Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project
Charles W. Warren,1 Leanne Riley,2 Samira Asma,3 Michael P. Eriksen,4 Lawrence Green,5 Curtis Blanton,6 Cliff Loo,6 Scott Batchelor,6 & Derek Yach7
The Global Youth Tobacco Survey (GYTS) project was developed by the World Health Organization and the US Centers for Disease Control and Prevention to track tobacco use among youth in countries across the world, using a common methodology and core questionnaire. The GYTS is school based and employs a two-stage sample design to produce representative data on smoking among students aged 1315 years. The first stage consists of a probabilistic selection of schools, and the second consists of a random selection of classes from the participating schools. All students in the selected classes are eligible for the survey.
In 1999, the GYTS was conducted in 13 countries and is currently in progress in over 30 countries. This report describes data from 12 countries: Barbados, China, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe. The findings show that tobacco use in the surveyed age group ranged from a high of 33% to a low of 10%. While the majority of current smokers wanted to stop smoking, very few were able to attend a cessation programme. In most countries the majority of young people reported seeing advertisements for cigarettes in media outlets, but anti-tobacco advertising was rare. The majority of young people reported being taught in school about the dangers of smoking. Environmental tobacco smoke exposure was very high in all countries. These results show that the GYTS surveillance system is enhancing the capacity of countries to design, implement, and evaluate tobacco prevention and control programmes.
Keywords: tobacco; smoking, epidemiology; tobacco use disorder, epidemiology; smoking cessation; adolescence; schools; data collection, methods; cluster analysis; questionnaires.
Tobacco use is one of the chief preventable causes of death in the world. The World Health Organization (WHO) attributes some 4 million deaths a year to tobacco, a figure whic is expected to rise to 8.4 million deaths a year by 2020 (1). By that time, 70% of these deaths will be occurring in the developing countries. Studies in the developed countries show that most people begin using tobacco before the age of 18 years (2,3). Recent trends indicate an earlier age of initiation and rising smoking prevalence rates among children and adolescents. If these patterns continue, tobacco use will result in the deaths of 250 million of the people who are children and adolescents today, many of them in the developing countries (4).In recent years, WHO (5), UNICEF (6), the Group of Eight (G8) Ministers of the Environment (7), the Ministers Responsible for Youth (8), and many national health agencies have called for concerted action against tobacco use by young people (9). Yet, information on tobacco use among young people is not available for most developing countries. To help fill in this data gap, WHO through its Tobacco Free Initiative (TFI) and the Office on Smoking and Health (OSH) in the Centers for Disease Control and Prevention (CDC) in the USA developed the Global Youth Tobacco Survey (GYTS), in consultation with countries in the sixWHO regions. Assessing tobacco use by youth through the GYTS forms an important part of the global tobacco surveillance system.
This article describes the design and developent of the GYTS, a project for international surveillance and comparisons of tobacco use, which is intended to enhance the capacity of countries to monitor tobacco use among youth, and to guide the implementation and evaluation of tobacco preven tion and control programmes. Reported below are the early results of the GYTS obtained from 12 countries: Barbados, C ina, Costa Rica, Fiji, Jordan, Poland, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), Venezuela and Zimbabwe.
Study design and methods
As one of the first steps, TFI and OSH worked with tobacco control experts from China, Fiji, Jordan, Sri Lanka, Ukraine (Kiev), Venezuela, and Zimbabwe to plan the design and implementation of an initial baseline assessment of tobacco use among youth in at least one country from each WHO region. The GYTS was thus created with the following design.
- The surveys in individual countries would be school-based because they are inexpensive, can be done in a short time frame, and require only limited field staff.
- The surveys would focus on school grades associated with students aged 13 15 years (at least 80% of young people in this age group are still either in regular schools or in vocational/technical schools).
- The questionnaire would have a core component which would provide essential data for comparisons between countries and regions, while allowing optional questions on specific issues according to the needs of individual countries. The GYTS core questions deal with tobacco use and related knowledge and attitudes, access to tobacco products, media and advertising exposure to tobacco, tobacco use as a subject in the school curriculum, smoking cessation, and environmental tobacco smoke. Most of the core questions were included in a cognitive lab testcompleted in 1999 (10) and, in addition, were pilot-tested in each country.
In the spring of 1999, the GYTS was conducted in Barbados, China, Jordan, the Russian Federation (Moscow), Sri Lanka, Ukraine (Kiev), and Venezuela. Subsequently, five other countries completed the survey Costa Rica, Fiji, Poland, South Africa, and Zimbabwe. Representatives from eight more countries were trained in 1999 to implement their surveys in 2000 Brazil, C ile, Colombia, Dominican Republic, India,Mexico, Philippines, and Singapore. Because of the demand, TFI and OSH are working to conduct surveys in an additional 20 30 countries in the year 2000. WHO and the CDC are thus committed to developing a global tobacco surveillance system with GYTS as one of the primary components.
The GYTS school-based surveys employ two-stage cluster sample designs within each country, state or city (depending on the scope of the countrys survey). The first stage consists of sampling schools with probability of selection proportional to the school enrolment size. The second stage consists of randomly selecting classes from the eligible grades within each chosen school. All students in the selected classes are eligible to participate in the survey.
A weighting factor was applied to each student record to adjust for non-responses and for the varying probabilities of selection. SUDAAN, a software package for statistical analysis of correlated data, was used to compute 95% confidence intervals (11). Differences between prevalence estimates were considered statistically significant if the 95% confidence intervals did not overlap.
Survey coordinators were trained in groups of countries that were conducting the GYTS to ensure that the survey protocol and procedures for administration would be identical across the countries. Survey procedures were designed to protect the students privacy by allowing for anonymous and voluntary participation. The students completed the self-administered questionnaire in their classrooms, recording their responses directly on a machine-readable answer sheet. The core questionnaire contained 57 multiple-choice questions, with each country adding further questions to meet individual needs. Country-level parental permission procedures were followed before the survey was conducted.
The results compare the extent of tobacco use among students aged 13 15 years across 12 countries. Gender-specific data are not shown in the Tables, but are reported in the text. School and student response rates for the GYTS were impressively high (Table 1). The school response rate ranged from 100% in Tianjin Province of China, Costa Rica, Ukraine (Kiev), and Zimbabwe to 76.9% in South Africa. The student response rate ranged from 99.7% in Venezuela to 81.4% in Ukraine (Kiev). The overall response rate (school rate ´ student rate) ranged from 96.8% in Tianjin Province of China to 65.7% in South Africa.
Students who had ever smoked cigarettes ranged from a high of nearly 70% in Ukraine (Kiev), Poland (urban), and the Russian Federation (Moscow) to a low of approximately 15% in Shandong Province of China, and Sri Lanka (median: 24.2%) (Table 2). Boys were significantly more likely than girls to have ever smoked cigarettes, except in Barbados, Venezuela, and Zimbabwe.
Current cigarette smoking (i.e.had smoked on one or more days during the 30 days preceding the survey) showed a median of 8.7% and ranged from one-third of students (33%) in Ukraine (Kiev) and the Russian Federation (Moscow), nearly 30% in Poland (urban), nearly 20% in Costa Rica, Jordan, Poland (rural),and South Africa,to 10% or less in the other countries (Table 2). Boys in China, Jordan, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev) were significantly more likely than girls to smoke cigarettes currently.
With a median of 8.9%, current use of tobacco products other than cigarettes ranged from approxiately 10% in Barbados, Chongqing Province of China, Jordan, Poland (urban), the Russian Federation (Moscow), Sout Africa, Venezuela, and Zimbabwe, 7% in Guangdong and Shandong Provinces of China, Costa Rica, Fiji, Poland (rural), Ukraine (Kiev), and Sri Lanka, to less than 5% in Tianjin Province of China (Table 2). Boys in Fiji, Jordan, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev) were significantly more likely than girls to use other tobacco products.
Current use of any tobacco product (cigarette smoking or use of other tobacco products) had a median of 15.9 % and ranged from a high of 35% in the Russian Federation (Moscow), Ukraine (Kiev), and Poland (urban), 15 20% in Barbados, Chongqing Province of China, Costa Rica, Jordan, Poland (rural), South Africa, Venezuela, and Zimbabwe, to less than 10% in Guangdong, Shandong, and Tianjin Provinces of China, and Sri Lanka (Table 2). Boys in China, Fiji, Jordan, the Russian Federation (Moscow), and Sri Lanka were significantly more likely than girls to currently use any tobacco product.
The highest prevalence of early initiation of cigarette smoking was in Chongqing and Guangdong Provinces of C ina, Poland (rural), and Manicaland in Zimbabwe, where nearly one-third (33%) of the students who ever smoked cigarettes started smoking before the age of 10 years (Table 2). The median for all countries was 26.4%. Over one-fifth of 13 15-year-old students began smoking before 10 years in Barbados, Fiji, Jordan, Poland (rural), Shandong and Tianjin Provinces of China, the Russian Federation (Moscow), South Africa, Sri Lanka, Ukraine (Kiev), and Zimbabwe (Harare). Initiation of smoking before 10 years was lowest in Venezuela (12.1%) and Costa Rica (10.9%). In the Russian Federation (Moscow) and Ukraine (Kiev), boys were significantly more likely than girls to begin smoking before 10 years of age.
Students who currently smoke were asked where they usually smoked (Table 3). In their home was the most likely location for smoking among students in Barbados and China (over 40%), followed by Jordan (33%), and Venezuela and Zimbabwe (over 25%) (median:30.5%). In the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev), public places were identified as the most likely place where students smoked. In Poland (urban and rural),social events were identified as the most likely venue where the students smoked. Girls in China, Fiji, Jordan, and Venezuela were significantly more likely than boys to smoke at home.
In every country, the most likely means of obtaining cigarettes by students who currently smoke was to purchase them in a store (Table 3). Nearly two-hirds of the surveyed students in the Russian Federation (Moscow) purchased cigarettes in a store, compared with about one-half in Guangdong Province of China, Poland (urban), South Africa, Venezuela, and Harare in Zimbabwe (median:38.5%). Between 30% and 40% of students purchased their cigarettes in a store in Chongqing and Tianjin Provinces of China, Costa Rica, Fiji, Jordan, Poland (rural), Sri Lanka, Ukraine (Kiev), and Manicaland in Zimbabwe; and less than 20% in Barbados and Shandong Province of China. In every country, except for Sri Lanka, the majority of students who currently smoke and buy their cigarettes in a store were not refused their purchase because they were under age (median:75.3%) (Table 3).
The core questionnaire asked current smokers if they wanted to stop smoking cigarettes now (Table 4). In every country, except Barbados and Jordan, over one-half of the surveyed 13 15-year-old smokers expressed a desire to stop smoking now (median: 68.0%). The desire to stop smoking was especially high (near 90%) in Shandong and Tianjin Provinces of China where many of the students started smoking at an early age. The desire to stop smoking was similar for boys and girls in every country, except Ukraine (Kiev)where more boys than girls wanted to stop.In every country, except Sri Lanka, Ukraine (Kiev), and Zimbabwe, approximately two-thirds of current smokers had tried to stop smoking during the 12 months preceding the survey (median:63.4%) (Table 4).
Media and advertising
Anti-tobacco messages were not widely seen by students in these countries either as media messages or at sporting or other events during the 30 days preceding the survey (Table 5). In most countries, only 2025% of students had seen an anti-smoking message during the 30 days preceding the survey (median: 19.2% for media and 25.6% at sports events). In contrast, in most countries, over two-thirds of students saw advertisements promoting cigarettes on billboards (median: 69.3%), in news- papers and magazines (median: 67.9%), and at public events (median:67.7%), or saw cigarette brand names at such events (median:78.3%).
In Fiji, Jordan, Poland (urban and rural), the Russian Federation (Moscow), and Ukraine (Kiev), over one in five students owned an object with a cigarette brand logo on it (median:14.0%) (Table 5). In the other countries, less than 15%of students had a brand logo item.The percentage of students who reported that they had been offered free cigarettes by a representative of a tobacco company was relatively high, wit a median of 7.2% (Table 5). This practice was most likely in Jordan (24.8%), the Russian Federation (Moscow) (16.7%), South Africa (15.2%), and in Manicaland in Zimbabwe (14.5%).
Environmental tobacco smoke
The percentage of students who lived in a home where others smoked ranged from over 67% in Jordan and Poland (urban and rural), to 22.5% in Barbados (median 49.0%) (Table 6). In China, Fiji, the Russian Federation (Moscow), Sri Lanka, and Ukraine (Kiev), approximately one-half of t e students were exposed to cigarette smoking from others in their home.In South Africa and Venezuela, over 40% of students were exposed to other people smoking at home. In every country, at least 40% of students were exposed to cigarette smoking by other people in places away from their homes (median: 56.5%) (Table 6). Boys in China, Fiji, Jordan, Sri Lanka, and Ukraine (Kiev)were more likely than girls to be exposed to smoke from others.
In the Russian Federation (Moscow), South Africa, Ukraine (Kiev), and Zimbabwe, only approxi- mately one-half of the students definitely thought that smoke from others was harmful to them (Table 6). In all the other countries, over two-thirds of the students thought smoke from others was harmful to them (median: 69.7%). Except in Zimbabwe, the majority of students thought that smoking should be banned from public places (median: 67.8%). Approximately 9 out of 10 students in Costa Rica (84.2%), Sri Lanka (91.4%) and Venezuela (87.3%) thought that smoking should be banned in public places.
The percentage of students who reported having been taught in school about the dangers of tobacco use varied from over 70% in China to approximately 33% in Barbados, Costa Rica, the Russian Federation (Moscow), Sout Africa, and Harare in Zimbabwe (median:53.5%) (Table 7). Those who reported having been taught the reasons not to smoke or were taught about the effects of tobacco use was much lower. Overall, less than one-half of the students reported having been taught about the effects of tobacco use (median:35.2%).
The GYTS was initiated by WHO and CDC as a means of providing baseline data to selected countries participating in a project on youth and tobacco funded by the United Nations Foundation for International Partnerships (UNFIP) project on youth and tobacco.
The findings of the GYTS in these countries and the growing need for data on youth and tobacco led other countries to ask for assistance in conducting their own surveys. WHO and CDCare therefore now mounting a multi-agency, international collaborative effort to provide this assistance.
The data available on tobacco use by youth and related problems is weak, except in a few developed countries. Global monitoring of the tobacco epidemic and comparisons between countries require a degree of standardization of core concepts and definitions, and of the methodology of data collection. Until now, no survey instrument had been designed or consistently applied to meet these conditions. The GYTS has several strengths in this regard: it is bot standardized and adaptable to the needs of each country; it is relatively simple and inexpensive to administer; and the data gathered are processed and returned to countries within a short time-frame.
The GYTS surveillance system will also enhance the capacity of countries to design, implement, and evaluate their own tobacco control and prevention programmes by following a standard format. It offers a unique tool for improving the information base on tobacco use among young people, whic will support medium-term and long-term programming and advocacy actions for youth-targeted tobacco control. The GYTS will serve in evaluating the success of national programmes and the WHO Framework Convention for Tobacco Control (FCTC) (12) , especially in the protection of children and adolescents.
- The percentage of young people using any tobacco product ranges from a high of 33% to a low of about 10%. Cigarette use is extremely high in two Eastern European urban areas Moscow and Kiev, where more than one-third of young people aged between 13 and 15 years currently smoke cigarettes. This high prevalence in such a young age group portends a lifetime of addiction for a large number of people, half of whom will die prematurely of tobacco-related diseases.
- In most countries, boys are more likely than girls to use tobacco. Where this tendency is reversed, we may be witnessing the success of advertising by the tobacco industry in making cigarettes fashionable.
- One-fifth or more of young people begin smoking cigarettes before the age of 10 years. This is of concern, since the younger they start to smoke, the more likely they are to become addicted, or become heavy smokers, or die from tobacco-related diseases.
- Young people usually smoke at home except in Moscow and Kiev where there is no restriction on smoking. Smoking in the home adds to the burden of secondary exposure of other persons and provides an unfortunate role model for younger siblings.
- Young people who wish to buy cigarettes in stores are very rarely refused purc ase if they are under age. Even where laws exist which restrict the sale of cigarettes to young people, these laws are seldom enforced.
- The majority of young people currently smoking want to stop smoking and over two-thirds have tried to stop. The traditional focus of youth prevention programmes has been on preventing t e start of tobacco use. Few have offered cessation programmes to those who may already be smoking. Programmes and interventions targeting young people therefore need to expand their focus to include bot preventing starting and offering tailored youth cessation programmes.
- Across the countries, anti-tobacco advertising is rare. Conversely, in most countries the majority of young people report having seen advertisements for cigarettes from a variety of media outlets (billboards, newspapers, magazines, etc. ). Thus, the influence of advertising by the tobacco industry is pronounced in most populations. Until legislation provides for labelling of tobacco products and support for counter-advertising, children and adolescents are seeing and hearing only pro-tobacco messages in the media.
- On the other hand, in most countries the majority of young people ave been taught in school about the dangers of smoking. The present survey does not provide details about the content or quality of the curriculum, the preparation of the teachers on this topic, or the number or duration of the lessons taught.
- Exposure of young people to environmental tobacco smoke is very high in all countries. The majority of young people definitely think that smoke from others is harmful to them. Also, the majority of young people feel smoking should be banned from public places. The environment in which most young people live therefore is contrary to their desire for freedom from exposure to tobacco smoke.§
The agencies contributing to the surveys, besides those within each country, included the United Nations Foundation for International Partnerships (UNFIP), the United Nations Childrens Fund (UNICEF), the US National Cancer Institute (NCI), and the Canadian Public Health Association (CPHA).
The Research Coordinators in the 12 countries described in the present study were A. Daniels (Barbados), Jiang-ping Sun (China), M. Shreim (Jordan), P. W. Gunasekera (Sri Lanka), K. Krasovsky (Kiev, Ukraine), R. Granero (Venezuela), K. V. Vyshinsky (Moscow, Russian Federation), I. Movono (Fiji), K. Przewozniak (Poland), D. Swart (South Africa), J. Bejarano (Costa Rica), and the Blair Research Group (Zimbabwe). Special support for the GYTS was also provided by the following A. Demine (Moscow, Russian Federation), N. Herrera (Venezuela), P. Reddy (South Africa), and W. Zatonski (Poland).
Le tabac chez les jeunes : surveillance du projet denquête mondiale sur le tabagisme chez les jeunes
Le tabagisme est lune des principales causes de décès évitables dans le monde. LOrganisation mondiale de la Santé lui attribue près de 4 millions de décès par an, un chiffre qui devrait passer à 8,4 millions dici 2020. A ce moment-là, 70 % de ces décès se produiront dans les pays en développement. La plupart des gens commencent à fumer avant lâge de 18 ans. Les tendances observeés récemment vont dans le sens dun accroisse-ment des taux de pré valence du tabagisme chez les enfants et les adolescents, qui commencent à fumer plus tôt.
Lenquête mondiale sur le tabagisme chez les jeunes a été élaboré e par linitiative Pour un monde sans tabac de lOMS et par lOffice on Smoking and Health des Centers for Disease Control and Prevention (CDC) des Etats-Unis dAmérique, afin danalyser le tabagisme chez les jeunes de pays du monde entier au moyen dune méthodologie et dun questionnaire de base communs. Cette enquête est réalisée dans les écoles et fait appel à un échantillonnage à deux degrés, afin dobtenir des données représentatives de ce quest le tabagisme chez des élèves de 13 à 15 ans. Dans un premier temps, on réalise un choix probabiliste des écoles et, dans un second temps, on choisit de façon aléatoire les classes dans lesquelles on va enquêter au sein des écoles participantes. Tous les élèves des classes choisies peuvent participer à lenquête.
Cet article décrit le principe et la mise au point de cette enquête et rapporte les résultats obtenus dans 12 pays : Afrique du Sud, Barbade, Chine, Costa Rica, Fédération de Russie (Moscou), Fidji, Jordanie, Pologne, Sri Lanka, Ukraine (Kiev), Venezuela et Zimbabwe. Les résultats montrent que le tabagisme chez les jeunes sétage entre un maximum de 33 % et un minimum de 10 %. La plupart des fumeurs actuels souhaitent arrêter de fumer, mais très peu dentre eux ont déjà suivi un programme pour y parvenir. Dans la plupart des pays, la majoritédes jeunes indiquent avoir vu des publicités pour les cigarettes dans les médias. La publicitéantitabac est rare, mais la majoritédes jeunes ont appris à lécole quels étaient les dangers du tabac. Lexposition au tabagisme ambiant est très importante dans tous les pays.
Les résultats de lenquête réalisée dans ces 12 pays et la nécessitécroissante de disposer de données sur le tabac chez les jeunes ont conduit dautres pays à demander de laide pour effectuer leurs propres enquêtes. LOMS/TFI et les CDC sont donc maintenant en train de mettre en place avec plusieurs autres organisations un important effort international concertépour fournir cette aide.
Le système de surveillance de ce type denquête vise à renforcer la capacitédes pays à concevoir, à mettre en oeuvre et à évaluer des programmes de prévention et de lutte antitabac en suivant un modèle commun/ standard. Ce type denquête constitue donc un moyen important dévaluer les succès remportés par les programmes nationaux et la convention-cadre OMS pour la lutte antitabac récemment lancée, surtout pour ce qui est protéger les enfants et les adolescents.
El consumo de tabaco entre los jóvenes: informe de vigilancia de la Encuesta Mundial sobre el Tabaco y los Jóvenes
El consumo de tabaco es una de las principales causas prevenibles de defunción en el mundo. La Organización Mundial de la Salud (OMS) atribuye al tabaco unos 4 millones de defunciones anuales, cifra que según las previsiones habrá aumentado a 8,4 millones anuales para 2020. En esa fecha el 70% de tales defunciones se producirán en los países en desarrollo. La mayor parte de la gente empieza a consumir tabaco antes de los 18 años. Las últimas tendencias muestran un aumento de las tasas de prevalencia de tabaquismo entre los niños y adolescentes y un comienzo más precoz del hábito.
La Encuesta Mundial sobre el Tabaco y los Jóvenes (GYTS) fue desarrollada por la Iniciativa «Liberarse del tabaco» (ILT) de la OMS y por la Oficina de Tabaco y Salud de los Centros de Control y Prevención de Enfermedades de los Estados Unidos (CDC), a fin de analizar la evolución del consumo del tabaco entre los jóvenes en países de todo el mundo, usando para ello una metodología común y un cuestionario básico. La GYTS es una encuesta escolar que emplea un método de muestreo en dos etapas para obtener datos representativos sobre el hábito de fumar entre los alumnos de 13 a 15 años de edad. En la primera fase se hace una selección probabilista de las escuelas, y en la segunda se seleccionan aleatoriamente clases de las escuelas participantes. Todos los estudiantes de las clases seleccionadas son incluibles en la encuesta.
En el presente artículo se describen el diseño y el desarrollo de la GYTS y se notifican los resultados de las encuestas llevadas a cabo en 12 países: Barbados, China, Costa Rica, Federación de Rusia (Moscú), Fiji, Jordania, Polonia, Sri Lanka, Sudáfrica, Ucrania (Kiev), Venezuela y Zimbabwe. Los resultados muestran que el consumo de tabaco se sitúa entre un máximo del 33% y un mínimo del 10%. La mayoría de los fumadores actuales desean dejar de fumar, pero son muy pocos los que han asistido en alguna ocasión a un programa de deshabituación. En la mayoría de los países la mayor parte de los jóvenes declaran que han visto anuncios de cigarrillos en los medios de comunicación. La publicidad contra el tabaco rara vez se menciona, pero a la mayoría de los jóvenes se les ha informado en la escuela sobre los peligros del hábito de fumar. La exposición a humo de tabaco ambiental era muy elevada en todos los países.
Los resultados obtenidos por la GYTS en estos 12 países y la creciente necesidad de datos sobre la juventud y el tabaco ha llevado a otros países a pedir ayuda para realizar sus propias encuestas. En conse-cuencia, OMS/ILT y los CDC están impulsando una enérgica iniciativa de colaboración internacional mul-tiorganismos para proporcionar esa ayuda.
El sistema de vigilancia de la GYTS tiene como objetivo aumentar la capacidad de los países para diseñar, aplicar y evaluar programas de prevención y control del tabaquismo con arreglo a un formato común/ estándar. La GYTS constituye por tanto un instrumento importante para evaluar el éxito de los programas nacionales y del recientemente iniciado Convenio Marco de la OMS para la Lucha Antitabáquica, sobre todo en lo que respecta a proteger a los niños y los adolescentes.
1. Murray CGL, Lopez AD Alternative projections of mortality and disease by cause, 19902020: global burden of disease study. Lancet, 1997, 349: 14981504.
2. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, GA, US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 1994. Reprinted with corrections, July 1994.
3. Secretary of State for Health and Secretaries of State for Scotland, Wales and Northern Ireland. Smoking kills. A White Paper on tobacco, 30 November 1999. London, H.M. Stationery Office, 1999.
4. Peto R et al. Developing populations: the future health effects of current smoking patterns. In: Mortality from smoking in developed countries, 19502000. Oxford, Oxford University Press, 1994: A101103.
5. Brundtland GH. Paediatricians enlisted in fight against childhood killers. WHO Press Release, No. 59, August 1998.
6. Bellamy C. Tobacco undermines child rights, UNICEF says. Marketing World No-Tobacco Day calls for concerted global action. Press release, New York, UNICEF, May 1998.
7. Declaration of the Environmental Leaders of the G-8 on Childrens Environmental Health. Miami, 1997.
8. Lisbon Declaration. First World Conference of Ministers Responsible for Youth, Lisbon, August 1998.
9. Yach D, Ferguson BJ. Can we stop children and adolescents from smoking? Social Science & Medicine, 1999, 48: 757758.
10. Willis GB, Mowery PD. 1999 youth tobacco survey questionnaire: report of cognitive testing results final report. Research Triangle Park, NC, Research Triangle Institute, 1999.
11. Shah BV, Barnwell BG, Bieler GS. SUDAAN: software for the statistical analysis of correlated data. Users manual (release 7.0). Research Triangle Park, NC, Research Triangle Institute, 1996.
12. Joossens L. Improving public health through an international Framework Convention of Tobacco Control (FCTC Technical Briefing Series, Paper No. 2). Geneva, World Health Organization, 1999 (unpublished document WHO/NCD/TFI/99.2).
▲ Distinguished Fellow/Statistician, Office on Smoking and Health, Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333, USA (email firstname.lastname@example.org). Correspondence should be addressed to this author.
▲ Scientist, Tobacco Free Initiative, World Health Organization, Geneva, Switzerland.
▲ Senior Service Fellow/Visiting Scientist, Office on Smoking and Health, CDC, Atlanta, GA, USA.
▲ Director, Office on Smoking and Health, CDC, Atlanta, GA, USA.
▲ Distinguished Fellow, Office on Smoking and Health, CDC, Atlanta, GA, USA.
▲ Statistician, Office on Smoking and Health, CDC, Atlanta, GA, USA.
▲ Executive Director, Noncommunicable Diseases and Mental Health, World Health Organization, Geneva, Switzerland.
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