Changes in Tobacco Use Among Youths Aged 13--15 Years --- Panama, 2002 and 2008

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Tobacco use is the single most preventable cause of death in the world today (1), and the majority of smokers begin using tobacco products before age 18 years (2). However, before the late 1990s, few countries had reliable data on youth tobacco use. In 1999, the World Health Organization (WHO), CDC, and the Canadian Public Health Association developed the Global Youth Tobacco Survey (GYTS) to help countries monitor youth tobacco use (3). At the same time, WHO initiated the Framework Convention on Tobacco Control (WHO FCTC), the first international public health treaty on tobacco control (4). Panama ratified WHO FCTC in 2004 and enacted two key antitobacco regulations in 2005 and 2008. To evaluate progress toward attaining tobacco control goals in Panama, Panama's Ministry of Health, CDC, and WHO compared results from GYTS surveys conducted in Panama in 2002 and 2008. This report summarizes the results of that comparison, which revealed substantial decreases from 2002 to 2008 in youth current cigarette smoking (13.2% versus 4.3%), current use of tobacco products other than cigarettes (9.8% versus 5.8%), and likely initiation of smoking by never smokers (13.8% versus 10.0%). In addition, factors influencing tobacco use showed substantial decreases, including 1) exposure to secondhand smoke (SHS) at home and in public places, 2) best friends smoking, 3) protobacco advertising in newspapers and magazines, and 4) having an object with a tobacco company logo on it. These results suggest that comprehensive regulations in Panama helped reduce tobacco use among adolescents and further gains are possible.

GYTS is a school-based survey that collects data from students aged 13--15 years and has been completed in 163 countries, with repeat surveys in 100 countries. GYTS uses a two-stage cluster sample design that produces representative samples of students in grades associated with students aged 13--15 years (3). GYTS uses a standardized methodology for constructing sampling frames, selecting schools and classes, preparing questionnaires, conducting field procedures, and processing data. At the first stage, the probability of schools being selected is proportional to the number of students enrolled in the specific grades. At the second sampling stage, classes within the selected schools are randomly selected. All enrolled students in selected classes the day the survey is administered are eligible to participate. Student participation is voluntary and kept anonymous by using self-administered data collection procedures.

GYTS was conducted in Panama in 2002 and 2008. In both years, GYTS sampling included all public and private schools with grades 8--10. In 2002, a total of 2,017 students completed the Panama GYTS from 50 selected schools. Of these students, 1,296 indicated that they were aged 13--15 years. In 2008, a total of 3,534 students completed the Panama GYTS from 50 selected schools, of whom 2,716 indicated that they were aged 13--15 years. The school response rate (number of participating schools divided by the number of selected schools) was 98.0% in 2002 and 96.0% in 2008; the class response rate (number of participating classes divided by the number of selected classes) was 100.0% in 2002 and 99.3% in 2008; the student response rate (number of participating students divided by the number of students enrolled in the class) was 89.1% in 2002 and 83.9% in 2008; and the overall response rate (product of the school response rate, the class response rate, and the student response rate) was 87.3% and 80.0%, respectively.

This report summarizes the results from 10 key GYTS tobacco-use indicators: 1) current cigarette smoking; 2) current use of tobacco products other than cigarettes; 3) likely initiation of cigarette smoking in the next year among never smokers (i.e., susceptibility) (5); 4) exposure to SHS at home and in public places; 5) one or more best friends smoke cigarettes; 6) in favor of banning cigarette smoking in public places; 7) exposure to protobacco advertising in newspapers and magazines, having protobacco promotional items, having been offered free cigarettes, and exposure to antitobacco media messages; 8) among current cigarette smokers, the desire to stop smoking; 9) among current cigarette smokers, those who bought their cigarettes in a store and were not refused the purchase because of their age; and 10) students who were taught in school about the dangers of smoking.* T-tests were used to determine differences between subpopulations (6). Differences between prevalence estimates were considered statistically significant at p<0.05.

From 2002 to 2008, prevalence of current cigarette smoking among students aged 13--15 years in Panama decreased 60% for boys, 75% for girls, and 67% overall (from 13.2% to 4.3%) (Table 1). The level of current cigarette smoking in 2002 and in 2008 did not differ by sex. Current use of other tobacco products decreased 41% overall from 2002 (9.8%) to 2008 (5.8%). The percentage of never smokers who were susceptible to initiation of smoking decreased 43% from 2002 to 2008 for girls (from 14.5% to 8.3%).

From 2002 to 2008, the percentage of students who reported exposure to SHS decreased 32% at home (from 32.0% to 21.9%) and 22% in public places (from 51.8% to 40.3%); and the percentage of students whose best friends smoke decreased 58% (from 14.5% to 6.1%) (Table 2). Support among students aged 13--15 years for a ban on smoking in public places increased 12% from 2002 (80.5%) to 2008 (89.9%).

The percentage of students who saw protobacco advertisements in newspapers or magazines decreased 16% (from 67.4% in 2002 to 56.7% in 2008) (Table 2). The percentage of students who owned an item with a tobacco logo on it decreased 47% from 2002 to 2008 (from 12.0% to 6.4%). The percentage of students reporting having been offered free cigarettes by a tobacco company representative did not change significantly over time (8.1% in 2002 and 5.9% in 2008). The percentage of students who saw antismoking mass media messages increased 7% from 2002 to 2008 (from 77.3% to 82.5%). The percentage of current smokers who wanted to stop smoking did not change over time, nor did the percentage of smokers who bought their cigarettes in a store and were not refused purchase because of their age. The percentage of students who were taught in school regarding the dangers of smoking also did not change over time.

Reported by: R Roa, MD, Ministry of Health, Panama. R Franklin-Peroune, World Health Organization, Pan American Health Organization. NR Jones, PhD, Univ of Wisconsin-Madison. CW Warren, PhD, J Lee, MPH, V Lea, MPH, A Goding, MSPH, S Asma, DDS, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

The findings in this report indicate that cigarette smoking, other tobacco use, and the likely initiation of smoking in the next year by never smokers declined substantially among Panama youths from 2002 to 2008. The Panama Ministry of Health has made tobacco control a priority and has established a national tobacco control agency (1). Panama is one of four Latin American countries (along with Bolivia, Costa Rica, and Paraguay) that has reported a significant decrease in adolescent tobacco use since 1999 (CDC, unpublished data, 2008). In all four countries, the enactment of antitobacco laws and regulations have proven important in leading to this behavior change among adolescents.

WHO notes that reductions in tobacco use most often are the result of measures such as 1) raising taxes on tobacco, 2) banning advertising promotion and sponsorship, 3) reducing exposure of the population to SHS, 4) informing the public regarding the dangers of tobacco, and 5) establishing tobacco cessation programs (1). Certain of the results in this report (e.g., significant declines from 2002 to 2008 in exposure to SHS at home and in public places, best friends smoking, having seen protobacco advertisements in newspapers and magazines, and having an object with a tobacco company logo on it) likely resulted from enactment of regulations in Panama in 2005 and 2008: the Ministry decree and Law No. 13.^§ The 2005 Ministry decree required health warnings on all tobacco product packages, banned the sale of individual cigarettes, prohibited use of vending machines for cigarettes, and banned protobacco advertising on billboards. The 2005 decree is believed to have had limited effect because of moderate enforcement (1). In January 2008, Panama adopted Law No. 13, which intensified tobacco control measures by banning protobacco statements on cigarette packages; requiring complete prohibition of any form of protobacco advertising, promotion, or sponsorship of all kinds in all venues, including sports venues; prohibiting tobacco consumption in all enclosed work environments; and requiring the integration of content on the health consequences of tobacco consumption into the curricula of general education and basic secondary education. Law No. 13 also included policies and penalties for violations of the law and its regulations. The 2008 GYTS was conducted in June, only 6 months after the law went into force in January; thus the results likely do not fully reflect the effects of Law No.13.

The findings in this report are subject to at least three limitations. First, because the sample surveyed was limited to youths attending school, they might not be representative of all persons age 13--15 years in Panama. Ministry of Education data by age show that 85% of youths aged 13 years, 80% of youths aged 14 years, and 69% of youths aged 15 years are enrolled in school (R. Roa, Panama Ministry of Health, personal communication, 2008). Second, these data apply only to youths who were in school the day the survey was administered and completed the survey. However, student response was 89% in 2002 and 85% in 2008, suggesting minimal bias resulting from absence or nonresponse. Finally, data are based on self-reports of students, which might result in underreporting or overreporting of tobacco use. However, responses to tobacco questions on surveys similar to GYTS have shown good test-retest reliability in the United States (7).

The ideal goal in Panama, as for all countries that ratify the WHO FCTC, is zero tobacco use among adolescents. To attain this goal, Panama's Ministry of Health should continue to make youth tobacco use prevention a programmatic priority and broaden the program to include excise tax increases, a complete ban on smoking in all indoor work places, and a complete ban on protobacco advertising. Repeating the GYTS in the future will be important for tracking the trend in adolescent tobacco use in Panama and monitoring the effect of the obligations of WHO FCTC.

References

* Results are based on specific responses to the following questions: 1) A response of "1 or more days" to the question, "During the past 30 days on how many days did you smoke cigarettes?" 2) A positive response to the question, "During the past 30 days did you smoke any tobacco product other than cigarettes?" 3) A negative response to the question, "Have you ever tried or experimented with cigarette smoking, even one or two puffs?" and a response of anything but "definitely no" to the questions, "If one of your best friends offered you a cigarette, would you smoke it?" and "Do you think you will try smoking a cigarette in the next year?" 4) A response of "1 or more days" to the questions: "During the past 7 days, on how many days have people smoked in your presence in your home?" and "During the past 7 days, on how many days have people smoked in your presence, in places other than your home?" 5) A response of "most" or "all" to the question, "Do most or all of your best friends smoke?" 6) A positive response to the question, "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?)" 7) A response of "a lot" or "a few" to the questions, "During the past 30 days (1 month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines?" and "During the past 30 days (1 month), how many anti-smoking media messages (e.g. television, radio, billboards, posters, newspapers, magazines, movies, drama) have you seen or heard," and a positive response to the questions, "Do you have something (T-shirt, pen, backpack, etc.) with a cigarette brand logo on it?" or "Has a cigarette company representative ever offered you a free cigarette?" 8) For current cigarette smokers, a positive response to the question, "Do you want to stop smoking now?" 9) For current cigarette smokers, a response of "bought them in a store" to the question, "During the past 30 days, how did you usually get your own cigarettes?" and a negative response to the question, "During the past 30 days, did anyone ever refuse to sell you cigarettes because of your age?" 10) A positive response to the question, "During this school year, were you taught in any of your classes about the dangers of smoking?"

Measures for preventing and reducing the consumption of tobacco and exposure to smoke from tobacco, because of its harmful effects on people's health [Spanish]. Executive Decree No. 17 (March 17, 2005). Republic of Panama. Official Gazette No. 25262; March 22, 2005.

^§ Measures for control of tobacco and its adverse health effects [Spanish]. Law No. 13 (January 13, 2008). Republic of Panama. Digital Official Gazette No. 25966; January 25, 2008.

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