Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey

Journal of Epidemiology and Global Health (2015) xxx xxxndashxxx

http wwwelsev ier com locate

Prevalence and correlates of tobaccouse among school-going adolescentsin Madagascar

httpdxdoiorg101016jjegh2014120052210-6006ordf 2015 Ministry of Health Saudi Arabia Published by Elsevier Ltd All rights reserved

Abbreviations CI Confidence Interval FCTC Frame-work Convention on Tobacco Control LMIC Low- andMiddle-Income Country NCD Non-Communicable Dis-ease OR Odds Ratio SHS Secondhand Smoke SSA Sub-Saharan Africa TTC Transnational Tobacco CompanyWHO World Health Organization Corresponding author at Department of Preventive Medicine

and Community Health The University of Texas Medical BranchEwing Hall 1128 301 University Blvd Galveston TX 77555-1150 USA Tel +1 409 772 2535 fax +1 409 772 5272

E-mail addresses drveerankigmailcom spveeranutmbedu (SP Veeranki)

Please cite this article in press as Veeranki SP et al Prevalence and correlates of tobacco use among school-going adolescents in Madagascar Jmiol Global Health (2015) httpdxdoiorg101016jjegh201412005

jegh

Sreenivas P Veeranki a Hadii M Mamudu b Rijo M John cAhmed EO Ouma d

a Department of Preventive Medicine and Community HealthUniversity of Texas Medical Branch Galveston TX USAb Department of Health Services Management and Policy College of Public HealthEast Tennessee State University Johnson City TN USAc Indian Institute of Technology Jodhpur Rajasthan Indiad Tobacco Control Division WHO Regional Office for Africa Brazzaville Congo

Received 3 June 2014 received in revised form 8 December 2014 accepted 14 December 2014

KEYWORDSTobacco useAdolescentsMadagascarTobacco controlLow- and middle-incomecountriesAfrica

Abstract Approximately 90 of adults start smoking during adolescence with lim-ited studies conducted in low-and-middle-income countries where over 80 of glo-bal tobacco users reside The study aims to estimate prevalence and identifypredictors associated with adolescents tobacco use in Madagascar We utilizedtobacco-related information of 1184 school-going adolescents aged 13ndash15 yearsrepresenting a total of 296111 youth from the 2008 Madagascar Global YouthTobacco Survey to determine the prevalence of tobacco use Gender-wise multivar-iable logistic regression models were conducted to identify key predictors

Epide-

2 SP Veeranki et al

Please cite this article in press as Veerankimiol Global Health (2015) httpdxdoior

Approximately 19 (307 males 102 females) of adolescents currently smokecigarettes and 7 (85 males and 58 females) currently use non-cigarettetobacco products Regardless of sex peer smoking behavior was significantly asso-ciated with increased tobacco use among adolescents In addition exposures totobacco industry promotions secondhand smoke (SHS) and anti-smoking media mes-sages were associated with tobacco use The strong gender gap in the use of non-cig-arette tobacco products and the role of peer smoking and industry promotions inadolescent females tobacco use should be of major advocacy and policy concernA comprehensive tobacco control program integrating parental and peer educationcreating social norms and ban on promotions is necessary to reduce adolescentstobacco use

ordf 2015 Ministry of Health Saudi Arabia Published by Elsevier Ltd All rightsreserved

1 Introduction

Tobacco use continues to be the leading cause ofpreventable death in the world and is a major riskfactor for many illnesses in children and youngadults including short-term health consequencessuch as respiratory and atopic diseases and nicotineaddiction and long-term health consequences suchas heart diseases stroke psychological disordersand cancer [1ndash3] In addition tobacco is an addic-tive product and is a gateway to other drug useamong adolescents [24] Over the past few dec-ades the tobacco epidemic has shifted to low-and middle-income countries (LMICs) yetresearch investigations to address this publichealth issue are sparse As approximately 90 ofsmokers start smoking during adolescence [2] itgenerates the need for investigations into tobaccouse behaviors among adolescents to inform effec-tive public health interventions advocacy and pol-icy efforts Moreover further research could helpaddress the increasing trend of tobacco use inmany LMICs particularly those with high adultprevalence rates including Madagascar [25ndash7]

Tobacco use in Sub-Sahara African (SSA) coun-tries is generally low but progressively increasingwhich provides potential market for transnationaltobacco companies (TTCs) to explore This is fur-ther augmented with increasing incomes global-ization urbanization demographic shifts inpopulations and low-levels of education in theregion [8] However in few SSA countries such asthe Madagascar the prevalence of tobacco useamong adults is exceptionally high [16] In factrecent studies demonstrated that approximatelyhalf of the adult population in Madagascar usesome form of tobacco product [79] which createsa bleak public health future for Madagascar Thesituation of public health in Madagascar is furtherexacerbated by the fact that approximately two-

SP et al Prevalence and correlateg101016jjegh201412005

thirds of the populations lives below the povertyline the Human Development Index is one of thelowest in the world and Non-communicable dis-eases (NCDs) have emerged as major causes ofmortality [10] Similar to other LMICs Madagascarratified the World Health Organization (WHO)Framework Convention on Tobacco Control (FCTC)in 2004 to combat the tobacco epidemic Thusinvestigating tobacco use among adolescents inMadagascar will provide insight into the behaviorand inform the effective implementation of theFCTC in the country LMICs and worldwide

The objective of this study was to estimate theprevalence and identify key factors associated withtobacco use among adolescents in MadagascarPreviously known as Malagasy Republic Madagas-car is the largest island in the Indian Ocean andlocated off the southeast coast of Africa As ofMay 2014 the total population of Madagascar wasapproximately 23 million [11] Although thetobacco industry has been in existence in Madagas-car since the 1950s the country has recently expe-rienced aggressive penetration of its market by theTTCs [12] In 2001 the Imperial Tobacco Limited(ITL) acquired the Tobacco Group and became anear monopoly in cigarette manufacturing The pri-mary goal of ITL in the acquisition of TobaccoGroup is to increase tobacco use in Madagascarand distribute tobacco products in the Easternand Southern Africa through common marketagreements [6] This situation provided potentialvenue for TTCs to target adolescents as these arethe populations with increased susceptibility andmore likely to become future tobacco users [13]On the other hand the government has takenaggressive steps to combat the increasing trend intobacco use in the country since 1998 by imple-menting some of the underlying provisions of theFCTC yet tobacco use in the country is one ofthe highest among SSA nations [6] Therefore find-

s of tobacco use among school-going adolescents in Madagascar J Epide-

Tobacco use among school-going adolescents in Madagascar 3

ings of this study will facilitate comprehensiveunderstanding of the tobacco use in Madagascarwith the potential to inform public health practicesand policy to address the issue at an early stageThis could prevent Madagascan adolescents fromtobacco use initiation and transition into futureand established smokers

2 Methods

21 Study setting and Madagascar GlobalYouth Tobacco Survey

The study data were obtained from the MadagascarGlobal Youth Tobacco Survey (GYTS) conducted in2008 to obtain tobacco-related information from1184 school-going adolescents aged 13ndash15 yearsand representing 296111 youth The MadagascarGYTS is a standard school-based survey designedto collect information on cigarette and non-ciga-rette tobacco products and on five determinantsof tobacco use ndash accessavailability and price sec-ondhand smoke (SHS) exposure cessation mediamessages and advertising and school curriculumfrom students who attend schools in the 3rd 4thand 5th standards The survey design and method-ology have been described in earlier studies[1314] Briefly it is a 2-stage cluster samplingdesign to obtain representative data for Madagas-car adolescents The schools proportional to theirenrollment size were selected during the firststage followed by random selection of classeswithin these schools in the second stage All stu-dents in selected classes were eligible to partici-pate in the survey The overall survey responserate was 833 with school class and studentsresponse rates being 100 100 and 833respectively The analysis of the GYTS datasetwas approved by Institutional Review Board of theauthors institution

22 Study measures

The status of tobacco use among Madagascan ado-lescents was examined using two outcome mea-sures ndash current cigarette smoking and currentuse of non-cigarette tobacco products The currentcigarette smoking status of an adolescent wasdetermined by hisher self-reported response ofone or more days to the question lsquolsquoDuring the past30 days (one month) on how many days did yousmoke cigarettesrsquorsquo and the current use of non-cigarette tobacco products status was determinedby hisher positive response to any of the followingtwo questions ndash lsquolsquoDuring the past 30 days (onemonth) did you use any form of smoked tobacco

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

products other than cigarettes (eg cigars waterpipes cigarillos little cigars pipes)rsquorsquo and lsquolsquoDuringthe past 30 days (one month) did you use any formof smokeless tobacco products (eg chewingtobacco snuff dip)rsquorsquo respectively Using existingliterature [2131516] 13 predictors were con-structed from 27 questions that could potentiallybe associated with status of tobacco use amongadolescents in Madagascar including parental orpeer smoking perception about smoking exposureto secondhand smoke inside or outside homeexposure to smoking or anti-smoking media mes-sages exposure to tobacco industry promotionsattitudes toward smoking ban knowledge aboutharmful effects of smoking and SHS age and sexThe responses to study questions were dichoto-mized based on the existing literature [1315]

23 Statistical analysis

To estimate the status of tobacco use among ado-lescents in Madagascar the sample data wereweighted to adjust for sampling design effectnon-responses at school class and student levelsand post-stratification of the sample relative tosex and grade distribution in the population similarto earlier studies [1315] Analyses were conductedin SAS v93 using proc survey commands to accountfor complex sampling design and for incorporatingweights as indicated above (SAS Institute IncCary NC USA) Because of the established gendergradient in the Sub-Saharan Africa separate analy-ses were conducted for male and female adoles-cents [1] Bivariate analyses were conducted toassess the crude relationship between outcomeand predictors using v2 contingency statisticsFinally multivariable logistic regression analyseswere conducted to delineate the predictors associ-ated with current cigarette smoking and currentuse of non-cigarette tobacco products separatelyfor males and female adolescents respectivelyAll models were checked for possible multicolline-arity but did not result in dropping any variableHowever the following predictors were droppedfrom the models because of lack of variability-knowledge about harmful effects of smoking andSHS exposure (for all four models) perceptionabout smoking and exposure to anti-smoking mediamessages (for current cigarette smoking amongfemales model) perception about smoking andexposure to smoking media messages (for currentuse of non-cigarette tobacco products amongmales model) and peer smoking perception aboutsmoking exposure to smoking and anti-smokingmedia messages exposure to tobacco industry pro-motion and receptivity of school anti-smoking edu-

s of tobacco use among school-going adolescents in Madagascar J Epide-

4 SP Veeranki et al

cation (for current use of non-cigarette tobaccoproducts among females model) respectivelyThe adjusted odds ratios (AOR) along with respec-tive 95 confidence intervals (CIs) were reportedA 2-sided 5 significance level was used for all sta-tistical inferences

3 Results

31 Study population

The study population included 1184 school-goingadolescents aged 13ndash15 years Majority of themwere females (548) and aged 14 years (367)Approximately one-third and half of the adoles-cents were exposed to parental and peer smokingbehavior respectively About 90 of the adoles-cents perceived that there were differences inappeal social skills or attractiveness betweensmokers and non-smokers were exposed to smok-ing or anti-smoking media messages and wereknowledgeable about harmful effects of smokingand SHS exposure Approximately 50 wereexposed to SHS inside home and 63 outside homeand 84 supported smoking ban in public places(data not shown)

32 Current cigarette smoking

Overall the prevalence of current cigarette smok-ing among adolescents in Madagascar was 193The prevalence among adolescent males andfemales was 307 and 102 with a significant dif-ference in cigarette smoking status between them(p lt 00001) Among males the prevalence of ciga-rette smoking was highest among those who self-reported exposure to tobacco industry promotionwhile among females it was highest among thosewho reported having smoking peers Approximately87 of adolescents received anti-smoking educa-tion in schools and they reported a smoking preva-lence of 21 (309 among males and 115 amongfemales) About 7 of adolescents were exposed totobacco industry promotions and reported a smok-ing prevalence of 28 (485 among males and 162among females) All predictors except for exposureto anti-smoking media messages (p = 006) expo-sure to tobacco industry promotion (p = 009)knowledge about harmful effects of smoking andSHS exposure (p = 097) and attitudes towardsmoking ban (p = 048) were significantly associ-ated with cigarette smoking status among Madaga-scan adolescents (Table 1)

Table 2 identifies the predictors associated withMadagascan male and female adolescent cigarettesmokers Among males those who had smoking

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

peers were almost 7 times more likely to smokecigarettes compared to those without such peers(AOR 738 95 CI 368 1482) Similarly thosewho were exposed to anti-smoking media messageswere almost 3 times more likely to smoke ciga-rettes (AOR 292 95 CI 147 748) compared tothose who were not Among females those whowere exposed to peer smoking SHS outside homeand tobacco industry promotion were almost 17(AOR 1692 95 CI 579 4945) three (AOR 33295 CI 118 936) and three (AOR 260 95 CI102 663) times more likely to smoke cigarettescompared to referent groups respectively In con-trast female adolescents aged 13 years were 78less likely to smoke cigarettes than 15 year olds(AOR 022 95 CI 007 065)

33 Current use of non-cigarette tobaccoproducts

Overall the prevalence of current use of non-ciga-rette tobacco products among adolescents in Mad-agascar was 70 The prevalence among male andfemale adolescents was 85 and 58 respectivelywith no significant difference in the use of non-cig-arette tobacco products (p = 034) Similar to ciga-rette smoking status the prevalence of non-cigarette tobacco products use in males was high-est among those who self-reported exposure totobacco industry promotions and in females itwas highest among those who reported havingsmoking peers All predictors except for parentalsmoking (p = 056) perception about smoking(p = 021) exposure to tobacco industry promo-tions (p = 023) attitudes toward smoking ban(p = 053) and receptivity of school anti-smokingeducation (p = 044) were significantly associatedwith use of non-cigarette tobacco products amongMadagascan adolescents (Table 1)

Table 2 delineates the predictors associatedwith the use of non-cigarette tobacco productamong male and female adolescents in Madagas-car Among males those who had smoking peerswere approximately 7 times (AOR 736 95 CI220 2466) more likely to use non-cigarettetobacco products compared to those who had nosmoking peers In contrast those who wereexposed to SHS outside the home were 63 lesslikely to use non-cigarette tobacco products (AOR037 95 CI 016 086) compared to those whowere not Among females exposures to SHS insideor outside the home were significantly associatedwith increased use of non-cigarette tobacco prod-ucts by almost 12 (AOR 1240 95 CI 392 3923)and 6 (AOR 571 95 CI 152 2140) times respec-

s of tobacco use among school-going adolescents in Madagascar J Epide-

Table 1 Prevalence of current cigarette smoking and non-cigarette tobacco products use among male and femaleadolescents in Madagascar Global Youth Tobacco Survey 2008 (n = 1184 N = 296111)

Characteristic Current cigarette smoker Current user of non-cigarette tobacco products

Total193

Males307

Females102

Total70

Males85

Females58

a

Age13 years 117 220 47 62 69 5014 years 192 322 79 42 89 1915 years 252 335 177 106 196 107

Parental smoking 243 379 138 86 175 79Peer smoking 347 435 230 129 171 144Perception about cigarette smoking 187 292 103 68 128 56Exposure to smoking media messages 210 322 113 77 130 68Exposure to anti-smoking media messages 201 320 106 74 133 65Exposure to tobacco industry promotion 276 485 162 121 294 66SHSb exposure inside home 279 395 165 109 165 117SHSb exposure outside home 263 365 161 91 162 93Knowledge about harmful effects of smoking and SHS 191 302 101 70 124 58Attitudes toward smoking ban 178 279 101 72 130 59Receptivity of school anti-smoking education 206 309 115 74 127 72a means weighted percentageb SHS means Secondhand Smoke

Tobacco use among school-going adolescents in Madagascar 5

tively Compared to 15 year old females thoseaged 14 years were 80 (AOR 020 95 CI 006060) less likely to use non-cigarette tobaccoproducts

4 Discussion

Tobacco use is the leading preventable cause ofmorbidity and mortality accounting for over 6 mil-lion global deaths each year [1] Non-communica-ble diseases (NCDs) including those attributed totobacco use such as cardiovascular diseases can-cer and respiratory diseases have emerged as thesecond leading cause of death in SSA [1718] How-ever the implementation of the FCTC to addressthe problem in SSA countries has been laggingdue to several factors including the tobacco indus-try interference and inadequate domestic-gener-ated data and surveillance [1920] The low butincreasing prevalence of tobacco use and NCDsposes a major public health threat in SSA Thisdemands investigations particularly in countriessuch as Madagascar where it is evident that adulttobacco use is exceptionally high but research toinform public policy and advocacy activities issparse [67] Tobacco use is considered as a pediat-ric disease because most adult users begin usingtobacco products during their adolescence [5]Therefore we used the GYTS a national represen-

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

tative survey of Madagascan youth to estimate theprevalence of tobacco use (cigarette smoking anduse of non-cigarette tobacco products) amongschool-going adolescents and identify factors asso-ciated with such behavior We found that 193 ofadolescents in Madagascar were cigarette smokersand 7 were users of non-cigarette tobacco prod-ucts These rates of tobacco use prevalence weregreater than those in most SSA countries includingGhana [21] the Republic of Congo [22] Cote dIvo-rie Eritrea Ethiopia Mozambique Niger and Zim-babwe [23] Similar to adults in the country [6] wefound significant gender differences in cigarettesmoking (307 males versus 102 females) butnot for non-cigarette tobacco products use (85males versus 58 females) Although the usagerate for non-cigarette tobacco products is lowthe absence of gender gap generates the impor-tance of incorporating gender while developingand implementing tobacco control policies More-over the use of non-cigarette tobacco productsincluding smokeless tobacco products is as equallydangerous to health as cigarette smoking and pub-lic health education and advocacy campaigns in thecountry should include such information [24]

The results of gender-wise regression analysesshowed that irrespective of sex peer smokingbehavior was most significantly associated with cig-arette smoking which is consistent with studies

s of tobacco use among school-going adolescents in Madagascar J Epide-

Table 2 Key determinants of current cigarette smoking and non-cigarette tobacco product use among male and female adolescents in Madagascar Global Youth TobaccoSurvey 2008

Determinant Current cigarette smoker Current user of non-cigarette tobacco products

Males Females Males Females

AOR (95 CI) AOR (95 CI) AOR (95 CI) AOR (95 CI)Age13 years 105(056 196) 022(007 065) 084(034 212) 058(025 134)14 years

(ref 15 years)112(065 194) 058(028 120) 047(019 118) 020(006 060)

Parental smoking(ref no parental smoking)

093(053 163) 173(074 403) 054(024 122) 062(028 137)

Peer smoking(ref no peer smoking)

738(368 1482) 1692(579 4945) 736(220 2466) ^

Perception about cigarette smoking(ref no perception about cigarette smoking)

029(013 066) ^ ^ ^

Exposure to smoking media messages(ref no exposure to smoking media messages)

244 (073 817) 169(043 662) ^ ^

Exposure to anti-smoking media messages(ref no exposure to anti-smoking media messages)

292(114 748) ^ 101 (029 342) ^

Exposure to tobacco industry promotion(ref no exposure to tobacco industry promotion)

240(084 688) 260(102 663) 323(101 1029) ^

SHS a exposure inside home(ref no SHS exposure inside home)

157(086 286) 085(036 203) 169(080 359) 1240(392 3923)

SHS exposure outside home(ref no SHS exposure outside home)

141(072 276) 332(118 936) 037(016 086) 571(152 2140)

Attitudes toward smoking ban(ref no attitude toward smoking ban)

057(030 107) 067(026 176) 221(068 716) 143(040 503)

Receptivity of school anti-smoking education(ref no receptivity of school anti-smoking education)

104(039 274) 116(033 401) 036(012 106) ^

AOR means adjusted Odds RatioCI means Confidence Interval

p lt 005 p lt 001 p lt 0001a SHS means Secondhand Smoke^ Predictors not included in the multivariable logistic regression models because of lack of variability

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Tobacco use among school-going adolescents in Madagascar 7

involving adolescents in other SSA countries LMICsand High-Income Countries (HICs) [2125] How-ever unlike them peer influence on female ciga-rette smoking is exceptionally strong While thestudy findings suggest the need for policies thatrestrict youth access to and demand for tobaccoproducts such as age verification and ban on saleto minors they also emphasize the necessity toeducate peers especially female cigarette smok-ers and create social norms against the use oftobacco products in social gatherings or amongpeers

Although the results were not consistent amongmales and females SHS exposure inside and out-side home provides insight into adolescents useof tobacco products in Madagascar Indeed 1 outof 2 adolescent tobacco users reported beingexposed to tobacco use inside or outside homewhich signifies a high level of exposure to SHSamong adolescents in Madagascar [3] In thisrespect while exposure to SHS inside homeincreased the likelihood of the use of non-cigarettetobacco products among females by over 12 timesexposure to SHS outside home increased cigarettesmoking and use of non-cigarette tobacco productsby approximately 3 and 6 times respectively Incontrast exposure to SHS outside home signifi-cantly reduced the use of non-cigarette tobaccoproducts among adolescent males by 63 Theseresults suggest that the use of non-cigarettetobacco products such as chewing tobacco amongfemale adolescents in Madagascar might bestrongly influenced by the home environment Thissituation needs urgent attention given the high useof non-cigarette tobacco products among adultfemales in the country [6] With adolescentfemales highly influenced by their adult counter-parts it is particularly important that policiesand programs are developed to reach and informadult tobacco users about the ramifications of theirbehaviors on their youth Moreover the use of non-cigarette tobacco products in the country is mostlyculturally related therefore it is important for thepublic health community policymakers and schooladministrators to create social norms against theuse of such products through education and mediacampaigns

Exposure to tobacco industry promotions wasassociated with increased tobacco use but signifi-cant only for female cigarette smokers whichaffirms earlier studies [26] This is likely due tothe targeting of female smokers by TTCs withimages of success sociability beauty and feminineliberation that might have stronger impact on ado-lescent females [27] While large cohort studies are

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

needed to evaluate these associations in detail itis important to develop tobacco youth control pro-grams that resembles the lsquolsquoTruth Campaignrsquorsquo in theUnited States that focused on tobacco industrysdeceptive practices aimed at youth and deliveryof anti-smoking messages through media appropri-ately [28]

Moreover exposure to anti-smoking messages inmedia was found to be significantly associated withincreased cigarette smoking among adolescentmales Although this finding both confirms and con-tradicts earlier studies it provided important evi-dence about the nature of anti-smoking messagesthat these adolescents were exposed throughmedia [1329] Although there was no significantassociation between parental smoking and use oftobacco products among adolescents in the studyit needs emphasis because studies from SSA otherLMICs and HICs have shown the positive effect ofparental smoking on an adolescents tobacco usebehavior [2130] For this reason future studiesshould be conducted to evaluate the associationin Madagascar Similarly we could not study therole of school personnels smoking behavior in ado-lescents tobacco use as suggested by earlier stud-ies [31] and future studies should be warranted inthis direction as it provides important evidenceabout the need for smoke- or tobacco-free schoolcampuses in Madagascar

We acknowledge that this study has certainimportant limitations The Madagascar GYTS wasa school-based survey and did not include adoles-cents who did not either attend schools or wereabsent on the day that this survey was adminis-tered however the school response rate was100 In addition the survey was a cross-sectionalstudy design limiting establishment of causal rela-tionship with the responses being self-reportedand subjected to recall bias Moreover 27 ques-tions were pooled to construct 13 predictors basedon the existing literature which limits identifyingdifferences in tobacco use status when exposedto individual components Only measures at indi-vidual level were used and no information onnational tobacco control programs or policies wastaken into account future studies should be con-ducted with inclusion of such country-level mea-sures Due to minimal variability many covariateswere not included in the regression models anddue to small sample sizes some predictors demon-strated wider confidence intervals however allmodels showed significant goodness-of-fit More-over the Madagascar GYTS survey has been con-ducted in 2008 (5 years ago) but we defined it aslsquolsquocurrentrsquorsquo as it provides information about the lat-

s of tobacco use among school-going adolescents in Madagascar J Epide-

8 SP Veeranki et al

est situation of adolescent tobacco use and war-rants administering future GYTS survey to under-stand the trends in tobacco use and determinethe impact of tobacco control efforts on adoles-cent behaviors in the country Nevertheless thisstudy is the first investigation to estimate preva-lence and identify factors associated with tobaccouse among Madagascan adolescents using a nation-ally representative sample and the study findingshave the potential to inform policy and publichealth practice about tobacco control efforts tar-geting adolescents in Madagascar

5 Conclusion

Approximately 1 out of 5 adolescents in Madagas-car currently smoke cigarettes and 1 out of 15 cur-rently use non-cigarette tobacco products Asignificant gender gap exists among cigarettesmokers but not among the users of non-cigarettetobacco products Regardless of sex peer smokingbehavior was significantly associated withincreased use of tobacco products especiallyamong female cigarette smokers With tobaccouse among adults being alarmingly high and scarcetobacco-related information among adolescents inMadagascar the study addresses a major gap inthe scientific literature by providing evidenceabout the need to reduce or prevent tobacco useamong adolescents at an early stage so as to helpprevent establishment of future adult smokers inMadagascar

Conflict of interests

The authors have no competing interests todeclare

Contributions

SPV identified the importance of understandingtobacco use among adolescents in MadagascarSPV collected and analyzed the data and wrotethe first draft of the manuscript HMM RMJ andAOE provided critical input into the data analysesand assisted SPV in interpretation of the results Allauthors were involved in several revisions of thefinal manuscript

Acknowledgements

The authors would like to thank the Department of Pre-ventive Medicine and Community at the University ofTexas Medical Branch and the Department of Pediatrics

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

at the Vanderbilt University School of Medicine for pro-viding the logistic support to conduct this study

References

[1] World Health Organization Research for InternationalTobacco Control WHO report on the global tobaccoepidemic 2013 Geneva World Health Organization2013 Available from lthttpwwwwho inttobaccoglobal_report2013enindexhtmlgt

[2] United States Public Health Service Office of the SurgeonGeneral Preventing tobacco use among youth and youngadults a report of the Surgeon General Rockville MD USDept of Health and Human Services Public Health ServiceOffice of the Surgeon General 2012 Available fromlthttppurlfdlpgovGPOgpo21718gt

[3] Oberg M Jaakkola MS Woodward A Peruga A Pruss-UstunA Worldwide burden of disease from exposure to second-hand smoke a retrospective analysis of data from 192countries Lancet 2011377(9760)139ndash46 PubMed PMID21112082

[4] Ogilvie D Gruer L Haw S Young peoples access totobacco alcohol and other drugs BMJ2005331(7513)393ndash6 PubMed PMID 16096309 PubMedCentral PMCID 1184256

[5] Lando HA Hipple BJ Muramoto M Klein JD Prokhorov AVOssip DJ et al Tobacco is a global paediatric concern BullWorld Health Organ 201088(1)2 PubMed PMID 20428341PubMed Central PMCID 2802441

[6] Mamudu HM John RM Veeranki SP Ouma AE The odd manout in Sub-Saharan Africa understanding the tobacco useprevalence in Madagascar BMC Public Health201313(1)856 PubMed PMID 24044737

[7] Blecher E Liber AC Chaussard M Fedewa S Marketstructures socioeconomics and tobacco usage patternsin Madagascar Nicotine Tob Res 2014(Suppl 1)S56ndash64httpdxdoiorg101093ntrntt020 [Epub 2013 May 23]

[8] Townsend L Flisher AJ Gilreath T King G A systematicliterature review of tobacco use among adults 15 years andolder in Sub-Saharan Africa Drug Alcohol Depend200684(1)14ndash27 PubMed PMID 16442750

[9] Veeranki SP Mamudu HM Anderson JL Zheng S Preva-lence and determinants of worldwide youth exposure toenvironmental tobacco smoke [Dissertation] Johnson CityEast Tennessee State University 2012

[10] World Bank Development Data Group World DevelopmentIndicators 2012 World Bank-free PDF 2012

[11] Central Intelligence Agency The World Factbook Mada-gascar Available from lthttpswwwciagovlibrarypublicationsthe-world-factbookgeosmahtmlgt

[12] Van Liemt G The world tobacco industry trends andprospects International Labour Office (ILO) 2002

[13] Veeranki SP Mamudu HM Anderson JL Zheng S Worldwidenever-smoking youth susceptibility to smoking J AdolescHealth 201454(2)144ndash50 PubMed PMID 24060576

[14] Warren CW Lee J Lea V Goding A OHara B Carlberg Met al Evolution of the Global Tobacco Surveillance System(GTSS) 1988ndash2008 Glob Health Promot 200916(Suppl 2)4ndash37 PubMed PMID 19770233 Epub 20090930 Eng

[15] Koh HK Alpert HR Judge CM Caughey RW Elqura LJConnolly GN et al Understanding worldwide youth atti-tudes towards smoke-free policies an analysis of theGlobal Youth Tobacco Survey Tob Control201120(3)219ndash25 PubMed PMID 21270072 Epub 20110129 Eng

s of tobacco use among school-going adolescents in Madagascar J Epide-

Tobacco use among school-going adolescents in Madagascar 9

[16] Warren CW Jones NR Eriksen MP Asma S Global TobaccoSurveillance System collaborative group Patterns of globaltobacco use in young people and implications for futurechronic disease burden in adults Lancet2006367(9512)749ndash53 PubMed PMID 16517275

[17] Yikona J Non-communicable disease in Sub-Saharan AfricaLancet 2001357(9249)74

[18] Marquez PV Farrington JL The challenge of non-commu-nicable diseases and road traffic injuries in Sub-SaharanAfrica an overview World Bank Washington DC ordf WorldBank 2013 lthttpsopenknowledgeworldbankorghan-dle1098616451gt License CC BY-NC-ND 30 IGO

[19] World Health Organization Implementation of the WHOframework convention on tobacco control in the Africanregion Brazzaville Republic of Congo 2013 SeptemberReport No AFRRC63INFDOC4

[20] Tumwine J Implementation of the framework conventionon tobacco control in Africa current status of legislationInt J Environ Res Public Health 20118(11)4312ndash31 Pub-Med PMID 22163209 PubMed Central PMCID 3228573

[21] Mamudu HM Veeranki SP John RM Tobacco use amongschool-going adolescents (11ndash17 years) in Ghana NicotineTob Res 201315(8)1355ndash64 PubMed PMID 23291638

[22] Rudatsikira E Muula AS Siziya S Current use of smokelesstobacco among adolescents in the Republic of Congo BMCPublic Health 20101016 PubMed PMID 20074362 PubMedCentral PMCID 2820474

[23] Warren CW Jones NR Peruga A Chauvin J Baptiste JPCosta De Silva V Global Youth Tobacco Surveillance 2000ndash2007 Morb Mortal Wkly Rep Surveill Summ200857(1)1ndash28 PubMed PMID 18219269

[24] IARC Working Group on the Evaluation of Carcinogenic Risksto Humans Smokeless tobacco and some tobacco-specificN-nitrosamines IARC Monogr Eval Carcinog Risks Hum2007891ndash592 PubMed PMID 18335640

Please cite this article in press as Veeranki SP et al Prevalence and correlatemiol Global Health (2015) httpdxdoiorg101016jjegh201412005

[25] Muula AS Siziya S Prevalence and determinants of eversmoked cigarettes among school-going adolescents inLusaka Zambia Afr Health Sci 20077(4)246ndash52 PubMedPMID 21499492 PubMed Central PMCID 3074373

[26] Difranza JR Wellman RJ Early dating and smoking initia-tion some thoughts about a common cause Addiction2006101(12)1682ndash3 PubMed PMID 17156163 Epub 20061213 Eng

[27] Samet JM Yoon S-Y World Health Organization JohnsHopkins University Institute for Global Tobacco ControlWomen and the tobacco epidemic challenges for the 21stcentury Geneva The World Health Organization in collab-oration with the Institute for Global Tobacco ControlJohns Hopkins School of Public Health 2001 xv 222pp

[28] Farrelly MC Davis KC Haviland ML Messeri P Healton CGEvidence of a dose-response relationship between lsquolsquotruthrsquorsquoantismoking ads and youth smoking prevalence Am J PublicHealth 200595(3)425ndash31 PubMed PMID 15727971 Pub-Med Central PMCID 1449196 Epub 20050225 Eng

[29] Thrasher JF Niederdeppe JD Jackson C Farrelly MC Usinganti-tobacco industry messages to prevent smoking amonghigh-risk adolescents Health Edu Res 200621(3)325ndash37PubMed PMID 16492681

[30] Ertas N Factors associated with stages of cigarette smokingamong Turkish youth Eur J Public Health200717(2)155ndash61 PubMed PMID 16837517 Epub 20060714 Eng

[31] Sorensen G Gupta PC Sinha DN Shastri S Kamat MPednekar MS et al Teacher tobacco use and tobacco useprevention in two regions in India results of the GlobalSchool Personnel Survey Prev Med 200541(2)417ndash23PubMed PMID 15917036

ScienceDirectAvailable online at wwwsciencedirectcom

s of tobacco use among school-going adolescents in Madagascar J Epide-