CENTERS FOR DISEASE CONTROL AND PREVENTION
Volume 14 • Number 3 • Fall 2001

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Youth Surveillance Aids Global Tobacco Control Efforts

The GYTS is working very well indeed; it has been completed in 46 countries, and more than 50 others are participating during the 2001– 2002 school year.

Tobacco control has world attention and tremendous momentum globally; the enormity of the health problems caused by tobacco are understood worldwide. Studies in the developed countries show that most people begin using tobacco before the age of 18 years, but information on young people's use of tobacco is not available for most developing countries. To help fill this data gap, the World Health Organization (WHO)—through its Tobacco Free Initiative—and CDC developed the Global Youth Tobacco Survey (GYTS).

The GYTS was begun as a means of providing baseline data to selected countries participating in a project on youth and tobacco. The survey is funded by the United Nations Fund for International Partnerships project on youth and tobacco. 

The GYTS is working very well indeed; it has been completed in 46 countries, and more than 50 others are participating during the 2001–2002 school year. Response rates have been uniformly high. "The GYTS is expanding rapidly, and we are learning as we go," said Charles (Wick) Warren, PhD, CDC statistician and GYTS project director. By February 2002, more than 108 countries (over half of WHO member states) will have participated. "The GYTS may be the most successful international surveillance system ever done," said Rosemarie Henson, MSSW, MPH, Director, Office on Smoking and Health, CDC. 

The success of the GYTS lies in its simplicity. It is inexpensive to administer, and the data can be processed and returned to countries rapidly. Planners decided that the survey would be school-based, to limit time and expense. The age group surveyed would be 13–15 (still in school, and similar to the age of respondents in the U.S. Youth Tobacco Survey conducted by CDC). The core component has 56 questions that cover tobacco use and related knowledge and attitudes, access to tobacco products, media and advertising exposure to tobacco, tobacco use as a subject in the school curriculum, smoking cessation, and environmental tobacco smoke, with optional questions added by countries.

School children taking the survey use answer sheets like those used for standardized tests. After the raw data are sent to CDC, they are sent to a contractor who builds a data file. The file is returned to CDC, where it is edited and weight-adjusted. "We produce about 200 tables for each country," Dr. Warren said. "The data belong to the country where they are collected." 

CDC and WHO lead regional workshops to teach coordinators how to conduct the survey. The coordinators gather the data, and CDC processes them and provides ongoing technical assistance. Dr. Warren is very pleased with the GYTS research coordinators' involvement with this project. "They make an incredible, very positive commitment to make the project work," he said. 

An analysis workshop was held in the Caribbean in August 2001. "We taught report writing, fact sheets, how to understand the data and analyses using Epi Info, and what to do with the information in terms of dissemination," said Dr. Warren. Some countries can do their own secondary analysis. Some lack the statistical software needed to analyze the survey data. "We train to build capacity," said Dr. Warren. 

The GYTS covers only cigarette use, but countries can customize it for other tobacco products. For instance, bidi use and applied tobacco products are covered in India. The Indian questionnaire is quite extensive. "India is a unique situation," Dr. Warren explained. "They have a central coordinator and one at each state level." 

The data have helped with the development of good, solid tobacco control programs by participating countries. Some countries are already using the data from the GYTS to drive policy changes and to establish the level of environmental tobacco smoke (ETS) to which children are exposed. One troubling finding of the GYTS is that exposure of young people to ETS is very high in all countries. 

Although survey data reflect variations among countries, the challenges of global tobacco control are clear, especially regarding ETS. More than half of the students in Jordan and Poland lived in a home where others smoked. In China, Fiji, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev), about half of the students were exposed to cigarette smoking from others in their home. In every country, at least 40% of students were exposed to cigarette smoking by other people in places away from their homes. Students reportedly think smoking is harmful and wish that it would be banned in public places. 

The tobacco industry's message is unopposed in many countries. Overall, less than one-half of the students reported having been taught about the effects of tobacco use. 

Another finding of the survey is that young people have easy access to tobacco products. Most students bought their cigarettes in a store without being challenged about their age. In most countries, over two-thirds of students reported seeing advertisements promoting cigarettes on billboards, in newspapers and magazines, and at public events. They also saw cigarette brand names at such events. Many had been offered free cigarettes by a representative of a tobacco company. 

Some countries also have an early age of initiation for smoking. In Chongqing and Guangdong Provinces of China, Poland (rural), and Manicaland in Zimbabwe, nearly a third of the students who ever smoked cigarettes started smoking before the age of 10 years. The median for all countries was 26.4%. Initiation of smoking before 10 years was lowest in Venezuela (12.1%) and Costa Rica (10.9%). 

Most current smokers said they wanted to stop, especially in China (Shandong and Tianjin), where the age of initiation is particularly low. Unfortunately, cessation programs are rare. 

World No-Tobacco Day in May is used to release and promote the GYTS data. The Framework Convention for Tobacco Control will use the survey as a monitoring tool to track prevalence, media exposure, ETS, and access to and availability of tobacco. 

For Further Reading 
Warren CW, Riley L, Asma S, Eriksen MP, Green L, Blanton C, Loo C, Batchelor S, Yach D. Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project. Bulletin of the World Health Organiza-tion 2000;78(7):868–76.

CDC's Global Tobacco Control Activities

1. WHO Collaborating Center on Global Tobacco Prevention and Control
CDC's Office on Smoking and Health (OSH) continues as a World Health Organization (WHO) Collaborating Center on global tobacco prevention and control. Priority contributions include (1) development of global surveillance, (2) facilitating knowledge exchange and application, (3) providing expertise through secondments to WHO and its regions, and (4) facilitating partnerships for strengthening national and global capacity. 

2. WHO-CDC Cooperative Agreement 
Through a cooperative agreement, CDC provides financial support to WHO for projects related to global surveillance, knowledge exchange, and capacity building. 

3. PAHO-CDC Cooperative Agreement 
CDC provides financial and technical assistance to the Pan American Health Organization (PAHO) to support its tobacco control activities in the region. 

4. Global Tobacco Surveillance 
CDC is partnering with WHO, the World Bank, UNICEF, the American Cancer Society, and other partners on a variety of surveillance projects, including the Global Youth Tobacco Survey, Global Health Professionals Survey, Global School Health Professional Surveys, Multi Risk Factor Survey, WHO Regional Survey, Country Profiles, and tracking of global tobacco legislation. Information gathered through these surveys is being compiled at CDC into an electronic Web-based system entitled NATIONS (National Tobacco Information Online System). 

5. Knowledge Exchange and Application 

• CDC is partnering with WHO, the Fédération Internationale de Football Association, and the International Olympic Committee to promote smoke-free sporting events and physical activity as a positive alternative to tobacco use. 

• In collaboration with WHO, CDC is planning a tobacco control training institute to be held in New Delhi, India, in 2002. The institute will include in-depth instruction in policy approaches to, and program planning for, tobacco control. 

• In partnership with WHO and the International Union for Health Promotion and Education, CDC is developing a seminar for media professionals in Francophone Africa in 2002. The seminar will help them increase their understanding of tobacco and health issues, communicate these facts to the public, and promote tobacco control. 

6. Secondments and Support to WHO 

• CDC has placed former OSH Director Michael Eriksen, ScD, in WHO Headquarters as Senior Advisor to the Non-Communicable Disease and Mental Health Cluster. 

• To increase national and regional tobacco control capacity, CDC has placed health educator Karen Klimowski, MPH, in Zimbabwe to support tobacco control in the AFRO region. 

• Under the auspices of the Western Pacific Regional Office, CDC has placed health policy analyst Burke Fishburn in Hanoi, Vietnam, to assist in tobacco control initiatives in Vietnam, Malaysia, and Laos. 

• CDC is sharing expertise with WHO through a temporary assignment of health communicator Katy Curran, MS, ATC, CSCS, to assist WHO in expanding global smoke-free sports initiatives. 

• CDC provides financial support for the placement of Clarence Pearson, a senior advisor to the WHO office at the United Nations in New York. Mr. Pearson facilitates the U.N. Taskforce on Tobacco. 

7. Binational Commissions 
Under DHHS leadership, CDC is collaborating with Mexico through the U.S.–Mexico Binational Commission and with Egypt on its Healthy Egyptian Initiative to enhance the capacity of these countries to promote tobacco control. 

8. World Bank Collaboration 
CDC provides the World Bank with financial and technical assistance for country-specific economic analyses and dissemination of the World Bank report Curbing the Tobacco Epidemic. 

9. Framework Convention on Tobacco Control 
Under DHHS leadership, CDC provides technical support to the U.S. Interagency Working Group, which coordinates the development of U.S. positions on the Framework Convention on Tobacco Control. 

10. USTR Interagency Process on Tobacco Trade 
Under DHHS leadership, CDC provides technical support to the U.S. Trade Representative (USTR) on tobacco trade issues. CDC's role in the interagency meetings is to advise USTR and other federal agencies of the potential public health impact of any tobacco-related trade action that is under consideration.

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