Indian Journal of Public Health

ISSN : 0019-557X Vol 55 / Issue 3 / Jul-Sep 2011 Indian Journal of Public Health Official Publication of The Indian Public Health Association Online full text at www.ijph.in Special Issue Tobacco Control in South-East Asia Region

Research Article Tobacco Use among Youth and Adults in Member Countries of South-East Asia Region: Review of Findings from Surveys under the Global Tobacco Surveillance System *Dhirendra N. Sinha 1, Krishna M. Palipudi 2, Italia Rolle 2, Samira Asma 2, Sonam Rinchen 1 1 Tobacco Free Initiative, World Health Organization, Regional Offi ce for South-East Asia, 2 Centers for Disease Control and Prevention, Atlanta Abstract Background: This paper examines the prevalence of current tobacco use among youth and adults in selected member countries of the South-East Asia Region using the data from school and household-based surveys included in the Global Tobacco Surveillance System. Materials and Methods: Global Youth Tobacco Survey (GYTS) data (years 2007-2009) were used to examine current tobacco use prevalence among youth, whereas Global Adult Tobacco Survey (GATS) data (years 2009-2010) were used to examine the prevalence among adults. GYTS is a school-based survey of students aged 13-15, using a two-stage cluster sample design, and GATS is a household survey of adults age 15 and above using a multi-stage stratified cluster design. Both surveys used a standard protocol for the questionnaire, data collection and analysis. Results: Prevalence of current tobacco use among students aged 13-15 varied from 5.9% in Bangladesh to 56.5% in Timor-Leste, and the prevalence among adults aged 15 and above was highest in Bangladesh (43.3%), followed by India (34.6%) and Thailand (27.2%). Reported prevalence was significantly higher among males than females for adults and youth in all countries except Bangladesh, Sri Lanka and Timor-Leste. Current use of tobacco other than manufactured cigarettes was notably higher than current cigarette smoking among youth aged 13-15 years in most countries of the Region, while the same was observed among adults in Bangladesh, India and Thailand, with most women in those countries, and 49% of men in India, using smokeless tobacco. Conclusion: Tobacco use among youth and adults in member countries of the region is high and the pattern of tobacco consumption is complex. Tobacco products other than cigarettes are commonly used by youth and adults, as those products are relatively cheaper than cigarettes and affordable for almost all segments of the population. As a result, use of locally produced smoked and smokeless tobacco products is high in the region. Generating reliable data on tobacco use and key tobacco control measures at regular intervals is essential to better understand and respond with effective tobacco control intervention. Key words: Adults, Cigerette smoking, Use of other tobacco products, Youth Introduction Tobacco is currently a major cause of preventable disease *Corresponding Author: Dr. Dhirendra N Sinha, Regional Advisor, Surveillance (Tobacco Control), World Health Organization, Regional Offi ce for South East Asia, IP Estate, New Delhi, India. E-mail: sinhad@searo.who.int Website: www.ijph.in DOI: 10.4103/0019-557X.89946 PMID: *** Access this article online Quick Response Code: and deaths in both developed and developing countries. Tobacco use is claiming the lives of nearly six million people a year worldwide, 1 including more than 600,000 non-smokers who die from exposure to tobacco smoke. 2 The death toll from tobacco is expected to increase to eight million a year by 2030; 3 and if the current trend continues unchecked, there will be up to one billion tobacco-related deaths during the 21 st century, many of which will be from developing countries. 4 The health effects of tobacco include cancers, cardiovascular diseases, respiratory diseases, and adverse reproductive outcomes. 5 There is increasing evidence that chronic diseases are on the rise in developing countries, but the association of these diseases with risk factors such as tobacco may

170 Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR not be acknowledged in these countries, since during the past century infectious diseases were a major cause of morbidity and mortality. 6,7 Despite scientific evidence linking tobacco to adverse health outcomes, a certain proportion of youth and adults are very likely to continue smoking, chewing and snuffing tobacco products unless there is continued public health action to control their use. Misperceptions about the dangers of using tobacco may partly explain why youth and adults use tobacco in developing countries. 8 The South-East Asia Region is composed of the following developing countries: Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste. Tobacco use is a growing public health problem in the region, killing about 1.2 million people annually. The region is home to nearly four hundred million tobacco users. Prevalence of smoking among men is especially high, in terms of proportion and absolute numbers, in Bangladesh, India, Indonesia, Myanmar and Thailand. 9 Although women commonly use smokeless tobacco, the rising trend in smoking among women is causing grave concern among governments in the region. 9 Tobacco use among youth, especially smoking, is quite high, due to the tobacco industry s creative and targeted marketing strategies and its weak regulation. 9 Other key factors contributing to the tobacco epidemic in the region are abundant tobacco production, weak enforcement of tobacco control measures, and easy accessibility and affordability of tobacco products. 9 As a part of strategy to implement the provisions of the WHO Framework Convention on Tobacco Control (WHO FCTC), tobacco surveillance was established to support tracking and monitoring of tobacco use and its related indicators. Countries in the South-East region participated in the Global Tobacco Surveillance System (GTSS). 10 The GTSS consists of three school-based surveys, namely the Global Youth Tobacco Survey (GYTS), the Global School Personnel Survey (GSPS), and the Global Health Professions Students Survey (GHPSS), and a household survey known as the Global Adult Tobacco Survey (GATS). The GTSS is a multi-partner initiative whose national partners include Ministries of Health (MOH), national statistical offices, and implementing agencies of the respective surveys. The international partners comprise the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), the CDC Foundation, the Research Triangle Institute (RTI), the Canadian Public Health Association, and the Johns Hopkins Bloomberg School of Public Health. The GTSS provides an opportunity to assess tobacco use and tobacco control indicators among youth and adults in a way that is comparable across various countries and in the same countries over time, using a standard and consistent methodology within each system of surveys. This paper presents the prevalence of current tobacco use among youth and adults by gender and type, using the data from GYTS (years 2007, 2009) and GATS conducted (years 2009-2010) in member countries of the South-East Asia Region. Variability of prevalence across the countries is reviewed, and some elements of consumption pattern and tobacco control measures are discussed. Materials and Methods Global Youth Tobacco Survey (GYTS) The GYTS was conducted at the national level in Bangladesh (2007), Bhutan (2009), India (2009), Maldives (2007), Myanmar (2007), Nepal (2007), Sri Lanka (2007), Thailand (2009) and Timor-Leste (2009), and at the sub national level (Java and Sumatra) in Indonesia (2009). In many countries, it has been repeated two or three times. The GYTS used a two-stage cluster sample design that produced representative samples of students in grades associated with ages 13 to 15. All students in the selected classes attending school the day the survey was administered were eligible to participate. The GYTS uses a standardized methodology for the questionnaire, sample design, data collection and analysis. It includes data on prevalence of cigarette and other tobacco use, perceptions and attitudes about tobacco, access and availability of tobacco products, exposure to secondhand smoke, school curricula, media and advertising, and smoking cessation. Questions related to use of cigarettes, indigenous smoking products, such as bidis for Bangladesh, India, Nepal and Sri Lanka, cheroots for Myanmar and kreteks for Indonesia, and smokeless tobacco products were included in the analysis. Current use of tobacco for youth was defined as use of any tobacco product on any of the 30 days preceding the survey. Appropriate weights associated with each student record were computed and employed in the analysis. SUDAAN, a software package for statistical analysis of correlated data, was used to produce prevalence estimates and associated 95% confidence intervals among youth.

Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR 171 Global Adult Tobacco Survey GATS is the global standard for systematically monitoring adult tobacco use (smoking and smokeless) and tracking key tobacco control indicators, which was conducted in Bangladesh (2009), India (2009-2010) and Thailand (2009) at the national level. GATS is a household survey of persons age 15 and above. A multi-stage nationally representative probability sample is used to provide national estimates by residence (urban and rural) and gender. Details of the methodology are explained elsewhere in reports and publications for both GYTS 11-17 and GATS. 18-20 The survey was designed to produce internationally comparable data using a standardized questionnaire, sample design, data collection and management procedures. GATS s core questionnaire includes information on respondents background characteristics, tobacco use (smoking and smokeless), cessation, secondhand smoke, economics, media, and knowledge, attitudes and perceptions towards tobacco use. Use of tobacco products other than manufactured cigarettes in the analysis of adult data include both smoked (hand-rolled, bidi, hukkah, pipe, cigar, cheroot, cigarillo or any other smoked tobacco) and smokeless (betel quid with tobacco, gul, khoinee, pan masala or any other) tobacco. Current tobacco use among adults is defined as persons who currently smoke or use any smokeless tobacco product, either daily or occasionally. To understand the type of tobacco use among males and females separately, current tobacco users were further distributed into three mutually exclusive groups (smoked only, both smoked and smokeless tobacco users, and smokeless tobacco users only). Survey information was collected from the adult population aged 15 and above. GATS Bangladesh had a sample of 9,629 with a response rate of 93.6%, whereas GATS India had a total of 69,296 completed interviews, of which 33,767 and 35,529 were men and women, respectively, with an overall response rate of 91.8%. In Thailand, there was a total of 20,566 completed interviews of adults, with an overall response rate of 94.2% [Table 1]. Due to non-proportional allocation of the sample to the different strata, appropriate sample weights were computed to ensure the actual representativeness of the sample at the national level. The sample weights were used in all analyses to produce prevalence estimates and 95% confidence intervals using SPSS 17.0 software for complex samples. For both youth and adult data, overlapping confidence intervals were used to detect differences between gender groups. Results Prevalence of tobacco use among youth For countries conducting the GYTS (years 2007, 2009), the overall response rate ranged from 77.3% to 97.5%. Prevalence of current tobacco use among school students aged 13-15 years varied from 5.9 % in Maldives to 56.5% in Timor-Leste [Table 1]. Among male students, tobacco use varied from 8.5% in the Maldives to 60.2% in Timor-Leste, and among female students, it varied from 3.4% in the Maldives to 53.4% in Timor-Leste. With the exception of Bangladesh, Sri Lanka and Timor-Leste, a higher percent of males used tobacco when compared to females. Prevalence of current manufactured cigarette smoking among students aged 13-15 varied from 1.2% in Sri Lanka to 24.6% in Timor-Leste. Current manufactured cigarette smoking among male students varied from 1.6% in Sri Lanka to 41% in Indonesia (Java and Sumatra), while it ranged from 0.9 % in Sri Lanka to 14.6% in Timor-Leste among female students. Prevalence of smoking among male students was less than 10% overall, but it was more than 20% in three countries. Current use of tobacco other than manufactured cigarettes varied from 3.5% in the Maldives to 51.6% in Timor- Leste. Among male students, use of tobacco other than manufactured cigarettes varied from 4.3% in the Maldives to 52.7% in Timor-Leste, and prevalence was reported to be more than 10% in seven countries. Among female students, use of tobacco other than manufactured cigarettes varied from 2.7% in the Maldives to 50.1% in Timor-Leste and prevalence was reported to be over 5% in seven countries. In the majority of countries (Bangladesh, India, Myanmar, Nepal, Sri Lanka and Timor-Leste), current use of tobacco other than manufactured cigarettes was reported higher than current manufactured cigarette smoking overall and for males. There was a higher percent of females using tobacco other than manufactured cigarettes in Bangladesh, India, Maldives, Myanmar, Nepal, Sri Lanka, Thailand, and Timor-Leste when compared to current manufactured cigarette smoking. Prevalence of tobacco use among adults GATS data was available for survey years 2009-2010 on the prevalence of current tobacco use by type and gender among adults in Bangladesh, India and Thailand. Among adults aged 15 and above, the prevalence of current

172 Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR Table 1: Prevalence of current tobacco use by type and gender among youth and adults in selected member countries of South-East Asia Region Country Survey Sample Response Tobacco use Current manufactured cigarette smoking Use of tobacco other than manufactured cigarettes year size rate (%) Total Male Female Total Male Female Total Male Female Youth (students) aged 13-15 years % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI Bangladesh 2007 2,135 88.9 6.9 (4.7 10.1) Bhutan 2009 1,019 97.5 18.8 (15.8-22.2) India 2009 10,112 79.6 14.6 (13.0-16.3) Indonesia 2009 3,319 94.0 22.5 (19.3-26.0) Maldives Myanmar Nepal 2007 1,870 85.6 5.9 (4.4 7.9) 2007 2,007 95.2 15.3 (12.4 18.7) 2007 1,296 94.6 9.4 (7.2 12.2) Sri Lanka 2007 1,428 85.0 9.1 (6.8 12.2) Thailand 2009 7,649 93.1 15.6 (12.8-19.0) Timor Leste 2009 890 77.3 56.5 (48.8-63.9) Adults age 15 years and above 9.1 (6.7 12.1) 5.1 (2.5 10.3) 27.6 (22.9-32.8) 11.6 (8.9-15.0) 19.0 (16.8-21.4) 8.3 (7.0-9.9) 41.0 (34.8-47.5) 6.2 (4.6-8.4) 8.5 (6.0 11.8) 3.4 (2.1 5.3) 22.5 (18.1 27.4) 8.2 (5.9 11.3) 13.0 (9.8 16.9) 5.3 (3.0 9.1) 12.4 (8.7 17.5) 5.8 (3.6 9.4) 24.0 (20.2-28.3) 7.5 (5.3-10.6) 60.2 (50.4-69.2) 53.4 (43.4-63.1) 2.0 (1.1 3.6) 12.4 (10.0-15.3) 4.4 (3.6-5.3) 20.3 (17.1-24.0) 3.8 (2.7 5.3) 4.9 (3.6 6.5) 3.9 (2.7 5.6) 1.2 (0.5 2.9) 11.7 (10.2-13.4) 24.6 (18.2-32.4) 2.9 (1.7 5.0) 1.1 (0.3 3.2) 6.0 (4.0-8.9) 8.0 (5.9-10.8) 18.3 (13.9-23.7) 7.9 (6.0-10.4) 12.0 (9.3-15.4) 17.7 (13.8-22.4) 5.8 (4.6-7.3) 2.4 (1.8-3.1) 12.5 (11.1-14.1) 16.2 (14.3-18.4) 41.0 (33.9-48.5) 3.5 (2.3-5.4) 6.5 (5.5-7.5) 10.3 (9.1-11.6) 6.6 (4.6 9.6) 0.9 (0.4 2.0) 3.5 (2.2-5.5) 4.3 (2.5-7.4) 8.5 (6.2 11.6) 1.3 (0.6 2.6) 14.1 (11.4-17.3) 20.3 (16.3-25.0) 5.7 (3.9 8.3) 1.9 (1.0 3.5) 8.0 (6.2-10.2) 11.1 (8.5-14.4) 1.6 (0.7 3.7) 0.9 (0.2 3.5) 8.6 (6.4-11.5) 11.6 (8.0-16.6) 20.1 (17.4-23.1) 3.8 (3.0-4.8) 5.7 (3.4-9.3) 7.3 (4.5-11.5) 38.2 (27.3-50.4) 14.6 (9.0-22.7) 51.6 (46.1-57.2) 52.7 (46.4-59.0) 4.2 (1.9-9.1) 7.0 (4.6-10.7) 7.2 (6.1-8.5) 3.1 (2.2-4.3) 2.7 (1.6-4.7) 7.9 (5.7-10.9) 4.4 (2.5-7.7) 5.6 (3.5-8.7) 4.1 (2.2-7.4) 50.1 (42.5-57.8) Bangladesh 2009 9,629 93.6 43.3 (41.7-45.0) India 2009-10 69,296 91.8 34.6 (33.6-35.5) Thailand 2009 20,566 94.2 27.2 (26.2-28.3) 58.0 (55.9-60.1) 28.7 (26.7-30.8) 47.9 (46.7-49.1) 20.3 (19.2-21.3) 46.4 (44.6-48.2) 9.1 (8.2-10.2) 14.1 (13.2-15.2) 5.2 (4.9-5.6) 15.0 (14.2-15.8) 28.3 (26.3-30.4) 0.2 (0.1-0.4) 34.7 (32.8-36.7) 40.8 (38.2-43.5) 9.6 (9.0-10.3) 0.5 (0.4-0.7) 32.6 (31.7-33.6) 44.3 (43.0-45.5) 29.6 (28.1-31.1) 1.1 (0.9-1.4) 17.8 (16.7-19.0) 28.1 (26.3-30.0) 28.7 (26.7-30.7) 20.2 (19.2-21.3) 8.1 (7.2-9.2) Note: smokeless tobacco and smoking other than manufactured cigarettes

Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR 173 tobacco use varied from 27.2% in Thailand to 43.3% in Bangladesh. Among both men and women prevalence was lowest in Thailand and highest in Bangladesh. In India, the prevalence of current tobacco use was 34.6% (47.9% men; 20.3% women). Current tobacco use among men in all three countries was considerably higher than among females. Current use of other tobacco products was reported to be higher than use of manufactured cigarettes in all three countries. There was a marked difference observed between males and females when smoked and smokeless tobacco use was considered separately [Figure 1]. In both Bangladesh and Thailand, prevalence of smoking was higher than smokeless tobacco use among men, whereas use of smokeless tobacco was higher in both males and females in India compared to smoked tobacco products. It was interesting to note that smokeless tobacco use was more prevalent among females than among males in all three countries [Figure 1]. The proportion of combined use (both smoking and smokeless together) was reported to be higher in Bangladesh and India as compared to Thailand, especially among males (>19% vs. 1%). However, the proportion of combined use among females was reported to be 2.5%, 5.5%, and 3.3%, in Bangladesh, India, and Thailand, respectively. Discussion Findings from both GYTS (years 2007-2009) and GATS (years 2009-2010) indicate that current tobacco other than manufactured cigarettes among youth and adults in the region is high. Further, the results clearly point out that the use of other tobacco products is more prevalent than manufactured cigarette smoking. Indigenous smoking products, such as bidi, are popular in Bangladesh, India, the Maldives, Nepal, and Sri Lanka, while cheroots are popular in Myanmar and Roll-Your-Own cigarettes (in palm leaves or paper) is popular in Thailand. Chewing products, known as khaini and betel quid with tobacco and other additives (Zarda, Kiwam, raw tobacco leaf, various combinations of tobacco with areca nut, lime, honey, alcohol) are popular in some countries. In Bangladesh, India and Nepal, people apply tobacco products such as gul, gudaku, mishri, masheri, lal dantmanjan, as dentifrice, and nasal inhalation of tobacco powder (nas and naswar). 21 In comparison to smoking products, use of smokeless tobacco is much more common among adults in India and Bangladesh. 18-20 GATS data suggests that smoking is the predominant practice among adult males, while smokeless tobacco use is more common among females [Figure 1]. It is important that national tobacco control policies address all tobacco products and not just limit to manufactured cigarettes. For example, Bangladesh has no tobacco control policies for smokeless products, which highlights the need to strengthen its tobacco control act by including smokeless tobacco. In addition, GATS shows that two in every five adult females use smokeless tobacco in Bangladesh and India requiring urgent policy intervention as outlined in the WHO FCTC and WHO MPOWER technical package. 4 Findings from GYTS indicate that cigarette smoking among students aged 13 15 in the South-East Asia Region is lower than among their peers in European, American, African and Western Pacific regions. However, rates Figure 1: Percentage distribution of current tobacco users by type of tobacco use and gender among adults aged 15 years and above in select member countries of the South East Asia Region

174 Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR of tobacco consumption (other than cigarettes) among youth in this region are almost the same as those in other regions. 12 Hence, youth interventions need to emphasize all tobacco products in the region. Although a large number of people know in general terms that tobacco use is harmful to their health, 18-20 many aspects of tobacco use have not been adequately explained and as a result are not well understood by most tobacco users. 22 Thus there is a greater need of health education addressing both smoking as well as smokeless tobacco products harm. Scientific evidence shows that graphic health warnings are the most cost effective intervention to educate people regarding tobacco. 22 India and Thailand have implemented graphic health warning on various tobacco products and other countries in the region are in the process of implementing such warnings. Thailand has adopted 100% smoke free policies in the majority of public places in addition to other countries in the region also extending 100% smoke free policies in public places. Countries in SEARO are trying to implement tobacco control policies. Examples of other tobacco initiatives include: India initiating state tobacco control cells; Bangladesh creating a task force to work at grass root level; and Thailand trying to strengthen provincial tobacco control mechanism. Affordability of indigenous smoking and smokeless tobacco products are important factors that increases access to these products in the region. The indigenous products are much cheaper than cigarettes, due in a large part to the fact that the tax imposed on such products is much less than that for cigarettes. This lowers the price, increases affordability and improves access to larger segments of the population, especially youth and females. For instance in India, bidis are under-taxed compared to cigarettes, and moreover, handmade bidis are taxed at a lower rate than manufactured bidis. Ironically, handmade bidis account for 98% of all bidis in India, yet bidis in general account for about 48% of the market, as opposed to 38% for chewing tobacco and only 14% for cigarettes. 23 Article 6 of the WHO Framework Convention on Tobacco Control provides guidance on how taxes on tobacco products can be increased to help curb the tobacco epidemic. 24 Increasing tax on tobacco products is considered one of the effective mechanism to reduce tobacco use. According to the 2010 Global and Regional Progress Reports on WHO FCTC Implementation, the average total tax rate levied on cigarettes was 57.7% in the South-East Asia Region, which was less than the World Bank s recommended threshold of 67%. 9,25 Although governments have been attempting to increase the tax on tobacco products, especially on cigarettes, WHO estimates show no progressive increase in taxes on tobacco products in recent times. 26 If the tax rise is not significant enough, the net effect on the affordability of tobacco products will be negligible. Since many countries do not take inflation rates into account when computing tax increases, any modest rise in the tax becomes counterproductive. Studies have shown that the percentage of GDP per capita required to buy cigarettes in the region has declined over the years, indicating an actual increase in the affordability of cigarettes. 26 In addition, there is a wide gap in application of tax rates among different tobacco products. In India, the tax on bidis is insignificant compared with cigarettes, even though ten bidis are smoked for every cigarette smoked. 23 Countries with widespread consumption of smokeless tobacco need to direct singular attention toward a tax increase that makes that product less affordable in the market. The Tobacco industry is known to influence individuals, institutions and governments, during the process of developing and implementing national tobacco control policies. 27 It has expanded its presence in South-East Asia, where it attempts to weaken tobacco control laws and often continues to influence marketing its products especially to young girls. 28 The findings of the GYTS reveal that over 60% of boys and girls have been exposed to cigarette advertising in outdoor and print media in most countries in the region. 28,29 For instance, in Bangladesh and India, there is no comprehensive ban on tobacco advertising and promotion at the point of sale. GATS findings reveal that almost half of men (about 48.6%) and one fifth of women (18%) had noticed tobacco product advertising at the point of sale in Bangladesh. 20 GYTS findings from several countries suggest that exposure of youth to direct advertising on billboards had not changed much between 2006 and 2009. 30 An important focus of any national tobacco control program is to promote policy relevant research. For instance, the proportion of mixed users (cigarettes and other tobacco products) in Bangladesh and India is high and studies of tobacco morbidity shows a dose-response relationship with tobacco use. 31 However, the evidence on the relative risk of combined use in the literature is

Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR 175 scarce. Research in such areas is crucial for improving the evidence base and use it for promoting public policy. Conclusion There is a high prevalence of tobacco use in South-East Asian countries, with smoking being more common among men and use of smokeless tobacco more common among women. A combination of factors, such as tobacco industry marketing, including targeting young people, weak enforcement of tobacco control policies, continuing affordability of tobacco products, and inadequate knowledge about the harmful effects of tobacco are all contributing to the seriousness of the problem in the Region. Strengthening monitoring systems is central to the management of the tobacco epidemic. Systematic global tobacco surveys are vital tools for measuring the prevalence of tobacco use and key policy indicators. WHO and CDC have made tools available for countries to monitor tobacco use and key tobacco control indicators. In turn, the survey findings will support formulation of national evidence-based and effective tobacco control strategies. Limitations The findings in this report are subject to the following limitations: (1) prevalence results are based on selfreports; (2) in certain settings, social norms (i.e., unacceptability of women and girls smoking) might result in underreporting; (3) surveys are cross-sectional and reflect only the time period the data were collected; and (4) the wider confidence intervals in the GYTS are result of lack of precision and inadequate sample size for the national estimates in some countries. In addition, this paper reports on gender, however, future studies can focus on other demographic characteristics such as education and socioeconomic status. Acknowledgements The authors would like to thank the Ministries of Health of member states and implementing agencies, the World Health Organization (WHO), and the CDC, who made completion of the GYTS and GATS possible. The authors also would like to thank the GATS collaborative group. Funding for GYTS is provided by the CDC. Funding for the Global Adult Tobacco Survey (GATS) is provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies. The Government of India contributed to GATS implementation in India. We thank the thousands of field workers for their contributions and the several thousand respondents for their cooperation, without whom this work would not have been realized. References 1. World Health Organization (WHO). Global health risks: Mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009. Available from: http://www.who. int/healthinfo/global_burden_disease/globalhealthrisks_ report_full.pdf. [Last Accessed on 2011 Jun 27]. 2. Öberg O, Jaakkola MS, Woodward A, Peruga A, Prüss-Ustün A. Worldwide burden of disease from exposure to secondhand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;377:139-46. 3. WHO. Global Status Report on Non-communicable Diseases 2010. Geneva: WHO; 2011. Available from: http:// whqlibdoc.who.int/publications/2011/9789240686458_eng. pdf. [Last Accessed on 2011 Jun 27]. 4. WHO. Tobacco Free Initiative. Tobacco Facts. Geneva: WHO; 2011. Available from: http://www.who.int/tobacco/ mpower/tobacco_facts/en/index.html. [Last Accessed on 2011 Jun 27]. 5. U.S. Department of Health and Human Services. The Health Consequences of Smoking. A Report of the Surgeon General. Public Health Service. Rockville, Maryland; 2004. 6. Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38. 7. Bouttayeb A. The double burden of communicable and non-communicable diseases in developing countries. Trans R Soc Trop Med Hyg 2006;100:191-9. 8. Elton-Marshall T, Fong GT, Zanna MP, Jiang Y, Hammond D, O Connor, et al. Beliefs about the relative harm of light and low tar cigarettes: Findings from the International Tobacco Control (ITC) China Survey. Tob Control 2010;19 Suppl 2:i54-62. 9. WHO. Office for South-East Asia (SEARO). Profile on Implementation of WHO Framework Convention on Tobacco Control in the South-East Asia Region. New Delhi, India, 2011. 10. Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO). Global Tobacco Surveillance System. Available from: http://www.cdc.gov/tobacco/global/ gtss/index.htm. [Last Accessed on 2011 Apr 18]. 11. The Global Youth Tobacco Survey Collaborative Group. Gender differences in worldwide tobacco use by gender: Findings from the global youth tobacco survey. J School Health 2003;73:207-15. 12. Global Tobacco Surveillance System Collaborating Group, Global Tobacco Surveillance System (GTSS): Purpose, Production and Potential. J School Health 2005;75:15-24. 13. Global Tobacco Surveillance System (GTSS) collaborative

176 Sinha DN, et al.: Tobacco Use among Youth and Adults in Member Countries of SEAR group. A cross country comparison of exposure to secondhand smoke among youth. Tob Control 2006;15 Suppl:1114-9. 14. Warren CW, Lea V, Lee J, Jones NR, Asma S, McKenna M. Change in tobacco use among 13-15 year olds between 1999 and 2008: Findings from the Global Youth Tobacco Survey. Glob Health Promot 2009;16 Suppl 2:38-90. 15. Global Tobacco Surveillance System (GTSS) collaborative group. The Global School Personnel Survey: A cross country overview. Tob Control 2006;15 Suppl 1:20-30. 16. Sinha DN, Singh G, Gupta PC, Pednekar M, Warrn CW, Asma S, et al. Linking India global health professions student survey data to the world health organization framework convention on tobacco control. Indian J Cancer 2010;47 Suppl 1:30-4. 17. WHO. Report on Global Youth Tobacco Survey (GYTS) and Global School Personnel Survey (GSPS) in Bangladesh. World Health Organization, Office for South-East Asia Region, New Delhi, India, 2007. Available from: http://www. searo.who.int/linkfiles/gyts_ban2007.pdf. [Last Accessed on 2011 Jun 27]. 18. WHO, Country Office for Bangladesh. Global Adult Tobacco Survey: Bangladesh report. Dhaka, Bangladesh: WHO; 2009. Available from: http://www.who.int/tobacco/surveillance/ global_adult_tobacco_survey_bangladesh_report_2009.pdf. [Last Accessed on 2011 Jun 27]. 19. WHO. Regional office for South East Asia. Global Adult Tobacco Survey: Thailand Country Report 2009. New Delhi, India, 2009. Available from: http://www.who.int/tobacco/ surveillance/thailand_gats_report_2009.pdf. [Last Accessed on 2011 Jun 27]. 20. Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey: India Report 2009-10. New Delhi, India, 2010. Available from: http://whoindia.org/en/ Section20/Section25_1861.htm. [Last Accessed on 2011 Jun 9, 27]. 21. Sinha DN. Report on Oral Tobacco Use and its Implications in South-East Asia. Patna: WHO SEARO; 2004. Available from: http://www.searo.who.int/linkfiles/nmh_oraltobaccouse. pdf. [Last Accessed on 2011 Jun 27]. 22. WHO. WHO report on the global tobacco epidemic 2011: Warning about the dangers of tobacco. Geneva: WHO; 2011. Available from: http://whqlibdoc.who.int/ publications/2011/9789240687813_eng.pdf. [Last Accessed on 2011 Jun 27]. 23. Sunley EM. India: The Tax Treatment of Bidis, 2008. Available from: http://www.tobaccofreeunion.org/files/44. pdf. [Last Accessed on 2011 Jun 27]. 24. WHO. Framework Convention on Tobacco Control. Geneva, WHO: WHO Press; 2003. Available from: http://whqlibdoc. who.int/publications/2011/9789241501316_eng.pdf. [Last Accessed on 2011 Jun 27]. 25. WHO. Global Progress Report on the Implementation of the WHO Framework Convention on Tobacco Control. Geneva: WHO Framework Convention on Tobacco Control; 2010. Available from: http://www.who.int/fctc/reporting/ progress_report_final.pdf. [Last Accessed on 2011 Jun 27]. 26. Blecherv E, van Walbeek C. An analysis of cigarette affordability. Paris: International Union against Tuberculosis and Lung Disease; 2008. Available from: http://tobaccofreecenter.org/ files/pdfs/en/tax_cigarette_affordability_report_en.pdf. [Last Accessed on 2011 Jun 27]. 27. WHO. Building Blocks for Tobacco Control: A handbook. Geneva, 2004. Available from: http://whqlibdoc.who.int/ publications/2004/9241546581_eng.pdf. [Last Accessed on 2011 Jun 27]. 28. WHO Office for South East Asia (SEAR), 2010. Brief Profile on Gender and Tobacco in the South-East Asia. Available from: http://www.searo.who.int/linkfiles/world_no_ Tobacco_Day_GenderandTobacco.pdf. [Last Accessed on 2011 Jun 27]. 29. WHO Office for South East Asia (SEAR), 2008. Brief Profile on Tobacco and Youth in the South-East Asia. Available from: http://www.searo.who.int/linkfiles/world_no_tobacco_ Day_TFI_Brief_Profile.pdf. [Last Accessed on 2011 Jun 27]. 30. Gajalakshmi V, Kanimozhi CV. A survey of 24,000 students aged 13 15 years in India: Global Youth Tobacco Survey 2006 and 2009. Libartas Academica Freedom to Research. Tob Use Insights 2010;3:23-31. 31. Lambert R, Sauvaget C, Cancela MC, Sankaranarayanan R. Epidemiology of cancer from the oral cavity and oropharynx. Eur J Gastroenterol Hepatol 2011;23:633-41. Disclaimer: The views expressed in this article are not necessarily those of the GATS and GYTS partner organizations. Cite this article as: Sinha DN, Palipudi KM, Rolle I, Asma S, Rinchen S. Tobacco use among youth and adults in member countries of South-East Asia region: Review of fi ndings from surveys under the global tobacco surveillance system. Indian J Public Health 2011;55:169-76. Source of Support: Funding for GYTS is provided by the CDC. Funding for the Global Adult Tobacco Survey (GATS) is provided by the Bloomberg Initiative to Reduce Tobacco Use, a program of Bloomberg Philanthropies. Conflict of Interest: None declared.