 355,222 46,616,886 52.3 Females 373,707 42,562,642 47.7 ^ SHS means secondhand smoke

Table 3.4 presents the results of the bivariate analysis of factors associated with youth exposure to ETS both inside and outside the home. It was found that adolescents were more likely to be exposed to ETS outside the home than inside the home, with the exception of those who had either smoking parents or peers living with them. Youth exposure to ETS both inside and outside the home was the highest among those who were knowledgeable about the harmful effects of smoking and SHS. All independent variables were statistically significant and were

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included in the final multivariate model. Students‟ age and gender were included as potential confounders.

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Table 3.4: Bivariate Analysis of Factors Associated with Worldwide Youth Exposure to Environmental Tobacco Smoke (ETS), Global Youth Tobacco Survey, 1999-2008 (n=728,929) Exposed to SHS^ inside home Exposed to SHS outside home Measure Percentage Unweighted Weighted Percentage P Unweighted Weighted Percentage P yes* count count exposed value count count exposed value Parental or 20.7 121,873 13,543,395 15.2 114,670 13,271,755 14.9 <.0001 peer smoking Susceptibility 23.7 127,365 12,257,985 13.7 <.0001 146,745 14,189,113 15.9 <.0001 to smoking Knowledge 88.9 294,687 32,105,826 36.0 <.0001 361,306 40,787,777 45.7 <.0001 about harmful effects of smoking and SHS School anti- 51.8 168,607 17,697,141 19.8 <.0001 205,617 22,972,302 25.8 0.3005 smoking education Age ≤ 11 years 3.1 10,926 1,061,115 1.2 <.0001 13,034 1,268,626 1.4 <.0001 12 years 6.8 30,887 2,672,533 3.0 37,375 3,236,340 3.6 13 years 24.9 67,672 7,681,436 8.6 79,515 10,156,351 11.4 14 years 27.4 84,419 9,382,673 10.5 101,413 11,858,648 13.3 15 years 23.3 69,899 8,251,829 9.3 85,516 10,188,344 11.4 16 years 8.6 36,726 3,656,052 4.1 47,544 4,319,164 4.8 ≥17 years 5.9 21,330 2,259,425 2.5 29,160 3,138,137 3.5 Gender Males 52.3 157,096 18,368,132 20.6 0.3713 194,428 23,604,305 26.5 <.0001 Females 47.7 164,763 16,596,931 18.6 199,129 20,561,306 23.1 * See Table 3.1 for details of variable dichotomization (yes/no), ^ SHS means secondhand smoke

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Table 3.5 describes the results of the multiple logistic regression analysis and identifies the key factors associated with exposure to ETS among youth.

Youth exposure to ETS inside the home

Youth with either parents or peers who were smokers, compared to those without smoking parents or peers, were five times more likely to be exposed to ETS inside the home

(AOR 5.40, 95% CI 5.14 to 5.68). The following categories had an increased likelihood of youth exposure to ETS inside the home: those having knowledge about the harmful effects of smoking and SHS (AOR 1.53, 95% CI 1.43 to 1.63) and those who were susceptible to cigarette smoking

(AOR 1.86, 95% 1.78 to 1.94).

The factor identified to be strongly associated with decreased exposure to ETS in youth inside the home was the anti-smoking education at schools who were found to be 4% less likely to have such exposure (AOR 0.96, 95% 0.92 to 0.99). It was found that males, compared to females, were 14% less likely to be exposed to ETS inside the home (AOR 0.86, 95% CI 0.83 to

0.90).

Youth exposure to ETS outside the home

The factors that were found to be positively associated with youth exposure to ETS outside the home were essentially the same as the factors identified with exposure to ETS inside the home, although the strength of associations varied. Youth who had either parents or peers who smoked were 2.7 times more likely to be exposed to ETS outside the home (AOR 2.67, 95%

CI 2.55 to 2.80). Other factors positively associated with youth exposure to ETS outside the home include knowledge about the harmful effects of smoking and SHS (AOR 1.92, 95% CI

1.80 to 2.06) and susceptibility to smoking (AOR 2.00, 95% CI 1.92 to 2.09).

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Anti-smoking school education, which was found to be negatively associated with youth exposure to ETS inside the home, was positively associated with youth exposure to ETS outside the home (AOR 1.04, 95% CI 1.00 to 1.09). Males and females showed no differences with youth exposure to ETS outside the home.

In conclusion, it was found that parental and peer smoking, higher susceptibility to smoking and knowledge about the harmful effects of smoking and SHS were associated with increased exposure to ETS among youth both inside and outside the home. On the other hand, those who received anti-smoking education at schools were less likely to be exposed to ETS inside the home and more likely to be exposed outside the home.

Table 3.5: Multivariate Analysis of Factors Associated with Worldwide Youth Exposure to Environmental Tobacco Smoke (ETS), Global Youth Tobacco Survey, 1999-2008 (n=728,929)

Exposed to SHS^ inside home Exposed to SHS outside home Measure Unadjusted Adjusted OR Unadjusted Adjusted OR OR! (95% CI) OR! (95% CI) (95% CI~) (95% CI~) Parental or peer 6.34 (6.04, 5.40 (5.14, 3.30 (3.16, 2.67 (2.55, smoking 6.66)*** 5.68)*** 3.45)*** 2.80)*** Susceptibility to 2.74 (2.64, 1.86 (1.78, 2.58 (2.47, 2.00 (1.92, smoking 2.85)*** 1.94)*** 2.69)*** 2.09)*** Knowledge about 1.68 (1.57, 1.53 (1.43, 2.05 (1.92, 1.92 (1.80, harmful effects of 1.79)*** 1.63)*** 2.18)*** 2.06)*** smoking and SHS School anti-smoking 0.93 (0.89, 0.96 (0.92, 1.02 (0.98, 1.04 (1.00, education 0.96)*** 0.99)*** 1.06) 1.09)* Age 1.06 (1.05, 1.04 (1.02, 1.08 (1.06, 1.06 (1.04, 1.07)*** 1.05)*** 1.09)*** 1.07)*** Gender (Males vs. 1.02 (0.98, 1.06) 0.86 (0.83, 1.10 (1.06, 1.00 (0.96, females) 0.90)*** 1.14)*** 1.04) ! OR means Odds Ratio, ~CI means Confidence Intervals, ^ SHS means secondhand smoke * p<0.05, ** p<0.01 *** p<0.001

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Discussion

Exposure to environmental tobacco smoke (ETS) poses a significant health risk for both smokers and non-smokers (18, 20, 21, 59). Our study, using the GYTS data for the years 1999-

2008 (till date) found that 39.2% and 49.5% youth were exposed to ETS inside and outside the home respectively. This prevalence is less when compared to earlier studies reported by the

GTSS collaborative group (47, 48, 50). Because four to five children out of 10 are exposed to

ETS, reducing the prevalence of ETS exposure has the great potential to address the global tobacco epidemic among youth.

Our study identified the 77.5% youth support smoking bans in public places, a positive finding. Comprehensive smoke-free policies (SFPs) reduce ETS exposure and create smoke-free environments by improving air quality, inhibiting smoking initiation, and encouraging smoking cessation (21, 56). In spite of high support for SFPs among youth, our study identified almost half of them are exposed to ETS either inside or outside the home. This infers the adolescents‟ inability to avoid exposure to ETS, though they support SFPs. This might be due to their close contact with smoking parents or peers. However, strong and comprehensive smoke-free policies

(SFPs) will reduce adolescents‟ exposure to ETS over the long term, as supported by findings from earlier studies (60-63).

The strongest determinant of youth exposure to ETS both inside and outside the home was parental and peer smoking behavior. It was found that youth who had either parents or peers who smoked were about five times more likely to be exposed to ETS inside the home and 2.5 more likely to be exposed to ETS outside the home, which is consistent with earlier studies (37,

64, 65). Earlier research studies identified that youth who had parents who smoked were much more likely to be exposed to ETS inside the homes and those who had peers who smoked had

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high exposure to ETS outside the homes (44, 46, 66, 67). The reason might be adolescents‟ constant and continuous exposure to parental smoking and also their incapacity to avoid such smoking environments. A study conducted in Taiwan found that youth who had nonsmoking friends were better prepared to avoid smoking environments than those who had smoking friends

(68). This finding states the need for implementing smoking bans at homes where regional and national tobacco action plans were already existing, or inclusion of „homes‟ in list of places for smoking bans while developing national tobacco control plans by countries where no such tobacco plans existed. This is evident from previous studies which showed that smoking bans at homes not only modified parental smoking behavior but also reduced adolescents‟ exposure to

ETS (62, 69-72).

Adolescents who received anti-smoking education at schools were less likely to be exposed to SHS inside the home. Similar results were observed for youth exposure to ETS outside the home, although the results were statistically insignificant. Various school-based approaches have been developed to educate adolescents about the harmful effects of smoking and SHS. These include classroom anti-smoking programs, anti-smoking week initiative, and school-based anti-smoking campaigns (73-75). However, effectiveness of these school-based anti-smoking education programs has been questionable. This is because of smoking in families of adolescents (76). Hence, it is important for parents to either participate in such programs or for these programs to use an “information giving” approach to influence parental smoking behavior.

Our study also found that the likelihood of exposure to ETS among adolescents increases with age. This might be due to greater opportunity for older children to be outside the home, where they are exposed to ETS. Another reason might be adolescents have developed tolerance towards continuous exposure to ETS from parents and peers. In addition, we also found that

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males were less likely to be exposed to ETS inside the home than females, which is inconsistent with earlier studies (44, 68).

This study has several limitations. First, the study is based on questionnaire with responses self-reported by the school-going adolescents leading to the potential for information and recall bias. Moreover, the GYTS is a school-based survey and administered on a particular day at a school, hence those adolescents who do not attend schools or those who did not attend schools on the day the survey was administered were not taken into consideration leading to the potential for selection bias. Second, five individual-level measures were developed using 12 questions from the GYTS „core‟ questionnaire, which limits the ability to evaluate associations for these 12 measures. For instance, adolescents‟ exposure to ETS differed when analyzed with parental and peer smoking behavior separately. In addition, only individual-level youth characteristics were chosen for this analysis. The country-level factors such as presence or absence of smoke-free policies and national tobacco control organizations or agencies or plans were not taken into analysis. Third, this global analysis obtained adolescents‟ data for the years

1999-2008. Future research studies should be conducted to understand youth exposure to ETS over time. Finally, a major limitation was about the assessment of exposure to ETS. This study used self-reported questionnaire responses to evaluate exposure to ETS among school-going adolescents; however, it has been reported that assessment of exposure to ETS using self- reported questionnaire responses differed significantly when compared to nicotine and cotinine biomarkers (77-82). Validity of assessment of exposure to ETS becomes more important in this study because the study participants were asked to report exposure to ETS in the past seven days.

Better results for seven day exposure to ETS would be obtained through detection of cotinine in urine (81, 83).

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Conclusion

Exposure to environmental tobacco smoke (ETS) has adverse health effects on adolescent smokers and non-smokers. With no level of exposure of ETS considered safe, it is important to protect adolescents starting at an early age. About 40% of adolescents are exposed to ETS inside the home and 50% of adolescents outside the home. Therefore, public health interventions such as comprehensive smoke-free laws (SFPs), smoking restrictions at homes, comprehensive ban on tobacco industry advertising, promotion, and marketing tobacco products, and school anti- smoking education should be developed to limit ETS exposure among adolescents. Identifying factors that contribute to adolescents‟ exposure to ETS, including parental or peer smoking behavior, knowledge about the harmful effects of smoking and SHS, and susceptibility to smoking can provide guidance to public health practitioners as they develop and deliver effective

ETS prevention programs.

Funding

The authors declare that no external funds were used to conduct this study.

Competing Interests

The authors have no competing interests to declare.

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Contributions

SPV worked with HMM and JLA to conceptualize the idea and conducted the data analysis. SPV worked with HMM and SZ to interpret the results and wrote the initial draft of the manuscript.

All authors contributed to revision of the manuscript.

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CHAPTER 4

SUPPORT FOR SMOKE-FREE POLICY AMONG SCHOOL-GOING ADOLESCENTS (11-

17 YEARS) GLOBALLY

Sreenivas P Veeranki 1, Hadii M Mamudu 2, James L Anderson1, Shimin Zheng1

1 Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State

University, Johnson City, TN 37604

2 Department of Health Services Management and Policy, College of Public Health, East

Tennessee State University, Johnson City, TN 37604

Address for correspondence:

Sreenivas P Veeranki

P O 12993

Johnson City, TN 37604

Phone: 412-378-3936

Email: [email protected]

[email protected]

Key words: Tobacco, youth, smoke-free policy, Global Youth Tobacco Survey

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Abstract

Background:

Adolescents are highly susceptible to becoming smokers when exposed to high rates of exposure to secondhand smoke (SHS). Smoke-free policies (SFPs) reduce youth exposure to SHS and protect nonsmokers, yet only 7% of the world‟s population is covered by comprehensive SFPs.

The objective of this study is to understand the worldwide youth support for SFPs using the

Global Youth Tobacco Survey (GYTS).

Methods:

Data for 164 countries were obtained from the GYTS for the years 1999-2008. Data were analyzed for simple and multiple logistic regression models to identify relationships between youth support for SFPs and individual-level characteristics, including current smoking status, smoking susceptibility, parental or peer smoking behavior, exposure to SHS, knowledge about the harmful effects of smoking and SHS, tobacco industry promotions, anti-smoking media messages, and anti-smoking education at schools.

Results:

Globally, about 78% of youth support SFPs. Knowledge about the harmful effects of smoking and SHS (AOR11 2.37, 95% CI12 2.22 to 2.54), exposure to anti-smoking media messages (AOR

1.41, 95% CI 1.34 to 1.48) and school anti-smoking education (AOR 1.36, 95% CI 1.29 to 1.42) were positively associated with youth support for SFPs. Currently being a smoker (AOR 0.50,

95% CI 0.46 to 0.54), exposure to tobacco industry promotional activities and items (AOR 0.83,

11 AOR means Adjusted Odds Ratio 12 CI means Confidence Interval 127

95% CI 0.78 to 0.89), and increased susceptibility to start smoking (AOR 0.89, 95% CI 0.85 to

0.94) were all associated with decreased youth support for SFPs. Two interesting findings were that youth who had either parents or peers smoking were more likely to support SFPs (AOR

1.08, 95% CI 1.02 to 1.14), but those exposed to SHS were less likely (AOR 0.91, 95% CI 0.83 to 0.99) to do so.

Conclusion:

The study identified very high youth support for SFPs and provided evidence for development and implementation of comprehensive SFPs globally. Increasing knowledge about the harmful effects of smoking and SHS among youth, and inclusion of anti-smoking education into the school curriculum along with a comprehensive ban on tobacco industry advertising, promotion, and marketing tobacco products will increase youth positive attitudes toward SFPs and create smoke-free environments to improve the health of adolescents globally.

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Introduction

Tobacco use is the leading preventable cause of morbidity and mortality worldwide, contributing to deaths of six million people annually and predicted to reach over eight million by

2030 (1). Unless action is taken, it is expected to kill a total of billion people or more by the end of the 21st Century (1). Although there is established evidence linking tobacco use and exposure to secondhand smoke (SHS) to adverse health outcomes (2, 3), the worldwide demand for tobacco continues to rise. This is mainly due to the disproportionate increase in tobacco use and tobacco industry marketing strategies targeting youth in developing countries (4). It has been difficult to identify all the reasons for this problem, especially in developing countries because of the paucity of data (5). To address this information gap, the World Health Organization (WHO), the United States Centers for Disease Control and Prevention (CDC), and the Canadian Public

Health Organization (CPHA) launched the Global Tobacco Surveillance System in 1999, under which the Global Youth Tobacco Survey (GYTS), a school-based survey for students aged 11 through 17 years, has been conducted. Several global and country-based research studies have used the GYTS to estimate tobacco use prevalence among youth. However, to date, only one research study has been conducted to help understand youth attitudes toward smoke-free policies

(SFPs) on a global scale (6). In their study, Koh et al. (6) used GYTS data for the years 2000-

2006 to conduct research among youth ages 13 through 15 years, and found that youth support for SFPs is positively associated with knowledge about the harmful effects of environmental tobacco smoke, exposure to counter-marketing, and school anti-smoking education. The objective of our current study is to identify the key determinants of support for SFPs among youth aged 11 through 17 years globally by using the GYTS data for the years 1999-2008.

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Youth smoking is a worldwide public health problem as youth are currently being targeted by the tobacco companies with their marketing strategies and promotional activities (7-

10). Of the 1.3 billion smokers worldwide (1), over 200 million (15%) are below 20 years of age

(7, 11). Approximately 80-90% of adult smokers began smoking as adolescents (7, 8, 12, 13), most of whom became addicted to smoking before they attain the legal age to purchase cigarettes

(4, 14). As a result, tobacco use is considered “a pediatric disease” (8, 15-17).

Previous studies on youth tobacco use and control have examined youth smoking prevention (18, 19), initiation (20-22), cessation (18, 23, 24), policy impacts on smoking behavior and attitudes (18, 21, 25), and the role of tobacco industry in smoking (26, 27). These studies suggested that the determinants of smoking among youth are complex and multifaceted, including such factors as social images of youth smokers (28, 29, 30 ), perceived youth smoking prevalence (31), smoking behavior and attitudes of familial relations (32-34), social norms (35,

36), school environment (17, 37), the media (38-40), and the tobacco industry marketing and promotional activities (1, 7, 9). A socio-ecological model of health behavior that is based on the idea that individual‟s behavior and practice emanate from a complex interaction at different levels between personal, societal, and environmental factors (1, 41) is used to delineate the determinants of the students‟ support for a smoke-free policy.

Methods

GYTS Questionnaire

The GYTS used a standard methodology for constructing sample frames, selecting clusters of schools and classes, preparing and administering questionnaires, carrying out field procedures, processing the data, and reporting the results (42, 43). The GYTS questionnaire was standardized

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and structured and included a 'core' set of 54 questions to collect information on tobacco use and its five major determinants including exposure to secondhand smoke (SHS), tobacco use cessation, access/availability and price of tobacco products, role of media and advertising, and school curriculum. Additional questions can be added to the „core‟ set by respective countries prior to administering the survey. The original questionnaire was developed in English, translated to respective non-English language by respective countries, and back-translated to English to ensure accuracy (43).

Data Collection

We used information related to tobacco use among school-going adolescents from the GYTS data for the years 1999-2008 for 164 countries. For countries surveyed more than once, we used the most recent survey. The GYTS used a two-stage cluster sampling design to select school-going adolescents, a sample to represent youth in each respective country. The sampling methods have been discussed in earlier studies (43-45). Briefly, the two-stage cluster sampling design involved selecting cluster of schools proportional to student enrollment size during the first stage, followed by random selection of classes in these schools during second stage. All students in the selected classes were eligible as study participants. The school, class, and student response rates were calculated respectively for each participating country.

Measures

Dependent variable.

The dependent variable school-going adolescents' attitudes toward SFPs was assessed by their response (Yes/No) to the question, "Are you in favor of banning smoking in public places

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(such as in restaurants, in buses, street cars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)?"

Independent variables.

Out of the 54 'core' questions, we identified 18 questions that influenced school-going adolescents' attitudes toward SFPs. Eight measures from these 18 survey questions were developed based on factors identified in earlier studies that influence an individual attitude towards SFPs (3,

12, 46-48). The eight measures were 1) current smoking status, 2) exposure to SHS, 3) parental or peer smoking influences, 4) susceptibility to smoking, 5) knowledge about the harmful effects of smoking and SHS, 6) exposure to anti-smoking media messages, 7) exposure to tobacco industry promotional activities and items and 8) anti-smoking school education (Table 4.1). The measures were dichotomized based on methods previously developed by Warren et al. (43) and employed by

Koh et al.(6). Students' age and gender were included as covariates.

To estimate the attitudes for support for SFPs among adolescents in 164 countries, the data were weighted to adjust for design effect (selection of school and class levels), nonresponses

(school, class, and student levels), and poststratification of the sample relative to the grade and sex distribution in the population. This method of weighting measures has been previously used and also described by the CDC in the help file of the GYTS dataset. The data were weighted to effectively resize the sample so that it is a true representative sample of the population from which it was obtained.

The weighting factor is given by the formula:

W = W1 * W2 * f1 * f2 *f3 *f4 where,

W1 = the inverse of the probability of selecting a school

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W2 = the inverse of the probability of selecting a classroom within a school f1 = a school-level nonresponse adjustment factor calculated by school size category (small, medium, large) f2 = a class-level nonresponse adjustment factor calculated for each school f3 = a student-level nonresponse adjustment factor calculated by class f4 = a post-stratification adjustment factor calculated by sex and grade

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Table 4.1: Study Measures, Survey Items with Responses from Global Youth Tobacco Survey (GYTS) Study Measure GYTS survey items GYTS item responses Dichotomized measure Dependent Variable Support for smoke-free policy Are you in favor of banning smoking in public No No (SFP) places (such as in restaurants, in buses, Yes Yes streetcars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)? Independent Variables Current Current During the past 30 days (one month), on how 0 days No= 0 days smoking status cigarette many days did you smoke cigarettes? 1 or 2 days Yes ≥ 1 day smoking 3 to 5 days status 6 to 9 days 10 to 19 days 20 to 29 days All 30 days Exposure to Home During the past week, on how many days have 0 No= 0 days for both secondhand people smoked in your home, in your presence? 1 to 2 items smoke During the past 7 days, on how many days have 3 to 4 Yes ≥ 1 day for Outside people smoked in your presence, in places other 5 to 6 both items home than in your home? 7 Parental or peer Parents Do your parents smoke? None No='none' or 'I don't smoking Both know' for both Father only items Mother only Yes= any other I don't know reasons for either Peers Do any of your closest friends smoke None of them items cigarettes? Some of them Most of them All of them

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Table 4.1 (continued)

Susceptibility to smoking If one of your friends offered you a cigarette, would you smoke Definitely No = 'Definitely not' it? not for all three items At any time during the next 12 months do you think you will Probably Yes= any other smoke a cigarette? not responses for any of the Do you think you will be smoking cigarettes 5 years from now? Probably three items yes Definitely yes Knowledge about Do you think cigarette smoking is harmful to your health? Definitely No = 'Definitely not' harmful effects of Do you think the smoke from other people's cigarettes is not for both items smoking and SHS harmful to you? Probably Yes= any other not responses for either Probably item yes Definitely yes Exposure to anti-smoking During the past 30 days (one month), how many anti-smoking None No= 'none/never' media messages media messages (e.g. television, radio, billboards, posters, A few response for both items newspapers, magazines, movies) have you seen or heard? A lot Yes= any other When you go to sports events, fairs, concerts, community response for either item events, or social gatherings, how often do you see anti-smoking messages? Tobacco industry Do you have something (t-shirt, pen, backpack, etc.) with a No No promotion cigarette brand logo on it? Yes Yes Has a (cigarette representative) ever offered you a free cigarette?

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Table 4.1 (continued)

Anti-smoking School During this school year, were you taught in any of your classes about the No No = 'No' or 'Not education dangers of smoking? Not sure' for all three During this school year, did you discuss in any of your classes the reasons sure items why people your age smoke? Yes Yes = Yes for any During this school year, were you taught in any of your classes about the of the three items effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad? Dichotomization of GYTS survey responses based on method in Warren et al.(43) and Koh et al. (6) All responses were dichotomized. 'No' responses were coded as '0' and 'Yes' responses as '1' for multivariate model

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Data Analysis

Univariate analysis was conducted for country-specific frequencies of the dependent variable for 164 countries. After adjusting for the GYTS survey design variables (primary sampling unit and stratum) and final weight, bivariate logistic regression analysis was conducted to identify associations between the dependent variable, youth attitudes toward support for SFPs, and each of the eight major independent measures that potentially influenced youth attitudes. A multiple logistic regression analysis was conducted to delineate the key determinants of youth attitudes toward SFPs.

Students‟ gender and age were used as covariates in the final multivariate models. Unadjusted and adjusted odds ratios along with respective confidence intervals were reported. The statistical significance was set at p < 0.05. All statistical analyses were weighted to reflect the likelihood of sampling a student based on his/her gender and grade within the population of school children in the same jurisdiction, accounting for nonresponse patterns (49). All statistical analyses were performed using SAS/STAT V.9.2 of the SAS System for Windows © 2011 SAS Institute Inc. Cary, NC, USA.

Results

For this global analysis, we obtained data for 752,824 school-going adolescents which were a representative sample of 91,696,755 (after weighting) youth worldwide in 164 countries. The sample included youth who responded to the GYTS survey question, "Are you favor of banning smoking in public places?" Table 4.2 illustrates the support for SFPs among youth globally and in six WHO regions. It was found that 77.6% of youth favored SFPs globally; this was highest

(83.7%) among youth in the Americas and lowest (64.2%) in the Africa continent.

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Table 4.2:

Youth Support for SFP by Region, Global Youth Tobacco Survey, 1999-2008

WHO region Number of Number of Sample size Youth Support for countries survey sites population SFP ^ Global 164 331 752,824 91,696,755 77.6 Africa 42 63 172,643 9,611,137 64.2 Eastern 28 34 78,388 12,167,857 77.1 Mediterranean Europe 30 37 176,648 10,309,129 82.8 The Americas 35 117 216,148 12,122,491 83.7 Southeast Asia 10 47 44,077 38,686,972 76.8 Western Pacific 19 33 64,920 8,799,169 81.8 ^SFP means smoke-free policy

Table 4.3 shows the descriptive characteristics of youth who participated in the GYTS.

Around 10% currently smoked, 6.4% were exposed to SHS, 88.9% were knowledgeable about the harmful effects of smoking and SHS, 11.2% were exposed to tobacco industry promotional activities and items, 61.1% were exposed to anti-smoking media messages, and 51.8% had received anti- smoking education in schools.

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Table 4.3:

Descriptive Characteristics of Youth in Developing Countries, Global Youth Tobacco Survey, 1999-2008 (n=752,824)

Measures Unweighted Weighted Weighted count count percentage Current cigarette smoker 95,286 8,692,834 9.5 Parental or peer smoking 168,625 19,075,775 20.8 Exposure to SHS ^ 63,958 5,885,545 6.4 Susceptibility to smoking 226,353 21,717,707 23.7 Knowledge about harmful effects of 672,149 81,559,102 88.9 smoking and SHS Exposure to anti-smoking media 469,627 56,063,579 61.1 messages Tobacco industry promotion 87,134 10,295,576 11.2 School anti-smoking education 384,176 47,470,498 51.8 Support for smoke-free policy 583,901 71,132,995 77.6 Age 11 years and younger 32,673 2,769,221 3.0 12 years 80,222 6,186,107 6.7 13 years 158,621 22,857,040 24.9 14 years 190,183 25,157,594 27.4 15 years 154,577 21,443,275 23.4 16 years 85,305 7,893,335 8.6 17 years and older 51,243 5,390,183 5.9 Gender Males 366,516 47,844,564 52.2 Females 386,308 43,852,191 47.8 ^ SHS means secondhand smoke

Results for the bivariate analysis have been presented in Table 4.4. The highest level of support for SFPs was among youth who were knowledgeable about the harmful effects of smoking and SHS, and the lowest level of support was among who were exposed to SHS. All independent variables were statistically significant (p value < .05) and were included in the final multiple logistic regression model.

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Table 4.4: Bivariate Analysis of Factors Associated with Youth (11-17 Years) Support for Smoke-Free Policies, Global Youth Tobacco Survey, 1999- 2008 (n=752,824) Unweighted count Weighted count Percentage P support value Measure Percentage Variable support Not in support Not in yes* * support support Current cigarette smoker 9.5 Yes 57,668 37,618 5,504,381 3,188,453 6.0 <.0001 No 526,233 131,305 65,628,614 17,375,307 71.6 Parental or peer smoking 20.8 Yes 125,604 43,021 14,563,509 4,512,266 15.9 0.0004 No 458,297 125,902 56,569,486 16,051,495 61.7 Exposure to SHS ^ 6.4 Yes 37,446 26,512 3,701,960 2,183,585 4.0 <.0001 No 546,455 142,411 67,431,035 18,380,175 73.5 Susceptibility to smoking 23.7 Yes 164,356 61,997 160,28,177 5,689,530 17.5 <.0001 No 419,545 106,926 551,04,818 14,874,230 60.1 Knowledge about harmful effects of 88.9 Yes 534,790 137,359 64,931,347 16,627,755 70.8 <.0001 smoking and SHS No 49,111 31,564 6,201,648 3,936,005 6.8 Exposure to anti-smoking media 61.1 Yes 366,160 103,467 44,924,045 11,139,534 49.0 <.0001 messages No 217,741 65,456 26,208,950 9,424,227 28.5 Tobacco industry promotion 11.2 Yes 62,523 24,611 7,358,320 2,937,256 8.0 <.0001 No 521,378 144,312 63,774,675 17,626,504 69.5 School anti-smoking education 51.8 Yes 305,726 78,450 38,225,002 9,245,496 41.7 <.0001 No 278,175 90,473 32,907,993 11,318,265 35.9 Age 3.0 ≤ 11 23,873 8,800 2,091,734 677,486 2.28 <.0001 years 6.7 12 years 644,68 15,754 5,040,181 1,145,927 5.5 24.9 13 years 128,110 30,511 17,669,413 5,187,627 19.3 27.4 14 years 150,252 39,931 19,744,172 5,413,422 21.5 23.4 15 years 117,923 36,654 16,524,972 4,918,303 18.0 8.6 16 years 62,804 22,501 5,957,124 1,936,211 6.5 5.9 ≥17 years 36,471 14,772 4,105,399 1,284,785 4.5 Gender 52.2 Male 281,587 84,929 36,680,624 11,163,941 40.0 <.0001 47.8 Female 302,314 83,994 34,452,371 9,399,820 37.6 * See Table 4.1 for details of variable dichotomization (yes/no), ^ SHS means secondhand smoke 140

Results of the multivariate analysis have been presented in Table 4.5. The strongest determinant of support for SFPs was among youth who were knowledgeable about the harmful effect of smoking and SHS (AOR13 2.37, 95% CI14 2.22 to 2.54), meaning that they were 2.4 times more likely to support SFPs. Youth who were exposed to anti-smoking media messages on television, radio, billboards, posters, newspapers, magazines, and movies were 1.4 times more likely to support SFPs than those who were not exposed (AOR 1.41, 95% CI 1.34 to 1.48).

Compared to youth who did not receive anti-smoking education in schools, those who received were 1.4 times more likely to support SFPs (AOR 1.36, 95% CI 1.29 to 1.42). Of note, youth who had either one or both parents or some or more peers smoking were 8% more likely to support SFPs than their peers (AOR 1.08, 95% CI 1.02 to 1.14).

The strongest determinant of decreased support for the SFP among youth was the current smoking status. Youth who currently smoke were 50% less likely to support SFPs compared to those who currently do not smoke (AOR 0.50, 95% CI 0.46 to 0.54). Similarly, youth who received tobacco promotional items from tobacco industry sale representatives were 17% less likely to support SFPs than those who did not (AOR 0.83, 95% CI 0.78 to 0.89). Youth who were susceptible to smoking were 11% less likely to support SFPs than those not susceptible

(AOR 0.89, 95% CI 0.85 to 0.94). An interesting finding was that youth who were exposed to

SHS were 9% less likely to support SFPs than those who were not (AOR 0.91, 95% 0.83, 0.99).

Females were 4% more likely to support SFPs than males, although the finding is not statistically significant.

13 AOR means Adjusted Odds Ratio 14 CI means Confidence Interval 141

Table 4.5:

Multivariate Analysis of Factors Associated with Youth Support for Smoke-Free Policies, Global Youth Tobacco Survey, 1999-2008 (n=752,824)

Measure Unadjusted OR! Adjusted OR (95% CI~) (95% CI) Current cigarette smoker 0.46 (0.44, 0.45)*** 0.50 (0.46, 0.54)*** Parental or peer smoking 0.92 (0.87, 0.96)** 1.08 (1.02, 1.14)** Exposure to SHS ^ 0.46 (0.44, 0.49)*** 0.91 (0.83, 0.99)* Susceptibility to smoking 0.76 (0.73, 0.80)*** 0.89 (0.85, 0.94)*** Knowledge about harmful effects of smoking 2.48 (2.32, 2.65)*** 2.37 (2.22, 2.54)*** and SHS Exposure to anti-smoking media messages 1.45 (1.38, 1.52)*** 1.41 (1.34, 1.48)*** Tobacco industry promotion 0.69 (0.65, 0.74)*** 0.83 (0.78, 0.89)*** School anti-smoking education 1.42 (1.36, 1.49)*** 1.36 (1.29, 1.42)*** Age 0.97 (0.96, 0.98)*** 0.97 (0.95, 0.98)*** Gender (Males vs. females) 0.90 (0.86, 0.94)*** 0.96 (0.91, 1.01) ! OR means Odds Ratio, ~CI means Confidence Intervals, ^ SHS means secondhand smoke * p<0.05, ** p<0.01 *** p<0.001

Discussion

The increasing trend of tobacco use worldwide (50) and high levels of youth exposure to

SHS (51) demands the development of SFPs to enhance smoking cessation and protect nonsmokers; however, to date only 7% of the world population is covered by comprehensive

SFPs. This low percentage of comprehensive SFPs emphasizes the need to examine youth attitudes toward them to facilitate policy development. This research study identified potential key determinants of worldwide youth support for smoking ban in public places (smoke-free policies, SFPs) using the Global Youth Tobacco Survey (GYTS). Similar to earlier studies (6,

42, 44, 52, 53), there was an overwhelming support for SFPs among youth. This high level of support for SFPs (77.6%) among school-going adolescents provided supportive evidence for

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policymakers to require public places (restaurants, buses, street cars, trains, schools, playgrounds, gyms, sports arenas, discos, etc.) around the world to be 100% smoke-free.

This study identified adolescents‟ knowledge of the harmful effects of smoking and SHS as the strongest determinant of youth support for SFPs, which was consistent with previous literature on the linkage between the level of knowledge about SHS and support for SFPs (54-

56). Therefore, increasing adolescents‟ level of awareness regarding the negative effects of SHS would increase not only their intentions to quit (46) but also their support for and compliance with SFPs. Perhaps, this will provide motivation for mobilization of actions against tobacco use as has been previously done at the national (57-60) and international (1) levels.

Although evidence on the effectiveness of school programs on the smoking behavior has been mixed (61-65), this study found that providing information to students about the harmful health effects of smoking and SHS, and discussing in class why youth smoking was not good increased the likelihood of support for SFPs. Thus, exposure of students to anti-smoking messages in schools is significant to both understanding their smoking behaviors (12, 66) and policy preferences. However, while it is important to include information about the harmful health effects of smoking and exposure to SHS in the school curriculum, it is also important to convey such messages in an unambiguous manner (67) and to avoid inconsistencies in the messages the students receive regarding smoking and SHS. For example, in an environment where the students are taught not to smoke in schools while at the same time they observe school personnel and adults smoking around them, the impact of such messages will be decreased (68,

69). Indeed, such a situation compromises messages that the students received in class (66).

Additionally, lack of enforcement of school-based programs (65, 69) and smoking on the school periphery (37) elevate the risk of smoking by sending mixed messages about tobacco use.

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Exposure to anti-smoking media messages enhances youth support for SFPs. It was evident that youth who were exposed to anti-smoking messages in television, radio, billboards, posters, magazines, and movies supported SFPs. This was consistent with earlier studies that identified that anti-smoking media messages about harmful effects of SHS and tobacco industry manipulative practices were highly effective not only in altering individual attitudes toward SFPs but also in preventing cigarette use behavior (46, 48). Therefore, a comprehensive ban on tobacco industry advertising, including the promotion and marketing of tobacco products, would help not only prevent youth smoking but also shape their attitudes toward SFPs.

The strongest predictor of decreased likelihood of support for SFPs is being a current smoker. This finding is in consistent with the existing literature as smokers generally have negative attitudes toward tobacco control policies (54, 70, 71) and low compliance rates (72, 73).

Therefore, smoking not only has negative implications for an individual‟s health and for those exposed to SHS, but also it is associated with the support for and compliance with tobacco control policies, including comprehensive SFPs.

Effects of tobacco industry promotions on youth smoking have well been established (7,

8, 47, 74, 75). In this study, tobacco industry promotions decreased the likelihood of youth support for SFPs. Specifically, owning a cigarette brand item and being offered cigarette by a tobacco company sales representative had negative effects on students‟ attitudes toward SFPs.

The tobacco industry promotions have dual impacts -- increased youth smoking and decreased youth support for SFPs. Therefore, as the public health community continues exploration of ways through which the tobacco industry seeks to undermine tobacco control (76), there is the need to disaggregate those activities that impact youth opinions and attitudes toward policy.

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This study identified two important findings. First, youth who were exposed to SHS inside or outside home were less likely to support SFPs, a finding that is inconsistent with the prior scientific literature (54, 71). Previous studies have identified cigarette smoking as a serious health problem for communities with exposure to SHS because exposure to SHS was not only harmful to the health of nonsmokers but also identified as a positive predictor of support for

SFPs (54, 70, 71). A second important finding was that adolescents who had either parents or peers who smoked were more likely to support SFPs, which was inconsistent with previous studies (77, 78). Future studies should evaluate these findings in detail.

This research study is sound and innovative because it pools all GYTS data for the years

1999-2008, irrespective of age to identify the key determinants of worldwide youth support of

SFPs using a socio-ecological theoretical model. Koh et al. were the first researchers to conduct a similar study (6), but their study was limited to youth aged 13-15 years and used data for years

2000-2006. A standardized questionnaire and methodology, large sample size and high response rates were some of the strengths of the study. At the same time, this study has several limitations.

The study included students‟ responses to the GYTS questionnaires based on self-report, which means the results may be affected by recall bias. The survey is school-based and does not include those adolescents who do not attend schools, a selection bias. Data were cross-sectional in nature and gathered at single point from the respective countries, limiting the ability to make causal inferences. Future research studies should examine youth attitudes toward SFPs over time. Only individual-level factors associated with GYTS „core‟ questionnaire were studied; other potential individual factors specific to countries‟ cultural norms were not considered. Moreover, country- level factors such as presence or absence of SFPs, any tobacco-legislating agency or organization, developmental status of a country were not taken into consideration. This study

145

provides vital information about the key determinants of students‟ support for SFPs and the large sample size (752,824) provides high statistical power and precision in the estimates.

Conclusion

Smoke-free policies (SFPs) have become one of the most effective measures for preventing smoking initiation, providing motivating for smoking cessation, and protecting nonsmokers, thereby becoming a core measure of the WHO Framework Convention on Tobacco

Control (FCTC), the first international public health treaty, and a tool for galvanizing civil society groups worldwide. In addition, SFPs are popular, having the support of both smokers and nonsmokers and over two-thirds of favorable public opinion worldwide, findings confirmed by this study. A major problem with tobacco control in many places is compliance, hence the attempt to delineate the determinants of support for SFPs using the GYTS. The unambiguous finding is that knowledge about the harmful effects of smoking and SHS, and exposure to SHS, and providing information to students about the harmful health effects of tobacco use are associated with an increased likelihood of support for SFPs. On the contrary, being a current smoker, exposure to tobacco industry promotional activities and items, and increased susceptibility to smoking decreased the likelihood of support for SFPs. This study suggested that development and compliance with SFPs could be enhanced and students‟ support for such policies on and outside school campuses could be elicited through education on the harmful health effects of SHS and integration of tobacco control in school curriculum, and restricting or prohibiting tobacco industry advertising and promotions. This will require the implementation of the WHO FCTC in all countries.

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Funding

The authors declare that no external funds were used to conduct this study.

Competing Interests

The authors have no competing interests to declare.

Contributions

SPV worked with HMM and JLA to conceptualize the idea and conducted the data analysis. SPV worked with HMM and SZ to interpret the results and wrote the initial draft of the manuscript.

All authors contributed to revision of the manuscript.

147

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CHAPTER 5

CONCLUSION

In September 2011 a high- level meeting of the United Nations (UN) General

Assembly, launched an all-out attack on non-communicable diseases (NCDs), especially cardiovascular diseases, cancers, diabetes mellitus, and chronic respiratory diseases

(Beaglehole et al., 2011; Partridge, Mayer-Davis, Sacco, & Balch, 2011). This summit was a historic moment in addressing global health and resulted in the aim to combat the

NCDs that are caused primarily by four risk factors: tobacco use, alcohol abuse, physical inactivity, and unhealthy diet (Mamudu, Yang, & Novotny, 2011; Probst-Hensch, Tanner,

Kessler, Burri, & Kunzli, 2011). The summit concluded with a political declaration that commits UN member states (governments of the world) to significant and sustained efforts to curb the burden of NCDs. It also provided an opportunity for strengthening and shaping “primary prevention”, one of the three core functions of the public health, to address the identified four major risk factors for NCDs.

Tobacco use, a major risk factor for NCDs, continues to be the leading preventable cause of morbidity and mortality in the world {World Health Organization., 2008

#114}.There has been a disproportionate increase in tobacco use in the LMICs. Of the over 1.3 billion smokers in the world, around 80% reside in the LMICs with over 200 million (15%) below 20 years of age. Prior research studies on adolescent tobacco use and its various characteristics have been conducted at local, state, or national levels only, leaving a major gap in the scientific literature to address the tobacco epidemic in youth on a global scale. The current study explored the key determinants of susceptibility to smoking of youth who had never smoked, adolescents‟ exposure to environmental tobacco

158

smoke (ETS), and the attitudes of youth toward SFPs globally. The findings from this study will provide knowledge that can assist the international health community, public health practitioners, policy makers, public health educators, and researchers in their tobacco control initiatives thereby preventing the burden of tobacco use globally.

This research study identified several key findings. It was found that 14% of youth who had never smoked were susceptible to start cigarette smoking globally. In addition, it was found that 77% of youth supported SFPs worldwide, while around 40% and 50% were exposed to ETS inside and outside the home respectively. A key finding across the three chapters was the effect of parental or peer smoking behavior on adolescents‟ tobacco use. It was found that youth who had either parents or peers who smoked were highly exposed to ETS, highly susceptible to start cigarette smoking, and, interestingly, also strongly supported SFPs. This emphasized a need for inclusion of homes in the list of places to be considered when developing comprehensive smoke-free laws. It is also important to educate parents about their smoking behavior and its influence on their children. Therefore, as envisioned by Article 8 of the WHO FCTC, every country should adopt and implement comprehensive smoke-free laws and/or effective measures to protect adolescents from exposure to ETS both inside and outside the home. Another key finding in the study was the role of tobacco industry on youth tobacco use. It was found that youth who were exposed to tobacco industry promotional items were highly susceptible to start cigarette smoking and were less likely to support SFPs. Therefore, as envisioned by

Article 13 of the WHO FCTC, every country should implement strong tobacco control strategies to counter tobacco industry advertising, promotional, and sponsorship activities that target youth. Another cross-cutting finding was that youth who were knowledgeable

159

about the harmful effects of smoking and SHS strongly supported SFPs. However, such youth were also more likely to be exposed to ETS and were highly susceptible to start cigarette smoking. Similarly, youth exposed to anti-smoking media messages supported

SFPs, but also were highly susceptible to start cigarette smoking. Finally, youth who received anti-smoking education at schools were less susceptible to start cigarette smoking, were less exposed to ETS inside the home, and strongly supported SFPs, emphasizing the need for inclusion of anti-smoking or anti-tobacco education into the school curriculum in the LMICs, as envisioned by Article 20 of the WHO FCTC.

The current study is unique and innovative. It is the first study to explore the key characteristics, on a global basis that influence the susceptibility to start cigarette smoking among youth who had never smoked. It is also the first study to assess worldwide youth exposure to ETS both inside and outside the home. Although it is the second study to evaluate worldwide youth attitudes toward SFPs, it is unique because it included adolescents aged 11-17 years and countries that were not analyzed in the first study (Koh et al., 2011). This study included only individual-level measures, consequently future research studies should be conducted that also include country-level measures such as the developing status of a country, presence or absence of SFPs, and national tobacco control programs and organizations to understand the influence of such measures on adolescents‟ susceptibility behavior, ETS exposure and attitudes toward SFPs. In addition, future research studies should be conducted at the WHO region level to provide guidance to the public health leaders at the WHO regional offices to effectively develop and implement tobacco control programs targeting youth in the respective regions. Finally, future research studies should be conducted targeting the tobacco industry, their role and

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interference in global tobacco control measures that target the youth as it is the key factor identified to be associated with increased susceptibility to smoking among youth who never smoked, increased exposure to ETS and decreased support for SFPs among youth.

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APPENDIXES

Appendix A

Human Subjects Protection

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Appendix B

Global Youth Tobacco Survey Questionnaire, 2008

CORE QUESTIONS

GLOBAL YOUTH TOBACCO SURVEY (GYTS)

2008

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INSTRUCTIONS

• 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:

☺

• If you have to change your answer, don‟t worry, just erase it completely, without leaving marks.

• Remember, each question only has one answer.

Example:

Questionnaire

24. Do you believe that fish 24. A

live in water?

a. Definitely yes

b. Probably yes

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c. Probably not d. Definitely not

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THE NEXT 11 QUESTIONS ASK ABOUT YOUR USE OF TOBACCO.

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

2. How old were you when you first tried a cigarette? a. I have never smoked cigarettes 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

3. During the past 30 days (one month), 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

4. During the past 30 days (one month), on the days you smoked, how many cigarettes did you usually smoke? a. I did not smoke cigarettes during the past 30 days (one month) b. Less than 1 cigarette per day c. 1 cigarette per day d. 2 to 5 cigarettes per day e. 6 to 10 cigarettes per day f. 11 to 20 cigarettes per day g. More than 20 cigarettes per day

5. During the past 30 days (one month), how did you usually get your own cigarettes? (SELECT ONLY ONE RESPONSE) a. I did not smoke cigarettes during the past 30 days (one month) b. I bought them in a store, shop or from a street vendor

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c. I bought them from a vending machine d. I gave someone else money to buy them for me e. I borrowed them from someone else f. I stole them g. An older person gave them to me h. I got them some other way

6. During the past 30 days (one month), what brand of cigarettes did you usually smoke? (SELECT ONLY ONE RESPONSE) a. I did not smoke cigarettes during the past 30 days b. No usual brand c- g. (Add 5 most common brands) h. Other

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7. During the past 30 days (one month), did anyone ever refuse to sell you cigarettes because of your age? a. I did not try to buy cigarettes during the past 30 days (one month) b. Yes, someone refused to sell me cigarettes because of my age c. No, my age did not keep me from buying cigarettes

8. During the past 30 days (one month), did you use any form of smoked tobacco products other than cigarettes (e.g. cigars, water pipe, cigarillos, little cigars, pipe)? a. Yes b. No

9. During the past 30 days (one month), did you use any form of smokeless tobacco products (e.g. chewing tobacco, snuff, dip)? a. Yes b. No

10. Where do you usually smoke? (SELECT ONLY ONE RESPONSE) a. I have never smoked cigarettes b. At home c. At school d. At work e. At friends‟ houses f. At social events g. In public spaces (e.g. parks, shopping centres, street corners) h. other

11. Do you ever have a cigarette or feel like having a cigarette first thing in the morning? a. I have never smoked cigarettes b. I no longer smoke cigarettes c. No, I don‟t have or feel like having a cigarette first thing in the morning d. Yes, I sometimes have or feel like having a cigarette first thing in the morning e. Yes, I always have or feel like having a cigarette first thing in the morning

THE NEXT 17 QUESTIONS ASK ABOUT YOUR KNOWLEDGE AND ATTITUDES TOWARD TOBACCO.

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12. Do your parents smoke? a. None b. Both c. Father only d. Mother only e. I don‟t know

13. If one of your best friends offered you a cigarette, would you smoke it? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

14. Has anyone in your family discussed the harmful effects of smoking with you? a. Yes b. No

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15. At any time during the next 12 months do you think you will smoke a cigarette? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

16. Do you think you will be smoking cigarettes 5 years from now? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

17. Once someone has started smoking, do you think it would be difficult to quit ? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

18. Do you think boys who smoke cigarettes have more or less friends? a. More friends b. Less friends c. No difference from non-smokers

19. Do you think girls who smoke cigarettes have more or less friends? a. More friends b. Less friends c. No difference from non-smokers

20. Does smoking cigarettes help people feel more or less comfortable at celebrations, parties, or in other social gatherings? a. More comfortable b. Less comfortable c. No difference from non-smokers

21. Do you think smoking cigarettes makes boys look more or less attractive? a. More attractive

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b. Less attractive c. No difference from non-smokers

22. Do you think smoking cigarettes makes girls look more or less attractive? a. More attractive b. Less attractive c. No difference from non-smokers

23. Do you think that smoking cigarettes makes you gain or lose weight? a. Gain weight b. Lose weight c. No difference

24. Do you think cigarette smoking is harmful to your health? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

185

25. Do any of your closest friends smoke cigarettes? a. None of them b. Some of them c. Most of them d. All of them

26. When you see a man smoking what do you think of him? (SELECT ONLY ONE RESPONSE) a. Lacks confidence b. Stupid c. Loser d. Successful e. Intelligent f. Macho

27. When you see a woman smoking, what do you think of her? (SELECT ONLY ONE RESPONSE) a. Lacks confidence b. Stupid c. Loser d. Successful e. Intelligent f. Sophisticated

28. Do you think it is safe to smoke for only a year or two as long as you quit after that? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

THE NEXT 4 QUESTIONS ASK ABOUT YOUR EXPOSURE TO OTHER PEOPLE’S SMOKING.

29. Do you think the smoke from other people’s cigarettes is harmful to you? a. Definitely not b. Probably not c. Probably yes d. Definitely yes

186

30. During the past 7 days, on how many days have people smoked in your home, in your presence? a. 0 b. 1 to 2 c. 3 to 4 d. 5 to 6 e. 7

31. During the past 7 days, on how many days have people smoked in your presence, in places other than in your home? a. 0 b. 1 to 2 c. 3 to 4 d. 5 to 6 e. 7

187

32. Are you in favor of banning smoking in public places (such as in restaurants, in buses, streetcars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)? a. Yes b. No

THE NEXT 6 QUESTIONS ASK ABOUT YOUR ATTITUDES TOWARD STOPPING SMOKING.

33. Do you want to stop smoking now? a. I have never smoked cigarettes b. I do not smoke now c. Yes d. No

34. During the past year, have you ever tried to stop smoking cigarettes? a. I have never smoked cigarettes b. I did not smoke during the past year c. Yes d. No

35. How long ago did you stop smoking? a. I have never smoked cigarettes b. I have not stopped smoking c. 1-3 months d. 4-11 months e. One year f. 2 years g. 3 years or longer

36. What was the main reason you decided to stop smoking? (SELECT ONE RESPONSE ONLY) a. I have never smoked cigarettes b. I have not stopped smoking c. To improve my health d. To save money e. Because my family does not like it f. Because my friends don‟t like it g. Other

188

37. Do you think you would be able to stop smoking if you wanted to? a. I have never smoked cigarettes b. I have already stopped smoking cigarettes c. Yes d. No

38. Have you ever received help or advice to help you stop smoking? (SELECT ONLY ONE RESPONSE) a. I have never smoked cigarettes 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

189

THE NEXT 9 QUESTIONS ASK ABOUT YOUR KNOWLEDGE OF MEDIA MESSAGES ABOUT SMOKING.

39. During the past 30 days (one month), how many anti-smoking media messages (e.g., television, radio, billboards, posters, newspapers, magazines, movies) have you seen or heard? a. A lot b. A few c. None

40. When you go to sports events, fairs, concerts, community events, or social gatherings, how often do you see anti-smoking messages? a. I never go to sports events, fairs, concerts, community events, or social gatherings b. A lot c. Sometimes d. Never

41. When you watch TV, videos, or movies, how often do you see actors smoking? a. I never watch TV, videos, or movies b. A lot c. Sometimes d. Never

42. Do you have something (t-shirt, pen, backpack, etc.) with a cigarette brand logo on it? a. Yes b. No

43. During the past 30 days (one month), when you watched sports events or other programs on TV how often did you see cigarette brand names? a. I never watch TV b. A lot c. Sometimes d. Never

44. During the past 30 days (one month), how many advertisements for cigarettes have you seen on billboards? a. A lot

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b. A few c. None

45. During the past 30 days (one month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines? a. A lot b. A few c. None

46. When you go to sports events, fairs, concerts, or community events, how often do you see advertisements for cigarettes? a. I never attend sports events, fairs, concerts, or community events b. A lot c. Sometimes d. Never

191

47. Has a (cigarette representative) ever offered you a free cigarette? a. Yes b. No

THE NEXT 4 QUESTIONS ASK ABOUT WHAT YOU WERE TAUGHT ABOUT SMOKING IN SCHOOL.

48. During this school year, were you taught in any of your classes about the dangers of smoking? a. Yes b. No c. Not sure

49. During this school year, did you discuss in any of your classes the reasons why people your age smoke? a. Yes b. No c. Not sure

50. During this school year, were you taught in any of your classes about the effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad? a. Yes b. No c. Not sure

51. How long ago did you last discuss smoking and health as part of a lesson? a. Never b. This term c. Last term d. 2 terms ago e. 3 terms ago f. More than a year ago

THE LAST 3 QUESTIONS ASK FOR SOME BACKGROUND INFORMATION ABOUT YOURSELF.

52. How old are you? a. 11 years old or younger

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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

53. What is your sex? a. Male b. Female

54. In what grade/form are you? a. List locally appropriate

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VITA

SREENIVAS PHANIKUMAR VEERANKI

Education: Dr.P.H. (Doctor of Public Health), East Tennessee State University, Johnson City, TN, USA, 2012. MPH, University of Illinois, Springfield, IL, USA, 2008. MBBS (Bachelor of Medicine and Bachelor of Surgery), Siddhartha Medical College, Vijayawada, Andhra Pradesh, India, 2006.

Professional Experience: Postdoctoral Research Fellow, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA, 2012 – Summer Research Assistant, College of Public Health, East Tennessee State University, Johnson City, TN, USA, 2012. Graduate Research Assistant, College of Public Health, East Tennessee State University, TN, USA, 2009-2012 Public Health Intern, Wellmont CVA Heart Institute, Kingsport, TN, USA, 2011. Research Data Analyst, Illinois Lead Program, Illinois Department of Public Health, Springfield, IL, USA, 2006- 2008. Resident intern, University Government Hospital, Vijayawada, Andhra Pradesh, India, 2005-2006

Publications: Veeranki SP, Mamudu HM, He Y. Tobacco use and impact of tobacco-free policy on university employees in an environment of high tobacco use and production. Environ Health Prev Med. 2012. (in press) Mamudu HM, Veeranki SP, He Y, Dadkar S, Boone E. University personnel's attitudes and behaviors toward the first tobacco-free campus policy in Tennessee. J Community Health. Aug 2012. Veeranki SP, Brooks B, Bolick S, Robichaux M, Aldrich T. Quality of care: the role of disease registries. J Registry Manag. 2010 Winter; 37(4):133-6 Mamudu HM, Dadkar S, Veeranki SP, He Y. (2011). Tobacco Control in Tennessee: Stakeholder Analysis of the Development of the Non-Smoker Protection Act, 2007. UC San Francisco: Center for Tobacco Control Research and Education.

[Many manuscripts either in review, submission or preparatory phase.]

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Presentations: Veeranki SP, Guidi K, Anderson JL, Mamudu HM. Early Identification of Patients with Coronary Artery Disease: Association between Risk factors and Coronary Artery Calcium Levels. Primary Care and Prevention Day Research. Feb 2012. Mamudu HM, Veeranki SP. Dealing with Corporate Interference in Health Policy through Governance: The Uruguayan Declaration on Trade and Health. World Congress of Tobacco or Health. Mar 2012 Mamudu HM, Veeranki SP. Global Tobacco Control Policymaking: An Insight into The Framework Convention On Tobacco Control Decision-Making Processes. World Congress of Tobacco or Health. Mar 2012 Veeranki SP, Mamudu HM. Determinants of adolescents' (11-17 years) support for Smoke-free Policies Globally. American Public Health Association Annual Meeting, Oct - Nov 2011 Veeranki SP, Mamudu HM, Freeman B. Community Determinants of College based Tobacco-free Policies in the United States: A mixed- methods approach. American Public Health Association Annual Meeting, Oct - Nov 2011 Veeranki SP, Mamudu HM, Johnson TE. Epidemiology of Smoke- free Policies in the United States. National Congress of Epidemiology, May 2011 [accepted only]

Honors and Awards: Student Researcher Award: Delta Omega Honorary Society in Public Health, Washington D.C. 2011. Golden Key International Honors Society, 2010- Certificate of Merit, Ministry of Human Resources and Development, Department of Education, New Delhi, India

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