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2 figures omitted
Tobacco use is one of the major preventable causes of premature death
and disease in the world. A disproportionate share of the global tobacco burden
falls on developing countries, where an estimated 84% of the world’s
1.3 billion current smokers live.1 The Global
Youth Tobacco Survey (GYTS), part of the Global Tobacco Surveillance System
(GTSS) initiated by the World Health Organization (WHO) and CDC, was developed
to monitor youth tobacco use, attitudes about tobacco, and exposure to tobacco
smoke, and has been completed by approximately 1.4 million students in 133
countries.2 A key goal of GTSS is for countries
to conduct the GYTS every 4 years. This report presents findings from the
GYTS conducted in the Philippines in 2000 and 2003, which revealed substantial
declines in the proportions of students aged 13-15 years who currently smoked
cigarettes, currently used other tobacco products, were likely to start smoking
in the next year, or were exposed to secondhand smoke in public places. The
findings also indicated an increase in the proportion of students who supported
bans on smoking in public places, had learned about the dangers of tobacco
use in school, and had seen antitobacco messages in media and advertising.
Public health authorities in the Philippines should evaluate their current
tobacco-control programs and enhance or expand them to further reduce youth
GYTS is a school-based survey that collects data from students aged
13-15 years by using a standardized methodology for constructing the sample
frame, selecting participating schools and classes, and processing data. GYTS
uses a two-stage, cluster-sample design that produces representative samples
of students in grades associated with ages 13-15 years.2 In
the Philippines, this age range is covered by the second, third, and fourth
years of secondary school; the GYTS sampling frame included all secondary
schools containing these grade levels. At the first sampling stage, the probability
of selecting a school was proportional to the number of students enrolled
in the specified grades. At the second stage, classes within the selected
schools were randomly selected. All students attending school in the selected
classes on the day the survey was administered were eligible to participate.
In 2000, a total of 11,630 students completed the GYTS, and in 2003, a total
of 7,478 completed the survey. The school response rate was 90.0% in 2000
and 99.3% in 2003; the student response rates were 88.7% and 85.4%, respectively;
and the overall response rates (i.e., school rate multiplied by student rate)
were 79.7% and 84.8%, respectively.
This analysis compared the 2000 and 2003 survey results by using several
indicators of tobacco use. The indicators included lifetime cigarette smoking,
age of initiation of cigarette smoking, current cigarette smoking, current
use of other tobacco products, likelihood of never smokers to initiate smoking
in the next year, exposure to secondhand smoke, tobacco education, exposure
to tobacco images in media and advertising, cessation efforts, and access
to tobacco. All differences noted are statistically significant (p<0.05)
with nonoverlapping 95% confidence intervals.
In both years, approximately four in 10 students in the Philippines
reported ever smoking cigarettes (i.e., even one or two puffs): 42.8% in 2000
and 41.9% in 2003. Adolescent boys were significantly more likely than adolescent
girls to have ever smoked. Approximately one in eight students who had smoked
cigarettes reported smoking their first cigarette before age 10 years: 12.9%
in 2000 and 12.7% in 2003, with no significant difference between adolescent
boys and girls.
Current tobacco use and likely initiation of smoking among never smokers
declined significantly from 2000 to 2003. The percentage of students who reported
being current cigarette smokers or currently using other tobacco products
declined significantly. Among adolescent boys, the percentage of current smokers
declined by approximately one third, from 32.6% in 2000 to 21.8% in 2003.
Among adolescent girls, the decline was similar, from 12.9% in 2000 to 8.8%
in 2003. Current use of other tobacco products declined by nearly half for
both adolescent boys and adolescent girls, from 18.3% in 2000 to 10.9% in
2003 for adolescent boys and from 9.5% in 2000 to 5.7% in 2003 for adolescent
girls. The percentage of students who had never smoked but were likely to
initiate smoking in the next year also decreased by nearly half, from 26.5%
in 2000 to 13.8% in 2003.
Changes in current tobacco use were mirrored by other results that indicated
an increase in antismoking sentiment in the Philippines. Although the percentage
of students who reported that their parents smoked did not change (approximately
56% in both 2000 and 2003), the percentage of students reporting exposure
to secondhand smoke in public places declined from 74.6% in 2000 to 59.0%
in 2003. In addition, support for bans on smoking in public places more than
doubled, from 39.2% of students in 2000 to 88.7% in 2003, and the percentage
of students who reported learning in school about the health hazards of tobacco
use increased from 58.6% in 2000 to 68.0% in 2003. A greater percentage (90.3%)
of students reported seeing an antitobacco message in the media in 2003 than
in 2000 (83.4%).
The percentage of current smokers who were not refused purchase of tobacco
products because of their age increased from 46.6% in 2000 to 62.8% in 2003.
The percentage of students who reported being offered free cigarettes decreased
from 17.6% in 2000 to 13.9% in 2003. In addition, a small but significant
increase was observed in the percentage of students who reported seeing tobacco
advertising on billboards (84.4% in 2000 versus 87.6% in 2003).
M Miguel-Baquilod, MD, Philippines Dept of Health. B Fishburn, MPP,
J Santos, MPH, Western Pacific Regional Office, World Health Organization,
Manila, Philippines. NR Jones, PhD, CW Warren, PhD, Office of Smoking and
Health, National Center for Chronic Disease Prevention and Health Promotion,
The findings in this report suggest that, from 2000 to 2003, tobacco
use and exposure to secondhand smoke in public places declined significantly
among students aged 13-15 years in the Philippines. In 2003, students were
less likely to use tobacco currently, less likely to be exposed to secondhand
smoke, more likely to support bans on smoking in public areas, and more likely
to have learned in school and from the media about the health hazards of tobacco
use. Finally, fewer students reported being offered free cigarettes in 2003
than in 2000.
During the same period, major changes in tobacco-control policies in
the Philippines might have contributed to these changes. For example, before
1999, no restrictions on tobacco advertising and promotion were in effect,
and few smoke-free policies existed. In addition, a lower level of taxation
on tobacco products, few education efforts, and low enforcement of age restrictions
for tobacco sales were observed. The Philippines Clear Air Act of 1999* identified
cigarette smoke among the country’s pollutants and instituted smoke-free
indoor air laws. The national law still allows designated smoking areas in
restaurants and other indoor areas, but some cities have declared all indoor
areas completely smoke-free. The government is also seeking increased taxes
on cigarettes. In 2003, the Youth Smoking Cessation Program† declared
smoke-free campuses, improved training for students and teachers, and levied
penalties for smoking. The Tobacco Regulatory Act of 2003‡ seeks to
increase public education measures, ban all tobacco advertisement, strengthen
warning labels on tobacco products, and prohibit sales to minors. All of these
smoke-free programs have received extensive national and local media coverage.
The findings in this report are subject to at least three limitations.
First, because the sample surveyed was limited to youths attending school,
it might not be representative of all adolescents aged 13-15 years in the
Philippines. During school year 2002-03, the gross enrollment ratio in secondary
schools was 65.7%.3 Second, these data apply
only to youths who were in school on the day of the survey and who completed
the survey. Despite this limitation, response rates were 89% in 2000 and 85%
in 2003, suggesting that bias attributable to absence or nonresponse might
be limited. Finally, data are based on the self reports of students, who might
under- or over-report their use of tobacco. The extent of this bias cannot
be determined from the Philippines data; however, responses to tobacco questions
on surveys in the United States similar to GYTS have demonstrated good test-retest
The declines from 2000 to 2003 in cigarette smoking and other tobacco
use among students in the Philippines were encouraging. However, other findings
were of concern. In 2003, 13.8% of students who had never smoked indicated
they would likely initiate smoking in the next year, with no difference between
adolescent boys and adolescent girls. In addition, approximately eight in
10 students reported seeing pro-tobacco messages on billboards and in newspapers
and magazines. Students who smoke also reported little difficulty purchasing
cigarettes in stores. To reduce tobacco use among adolescents in the Philippines,
continued efforts are needed to monitor these behaviors and to develop, evaluate,
and disseminate effective prevention strategies.
Systematic global surveillance of youth tobacco use is the essential
first step in attempting to prevent the projected epidemic of death and disease
that smoking will cause in the 21st century.5 The
GYTS enhances the capacity of countries to evaluate their tobacco-prevention
and -control programs. The more than 30% reduction in current tobacco use
observed in the Philippines should encourage other countries that youth tobacco
use can be reduced substantially during a short period.
*Republic Act No. 8749, enacted June 1999.
†Youth Smoking Prevention Program, Philippines Department of
Education Order No. 33 series, enacted 2003.
‡Republic Act No. 9211, enacted July 2003.
Tobacco Use Among Students Aged 13-15 Years—Philippines, 2000 and 2003. JAMA. 2005;293(11):1319–1320. doi:10.1001/jama.293.11.1319