—from Epidemiological Bulletin, Vol. 23 No. 2, June 2002—

The Global Youth Tobacco Survey: Results in the Americas

Introduction
The Global Youth Tobacco Survey (GYTS) was developed by the Tobacco Free Initiative of the World Health Organization (WHO), in collaboration with the Office on Smoking and Health (OSH) of the United States’ Centers for Disease Control and Prevention (CDC). The Pan American Health Organization has assisted in the survey’s application in Latin America and the English-speaking Caribbean.

The objectives of this survey are to measure the prevalence of tobacco use, exposure to environmental tobacco smoke, knowledge and attitudes, and factors that make youth susceptible to tobacco use. During 1999, 2000, and 2001, information was gathered from 23 countries within the Americas (12 from the Caribbean, 10 from Latin America, and the United States). In some of these countries, data were obtained from different geographical aggregation levels, which explains why the following analysis is based on results from 33 areas.

The methodology used for the survey is presented in the following web site: http://www.cdc.gov/tobacco/global/gyts/GYTS_intro.htm, and may also be found in the Epidemiological Bulletin 2001;22(2):12-14. A description of the current state of execution may be consulted in the following web page: http://www.cdc.gov/tobacco/global/gyts/GYTS_factsheets.htm. Some results of the survey in the Region of the Americas are presented below.

In some countries, 40% of adolescents smoke
Nearly 40% of the young people surveyed smoke regularly in Chile, which is the country with the highest prevalence of smoking among adolescents 13 to 15 years old. In 19 of the 33 areas surveyed, more than 20% of adolescents currently smoke, too high a proportion for an age group (13-15 years) at which tobacco consumption barely starts. After the Southern Cone, the Andean Area presents the second highest smoking prevalence, followed by the United States, Costa Rica, Mexico, the Latin Caribbean and the English-speaking Caribbean (Table 1).

Adolescents who do not currently smoke but who say they will probably initiate tobacco consumption shortly should be added to those who currently smoke. In some areas of the Andean Area and the Southern Cone, at least one fourth of young non smokers intends to start smoking soon, while in the Caribbean a little more than one tenth of young people intends to follow the steps of their Latin American counterparts. In the majority of the areas surveyed (20 out of 31 with information available), at least 1 out of 6 adolescents who currently do not smoke said they intend to start some time during the following year. Both current smokers and those who intend to begin smoking soon could become experimental smokers who will quit smoking once they pass adolescence. However, the data on those who attempt to quit smoking are not very encouraging.

More than half have attempted to quit smoking without success
In 27 of the 30 areas with available data, more than half the young smokers want to quit smoking. In some areas of the Southern Cone, somewhat less than half want to stop smoking. However, the results show that in some areas of the Andean Area and in the Caribbean in general, 3 out of 4 young smokers want to quit smoking (Table 2).

In all the countries and areas surveyed, more than half of the adolescents who smoke have attempted to quit smoking over the last year unsuccessfully. This is one further evidence of the addictive power of tobacco, even among people with a short history of smoking. In addition, the proportion of smokers who have attempted to quit smoking vary by subregion. In some areas of Peru and the Caribbean, around three quarters of young smokers have attempted to quit, while this proportion is reduced to less than 60% in the United States, Mexico, and most of the Southern Cone.

The reasons for a youth to start or quit smoking are complex. Between 10 and 35% of those surveyed declare that they believe smokers have more friends (this figure is slightly reduced in the case of young women). Nevertheless, the scientific literature has demonstrated that a powerful factor in smoking initiation is the influence of both direct and indirect promotion of tobacco products.

Adolescents are massively subjected to tobacco advertising
Logically enough, countries with higher prevalence of young smokers are those where adolescents are more exposed to the influence of direct publicity both on billboards and in written media. In the Southern Cone, almost 9 out of 10 youths are exposed to tobacco promotion on billboards and 8 out of 10 to advertisements in printed publications. A similar situation exists in Bolivia, Costa Rica, and Mexico. It is also the same in the United States, although the data are only available for messages in the written media. The situation of young people in the rest of the countries of the Americas is not much better. In all these countries, at least half of young people 13 to 15 years of age are exposed to direct publicity by tobacco companies.

These data show that adolescents are massively subjected to publicity and promotion on the part of the tobacco industry. Even assuming that this industry does not deliberately seek to target them, the data indicate the difficulty of excluding young people from the audiences to which the publicity is directed. As a result, measures that only allow publicity directed to adults are inherently ineffective in protecting youth. However, the data contributed by this survey makes it clear that the tobacco industry actively tries to target adolescents. Despite their own standards against this type of business practice, between 10 and 20% of the under 16 have received free cigarette offers from industry representatives in most of the countries of the Americas. It is important to point out that in Montevideo, 22% of young people have been the subject of this aggressive business practice. Youth in this Uruguayan city are also the most exposed to billboard publicity. As a result of aggressive commercial practices, in most countries of the Americas at least 1 in 7 youths owns advertising items with the name or logo of a tobacco brand. Most of these items can only be obtained directly from the companies themselves.

Lack of compliance with legislation on minor’s access to tobacco in all the countries
The few existing legal restrictions imposed on tobacco companies to protect adolescents from the pressures of the industry are not implemented in many cases. The best example is the selling of tobacco to minors. While in the United States less than 10% of adolescents obtain their cigarettes from stores, in the Southern Cone, Mexico, and the Andean Area this figure exceeds 50%. In Montevideo, almost 70% of youths under 16 obtain tobacco from stores. The survey also shows that, except in the Caribbean state of Saint Vincent, more than 60% of young people in all countries are not refused because they are underage when they attempt to purchase tobacco. Countries of the Southern Cone show a particularly high level of permissiveness (in Buenos Aires, more than 93% of underage people are able to purchase tobacco), followed by the Andean Area, with the lowest percentage (61%) in the United States. This figure exceeds 70% in 24 of the 27 areas where this information is available. The results of this survey suggest a very high degree of tolerance toward smoking in adolescents, in addition to a systematic lack of compliance with laws on sales to minors.

The majority of young people involuntarily breath second hand smoke
People who breathe air contaminated by tobacco smoke suffer the same diseases as smokers themselves. Children and young people exposed to second hand smoke have greater probability of suffering, among other diseases, bronchitis, otitis and asthma, which are the leading causes of pediatric consultation in many countries. For this reason, it is troubling that the vast majority of young people are involuntarily exposed to the smoke of others, both at home and in public places. In 25 of the 33 areas surveyed, more than 50% of youths are exposed to tobacco smoke in public places. This percentage is almost 90% in Buenos Aires and 80% in Montevideo, followed by the United States and the Andean area. At-home exposure to second hand tobacco smoke is cause for special alarm since it often represents the inhalation of large doses of toxic by-products. The subregions of the Americas with the greatest proportion of young people exposed to tobacco smoke at home are in the Southern Cone with 70% in Buenos Aires, followed by the Latin Caribbean, and in last place the English-speaking Caribbean. The detrimental results of second-hand smoking on health and the fact that young people learn from what they see in their family environment make exposure to tobacco smoke in the home a double concern.

The highest proportion of young people who would prohibit tobacco use in public places is in the Andean Area with 90% in Trujillo, Peru, followed by Costa Rica. It should be noted that in 30 out of the 32 remaining regions with available data, more than 70% of the surveyed young people would prohibit smoking in public places. There seems to be a large consensus in favor of the prohibition of smoking in public places by adolescent, both smokers and non smokers.

Conclusions
The results of the GYTS in the Americas give a troubling panorama of the situation. The prevalence of regular tobacco use is high in many countries and the majority of those who do not smoke are exposed to second hand smoke. In addition, the majority of young people are subject to constant pressures to initiate or to keep smoking. In light of this situation, in September 2001, PAHO’s Directing Council called upon the countries of the Americas to act upon preventing the initiation of tobacco use, and promoting cessation, especially in light of the vulnerability of children and adolescents. This requires the implementation and enforcement of cost-effective measures to reduce tobacco use, among them the increase of tobacco taxes at levels that reduce consumption and the progressive elimination of the promotion of tobacco products, within the constraints of national Constitutions. On the other hand, the Directing Council also urged Member States to protect all non-smokers, in particular children and pregnant women, from exposure to second hand tobacco smoke through the immediate creation of smoke free environments in government buildings, health care facilities, and educational institutions. It also asked for the timely creation of smoke free environments in the workplace and in public places. Smoke free environments also promote the cessation of tobacco use and reduce the risk of smoking initiation.

Source: Prepared by Dr. Jaime Pérez Martín and Dr. Armando Peruga from the Mental Health Program (HPM) of PAHO’s Division of Health Promotion and Protection (HPP).

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Epidemiological Bulletin, Vol. 23 No. 2, June 2002