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 Table of Contents  
ORIGINAL RESEARCH
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 159-166

Tobacco-promotional activities in rural Sri Lanka: a cross-sectional study of knowledge, exposure and responses among adolescent schoolchildren


1 Epidemiology Unit, Ministry of Health and Indigenous Medicine, Colombo, Sri Lanka
2 Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Date of Web Publication22-May-2017

Correspondence Address:
Nalika s Gunawardena
Nalika S Gunawardena, Professor in Community Medicine, Department of Community Medicine, Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 08
Sri Lanka
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DOI: 10.4103/2224-3151.206685

PMID: 28607314

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  Abstract 


Background: Tobacco promotions are linked to tobacco consumption in adolescents. The aim of this study was to determine knowledge of and exposure and responses to tobacco-promotional activities and factors associated with knowledge among adolescents in a rural setting in Sri Lanka.
Methods: Seven schools in Polonnaruwa district were randomly selected for this cross-sectional study. Adolescents (n = 500) aged 14–15 years in grade 10 were selected using convenience sampling and studied by using a self-administered questionnaire during June–October 2014. The questions on exposure to tobacco-promotional activities were based on the validated questionnaire of the Global Youth Tobacco Survey. Adolescents were categorized into two levels of knowledge, exposure and responses to tobacco promotions, based on the scores obtained. Selected factors associated with knowledge of tobacco promotions were assessed using univarate and multivariate analyses.
Results: The response rate was 99.6% (498/500). The mean age of the adolescents was 14.9 years (standard deviation ±0.37) and the proportion of females was slightly higher (n = 280, 56.2%) than for males. The prevalence of current smoking was 3.2% (n = 16). Half (48.6%, n = 242) of the adolescents had a good level of knowledge of tobacco-promotional activities. Most (64.9%, n = 323) had experienced a low level of exposure to tobacco-promotional activities, while 85.7% (n = 427) indicated that they had responded/would respond assertively to exposure to tobacco promotion. In the univariate analysis, having a mother with a high level of education (odds ratio [OR] 1.742), having a father with a high level of education (OR 1.997) and the student attending a type 1AB school (OR 1.310) were significant factors associated with a good level of knowledge of tobacco-promotional activities. A father with a high level of education (adjusted OR 1.772) and the student attending a type 1AB school (adjusted OR 1.455) were the factors associated with a good level of knowledge for tobacco-promotional activities, when confounding effects of the variables were taken into consideration.
Conclusion: Knowledge of tobacco-promotional activities was poor among the adolescents in the rural setting in Sri Lanka. Nevertheless, most of the adolescents in the study population indicated that their responses to such exposures were/ would be assertive.

Keywords: adolescent, tobacco, tobacco promotion, Sri Lanka


How to cite this article:
Perera E M, Gunawardena Ns. Tobacco-promotional activities in rural Sri Lanka: a cross-sectional study of knowledge, exposure and responses among adolescent schoolchildren. WHO South-East Asia J Public Health 2015;4:159-66

How to cite this URL:
Perera E M, Gunawardena Ns. Tobacco-promotional activities in rural Sri Lanka: a cross-sectional study of knowledge, exposure and responses among adolescent schoolchildren. WHO South-East Asia J Public Health [serial online] 2015 [cited 2019 Jul 19];4:159-66. Available from: http://www.who-seajph.org/text.asp?2015/4/2/159/206685




  Background Top


Tobacco promotions are linked with adolescent tobacco consumption.[1] The 2005 World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) imposed a ban on direct or indirect commercial communication, recommendation or action promoting a tobacco product/ tobacco use.[2] However, the tobacco industry uses stealth-marketing strategies to attract new adolescent tobacco users.[3],[4] Provision of free samples and incentives, brand extensions and offering sponsorships are some of these strategies.[1],[5],[6] Sri Lanka enacted the National Authority on Tobacco and Alcohol (NATA) Act No. 27 in 2006, following ratification of the FCTC.[7]

The latest national estimates of prevalence of adult smoking in Sri Lanka are from the STEPwise approach to Surveys (STEPS) survey in 2006.[8] That survey was conducted in five randomly selected districts of the 25 districts in the country, among 12 401 adults aged 15–64 years (6140 males and 6261 females). The survey revealed a prevalence of current smoking (having smoked tobacco at any time during the past 30 days) of 15% among adults, with prevalences among males and females of 29.8% and 0.4%, respectively.

In 2003, 2007 and 2011, Sri Lanka took part in the Global Youth Tobacco Survey (GYTS), which provides internationally comparable information related to tobacco use among youth aged 13–15 years.[9] The latest GYTS in 2011[10] was conducted among a nationally representative sample of 4963 eligible students in grades 9–11, of which 4031 were aged 13–15 years. The survey estimated the number of current tobacco smokers, defined as having smoked tobacco at any time during the past 30 days, to be 3.9% among all adolescents, with a prevalence of 5.5% among boys and 2.2% among girls. The percentage of current users of smokeless tobacco (that is, had used smokeless tobacco at any time during the past 30 days) was 8.5% (boys 13.0%, girls 4.1%). Combining these two indicators together, the GYTS in Sri Lanka in 2011 estimated that 10.5% were current users of tobacco (that is, had smoked tobacco and/or used smokeless tobacco at any time during the past 30 days), with corresponding estimates for boys being 15.7% and girls being 5.4%. Compared with the 2007 GYTS, which indicated that current tobacco use was 9.1%, the more recent results represented a slight increase in current tobacco use among adolescents. When compared with other countries of the South-East Asia Region, tobacco use among Sri Lankan adolescents was found to be low, and higher only than tobacco use among adolescents in Bangladesh.[9]

The GYTS also assessed the influence of tobacco in the media on adolescents.[10] Of the study population, 62.1% (59.7% among boys and 64.1% among girls) had noticed tobacco advertisements in newspapers or magazines in the past 30 days, and 2.9% (4.2% among boys and 1.8% among girls) had been offered a free cigarette from a tobacco company representative. The proportion of adolescents who owned an item displaying a cigarette brand logo was 4.6% (5.7% among boys and 3.5% among girls). The great majority of adolescents (82.6%) had also noticed anti-tobacco messages in the media during the past 30 days, with the corresponding proportions among boys and girls being 83.1% and 82.2%, respectively.

Another source of evidence of the exposure of adolescents to tobacco-promotional activities through the media was a recent case–control study conducted in an urban setting in Anuradhapura Divisional Secretariat in Sri Lanka.[11] The aim of that study was to assess the effectiveness of tobacco-control measures on behaviour changes related to tobacco use among adolescents and young adults. Cases (current quitters) and controls (current smokers) were compared, to ascertain the effectiveness of the tobacco-control measures implemented by NATA to bring about the behaviour change of quitting. Information was gathered using a self-administered questionnaire and focus group discussions. The study included a total of 198, with 66 (27.3% adolescents and 72.7% young adults) quitters and 132 current smokers (18.2% adolescents and 81.8% young adults). Univariate analysis of the data revealed that 95.5% of cases and 87.9% of controls had noticed anti-smoking messages in the media during the 6 months preceding the study (P < 0.001). Exposure to anti-smoking media messages on television was more effective in motivating smokers to quit (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.14–1.87) than exposure to messages on radio (OR 1.22, 95% CI 0.46–3.25). Assessing exposure to the tobacco-promotion messages in the media, a majority (66%) of cases and controls did not report exposure to tobacco-promotion advertisements, while the numbers who had never seen tobacco advertisements during community events were 47% and 50% among the cases and the controls, respectively. That study also reported that all cases (n = 66), as well as 89% (n = 118) of the controls, had not noticed competitions or prizes sponsored by the tobacco industry during the past year. The study concluded that the tobacco-control measures implemented by NATA had had a favourable impact on motivating people to quit tobacco use, and that television was the strongest media source for information on the ill-effects of tobacco use.

Against this background, the present study aimed to describe the knowledge of and exposure and responses to activities promoting tobacco use among adolescents in a rural setting in Sri Lanka, and to assess factors associated with knowledge of activities promoting tobacco use.


  Methods Top


This was a descriptive cross-sectional study of students in three randomly selected type 1C schools and four type 1AB schools in the educational division of Thamankaduwa in Polonnaruwa District. Polonnaruwa District is one of the 25 districts in the country and one of the two districts of the North Central Province of Sri Lanka. Typing of schools in Sri Lanka is based on the different age groups that they teach, and types 1AB and 1C are schools that teach adolescents of the age group selected for this study.

The study unit was an adolescent in grade 10, and the study aimed to recruit a sample of 500. There were four type 1AB schools and six type 1C schools in Thamankaduwa. For logistic feasibility of the study, it was decided to conduct the study in adolescents from 7 of the 10 schools: the four type 1AB schools, and three randomly selected type 1C schools. The number of students to be included in the study was 300 from type 1AB schools and 200 from type 1C schools, based on the ratio of the approximate numbers of students in the relevant age group in each type of school. The number of students selected from each school within each type of school was more or less equal. The study was conducted during June–October 2014.

A pretested self-administered questionnaire consisting of mostly closed-ended multiple choice questions was used to collect the data. The initial section of the questionnaire contained questions relating to selected sociodemographic characteristics such as sex, parents’ highest education level and whether the adolescent was involved in extracurricular activities, including whether he/she was a leader in clubs/ groups in school.

The current status of smoking of the adolescent was investigated using the validated question of the GYTS:[10] “During the past 30 days (1 month), on how many days did you smoke cigarettes?”.

The questions on knowledge of tobacco-promotional activities were based on tobacco-control laws in Sri Lanka and promotion strategies used by the tobacco industry. Assessment of exposure to tobacco-promotional activities was based on seven questions; several of these questions were the same as those in the GYTS, while others were slightly adapted versions of the questions in the GYTS. Exposure to pro-tobacco advertising and promotion, either directly or indirectly through the media, was ascertained by using questions from the GYTS: “During the past 30 days (1 month), how many advertisements for cigarettes have you seen on billboards?” and “During the past 30 days (1 month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines?”. Furthermore, other questions from the GYTS, “Do you have something (T-shirt, pen backpack, etc.) with a cigarette brand logo on it?” and “Has a cigarette company representative ever offered you a free cigarette?”, were also used in the present study to assess the response. Many measures were taken to minimize nonresponse and to ensure honest responses. The confidentiality of the information was guaranteed by not asking for the names of the students or the schools of the study participants. It was ensured that the school teachers were not present at the data-colletion sessions. Students were made to sit apart from each other, to make sure that the answers were not shared. The principal investigator was present throughout the data-collection period to answer any queries of individual students regarding the questionnaire.

Informed written consent was obtained from parents and assent was obtained from the students prior to administering the questionnaire. Ethical clearance was obtained from the ethics review committee of the Faculty of Medicine, University of Kelaniya, Sri Lanka.

In assessing the responses of adolescents to tobacco-promotional activities, the students who had previously been offered free cigarettes by someone working for a cigarette company or who had been offered gifts displaying a tobacco logo were asked about the way/ways in which they had responded. Those who had not experienced these situations were requested to indicate the likely way/ways in which they would respond. The sudents were also asked whether they had carried out any activities in school against tobacco promotion.

In the analysis, the questions on knowledge of activities promoting tobacco were awarded one mark each if the responses were accurate, while each inaccurate response was awarded a zero mark. The maximum score was 15 and the minimum score was 0. A score of 8 or more was used to categorize the adolescents as having a “good” level of knowledge of activities promoting tobacco, while a score of less than 8 was regarded as a “poor” level of knowledge. The decision to use this cut-off score was based on the areas of knowledge considered to be “must know” by a group of experts on tobacco control in the country.

When assessing the overall exposure to activities promoting tobacco, responses to questions were allocated a weighted score, with a higher exposure status allocated a higher score. Applying a predetermined cut-off score of 7 to a range of scores from 0 to 15, the students were categorized as having a “high” or “low” level of exposure. The decision to use this cut-off score for responses was based on the consensus of a group of experts on tobacco control in the country.

The questions regarding how each adolescent responded to exposure to activities promoting tobacco or would respond to such activities in the future were analysed using a system of weighted scoring in which assertive responses were given a higher score. The maximum score possible was 14 and the minimum score was 0. Using a pre-agreed cut-off score of 7, the adolescents were categorized as having an “assertive” response (a score of 7 or more) or a “nonassertive” response (a score of less than 7).

Factors were cross-tabulated to the two levels of knowledge on tobacco-promotional activities and their associations were assessed using univariate analysis and multiple logistic regression analysis to determine factors adjusted for confounding effect. Sex, ethnicity, religion, level of education of both the mother and the father, engagement in extracurricular activities, type of school, status of smoking, and responses following exposure to tobacco-promotional activities were the factors assessed for their association with knowledge. A P value of 0.05 was used to determine significance.


  Results Top


The study included 498 adolescents, following a response rate of 99.6% (498/500). The mean age of the study participants was 14.9 years (standard deviation ±0.37). The sample comprised a slightly higher proportion of females (n = 280, 56.2%). The majority (82.5%, n = 411) were Sinhalese and were living with their parents (n = 457, 91.8%). Most (68.9%, n = 343) participated in either sports or school clubs, or both. The percentage of current smokers was 3.2% (n = 16).

Knowledge of tobacco-promotional activities among adolescents

Adolescents were questioned regarding the current laws in the country relating to tobacco-promotional activities (see [Table 1]).
Table 1: Distribution of the study population by their knowledge on laws to control tobacco-promotional activity in Sri Lanka

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The majority of the adolescents (89.4%, n = 445) were aware that selling cigarettes to anyone below 21 years of age was against the law. The next most commonly known law was the prohibition of tobacco advertisements (52.4%, n = 261). The least-known law was prohibition of free distribution of tobacco products (0.6%, n = 3). It was noted that more than a quarter of the adolescents had responded “do not know” for six of the eight aspects related to law on which they were questioned.

The study population was also questioned about awareness of promotion strategies used by the tobacco trade (see [Table 2]). About half were aware that using social media (51.6%, n = 257), using incidents of smoking in electronic and printed media in a manner in which the habit is glamorized (53%, n = 264), and paying famous individuals to smoke in public (50%, n = 249) are used as tobacco-promotional activities. Approximately half (51.2%, n = 255) of the study population had “poor” knowledge of tobacco-promotional activities.
Table 2: Distribution of the study population by the awareness of promotion strategies used by the tobacco trade

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Exposure to tobacco-promotional activities among the adolescents

The adolescents were asked about their exposure to tobacco-promotional activities (see [Table 3]). A substantial proportion of study participants (41%, n = 204) were exposed to “a lot” of media messages promoting tobacco smoking, on television, radio, billboards and posters, and in newspapers, magazines and movies, during a period of 30 days preceding the study. Three quarters of the study participants (74.3%, n = 370) had at least sometimes witnessed messages on tobacco promotion at sports events, fairs, concerts, community events or social gatherings, during the period of 30 days preceding the study, while approximately half of the students (47.64%, n = 236) had frequently seen actors smoking in television programmes, videos or movies. More than half of the study participants (63.3%, n = 315) claimed that they had not come across any cigarette brand names when they watched sports events or other programmes on the television during the period of 30 days preceding the study, while approximately half (46.6%, n = 232) had seen “a few” advertisements or promotions for cigarettes in newspapers or magazines during the period of 30 days preceding the study.
Table 3: Distribution of the study population by exposure to media messages that promote tobacco smoking during the period of 30 days preceding the study

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When asked whether they owned something (T-shirt, pen, backpack, etc.) displaying a cigarette brand logo, only a minority (2.8%, n = 14) of adolescents reported owning such an item. When asked whether someone working for a cigarette company had offered them a free cigarette, the majority (99.6%, n = 496) said they had not had this experience. The majority (98.6%, n = 491) had never been offered a gift showing a tobacco logo. The majority (64.9%, n = 323) of the study participants had had a “low” level of exposure to tobacco-promotional activities.

Responses to tobacco-promotional activities among the adolescents

When adolescents were requested to indicate the way they in which they had reacted, or the likely way/ways in which they would respond, to being offered free cigarettes by someone working for a cigarette company, or to being offered gifts displaying a tobacco logo, the majority (63.1%, n = 314) said they had refused/would refuse the offer. More than half of the study participants (55.2%, n = 275) said that they had informed/ would inform an adult about the incident. When asked whether they had carried out any activities in school against tobacco promotion, the majority of adolescents (77.1%, n = 384) said that they had not engaged in any activities against tobacco promotion in school. Those who responded positively to this question were asked about the activities they had carried out. The responses indicated that the activities included taking part in educational programmes (5.2%, n = 6), taking part in street dramas (2.6%, n = 3), and taking part in quizzes and essay and poster competitions (7.0%, n = 8) to build awareness against tobacco-promotional activities. The majority of adolescents (85.7%, n = 427) indicated that they would respond or had responded assertively to exposure to tobacco-promotional

Factors associated with knowledge on tobacco-promotional activities among the adolescents

Univariate analysis was carried out to determine the relationship between knowledge of tobacco-promotional activities and characteristics of the study population (see [Table 4]).
Table 4: Factors associated with “good” knowledge of tobacco-promotional activities, assessed by univariate and multivariate analyses

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Having a mother who had completed the General Certification of Education Ordinary Level (GCE O Level) examination or a higher-level examination (odds ratio [OR] 1.742, 95% confidence interval [CI] 1.127–2.692), a father who had completed the GCE O Level examination or a higher-level examination (OR 1.997, 95% CI 1.260–3.167), and attending a type 1AB school (OR 1.310, 95% CI 1.069–1.606) were significant factors associated with a good level of knowledge of tobacco-promotional activities, in the univariate analysis.

Results of the multiple logistic regression analysis revealed that the father’s highest level of education being GCE O Level or higher (adjusted OR 1.772, 95% CI 1.024-3.067) and the student attending a type 1AB school (adjusted OR 1.455, 95% CI 1.15-2.227) were the only factors associated with a good level of knowledge of tobacco-promotional activities when confounding effects of the variables were taken into consideration (see [Table 4]).


  Discussion Top


The FCTC bans advertising and promotional activities for tobacco. This strategy is designed to protect adolescents in particular from taking up smoking. Assessing knowledge of and exposure and responses to tobacco-promotional activities among adolescents in a rural setting provides an indication of the extent of implementation of the FCTC recommendations in a rural setting in Sri Lanka.

The study revealed inadequate knowledge of the current laws in the country regarding tobacco-promotional activities and the stealth-marketing strategies used by the tobacco industry, with about only half (48.6%, n = 242) of the adolescents in the rural setting reporting a “good” level of knowledge of tobacco-promotional activities. One can argue that some of the laws on which they were questioned were too “advanced” to be known by the adolescents. The results show some evidence of the validity of this argument, as more than one quarter of the adolescents responded “do not know” for six of the eight laws on which they were questioned.

A study conducted among college students with a mean age of 16.7 years in Guangzhou city in China also reported inadequate knowledge related to the FCTC, with only 25.7% of nonsmokers and 30.7% of smokers knowing the laws.[12]

A cross-sectional study among university students, aimed at assessing awareness of existing legislation at the national level using a self-administered questionnaire, reported that knowledge of anti-smoking laws was low (11.3–25% of students).[13] That study was carried out among 1104 students in universities in the Gaza Strip, Palestine, and the findings supported those of the present study.

A cross-sectional study among Jordanian women using a self-administered questionnaire revealed that only 52.2% were aware of workplace anti-smoking policies.[14] The women were highly educated, with a college degree or higher level of education and a mean age of 34.6 years, and they were working in universities, unlike the participants of the present study who were adolescents.

The present study measured the level of exposure to tobacco-promotional activities, using a series of validated questions included in the GYTS. Though a majority (64.9%, n = 323) of the study participants had had a “low” level of overall exposure to tobacco-promotional activities, the present study revealed that many had been exposed to tobacco-promotional activities through media and had witnessed tobacco-promotional messages at events.

In the present study, only a few adolescents (2.8%, n = 14) reported owning an object displaying a cigarette brand logo. According to the data of the 2011 GYTS, 4.6% of adolescents in Sri Lanka owned an object displaying a cigarette company logo.[10] The lower rate reported in the present study may be due to enforcement of NATA and the result of successful anti-tobacco campaigns.

According to the latest GYTS,[10] 2.9% of students in Sri Lanka had been offered free cigarettes, while the corresponding percentage was 0.4% in the present study. Again, the lower rate reported in the present study can be attributed to successful implementation of the legislature and to successful anti-tobacco campaigns.

The present study showed that the majority of adolescents 85.7% (n = 427) had responded assertively or would respond assertively to tobacco-promotional activities; this is an encouraging finding.

The fact that the majority of adolescents (77.1%, n = 384) had not engaged in any activities against tobacco promotion in school indicates a lost opportunity to implement FCTC-recommended activities in schools.

Having a father with an education level of GCE O Level or higher was found to be associated with a good level of knowledge of tobacco-promotional activities in univariate (OR 1.997, CI 1.260–3.167) and multivariate (adjusted OR 1.772, 95% CI 1.024–3.067) analyses. A higher level of knowledge of tobacco-promotional activities among adolescents whose parents had high levels of education was to be expected. This can be considered to be another benefit of improving school education among all age groups in the country.

Though exposure to tobacco-promotional activities was mostly low among the adolescents in rural areas, it is recommended that occurrences of exposure to advertising that is legally banned, but that had been experienced by the study population, be explored, and that the necessary legal action be taken to further reduce the exposure. A large proportion (87%) of adolescents in rural areas had given or would give an assertive response to exposure to tobacco-promotional activities. It is recommended that adolescents should be further empowered to give assertive responses, by teaching them effective actions.

Source of Support: Nil.

Conflict of Interest: None declared.

Contributorship: MEP conceptualized the research stuady and its design, collected the data, analysed the data, wrote the first draft of the article and contributed to the revisions. NSG contributed to the study design, analysis of the data and to the revisions of the article.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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