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Tobacco Use Among Students Aged 13--15 Years --- Philippines, 2000 and 2003
Tobacco use is one of the major preventable causes of premature death and disease in the world. A disproportionate share of the global tobacco burden falls on developing countries, where an estimated 84% of the world's 1.3 billion current smokers live (1). The Global Youth Tobacco Survey (GYTS), part of the Global Tobacco Surveillance System (GTSS) initiated by the World Health Organization (WHO) and CDC, was developed to monitor youth tobacco use, attitudes about tobacco, and exposure to tobacco smoke, and has been completed by approximately 1.4 million students in 133 countries (2). A key goal of GTSS is for countries to conduct the GYTS every 4 years. This report presents findings from the GYTS conducted in the Philippines in 2000 and 2003, which revealed substantial declines in the proportions of students aged 13--15 years who currently smoked cigarettes, currently used other tobacco products, were likely to start smoking in the next year, or were exposed to secondhand smoke in public places. The findings also indicated an increase in the proportion of students who supported bans on smoking in public places, had learned about the dangers of tobacco use in school, and had seen antitobacco messages in media and advertising. Public health authorities in the Philippines should evaluate their current tobacco-control programs and enhance or expand them to further reduce youth smoking.
GYTS is a school-based survey that collects data from students aged 13--15 years by using a standardized methodology for constructing the sample frame, selecting participating schools and classes, and processing data. GYTS uses a two-stage, cluster-sample design that produces representative samples of students in grades associated with ages 13--15 years (2). In the Philippines, this age range is covered by the second, third, and fourth years of secondary school; the GYTS sampling frame included all secondary schools containing these grade levels. At the first sampling stage, the probability of selecting a school was proportional to the number of students enrolled in the specified grades. At the second stage, classes within the selected schools were randomly selected. All students attending school in the selected classes on the day the survey was administered were eligible to participate. In 2000, a total of 11,630 students completed the GYTS, and in 2003, a total of 7,478 completed the survey. The school response rate was 90.0% in 2000 and 99.3% in 2003; the student response rates were 88.7% and 85.4%, respectively; and the overall response rates (i.e., school rate multiplied by student rate) were 79.7% and 84.8%, respectively.
This analysis compared the 2000 and 2003 survey results by using several indicators of tobacco use. The indicators included lifetime cigarette smoking, age of initiation of cigarette smoking, current cigarette smoking, current use of other tobacco products, likelihood of never smokers to initiate smoking in the next year, exposure to secondhand smoke, tobacco education, exposure to tobacco images in media and advertising, cessation efforts, and access to tobacco. All differences noted are statistically significant (p<0.05) with nonoverlapping 95% confidence intervals.
In both years, approximately four in 10 students in the Philippines reported ever smoking cigarettes (i.e., even one or two puffs): 42.8% in 2000 and 41.9% in 2003 (Table 1). Adolescent boys were significantly more likely than adolescent girls to have ever smoked. Approximately one in eight students who had smoked cigarettes reported smoking their first cigarette before age 10 years: 12.9% in 2000 and 12.7% in 2003, with no significant difference between adolescent boys and girls.
Current tobacco use and likely initiation of smoking among never smokers declined significantly from 2000 to 2003. The percentage of students who reported being current cigarette smokers or currently using other tobacco products declined significantly. Among adolescent boys, the percentage of current smokers declined by approximately one third, from 32.6% in 2000 to 21.8% in 2003. Among adolescent girls, the decline was similar, from 12.9% in 2000 to 8.8% in 2003. Current use of other tobacco products declined by nearly half for both adolescent boys and adolescent girls, from 18.3% in 2000 to 10.9% in 2003 for adolescent boys and from 9.5% in 2000 to 5.7% in 2003 for adolescent girls. The percentage of students who had never smoked but were likely to initiate smoking in the next year also decreased by nearly half, from 26.5% in 2000 to 13.8% in 2003.
Changes in current tobacco use were mirrored by other results that indicated an increase in antismoking sentiment in the Philippines. Although the percentage of students who reported that their parents smoked did not change (approximately 56% in both 2000 and 2003), the percentage of students reporting exposure to secondhand smoke in public places declined from 74.6% in 2000 to 59.0% in 2003 (Table 2). In addition, support for bans on smoking in public places more than doubled, from 39.2% of students in 2000 to 88.7% in 2003, and the percentage of students who reported learning in school about the health hazards of tobacco use increased from 58.6% in 2000 to 68.0% in 2003. A greater percentage (90.3%) of students reported seeing an antitobacco message in the media in 2003 than in 2000 (83.4%).
The percentage of current smokers who were not refused purchase of tobacco products because of their age increased from 46.6% in 2000 to 62.8% in 2003. The percentage of students who reported being offered free cigarettes decreased from 17.6% in 2000 to 13.9% in 2003. In addition, a small but significant increase was observed in the percentage of students who reported seeing tobacco advertising on billboards (84.4% in 2000 versus 87.6% in 2003).
Reported by: M Miguel-Baquilod, MD, Philippines Dept of Health. B Fishburn, MPP, J Santos, MPH, Western Pacific Regional Office, World Health Organization, Manila, Philippines. NR Jones, PhD, CW Warren, PhD, Office of Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.
The findings in this report suggest that, from 2000 to 2003, tobacco use and exposure to secondhand smoke in public places declined significantly among students aged 13--15 years in the Philippines. In 2003, students were less likely to use tobacco currently, less likely to be exposed to secondhand smoke, more likely to support bans on smoking in public areas, and more likely to have learned in school and from the media about the health hazards of tobacco use. Finally, fewer students reported being offered free cigarettes in 2003 than in 2000.
During the same period, major changes in tobacco-control policies in the Philippines might have contributed to these changes. For example, before 1999, no restrictions on tobacco advertising and promotion were in effect, and few smoke-free policies existed. In addition, a lower level of taxation on tobacco products, few education efforts, and low enforcement of age restrictions for tobacco sales were observed. The Philippines Clear Air Act of 1999* identified cigarette smoke among the country's pollutants and instituted smoke-free indoor air laws. The national law still allows designated smoking areas in restaurants and other indoor areas, but some cities have declared all indoor areas completely smoke-free. The government is also seeking increased taxes on cigarettes. In 2003, the Youth Smoking Cessation Program declared smoke-free campuses, improved training for students and teachers, and levied penalties for smoking. The Tobacco Regulatory Act of 2003§ seeks to increase public education measures, ban all tobacco advertisement, strengthen warning labels on tobacco products, and prohibit sales to minors. All of these smoke-free programs have received extensive national and local media coverage.
The findings in this report are subject to at least three limitations. First, because the sample surveyed was limited to youths attending school, it might not be representative of all adolescents aged 13--15 years in the Philippines. During school year 2002--03, the gross enrollment ratio in secondary schools was 65.7% (3). Second, these data apply only to youths who were in school on the day of the survey and who completed the survey. Despite this limitation, response rates were 89% in 2000 and 85% in 2003, suggesting that bias attributable to absence or nonresponse might be limited. Finally, data are based on the self reports of students, who might under- or over-report their use of tobacco. The extent of this bias cannot be determined from the Philippines data; however, responses to tobacco questions on surveys in the United States similar to GYTS have demonstrated good test-retest reliability (4).
The declines from 2000 to 2003 in cigarette smoking and other tobacco use among students in the Philippines were encouraging. However, other findings were of concern. In 2003, 13.8% of students who had never smoked indicated they would likely initiate smoking in the next year, with no difference between adolescent boys and adolescent girls. In addition, approximately eight in 10 students reported seeing pro-tobacco messages on billboards and in newspapers and magazines. Students who smoke also reported little difficulty purchasing cigarettes in stores. To reduce tobacco use among adolescents in the Philippines, continued efforts are needed to monitor these behaviors and to develop, evaluate, and disseminate effective prevention strategies.
Systematic global surveillance of youth tobacco use is the essential first step in attempting to prevent the projected epidemic of death and disease that smoking will cause in the 21st century (5). The GYTS enhances the capacity of countries to evaluate their tobacco-prevention and -control programs. The more than 30% reduction in current tobacco use observed in the Philippines should encourage other countries that youth tobacco use can be reduced substantially during a short period.
* Republic Act No. 8749, enacted June 1999.
Youth Smoking Prevention Program, Philippines Department of Education Order No. 33 series, enacted 2003.
§ Republic Act No. 9211, enacted July 2003.
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