The prevalence & determinants of tobacco-use among Grade 8 - 10 learners in South Africa

Report on the Results of the Global Youth Tobacco Survey in South Afirca ( PDF - 1414.36k)

Page 1 of 3

The Global Youth Tobacco school-based Survey

Dehran Swart Priscilla Reddy Blanche Pitt Saadhna Panday

 

Contents
List of Tables	. . .  . . . . . . . . . . .	iv
Foreword	. . .  . . . . . . . . . . .	v
Executive Summary	. . .  . . . . . . . . . . .	vi
1. Introduction	. . .  . . . . . . . . . . .	2
1.1 Public Health Impact of Tobacco-use	. . .  . . . . . . . . . . .	2
1.2 Tobacco-use in South Africa	. . .  . . . . . . . . . . .	2
1.3 The International Response to the Tobacco Epidemic	. . .  . . . . . . . . . . .	3
1.3.1 WHO Resolutions	. . .  . . . . . . . . . . .	3
1.3.2 The United Nations Foundation Project	. . .  . . . . . . . . . . .	3
2. The Global Youth Tobacco Survey	. . .  . . . . . . . . . . .	5
2.1 Objectives of GYTS	. . .  . . . . . . . . . . .	5
2.2 Content of GYTS	. . .  . . . . . . . . . . .	5
2.3 Methodology	. . .  . . . . . . . . . . .	5
2.3.1 Sampling	. . .  . . . . . . . . . . .	5
2.3.2 Questionnaire Development	. . .  . . . . . . . . . . .	6
2.3.3 Data Collection	. . .  . . . . . . . . . . .	6
2.3.4 Analysis	. . .  . . . . . . . . . . .	7
3. Selected results	. . .  . . . . . . . . . . .	8
3.1 Study Sample Size and Response Rates	. . .  . . . . . . . . . . .	8
3.2 Background Characteristics of Learners	. . .  . . . . . . . . . . .	9
3.3. Prevalence of Tobacco-using Behaviour	. . .  . . . . . . . . . . .	10
3.4 Access to Cigarettes	. . .  . . . . . . . . . . .	13
3.5 Cessation and Addiction	. . .  . . . . . . . . . . .	15
3.6 Media, Advertising, Marketing and Regulations	. . .  . . . . . . . . . . .	17
3.7 Environmental Tobacco Smoke	. . .  . . . . . . . . . . .	19
3.8 School Curriculum	. . .  . . . . . . . . . . .	21
4. Discussion	. . .  . . . . . . . . . . .	22
5. Conclusion and Recommendations	. . .  . . . . . . . . . . .	25
References	. . .  . . . . . . . . . . .	26
Appendix I: The Questionnaire	. . .  . . . . . . . . . . .	27
Appendix II: Languages used in each Province	. . .  . . . . . . . . . . .	45
Appendix III: Graph 1 - Prevalence: Ever-smokers	. . .  . . . . . . . . . . .	46
Appendix IV: Graph 2 - Prevalence: Current use of cigarettes	. . .  . . . . . . . . . . .	47
Appendix V: Graph 3 - Prevalence: Current use of other tobacco products	. . . . . . . . . . . . . .	48
Appendix VI: Graph 4 - Prevalence:  Current use of any tobacco product	. . .  . . . . . . . . . . .	49
Appendix VII: Graph 5 - Prevalence: First smoked cigarettes before the age of 10	. . .  . . . . . . . . . . .	50
Appendix VIII: Graph 6 - Prevalence: Frequent smokers	. . .  . . . . . . . . . . .	51

List of Tables

Table 1: Study Sample Size and Response Rates
Table 2: Background Characteristics of Learners
Table 3: Prevalence of Tobacco-using Behaviour
Table 4: Access to Cigarettes
Table 5: Cessation and Addiction
Table 6: Media, Advertising, Marketing and Regulations
Table 7: Environmental Tobacco Smoke
Table 8: School Curriculum 

Foreword

The South African Tobacco Products Control Amendment Act of 1999 was one of the most groundbreaking pieces of public health legislation, not just in South Africa but in the world. The National Health Promotion Research and Development Group of the Medical Research Council in South Africa, provided much of the research evidence that underpinned the formulation of that Act, assisted in its defence through public hearings in parliament and challenges in law courts, and advised on the development of its regulations. With such comprehensive legislation in place - banning smoking in public places and prohibiting advertising and sponsorship of cigarettes - one might have thought the job done; and time for these behavioural scientists and their fellow public health activists to move on to the next dragon to slay. 

Not so. This little band of humanitarians were prescient enough to realise that the industry, acknowledging defeat in this quarter, had already moved on to a new battlefront for the new century - a field that stands at the heart of the entire business model of tobacco - if you get them addicted young, you have a revenue stream for life. As in any theory of war, a new front requires early reconnoitring and surveillance before battle is enjoined. The Global Youth Tobacco Survey (GYTS) is just that. Conceived by the Tobacco Free Initiative of WHO, it seeks to pro-vide insights into the determinants of tobacco-using behaviour that place young people and school-aged children at risk. This data can then be used to develop scientifically robust interventions to increase adolescent tobacco health literacy and self-efficacy, so as to prevent adolescents starting to smoke; or in order to help them to quit.

This is critical if we are to prevent the currently estimated 4 million tobacco-related deaths annually increasing to a projected 10 million deaths per year by 2030. By that date 70% of such deaths would be in developing countries such as ours - where smoking already kills 25 000 annually, or 7% of the total deaths per annum.

The team is to be commended for their remarkable achievement in rapidly adding South Africa to the list of GYTS participating countries, raising the necessary funds and completing the nationwide study in record time. This would have been impossible without the assistance of the National Department of Health, particularly its Health Promotion Directorate, National Department of Education, UNICEF, WHO/TFI and CDC.

Undoubtedly the data from this study will provide a solid logistical base for the next onslaught in the battle to protect our fellow citizens, and ensuing generations, from premature and unpleasant death and disability from tobacco.

Dr AD MBewu
Executive Director of Research
Medical Research Council

Executive Summary

The Global Youth Tobacco Survey (GYTS) is a school-based tobacco specific survey which focuses on adolescents aged 13-15. In 1999 thirteen countries, including South Africa, conducted this survey. Presently one hundred and eleven countries are currently involved in various stages of participating in the GYTS.

The survey aimed to document and monitor the prevalence of tobacco-use such as smoking cigarettes, cigars, pipes and the use of smokeless tobacco. In addition, this survey assessed learners' knowledge, beliefs and attitudes related to tobacco-using behaviour, as well as smoking cessation, environmental tobacco smoke (ETS), minor's access to tobacco, school curriculum, and media and advertising.

This nationally representative survey was con-ducted in all nine provinces of South Africa. A two-stage cluster sample design was used to obtain a sample of learners from Grades 8, 9 and 10. The first-stage sampling frame consisted of all public schools. Schools were selected with a probability proportional to the school enrollment size. The second sampling stage consisted of systematic equal probability sampling of classes from each selected school. All Grade 8, 9 and 10 classes in the selected schools were included in the sampling frame. All learners in the selected classes were eligible to participate in the survey. The South African version of the questionnaire consisted of 54 core questions and 39 country specific questions. The questionnaire was administered in seven languages. Survey administrators were trained intensively and were assigned schools within their geographic area of responsibility.

The data was analysed by applying a weighting factor to adjust for non-response and for the varying probabilities of selection. Prevalence rates were computed with 95% confidence intervals for the estimates. Of the 160 selected schools, 123 schools participated in the survey. The survey was completed by 6045 out of 7074 selected learners. 

Ever smokers (smoked a cigarette, even a puff or two) made up 46.7% of the sample. Current smokers (smoked cigarettes on one or more days in 30 days preceding the survey) made up 23% of the sample. On the issue of age at initiation, 18. 5% of learners reported first smoking cigarettes before the age of 10. Almost a fifth of the sample (18.2%) had used tobacco products other than cigarettes such as chewing tobacco and snuff.

Almost two thirds of current smokers (64.2%) were not refused cigarettes because of their age when they purchased them in a store. A significant percentage of current smokers (73.9%) expressed a desire to stop smoking with equal numbers making an attempt to stop smoking (76.6%). A large proportion of adolescents in this study have been exposed to tobacco advertising in magazines, newspapers and on billboards. About twice as many current smokers than never smokers were exposed to someone else's smoke in their homes or in places other than their homes in their presence in seven days preceding the survey. The level of smoking-related issues covered in the school curriculum was low.

The findings of this survey provide evidence for the need to develop adolescent specific tobacco control interventions to avert the potential escalation in tobacco-related health care costs. Before developing these interventions, determinant studies on the use of cigarettes and other tobacco products are needed. In addition, in order to tailor programmes to the specific needs of learners, these determinant studies must address the historical "racial", gender and provincial differences that have emerged from the data. 

Community wide interventions that educate, encourage and support adults in protecting themselves and their children from tobacco will augment adolescent specific programmes. The Global Youth Tobacco Survey should be repeated periodically and it should become an integral part of the surveillance system to monitor tobacco-use in South Africa.

1. Introduction
1.1 Public Health Impact of Tobacco-use

Despite widespread knowledge of the harm caused by smoking, and concerted tobacco control efforts in the last decade, only modest success has been achieved in lowering the impact of tobacco morbidity and mortality. The World Health Organisation (WHO) estimated that currently, tobacco accounts for over 4 million deaths each year, a figure projected to rise to about 10 million deaths per year by 2030. 1 By that date, 70% of those deaths will occur in developing countries. ²

Tobacco use is considered to be one of the chief preventable causes of death in the world. ³ The majority of adult smokers initiate the use of tobacco before the age of 18 during their adolescent years. ⁴ Recent trends show that the smoking prevalence rates among adolescents is rising; ^4,5,6 and that the age of initiation is decreasing. ^4,7,8 If these patterns continue, tobacco use will result in the death of 250 million children and young people alive today, many of them in developing countries. ⁹ Thus, adolescents and school-aged children should be a primary focus for intervention strategies. Carefully designed studies must provide an insight into the determinants of tobacco-using behaviour that place young people and school-aged children at risk. This data can then be used to develop scientifically sound interventions in order to increase adolescent tobacco health literacy, self-efficacy to prevent the initiation of tobacco-use or to increase their self-efficacy to quit. It could also provide the impetus for more effective and comprehensive tobacco control policies.

1.2 Tobacco-use in South Africa

Tobacco-use in South Africa (SA) is an ever-increasing health and economic problem. In 1990, 25 000 tobacco-related deaths were reported annually. The 1994 estimates of the economic cost of tobacco in terms of lost productivity due to premature deaths and hospitalisation exceeded R2,5 billion, while the direct cost of hospitalisation and outpatient treatment for smoking-related diseases in the public sector alone was approximately R1,5 billion per year. ¹⁰

Reddy and associates 11, in a study in February 1995, reported that 34% of adult South Africans, or a total of seven million adults, smoke. This overall figure has increased by 1% per year since 1992. In particular, the smoking rate among the "Coloured" a population has increased by 12% when compared to the 1992 figure. The highest rate of tobacco-related deaths (one in five) compared to the national average of one in nine, occurred in the Western Cape. ¹² The high smoking rates among this group were also reflected in the 100% increase in lung cancer mortality rates among "Coloured" men and the 300% increase among "Coloured" women during the 1970s and 1980s in the Western Cape. ¹³

The October 1996 tobacco survey showed that the overall smoking prevalence amongst adults remained at 34%. However there had been an increase in the prevalence of smoking among adults in five provinces when compared to the prevalence rates of the February 1995 survey. ¹⁴ The smoking prevalence analysed by "race" and gender shows that the rate had increased for "Coloured", "Indian" and "White" males; and for "Black/ African", "Indian" and "White" females. From February 1995 to October 1996, smoking prevalence in the 18 - 24 age group increased from 31% to 36%. The inference can be made that most of the members in this 18 - 24 age group most likely became regular smokers during their adolescent years. ¹⁵

Meyer-Weitz et. al. ¹⁵ reported that the smoking prevalence rate for adults dropped to 25% in the 1998 survey. This corresponds with the smoking rate of 24% obtained from the South African Demographic and Health Survey (SADHS). ¹⁶ A possible explanation for the dramatic decrease in smoking prevalence from a. During the Apartheid years, all South Africans were classified in accordance with the Population Registration Act of 1950 into "racial groups" viz. "Black/African", "Coloured", "White" or "Indian"; and the provision of services occurred along these "racially" segregated lines. The disproportionate provision of services to different "race groups" led to inequities. Information is still collected along these "racial" divisions in order to redress these inequities. In no way do the authors subscribe to this classification. 34% in 1996 to 24% in 1998 could be attributed to the introduction of health warnings on cigarette packages and all tobacco advertisements, together with the extensive media coverage that the impending tobacco control legislation received during that time period. In addition, the consistent increase in tobacco excise tax could also have impacted on the prevalence of smoking.

Despite all this information on adult smoking behaviour, there is a dearth of knowledge on the smoking behaviour of adolescents in South Africa. According to a literature review conducted on children and tobacco in Southern Africa, ¹⁷ it is difficult to obtain an overall impression of smoking prevalence due to lack of national representivity, differing sample sizes and methodologies as well as small  geographical areas or "racial" groups being studied. The most recent national survey in SA, the SADHS, reported that the prevalence of smoking in the 15 - 19 year age group was ten percent."

1.3 International Response to the Tobacco Epidemic

1.3.1 WHO Resolutions
Between 1970 and 1995, the WHO adopted 14 resolutions on the need for both national and international tobacco control policies. Four of the 14 resolutions underpin WHO's Tobacco Free Initiative (TFI), a United Nations Foundation (UNF) project. Member states were encouraged to implement comprehensive tobacco control strategies that contain the following: 

4 Measures to ensure that non-smokers receive effective protection, to which they are entitled, from involuntary exposure to tobacco smoke.

4 Measures to promote abstention from the use of tobacco so as to protect children and young people from becoming addicted.

4 The establishment of programmes of education and public information on tobacco and health issues, including smoking cessation programmes, with active involvement of the health professions and the media.

4 Monitoring of trends in smoking and other forms of tobacco use, tobacco-related disease, and effectiveness of national smoking control action.

1.3.2 The United Nations Foundation Project

TFI/WHO received an award from the United Nations Foundation for International Partnerships (UNFIP), probably the largest single tobacco prevention grant, to initiate a joint project with the United Nations Children's Fund (UNICEF) titled "Building alliances and taking action to create a generation of tobacco free children and youth". The aim of the project is to collate the evidence, provide technical support, and create strategic alliances necessary to positively address the negative impact of tobacco and to encourage and support children and adolescents in leading healthy and active lives free of tobacco.

The project initially focused on a small group of developing countries, one per WHO Region, and draws upon the combined technical expertise and operational resources of a number of UN agencies - in particular WHO, UNICEF, and the World Bank. These agencies work together with the global scientific community, government and non-government agencies, institutions and systems within countries, the media, and with young people to show that together they can make a difference in this important public health issue.

The project is conceived as a dynamic and interactive process, whereby the activities and products of each phase will be used to inform and guide subsequent activities. The project consists of three distinct, but overlapping phases. The first phase focuses on harnessing the evidence for action viz.: synthesising the existing evidence from countries, some of which may participate in subsequent phases; undertaking new areas of research to support actions; and establishing the research-based evidence for developing future actions. 

The second phase is the activating phase. Country Activating Groups (CAGs), with broad membership, will be formed in each of the participating countries as the coordinating and implementing mechanism to select and develop the components of a comprehensive country-based approach in addressing tobacco-use among children and young people. Opportunities to promote the exchange of experiences and issues between countries and global activities will be developed and strengthened.

WHO and UNICEF technical staff from country offices, headquarters and regional offices, as well as other technical partners (e.g. The World Bank and the Center of Disease Control and Prevention, USA) play a key role in supporting the country-level work, in particular, through assistance with the identification, development and dissemination of programme support tools and resources; with young people in the project activities. In addition, WHO and UNICEF will ensure that tobacco is included as a component of existing programmes they operate within the country and any plans or agreements they develop with relevant governments.

The third phase involves taking the project to scale: producing and disseminating resources; strengthening regional capacity to sustain activities; integrating the products and results of the project into ongoing tobacco control work at the national, regional and global levels: transferring technology and experience between countries and regions; and strengthening cooperation and collaboration at all levels.

The overall coordination of this project is through TFI/WHO. The harnessing the evidence for action phase of the project will be coordinated by WHO, in collaboration with identified research experts from a range of developing countries. The activating phase will be coordinated by UNICEF country offices, with technical support and assistance from

2. The Global Youth Tobacco Survey (GYTS) 

WHO and CDC organised a small technical meeting in Geneva on 7 - 9 December 1998, to plan for the development and implementation of an initial baseline assessment of tobacco-use by young people in each country using a school survey instrument-the Global Youth Tobacco Survey (GYTS). The purpose of the meeting was to work with a key tobacco control expert from each country to develop a suitable instrument to use for the survey. Thirteen countries participated in the activating phase (Phase 2) of this project in 1999. South Africa formed part of this group of countries which implemented this survey. Presently, 111 countries are currently involved in various stages of participating in the GYTS.

The survey questionnaire was designed to have a core set of questions to be used by all countries. In addition, it was also designed to be flexible enough to include specific issues and individual needs of each of the participating countries (i.e. optional questions could be added). The survey is intended to enhance the capacity of countries to design, implement, and evaluate the tobacco control and prevention programmes for young people which will be initiated at the country level.

The GYTS is a school-based tobacco specific survey which focuses on adolescents age 13-15 (Grades 8-10). School surveys have been found to be useful tools in gathering data as they are relatively inexpensive and easy to administer, tend to report reliable results, and refusals are significantly lower than in house-hold surveys. The most common research approach for this specific population, has been the self-administered questionnaire.

In order to ensure the development of a comprehensive tobacco control programme for SA, the Medical Research Council (MRC), in addition to conducting the GYTS, is also conducting several in-depth qualitative and quantitative determinant studies that clearly and succinctly target local tobacco-using behaviours.

2.1 Objectives of the GYTS
4 To document and monitor the prevalence of tobacco-use including: cigarette smoking, and current use of smokeless tobacco, cigars or pipes. 

4 To obtain an improved understanding of and to assess learners' attitudes, knowledge and behaviours related to tobacco-use and its health impact, including: cessation, environmental tobacco smoke (ETS), media and advertising, minor's access, and school curriculum.

2.2 Content of GYTS
The GYTS addresses the following issues:

4 the level of tobacco-use
4 age at initiation of cigarette use
4 levels of susceptibility to become cigarette smokers
4 exposure to tobacco advertising
4 identifying key intervening variables, such as attitudes and beliefs on behavioural norms with regard to tobacco-use among young people which can be used in prevention programmes 

2.3 Methodology
2.3.1 Sampling
The survey was planned for all nine provinces in South Africa. A two-stage cluster sample design was used to obtain a nationally representative sample of learners in Grades 8, 9 and 10. The first-stage sampling frame consisted of all public schools containing any of Grades 8, 9 and 10. Schools were selected with a probability proportional to the school enrollment size i.e. larger schools had a greater chance of being selected. Enrollment data was obtained from Provincial Departments of Education. 

The second sampling stage consisted of systematic equal probability sampling (with a random start) of classes from each school that participated in the survey. All Grade 8, 9 and 10 classes in the selected schools were included in the sampling frame. All learners in the selected classes were eligible to participate in the survey. The aim was to select 13 schools per province with an 80% expected participation rate i.e. 10 schools per province. The enrollment distribution across the provinces necessitated an increase in the number of schools selected in five provinces viz. Eastern Cape, Gauteng, North West, Northern Cape and Western Cape. The target number of learners per province was 625 with an expectation of 500 completed  questionnaires. The target for the sample size took into account time, financial and human resources. 

2.3.2 Questionnaire Development
The South African version of the questionnaire (Appendix I) consisted of 93 questions: 54 core questions and 39 additional questions in order to take into account local tobacco-using behaviour and the psycho-social, cultural and contextual  determinants thereof. Many questions were included to determine the extent of smokeless tobacco-use among youth as this was highlighted from qualitative studies conducted by the authors in the Southern Cape Karoo Region of the Western Cape Province. Several challenges were encountered when developing local questions, for example, the names of the five most popular brands of cigarettes used by the youth in South Africa for the question on brand preferences were not known. This question had to be developed by using the 15 brands of cigarettes most heavily advertised in South Africa.

South Africa has 11 official languages. It was necessary to translate the questionnaire, the parent notification form and the script for survey administrators into several languages. The initial letter to the principals was in English, the language most commonly used within the Department of Education. It is also the medium of instruction in most schools in South Africa.

The questionnaire was translated into seven languages. Initially it was translated from English to Afrikaans, Xhosa and Zulu. However, further discussions with principals resulted in the English questionnaire being translated into another three languages viz. North Sotho, South Sotho and Tsonga (Appendix II). The translation of the English questionnaire into other languages required cultural sensitivity and was a necessary but time consuming exercise. Translated questionnaires were checked by back-translating them into English. The translated questionnaires differed in length due to varying sentence construction in each language. In some languages, there were words that did not have a direct translation e.g. in Tsonga, one word is used for all tobacco products, so "snuff" was translated as "tobacco that is sniffed" and "chewing tobacco" as "tobacco that is "chewed". 

In order to ensure face validity, the questions were pre-tested in the various languages. At the pilot phase of the project, the time required to complete the questionnaire was established. Learners required between 20 to 60 minutes to answer all questions.

2.3.3 Data Collection
Before data collection could take place, extensive networking occurred with the various stakeholders in the Departments of Health and Education to obtain their endorsement and support for the project. The project was discussed in detail with the Director of Health Promotion and it was agreed that GYTS would be linked to the Health Promoting Schools Initiative, using tobacco control as an entry point for Health Promoting Schools. This facilitated the participation of staff of the Provincial Health Promotion Departments as survey administrators. Letters were sent to the Provincial Directors of Health Promotion. All agreed to coordinate the allocation of survey administrators to the selected school.

Letters were sent to all the principals of the 160 selected schools inviting them to participate in the GYTS. This letter also asked for enrollment figures as well as the language preference of the learners.

After schools had indicated their willingness to participate, a letter was sent to schools listing the classes that were chosen. Copies of the Parent Notification Form for each learner in the selected class accompanied this letter. The principal took responsibility for the distribution of letters informing learners and parents about the study and requesting their consent.

Training workshops with survey administrators were held over a two week period in all nine provinces. Each survey administrator was assigned one, two or three schools depending on whether the selected school was located in their area of responsibility.

Packages were couriered to the survey administrators  due to delays in printing of questionnaires and a postal strike. A specific pencil had to be used for completion of the answer sheet to facilitate automated capturing of data. The answer sheets were checked and enrolment data was reconciled with the number of questionnaires. They were then couriered to the Centers for Disease Control, USA, where the data was captured.

2.3.4 Analysis
A weighting factor was applied to each learner record to adjust for non-response and for the varying probabilities of selection. Epi Info and SUDAAN, a software package for statistical analysis of correlated data, were used to compute prevalence rates and 95% confidence intervals for the estimates. Differences between prevalence estimates were considered statistically significant if the 95% confidence intervals did not overlap.

Current users of cigarettes
23% [19.0-27.0] of the sample were current users of cigarettes (smoked cigarettes on one or more days in the past 30 days preceding the survey), with significantly more males (28.8% [24.5-33.1]) using cigarettes than females (17.5% [13.1-21.9]). Significantly more learners who were 12 years old or younger (28.7% [21.7-35.7]) were current users of cigarettes when compared to 13 (14.7% [8.9-20.5]) and 14 year olds (17.4% [13.2-21.6]). Grade 9 learners had a significantly higher prevalence of current cigarette use (28.1% [20.9-35.3]) than Grade 8 learners (16.9% [14.4-19.4). Significantly more Grade 10 learners (24.9% [19.5-30.3]) were current users of cigarettes compared to Grade 8  learners. 37. 4% [33.8-41.0] of "Coloured" learners and 29% [22.5-35.6] of "White" learners currently used cigarettes. The prevalence rate for current use of cigarettes among "Coloured" learners was significantly greater than that for "Black/African" learners (18.4% [13.1-23.7]). 

Current use of tobacco products other than cigarettes
18.2% [15.1-21.3] of the sample had used tobacco products other than cigarettes. Significantly more 12 year olds and younger (30.7% [20.8-40.6]) than 13 (7.3% [3.2-11.4]), 14 (12.4% [8.5-16.3]) and 15 year olds (13.2% [6.6-19. 8]) were current users of other tobacco products. Additionally, 16 years and older learners (19.7% [16.3-24.1]) who were current users of other tobacco products, used these products significantly more than those who w e re 13 years old. While "Black/African" learners had the lowest prevalence for having ever smoked cigarettes and for current use of cigarettes, they had the highest prevalence of current use of other tobacco products. 

Any tobacco product 
32.5% [28.4-36.6] of learners had used any tobacco product on one or more days in the past 30 days preceding the survey. Significantly more males (38.0% [33.6-42.4]) than females (26.5% [21.5-31.5]) were current users of any tobacco product. Learners who were 12 years old and younger (43.6% [34.5-52.7]) were significantly more likely to be current users of any tobacco product when compared to 13 year olds (17.6% [9.8-25.4]), 14 year olds (24.4% [19.8-29.0]) and 15 year olds (26.9% [20.9-32.9]). What is more, current users who were 16 years and older (36.5% [31.0-42.0]) used any tobacco product significantly more than those who were 14 years old. The prevalence of current use of any tobacco product for "Coloured" learners (41.2% [37.8-44.6]) was significantly higher than that for "Black/African" learners (28.6% [22.8-34.5]). However there was no significant difference between that of "Coloured" and "White" learners (32.4% [26.1-38.7]). 

First smoked cigarettes
18.5% [16.6-20.4] of learners first smoked cigarettes before the age of 10. Significantly more learners in Grade 8 (24.4% [18.6-30.2]) first smoked cigarettes before the age of 10 when compared to those learners in Grade 9 (14.3% [10.2-18.4]). More "Black/African" learners (20% [16.9-23.1]) first smoked cigarettes before the age of ten when compared to "Coloured" learners (14.2% [12.2-23.1]). 

Current Frequent smokers
10.1% [7.3-12.9] of current smokers have been classified as current frequent smokers (smoked cigarettes on 20 or more days in the past 30 days p receding the survey). Significantly more Grade 9 learners (12.6% [7.3 - 17.9]) were current frequent smokers when compared to Grade 8 learners (5.5% [3.8 - 7.2]). In addition, significantly more Grade 10 learners (13.3% [9. 8 - 16.8]) were current frequent smokers when compared to Grade 8 learners. When looking at current frequent smokers, the trend indicates that the number of current frequent smokers increased for 13-16 years and older with age. Those learners who were 16 years old or older (13.8% [10.0 - 17.6]) tended to smoke significantly more frequently than the 13 (4.5% [1.4 - 7.6]), 14 (4.9% [3.1 - 6.7]) and 15 year olds (6.1% [4.3 - 7.0]). Significantly more "Coloured" learners (14.6% [11.4 - 17.8]) were currently frequent smokers when compared to "Black/ African" learners (7. 3% [3. 7 - 10. 8]). Significantly fewer "Black/African" learners were current frequent smokers compared to "White" learners (17.0% [11.2 - 22.7]). However, there was no significant difference in current frequent smoking between "Coloured" and "White" learners. 

Provincial Highlights
The prevalence of ever smokers in the Northern Province (27.4% [21.1 - 33.7]) was significantly lower than the national average of 46.7% [41.8 - 51.6]. However the Western Cape showed an opposite trend with a significantly higher prevalence of ever smokers (65.8% [58.2 - 73.4]) compared to the national average. A similar trend regarding current use of cigarettes was found in both the Northern Province (12.2% [6.6 - 17. 8]) and the Western Cape (40.7% [ 35.6 - 45.8]) compared to the national average of 23% [19.0 - 27.0]. Current use of any tobacco product was significantly higher in the Western Cape (44.8% [40.5 - 49.1]) when com-pared to the national prevalence of 32.5% [28.4 Ð 36.6]. Both Gauteng (12.7% [9.6 - 15.8]) and North West Province (11.4% [6.5 - 16.3]) displayed significantly lower prevalence of learners who first smoked cigarettes before the age of 10 compared to the national prevalence of 18.5% [16.6 - 20.4].  A graphical representation of the prevalence of tobacco-use across all province is presented in Appendices III to VIII. 

3.4 Access to Cigarettes

Learners were asked about their accessibility to cigarettes. 50.7% [43.5 - 57.9] of current smokers purchased their own cigarettes in a store. Most "Coloured" current smokers (63.2% [57.7 - 68.7]) bought their own cigarettes in a store. Significantly more "Coloured" current smokers purchased their own cigarettes in a store when compared to "Black/ African" current smokers (48.8% [41.1 - 56.6]). "Black/ African" current smokers were also least likely of all four "race" groups to purchase their own cigarettes in a store. A large percentage (64.2% [52.6 - 75.8]) of current smokers were not refused cigarettes because of their age when they bought them in a store. 80.2% [74.5 Ð 85.8] of "White" current smokers were not refused cigarettes because of their age when they bought them in a store. This  figure differed significantly from that of " Coloured" current smokers (69.7% [65. 2 - 74.3]) as well as from "Black/African" current smokers (56.6% [44.1 - 69.0]). 

Besides purchasing their cigarettes themselves, various other means were used to obtain cigarettes. 14.7% [8.0 - 21.4] of current smokers recruited another person to purchase cigarettes for them, 9.5% [6.2 - 12.8] of current smokers borrowed their cigarettes from someone else while 5.6% [3.6 - 7.6] of current smokers obtained their cigarette from an older person. A large percentage of "Black/African" current smokers (18.1% [12.2 - 24.0]) got someone else to purchase cigarettes on their behalf. This percentage differed significantly from "White" current smokers (4.5% [2.9 - 6.1]) as well as "Coloured" current smokers (9.8% [7.5 - 12.1]). In addition, significantly more "Coloured" current smokers recruited someone else to buy their cigarette when compared to "White" current smokers. "White" current smokers (17.1% [14.5 - 19.7]) were significantly more likely than the other "Coloured" (9.9% [7.8 - 12.1]) and "Black/African" (6.4% [4.2 - 8.6]) current smokers to have borrowed their cigarettes from someone else. Almost one third of current smokers (29.7% [25.8 - 33.6]) reported being offered free cigarettes by a tobacco representative. Significantly more 16 years and older current smokers (30.3% [26.2 - 34.4]) than 14 year old current smokers (18.1% [12.1 - 24.1]) w e re off e red free cigarettes by a tobacco representative. 

Provincial Highlights
Significantly fewer current smokers in the Northern Province (27.2% [19.6 - 34.8]), compared to the composite figure for the entire country (50.7% [43.5 - 57.9]) bought their own  cigarettes in a store. 44.1% [35.0 - 53.2] of current smokers in the Free State, a significantly higher figure compared to the national prevalence of 29.7% [25.8 - 33.6], were offered free cigarettes by a tobacco representative. On the other hand, a significantly lower percentage of current smokers in the Northern Cape (17.4% [12.2 - 22.6]), compared to the national prevalence, were offered free cigarettes by a tobacco representative. 

Page 1 of 3

GYTS Reports