Prevalence of Cigarette Smoking Among Secondary School Students -- Budapest, Hungary, 1995

Because of the high prevalence of tobacco use in countries of Central and Eastern Europe, public health officials in many of these countries have designated as a priority the prevention of smoking initiation among youth. In 1995, a nationally representative survey in the Republic of Hungary documented that 35.8% of 16-year-old students in that country had smoked cigarettes during the preceding 30 days (1). To better characterize smoking among youth in Hungary, the Field Epidemiology Training Program, Hungarian Ministry of Welfare, conducted a cross-sectional survey in Budapest (1995 population: 1,906,798) among secondary school students aged 14-18 years. Specific objectives of the survey were to assess the prevalence of cigarette smoking among these students, determine factors associated with higher prevalences, and describe the smoking habits of current cigarette smokers. This report summarizes the findings, which indicate that one third of all students smoked; half of all 18-year-olds smoked; and of those students who smoked, 41% most frequently smoked an imported, internationally recognized cigarette brand.

Among the 105,209 Budapest students aged 14-18 years, approximately 80% attended traditional public high schools, and 20% attended public vocational/technical schools. A sample of students was selected from a stratified sample of the 199 secondary schools in Budapest. Twenty (80%) traditional high schools and five (20%) vocational/technical schools were selected with a probability proportional to their size. Classrooms in these 25 schools were then randomly selected. During 3 weeks in January 1995, all 2878 students in attendance completed a pretested, standardized questionnaire that included questions translated from the U.S. Youth Risk Behavior Survey (2) and that asked about culturally relevant factors possibly associated with smoking. Current smokers were defined as students who reported having smoked at least one cigarette during the preceding 30 days. Of the 2878 students, 79 (2.7%) were excluded because their smoking status could not be determined. Epi Info 6.02 was used for data analysis that accounted for the stratification and clustering of students within classrooms; 95% confidence intervals (CIs) were calculated using SUDAAN (3).

Among the 2799 students, 987 (35.3%) (95% CI=30.6%-39.9%) reported current smoking (Table_1). Although the prevalences were similar among male and female students (prevalence odds ratio {POR}=1.0; 95% CI=0.8-1.5), students aged 18 years were more likely to smoke than students aged 14 years (47.9% and 23.8%, respectively {POR=2.9; 95% CI=1.3-6.6}). The prevalences of current smoking also were higher among vocational/technical students than traditional high school students (53.1% and 31.0%, respectively {POR=2.5; 95% CI=1.6-3.9}); among students whose friends smoked than those whose friends did not smoke (42.6% and 6.8%, respectively {POR=10.1; 95% CI=7.5-13.7}); among students who reported that they had seen a teacher smoking during the school year than those who had not seen a teacher smoking (37.3% and 19.0%, respectively {POR=2.5; 95% CI=1.8-3.6}); and among students with a family member who smoked than students whose family members abstained from smoking (40.7% and 27.0%, respectively {POR=1.9; 95% CI=1.6-2.1}). The prevalences of smoking were similar among students who received instruction at school about the harmful health effects of smoking and among those who did not receive such instruction (POR=1.0; 95% CI=0.9-1.1).

Among current smokers, during the preceding 30 days, 17.3% smoked greater than or equal to 11 cigarettes daily, 38.0% smoked daily, and approximately half (51.0%) smoked on school property on at least 1 day (Table_2). Approximately 60% of current smokers smoked a variety of brands of cigarettes. Current smokers reported that the brands they most frequently smoked were Hungarian brands (Multifilter {57%} and Sopianae {33%}) and a U.S. brand (Marlboro {41%}).

Reported by: G Ursicz, MD, Hungarian Field Epidemiology Training Program, Ministry of Welfare; E Kiss, MD, Div of Child and Adolescent Health, K Lun, MD, Director, Budapest Institute of Public Health and Medical Officer Svc, Ministry of Welfare; Ministry of Culture and Education, Budapest, Republic of Hungary. Div of International Health (proposed), Epidemiology Program Office; Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings of the survey described in this report indicate that in 1995, a substantial proportion (35%) of secondary school students in Budapest reported smoking cigarettes. This prevalence is identical to that among U.S. students in grades 9-12 during 1995 (2); however, the findings for the United States reflected a national sample of persons who resided in urban and rural areas, and the findings for Hungary reflected a sample of persons who resided in one large urban area. The prevalence of smoking in Budapest increased directly with age and was 48% among 18-year-old students. Worldwide, about half of persons who initiate smoking during their teenage years and continue to smoke cigarettes regularly will die as a result of a tobacco- related disease (4). The death rates for diseases attributable to smoking are higher in Hungary than in most other developed countries (4,5).

A survey of the prevalence of smoking among adolescents in European countries during 1993-1994 indicated that among five countries in central and eastern regions (Czech Republic, Hungary, Republic of Poland, Russian Federation, and Slovak Republic), approximately 10% of adolescents reported smoking cigarettes at least weekly. However, the overall prevalence of cigarette smoking for all age groups in Hungary is among the highest of all countries in central and eastern Europe. Each year from 1976 through 1990, annual average per capita cigarette consumption in Hungary was higher than the combined average for all central and eastern European countries (5).

The finding that most current smokers varied the brand of cigarette they smoked may reflect the ease with which students can purchase individual cigarettes at newsstands and other stores in Hungary. Students may vary the brand of cigarette they smoke based on the availability and cost of individual cigarettes. In general, in Budapest, imported western brand-name cigarettes are more expensive than central and eastern European brand-name cigarettes.

To decrease the initiation and prevalence of smoking in Hungary, health officials are developing a population-based tobacco education campaign that will include a pre- and postintervention smoking prevalence survey to evaluate the impact of the program. In addition, a pilot intervention project is being planned in a large city (Szekesfehervar) to decrease exposure to passive smoke (environmental tobacco smoke); this project will include both a general media campaign and a program to educate kindergarten children and their parents about the hazards of passive and active smoking. Public health officials in Budapest also have recommended that teachers who smoke do so in restricted areas that are out of sight of students.

Although cigarette advertising that actively promotes the purchase of cigarettes is prohibited in Hungary, such advertising is common in many public locations, including sports arenas, large city squares, housing complexes, and busy traffic intersections. Public health officials also have recommended stronger enforcement of the ban on cigarette advertising (E. Morava, Hungarian Ministry of Welfare, personal communication, 1996).

References

1. Elekes Z, Paksi B. The European School Survey Project on Alcohol and Drugs {Hungarian}. Budapest, Hungary: Hungarian Ministry of Welfare, 1996.

2. CDC. Tobacco use and usual source of cigarettes among high school students -- United States, 1995. MMWR 1996;45:413-8.

3. Shah BV. Professional software for Survey Data Analysis (SUDAAN), version 6.40 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Park Institute, 1995.

4. Peto R, Lopez AD, Boreham J, Thun M, Health C Jr. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992;339:1268-78.

5. World Health Organization. Health for all {Software documentation}. Geneva, Switzerland: World Health Organization, 1995.

Table_1
Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.

TABLE 1. Number and percentage of current smokers * among secondary school students aged
14-18 years, by selected characteristics -- Budapest, Hungary, 1995
==========================================================================================
                                                               Current
                                                               smokers
                                                ------------------------------------------
Characteristic            Sample size +          No.           (%)           (95% CI &)
------------------------------------------------------------------------------------------
Sex
Male                              1470           525        (35.7)        (28.5%-42.9%)
Female                            1324           461        (34.8)        (32.2%-37.5%)
Age (yrs)
14                                 168            40        (23.8)        (23.0%-24.7%)
15                                 720           191        (26.5)        (20.5%-32.6%)
16                                 806           286        (35.5)        (27.6%-43.4%)
17                                 696           274        (39.4)        (34.6%-44.2%)
18                                 399           191        (47.9)        (32.9%-62.9%)
School type
Vocational/ technical              537           285        (53.1)        (46.7%-59.5%)
Traditional high school           2262           702        (31.0)        (26.2%-35.9%)

Total                             2799           987        (35.3)        (30.6%-39.9%)
------------------------------------------------------------------------------------------
* Defined as students who reported having smoked at least one cigarette during
  the preceding 30 days.
+ For some characteristics, the sample size may not equal 2799 because of missing data.
& Confidence interval.
==========================================================================================

TABLE 2. Number and percentage of secondary school students aged 14-18 years who
were current smokers *, by selected characteristics -- Budapest, Hungary, 1995
====================================================================================
                                                          Current smokers

Characteristic                                     No. &     (%)      (95% CI @)
------------------------------------------------------------------------------------
No. cigarettes smoked per day
    1                                               223   (23.3)   (20.3%-26.2%)
 2-10                                               569   (59.4)   (57.3%-61.5%)
 >=11                                               166   (17.3)   (14.1%-20.5%)

No. days used
 1- 2                                               201   (20.4)   (17.3%-23.5%)
 3- 9                                               148   (15.0)   (12.1%-17.9%)
10-29                                               263   (26.6)   (23.2%-30.1%)
   30                                               375   (38.0)   (34.7%-41.3%)

No. days used on school property
    0                                               469   (49.0)   (42.6%-55.3%)
 1- 2                                                98   (10.2)   ( 7.5%-13.0%)
 3- 9                                               109   (11.4)   ( 8.6%-14.2%)
 >=10                                               282   (29.4)   (24.7%-34.2%)
------------------------------------------------------------------------------------
* Defined as students who reported having smoked at least one cigarette during
  the preceding 30 days.
+ n=987.
& For each characteristic, the sample size does not equal 987 because of missing
  data.
@ Confidence interval.
====================================================================================

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