Alcohol and Drug Information Centre (ADIC - Ukraine)
Global Youth Tobacco Survey in Ukraine Report (1999)
Tobacco use is considered to be one of the most preventable causes of death in the world. The World Health Organization (WHO) estimates upwards of 4 million deaths a year associated with the use of tobacco products (1). Tobacco mortality and morbidity are very high in countries of the former USSR. Based on calculations produced by WHO, about 120,000 deaths per year in Ukraine are attributed to tobacco use (2).
It is well known that most people begin using tobacco before the age of 18 years. Comprehensive tobacco prevention and control information related to young people, however, is not available for Ukraine and other former USSR countries. Data on smoking prevalence among adults were never collected in the USSR. In recent years only a few surveys concerning tobacco use were conducted in Ukraine. For example, the European School Survey on Alcohol and other Drugs (ESPAD) (3) conducted in 1995 and 1999 for 15 and 16 year olds contained only two questions on tobacco use. Lack of such information makes it difficult to develop tobacco control policy measures and to design prevention programs. The situation became worse in recent years as the tobacco industry, on the one hand, uses every opportunity to advertise tobacco products aimed at "young adults" and, on the other hand, funds "youth prevention" programs in Ukraine and other countries (4, 5). There is an urgent need for information about young peoples' behaviour and attitudes concerning tobacco use in order to counteract the tobacco industry's activities and decrease smoking prevalence among young people. To address this need, the Tobacco Free Initiative, World Health Organization (WHO) and U.S. Centres for Disease Control and Prevention (CDC) have developed the Global Youth Tobacco Survey, in consultation with a range of countries representing the six WHO Regions.The GYTS is a school-based tobacco specific survey which focuses on adolescents aged 13-15 years. The objectives of these survey are: to document and monitor prevalence of tobacco use and to better understand and assess students' attitudes, knowledge and behaviours related to tobacco use and its health impact, including cessation, environmental tobacco smoke, media and advertising, minors' access to tobacco products, and school curriculum. The GYTS was intended to enhance the capacities of countries to monitor tobacco use among youth, and to guide the implementation and evaluation of tobacco prevention and control programs and policies.
Ukraine took part in the GYTS since the very beginning of the project, participating in the initial meeting in December 1998 in Geneva, when the first GYTS questionnaire was developed. In February 1999 the first pre-test of the GYTS was conducted in several schools in the Ukraine's capital city, Kiev. The first GYTS survey in the world was conducted in April and May 1999 by the Alcohol and Drug Information Center (ADIC-Ukraine) in 100 schools in the city of Kiev.
The Ukraine GYTS was a self administered, school-based survey of students in Forms 8, 9 and 10 and in professional and technical schools (Courses 1 and 2), conducted in April/May 1999 in the city of Kiev. Data about school location, number of classes with students aged 13 to 15 years old and number of students per class were obtained from the Statistics Unit of the City of Kiev Department of Education, the City of Kiev Professional Schools Authority and the City of Kiev Department of Statistics. A two-stage cluster sample design was used to produce representative data for the city of Kiev. Data about schools were obtained from the Ministry of Education and sent to the Office on Smoking and Health at the US Centers for Disease Control and Prevention (OHS/CDC) to calculate the study sample. At the first stage, schools were selected with probability proportional to enrolment size. One hundred schools were selected. At the second stage, classes were randomly selected and all students in selected classes were eligible to participate. The Ukraine GYTS questionnaire consisted of 66 questions, including a "core" set of 54 questions that were used by all countries, and an additional country-specific set of 12 questions reflecting national needs and priorities. Students recorded their responses directly on a separate answer sheet provided by OSH/CDC that was optically scanned for data entry. The questions cover prevalence of tobacco use, age of starting smoking, attitudes and beliefs in relation to smoking, ETS, media and advertising, economics, and school health/tobacco-related curriculum. The questionnaire was translated into Ukrainian and Russian. All students in the selected classes were eligible to participate in the survey. Their participation was voluntary. Students' privacy was ensured as participation in the GYTS was anonymous and voluntary. The school response rate was 100%. A total of 4,156 students participated in the study, out of a total class enrolment of 5,104 from the selected schools. The student response rate was 81.4%. The overall response rate was 81.4%. The GYTS data are weighted to adjust for sample selection (school and class levels), non-response (school, class, and student levels), and post-stratification of the sample population relative to the grade and sex distribution in the total population.
Over three-quarters (77.3%) of all students have ever smoked cigarettes, with smoking significantly higher for boy than for girl students (Table 1). Over four in ten students (41.2%) currently use any form of tobacco and close to half of them smoke cigarettes (41.1%). Use of other tobacco products is relatively small (8.0%). Current use of cigarettes and other tobacco products is significantly higher for boy students than for girl students (46.8% and 33.8%, respectively). Overall, 26.3% of never smokers indicated that they are likely to initiate smoking during the next year. Significantly more girl never smokers (29.6%) than boy never smokers (19.4%) indicated that they were likely to initiate cigarette smoking sometime during the next year.
Over half of all students (51.6%) indicated they had been taught in the school during the past year about the danger of smoking (Table 2). A considerably lower proportion of the students (36.1%) reportedly had discussed in school why people their age smoke. Almost six in ten current smokers (58.0%) stated that they desire to stop smoking (Table 3). . Significantly more boys (65.1%) than girls (45.9%) wished to quit smoking. Over 6 in 10 current smokers (62.3%) reported that they had tried to stop smoking during the past year but failed. Significantly fewer girls (54.6%) than boys (66.7%) tried unsuccessfully to stop smoking sometime over the past year. Exposure to second hand tobacco smoke was high for most students in Kiev, both in their home and in public places (Table 4). Students who had never smoked were significantly less likely than current smokers to be exposed to second-hand smoke (35.0% versus 59.2%). But over half of never smokers (57.4%) reported being exposed to tobacco smoke from others in a public place, while almost nine in ten current smokers (89.3%) reported this situation. Almost nine in ten never smokers (85.4%) and almost half (45.6%) of current smokers think smoking should be banned in public places. Over half of never smokers (58.3%) and about half of current smokers (45.6%) think smoke from others is definitely harmful to them. The data were not statistically significant by gender.
Almost four in ten never smokers (39.0%) think that smoking cigarettes helps people feel more comfortable at parties and social gatherings, while less than two in ten of current smokers (14.5%) share this perception (Table 5). Among never smokers, eight in ten (84.9%) believe that a person who smokes should ask permission beforehand. Slightly over half of the never smokers (56.9%) stated that they do not allow someone to smoke even if they ask permission beforehand. Among never smokers, less than one in ten (5.5%) believe that smoking makes boys look more attractive, while only 2.1% think smoking makes girls look more attractive. Among current smokers, 13.4% think that smoking makes boys look more attractive, while less than one in ten (5.7%) think that smoking makes girls look more attractive. About eight in ten students (78.7%) reported having seen anti-smoking messages in the past 30 days (Table 6). Almost nine in ten students (86.7% of never smokers and 87.6% of current smokers) had seen pro-tobacco messages in newspapers and magazines. The differential between boy and girl current smokers was significant, with girls more likely to have noticed the pro-tobacco messages. Significantly more current smokers possessed an object with a cigarette brand logo on it than never smokers (29.3% and 21.7%, respectively). Less than one in ten never smokers (5.5%) and more than one in ten current smokers (11.0%) were offered free cigarettes by a tobacco company representative. The majority of respondents (both current smokers, at 66.2%, and non-current smokers at 85.4%) support the application of harsh restrictions on tobacco advertising, including a total ban. The data were not statistically significant by gender.
Almost half (43.2%) of students who are current smokers prefer to smoke in public places (Table 7). Almost four in ten (39.2%) current smokers purchase their cigarettes in a store. The vast majority of them (93.5%) had not been refused the sale of cigarettes because of their age. Half of the students (50.4%) prefer to smoke cigarettes that are more expensive than the average price of cigarettes in Ukraine (more than 2 hryvnas, whereas the average weighted price of cigarettes in Ukraine in 1999 was 1.1 hryvna). A significantly greater proportion of girl students (64.5%) than boy students (41.9%) reported purchasing cigarettes that costs more than the average price of cigarettes in Ukraine.
DiscussionI, Conclusions and recommendations
The 1999 GYTS was the first comprehensive survey carried out in Ukraine about tobacco use among school children. The survey provides important baseline data about the extent of smoking among youth as well as their attitudes and behaviour towards smoking, and the impact that advertising and exposure to tobacco-related campaigns, both promoting and against smoking. This is the first such study in Ukraine, and it provides important information for decision-makers and practitioners for the development of effective tobacco control policy and smoking prevention interventions aimed at youth.
The GYTS reveals that tobacco use among adolescents in Ukraine is an acute problem. The percentage of respondents in city of Kiev who have ever smoked (77.3%) was among the highest of all GYTS settings carried out in 1999. The percentage of current smokers among students is also very high (46.8% among boys and 34.6% among girls). While at present boys are more likely than girls to use tobacco, the difference will likely decrease as many more girl students who have never smoked cigarettes than boy students (29.6% versus 19,4 %) indicate that they will likely initiate smoking in the next year.
The low proportion of students who indicated that they had received any lessons about the dangers of smoking indicates the need to develop a comprehensive school health education program in Ukraine that includes a strong tobacco prevention component.
The Ukraine GYTS revealed that although most current smokers wish to quit smoking, the majority of those that have attempted to quit often fail. Again, school-based health education programs could be developed or revised to accord more attention to cessation in addition to smoking prevention. Special gender-sensitive cessation services for young people need to be established. The survey also shows that young smokers in the city of Kiev have few if any constraints to buy cigarettes. There is little hope that better enforcement or stricter laws could change the situation because a large network of street vendors selling cigarettes still exists.
Environmental Tobacco Smoke
The exposure of teenagers to smoke in Kiev, both in the home and in public places, is high. Especially alarming is the high exposure for never smokers. Interestingly, almost nine in ten never smokers and almost half of current smokers think smoking should be banned in public places. These data indicate the need for legislation banning smoking in public places, with strong enforcement provisions.
Media and Advertising
Restrictions on tobacco advertising have proven effective in other countries as a means of reducing smoking prevalence among children. The GYTS reveals that the majority of adolescents, even among current smokers, support the application of very strict restrictions on tobacco advertising, including a total ban on advertising and the banning of smoking in public places. The government and parliament should take into account the opinion of young people and adopt comprehensive tobacco control legislation.
The Ukraine GYTS also revealed the continuing practice by the tobacco industry to offer free cigarettes to children (which is illegal according to Ukrainian legislation, even for adults). This suggests the need to strengthen enforcement of the existing legislation.
Access and Availability
According to the economic analysis of the Global Youth Tobacco Survey (GYTS) price elasticity for cigarettes in Kiev was -0.5 (6). The analysis provides evidence that both cigarette prices and tobacco control policies can reduce cigarette demand among teenage students in Ukraine. Price simulation based on the estimates of participation price elasticity indicates that a 100 percent increase of the cigarette excise tax in Ukraine (from the current level of 0.2 UAH per pack to 0.4 UAH per pack) would lead to an 8.8% increase in cigarette prices and consequently to an estimated 4.4 percentage point decrease in smoking participation among Ukraine teenagers. Theoretically, this would reduce the current smoking prevalence among youth from 41.1% to 36.6%. Care must be taken in interpreting these data as the estimate is based upon a short-term reaction to a price change. The long-term effects of this price increase might be even larger due to the addictive nature of cigarette consumption.
Finally, the GYTS should be repeated periodically and become an integral part of the tobacco control and smoking prevalence surveillance system. It is especially true for Ukraine where such a surveillance system does not exist. Any future GYTS carried out in Ukraine should be expanded to a national scale, to include other urban and rural areas. It should also be repeated in the city of Kiev to examine the trends since 1999. The survey questions should be updated to reflect changing realities in Ukraine.
1. Tobacco -- health facts (http://www.who.int/inf-fs/en/fact221.html). Copenhagen, WHO Regional Office for Europe, 1999 (Fact Sheet No. 221) (accessed 11 October 2002).
2. Tobacco or Health in Ukraine. (http://adic-ukraine.narod.ru/adic ).
3. The 1995 ESPAD Report and The 1999 ESPAD Report. Stockholm. The Swedish Council for Information on Alcohol and Other Drugs (CAN), 2000. (http://www.can.se, accessed 2 November 2001)
4. Ukraine: in the club with L&M. - Tobacco Control, 2002, 11, No. 2, pp. 89.
5. Kazakhstan: PM's "PR department" ignores tobacco. - Tobacco Control, 2000, 9, No. 2, p. 133.
6. Hana Ross. Report from GYTS - Kiev, Ukraine, 2001 (unpublished report of the World Bank).