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1.  The Global Youth Tobacco Survey: 2001–2002 in Riyadh region, the Kingdom of Saudi Arabia 
Tobacco use is a major public health problem, and its prevalence is globally increasing, especially among children and adolescents.
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.
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.
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.
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
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.
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.
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.
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.
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.
PMCID: PMC3131756  PMID: 21760845
Cigarette smoking; prevalence; Saudi Arabia
3.  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.
PMCID: PMC3827661  PMID: 24159909
Co-substance use; priority/special populations; tobacco
4.  Smoking pattern among female college students in Dammam, Saudi Arabia 
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.
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 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%).
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.
PMCID: PMC3159230  PMID: 21897913
College students; females; Saudi Arabia; smoking
5.  Knowledge, attitude and practice of tobacco smoking by medical students in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2010;5(3):145-148.
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.
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.
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).
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.
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.
PMCID: PMC2930652  PMID: 20835308
Medical students; Saudi Arabia; smoking
6.  E-cigarettes and conventional cigarette use among US adolescents: A cross-sectional study 
JAMA pediatrics  2014;168(7):610-617.
E-cigarette use is increasing rapidly among adolescents and e-cigarettes are currently unregulated.
Examine e-cigarette use and conventional cigarette smoking.
Cross-sectional analyses of survey data.
2011 and 2012 National Youth Tobacco Surveys (NYTS)
Representative sample of US middle and high school students in 2011 (n=17,353) and 2012 (n=22,529)
Ever and current e-cigarette use
Main outcome measures
Experimentation with, ever, and current smoking; smoking abstinence
In pooled analyses, among cigarette experimenters (≥1 puff), ever e-cigarette use was associated with higher odds of ever smoking cigarettes (≥100 cigarettes; OR= 6.31, 95% CI [5.39-7.39) and current cigarette smoking (OR=5.96 [5.67-6.27]). Current e-cigarette use was positively associated with ever smoking cigarettes (OR=7.42 [5.63-9.79]) and current cigarette smoking (OR= 7.88 [6.01-10.32]. In 2011, current cigarette smokers who had ever used e-cigarettes were more likely to intend to quit smoking within the next year (OR=1.53 [1.03-2.28]). Among experimenters with conventional cigarettes, ever use of e-cigarettes was also associated with lower 30-day (OR=0.24 [0.21-0.28]), 6-month (OR=0.24 [0.21-0.28]), and 1-year (OR=0.25 [0.21-0.30]) abstinence from cigarettes. Current e-cigarette use was also associated with lower 30-day (OR=0.11 [0.08-0.15]), 6-month (OR=0.11 [0.08-0.15]), and 1-year (OR=0.12 [0.07-0.18]) abstinence. Among ever smokers of cigarettes (≥100 cigarettes), ever e-cigarette use was negatively associated with 30-day (OR=0.61, [0.42-0.89]), 6-month (OR=0.53, [0.33-0.83]) and one-year (OR=0.32 [0.18-0.56) abstinence from conventional cigarettes. Current e-cigarette use was also negatively associated with 30-day (OR=0.35 [0.18-0.69]), 6-month (OR=0.30 [0.13-0.68]), and one-year (OR=0.34 [0.13-0.87]) abstinence.
E-cigarette use was associated with higher odds of ever or current cigarette smoking, higher odds of established smoking, higher odds of planning to quit smoking among current smokers, and, among experimenters, lower odds of abstinence from conventional cigarettes.
Results suggest e-cigarette use does not discourage, and may encourage, conventional cigarette use among US adolescents.
PMCID: PMC4142115  PMID: 24604023
7.  Prevalence and Determinants of Waterpipe Tobacco Use among Adolescents in Oman 
To assess the prevalence and determinants of waterpipe use among school-going adolescents in Oman.
A cross-sectional, school-based study was conducted in 2003 involving 9 regions of Oman, as part of the Global Youth Tobacco Survey. Participants were requested to complete an anonymous questionnaire containing demographic characteristics, current and previous use of waterpipe tobacco, attitudes towards cigarette smoking, parents’ and friends’ cigarette smoking habits. Proportions were used to calculate prevalence rates and logistic regression analysis to obtain odds ratio (OR) and 95% confidence interval (CI).
1,962 students participated of whom 1,005 (51.2%) were males. Eighty-eight percent were between 13 and 16 years of age. Five hundred and twenty-two (26.6%) reported ever smoking waterpipe tobacco while 189 (9.6%) were current users. Among males, 155 (15.5%) were current users while among females only 24 (2.6%) smoked currently. Study participants were more likely to use waterpipe if they had a parent or friend who smoked cigarettes. Adolescents were, however, less likely to use waterpipe tobacco if they believed that cigarette smoking was harmful to health. Students who were receiving 500 Baisas (US$ 1.3) or more per day pocket money were more likely to use waterpipe tobacco compared to those receiving less (OR 3.3, 95% CI 2.3 to 4.6). In multivariate analysis, the OR for males being a smoker of waterpipe tobacco compared to females was 4.46 (95% CI, 2.38 to 8.35); while the OR for most or all friends smoking cigarettes compared to non-smoking was OR 5.65 (95% CI 2.87 to 11.13). Study participants who perceived smoking as harmful to health were less likely to use waterpipe tobacco compared to those who did not believe smoking was harmful (OR 0.31, 95% CI 0.29 to 0.92) and those receiving 500 Baisas or more (OR 2.2, 95% CI 1.5 to 3.2).
Waterpipe smoking among Omani adolescents is an emerging public health concern. Efforts to prevent adolescent smoking should be designed with knowledge of associated factors of such behaviour and should include all forms of tobacco.
PMCID: PMC3087736  PMID: 21654955
Tobacco; Waterpipe; Adolescents; Oman
8.  Changes in Exposure to Secondhand Smoke Among Youth in Nebraska, 2002–2006 
Preventing Chronic Disease  2008;5(3):A84.
Secondhand smoke is a major cause of morbidity and mortality. It has been associated with serious health problems in both children and adults. Efforts to reduce exposure to secondhand smoke in Nebraska have included programs to prevent tobacco use among young people and campaigns for smoke-free workplaces and homes. Despite these interventions, young people continue to be exposed to secondhand smoke at an unacceptably high rate. The objective of this study was to examine the extent to which Nebraska public middle and high school students were exposed to secondhand smoke in 2002 and 2006, to evaluate factors associated with this exposure, and to propose interventions.
The Nebraska Youth Tobacco Survey was administered in 2002 and 2006 to a representative sample of students from public middle and high schools. All students who chose to participate completed an anonymous, self-administered survey that included questions on demographics, tobacco use, tobacco-related knowledge and attitudes, and exposure to secondhand smoke. Data were weighted to account for nonresponses at both student and school levels and to ensure generalizability of the estimates for public school students in Nebraska according to their grade, sex, and race/ethnicity. This study analyzed a subset of responses on secondhand smoke exposure, which was defined as being in a room or vehicle during the previous 7 days with someone who was smoking cigarettes.
Secondhand smoke exposure in a room, a vehicle, or both declined significantly among all students from 2002 (69.0%) to 2006 (61.3%). In both 2002 and 2006, students were significantly more likely to be exposed to secondhand smoke in a room than in a vehicle (64.4% vs 48.2% in 2002 and 56.9% vs 40.2% in 2006). Among racial and ethnic groups, only white students experienced a significant decline in exposure from 2002 (70.0%) to 2006 (61.4%). Girls were significantly more likely to be exposed to secondhand smoke in 2006 than were boys, and only boys experienced a significant overall decline in exposure from 2002 (69.3%) to 2006 (57.7%). Smoking behaviors and attitudes continued to influence secondhand smoke exposure from 2002 to 2006, although students experienced significant declines whether they were smokers or nonsmokers, and whether they lived with a smoker or not. Those with close friends who smoked and those who did not perceive secondhand smoke as harmful, however, did not benefit.
These data indicate reductions in exposure to secondhand smoke among Nebraska's middle and high school students, but exposure remains a problem, particularly in rooms. Adoption of a comprehensive statewide smoke-free policy will contribute to significantly reduced exposure to secondhand smoke among young people in public places, but other measures to address exposure in the home and private vehicles are needed or should be strengthened. These include physician counseling based on behavioral change theory to encourage cessation and home-based no-smoking rules, in addition to interventions that target minorities, who are disproportionately affected by secondhand smoke exposure. Evaluation of existing measures, such as programs to prevent tobacco use among young people and campaigns to collect pledges for smoke-free homes, will be required to determine their effectiveness in reducing exposure to secondhand smoke among youth in Nebraska.
PMCID: PMC2483572  PMID: 18558034
9.  The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation 
PLoS Medicine  2012;9(11):e1001336.
David Levy and colleagues use the SimSmoke model to estimate the effect of Brazil's recent stronger tobacco control policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.
Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.
Methods and Findings
The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%–66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000–715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million–10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%–54%), and 1.3 million (0.9 million–2.0 million) out of 9 million future premature deaths could be averted.
Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives.
Please see later in the article for the Editors' Summary
Editors' Summary
Tobacco kills up to half its users—more than 5 million smokers die every year from tobacco-related causes. It also kills more than half a million non-smokers annually who have been exposed to second-hand smoke. If current trends continue, annual tobacco-related deaths could increase to more than 8 million by 2030. In response to this global tobacco epidemic, the World Health Organization has developed an international instrument for tobacco control called the Framework Convention on Tobacco Control (FCTC). Since it came into force in February 2005, 176 countries have become parties to the FCTC. As such, they agree to implement comprehensive bans on tobacco advertizing, promotion, and sponsorship; to ban misleading and deceptive terms on tobacco packaging; to protect people from exposure to cigarette smoke in public spaces and indoor workplaces; to implement tax policies aimed at reducing tobacco consumption; and to combat illicit trade in tobacco products.
Why Was This Study Done?
Brazil has played a pioneering role in providing support for tobacco control measures in low and middle income countries. It introduced its first cigarette-specific tax in 1990 and, in 1996, it placed the first warnings on cigarette packages and introduced smoke-free air laws. Many of these measures have subsequently been strengthened. Over the same period, the prevalence of smoking among adults (the proportion of the population that smokes) has halved in Brazil, falling from 34.8% in 1989 to 18.5% in 2008. But did the introduction of tobacco control policies contribute to this decline, and if so, which were the most effective policies? In this study, the researchers use a computational model called the SimSmoke tobacco control policy model to investigate this question and to examine the possible effect of introducing additional control policies consistent with the FCTC, which Brazil has been a party to since 2006.
What Did the Researchers Do and Find?
The researchers developed Brazil SimSmoke by incorporating policy, population, and smoking data for Brazil into the SimSmoke simulation model; Brazil SimSmoke estimates smoking prevalence and smoking-attributable deaths from 1989 forwards. They then compared smoking prevalences and smoking-attributable deaths estimated by Brazil SimSmoke for 2010 with and without the inclusion of the tobacco control policies that were introduced between 1989 and 2010. The model estimated that the smoking prevalence in Brazil in 2010 was reduced by 46% by the introduction of tobacco control measures. Almost half of this reduction was explained by price increases, 14% by smoke-free laws, 14% by marketing restrictions, 8% by health warnings, 6% by anti-smoking media campaigns, and 10% by cessation treatment programs. Moreover, as a result of past policies, the model estimated that almost 420,000 tobacco-related deaths had been averted by 2010 and that almost 7 million deaths will have been averted by 2050. Finally, using the model to compare the effects of a scenario that includes stricter policies (for example, an increase in tobacco tax) with a scenario that includes the 2010 policies only, indicated that stricter control policies would reduce the estimated smoking prevalence by an extra 39% between 2010 and 2050 and avert about 1.3 million additional premature deaths.
What Do These Findings Mean?
These findings indicate that the introduction of tobacco control policies has been a critical factor in the rapid decline in smoking prevalence in Brazil over the past 20 years. They also suggest that the introduction of stricter policies that are fully consistent with the FCTC has the potential to reduce the prevalence of smoking further and save many additional lives. Although the reduction in smoking prevalence in Brazil between 1989 and 2010 predicted by the Brazil SimSmoke model is close to the recorded reduction over that period, these findings need to be interpreted with caution because of the many assumptions incorporated in the model. Moreover, the accuracy of the model's predictions depends on the accuracy of the data fed into it, some of which was obtained from other countries and may not accurately reflect the situation in Brazil. Importantly, however, these findings show that, even for a middle income nation, reducing tobacco use is a “winnable battle” that carries huge dividends in terms of reducing illness and death without requiring unlimited resources.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization provides information about the dangers of tobacco (in several languages), about the Framework Convention on Tobacco Control, and about tobacco control in Brazil
The Framework Convention Alliance provides more information about the FCTC
The Brazilian National Cancer Institute (INCA) provides information on tobacco control policies in Brazil; additional information about tobacco control laws in Brazil is available on the Tobacco Control Laws interactive website, which provides information about tobacco control legislation worldwide
More information on the SimSmoke model of tobacco control policies is available in document or slideshow form
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
PMCID: PMC3491001  PMID: 23139643
10.  Prevalence of and factors associated with daily smoking among Inner Mongolia medical students in China: a cross-sectional questionnaire survey 
To date, no study on smoking behavior of medical students in Inner Mongolia has been reported. The aim of the present study was to determine the 1-month prevalence of and factors associated with daily smoking among medical students in Inner Mongolia of China, to assist interventions designed to reduce the smoking behavior of medical college students in this region.
During December 2010 and January 2011 a cross-sectional survey was conducted among medical students at the Inner Mongolia Medical College using a self-administered questionnaire. The questionnaire consisted of three sections: students’ basic information, attitude on smoking behavior, and smoking status of the student daily smokers. Students who smoked every day in the last 30 days were regarded as daily smokers. Factors associated with smoking were identified using binary logistic regression analysis.
A total of 6044 valid surveys were returned. The overall prevalence of daily smoking was 9.8% while the prevalence of daily smoking among males and females were 29.4% and 1.7%, respectively. Males in the Faculty of Medicine Information Management had the highest daily smoking rate (48.9%). Logistic regression models found that the main factors associated with daily smoking among male medical students were highest year of study (OR = 3.62; CI: 1.18–11.05); attitude towards smoking behavior Do not care about people smoking around you (OR = 2.75; CI: 2.08–3.64); and Smoking is harmful to their health (OR = 4.40; CI: 2.21–8.75). The main factor associated with daily smoking among female medical students was attitude towards smoking behavior Eliminate smoking on campus (OR = 0.11; CI: 0.06–0.23). Both for male and female medical students, there was no association between ethnicity and cigarette daily smoking. In regard to smoking status, more than 60% of daily smokers began smoking in high school, 61.3% smoked less than 5 cigarettes per day, 62.9% of the daily smokers’ families opposed their smoking behavior, and after an hour of not smoking 74.6% daily smokers did not feel uncomfortable.
Antismoking education should be further promoted in Inner Mongolia medical students, with consideration given to the factors associated with daily smoking behavior found in the present study.
PMCID: PMC3419670  PMID: 22591602
Daily smoking; Behavior; Medical students; Prevalence
11.  Prevalence and social environment of cigarette smoking in Cyprus youth 
BMC Public Health  2008;8:190.
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.
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.
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.
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.
PMCID: PMC2435118  PMID: 18518947
12.  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.
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.
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.
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.
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
13.  Khat Chewing Habit among School Students of Jazan Region, Saudi Arabia 
PLoS ONE  2013;8(6):e65504.
The use of Khat leaves (Catha edulis) in Jazan, southwest of KSA, is prevalent among all segments of the population.
This study was conducted to assess the prevalence and predictors of Khat chewing among intermediate and secondary school students of Jazan region.
A cross-sectional survey was conducted in late 2011 in Jazan region. A random sample of 3923 students was selected from 72 intermediate and upper secondary schools representing the different educational sectors of the region. A structured self-administered questionnaire was used for data collection. Descriptive statistics, a chi-squared test and logistic regression were performed to examine the prevalence, associations and predictors of Khat chewing.
The overall Khat chewing prevalence among students was 20.5% (95% C.I.: 19.27–21.79). The prevalence was significantly higher among males, at 33.1% (95% CI: 31.16–35.08), than among females 4.3% (95% C.I.: 3.39–5.31) (P<0.001). Univariate analysis revealed that gender, age, academic performance, friends’ smoking and Khat chewing, and students’ smoking status were associated with a significantly high risk of Khat chewing (P<0.001 for all). The multivariate logistic regression analysis suggested that the most important independent predictors of Khat chewing among the students in our sample were students’ smoking status (OR = 13.02, P<0.001), friends’ use of Khat (OR = 5.65, P<0.001), gender (OR = 4.62, P<0.001), and friend’s use of tobacco (OR = 1.43, P<0.001).
A significant percentage of students chew Khat. The abuse of Khat is significantly associated with gender, peer influence, and cigarette smoking. Intervention programs are needed to create awareness among school students and to reduce the prevalence of the habit and its unfavorable consequences.
PMCID: PMC3679146  PMID: 23776490
14.  Self-reported tobacco smoking practices among medical students and their perceptions towards training about tobacco smoking in medical curricula: A cross-sectional, questionnaire survey in Malaysia, India, Pakistan, Nepal, and Bangladesh 
Tobacco smoking issues in developing countries are usually taught non-systematically as and when the topic arose. The World Health Organisation and Global Health Professional Student Survey (GHPSS) have suggested introducing a separate integrated tobacco module into medical school curricula. Our aim was to assess medical students' tobacco smoking habits, their practices towards patients' smoking habits and attitude towards teaching about smoking in medical schools.
A cross-sectional questionnaire survey was carried out among final year undergraduate medical students in Malaysia, India, Nepal, Pakistan, and Bangladesh. An anonymous, self-administered questionnaire included items on demographic information, students' current practices about patients' tobacco smoking habits, their perception towards tobacco education in medical schools on a five point Likert scale. Questions about tobacco smoking habits were adapted from GHPSS questionnaire. An 'ever smoker' was defined as one who had smoked during lifetime, even if had tried a few puffs once or twice. 'Current smoker' was defined as those who had smoked tobacco product on one or more days in the preceding month of the survey. Descriptive statistics were calculated.
Overall response rate was 81.6% (922/1130). Median age was 22 years while 50.7% were males and 48.2% were females. The overall prevalence of 'ever smokers' and 'current smokers' was 31.7% and 13.1% respectively. A majority (> 80%) of students asked the patients about their smoking habits during clinical postings/clerkships. Only a third of them did counselling, and assessed the patients' willingness to quit. Majority of the students agreed about doctors' role in tobacco control as being role models, competence in smoking cessation methods, counseling, and the need for training about tobacco cessation in medical schools. About 50% agreed that current curriculum teaches about tobacco smoking but not systematically and should be included as a separate module. Majority of the students indicated that topics about health effects, nicotine addiction and its treatment, counselling, prevention of relapse were important or very important in training about tobacco smoking.
Medical educators should consider revising medical curricula to improve training about tobacco smoking cessation in medical schools. Our results should be supported by surveys from other medical schools in developing countries of Asia.
PMCID: PMC2994841  PMID: 21080923
15.  Comparison of Cigarette and Water-Pipe Smoking By Arab and Non–Arab-American Youth 
Water-pipe smoking is a rapidly growing form of tobacco use worldwide. Building on an earlier report of experimentation with cigarette and water-pipe smoking in a U.S. community sample of Arab-American youth aged 14–18 years, this article examines water-pipe smoking in more detail (e.g., smoking history, belief in harmfulness compared to cigarettes, family members in home who smoke water pipes) and compares the water-pipe–smoking behaviors of Arab-American youth with non–Arab-American youth in the same community.
A convenience sample of 1872 Arab-American and non–Arab-American high school students from the Midwest completed a 24-item tobacco survey. Data were collected in 2004–2005 and analyzed in 2007–2008.
Arab-American youth reported lower percentages of ever cigarette smoking (20% vs 39%); current cigarette smoking (7% vs 22%); and regular cigarette smoking (3% vs 15%) than non–Arab-American youth. In contrast, Arab-American youth reported significantly higher percentages of ever water-pipe smoking (38% vs 21%) and current water-pipe smoking (17% vs 11%) than non–Arab-American youth. Seventy-seven percent perceived water-pipe smoking to be as harmful as or more harmful than cigarette smoking. Logistic regression showed that youth were 11.0 times more likely to be currently smoking cigarettes if they currently smoked water pipes. Youth were also 11.0 times more likely to be current water-pipe smokers if they currently smoked cigarettes. If one or more family members smoked water pipes in the home, youth were 6.3 times more likely to be current water-pipe smokers. The effects of ethnicity were reduced as a result of the explanatory value of family smoking.
Further research is needed to determine the percentages, patterns, and health risks of water-pipe smoking and its relationship to cigarette smoking among all youth. Additionally, youth tobacco prevention/cessation programs need to focus attention on water-pipe smoking in order to further dispel the myth that water-pipe smoking is a safe alternative to cigarette smoking.
PMCID: PMC2575814  PMID: 18675529
16.  Evaluation of factors influencing intention to quit smokeless and cigarette tobacco use among Nigerian adolescents 
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.
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).
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.
PMCID: PMC3530241  PMID: 23271842
Adolescents; cigarettes; intention to quit; interventions; smokeless-tobacco; smoking; tobacco
17.  Patterns of tobacco consumption in food facilities in Riyadh, Saudi Arabia 
Annals of Thoracic Medicine  2014;9(3):173-178.
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.
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.
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.
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.
PMCID: PMC4073576  PMID: 24987478
Food facilities; Riyadh; Saudi Arabia; tobacco use
18.  Prevalence of smoking among male secondary school students in Jeddah, Saudi Arabia 
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.
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.
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.
PMCID: PMC3957170  PMID: 24672274
Smoking; male students; secondary school; prevalence; behavior
19.  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
20.  Prevalence and determinants of tobacco use among Iraqi adolescents: Iraq GYTS 2012 
Tobacco Induced Diseases  2013;11(1):14.
The use of any form of tobacco by 13–15 year old individuals is 10% globally as identified through the Global Youth Tobacco Survey (GYTS). This study aimed at assessing the prevalence and determinants of tobacco use among Iraqi adolescents.
A cross sectional study was carried out on 1750 participants selected randomly from preparatory and secondary schools in Baghdad, Iraq in 2012. Through a multistage stratified random sample scheme. The GYTS questionnaire was applied.
The study results indicated that 21.8% of Iraqi adolescents are tobacco users (male 27.1%, female 12.7%). Cigarette smoking was noted as the main type of tobacco use (13.9%) followed by shisha (4.8%) and pipe (1.4%). The stepwise logistic regression indicated a number of predictors of tobacco use. Male adolescents were twice more likely to be tobacco users than female students (OR 2.31; 95%C.I: 1.57-3.42). Furthermore, students whose parents or sibling were smokers had doubled the risk of tobacco use relative to those with no parents or siblings current smokers (OR1.97; 95%C.I: 1.04-2.77 and OR1.86; 95%C.I: 1.21-2.87 respectively). Having close friends who smoked was also identified as an important risk factor towards adolescent tobacco use. Those who reported that some of their friends smoked were 2.67 times more likely to be smokers (95%C.I: 1.83-3.89), while those who reported that most/all of their friends were smokers were 8.18 times more likely to be smokers themselves (95%C.I: 4.65-14.39).
Smoking rates among Iraqi adolescents were found to be among the higher rates of adolescent smoking prevalence in the Middle East. Multiple family and peer related characteristics were related to tobacco use. Preventive activities should take place to curb the tobacco epidemic in Iraq.
PMCID: PMC3750642  PMID: 23810083
Adolescents; Determinants; Smoking; Prevalence; Tobacco use; GYTS
21.  Tobacco use among youth: a cross country comparison 
Tobacco Control  2002;11(3):252-270.
Methods: The GYTS employs a standard methodology where self administered questionnaires, consisting of a set of core questions, are completed by a representative school based sample of students primarily between the ages of 13–15 years.
Results: Data are presented from 75 sites in 43 countries and the Gaza Strip/West Bank region. Current use of any tobacco product ranges from 62.8% to 3.3%, with high rates of oral tobacco use in certain regions. Current cigarette smoking ranges from 39.6% to less than 1%, with nearly 25% of students who smoke, having smoked their first cigarette before the age of 10 years. The majority of current smokers want to stop smoking and have already tried to quit, although very few students who currently smoke have ever attended a cessation programme. Exposure to advertising is high (75% of students had seen pro-tobacco ads), and exposure to environmental tobacco smoke (ETS) is very high in all countries. Only about half of the students reported that they had been taught in school about the dangers of smoking during the year preceding the survey.
Conclusions: Global youth tobacco use is already widespread throughout the world, but there is great variation among nations. Valid and reliable data on the extent of youth tobacco use, and correlates of use, are essential to plan and evaluate tobacco use prevention programmes. The GYTS has proven the feasibility of an inexpensive, standardised, worldwide surveillance system for youth tobacco use. The GYTS will be expanded to the majority of countries in the next few years, and can serve as a baseline for monitoring and evaluating global and national tobacco control efforts.
PMCID: PMC1759013  PMID: 12198280
22.  Current use of smokeless tobacco among adolescents in the Republic of Congo 
BMC Public Health  2010;10:16.
Tobacco use is a leading cause of global morbidity and mortality. Much of the epidemiologic research on tobacco focuses on smoking, especially cigarette smoking, but little attention on smokeless tobacco (SLT).
Using data from the Republic of Congo Global Youth Tobacco Survey (GYTS) of 2006, we estimated the prevalence of SLT use among in-school adolescents. We also assessed the association between SLT use and cigarette smoking as well as the traditional factors which are associated with cigarette smoking among adolescents (e.g. age, sex, parental or peer smoking). Unadjusted odds ratios (OR) and adjusted odds ratios (AOR) together with their 95% confidence intervals (CI) were used to measure magnitudes of associations.
Of the 3,034 respondents, 18.0% (18.0% males and 18.1% females) reported having used smokeless tobacco (chewing tobacco, sniff or dip) in the last 30 days. In multivariate analysis, no significant associations were observed between age and sex on one hand and current smokeless tobacco use on the other. Cigarette smokers were more than six times likely to report current use of smokeless tobacco (AOR = 6.65; 95% CI [4.84, 9.14]). Having parents or friends smokers was positively associated with using smokeless tobacco (AOR = 1.98; 95% CI [1.51, 2.59] for parents who smoked cigarettes, AOR = 1.82; 95% CI [1.41, 2.69] for some friends who smoked cigarettes, and AOR = 2.02; 95% CI [1.49, 2.47] for most or all friends who smoked cigarettes). Respondents who reported have seen tobacco advertisement on TV, billboards and in newspapers/magazines were 1.95 times more likely to report current use of smokeless tobacco (AOR = 1.95; 95% CI [1.34, 3.08]). Perception that smoking was harmful to health was negatively associated with current use of smokeless tobacco (AOR = 0.60; 95% CI [0.46, 0.78]).
Prevention programs aimed to reduce teen [cigarette] smoking must also be designed to reduce other forms of tobacco use. The teenagers environment at home, at school and at leisure must also be factored in order to prevent their uptake or maintenance of tobacco use.
PMCID: PMC2820474  PMID: 20074362
23.  Prevalence and determinants of susceptibility to cigarette smoking among school students in Pakistan: secondary analysis of Global Youth Tobacco Survey 
Susceptibility to smoke has been recognized as a strong predictor of smoking experimentation and taking up regular smoking habit. The identification of smoking susceptible individuals and its determinants is important in the efforts to reduce future smoking prevalence. The aims of this study are to estimate prevalence of susceptibility to smoke among adolescents, and identify factors associated with it.
Cross sectional data was obtained from Global Youth Tobacco Survey conducted in three cities of Pakistan in year 2004. Study population consisted of students in grades, 8th, 9th, and 10th; aged 13 to 15 years. Secondary analysis using univariate and multivariate logistic regression analyses were performed to estimate the associations between smoking susceptibility and co-variates. Descriptive statistics were reported in proportions, and adjusted odds ratios with 95% confidence interval were used to report logistic regression analyses.
Approximately 12% of nonsmoking students were found susceptible to smoking. Students, who were females (OR = 1.53, 95% CI [1.24-1.89]); whose parents (OR = 1.64, 95% CI [1.35-1.99]); or close friend smoked (OR = 2.77, 95% CI [2.27- 3.40]) were more susceptible to cigarette smoking. Students who had good knowledge about harmful effects of smoking (OR = 0.54, 95% CI [0.43-0.69]); and had access to anti-smoking media (OR = 0.73, 95% CI [0.59-0.89]) were less likely to be susceptible to smoking.
Students who were females, had smoking parents, friends or exposure to newspaper/magazines cigarette marketing, were more susceptible to cigarette smoking among Pakistani adolescents. While knowledge of harmful effects of smoking and access to anti-smoking media served as protective factors against susceptibility to smoking.
PMCID: PMC3936926  PMID: 24555481
Smoking; Adolescents; Students; Susceptibility to cigarette smoking; Pakistan
24.  Anti-smoking initiatives and current smoking among 19,643 adolescents in South Asia: findings from the Global Youth Tobacco Survey 
Cigarette smoking habit usually begins in adolescence. The developing countries in South Asia like Pakistan, India, Bangladesh, and Nepal, where the largest segment of the population is comprised of adolescents, are more susceptible to smoking epidemic and its consequences. Therefore, it is important to identify the association between anti-smoking initiatives and current smoking status in order to design effective interventions to curtail the smoking epidemic in this region.
This is a secondary analysis of national data from the Global Youth Tobacco Survey (GYTS) conducted in Pakistan (year 2003), India (year 2006), Bangladesh (year 2007), and Nepal (year 2007). GYTS is a school-based survey of students targeting adolescents of age 13–15 years. We examined the association of different ways of delivering anti-smoking messages with students’ current smoking status.
A total of 19,643 schoolchildren were included in this study. The prevalence of current smoking was 5.4% with male predominance. No exposure to school teachings, family discussions regarding smoking hazards, and anti-smoking media messages was significantly associated with current smoking among male students. Participants who were deprived of family discussion regarding smoking hazards (girls: odds ratio (OR) 1.56, 95% confidence interval (CI) 0.84–2.89, p value 0.152; boys: OR 1.37, 95% CI 1.04–1.80, p value 0.025), those who had not seen media messages (girls: OR 2.89, 95% CI 1.58–5.28, p value <0.001; boys: OR 1.32, 95% CI 0.91–1.88, p value 0.134), and those who were not taught the harmful effects of smoking at school (girls: OR 2.00, 95% CI 0.95–4.21, p value 0.066; boys: OR 1.89, 95% CI 1.44–2.48, p value <0.001) had higher odds of being current smokers after multivariate adjustment.
School-going adolescents in South Asia (Pakistan, India, Nepal, and Bangladesh) who were not exposed to anti-tobacco media messages or were not taught about the harmful effects in school or at home had higher odds of being current smokers than their counterparts.
PMCID: PMC3938898  PMID: 24568532
Smoking; Adolescents; Anti-smoking initiatives; South Asia
25.  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.
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.
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.
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.
PMCID: PMC3717105  PMID: 23867000
Tobacco; Tobacco smoke pollution; Adolescent; Perception; Risk; Students

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