Linking Global Youth Tobacco Survey (GYTS) Data to the WHO Framework Convention on Tobacco Control (FCTC): The Case for Brazil

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Preventive Medicine 47 (2008) S4 – S10 www.elsevier.com/locate/ypmed

Linking Global Youth Tobacco Survey (GYTS) Data to the WHO Framework Convention on Tobacco Control (FCTC): The Case for Brazil Liz Maria de Almeida a,⁎, Tânia Maria Cavalcante a , Letícia Casado a , Elaine Masson Fernandes a , Charles Wick Warren b , Armando Peruga c , Nathan R. Jones b , Ana Luiza Curi Hallal d , Samira Asma b , Juliette Lee b a

d

Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer, Rua dos Inválidos, 212, 3o. andar, 20231-048, Rio de Janeiro, RJ, Brazil b Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, MS K-50, Atlanta, GA 30341, USA c Pan American Health Organization, 525 23rd Street NW, Washington DC 20037 Maternidade Carmela Dutra, Secretaria de Estado da Saúde de Santa Catarina, Rua Irmã Benwarda, 208, Centro, Florianópolis, Santa Catarina, Brazil Available online 4 December 2007

Abstract Objective. The Global Youth Tobacco Survey (GYTS) in Brazil was developed to provide data on youth tobacco use to the National Tobacco Control Program. Method. The GYTS uses a standardized methodology for constructing sampling frames, selecting schools and classes, preparing questionnaires, carrying out field procedures, and processing data. The GYTS questionnaire is self-administered and includes questions about: initiation; prevalence; susceptibility; knowledge and attitudes; environmental tobacco smoke; cessation; media and advertising. SUDDAN and Epi-Info Software were used for analysis. Weighted analysis was used in order to obtain percentages and 95% confidence intervals. Results. Twenty-three studies were carried out between 2002 and 2005 in Brazilian capitals: 2002 (9); 2003 (4); 2004 (2) and 2005 (9). The total number of students was 22832. The prevalence rate among the cities varied from 6.2% (João Pessoa, 2002) to 17.7% (Porto Alegre, 2002). Conclusion. The tobacco use prevalence rates in 18 Brazilian cities show significant heterogeneity among the macro regions. Data in this report can be used to evaluate the efforts already done and also as baseline for evaluation of new steps for tobacco control in Brazil regarding the goals of the WHO FCTC. © 2007 Pan American Health Organization. Keywords: Tobacco use; Youth; Epidemiology; Surveillance

Introduction The purpose of this paper is to use data from the Global Youth Tobacco Survey (GYTS) conducted in Brazil in 18 cities (and repeated in five of them) between 2002 and 2005, to set the baseline and monitor changes among youth in self-reported prevalence of tobacco use and smoking cessation, exposure to secondhand smoke and tobacco industry marketing, access to ⁎ Corresponding author. Divisão de Epidemiologia, Coordenação de Prevenção e Vigilância, Instituto Nacional de Câncer, Rua dos Inválidos 212, 3°. andar, Centro, 20231-048 Rio de Janeiro, RJ, Brazil. E-mail address: [email protected] (L.M. de Almeida).

and availability of tobacco products, and school curricula teachings. Monitoring these changes will allow discussing the relation of these changes to the implementation of tobacco control measures in Brazil as they relate to the articles in the World Health Organization (WHO) Framework Convention on Tobacco Control (WHO FCTC) (CEBRID, 1997). Brazil ratified the WHO FCTC on November 3, 2005. The WHO FCTC provides the driving force and blueprint for the global response to the pandemic of tobacco-induced death and disease. The Convention embodies a coordinated, effective, and urgent action plan to curb tobacco consumption, laying out costeffective tobacco control strategies for public policies, such as bans on direct and indirect tobacco advertising, tobacco taxes

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L.M. de Almeida et al. / Preventive Medicine 47 (2008) S4–S10

and price increases, promoting smoke-free public places and workplaces, and prominent health messages on tobacco packaging. The WHO FCTC calls for countries to establish programs for national, regional, and global surveillance. WHO, the U.S. Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA) developed the Global Tobacco Surveillance System (GTSS) to assist all 193 WHO Member Cities in establishing continuous tobacco control surveillance and monitoring (GYTS, 2006). The GTSS provides a flexible system that includes common data items but allows countries to include important unique information, at their discretion. It also uses a common survey methodology, similar field procedures for data collection, and similar data management and processing techniques. The GTSS includes collection of data through three surveys: the Global Youth Tobacco Survey (GYTS) for youth, and the Global School Personnel Survey (GSPS) and the Global Health Professional Survey (GHPS) for adults. Over 2 million students in 140 countries completed the GYTS (Ministério da Saúde do Brasil, 1999; Pierce et al., 1996). The Global Youth Tobacco Survey (GYTS) in Brazil was developed to provide data on youth tobacco use to the National Tobacco Control Program. Methods The GYTS is a school-based survey of defined geographic sites that can be countries, provinces, cities, or any other sampling frame including sub national areas, non-Member Cities, or territories. The GYTS uses a standardized methodology for constructing sampling frames, selecting schools and classes, preparing questionnaires, carrying out field procedures, and processing data. The GYTS questionnaire is self-administered in classrooms, and school, class, and student anonymity is maintained throughout the GYTS process. Country-specific questionnaires consist of a core set of questions that all countries ask and unique country-specific questions. The final country questionnaires are translated in country into local languages and back translated to check for accuracy. GYTS country research coordinators conduct focus groups of students aged 13–15 to further test the accuracy of the translation and student understanding of the questions. CDC provides technical support for GYTS, including survey design and sample selection, training research coordinators (RC) for fieldwork implementation procedures, data management and processing, initial tabulation of the data, and training the RC to analyze the data. The following data are presented in this report: lifetime cigarette use; initiation of smoking before age 10; likely initiation of smoking during the next year among never smokers (i.e., susceptibility)11; current cigarette smoking, current use of tobacco products other than cigarettes; dependency on cigarettes among current smokers; exposure to secondhand smoke (SHS) at home; exposure to SHS in public places; desire for a ban on smoking in public places; students who were taught in school about the dangers of smoking, the reasons why young people smoke, or taught about the effects of smoking; students who saw advertisements for cigarettes on billboards or newspapers or magazines; students who have an object with a cigarette brand logo on it; smokers who want to stop, have tried to stop, and received help to stop smoking; and access and availability to cigarettes among smokers.

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The GYTS uses a two-stage cluster sample design that produces representative samples of students in grades associated with ages 13–15. The sampling frame includes all schools containing any of the identified grades. At the first stage, the probability of schools being selected is proportional to the number of students enrolled in the specified grades. At the second sampling stage, classes within the selected schools are randomly selected. All students in selected classes attending school the day the survey is administered are eligible to participate. Student participation is voluntary and anonymous. The GYTS sample design produces representative, independent, cross-sectional estimates for each site. For cross-site comparisons, data in this paper are limited to students aged 13–15 years old. Table 1 Percent of students who had ever smoked cigarettes, ever smoked their first cigarette before age 10, and of students who had never smoked cigarettes that are likely to initiate smoking in the next year (i.e., susceptible), Brazil GYTS 2002–2005 Regions/Cities

North Region Belém, 2005 Boa Vista, 2003 Palmas, 2002 Palmas, 2005 Northeast Region Aracaju, 2002 Fortaleza, 2002 Fortaleza, 2005 João Pessoa, 2002 João Pessoa, 2005 Maceió, 2003 Natal, 2002 Natal, 2005 Salvador, 2004 São Luis, 2003 Southeast Region Rio de Janeiro, 2005 Vitória, 2003 Cataguases, 2005 South Region Curitiba, 2002 Curitiba, 2005 Florianópolis, 2004 Porto Alegre, 2002

Ever smoked cigarettes, even one or two puffs

Ever smokers who initiated smoking before age 10

Never smokers likely to initiate smoking in the next year

37.7 (32.4–43.3) 37.1 (31.5–43.0)

12.4 (7.6–19.7) 23.2 (19.2–27.9)

12.2 (9.5–15.5) 16.0 (12.0–21.0)

39.6 (32.7–46.8) 35.0 (32.5–37.7)

22.3 (14.6–32.6) 18.2 (14.2–23.0)

13.1 (9.3–18.2) 13.5 (10.5–17.2)

29.8 (25.8–34.3)

8.1 (3.9–15.8)

14.2 (10.9–18.2)

47.5 (41.5–53.5)

11.3 (5.9–20.6)

14.5 (10.1–20.3)

34.1 (28.7–40.1)

14.3 (9.9–20.1)

15.5 (13.0–18.4)

28.2 (24.3–32.6)

18.2 (11.3–28.0)

15.4 (11.1–21.0)

22.3 (17.8–27.5)

16.5 (12.1–22.0)

15.1 (12.2–18.6)

29.0 (23.4–35.3) 31.0 (27.1–35.1) 26.0 (22.7–29.6) 23.0 (16.8–30.6)

15.9 (10.5–23.2) 15.0 (10.5–21.0) 18.8 (14.5–24.2) 27.3 (19.0–37.5)

7.7 (3.9–14.6) 13.6 (10.7–17.2) 17.4 (14.9–20.2) 14.0 (10.6–18.2)

36.8 (32.6–41.2)

12.6 (8.8–17.6)

19.5 (15.6–24.0)

34.5 (30.9–38.3)

14.2 (10.1–19.7)

17.9 (15.2–21.0)

29.2 (22.5–37.1) 34.2 (27.9–41.2)

26.7 (18.0–37.5) 14.2 (10.2–19.5)

17.5 (12.5–23.9) 20.0 (16.5–24.1)

43.5 (37.1–50.1)

15.2 (12.3–18.7)

19.3 (16.0–23.0)

41.8 (38.8–44.9)

18.9 (16.5–21.5)

20.5 (18.0–23.2)

30.0 (25.4–35.0)

13.5 (9.8–18.2)

15.9 (13.3–18.9)

46.0 (40.8–51.4)

11.4 (9.4–13.9)

18.7 (14.9–23.3)

39.4 (36.3–42.7)

15.7 (12.2–20.0)

16.8 (13.0–21.5)

40.0 (35.5–44.7)

18.1 (13.7–23.4)

13.9 (10.7–17.8)

1

Susceptibility, defined as the absence of a firm decision not to smoke, precedes the early experimentation stage of smoking onset. Smoking onset is generally agreed to be a time-dependent, four-level process that includes 1. preparation, 2. early experimentation 3. more advanced regular but non-daily smoking, and 4. a stable level of addiction The Global Tobacco Surveillance System Collaborating Group, 2005.

Mid West Region Campo Grande, 2002 Goiânia, 2002

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Statistical analysis A weighting factor was applied to each student record to adjust for nonresponse (by school, class, and student) and variation in the probability of selection at the school, class, and student levels. A final adjustment sums the weights by grade and gender to the population of school children in the selected grades in each sample site. SUDAAN (Warren et al., 2006), a software package for statistical analysis of correlated data, was used to compute standard errors of the estimates and produced 95% confidence intervals which are shown as lower and upper bounds. Comparisons across sites and over time were deemed statistically significant when 95% confidence intervals did not overlap. The Ethical Approval was obtained from the National Cancer Institute Ethic Committee (CEP/INCA) and National Ethic Committee (CONEP).

Results The school response rate was greater than 88% in all cities (except Palmas — 72%) and was 100% in nine sites. The student response rate ranged from 59% in Maceió to 92% in Curitiba (2006). Twenty-three studies were carried out between 2002 and 2005 in Brazilian capitals: 2002 (9); 2003 (4); 2004 (2) and 2005 (9). The total number of students enrolled was 22832. The GYTS data in this report included students from the following cities of the five geopolitical regions in Brazil: North Region-Belém (N = 655; 2005), Boa Vista (N = 1,072; 2003) and Palmas (N = 446; 2002 and N = 1,000; 2005); Northeast Region: São Luis (N = 788; 2003), Fortaleza (N = 493; 2002 and N = 1,141; 2005), Natal (N = 882; 2002 and N = 1,512; 2005), João Pessoa (N = 592; 2002 and N = 1,107; 2005), Maceió (N = 464; 2003), Aracaju (N = 703; 2002), Salvador (N = 793; 2004); Southeast Region: Vitória (N = 873; 2003), Cataguases (N = 709; 2005), Rio de Janeiro (N = 1,858; 2005); South Region: Curitiba (N = 1,161; 2002 and N = 2,433; 2005), Florianópolis (N = 1,298; 2004), Porto Alegre (N = 1,231; 2002); Mid West Region: Goiânia (N = 770; 2002) and Campo Grande (N = 851; 2002). Prevalence Lifetime cigarette smoking ranged from 22.3% in João Pessoa [2005] to 47.5% in Fortaleza [2002], (Table 1). Lifetime cigarette smoking was 40% and over in 4 of the 18 cities (Porto Alegre [2002], Fortaleza [2002], Curitiba [2002 and 2005], and Goiânia [2002]). Lifetime cigarette smoking significantly declined between 2002 and 2005 in Fortaleza, Natal and João Pessoa. Among ever smokers, early initiation of smoking (i.e., initiating smoking before age 10) was lowest in Aracaju (8.1%) and highest in Salvador (27.3%). Early initiation was over 20% in three other cities (Vitória, Boa Vista and Palmas). A series of questions were used to develop an index of likely initiation of smoking among never smokers (i.e., susceptibility). Among never smokers in Brazil, likely initiation was lowest in Maceió (7.7%) and highest in Curitiba (20.5% in 2005) and Cataguases (20.0%). The prevalence of current cigarette smoking was lowest in João Pessoa (6.2% in 2002) and Salvador (6.4%) and highest in Porto Alegre (17.7%) and Fortaleza (17.2% in 2002) (Table 2). Current cigarette smoking was less than 10% in 7 cities (Maceió, Aracaju, Vitória, Natal [2002 and 2005], João Pessoa [2005] and Salvador).

Table 2 Percent of students who were current cigarette smokers, current users of tobacco products other than cigarettes, and percent of current smokers who were dependent on tobacco products, Brazil GYTS 2002–2005 Regions/Cities

Current cigarette smoker

Currently use other tobacco products

Current cigarette smokers who feel like having a cigarette first thing in the morning

14.6 (9.6–21.6) 10.2 (8.1–12.8) 12.3 (7.8–18.9) 11.9 (9.2–15.2)

3.6 (2.3–5.6) 10.1 (6.3–15.7) 4.0 (2.2–7.3) 4.7 (2.9–7.6)

9.9 (2.7–30.6)

8.7 (6.2–11.9) 17.2 (11.9–24.1) 10.7 (42.1–74.9) 6.2 (4.2–9.2) 9.1 (6.3–12.9) 7.9 (5.2–11.7) 8.2 (6.2–10.7) 7.4 (5.6–9.6) 6.4 (4.4–9.3) 13.2 (10.0–17.2)

3.4 (2.1–5.7)

2.5 (0.4–14.7)

3.4 (2.2–5.3)

10.8 (7.1–16.0)

4.1 (2.8–5.9)

6.6 (1.9–20.3)

3.5 (2.1–5.9) 3.7 (2.4–5.6) 2.5 (1.0–5.8) 4.9 (3.3–7.1) 4.3 (3.3–5.7) 2.9 (1.9–4.4) 3.2 (1.9–5.6)

⁎ 15.9 (6.6–33.5) ⁎ 2.5 (0.3–16.1) 3.3 (0.8–13.4) ⁎ 3.3 (0.4–20.3)

12.3 (10.0–15.1) 8.2 (5.5–11.8) 12.5 (9.1–16.9)

6.1 (4.8–7.7)

5.8 (2.5–12.7)

6.7 (3.7–11.9) 5.6 (3.7–8.3)

⁎ 8.9 (5.1–15.0)

3.4 (2.6–4.2)

3.5 (1.2–10.2)

5.7 (4.7–6.8)

6.8 (3.8–11.7)

Florianópolis, 2004 Porto Alegre, 2002

12.6 (9.5–16.6) 13.7 (11.6–16.0) 10.7 (8.0–14.1) 17.7 (13.1–23.4)

4.2 (3.3–5.4)

4.0 (1.6–10.1)

6.0 (4.2–8.6)

23.8 (15.8–34.4)

Mid West Region Campo Grande, 2002 Goiânia, 2002

14.4 (12.2–16.9) 10.6 (8.1–13.8)

4.9 (3.6–6.8)

11.3 (4.8–24.3)

5.7 (3.6–9.0)

5.9 (1.2–23.9)

North Region Belém, 2005 Boa Vista, 2003 Palmas, 2002 Palmas, 2005

Northeast Region Aracaju, 2002 Fortaleza, 2002 Fortaleza, 2005 João Pessoa, 2002 João Pessoa, 2005 Maceió, 2003 Natal, 2002 Natal, 2005 Salvador, 2004 São Luis, 2003

Southeast Region Rio de Janeiro, 2005 Vitória, 2003 Cataguases, 2005

South Region Curitiba, 2002 Curitiba, 2005

12.2 (5.4–25.5) ⁎ 6.5 (2.3–17.1)

⁎ b35 cases in the denominator.

Use of other tobacco products was less than 5% in almost every city, except Boa Vista (10.1%) (Table 2). Tobacco dependency (i.e., feel like having a cigarette first thing in the morning) was less than 5% in 5 cities (Aracaju, Curitiba [2002], Florianópolis, Natal [2002 and 2005], and Sao Luis) and over 10% in 5 cities (Boa Vista, Fortaleza [2002], Campo Grande, Porto Alegre [23.8%, highest], and João Pessoa [2005]).

L.M. de Almeida et al. / Preventive Medicine 47 (2008) S4–S10 Table 3 Percent of students exposed to smoke at home, exposed to smoke in public places, and support ban on smoking in public places, Brazil GYTS 2002–2005 Regions/Cities

North Region Belém, 2005 Boa Vista, 2003 Palmas, 2002 Palmas, 2005 Northeast Region Aracaju, 2002 Fortaleza, 2002 Fortaleza, 2005 João Pessoa, 2002 João Pessoa, 2005 Maceió, 2003 Natal, 2002 Natal, 2005 Salvador, 2004 São Luis, 2003 Southeast Region Rio de Janeiro, 2005 Vitória, 2003 Cataguases, 2005 South Region Curitiba, 2002 Curitiba, 2005 Florianópolis, 2004 Porto Alegre, 2002 Mid West Region Campo Grande, 2002 Goiânia, 2002

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(41.9%) but over 60% in 3 cities (Curitiba [2002], Fortaleza [2002], and Porto Alegre [62.2%, highest]). Over 80% of students in all 18 cities thought smoking should be banned in public places, with the highest support (92.7%) in Salvador.

Exposed to smoking from others at home in the past 7 days

Exposed to Think smoking smoke in public should be banned places in the past in public places 7 days

31.8 (27.0–37.1) 34.8 (30.1–39.8)

46.5 (39.3–53.7) 46.0 (40.3–51.9)

85.5 (82.0–88.5) 84.2 (80.8–87.1)

Table 4 Percent of students who were taught dangers of smoking, discussed reasons why people their age use tobacco, or were taught effect of using tobacco, Brazil GYTS 2002–2005

36.5 (29.1–44.6) 32.4 (29.9–35.0)

49.8 (42.7–56.9) 42.3 (39.9–44.8)

89.6 (85.4–92.7) 89.1 (86.8–91.1)

Regions/Cities

31.1 (27.0–35.5)

51.3 (47.3–55.2)

87.1 (83.6–89.9)

44.9 (38.3–51.7)

61.0 (55.9–66.0)

87.1 (82.1–90.9)

34.9 (31.4–38.5)

52.1 (48.0–56.1)

86.6 (83.0–89.5)

33.6 (29.4–38.0)

47.8 (42.9–52.8)

88.3 (83.5–91.9)

30.2 (26.9–33.7) 37.4 (33.8–41.2) 36.9 (31.7–42.5) 31.1 (27.8–34.7) 20.4 (16.4–24.9)

45.1 (41.6–48.7) 50.6 (44.8–56.3) 43.0 (39.2–46.9) 45.7 (43.1–48.4) 41.9 (35.6–48.4)

89.5 (87.8–91.0) 88.8 (85.3–91.5) 87.7 (84.5–90.3) 89.3 (86.9–91.3) 92.7 (89.6–94.9)

29.6 (25.6–34.0)

46.0 (43.4–48.6)

85.5 (80.9–89.2)

35.0 (31.2–39.0)

50.0 (47.2–52.8)

86.8 (83.8–89.3)

27.8 (23.9–32.2) 37.2 (30.6–44.4)

49.5 (46.2–52.8) 52.8 (46.1–59.3)

86.8 (83.8–89.3) 86.2 (81.9–89.6)

40.4 (35.9–45.1)

60.3 (55.1–65.4)

84.2 (80.4–87.4)

39.6 (37.5–41.8)

55.3 (53.1–57.5)

85.1 (83.1–86.8)

38.4 (34.6–42.4) 48.2 (43.6–52.8)

53.6 (50.5–56.7) 62.2 (57.2–66.8)

85.3 (83.1–87.2) 83.3 (81.0–85.4)

40.6 (35.3–46.2)

53.3 (48.6–57.9)

88.1 (84.9–90.6)

34.7 (29.4–40.4)

50.7 (46.4–55.0)

86.2 (81.7–89.7)

There was no significant change over time in any of the five cities that repeated the survey in the prevalence of lifetime or current use of cigarettes or other tobacco forms, with the exception of Fortaleza. In this city lifetime prevalence decreased significantly. Exposure to Secondhand Smoke (SHS) Exposure to SHS at home was lowest in Salvador (20.4%) but greater than 40% in 4 cities (Curitiba [2002], Fortaleza [2002], Campo Grande, and Porto Alegre [48.2%, highest]) (Table 3). Exposure to SHS in public places was lowest in Salvador

North Region Belém, 2005 Boa Vista, 2003 Palmas, 2002 Palmas, 2005 Northeast Region Aracaju, 2002 Fortaleza, 2002 Fortaleza, 2005 João Pessoa, 2002 João Pessoa, 2005 Maceió, 2003 Natal, 2002 Natal, 2005 Salvador, 2004 São Luis, 2003 Southeast Region Rio de Janeiro, 2005 Vitória, 2003 Cataguases, 2005 South Region Curitiba, 2002 Curitiba, 2005 Florianópolis, 2004 Porto Alegre, 2002 Mid West Region Campo Grande, 2002 Goiânia, 2002

At school during the past year, taught dangers of smoking tobacco

At school during the past year, discussed reasons why people their age smoke

At school during the past year, taught about the effects of smoking

38.0 (29.2–47.6) 47.7 (42.3–53.2)

21.3 (15.5–28.5) 30.5 (25.3–36.2)

33.7 (26.2–42.2) 44.4 (39.0–49.8)

69.5 (58.8–78.4) 44.4 (40.7–48.1)

45.4 (40.9–49.9) 27.6 (24.9–30.6)

58.4 (51.8–64.8) 42.2 (37.4–47.2)

52.8 (41.7–63.7)

31.2 (20.1–44.9)

44.1 (33.5–55.3)

58.9 (52.0–65.5)

38.5 (31.3–46.1)

54.0 (44.8–62.9)

44.0 (36.0–52.4)

27.1 (20.0–35.6)

41.0 (32.6–50.0)

53.8 (46.1–61.3)

34.6 (28.2–41.6)

44.3 (37.8–51.0)

34.6 (30.8–38.6)

19.9 (15.8–24.7)

31.9 (27.3–36.9)

41.6 (34.7–48.9) 51.0 (43.3–58.7) 43.5 (35.0–52.4) 40.0 (31.3–49.4)

22.2 (16.5–29.1) 29.7 (22.9–37.5) 23.5 (17.8–30.3) 21.5 (15.9–28.3)

33.9 (27.7–40.6) 41.3 (33.9–49.1) 38.9 (31.8–46.4) 35.4 (26.4–45.6)

54.4 (44.5–63.9)

35.6 (28.5–43.4)

47.0 (39.6–54.6)

37.9 (33.4–42.7)

21.1 (18.1–24.4)

34.3 (29.4–39.5)

52.6 (43.6–61.5) 59.7 (48.7–69.8)

32.4 (25.1–40.7) 36.9 (29.5–44.9)

46.0 (37.6–54.7) 55.6 (46.3–64.5)

57.0 (47.2–66.4)

33.1 (24.1–43.5)

49.5 (40.5–58.6)

44.6 (38.2–51.2)

24.8 (21.4–28.5)

41.1 (35.8–46.7)

35.5 (30.6–40.6)

14.4 (12.0–17.2)

25.4 (20.9–30.4)

53.6 (46.2–60.9)

37.3 (28.7–46.8)

49.8 (42.9–56.6)

61.3 (57.3–65.2)

33.5 (28.8–38.4)

50.3 (45.0–55.6)

56.7 (49.2–63.9)

32.8 (26.9–39.2)

47.8 (40.6–55.2)

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Table 5 Percent of students who saw ads on billboards, saw ads in newspapers or magazines, and those offered free cigarettes by a tobacco company representative, Brazil GYTS 2002–2005 Regions / Cities

North Region Belém, 2005

Saw ads for cigarettes on billboards in the past month

Ever been offered “free” cigarettes by a cigarette company representative

Taught in School about the Tobacco Students were asked if, during the past school year in classes, they had been taught about the dangers of tobacco, discussed the reasons why young people smoke, or if they had been taught about the effects of tobacco on their health (Table 4). Less than 40% of students had been taught in 4 cities (Florianópolis, Rio de Janeiro, João Pessoa [2005] and Belém) and but over 60% had been taught in 2 cities (Campo Grande and Palmas [2002, 69.5%, highest]). Less than 20% of students had discussed reasons why young people use tobacco in 2 cities (Florianópolis and João Pessoa [2005]) compared to 45.4% in Palmas (2002). Less than 30% of students had these lessons on the effects of smoking in Florianópolis (25.4%) but over 50% in 4 cities had lessons on this topic (Cataguases, Fortaleza [2002], Campo Grande, and Palmas [2002, 58.4%, highest]). Youth in two cities, Palmas and Joao Pessoa, reported a significant decrease in exposure at school to teachings of tobacco harms, to discussing reasons to smoke and the effects of smoking. The other three that repeated the survey did not report any changes.

47.9 (43.6–52.3)

9.8 (7.4–13.0)

60.5 (57.2–63.8)

12.5 (9.7–15.9)

53.8 (48.2–59.3)

9.4 (5.2–16.3)

40.7 (36.6–45.0)

9.3 (7.6–11.4)

78.7 (75.6–81.5) 78.5 (73.1–83.0) 65.8 (59.5–71.5) 80.2 (76.6–83.3) 68.7 (65.6–71.6) 80.7 (76.5–84.3) 77.7 (75.1–80.2) 64.4 (61.0–67.7) 60.6 (55.2–65.6) 83.5 (81.4–85.4)

60.0 (55.5–64.4)

6.6 (3.9–11.0)

60.8 (53.7–67.4)

11.3 (7.8–16.0)

50.2 (46.7–53.7)

7.4 (6.3–8.7)

56.1 (50.8–61.2)

6.6 (4.6–9.3)

47.1 (44.2–50.0)

8.5 (6.4–11.2)

60.0 (54.2–65.5)

5.9 (3.6–9.3)

58.5 (53.3–63.6)

5.3 (3.6–7.8)

46.9 (44.4–49.5)

5.8 (4.5–7.5)

46.4 (42.5–50.4)

3.7 (2.6–5.3)

61.7 (58.4–64.9)

8.2 (6.7–10.0)

53.7 (50.4–56.8)

7.4 (5.8–9.3)

58.2 (53.2–63.1)

9.4 (6.4–13.6)

Cataguases, 2005

71.1 (68.3–73.9) 73.4 (68.0–78.2) 64.3 (58.0–70.1)

43.1 (39.4–46.8)

8.8 (6.7–11.4)

South Region Curitiba, 2002 Curitiba, 2005 Florianópolis, 2004 Porto Alegre, 2002

84.4 (81.4–87.1) 70.3 (68.4–72.1) 76.4 (73.3–79.2) 88.0 (86.6–89.3)

70.3 (66.7–73.8)

8.0 (6.2–10.3)

52.8 (51.0–54.7)

8.7 (6.7–11.4)

56.7 (54.0–59.3)

6.6 (5.3–8.2)

Exposure to advertisements on billboards was lowest in Salvador (60.6%) and highest in Porto Alegre (88.0%) (Table 5). Exposure to advertisements on billboards was greater than 80% in 6 cities (Maceió, Goiania, Campo Grande, João Pessoa [2002], Porto Alegre, Curitiba [2002] and São Luis). Exposure to pro-tobacco advertisements in newspapers or magazines was lowest in Palmas (2005, 40.7%) and highest in Porto Alegre (71.9%) (Table 5). Exposure to tobacco ads on billboards and print media significantly declined in all five cities that repeated the survey, except in Palmas where the decrease in exposure to ads on billboards was barely non-significant. Students were asked if a tobacco company representative had offered them “free” cigarettes at any time. Having been offered “free” cigarettes was lowest in Salvador (3.7%) and highest in Boa Vista (12.5%). There was no significant change over time in offering of free cigarettes in any of the surveyed sites between 2002 and 2005 (Table 5).

71.9 (69.0–74.6)

9.4 (7.2–12.2)

Discussion

Boa Vista, 2003 Palmas, 2002 Palmas, 2005

Northeast Region Aracaju, 2002 Fortaleza, 2002 Fortaleza, 2005 João Pessoa, 2002 João Pessoa, 2005 Maceió, 2003 Natal, 2002 Natal, 2005 Salvador, 2004 São Luis, 2003 Southeast Region Rio de Janeiro, 2005 Vitória, 2003

Mid West Region Campo Grande, 2002 Goiânia, 2002

66.8 (62.9–70.5) 71.9 (67.7–75.8) 73.1 (65.6–79.4) 62.0 (58.0–65.8)

Saw ads for cigarettes in newspapers or magazines in the past month

There was no significant change over time in any of the five cities that repeated the survey in the prevalence of exposure to SHS at home or in public places. However, Fortaleza experiences a decrease in exposure to SHS that bordered statistically significance. Support to smoking bans remained high but unchanged between 2002 and 2005.

Media and advertising exposure

80.4 (77.7–82.8)

67.0 (62.9–71.0)

6.2 (4.6–8.3)

82.6 (79.9–84.9)

65.3 (61.6–68.9)

9.0 (7.6–10.5)

Article 20 of the WHO FCTC calls for countries to use consistent methods and procedures in their surveillance efforts. All GYTS surveys use exactly the same sampling procedures, core questionnaire items, training in field procedures. Therefore the analysis of data is consistent and comparable across all survey sites and over time. For the first time in Brazil, it is

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possible to compare data on prevalence, exposure to secondhand smoke, school-based tobacco control, cessation, media and advertising, and minor's access and availability across 18 sites and it is possible to measure changes over time in five of them. In terms of tobacco use, Brazil is a diverse country and having data for 18 cities can ensure a focused the national and also the regional tobacco control strategy. The data in this report show current cigarette smoking ranges from 6% to over 17%. Current use of other tobacco products ranges from less than 5% in 14 cities to over 10% in Boa Vista. The proportion of young initiating the tobacco use before 10 years old was more then 10% in the majority of studies and more then 20% in four cities. A survey carried out by the Brazilian Center of Information on Psychotropic Drugs (CEBRID, 1997) showed that tobacco initiation occurs early in the life of public school students in 10 Brazilian cities1: by age 12, about 11.6% had already tried smoking. A very significant proportion of young smokers wants to stop smoking but of those who tried over 70% failed. This is an indication of how addictive tobacco can be little after young people start to smoke. There are many social and individuals aspects those influences people to smoke. Young people are strongly influenced by social factors, probably, more than individual factors. Brazil law regarding tobacco control has just included cessation program in the public health system, but these services are available only for adults. This situation suggests a need to develop, pilot test, and evaluate potential youth cessation approaches. Once effective programs have been identified, they need to be made widely available throughout Brazil. Despite all efforts in Brazil, the GYTS data shows that the prevalence of current tobacco use has not decreased and that no increase in willingness to quit or in successful quitting was observed between 2002 and 2005. This absence of changes presents challenges and requires careful planning by the Ministry of Health and others sectors of government at the central and city levels. GYTS data show a high proportion for kids that buy their tobacco in stores and they are seldom refused purchase because of their age. This situation has not changed between 2002 and 2005, despite the fact that since (2003) Brazil has a law prohibiting the sale of tobacco products to minors (Law no. 10.702). Given the geographic size of Brazil and the large number and variety of points of sale locating, enforcement of this law has been limited. This situation suggests that a more efficient approach may be to limit points of sales to only a few types of store and also to develop a strong educative campaign targeting the sellers. In 1998, the NTCP developed and began implementing a school based program, Saber Saúde (Warren et al., 2000). This program promotes healthy life styles among adolescents including the health consequences on smoking. Saber Saúde program includes teacher training on the use of curricula and material during classroom instruction and special activities in the schools. Teachers are trained to focus different aspects of social determinants that induce unhealthy behaviors, to stimulate a critical view of this social dynamics among students and also to transform the school into an environment that reinforces the adoption of healthy choices. As of the end of the current school year, only 6%

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(13.379 units) of public schools has been reached within a period of 8 years of development of this program. Nevertheless, approximately half of the students in 10 of the 18 cities reported that during the past school year they had been taught about the dangers of smoking but less than one third of the students in 15 of the 18 cities reported they had discussed reasons why people their age smoke. Considering that there is still a low coverage of the formal school based program for smoking prevention (“Saber Saúde”) in Brazil, and the fact that the question of GYTS doesn’t differentiate schools that are implementing formal school based program from the one that are not, this result may reflect an spontaneous initiative of schools, probably as a consequence of a set of interventions for tobacco control that are in place in Brazil. In this regard, it is important to mention that some schools, even not having implemented a formal school based program for smoking prevention, have already adopted didactic books introducing this issue. Some schools have also developed focal actions such campaigns as World No Tobacco Days, and National Tobacco Control Day. By the other hand, all cities that repeated the survey showed a decrease in the approach of tobacco issues at school, but only two cities reported a statistically significant difference. These results need a more in depth evaluation because it can reflect a decrease in the Federal Government support to states to keep on the set of intervention in local level. These data show that renewed effort needs to be done to achieve the objectives set by article 12 of the WHO FCTC on education, communication, training and public awareness. However, education and information should walk together with legislation because they reinforce each other. Article 12 is an important step to form a critical mass that, from its turn, is important to push strong legislation for tobacco control as well its implementation. And the implementation of legislation will be a tool to educate people, to reduce social stimulus for smoking and to change the social acceptability. Exposure to Second Hand Smoking (SHS) is high in Brazil. Over half of the students in 10 of the 18 cities reported that they were exposed to smoke in public places while over 80% think smoking should be banned in public places. In 1996, a Federal Law no. 9294 was passed in Brazil that restricts smoking in all indoors-public places but allows smoking areas (World Health Organization, 2003). The enforcement of this legislation depends on each municipality passing complementary legislation thus providing authority for inspecting the compliance in public places and applying penalties for the infractions. In addition, the Brazilian National Tobacco Control Program (NCTP) has been working to disseminate information nationwide on the risks of passive smoking and to promote smoke-free environments at schools, workplaces and health units with the support of a network formed by health office of the cities and municipalities. The media and civil society organizations have also been very supportive of this network. In this regard, the finding of high support for banning smoking in public places among the students can reflect the high level of awareness on the risks of passive smoking as a result of the national educative process developed by NTCP. Further, the high level of secondhand

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smoke exposure reported and the absence of changes over time in the level of exposure may reflect the still low level of enforcement of the legislation by municipalities. Furthermore, it is unlikely that this proportion will decrease unless all workplaces become totally smoke free. Exposure to pro-cigarette messages on billboards was over 80% in 6 of the 18 cities. Exposure to pro-cigarette advertisements in newspapers or magazines was over 60% in 7 of the 18 cities. However, all five cities that repeated the survey experienced reductions in exposure to tobacco ads on billboards and print media between 2002 and 2005. This is indeed a good sign that the legislation passed in Brazil restricting tobacco promotion is beginning to work. Three legislative acts have been passed in Brazil banning advertising and promotion of tobacco products. In December 2000, Brazil passed legislation banning advertising and promotion tobacco on the main mass media such as TV, radio, outdoors, magazines, and newspapers (World Health Organization, 2003). But, the enforcement of the ban of sponsorship of art and sport international events by tobacco products, when it takes place in Brazil, was scheduled to start in 2003. But, in 2003 due to F1 race organization pressure this ban enforcement was delayed to September 2005. Points of sale locations were excluded from the bans on advertising. Thus, there is still a high exposure to pro-cigarette messages through posters inside of these points of sale locations. Tobacco sales points are highly disseminated in many stores such as bakeries, newsstand, supermarkets, snack bars, gas stations, shopping and others, which could be a confounding factor inducing some students to report still seeing tobacco advertising in magazines, and newspapers. No changes in tobacco consumption prevalence and exposure to SHS were observed between 2002 and 2005 in the five cities that repeated the survey. However, exposure to tobacco advertising was decreased very likely as a result of the restrictive legislation approved in Brazil. During the last 15 years, the Brazilian government has been promoting a national network for disseminating knowledge on harmful effects of tobacco and mobilizing tobacco control efforts through capacity building and development of partnerships with health offices of cities and municipalities, media, and civil society organizations. This movement has created a national critical mass and a social environment supportive of strong improvements in the NCTP national legislation for tobacco control. Most of the original provisions of the NCTP have already been implemented or will be implemented in the near future. However, some of these provisions need to be enhanced or redirected to new ways, using GYTS data as one source of feedback to identify unmet goals. Perhaps efforts to create smoke free environments in public places and workplaces should be renewed. Some limitations of this study may be considered. Probably, the no significant changes over time in any of the five cities that repeated the survey are associated to the short period between the first and the second rounds. The comparisons among the Brazilian capitals are more appropriated only among that the surveys conducted at the same year, although the changes are not expected in short periods.

The youth tobacco use initiation susceptibility cannot measured only in a quantitative form. The qualitative approaches are more appropriated for this. Finally, the role of the GYTS as evaluation instrument should be highlighted. Developing an effective comprehensive tobacco control program requires careful monitoring and evaluation of existing programs and the likely development of new efforts. Data from the GYTS can be used to evaluate the efforts already done and also as baseline data for future evaluation of new steps for tobacco control to be implemented by the Ministry of Health and other sectors of government toward achieving the goals of the WHO FCTC. Data from this survey will enhance the capacity of Brazil and these cities to develop, implement, and evaluate effective tobacco control programs. Conflict of interest The authors have no conflict of interest to declare.

Acknowledgments This study was partially supported by a grant from Pan American Health Organization and CDC/USA. We also sincerely thank to the Brazilian State Health Secretaries, Brazilian State Education Secretaries, all the enrolled schools, teachers, students (and their parents) who contributed with many ways for the good result of this survey. Financial Support: CDC/ USA; OPAS; INCA/MS and the Brazilian State Health Secretaries.

References CEBRID (Centro Brasileiro de Informações sobre Drogas Psicotrópicas), UFSP (Universidade Federal de São Paulo), EPM (Escola Paulista de Medicina e Departamento de Psicobiologia), 1997. lV Levantamento sobre o uso dedrogas entre estudantes de 1° e 2 ° graus em 10 capitais brasileiras., F.J.C., Noto, A.R. UFSP/CEBRID/EPM, São Paulo, p. 130. GYTS — Global Youth Tobacco Survey: Facts and sheets from 12 Brazilian capitals, Vol.1. In: http://www.inca.gov.br/vigescola/docs/vigescola_ingles. pdf (17/06/2006). Ministério da Saúde do Brasil, 1999. Instituto Nacional de Câncer (INCA). Implantando o Programa Saber Saúde de Controle do Tabagismo e Outros Fatores de Risco de Câncer nas Escolas, Rio de Janeiro. Pierce, J.P., Choi, W.S., Gilpin, E.A., Farkas, A.J., Merritt, R.K., 1996. Validation of susceptibility as a predictor of which adolescents take up smoking in the United Cities. Health Psychol. 15 (5), 355–361. The Global Tobacco Surveillance System Collaborating Group, 2005. The global tobacco surveillance system (GTSS): purpose, production and potential. J. Sch. Health 75 (1), 15–24. Warren, C.W., Jones, N.R., Eriksen, M.P., Asma, S., 2006. Patterns of global tobacco use among young people and implications for future chronic disease burden in adults. Lancet 367, 749–753. Warren, C.W., Riley, L., Asma, S., et al., 2000. Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey Project. Bull WHO 78, 868–876. World Health Organization, 2003. WHO Framework Convention on Tobacco Control. World Health Organization, Geneva. Available at http://www.who. int/tobacco/framework.