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William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN
David W. Fleming, MD, Seattle, WA

William E. Halperin, MD, DrPH, MPH, Newark, NJ
Margaret A. Hamburg, MD, Washington, DC
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA
John K. Iglehart, Bethesda, MD
Dennis G. Maki, MD, Madison, WI
Sue Mallonee, MPH, Oklahoma City, OK
Stanley A. Plotkin, MD, Doylestown, PA
Patricia Quinlisk, MD, MPH, Des Moines, IA
Patrick L. Remington, MD, MPH, Madison, WI
Barbara K. Rimer, DrPH, Chapel Hill, NC
John V. Rullan, MD, MPH, San Juan, PR
Anne Schuchat, MD, Atlanta, GA

Dixie E. Snider, MD, MPH, Atlanta, GA
John W. Ward, MD, Atlanta, GA

GYTS is a school-based survey that collects data on st.dents aged 13-15 years using a standardized methodolog for constructing the sample frame, selecting schools and classes, and processing data. The Sri Lanka GYTS uses a two-stage cluster sample design that produces representtive samples of students in grades 8-10, which are associ ated with ages 13-15 years (3). At the first sampling stage school selection was proportional to the number of stu dents enrolled in grades 8-10. At the second stage, classes within the selected schools were randomly selected. All stu dents attending school in the selected classes on the da the survey was administered were eligible to participate. A weighting factor was applied to each student record o adjust for nonresponse (by school, class, and student) and probability of selection at the school and class levels (3). final adjustment sums the weights by grade and sex to the population of school children in the selected grades in each sample site (3). In 1999, a total of 2,896 students com pleted GYTS; 1,845 did so in 2003, and 1,764 did so in 2007. The school response rate was 85.7% in 1999, 100in 2003, and 100% in 2007. The class response rate was 100% in all survey years. The student response rate was 89.0% in 1999, 79.1% in 2003, and 85.0% in 200 The overall response rate was 76.3% in 1999, 79.1% it 2003, and 85.0% in 2007.*

This report describes changes during 1999-2007 in several important tobacco-use indicators, including 1) lifetime cigarette smoking; 2) current cigarette smoking; 3 current use of other tobacco products; 4) likely initiation of smoking in the next year among never smokers (i.e., susceptibility) (4)**; 5) exposure to SHS in public places 6) exposure to pro-tobacco advertising and promotion either direct (e.g., exposure to billboards, newspapers, and magazines) or indirect (having been offered a free cigarette by a cigarette company representative or having an objec

* The overall response rate is calculated as the school response rate x the cas response rate x the student response rate.

Based on a positive response to the question, "Have you ever tried experimented with cigarette smoking, even one or two puffs?"

$ Based on a response of "1 or more days" to the question, "During the pa days (1 month), on how many days did you smoke cigarettes?" Based on positive responses to either of the following questions: "During past 30 days (1 month), did you use any form of smoked tobacco prod other than cigarettes (e.g., cigars, water pipe, cigarillos, little cigars, or pipe. and "During the past 30 days (1 month), did you use any form of smokes tobacco products (e.g., chewing tobacco, snuff, or dip)?"

Based on a responses of anything but "definitely no" to the questions. If best friend offered you a cigarette, would you smoke it?" and "Do you you will try smoking a cigarette in the next year?"

#Based on a response of "1 or more days" to the question, "During the past days, on how many days have people smoked in your presence, in places than your home?"

th a cigarette logo on it)§§; 7) cessation efforts (among rrent smokers); and 8) tobacco education.*** StatistiI differences were determined by comparing 95% confince intervals; nonoverlapping confidence intervals were -nsidered statistically significant. Data are based on at 1st 35 respondents for each denominator.

The

percentage of students aged 13-15 years in Sri Lanka no reported lifetime cigarette smoking declined from 1999 2.1%) to 2003 (6.3%); the percentage in 2007 (5.1%) as not significantly different from 2003 (Table 1). Boys ere more likely than girls to have ever smoked cigarettes § 1999 and 2003, but no significant difference was served in 2007. For boys, current cigarette smoking creased from 1999 (6.2%) to 2007 (1.6%); for girls the rcentage did not change significantly. Boys were more ely than girls to smoke cigarettes in 1999, but no sigficant difference was observed in 2003 and 2007. Curnt use of other tobacco products remained unchanged ɔm 1999 and 2007, both overall and for both sexes. Boys re more likely than girls to use other tobacco products 1999, but no significant difference was observed in 2003 d 2007. Current use of other tobacco products was higher an cigarette smoking overall in 1999, 2003, and 2007; · boys in 2003 and 2007; and for girls in 1999 and 2003. le percentage of never smokers who were susceptible to tiation of smoking did not change significantly from 1999 2007, both overall and for both sexes. Susceptibility was gher for boys than girls in 1999, but no significant difence was observed in 2003 and 2007.

The percentage of students who reported that their parts smoke decreased from 50.8% in 1999 to 41.2% in 03 to 29.9% in 2007; however, exposure to SHS in pubplaces remained unchanged over time (67.9% in 1999 d 65.9% in 2007) (Table 2). Support for a ban on smok3 in public places did not change from 1999 (91.4%) to 07 (87.9%).

Based on 1) a response of "a lot" or "a few" to the question, “During the past 30 days (1 month), how many advertisements for cigarettes have you seen on billboards?" 2) a response of “a lot” or “a few” to the question, “During the past 30 days (1 month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines?” 3) a positive response to the question, “Do you have something (t-shirt, pen, backpack, etc.) with a cigarette brand logo on it?" and 4) a positive response to the question, “Has a cigarette company representative ever offered you a free cigarette?

Based on a response of “1 or more days" to the question, “During the past 30 days (1 month), on how many days did you smoke cigarettes?” and a positive response to the question, “Do you want to stop smoking now?"

Based on a positive response to the question, “During this school year, were you taught in any of your classes about the dangers of smoking?”

Exposure to cigarette advertising and promotion decreased from 1999 to 2007. The percentage of students who saw pro-cigarette advertisements on billboards did not change from 1999 to 2003 but decreased from 2003 (79.3%) to 2007 (67.4%). The percentage of students who saw procigarette advertisements in newspapers or magazines decreased from 1999 to 2007 (83.4% in 1999, 78.4% in 2003, and 68.4% in 2007). The percentage of students who owned an item with a cigarette brand logo on it did not change from 1999 to 2003 but decreased from 2003 (11.0%) to 2007 (5.7%). The percentage of students who reported receiving free cigarettes from a cigarette company representative decreased from 1999 (6.4%) to 2007 (3.0%).

In 2007, 76.5% of current smokers indicated that they would like to stop smoking; this percentage was not significantly different from 1999 to 2007. The percentage of students who reported having been taught in school during the past school year about the dangers of tobacco use increased from 1999 (62.7%) to 2003 (79.8%) but remained unchanged from 2003 to 2007 (72.8%). Reported by: PW Gunasekara, Ministry of Education, Sri Lanka. K Rahman, PhD, DN Sinha, MD, South-East Asia Regional Office, World Health Organization, New Delhi, India. CW Warren, PhD, J Lee, MPH, V Lea, MPH, S Asma, DDS, CDC.

Editorial Note: The findings in this report indicate that, among students aged 13-15 years in Sri Lanka, cigarette smoking and the likely initiation of smoking by never smokers decreased from 1999 to 2007, whereas other tobacco use remained unchanged over time. During 1999–2007, other tobacco use was consistently higher than cigarette smoking.

Some of the changes in tobacco use reflected in this analysis can be attributed to various tobacco-control policies implemented by the government of Sri Lanka (2). In 2003, Sri Lanka ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) (5). In 2006, the Parliament of Sri Lanka enacted the National Authority on Tobacco and Alcohol Act (NATAA) (6). NATAA includes 1) a ban on smoking in health-care, education, and government facilities and in universities, indoor offices, and other indoor workplaces; 2) prohibition of pro-tobacco advertisements on national television and radio, in local magazines and newspapers, on billboards, at point of sale, and on the Internet; and 3) a ban on tobacco-product promotions, such as free distribution, promotional discounts, and sponsored events. In concordance with NATAA, Sri Lanka has enacted strong enforcement policies (2).

TABLE 1. Percentage of students aged 13-15 years who reported using tobacco products and, among never smokers, percentage likely to initiate smoking in the next year, by sex and year· Global Youth Tobacco Survey, Sri Lanka, 1999, 2003, and 2007

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† Based on a positive response to the question, "Have you ever tried or experimented with cigarette smoking, even one or two puffs?"
Based on a response of "1 or more days" to the question, "During the past 30 days (1 month), on how many days did you smoke cigarettes?"

1 Based on positive responses to either of the following questions: "During the past 30 days (1 month), did you use any form of smoked tobacco products other than cigaretes (e.g., cigars, water pipe, cigarillos, little cigars, or pipes)?" and "During the past 30 days (1 month), did you use any form of smokeless tobacco products (e.g., chewing tobacco, snuff, or dip)?"

Based on a responses of anything but "definitely no" to the questions, "If your best friend offered you a cigarette, would you smoke it?" and "Do you think you will try smoking a cigarette in the next year?"

TABLE 2. Percentage of students aged 13-15 years who reported exposure to secondhand smoke, exposure to pro-cigarette media advertising and promotion, interest in stopping smoking, and having been taught in school about the dangers of smoking, by year—Global Youth Tobacco Survey, Sri Lanka, 1999, 2003, and 2007

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Based on a response of "1 or more days" to the question, "During the past 30 days (1 month), on how many days did you smoke cigarettes?" and a positive response to the question, "Do you want to stop smoking now?"

Exposure to pro-cigarette advertising and promotion declined from 1999 to 2007, but exposure to SHS in public places did not decrease. One reason for this might be that the NATAA ban on SHS exposure does not include smoking in restaurants, pubs, or bars; thus, the overall impact of the ban might be limited. To protect the health of all persons from the harmful effects of SHS, WHO recommends that countries enact and enforce legislation.

requiring all indoor workplaces and public places to 100% smoke-free (7). GYTS has been shown to be use for monitoring the impact of NATAA provisions (3), and i will be a useful data source for monitoring the impact o the WHO FCTC.

The findings in this report are subject to at least thre limitations. First, because the sample surveyed was limite to youths attending school, it is not representative of all St

inka youths aged 13-15 years. Second, the findings -ply only to youths who were in school on the day the rvey was administered and who completed the survey. Fɔwever, student response was high (89% in 1999, 79% 2003, and 85% in 2007), suggesting that bias ributed to absence or nonresponse was limited. Finally, ta are based on self-reports of students, who might have derreported or overreported their tobacco use or that of eir parents. The extent of this bias cannot be determined; wever, responses to tobacco-related questions on surveys nilar to GYTS have shown good test-retest reliability (8). Comprehensive tobacco-control programs are the most ective means to reduce tobacco use (1). Such programs clude demand-reduction measures (primarily those that crease the price of tobacco) and other interventions, such restrictions on smoking in public places and work places, complete ban on advertising and promotion by tobacco mpanies, dissemination of information on the health conquences of smoking through various media (e.g., promint warning labels on cigarette packets and unter-marketing campaigns), and development and plementation of school-based educational programs in mbination with community-based activities. Although rrent cigarette smoking is low among students aged 13years in Sri Lanka (1.2% in 2007), future declines in e use of other tobacco products will depend on developent of new measures aimed at those products. ferences

́ha P, Chaloupka FJ. Tobacco control in developing countries. Oxford, England: Oxford University Press; 2000.

World Health Organization. WHO report on the global tobacco epidemic, 2008. Geneva, Switzerland: World Health Organization; 2008. Available at http://www.who.int/tobacco/mpower/mpower_report_full_ 2008.pdf.

CDC. Global youth tobacco surveillance, 2000–2007. MMWR 2008;57(No. SS-1).

Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Merritt RK. Validation of usceptibility as a predictor of which adolescents take up smoking in he United States. Health Psychol 1999;15:355–61.

World Health Organization. WHO framework convention on tobacco control. Geneva, Switzerland: World Health Organization; 2005. Availble at http://www.who.int/tobacco/framework/WHO_FCTC_english.pdf. Parliament of Sri Lanka. National authority on tobacco and alcohol ct, no. 27, 2006. Available at http://www.documents.gov.lk/actspg/ cts2006-2.htm.

World Health Organization. Smoke-free inside: create and enjoy 100% moke-free environments. Geneva, Switzerland: World Health Orgaization; 2007. Available at http://www.who.int/tobacco/resources/ ublications/wntd/2007/en/index.html.

rener ND, Kann L, McMannus T, Kinchen SA, Sundberg EC, Ross G. Reliability of the 1999 Youth Risk Behaviors Survey questionnaire. Adolesc Health 2002;31:336–42.

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United States, 2004 and 2007

Secondhand smoke (SHS) contains more than 50 carcinogens and causes heart disease and lung cancer in nonsmoking adults (1). Eliminating smoking in indoor spaces is the only way to fully protect nonsmokers from SHS exposure (1). Smoking restrictions limit smoking to certain areas within a venue; smoke-free policies prohibit smoking within the entire venue. A Healthy People 2010 objective (27-13) calls for establishing laws in all 50 states and the District of Columbia (DC) that make indoor public places and worksites completely smoke-free (2). To assess progress toward meeting this objective, CDC reviewed the status of state laws restricting smoking in effect as of December 31, 2007, updating a 2005 study that reported on such laws as of December 31, 2004 (3). This report summarizes the changes in state smoking restrictions for private-sector worksites, restaurants, and bars that occurred from 2004 to 2007. The findings indicated a substantial increase in the number and restrictiveness of state laws regulating smoking in these three settings, providing nonsmokers with increased protection from the health risks posed by SHS. If current trends continue, achieving the national health objective by 2010 might be possible.

This report focuses on smoking restrictions in indoor areas in private-sector worksites, restaurants, and bars. These three settings were selected because worksites are a major source of SHS exposure for nonsmokers and because workers in restaurants and bars are especially likely to be exposed to SHS, often at high concentrations (1). The smoking restrictions in effect in each of the 50 states and DC* as of December 31, 2004, and December 31, 2007, were categorized into one of four levels (Table). The four levels. were 1) no restrictions, 2) designated smoking areas required or allowed (i.e., smoking is restricted to specific areas), 3) no smoking allowed or designated smoking areas allowed if separately ventilated, and 4) no smoking allowed (i.e., 100% smoke-free). These data were compiled from CDC's State Tobacco Activities Tracking and Evaluation (STATE) System database, which contains tobacco-related epidemiologic and economic data and information on state tobacco-related legislation (4). The data used for this

* For this report, DC is included among results for states.

TABLE. State smoking restrictions* for private-sector worksites, restaurants, and bars
December 31, 2004, and December 31, 2007

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* None = no restrictions; designated = designated smoking areas required or allowed; ventilated = no smoking allowed or designated smoking areas allowed if separately ventilated; smoke-free = no smoking allowed (i.e., 100% smoke-free).

t

Restriction exempts restaurants that are off-limits to minors.

§

Restriction bans smoking in most settings, but exempts separately ventilated employee break rooms or lounges.

Corrected from 2005 report. Idaho and Maryland were previously listed as making private-sector workplaces smoke-free. Vermont was previous listed as making restaurants smoke-free.

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