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1.  The Global Youth Tobacco Survey: 2001–2002 in Riyadh region, the Kingdom of Saudi Arabia 
Background
Tobacco use is a major public health problem, and its prevalence is globally increasing, especially among children and adolescents.
Objective
The Global Youth Tobacco Survey aimed to explore the epidemiological trends and risk factors of tobacco smoking among intermediate school boys in Riyadh region of the Kingdom of Saudi Arabia.
Method
A two-stage cluster sample design was used to produce a representative sample of male students from selected schools. The participants (n = 1830) self recorded their responses on the Global Youth Tobacco Survey questionnaire.
Results
Lifetime prevalence of cigarette smoking was 35%, while 13% of students currently used other tobacco products. About 16% of students currently smoked at home, and 84% of students bought cigarettes without any refusal from storekeepers. Thirty-one percent and 39% of students were exposed to secondhand tobacco smoke inside and outside the house, respectively, which was definitely or probably harmful to health as opined by 87% of participants, and 74% voiced to ban smoking from public places. Among current smokers, 69% intended (without attempt) to quit and 63% attempted (but failed) to quit during the past year. Almost an equal number of students saw antismoking and prosmoking media messages in the last month, and 28% of students were offered free cigarettes by a tobacco company representative. In schools, more than 50% of students were taught about the dangers of cigarette smoking in the last year. Smoking by parents, older brothers, and close friends, watching prosmoking cigarette advertisements, free offer of cigarettes by tobacco company representatives, perception of smoking being not harmful, and continuing smoking which can be easily quit significantly increased the odds of smoking by students.
Conclusion
The common use of tobacco in school populations needs to be addressed by, among other tobacco control measures, a strict ban on cigarette selling to minors and intensive regular tobacco control campaigns involving health and religious messages.
Video abstract
doi:10.2147/SAR.S23626
PMCID: PMC3846322  PMID: 24474857
tobacco use; secondhand tobacco smoke; environmental tobacco smoke; intermediate school boys; Global Youth Tobacco Survey; Saudi Arabia
2.  Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia 
Annals of Thoracic Medicine  2011;6(3):137-140.
OBJECTIVE:
To study the prevalence and characteristics of cigarette smoking among secondary school students (16- to 18-year-old boys and girls) in Riyadh city, Saudi Arabia.
METHODS:
We applied a standard two-stage, cross-sectional study design. Secondary schools for both boys and girls in Riyadh city were randomly selected using a cluster sampling method. We used the global youth tobacco survey (GYTS) tool to achieve our objectives.
RESULTS:
Among 1272 students (606 boys and 666 girls), the prevalence of those ever smoked cigarettes was 42.8% (55.6% of boys and 31.4% of girls). The prevalence of current smoking was 19.5% (31.2% of boys and 8.9% of girls). Despite the fact that the majority of students think smoking is harmful, most do not wish to stop smoking, and they had not tried to stop in the past year. Cigarette smoking is significantly associated with the male gender, having friends who smoke, and having parents who smoke, but is not significantly associated with the type of school attended.
CONCLUSION:
Smoking prevalence among secondary schools students in Saudi Arabia is high and alarming. There is a need to implement an education program about the risks of smoking and to include parents and friends as healthy models to prevent students from beginning to smoke.
doi:10.4103/1817-1737.82447
PMCID: PMC3131756  PMID: 21760845
Cigarette smoking; prevalence; Saudi Arabia
3.  Knowledge, attitude and practice of tobacco smoking by medical students in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2010;5(3):145-148.
BACKGROUND:
Tobacco consumption is associated with considerable negative impact on health. Health professionals, including future doctors, should have a leading role in combating smoking in the community.
OBJECTIVES:
The aims of the study were to assess the prevalence of smoking among medical students of newly established medical colleges in Riyadh city, the capital of Saudi Arabia, as well as to assess students' attitude, practice and their knowledge on the risk factors of tobacco consumption.
METHODS:
A cross-sectional, questionnaire-based study of students from two medical colleges in Riyadh, Saudi Arabia was carried out. The questionnaire used was anonymous, self-administered and developed mainly from Global Adult Tobacco Survey (GATS).
RESULTS:
A total of 215 students participated in this study. Forty students (19%) indicated that they smoke tobacco at the time of the study. All of them were males, which raise the prevalence among male students to 24%. Tobacco smoking was practiced by males more than females (P value <0.0001) and by senior more than junior students (<0.0001). About 94% of the study sample indicated that smoking could cause serious illnesses. About 90% of the students indicated that they would advice their patients to quit smoking in the future and 88% thought that smoking should be banned in public areas. Forty-four students (20%) thought that smoking has some beneficial effects, mainly as a coping strategy for stress alleviation.
CONCLUSION:
Despite good knowledge about the hazards of tobacco consumption, about 25% of the medical students in this study continue to smoke. The main reported reasons should be addressed urgently by policy-makers. Special efforts should be taken to educate medical students on the effective strategies in managing stress during their study as they thought that tobacco smoking could be used as a coping strategy to face such a stress.
doi:10.4103/1817-1737.65044
PMCID: PMC2930652  PMID: 20835308
Medical students; Saudi Arabia; smoking
4.  Sociodemographic Factors Associated With Tobacco Smoking Among Intermediate and Secondary School Students in Jazan Region of Saudi Arabia 
Substance Abuse  2013;34(4):381-388.
Background: The objectives of this study were to (i) determine the prevalence of and characteristics associated with tobacco smoking; (ii) identify the factors associated with tobacco smoking; and (iii) evaluate the association between tobacco smoking and khat chewing among intermediate and secondary school students in Jazan Region, Saudi Arabia. Methods: A cross-sectional study was conducted with a representative sample (N = 4100) of intermediate and secondary school students in Jazan Region. The data were collected using a pretested modified version of the global youth tobacco survey questionnaire. Results: A total of 3923 students from 72 intermediate and secondary schools for males and females in Jazan Region, Saudi Arabia, were included in this study. The ever having smoked prevalence was 17.3%, and the current smoking prevalence was 10.7%. The most important independent predictors of smoking were academic performance (odds ratio [OR]: 5.32), having friends who used khat (OR: 3.23), and having friends who used tobacco (OR: 2.88). Conclusions: Understanding the factors and predictors associated with tobacco use are crucial to identifying high-risk groups to design tobacco prevention and control programs. For the first time, a strong and statistically significant association was identified between tobacco smoking and khat chewing among intermediate and secondary school students in Jazan Region. Because the use of khat is increasingly spreading outside of its traditional areas to Europe and America, this finding may have an important impact on tobacco control efforts internationally.
doi:10.1080/08897077.2013.779361
PMCID: PMC3827661  PMID: 24159909
Co-substance use; priority/special populations; tobacco
5.  Smoking behaviour and attitudes among adult Saudi nationals in Riyadh City, Saudi Arabia 
Tobacco Control  1996;5(3):215-219.
OBJECTIVE: To measure the smoking behaviour and attitudes among Saudi adults residing in Riyadh City, the capital of the Kingdom of Saudi Arabia. DESIGN: Cross-sectional survey. SETTING AND SUBJECTS: Primary health care centres (PHCCs) in Riyadh City were selected by stratified random sampling. Subjects resident in each PHCC catchment area were selected by systematic sampling from their records in the PHCCs; 1534 adults aged 15 years and older were interviewed during January to April 1994. MAIN OUTCOME MEASURES: Self-reported smoking prevalence; age of smoking initiation; daily cigarette consumption; duration of smoking; reasons for smoking, not smoking, and quitting smoking; intentions to smoke in the future; and attitudes toward various tobacco control measures. RESULTS: 25.3% of respondents were current smokers, 10.2% were ex-smokers, and 64.5% had never smoked. About 79% of all smokers started smoking between the ages of 15 and 30 years, and 19.5% before age 15. Significantly higher smoking prevalence and daily cigarette consumption were associated with being male, single, and being more highly educated. Relief of psychological tension, boredom, and imitating others were the most important reasons for smoking, whereas health and religious considerations were the most important reasons for not smoking among never-smokers, for quitting among ex-smokers, and for attempting to quit or thinking about quitting among current smokers. About 90% of all subjects thought that they would not smoke in the future. Physicians and religious men were identified as the most effective anti-smoking advocates by a much higher proportion of respondents (44%) than nurses, health educators, and teachers (each less than 5%). Health and religious education were generally cited as more effective in deterring smoking than tobacco control laws and policies. CONCLUSIONS: Cigarette smoking is prevalent among Saudi adults in Riyadh, particularly males, most of whom begin to smoke rather early in life and continue for many years. Health and religious education should be the cornerstone for any organised tobacco control activities, which are urgently needed to combat the expected future epidemic of smoking-related health problems. 





PMCID: PMC1759520  PMID: 9035357
6.  Predictors of smoking among male junior secondary school students in Riyadh, Saudi Arabia 
Tobacco Control  1996;5(1):26-29.
OBJECTIVE: To determine the prevalence and determinants of cigarette smoking among intermediate (junior secondary) schoolboys in Riyadh, Saudi Arabia. PARTICIPANTS: A sample of 1382 students (ages 12-19 years) in 45 classes randomly selected from 15 schools, using a two- stage stratified cluster sampling scheme. DESIGN: Students in the selected classes were requested to complete an anonymous questionnaire, under the supervision of trained interviewers. Univariate and multivariate statistical analyses of potential risk factors were performed. SETTING: Intermediate schools in Riyadh, Saudi Arabia. MAIN OUTCOME MEASURES: Association between current smoking and socio- demographic variables, history of smoking, age of smoking initiation, smoking behaviour among family members, knowledge of the harmful effects of smoking, and whether smoking is allowed in the presence of relatives and acquaintances. RESULTS: The prevalence of current smokers was 13.2% overall, ranging from 3.2% in those 12-13 years old to 31.1% in those aged 18-19. Some of the variables (nationality, father's education, and smoking allowed in the presence of parents or teachers) found to be associated with current smoking in a univariate analysis were no longer significantly associated with smoking in the multivariate analysis. By multivariate analysis, knowledge of the harmful effects of smoking, age, smoking allowed in the presence of friends or brothers, and previous smoking were statistically significant determinants of current smoking. CONCLUSIONS: Current health education activities against smoking should be continued and extended to the young population to further reduce the prevalence of smoking and its health consequences. Religious antipathy toward smoking should be emphasised in any local anti-smoking campaigns. 



PMCID: PMC1759483  PMID: 8795855
7.  Smoking Experimentation among Elementary School Students in China: Influences from Peers, Families, and the School Environment 
PLoS ONE  2013;8(8):e73048.
The aim of this study was to investigate experimentation with smoking among primary school students in China. Data were acquired from a recent survey of 4,073 students in grades 4 to 6 (ages 9–12) in 11 primary schools of Ningbo City. The questions were adapted from the Global Youth Tobacco Survey (GYTS). Results suggest that although the Chinese Ministry of Education (MOE) encourages smoke-free schools, experimentation with cigarettes remains a serious problem among primary school students in China. Peers, family members, and the school environment play important roles in influencing smoking experimentation among students. Having a friend who smoked, seeing a family member smoke, and observing a teacher smoking on campus predicted a higher risk of experimentation with smoking; the exposure to anti-tobacco materials at school predicted a lower risk of experimentation with smoking. The evidence suggests that public health practitioners and policymakers should seek to ensure the implementation of smoke-free policies and that intervention should target young people, families, and communities to curb the commencement of smoking among children and adolescents in China.
doi:10.1371/journal.pone.0073048
PMCID: PMC3750020  PMID: 23991172
8.  Prevalence of smoking among male secondary school students in Jeddah, Saudi Arabia 
Objectives:
This study was conducted to examine the prevalence of smoking and habits of smoking among male secondary school students in Jeddah, Kingdom of Saudi Arabia (KSA) and to assess their knowledge and attitudes toward it.
Materials and Methods:
A cross-sectional study was conducted in Jeddah, using a two-stage cluster sampling, randomly selecting 4 out of 85 government male secondary schools. Data were obtained through a self-administered questionnaire eliciting responses to questions on personal background, smoking behavior, knowledge, behavior, and attitude toward smoking. A total of 695 students responded to the questionnaires with 87.4% response rate.
Results:
Of the studied group, 258 (37%) currently smoked, and of these, 83.7% had started smoking at the age of 14 years or less. The most common reason for smoking was the influence of family, especially the presence of someone at home who smoked (65, 9%) and friends who smoked (42.5%). Many of the students search for information on the risks of smoking (66.3%), and only (45.3%) knew about the bad effects of passive smoking on others. Two-third of the students who smoked wanted to quit smoking (63.2%), especially if suitable help was offered, whereas (60.9%) had tried to quit. While 50% of students smoked for recreation and entertainment, and (33.6%) had difficulty avoiding smoking in no smoking areas.
Conclusion:
A well-planned integrated antismoking campaign is urgently required, especially among students and teachers. The study revealed that the prevalence of smoking was high. This will contribute to an increase in smoking-related health problems in the future if proper preventive measures are not taken.
doi:10.4103/2230-8229.121993
PMCID: PMC3957170  PMID: 24672274
Smoking; male students; secondary school; prevalence; behavior
9.  Students’ attitude toward use of over the counter medicines during exams in Saudi Arabia 
Purpose
To explore the use of over the counter (OTC) medicines among students during exams in Riyadh City, Kingdom of Saudi Arabia.
Method
A cross-sectional study was designed; using a self-administered twenty-two item online questionnaire for the students’ convenience and easy response disclosure. Data were analyzed using Statistical Package for Social Science (SPSS) version 13®.
Results
A total of N = 1596 students participated in this survey, of whom 829 (51.9%) were university students and 767 (48.1%) were high school students. Overall, 80.0% of the respondents disclosed the use of OTC non-steroidal anti-inflammatory drugs for headache and pain relief. In addition, other substances used during the exams were Energy Drinks (5.0%), Flu Medication (5.0%), Vitamins (5.0%) and Antibiotics (5.0%). Female students were found to be more knowledgeable about safety issues concerning the use of OTC medicines (5.11 ± 1.27, p = <0.001) than male students. Ease in access to OTC medicine, availability of pharmacist consultation and advertisement in print and electronic media were the main factors disclosed by the respondents that may result in an increase in the use of OTC products. The use of OTC medicines was generally higher among female students (p = 0.001).
Conclusion
The use of OTC medication during exams was more among high school and university students. Gender, age and educational institution were found significantly affecting the use of OTC medicines during exams.
doi:10.1016/j.jsps.2013.02.004
PMCID: PMC3950531  PMID: 24648821
OTC medications; High school students; University students; Exams; Saudi Arabia
10.  The association between senior student tobacco use rate at school and alternative tobacco product use among junior students in Canadian secondary schools 
Tobacco Induced Diseases  2014;12(1):8.
Background
The use of alternative tobacco products (ATPs) has grown in popularity among Canadian youth. This study examined the association between a school-level characteristic (the senior student tobacco use rate) and the current use of manufactured cigarettes, little cigars or cigarillos, cigars, roll-your-own cigarettes, smokeless tobacco (SLT), and a hookah among junior students.
Methods
This study used nationally representative Canadian data from 29,495 students in grades 9 to 12 as part of the 2010/2011 Youth Smoking Survey. For each ATP, we described rates of senior and junior tobacco use, calculated the variance attributed to school-level factors, and examined the association between the senior student (grades 11 and 12) tobacco use rate and the current use of each ATP among junior students (grades 9 and 10) while accounting for relevant student-level characteristics. SAS 9.3 was used for all analyses.
Results
Over half of schools sampled had senior students that reported using each ATP. School-level differences accounted for between 14.1% and 29.7% of the variability in ATP current use among junior students. Each one percent increase in the number of senior students at a school that currently use manufactured cigarettes, SLT, or a hookah was significantly independently associated with an increased likelihood that a junior student at that school currently used manufactured cigarettes (OR 1.04, 95% CI 1.01 to 1.06), SLT (OR 1.14, 95% CI 1.06 to 1.24), or a hookah (OR 1.09, 95% CI 1.03 to 1.14).
Conclusions
Characteristics of the school environment a junior student attends appear to play an important role in ATP use, and tobacco control programs and policies should be designed to ensure that they include strategies to curb the use of all tobacco products. Additional evidence is needed for the impact of comprehensive school-based tobacco control approaches.
doi:10.1186/1617-9625-12-8
PMCID: PMC4012246  PMID: 24808817
Tobacco products; Adolescent; Tobacco use
11.  The Global School Personnel Survey: a cross‐country overview 
Tobacco Control  2006;15(Suppl 2):ii20-ii30.
Teachers and administrators are role models for students, conveyors of tobacco prevention curricula, and key opinion leaders for school tobacco control policies. School teachers and administrators have daily interaction with students and thus represent an influential group for tobacco control. Data collected by the Global School Personnel Survey between 2000 and 2005 have shown that an alarming proportion of school personnel smoke cigarettes and use other forms of tobacco. At the regional level, current cigarette smoking is between 15% and 19% among school personnel included in this report around the world. The scarcity of tobacco‐free schools and the high level of smoking on school grounds by school personnel reported in this study indicate how seriously school practice and staff actions undermine the educational messages and other prevention efforts to reduce adolescent smoking prevalence. However, the majority of school personnel in most sites strongly agreed that they should receive specific training to help students avoid or stop using tobacco.
doi:10.1136/tc.2006.015693
PMCID: PMC2563538  PMID: 16731521
tobacco; teachers; school; surveillance
12.  Evaluation of factors influencing intention to quit smokeless and cigarette tobacco use among Nigerian adolescents 
Background:
Smokeless and cigarette tobacco use is becoming increasingly popular among Nigerian adolescents. This study aimed to evaluate predictors of intention to quit tobacco use among adolescents that currently use tobacco products in Nigeria.
Materials and Methods:
A total of 536 male and female high school students in senior classes in Benue State, Nigeria were enrolled into the cross-sectional study. The survey instrument was adapted from the Global Youth Tobacco Survey (GYTS) questionnaire.
Results:
Among adolescents with tobacco habits, 80.5% of smokeless tobacco users and 82.8% of cigarette smokers intended to quit tobacco use within 12 months. After adjustment, significant predictors of intention to quit cigarette smoking were parents’ smoking status (P<0.01), peers’ smokeless use status (P<0.01) and perception that smoking made one comfortable at social events (P<0.01). For intention to quit smokeless tobacco use, significant predictors after adjustment were parents’ smokeless use status, (P=0.03) perception that smokeless tobacco use made one more comfortable at social events (P=0.04) and perception of harm from smokeless use (P=0.02).
Conclusion:
This study demonstrates that the intention to quit smokeless and cigarette tobacco use is significantly predicted by perception about the societal acceptance of tobacco use at social events, parents and peers’ tobacco use status as well as the perception of harm from use of tobacco products. Providing social support may increase quit attempts among youth smokers.
doi:10.4103/0300-1652.99829
PMCID: PMC3530241  PMID: 23271842
Adolescents; cigarettes; intention to quit; interventions; smokeless-tobacco; smoking; tobacco
13.  Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2014;9(3):173-178.
AIM:
This study aimed at assessing prevailing patterns and risk factors of tobacco consumption among clients, food handlers and employers of food facilities, in Riyadh, Saudi Arabia.
METHODS:
A cross-sectional approach to a representative sample of food facilities in Riyadh was used. A sample of 3000 participants included clients (75%); food handlers/hospitality workers (20 %) and employers (5 %). Participants were reached at restaurants, food courts or cafes. A modified version of the WHO-CDC-Global Youth Tobacco Survey questionnaire was used for data collection.
RESULTS:
The prevalence of tobacco use at food facilities was found to be 40.3 %, of which 74% were customers, 18.8% were food handlers and 7.2% were managers. The consumption of tobacco was higher at restaurants (39.9%), but lowest at food courts of shopping malls. Water pipe (55.3%) was the main consumption type, followed by cigarettes (42.6%) and chewing tobacco (2.1%). Multivariate analysis showed that gender (male), marital status (single), and type of food facility (Estaraha and café/coffee shop) were independent risk factors associated with tobacco use at food facilities.
CONCLUSION:
Tobacco use is very common in food facilities in Riyadh as reflected by results of our study, especially among single males Saudis. We should build on success encountered in banning smoking in airports, airplanes, shopping malls, market places, educational institutions and healthcare facilities, extending the ban to include food facilities as well. This is important for the health of non-smokers as well as smokers themselves.
doi:10.4103/1817-1737.134075
PMCID: PMC4073576  PMID: 24987478
Food facilities; Riyadh; Saudi Arabia; tobacco use
14.  Prevalence and social environment of cigarette smoking in Cyprus youth 
BMC Public Health  2008;8:190.
Background
Tobacco use is the single most preventable cause of morbidity and mortality in humans. Limited data exist regarding the extent of the problem among Cyprus youth. We use the Global Youth Tobacco Survey to assess the prevalence of cigarette smoking among middle and high school students as well as the social environment in which this is taking place.
Methods
The survey was conducted by the Cyprus International Institute for the Environment and Public Health in association with Harvard School of Public Health. A two-stage cluster sample design was used to select a representative sample of students from middle and high schools registered with the Republic of Cyprus in 2005–2006. The study questionnaire consisted of 99 questions and participation in the survey was voluntary. Statistical analyses were performed taking into consideration the specific design of the study and the sample weights associated with each completed questionnaire.
Results
The prevalence of current smoking, defined as having smoked cigarettes on one or more days of the past 30 days, is 13% among boys and 7% among girls in middle schools, and 36% among boys and 23% among girls in high schools. Furthermore, 16% of middle school students and more than 24% of high school students that had never smoked indicated that they are likely to initiate smoking within the next year. Exposure to environmental tobacco smoke is also very high with 91% of students reporting being exposed to smoke in places outside home. In addition, more than 95% of current smokers reported that they had bought cigarettes in a store during the past month and were not refused cigarettes because of their age.
Conclusion
Smoking prevalence among Cyprus middle and high school students is high and there are indications of an increase in the prevalence of smoking among girls over the last few years. Susceptibility rates, exposure to second-hand smoke, and access to and availability of cigarettes to youth are also high and concerning. The present survey indicates that the problem of cigarette smoking among youth in Cyprus is significant and requires collective action immediately.
doi:10.1186/1471-2458-8-190
PMCID: PMC2435118  PMID: 18518947
15.  Smoking pattern among female college students in Dammam, Saudi Arabia 
Background:
Smoking is the most important avoidable cause of premature morbidity and mortality in the world. The estimated annual death rate of 4.9 million people in 1999 is expected to rise to 10 million by the 2020s and 2030s, 7 million of which will occur in developing countries.
Aim:
The aim of the present study was to estimate the prevalence of smoking and assess its pattern among non-medical female college students in Dammam, Saudi Arabia.
Materials and Methods:
A cross-sectional study was conducted of 1020 female students selected from the literature and science colleges by multi-stage stratified random sampling technique with proportional allocation. Data were collected using a self-administered modified WHO Global Youth Tobacco Survey questionnaire.
Results:
Results revealed that occurrence of smoking among female college students was 8.6%. It was significantly higher among literature college students (12.1%) than among Science College students (3.4%). The mean age at which smoking started was 16 ± 2.4 years, with a minimum of 11 years. More than half of the students who smoked were cigarette smokers, while 43.2% were shisha smokers. There was a strong relationship between parents who smoked and daughters who smoked. The main motive for smoking was curiosity (44.3%), followed by relief of tension (26.1%).
Conclusions:
It may be concluded that smoking is increasing among female college students in Saudi Arabia. Accordingly, it is recommended that a preventive comprehensive health education program on smoking be initiated for females in middle schools, that stricter tobacco control measures be adopted by the government, and that anti-smoking clinics be established in colleges.
doi:10.4103/2230-8229.83370
PMCID: PMC3159230  PMID: 21897913
College students; females; Saudi Arabia; smoking
16.  A Longitudinal Study of Exposure to Retail Cigarette Advertising and Smoking Initiation 
Pediatrics  2010;126(2):232-238.
OBJECTIVES
Accumulating evidence suggests that widespread advertising for cigarettes at the point of sale encourages adolescents to smoke; however, no longitudinal study of exposure to retail tobacco advertising and smoking behavior has been reported.
METHODS
A school-based survey included 1681 adolescents (aged 11–14 years) who had never smoked. One measure of exposure assessed the frequency of visiting types of stores that contain the most cigarette advertising. A more detailed measure combined data about visiting stores near school with observations of cigarette advertisements and pack displays in those stores. Follow-up surveys 12 and 30 months after baseline (retention rate: 81%) documented the transition from never to ever smoking, even just a puff.
RESULTS
After 12 months, 18% of adolescents initiated smoking, but the incidence was 29% among students who visited convenience, liquor, or small grocery stores at least twice per week and 9% among those who reported the lowest visit frequency (less than twice per month). Adjusting for multiple risk factors, the odds of initiation remained significantly higher (odds ratio: 1.64 [95% confidence interval: 1.06–2.55]) for adolescents who reported moderate visit frequency (0.5–1.9 visits per week), and the odds of initiation more than doubled for those who visited ≥2 times per week (odds ratio: 2.58 [95% confidence interval: 1.68–3.97]). Similar associations were observed for the more detailed exposure measure and persisted at 30 months.
CONCLUSIONS
Exposure to retail cigarette advertising is a risk factor for smoking initiation. Policies and parenting practices that limit adolescents’ exposure to retail cigarette advertising could improve smoking prevention efforts.
doi:10.1542/peds.2009-3021
PMCID: PMC3046636  PMID: 20643725
adolescence; advertising; cohort studies; smoking
17.  Perceptions about the harm of secondhand smoke exposure among U.S. middle and high school students: findings from the 2012 National Youth Tobacco Survey 
Tobacco Induced Diseases  2013;11(1):16.
Background
Increased knowledge of the harmful effects of SHS is an evidence-based key indicator for eliminating nonsmokers’ exposure to SHS. This study assessed the prevalence and predictors of perceptions about the harm of secondhand smoke (SHS) exposure among U.S. middle and high school students.
Findings
Data were obtained from the 2012 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6–12. Respondents who reported that they thought breathing smoke from other people’s cigarettes or other tobacco products causes “some” or “a lot” of harm were considered to have the perception that SHS is harmful. Multivariate logistic regression was used to identify predictors of the perception that SHS is harmful. Predictors included sex, race/ethnicity, school grade level, current tobacco use, and whether the respondent currently lived with a tobacco user. Overall, 75.4% of students perceived SHS exposure as harmful. The adjusted odds of perceiving SHS exposure as harmful were higher among non-Hispanic Asians than among non-Hispanic whites, and among students in 10th-12th grades than among students in 8th grade. Adjusted odds were lower among boys than among girls, among non-Hispanic blacks than among non-Hispanic whites, among students living with a tobacco user than among those not, and among those who use combustible tobacco only or both combustible and non-combustible tobacco than among those who use no tobacco.
Conclusions
Most middle and high school students perceive SHS exposure as harmful, but efforts are needed to increase the prevalence of this perception in certain subpopulations, particularly tobacco users.
doi:10.1186/1617-9625-11-16
PMCID: PMC3717105  PMID: 23867000
Tobacco; Tobacco smoke pollution; Adolescent; Perception; Risk; Students
18.  Prevalence of Smoking and its Related Behaviors and Beliefs Among Secondary School Students in Riyadh, Saudi Arabia 
Objective:
To estimate the prevalence of smoking among secondary school students in National Guard area of Riyadh, and explore the reasons for the smoking and the attitude of non-smoker toward smoking habit.
Design:
A cross-sectional study was conducted in June 2009. By random sampling technique 255 students were enrolled from secondary school of National Guard area, Riyadh, Saudi Arabia. A self-administered questionnaire was used for data collection.
Results:
Current smokers represented 28.6% of the students. The most common reasons for smoking were: having free time (81.6%), for the relief of stress (63.2%) and seeing some of their teachers smoking (61.8%).
Most of the smokers started the habit before the age of 15 years old (89%). 84% of non-smokers suggested to ban smoking in public places. 42.2% of students were planning to start smoking in future.
Religion was the most important reason for not smoking among non smokers.
Conclusion:
The prevalence of smoking is big enough a problem to be considered as a warning for an impending epidemic Health education provision should have a greater role in schools Governmental commitment and social support are vital if health education and awareness and especially quit smoking programs are to be implemented and sustained.
PMCID: PMC3312769  PMID: 22489230
Secondary school student; smoking; shisha; magha; Riyadh
19.  Cigarette smoking among female students in five medical and nonmedical colleges 
Objectives
This study was conducted to determine the prevalence of smoking, knowledge about the ill effects of smoking on health, and the influence of family members’ smoking habits among Saudi female students.
Methods
This is a type of cross-sectional study. A sample of 1,070 female students was selected by a nonrandom and convenient sampling method from five colleges (Medicine, Business and Administration, Computer Sciences, Education, and Languages and Translation) of King Saud University, Riyadh, Saudi Arabia. A self-administrated questionnaire was used to determine the personal, social, and educational characteristics of the respondents. In addition, questions about their smoking types, status, duration of smoking, knowledge about the ill effects of smoking, daily cigarette consumption, and reasons for quitting smoking were included.
Results
The students’ response rate was 85%. The prevalence of current smoking was 4.3% and 5.6% for cigarettes and water-pipes, respectively, whereas 3.9% of the participants were ex-smokers. The prevalence of current smoking was highest in the College of Business and Administration (10.81%) and lowest in the College of Medicine (0.86%). The majority (77%) of the smokers’ parents (current and ex-smokers) were also smokers. More than half (54%) of the smokers started their smoking habit for entertainment, and 44.4% of the participants did not know that smoking causes serious health problems. The most common factors for quitting smoking were health concerns (54%), religious beliefs (29%), and parent’s advice (17%).
Conclusion
The study concludes that the prevalence of smoking varies in different subject streams and that family and friends have a great influence on individuals starting or stopping smoking. Extensive health education programs are needed to educate young women on the health hazards of smoking and help stop them from smoking.
doi:10.2147/IJGM.S48630
PMCID: PMC3754488  PMID: 23986648
smoking prevalence; quitting smoking; female students; cigarettes per day
20.  Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey 
BMC Public Health  2008;8:97.
Background
College students are vulnerable to tobacco addiction. Tobacco industries often target college students for marketing. Studies about prevalence of tobacco use and its correlates among college students in Nepal are lacking.
Methods
A cross-sectional survey was carried out in two cities of western Nepal during January-March, 2007. A pre-tested, anonymous, self-administered questionnaire (in Nepali) adapted from Global Youth Tobacco Survey (GYTS) and a World Bank study was administered to a representative sample of 1600 students selected from 13 junior colleges by two-stage stratified random sampling.
Results
Overall prevalence of 'ever users' of tobacco products was 13.9%. Prevalence among boys and girls was 20.5% and 2.9% respectively. Prevalence of 'current users' was 10.2% (cigarette smoking: 9.4%, smokeless products: 6.5%, and both forms: 5.7%). Median age at initiation of cigarette smoking and chewable tobacco was 16 and 15 years respectively. Among the current cigarette smokers, 58.7% (88/150) were smoking at least one cigarette per day. Most (67.8%) 'Current users' purchased tobacco products by themselves from stores or got them from friends. Most of them (66.7%) smoked in tea stalls or restaurants followed by other public places (13.2%). The average daily expenditure was 20 Nepalese rupees (~0.3 USD) and most (59%) students reported of having adequate money to buy tobacco products. Majority (82%) of the students were exposed to tobacco advertisements through magazines/newspapers, and advertising hoardings during a period of 30 days prior to survey. The correlates of tobacco use were: age, gender, household asset score and knowledge about health risks, family members, teachers and friends using tobacco products, and purchasing tobacco products for family members.
Conclusion
School/college-based interventions like counseling to promote cessation among current users and tobacco education to prevent initiation are necessary. Enforcement of legislations to decrease availability, accessibility and affordability of tobacco products and policies to change social norms of tobacco use among parents and teachers are necessary to curb the tobacco use among college students.
doi:10.1186/1471-2458-8-97
PMCID: PMC2292712  PMID: 18366781
21.  Perceived Enforcement of School Tobacco Policy and Adolescents’ Cigarette Smoking 
Preventive medicine  2009;48(6):562-566.
Objectives
School tobacco use policies are part of a comprehensive strategy for preventing or reducing adolescent cigarette smoking. This study examines the relationship between perceived tobacco policy enforcement at the school level and smoking behaviors among students.
Methods
21,281 middle and high school students of 255 schools in the 2006 Oregon Health Teens Survey. Multilevel logistic regression was conducted, using a school-level policy enforcement measure based on aggregated student reports, and individual-level characteristics (e.g., age, gender, cigarette smoking before age 12, personal beliefs about smoking) as predictors of past-30-day cigarette smoking behaviors (e.g., any smoking, daily smoking, heavy episodic smoking, smoking on school property).
Results
Higher levels of perceived enforcement of anti-smoking policy at the school level were inversely associated with the prevalence of past-30-day smoking behaviors, independent of individual-level predictors.
Conclusions
Stricter enforcement of school policies against tobacco use may help prevent or reduce adolescents’ cigarette smoking on and outside of school property.
doi:10.1016/j.ypmed.2009.03.008
PMCID: PMC2748128  PMID: 19285525
Adolescents; Cigarette smoking behaviors; School tobacco policy; Prevention
22.  A Multiple Indicators and Multiple Causes Model of Alternative Tobacco Use 
Objective
To examine the relationship between adolescents’ cigarette smoking experiences and alternative tobacco product (ATP) use.
Methods
Multiple indicators and multiple causes (MIMIC) models estimated simultaneously the relationship between cigarette smoking experiences and ATP use among high school students (N=1827) completing the 2009 Virginia Youth Tobacco Survey.
Results
Overall, ATP use was associated with adolescents’ ever use of cigarettes, early onset of cigarette smoking, cigarettes smoked per day, and peer smoking; however, important model differences between racial/ethnic groups were observed.
Conclusions
Prevention and cessation programs might reduce adolescent ATP use by targetting specific characterstics of cigarette smoking.
doi:10.5993/AJHB.37.1.3
PMCID: PMC3739477  PMID: 22943098
adolescents; cigarette smoking; alternative tobacco product use; polytobacco
23.  State-Level Tobacco Control Policies and Youth Smoking Cessation Measures 
Objective
Research on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991–2006.
Methods
The study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.
Results
Results showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.
Conclusions
Findings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.
doi:10.1016/j.healthpol.2010.04.009
PMCID: PMC2930051  PMID: 20483500
adolescent; smoking cessation; tobacco control; policy
24.  Prevalence of and Susceptibility to Cigarette Smoking Among Female Students Aged 13 to 15 Years in Vietnam, 2007 
Preventing Chronic Disease  2009;7(1):A11.
Introduction
Recent reports show a sharp increase in smoking rates among girls. We describe prevalence of cigarette smoking and susceptibility to cigarette smoking among female students aged 13 to 15 years in Vietnam and examine the associated factors.
Methods
We used data from female secondary school students aged 13 to 15 years (grades 8-10) from the 2007 Global Youth Tobacco Survey that was conducted in 9 provinces in Vietnam. We used multivariate logistic regression analysis to determine associations between independent variables with smoking status and susceptibility to smoking.
Results
Prevalence of cigarette smoking among girls was 1.2% (95% confidence interval [CI], 0.9-1.5), and 1.5% (95% CI, 1.2-1.9) of girls were susceptible to smoking. Having friends who smoke was the strongest predictor of both smoking status and susceptibility to smoking. Attendance at school classes that described the harmful effects of smoking had significant effects in reducing cigarette smoking. Girls who were exposed to billboard cigarette advertising were more likely to be susceptible to smoking than were those who had not seen advertisements.
Conclusion
Our findings highlight the need for pursuing school-based intervention programs in Vietnam and for countering tobacco advertising and marketing practices that target young women.
PMCID: PMC2811506  PMID: 20040226
25.  Exploration of the Link between Tobacco Retailers in School Neighborhoods and Student Smoking 
The Journal of school health  2013;83(2):112-118.
BACKGROUND
School smoking bans give officials the authority to provide a smoke-free environment, but enacting policies within the school walls is just one step in comprehensive tobacco prevention among students. It is necessary to investigate factors beyond the school campus and into the neighborhoods that surround schools. The purpose of this study was to explore the relationship between the density of tobacco retailers and the illegal tobacco sales rate within school neighborhoods and smoking behaviors among students.
METHODS
This study utilized secondary data from the baseline of the Youth Tobacco Access Project. Data were collected from 10,662 students attending 21 middle schools and 19 high schools, in addition to 512 tobacco retailers, all within 24 towns in Illinois during 2002. A random-effects regression analysis was performed to assess the relationship between the density of tobacco retailers and illegal tobacco sales rates on current smoking and lifetime smoking prevalence.
RESULTS
Schools had a range of between zero and 9 tobacco retailers within their neighborhood with a mean of 2.76 retailers (SD= 2.45). The illegal sales rate varied from zero to 100%, with a mean of thirteen percent. The density of tobacco retailers was significantly related to the prevalence of ever smoking among students (b= 0.09, t(29) = 2.03, p = .051, OR = 1.10), but not to current smoking (p >.05); the illegal tobacco sales rate was not related to current smoking or lifetime smoking prevalence (p >.05).
CONCLUSION
Results indicate that tobacco retailer density may impact smoking experimentation/initiation
doi:10.1111/josh.12006
PMCID: PMC3556821  PMID: 23331271

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