Tobacco use among students aged 13–15 years in Greece: the GYTS project

Tobacco use is one of the most important preventable causes of premature death, disease and disability around the world [1, 2]. Nearly 5 million persons die annually from tobacco-related illnesses, and many more suffer from smoking-related morbidity while the number of fatalities is expected to more than double by year 2020 [3‐5]. The Global Youth Tobacco Survey (GYTS), as part of the Global Tobacco Surveillance System (GTSS), initiated by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), and the Canadian Public Health Association (CPHA), was developed to monitor tobacco use, elicit attitudes about tobacco, and obtain information on exposure to tobacco smoke among youth. It has been completed so far by over 2 million students around the world [6].

Although, a few studies have been conducted in the past with respect to the prevalence of smoking among high-school students in Greece, there are no data available on smoking among middle-school students [7‐9]. In addition, in contrast to most countries in the European Union (EU), where per capita consumption has decreased, the annual per capita consumption of cigarettes has risen steadily in Greece since the 1970s among adults and teenagers 15 years of age or older. In the mid '90s, annual per capita consumption in Greece was one of the highest in the EU; averaging about 4,300 cigarettes [10]. Therefore, the need to examine the problem of smoking among youth constitutes an urgent priority for Greece.

The objective of our current study was to examine the prevalence of smoking among middle-school students and to describe the prevalence of different indicators of smoking consumption using the information collected from the Global Youth Tobacco Survey (GYTS) implemented in Greece in 2005. We present data on the prevalence of different indicators of smoking including lifetime cigarette smoking, age of initiation, current smoking and tobacco dependency as well as current use of other tobacco products. Data are also presented on second-hand smoke exposure among students, and susceptibility of students to smoking.

The Global Youth Tobacco Survey (GYTS) was implemented in Greece by the University of Thessaly, School of Medicine and the National School of Public Health in collaboration with the Ministry of Health and Social Solidarity.

Our study is one of the first comprehensive evaluations of the problem of smoking among adolescent students in Greece. We found a relatively high prevalence of current smokers among middle-school students for both cigarettes and other tobacco products. In addition, students were susceptible to initiate smoking in the next year at twice the prevalence of current users. An important finding included the very high percentage of students being exposed to second-hand smoke in both their home as well as in public places. Another disturbing finding was also the fact that girls were as likely as boys to smoke cigarettes and also use other forms of tobacco.

Findings in this report indicate that tobacco control efforts in Greece face a number of significant challenges. First, the finding that boys and girls smoke at a comparable level is in contrast with previous studies among high-school students [7, 8], where the smoking prevalence was higher among boys compared with girls. Furthermore, boys and girls, who have never smoked, do not differ in their likelihood to initiate smoking in the near future. Second, the prevalence of susceptibility for smoking initiation among never smokers (19.5%) was almost twice that of current cigarette smokers (10.5%), for both genders, possibly suggesting that adolescents smoking rates are likely to increase dramatically in the next few years. Third, the prevalence of tobacco use other than cigarettes (10.9%) is similar to that of cigarettes (10.4%), indicating that tobacco control efforts in Greece should address all forms of tobacco products and not just cigarettes. Fourth, the high rate of students' exposure to second-hand smoke indicates a need to enforce already existing laws governing smoking and exposure to second-hand smoke in public places. Creating smoke-free areas and educating the public about the dangers of second-hand smoke will have complementary effects on efforts to control smoking by reducing the social acceptability of tobacco use around people who do not smoke especially children [14, 15]. Moreover an alarming finding of our study is the age of smoking initiation, which is decreasing over time with 1 in 4 students initiate smoking at the age of 10 years old. Such finding suggests that the anti-smoking campaign should also target students of elementary school and especially the fifth and sixth grades.

Greece is one of the first European countries to implement the Global Youth Tobacco Survey (GYTS). Previous limited reports showed that Greece had one of the highest smoking rates. However, few European countries have implemented GYTS and have reported smoking rates among their middle-school students. For example, GYTS in Hungary in 2003 showed that 33.5% of students report current use of cigarettes, whereas in Slovenia the percentage was 28.5% and in Slovakia the same survey showed that 24.3% were current users of cigarettes as opposed to only 10.4% in Greece. The corresponding rate of current cigarette use in Poland in 2003 was 23.3%, in Romania it was 23.2% and in Albania it was only 12%, which was very similar to Greece. Therefore, the results show that there is a much lower cigarette use among middle-school students in the Balkans as opposed to central Europe.

Several laws regulate the advertisement and sale of tobacco products in Greece. However, one of the weaknesses of the current situation is the efforts to enforce the existing legislation. For example, the European Union legislation on labeling, requiring rotating health warnings and listing of tar and nicotine levels, has also been implemented into Greek law. However, there are no laws regulating sales to minors, although vending and single stick sales of cigarettes are banned and the sale of tobaccoproducts through automatic vending machines is prohibited. A strong indication for the need to develop and implement legislation on the access of cigarette products for minors is the extremely high percentage of students being able to buy cigarettes from stores (95%). In addition, although new legislation has been introduced restricting smoking in government buildings, hospitals, trains, buses, and other public places, there is an urgent need for law enforcement in order to protect both adults and children from second-hand smoke.

A number of limitations of our study need to be acknowledged. First, there was some non-response in our study that may have introduced selection bias if the non responding was associated in any way with smoking. In addition, the possibility of information bias cannot be excluded given that some students may not provide valid answers and also may underreport the level of smoking since the data collected are based on a self-administered questionnaire. Nevertheless, in our study, we reached a student participation rate, which although not perfect, it was sufficient enough to draw significant conclusions on several scientific questions [16]. Furthermore, another limitation was that we used several field workers, however we do not believe that this introduced bias in the data collection process since the questionnaire was self-administered by the students. Although, GYTS represents a cross-sectional survey, it is an excellent tool for Greece to track changes over time and evaluate future tobacco control programs. The Ministry of Health and Social Solidarity in Greece has made initial efforts in tobacco control by establishing a tobacco control unit and making tobacco control a priority among health care workers and youth, however many more programs are needed to considerably improve the current situation.

The systematic surveillance of youth tobacco use constitutes an essential first step in our efforts to prevent the worldwide epidemic of death, disease and disability that smoking is projected to cause in the 21^st century. An important finding, revealed by our study, is the level of exposure of a large proportion of students to second-hand smoke, which needs to be addressed in a systematic way because it affects not only the smokers but almost all students at home and in public places. The results from the first GYTS implemented in Greece have significantly enhanced our capacity to develop, implement, and evaluate tobacco prevention and control programs in Greece.

The Ministry of Health and Social Solidarity in Greece in collaboration with public and private agencies is urgently called upon to use the current baseline data in order to develop a comprehensive tobacco control program targeting children and adolescent smoking rates as well as the issue of passive smoking. Future repeated rounds of the GYTS should also be used to evaluate the effectiveness of recommended programs at consecutive intervals. The problem of smoking in Greece has now been documented in its most alarming dimensions, and there is no excuse to stay still while the tobacco industry continues to target our children on a daily basis.