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ORIGINAL ARTICLE
Year : 2017  |  Volume : 61  |  Issue : 5  |  Page : 54-59  

Tobacco use among young adolescents in Myanmar: Findings from global youth tobacco survey


1 Assistant Director, Basic Health Service Section, Department of Public Health, Ministry of Health and Sports, Myanmar
2 Deputy Director General (Training), Department of Public Health, Ministry of Health and Sports, Myanmar
3 Surveillance Management Associate, Noncommunicable Disease and Tobacco Surveillance, Department of Noncommunicable Diseases and Environmental Health, World Health Organization, Regional Office for South East Asia, New Delhi, India
4 Deputy Director, Basic Health Service Section, Department of Public Health, Ministry of Health and Sports, Myanmar
5 Health Impact Assessment Coordinator, (Consultant), Asian Development Bank, Myanmar

Date of Web Publication15-Sep-2017

Correspondence Address:
Naveen Agarwal
Noncommunicable Disease and Tobacco Surveillance, Department of Noncommunicable Diseases and Environmental Health, World Health Organization, Regional Office for South East Asia, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_236_17

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   Abstract 

Background: Tobacco consumption among youths poses significant public health problem in developing countries. This study utilized the available data of Global Youth Tobacco Survey (GYTS) to assess the prevalence of tobacco use among Myanmar adolescents. Objectives: We have conducted the fourth round of the GYTS in Myanmar during 2016 to monitor trends in tobacco use. Methods: We have selected 51 schools using random sampling based on probability proportional to school enrollment. In each school, we selected grades 9–11 by random sampling. All students in these classes completed a self-administered standard questionnaire. Results: A total of 3633 students who were participated in the survey 2621 students were 13–15 year. Overall 13.6% of students currently used tobacco; boys 26.3% and girls 3.7%. The prevalence of current cigarette smoking was 8.3%; boys 17.0%, girls 1.5%, whereas 5.7% of students currently smokeless tobacco users; boys 11.0%, girls 1.5%. Exposure to secondhand smoke (SHS) at home, in enclosed public places, and school was reported by 33.2%, 28.4%, and 64.5%, respectively. More than four out of 5 (83.4%) students had noticed someone using tobacco on television, videos or movies, and 42.3% had noticed tobacco advertising at points of sale. Among current smokers, 62.9% were not refused by purchasing cigarettes because of their minor age. Conclusion: Myanmar has higher prevalence of tobacco use among students, especially among boys. The study provides evidence-based information for developing comprehensive tobacco control programs – both education and policy interventions to reduce smoking rate among young people in Myanmar.

Keywords: Adolescents, cigarette smoking, Global Youth Tobacco Survey, Myanmar, secondhand smoke, smoking pattern, tobacco prevalence


How to cite this article:
Tun NA, Chittin T, Agarwal N, New ML, Thaung Y, Phyo PP. Tobacco use among young adolescents in Myanmar: Findings from global youth tobacco survey. Indian J Public Health 2017;61, Suppl S1:54-9

How to cite this URL:
Tun NA, Chittin T, Agarwal N, New ML, Thaung Y, Phyo PP. Tobacco use among young adolescents in Myanmar: Findings from global youth tobacco survey. Indian J Public Health [serial online] 2017 [cited 2019 Jul 18];61, Suppl S1:54-9. Available from: http://www.ijph.in/text.asp?2017/61/5/54/214905


   Introduction Top


Tobacco use by adolescents remains a major public health concern worldwide, and some evidence suggested that the majority of smokers, who begin using tobacco products before the age of 18 years, continue to be permanent smokers.[1] Tobacco smoking is a preventable public health problem which leads to premature deaths worldwide.[2] Adolescence is the phase of transition from a “child” into an “adult.” It is also a period of change in a person's way of thinking. Smoking is a lifestyle habit which is associated with morbidity and mortality. It is therefore important to determine the factors associated with cigarette smoking in this age group to institute preventive measures and health policies to protect these adolescents early.

The Global Youth Tobacco Survey (GYTS) is a systematic youth survey among 13–15-year-old school going students. Myanmar systematically monitored tobacco use among youth and conducted four rounds of GYTS since 2004.[3] The data points from these rounds used to compare tobacco use prevalence among youth and gave an evidence support which needed for policy formulation and implementation to better control of tobacco use.

This study aims to use data from different rounds of GYTS conducted in Myanmar to determine the prevalence of tobacco use among young adolescents, secondhand tobacco smoke exposure, initiation of tobacco use, accessibility and use of tobacco pattern, and knowledge of the harmful effects of smoking in these adolescents.


   Materials and Methods Top


In 2016, Myanmar has conducted their fourth round of GYTS. The survey was cross-sectional among aged 13–15 years corresponding to grades 9–11. Two-stage stratified sampling methodology used to produce a representative sample of students for all over the country. In the first stage, 51 schools have been selected in 12 states and divisions using probability proportional based on the size of school enrollment and schools having <40 students were excluded. At the second stage, classes have been selected by systematic sampling with a random start. All students in the selected class were invited to undertake the survey irrespective of age. Out of 3633 students from 70 selected classes, 2621 students were included in this study as they were belonged to age group of 13–15 years (44.4% of boys and 55.6% of girls).

The survey used standard core questionnaires with a set of optional questions. The questionnaires covered tobacco use (smoked and/or smokeless); cessation; secondhand smoke (SHS); pro- and anti-tobacco media and advertising; access to and availability of tobacco products; and knowledge and attitudes regarding tobacco use.

“Ever user” was defined who had ever used any tobacco product even once in the lifetime, while a “current use” was defined as the use of tobacco product in the past 30 days preceding the day of survey. Tobacco use included smoking cigarettes, cheroot, cigar and pipe and use of smokeless tobacco, such as tobacco leaf, hnat hsay, hsay paung, chewing tobacco leaf or applying tobacco.

Data were analyzed using SUDAAN Ver. 9.0 (Research Triangle Park, NC, United States), which computed standard errors of the prevalence estimates and produced 95% confidence intervals. A weighting factor was applied to each student record to account for nonresponse by school, class, and student, and probability of selection at the school and class levels. The school and class response rate were 100%, and the student response rate was 95.5%. Thus, the overall response rate was 95.5%.


   Results Top


Tobacco use

The overall current cigarette smoker rate (the weighted percentage of respondents who reported having smoked a cigarette any time during the previous 30 days) showed an increased that was not statistically significant from 4.9% in 2007 to 8.3% in 2016. Among males, the rates were statistically significant increased to double from 8.5% in 2007 to 17% in 2016. Rates of ever cigarette smoking (ever taking a puff on a cigarette) significantly increased from 14.7% in 2007 to 22.3% in 2016, and moreover, among males, the rate increased nearer to double from 23.4% in 2007 to 41.1% in 2016. In addition, the overall rates for frequent cigarette smoking (smoking on 20 or more days of the previous 30 days) in 2016 were 0.6% and 1.1% among males.

The overall smokeless tobacco user rate was 6.5% in 2007 and 5.7% in 2016, a decrease that was not statistically significant and remained higher among males than females.

The tobacco use rate (either smoked or smokeless) also showed a decrease that was not statistically significant, from 15.3% in 2007 to 13.6% in 2016, and remained higher among males than females. The overall ever tobacco users (ever taking either smoked or smokeless) were more than double to current tobacco users in 2016.

The overall current tobacco smoking rate (any tobacco smoking product) is significantly higher among males (21.1%) than females (2.4%). Overall ever tobacco smokers (27.3%) were almost triple from current tobacco smokers (10.6%) in 2016, whereas it was more than double in boys (46.2% vs. 21.1%) and five times more in girls (12.2% vs. 2.4%).

The overall current tobacco smoking other than cigarette rate (e.g., cheroot, cigar, and pipe) has decreased, from 10.1% in 2007 to 4.1% in 2016. Among males, the rates were decreased from 14.1% in 2007 to 7.5% in 2016; among females, the rates were decreased 6.2% and 1.3%, respectively [Table 1].
Table 1: Prevalence of tobacco use among students aged 13-15 years, by gender, Global Youth Tobacco Survey, Myanmar, 2007 and 2016

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Exposure to secondhand smoke (SHS)

Exposure to SHS at home, inside enclosed public place, and any outdoor public place were reported by student 33.2%, 28.4%, and 29%, respectively, in 2016. Importantly, three in five (64.5%) students saw anyone smoking inside school or near to school premises [Table 2].
Table 2: Prevalence of secondhand smoke among students aged 13-15 years, by gender, Global Youth Tobacco Survey, Myanmar, 2016

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Initiation of tobacco smoking, accessibility of tobacco, and smoking pattern

In 2016, overall around two in five students who were ever cigarette smokers reported that they first tried a cigarette at the age of <10 years. Mostly, two in five (40.8%) students initiated cigarette smoking between aged 12 and 13 years followed by 30.9% of students started between aged 14 and 15 years. Over half of (58.4%) students smoked less than one cigarette a day. More than one-fourth (27%) of the students responded that they used to smoke one cigarette per day followed one in ten students reported 2–5 cigarettes per day. The accessibility of cigarettes and other tobacco products increased and become more than double from 23.7% in 2007 to 54.5% in 2016. Tobacco products seem easily available in Myanmar because 38.8% of students reported that they purchased cigarettes from a street vendor. Importantly, more than half (62.9%) current cigarette smokers not prohibited from buying cigarette though they were minors. Three in five (61.9%) current cigarette smokers purchased loose cigarettes as individual sticks [Table 3].
Table 3: Initiation of tobacco smoking, accessibility of tobacco and smoking pattern among students aged 13-15 years, by gender, Global Youth Tobacco Survey, Myanmar, 2016

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Exposure to pro- and anti-tobacco messages, knowledge, and thinking about tobacco use

Over two in five (42.3%) students who visited and noticed tobacco advertisement at the point of sale and over four in five (83.4%) students who watched television, videos, and movies and saw anyone who was smoking. On the other hand, four in five (80.2%) students reported that they noticed anti-tobacco messages in the media and three in five students (59.6%) attended and saw anti-tobacco messages in sports and community events. Two in five (40%) students noticed health warnings on cigarette packages and thought of quitting tobacco. More than three in five (64.2%) students said that they have been taught in school about the danger of tobacco use.

The majority of students were in favor to ban smoking in public places and as thought that other people's smoking was harmful to them. Near to one in three (30.4%) students thought that it would be difficult to quit once someone started smoking tobacco. However, in contrast, more than one-fourth (25.8%) of the students felt that smoking tobacco helps people feel more comfortable at celebrations, parties, and social gatherings. More than two in five (43.3%) current smokers showed smoking dependence in 2016 [Table 4].
Table 4: Exposure to pro- and anti-tobacco messages, knowledge, and attitudes toward tobacco use and smoking cessation among students aged 13-15 years, by gender, Global Youth Tobacco Survey, Myanmar, 2016

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Cessation

Near to three-fourth current smokers (74.5%) had tried to quit smoking in the past 12 months. In addition, nearly seven in ten (69.4%) wanted to stop smoking. However, less than half (45.8%) had received help or advice from cessation program or professional to stop smoking [Table 4].


   Discussion Top


Myanmar is one of the countries in the WHO South-East Asia Region where tobacco use among young population remarkably high.[3]

Myanmar ratified the WHO Framework Convention on Tobacco Control in 2004 and initiated tobacco control activities. The Myanmar government introduced “The control of smoking and consumption of tobacco product law” in May 2006. However, according to survey results, enforcement of tobacco control law is challenge and needs to be strengthened to control the rise of cigarette smoking among young population.

The study found that tobacco use remains high among youth, with one out of ten students currently using tobacco. Males were significantly high in using tobacco than girls in all GYTS surveys since 2001. The tobacco use not decreased over the time. In addition to this cigarette smoking showing increasing trend from 4.9% in 2007, to 6.8% in 2011–8.3% in 2016. Cigarette smoking among youth is much higher in Myanmar schoolchildren compared to among the WHO-South-East Asia Regional Office (WHO-SEARO) countries, i.e., Bangladesh, India, Maldives, Nepal, and Sri Lanka. However, the prevalence of smokeless tobacco use among student shows downtrend from 9.8% in 2011 to 5.7% in 2016.

Although the laws clearly prohibit the sale of tobacco products to young people <18 and sale of loose cigarettes or in a package containing <20 to enable easy purchase and smoking.[4] The survey shows that the cigarettes are more accessible year by year to youth as cigarettes buying prevalence remarkably increased in the past 15 years with 23.7% in 2001, 39.2% in 2011–54.5% in 2016. The percentage of students who not prevented from buying cigarettes because of their minor age also become high as three students out of five reported that they were not stopped to buy cigarettes. More than half of current smokers were able to buy the individual sticks which mean tobacco laws need to be reinforced.

The national survey of diabetes mellitus and risk factors for noncommunicable diseases (NCDs) in Myanmar shows about 44% of current smokers tried to quit smoking. This survey was done among adults aged 25–64 years in 2014.[5] The GYTS 2016 revealed that 74.5% current smokers tried to stop smoking in the past 12 months. The attempts of trying to stop smoking are higher in youth than adult which is good sign. However, less than half current smoker received help or advice from a program or professional to stop smoking. This shows that the cessation services and clinic should be feasible and accessible to the young generation in the country. Apart from that training for tobacco cessation to all the level of health-care providers and the tobacco cessation topic should include in the curriculum of all health-care course.

According to the GYTS results, over one-third of students are exposed to tobacco smoke at home and it is constantly same since 2001. However, exposure to tobacco smoke at public place has decreased. This shows that law implemented effectively, but still the awareness on harmful effects of SHS should be increase to save youth at home.

Myanmar signed the directive in 2016 to increase the size of health warning signs on tobacco packs to 75% and it is implementing.[6] However, a regular monitoring of the tobacco packages in the market is also very important for its effective implementation. Myanmar still needs to follow the commercial tax law which was legalized in 1990. At the time of the implementation of the pictorial health warnings, the amendment of the control of smoking and consumption of tobacco product law and commercial tax law should be the priority areas for the government to reduce the tobacco prevalence.

The study found that a significant proportion of students are being exposed to pro-smoking media campaigns and tobacco promotion by the tobacco industry. More than two in five students noticed tobacco advertisement at points of sale and four in five students noticed anyone using tobacco on television, videos, or movies. This is also the reflection of the weakness of the enforcement of the tobacco law.

The survey also shows that students are aware of harmful effects of tobacco use as near to two-third of the students thought other people's tobacco smoking is harmful to them and almost all students were in favor of banning smoking at public places.

Myanmar is also one of the countries with high NCDs burden where 59% of total deaths are estimated due to NCDs. The premature mortality (the probability of dying between age 30 and 70 years) due to four major NCDs (cancers, cardiovascular diseases, diabetes, and chronic respiratory diseases) is 24%.[7] Tobacco use is the major risk factor for NCDs and rising of youth cigarette smoking can lead to increase mortality and morbidity due to NCDs.

While the governments committed a 30% relative reduction in the prevalence of current tobacco use by 2025 to reduce NCD-related premature deaths.[8] Myanmar needs to strengthen its tobacco control activities, especially among young people to achieve NCD-related targets. Strengthening tobacco and other relating NCD risk factors will give platform for Myanmar to achieve health-related sustainable development goals which are ensure healthy life and promote well-being for all its citizens at all ages by 2030.[9]

Therefore, Myanmar should accelerate its tobacco control activities by strengthening the enforcement of tobacco control law, amending commercial tax law to increase the taxation of tobacco products, creating, and promoting the tobacco cessation services and clinics in the community level, promoting the campaigns to increase the awareness of the risks of tobacco use to reduce the tobacco use, especially cigarette smoking among young generation.


   Conclusion Top


Undoubtedly, smoking behavior among adolescents in Myanmar is associated with some determinant factors such as availability of tobacco product, easy access, or lack of preventive laws and other factors such as family and peer smoking. Despite the known health problems associated with tobacco use through family health education and anti-smoking messages, young people in country continue to initiate and develop regular patterns of tobacco use.

School-based interventions and tobacco education are necessary to prevent initiation and cessation of tobacco use. Legislations related to tobacco control should be enforced to decrease availability, accessibility, and affordability of tobacco products. Social norms of tobacco use among parents and others at home as well as at public place should be modified to curb the tobacco use among school students.

Prohibiting initiation of cigarette smoking among young people is crucial because the earlier the age of smoking, the probability of nicotine addiction is higher. To meet reduced prevalence of NCDs and meet a 30% relative reduction in the prevalence of current tobacco use in persons aged 15+ years by 2025, reducing the prevalence of cigarette smoking among youth are crucial, and therefore, Myanmar should accelerate its comprehensive tobacco control activities.

This is very alarming because youth tobacco use causes not only immediate damage but also long-term bad consequences. The earlier the age of tobacco use, the more likely that they will be addicted, especially nicotine addiction.[10]

Therefore, the control of using tobacco products in school youths needs to be prioritized for adolescent health and tobacco control.

Strengths and limitations of study

The major strength is dataset used is a nationally representative, which was specifically designed to collect tobacco survey among young people in Myanmar. This study can be generalizable to the young population in the same age with tobacco use in Myanmar. Our analysis highlights the importance of implementation of national tobacco law to support education and behavioral change interventions. However, our research has some limitations. One limitation has been the type of study, which is a cross-sectional study that allows us to only analyze the association, but not the cause and effects. Another limitation has been the potential of recall bias due to the data are self-reported and not including out of school students.

Acknowledgments

The authors acknowledge the guidance of Director General and Deputy Director General of Department of Public Health of Ministry of Health and Sports Myanmar and collaboration and technical support of the World Health Organization (Myanmar country office and SEARO) and financial and technical support of the Centers for Disease Control and Prevention (CDC), Atlanta, United States. The authors sincerely thank to the students, teachers, and field workers who helped contribute to the survey.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

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The Union of Myanmar the State Peace and Development Council. The Control of Smoking and Consumption of Tobacco Product Law; 2006. Available from: http://www.tobaccocontrollaws.org/files/live/Myanmar/Myanmar%20-%20TC%20Law.pdf. [Last accessed on 2017 Jun 13].  Back to cited text no. 4
    
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The Government of the Republic of the Union of Myanmar, Ministry of Health. Order of Printing Warning Images and Texts on the Packaging of Tobacco Products; 2016. Available from: http://www.tobaccocontrollaws.org/files/live/Myanmar/Myanmar%20-%202016%20GHWs%20Notification.pdf. [Last accessed on 2017 Jun 13].  Back to cited text no. 6
    
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Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General, The US Government of Health and Services; 2012. Available from: https://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/index.html. [Last accessed on 2017 Jun 13].  Back to cited text no. 10
    



 
 
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