Tobacco Use Among School-Going Adolescents (11-17 Years) in Ghana

© The Author 2013. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected]

doi:10.1093/ntr/nts269

Original Investigation

Tobacco Use Among School-Going Adolescents (11–17 Years) in GhanaHadii M. Mamudu, Ph.D., M.P.A.,1 Sreenivas P. Veeranki, M.D., Dr.P.H., M.P.H.,2 & Rijo M. John, Ph.D.3

1 Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, Johnson City, TN 376142 Division of General Pediatrics, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN 372323 Research Consultant, Bangalore, India

Corresponding Author: Hadii M. Mamudu, Ph.D., M.P.A., Department of Health Services Management and Policy, College of Public Health, East Tennessee State University, S. Dossett Drive, Lamb Hall, P.O. Box 70264, Johnson City, TN 37614, USA. Telephone: 423-439-4484; Fax: 423-439-6710; E-mail: [email protected]

Received April 11, 2012; accepted November 20, 2012

AbstractPurpose: To assess tobacco use among school-going adoles-cents and delineate determinants of their tobacco-use status.

Methods: The study utilizes Global Youth Tobacco Survey data collected in 2006 (9,990 unweighted; 773,982 weighted). Univariate and bivariate analyses were performed to determine the relationship between the dependent (tobacco-use status) and independent variables. Logistic regression analyses were conducted to identify the key determinants of tobacco use among adolescents in Ghana.

Results: The gap in tobacco use between males and females was narrow (6.7% vs. 4.4% for ever cigarette smoker; 2.4% vs. 1.4% for current cigarette smoker; 6.8% vs. 5.2% for user of non-cigarette tobacco products). Youth tobacco use was significantly associated with exposure to tobacco industry promotions and tobacco-use behavior of familial relations. Conversely, knowl-edge about the harmful effects of secondhand smoke was associ-ated with decreased likelihood of tobacco use; however, it was significant only for users of noncigarette tobacco products.

Conclusions: The narrow gap in tobacco use among school-going adolescents in a country where tobacco-use prevalence among adult males is more than 10 times that of females is a major policy concern. Additionally, the finding that about 15% of students have either acquired tobacco-branded merchandise or been offered a free cigarette suggest that tobacco marketing is reaching adolescents in the country, which demands urgent policy response. Dealing with such problems requires a compre-hensive ban on tobacco industry advertising and promotion and marketing strategies, and policies that restrict youth access to and demand for tobacco products.

IntroductionTobacco use is a global problem because it is the leading prevent-able cause of premature mortality and a risk factor for several

diseases, including cancer and cardiovascular and respiratory diseases (USDHHS, 2010; WHO, 2011). Additionally, smok-ing has been linked to changes in serum cholesterol, nicotine dependence, and withdrawal in children. Secondhand smoke (SHS) is also linked to respiratory diseases in children, such as bronchial diseases (IARC, 2002; USDHHS, 2006). Of the 603,000 deaths attributable to SHS in 192 countries in 2004, 28% were children (Oberg, Jaakkola, Woodward, Peruga, & Prüss-Ustün, 2011), making tobacco use and control important public health issues for adults and children, particularly because 80% to 90% of smokers start smoking during childhood (USDHHS, 2012).

There are more than 1 billion smokers worldwide (WHO, 2011), of which more than 150 million are children (WHO, 1999), about a third of whom will become regular smokers (USDHHS, 2012) and half will die prematurely (USDHHS, 2010). Increasingly, tobacco use has shifted toward low- and medium-income countries (LMICs), where more than 80% of global smokers reside (WHO, 2011). However, assessing the problem and finding appropriate solutions in these LMICs are challenging because of limited country- and regional-specific data (Lando et al., 2005). In 1999, the World Health Organization (WHO), the U.S. Centers for Disease Control and Prevention (U.S. CDC), and the Canadian Public Health Association (CPHA) launched the Global Tobacco Surveillance System to close this information gap (GTSS Collaborative Group, 2006). An integral part of this system is the Global Youth Tobacco Survey (GYTS), a school-based survey for adolescents to collect information on the use of cigarette and noncigarette tobacco products and on five major determinants of tobacco use, including access/availability and price of tobacco products, exposure to SHS, tobacco-use cessation, role of media and advertising, and school curriculum. This study aims to utilize this survey to assess the level of and delineate the determinants of tobacco use among school-going adolescents in Ghana to add to the sparse literature on tobacco use among adolescents in Ghana and other LMICs, and inform health policies and interventions.

Until the GYTS, research in Ghana has been primarily focused on adults’ smoking in specific population subgroups

Nicotine & Tobacco Research

of 10

Nicotine & Tobacco Research Advance Access published January 4, 2013 by guest on M

arch 29, 2013http://ntr.oxfordjournals.org/

Dow

nloaded from

http://ntr.oxfordjournals.org/

Tobacco use among school-going adolescents

and administrative regions or cities (Dennis-Antwi et al., 2003; John, Mamudu, & Liber, 2012; Owusu-Dabo, Lewis, McNeill, Gilmore, & Britton, 2009; Pampel, 2008), finding that tobacco use starts in adolescent years. Moreover, similar to other LMICs, the tobacco industry targeted adolescents in Ghana with vari-ous marketing and promotional activities (WHO, 1999). At the same time, tobacco companies have used youth smoking pre-vention programs to bolster their image and thwart the enact-ment and implementation of effective tobacco control policies and programs in LMICs (Assunta & Chapman, 2004; Braun, Mejia, Ling, & Pérez-Stable, 2008), including Ghana. Thus, this study could help policymakers and public health groups in the country to have an insight into adolescent tobacco-use behavior and to embark on programs and activities to curtail its spread and thwart the predatory practices of tobacco companies aimed at the youth.

Policy Context: Description of GhanaGhana is located in the western part of Sub-Saharan Africa and gained independence in 1957. Since 1992, it has been a multi-party constitutional democracy. As of July 2011, its population was about 25 million, of which about a third (36.5%) was below 15 years of age (Central Intelligence Agency, n.d.). The World Bank has classified Ghana as a low-income country (World Bank, 2010) with Gross Domestic Product of U.S. $35.99 bil-lion and per capita income of U.S. $1,500 in 2009 (Central Intelligence Agency, n.d.). In 2010, the Human Development Index of the country was 0.467, ranking 130th out of 169 countries (United Nations Development Programme, 2010). The adult smoking prevalence rate in the country was one of the lowest in the world, and the tobacco use by males was over 10 times more than females (7.1% vs. 0.4% in 2008 for those between 15 and 49 years old) (John et al., 2012). As of September 2012, although policies such as excise tax, minimal restrictions on advertising and smoking in workplaces, and educational and health facilities existed, Ghana did not have comprehensive tobacco control legislation. This is because the President has not yet signed the Public Health Bill 2011, a com-prehensive public health legislation in Ghana, which entails tobacco control measures such as prohibition of smoking in public places, ban on tobacco advertising, health warning on tobacco packages, and minimum age restrictions (Ghana Broadcasting Corporation, n.d.). The bill was unanimously passed by the Parliament on July 11, 2012, to bring the coun-try into compliance with the WHO Framework Convention on Tobacco Control (FCTC), the first international public health treaty negotiated by the WHO to deal with the use and spread of tobacco around the world (WHO, 2003), which Ghana rati-fied in November 2004.

MethodsData CollectionThis research study utilized GYTS data collected in Ghana in 2006; a sample size of 9,990 unweighted (773,982 weighted) school-going adolescents aged 11–17 years. The GYTS data were based on a standardized questionnaire, which was publicly avail-able from the CDC, and the detailed description of the sampling method and the data collection procedure has been published in

earlier studies (GTSS Collaborative Group, 2006; Warren et al., 2000, 2008). Briefly, the GYTS was a two-step cluster sampling design to gather data about tobacco use in school-going adoles-cents in Ghana. At the first stage, clusters of schools were col-lected with probability proportional to their enrollment size. During the second stage, the classrooms were randomly selected in each school cluster, and all students in these classrooms were eligible to participate in the survey. The school, class, and student response rates were 96.7%, 100%, and 88.6%, respec-tively, with an overall response rate of 85.6%. The Institutional Review Board of the corresponding author’s university approved this study.

To estimate the prevalence of tobacco use among adoles-cents in Ghana, the data were weighted to adjust for design effect (selection of school and class levels), nonresponses (school, class, and student levels), and poststratification of the sam-ple population relative to the grade and sex distribution in the population. This method of weighing measures has been previ-ously used (Global Tobacco Youth Survey Group, 2002) and also reported by the CDC in the help file of the GYTS dataset (Global Tobacco Youth Survey Group, 2002).

The weighting factor is given by the formula:

W W1 W2 f1 f2 f3 f4= * * * * *

Here, W1 is the inverse of the probability of selecting a school; W2 is the inverse of the probability of selecting a classroom within a school; f1 is a school-level nonresponse adjustment factor calculated by school size category (small, medium, large); f2 is a class-level nonresponse adjustment factor calculated for each school; f3 is a student-level nonresponse adjustment factor calculated by class; f4 is a poststratification adjustment factor calculated by sex and grade.

MeasuresThe outcome measure or dependent variable, tobacco-use prevalence, was measured as tobacco-use status of respondents based on three questions: (a) “Have you ever tried or experi-mented with cigarette smoking, even one or two puffs?” (ever cigarette smoker); (b) “During the past 30 days (one month), on how many days did you smoke cigarettes?” (current ciga-rette smoker); and (c) “During the past 30 days (one month), have you ever used any form of tobacco products other than cigarettes?” (user of noncigarette tobacco products). Although the GYTS’ measure for ever cigarette smoker and user of non-cigarette tobacco products (0 = no; 1 = yes) was retained, the current cigarette smoker measure was recoded as 0 if the person did not smoke any day in the past 30 days and 1 if smoked in the past 30 days.

The independent variables included age, age squared, sex, perceptions about tobacco use, knowledge of SHS, tobacco-use behavior of familial relations, media and advertising, tobacco industry promotion, school curriculum, and attitude toward smoking bans in public places. The coding of responses of these GYTS measures as dichotomous variables for data analysis is detailed in Table 1. An age-squared variable was used because it was observed from the descriptive statistics that tobacco-use prevalence seemed to peak at some age among various types of tobacco users. In this respect, the proportion of ever

of 10

by guest on March 29, 2013

http://ntr.oxfordjournals.org/D

ownloaded from



Table 1. Study Measures, Survey Items With Responses From Global Youth Tobacco Survey (GYTS), Ghana, 2006

Study measure GYTS survey items GYTS item responses Dichotomized measure

Ever cigarette smoker

Have you ever tried or experimented with cigarette smoking, even one or two puffs?

NoYes

NoYes

Current cigarette smoker

During the past 30 days (1 month), on how many days did you smoke cigarettes?

0 days1 or 2 days3 to 5 days6 to 9 days10 to 19 days20 to 29 daysAll 30 days

No = 0 daysYes ≥ 1 day

User of noncigarette tobacco products

During the past 30 days (1 month), have you ever used any form of tobacco products other than cigarettes (e.g., chewing tobacco, snuff, dip, cigars, cigarillos, little cigars, pipe)?

NoYes

NoYes

Age How old are you? 11 years old or younger12 years old13 years old14 years old15 years old16 years old17 years old or older

Age as continuous variable

Sex What is your sex? FemaleMale

No = femaleYes = male

Perceptions about tobacco use

Do you think boys who smoke cigarettes have more or less friends?Do you think girls who smoke cigarettes have more or less friends?

No difference from nonsmokersLess friendsMore friends

No = no difference from nonsmokersYes = either more or less friends

Do you think smoking cigarettes makes boys look more or less attractive?Do you think smoking cigarettes makes girls look more or less attractive?

No difference from nonsmokersLess attractiveMore attractive

No = no difference from nonsmokersYes = either more or less attractive

Knowledge about secondhand smoke (SHS)

Do you think the smoke from other people’s ciga-rettes is harmful to you?

Definitely notProbably notProbably yesDefinitely yes

No = definitely notYes = any other response

Tobacco-use behavior of familial relations

During the past 7 days, on how many days have people smoked in your home, in your presence?During the past 7 days, on how many days have people smoked in your presence, in places other than in your home?

01 to 23 to 45 to 67

No = 0 daysYes ≥ 1 day

Do your parents smoke?Do any of your closest friends smoke cigarettes?

NoneBothFather onlyMother onlyI don’t knowNone of themSome of themMost of themAll of them

No = “none” or “I” or “none of them”Yes = any other response for each survey item

Media During the past 30 days (1 month), how many advertisements for cigarettes have you seen on billboards?During the past 30 days (1 month), how many advertisements or promotions for cigarettes have you seen in newspapers or magazines?

NoneA fewA lot

No = none/neverYes = any other response

Continued

of 10



ownloaded from



Study measure GYTS survey items GYTS item responses Dichotomized measure

Tobacco industry promotion

Do you have something (t-shirt, pen, backpack, etc.) with a cigarette brand logo on it?Has a cigarette representative ever offered you a free cigarette?

NoYes

NoYes

School curriculum During this school year, were you taught in any of your classes about the dangers of smoking?During this school year, did you discuss in any of your classes the reasons why people your age smoke?During this school year, were you taught in any of your classes about the effects of smoking like it makes your teeth yellow, causes wrinkles, or makes you smell bad?

NoNot sureYes

No = “No” or “Not sure”Yes = yes

Attitude toward smoking ban

Are you in favor of banning smoking in public places (such as in restaurants, in buses, streetcars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)?

NoYes

NoYes

Notes. All responses were dichotomized except for age, which is a continuous variable. “No” responses were coded as “0” and “Yes” responses as “1” for logistic regression model.

Table 1. Continued

cigarette smokers and user of noncigarette tobacco products peaked at age 15 and that of current cigarette smokers peaked at ages 15–16 years, respectively. This phenomenon indicates a quadratic relationship between age and tobacco use, which can statistically be tested with the inclusion of a squared term for age in the regression. Thus, if the squared term turns out significant, it suggests that one can estimate the age at which tobacco use peaks for the adolescents in Ghana.

Data AnalysisBivariate analyses were conducted to determine the relation-ship between the dependent variables (tobacco-use status) and independent variables. Unweighted frequencies and weighted percentages were reported. Differences in tobacco-use sta-tus across categories were assessed using a t test for continu-ous variables and a χ2 test for categorical variables (Hinkle, Wiersma, & Jurs, 2003). Proc SurveyLogistic in SAS version 9.2 was used to perform the logistic regression analyses to deter-mine the associations between the dependent and independent variables. Individual logistic regression analytic models were conducted for ever cigarette smoker, current cigarette smoker, and user of noncigarette tobacco products. The adjusted odd ratios (OR) along with respective 95% confidence intervals (CI) were reported. The significance level was set at 95% (p value ≤ .05). The data analysis was performed using SAS/STAT software, Version 9.2 of the SAS System for Windows (SAS Institute Inc.).

ResultsPattern of Tobacco-Use PrevalenceTable 2 illustrates the unweighted frequencies and weighted per-centages of adolescents’ tobacco use in Ghana. Of the total sam-ple population 9,990, 11.5% were ever cigarette smokers (6.7% males and 4.4% females), 4.0% were current cigarette smokers

(2.4% males and 1.4% females), and 12.5% were users of non-cigarette tobacco products (6.8% males and 5.2% females), respectively. Although the gap in tobacco-use status was narrow, the results of t test and χ2 test analyses show that males were significantly more likely to be ever cigarette smokers (p < .01), current cigarette smokers (p < .01), and users of noncigarette tobacco products (p < .05) than females. Moreover, it was found that the prevalence of tobacco use was highest among adoles-cents of 15 years.

Logistic Regression AnalysisLogistic regression analyses (Table 3) illuminated the key deter-minants of tobacco-use status among school-going adolescents in Ghana. The adjusted estimates showed that as age increased, the likelihood of usage of noncigarette tobacco products decreased by 36% (OR = 0.64, 95% CI [0.44,0.91]). However, the significant relationship between tobacco-use status and age squared confirmed that age has a quadratic relationship with ever cigarette smoking status and usage of noncigarette tobacco products among school-going adolescents in Ghana, peaking at a certain age and declining then. Compared with females, the adjusted estimates revealed that males were significantly associ-ated with the increased likelihood of being a current smoker by two times (OR = 2.07, 95% CI [1.26, 3.40]).

It was found that tobacco industry promotion and tobacco-use behavior of familial relations significantly increased the likelihood of being an ever cigarette smoker, current cigarette smoker, or user of noncigarette tobacco products, whereas knowledge that SHS is harmful decreased the likelihood for usage of noncigarette tobacco products. For example, the adjusted estimates revealed that owning objects with a cigarette brand logo significantly increased the likelihood of being an ever cigarette smoker (OR = 2.19, 95% CI [1.54, 3.12]) or user of noncigarette tobacco products (OR = 2.06, 95% CI [1.48, 2.87]), respectively, by about two times. Similarly, those adolescents

of 10



ownloaded from



who were offered a free cigarette by a tobacco company sales representative were two times more likely to be an ever ciga-rette smoker (OR = 2.14, 95% CI [1.48, 3.10]), a current cigarette smoker (OR = 2.51, 95% CI [1.41, 4.50]), or a user of nonciga-rette tobacco products (OR = 1.53, 95% CI [1.07, 2.19]). With respect to tobacco-use behavior of familial relations, living in a home with one or more smoking persons, having one or more parents who smoke, and having most or all friends (peers) who smoke were significantly associated with increased probability

of tobacco use. In particular, living in a home with one or more smoking persons increased the likelihood of being a current cigarette smoker by about six times (OR = 5.47, 95% CI [2.80, 10.40]). Adolescents who had most or all friends smoking were about four times more likely to currently smoke (OR = 3.69, 95% CI [2.17, 6.26]), compared with those who did not have such peers. Similarly, exposure to peer or family smoking sig-nificantly increased the likelihood of use of noncigarette tobacco products by 1.7 and 1.6 times, respectively, compared with those

Table 2. Unweighted Frequencies and Weighted Percentages of Adolescents’ Tobacco Use in Ghana, 2006a

Total (9,990)

Ever cigarette smoker 11.5% (1,386)

Current cigarette smoker 4.0% (513)

User of non-cigarette tobacco products12.5% (1,352)

Characteristics % (n) % (n) % (n) % (n)

Age 11 years or younger 8.8 (901) 1.4 (194) 0.6 (68) 1.8 (200) 12 years 12.0 (1,188) 1.6 (181) 0.5 (70) 1.8 (196) 13 years 15.8 (1,451) 1.7 (170) 0.4 (62) 2.0 (169) 14 years 19.0 (1,719) 1.4 (153) 0.4 (59) 1.8 (168) 15 years 21.4 (2,015) 2.2 (243) 0.7 (73) 2.1 (230) 16 years 14.1 (1,412) 1.7 (208) 0.7 (81) 1.7 (190) 17 years or older 8.9 (961) 1.4 (175) 0.6 (75) 1.2 (141) (Missing) (343) 0.1 (62) 0.1 (25) 0.1 (58)Sex Male 54.6 (4,896) 6.7 (696) 2.4 (250) 6.8 (665) Female 45.4 (4,662) 4.4 (583) 1.4 (207) 5.2 (589) Missing (432) 0.4 (107) 0.2 (56) 0.5 (98)Perceptions about tobacco use Boys: smokers have more friends 82.0 (7,857) 8.8 (996) 3.0 (358) 10.0 (1,002) Girls: smokers have more friends 81.4 (7,826) 8.6 (993) 3.0 (353) 9.5 (984) Boys: smokers are attractive 85.5 (8,345) 9.4 (1,087) 3.2 (391) 10.2 (1,063) Girls: smokers are attractive 84.2 (8,180) 9.0 (1,052) 2.9 (372) 09.8 (1,039)Knowledge about secondhand smoke (SHS) SHS is harmful 54.1 (5,226) 5.1 (574) 1.7 (207) 4.9 (541)Tobacco-use behavior of familial relations Live in a home with one or more smoking 18.1 (1,962) 4.7 (576) 2.7 (336) 4.0 (497) Around others who smoke outside home 32.2 (3,242) 5.7 (687) 2.7 (347) 5.2 (613) Have one or more parents who smoke 10.5 (1,335) 2.7 (403) 1.3 (203) 2.7 (382) Have most or all friends who smoke 19.1 (2,024) 4.7 (603) 2.5 (313) 4.8 (542)Media Seen cigarette billboard in past 30 days 48.8 (4,842) 7.1 (834) 2.6 (330) 7.2 (811) Seen cigarette ad in newspaper or magazine

in past 30 days44.5 (4,360) 6.9 (784) 2.5 (301) 6.7 (758)

Tobacco industry promotion Owned object with cigarette brand logo 15.7 (1,618) 3.5 (414) 1.4 (177) 4.1 (465) Offered free cigarette by tobacco company rep 14.5 (1,557) 3.6 (439) 1.5 (182) 4.0 (470)School curriculum Taught about dangers of smoking in past year 55.2 (4,958) 6.1 (644) 1.8 (219) 5.9 (607) Discussed why people at young age should not

smoke38.2 (3,521) 5.0 (536) 1.7 (189) 5.4 (538)

Taught about effects of smoking 61.6 (5,641) 7.1 (774) 2.2 (272) 7.8 (788)Attitude toward smoking ban Favor 54.2 (5,263) 6.4 (753) 2.1 (264) 6.8 (714)

aUnweighted frequencies are in parentheses.

of 10



ownloaded from



adolescents whose parents or peers did not smoke. Although results for school curriculum were mixed, it was found that teaching students about dangers of smoking was significantly associated with increased likelihood of being an ever cigarette smoker by approximately one and a half times (OR = 1.56, 95% CI [1.07, 2.26]), and discussing why young people at their age should not smoke increased the odds by similar margin for users of noncigarette tobacco products (OR = 1.41, 95% CI [1.01, 1.97]). The only variable that was significantly associated with decreased probability of tobacco use was the knowledge about the harmful effects of SHS, which reduced the likelihood of being a user of noncigarette tobacco products by 45% (OR = 0.55, 95% CI [0.40, 0.74]). The unadjusted and adjusted estimates revealed that other independent variables, with respect to tobacco use, were either significant when unadjusted, not significant when adjusted, or both not significant.

Stratified analyses based on sex were conducted to deline-ate the determinants associated with tobacco use among male and female school-going adolescents in Ghana (Table 4). Similar to results identified in Table 3, it was found that the same fac-tors (tobacco industry promotion and familial tobacco-use behavior—positively associated; knowledge that SHS is harm-ful—negatively associated) were identified to be associated with tobacco use among male and female adolescents in Ghana but with minor variations in the strength of association and level of significance. A major difference occurred in the media vari-able where seeing cigarette advertisements on billboard signifi-cantly increased the likelihood for males to be current cigarette smokers (OR = 2.40, 95% CI [1.15, 5.01]) but significantly decreased the likelihood for females to be ever cigarette smok-ers (OR = 0.44, 95% CI [0.28, 0.70]). Another major difference was that school education about why youth should not smoke significantly increased the likelihood for males to be users of

noncigarette tobacco products (OR = 1.75, 95% CI [1.12, 2.71]), and teaching youth about the dangers of smoking significantly increased the likelihood for females to be ever cigarette smokers (OR = 2.03, 95% CI [1.10, 3.74]). In conclusion, tobacco indus-try promotion and tobacco-use behavior of familial relations significantly increased the likelihood although knowledge that SHS is harmful decreased the likelihood of tobacco-use status among school-going adolescents in Ghana.

DiscussionTobacco use has been described as a “pediatric disease” because most smokers begin as youth (Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, & Committee on Native American Child, 2009). However, tobacco-use information on Ghana has been lim-ited not only because of the absence of nationally representa-tive data but also due to the focus primarily on adults (Addo, Smeeth, & Leon, 2009; Dennis-Antwi et al., 2003; John et al., 2012; Owusu-Dabo, Lewis, McNeil, Gilmore, et al., 2009; Pampel, 2008). In contrast, this study utilized GYTS, a nation-ally representative data, and found a narrow gap in tobacco use among male and female school-going adolescents in Ghana (6.7% vs. 4.4% for ever cigarette smoker; 2.4% vs. 1.4% for cur-rent cigarette smoker; and 6.8% vs. 5.2% for user of noncigarette tobacco products). This narrow gap perhaps accounts for why the regression results for gender were not significant, which is not consistent with studies on youth tobacco use from Europe and North America (USDHHS, 2012). Thus, it is important to contemplate the factors that make tobacco products available to these adolescents, including the sale of single cigarettes (Shafey, Dolwick, & Guindon, 2003), low price of cigarettes (Owusu-Dabo, Lewis, McNeil, Gilmore, et al., 2009; WHO, 2008), and

Table 3. Smoking Status Among Adolescents in Ghana, 2006

Characteristics

Ever cigarette smoker

Current cigarette smoker

User of noncigarette tobacco products

Adjusted OR (95% CI) Adjusted OR (95% CI) Adjusted OR (95% CI)

Age (in years) 0.77 (0.55, 1.08) 0.71 (0.38, 1.32) 0.64* (0.44, 0.91)Age squared 1.05* (1.01, 1.09) 1.07 (0.99, 1.15) 1.05* (1.01, 1.10)Males (vs. females) 1.22 (0.91, 1.63) 2.07** (1.26, 3.40) 1.21 (0.91, 1.61)Knowledge about secondhand smoke (SHS) SHS is harmful 0.79 (0.59, 1.06) 0.80 (0.47, 1.35) 0.55*** (0.40, 0.74)Tobacco-use behavior of familial relations Live in home with one or more smoking persons 1.66* (1.12, 2.44) 5.47*** (2.88, 10.40) 1.71* (1.11, 2.66) Around others who smoke outside home 1.66** (1.17, 2.35) 2.08** (1.12, 3.86) 0.84 (0.59, 1.20) Have one or more parents who smoke 1.57* (1.07, 2.32) 1.58 (0.85, 2.93) 1.59* (1.04, 2.42) Have most or all friends who smoke 2.04*** (1.44, 2.90) 3.69*** (2.17, 6.26) 1.73** (1.20, 2.50)Tobacco industry promotion Owned object with cigarette brand logo 2.19*** (1.54, 3.12) 1.65 (0.94, 2.90) 2.06*** (1.48, 2.87) Offered free cigarette by tobacco company representative 2.14*** (1.48, 3.10) 2.51** (1.41, 4.50) 1.53* (1.07, 2.19)School curriculum Taught about dangers of smoking in past year 1.56* (1.07, 2.26) 0.89 (0.50, 1.61) 0.80 (0.55, 1.15) Discussed why people at young age should not smoke 1.27 (0.92, 1.75) 0.93 (0.53, 1.65) 1.41* (1.01, 1.97) Taught about effects of smoking 0.79 (0.55, 1.12) 0.91 (0.53, 1.55) 1.12 (0.77, 1.62)

Note. OR = adjusted odds ratio; CI = confidence intervals.*p < .05, **p < .01, ***p < .001.

of 10



ownloaded from



Tabl

e 4.

Sm

okin

g St

atus

Am

ong

Adol

esce

nts

in G

hana

by

Sex

Char

acte

ristic

s

Mal

esFe

mal

es

Ever

ciga

rette

sm

oker

Curr

ent c

igar

ette

sm

oker

User

of n

oncig

aret

te

toba

cco

prod

ucts

Ever

ciga

rette

sm

oker

Curr

ent c

igar

ette

sm

oker

User

of n

oncig

aret

te

toba

cco

prod

ucts

Adju

sted

OR

(95%

CI)

Adju

sted

OR

(9

5% C

I)Ad

juste

d O

R

(95%

CI)

Adju

sted

OR

(9

5% C

I)Ad

juste

d O

R

(95%

CI)

Adju

sted

OR

(9

5% C

I)

Age (

in ye

ars)

0.73

(0.4

8, 1.

11)

0.68

(0.3

5, 1.

33)

0.57

* (0.

37, 0

.89)

0.84

(0.4

7, 1.

51)

1.05

(0.2

5, 4.

46)

0.82

(0.4

5, 1.

51)

Age s

quar

ed1.

05* (

1.01

, 1.1

1)1.

07 (0

.99,

1.16

)1.

06 (0

.99,

1.12

)1.

03 (0

.97,

1.10

)1.

02 (0

.87,

1.20

)1.

03 (0

.96,

1.11

)Kn

owled

ge ab

out s

econ

dhan

d sm

oke (

SHS)

SH

S is

harm

ful

0.80

(0.5

5, 1.

17)

0.90

(0.4

9, 1.

67)

0.55

** (0

.37,

0.81

)0.

77 (0

.49,

1.22

)0.

54 (0

.22,

1.35

)0.

54 (0

.33,

0.87

)To

bacc

o-us

e beh

avio

r of f

amili

al re

latio

ns

Live

in h

ome w

ith o

ne o

r mor

e sm

okin

g pe

rson

s2.

04**

(1.2

6, 3.

29)

5.26

*** (

2.52

, 10.

96)

2.26

** (1

.37,

3.74

)1.

08 (0

.57,

2.03

)5.

48**

(1.8

2, 16

.52)

1.07

(0.4

8, 2.

37)

Ar

ound

oth

ers w

ho sm

oke o

utsid

e hom

e1.

41 (0

.93,

2.14

)1.

88 (0

.95,

3.73

)0.

79 (0

.51,

1.22

)2.

36**

(1.3

0, 4.

29)

2.94

(0.8

3, 10

.45)

0.94

(0.5

1, 1.

74)

H

a ve o

ne o

r mor

e par

ents

who

smok

e1.

77* (

1.08

, 2.9

0)1.

53 (0

.75,

3.13

)1.

08 (0

.65,

1.80

)1.

20 (0

.65,

2.21

)1.

59 (0

.60,

4.21

)3.

10 (1

.55,

6.23

)

Hav

e mos

t or a

ll fri

ends

who

smok

e2.

27**

* (1.

46, 3

.53)

3.14

*** (

1.67

, 5.9

1)1.

49 (0

.95,

2.34

)1.

80* (

1.02

, 3.1

7)7.

20**

* (2.

47, 2

0.99

)2.

21 (1

.21,

4.04

)M

edia

Se

en ci

gare

tte b

illbo

ard

in p

ast 3

0 da

ys1.

45 (0

.96,

2.20

)2.

40**

(1.1

5, 5.

01)

0.81

(0.5

4, 1.

21)

0.44

*** (

0.28

, 0.7

0)0.

62 (0

.22,

1.73

)0.

99 (0

.60,

1.66

)To

bacc

o in

dustr

y pro

mot

ion

Ow

ned

obje

ct w

ith ci

gare

tte b

rand

logo

1.90

** (1

.24,

2.92

)1.

35 (0

.68,

2.68

)2.

28**

* (1.

51, 3

.45)

3.01

*** (

1.62

, 5.6

0)3.

20**

(1.3

5, 7.

62)

1.66

(0.9

1, 3.

03)

Off

ered

free

ciga

rette

by t

obac

co co

mpa

ny

repr

esen

tativ

e2.

08**

(1.2

8, 3.

38)

2.42

** (1

.19,

4.93

)1.

56 (0

.99,

2.47

)2.

82**

* (1.

55, 5

.13)

2.55

(0.9

8, 6.

66)

1.37

(0.7

6, 2.

47)

Scho

ol cu

rric

ulum

Ta

ught

abou

t dan

gers

of s

mok

ing i

n pa

st ye

ar1.

38 (0

.85,

2.24

)1.

02 (0

.48,

2.18

)0.

72 (0

.44,

1.18

)2.

03* (

1.10

, 3.7

4)0.

80 (0

.33,

1.94

)0.

89 (0

.51,

1.56

)

Di

scus

sed

why p

eopl

e at y

oung

age s

houl

d no

t sm

oke

1.35

(0.8

9, 2.

05)

0.95

(0.4

7, 1.

92)

1.75

* (1.

12, 2

.71)

1.11

(0.6

5, 1.

89)

0.94

(0.4

1, 2.

14)

0.99

(0.6

0, 1.

65)

Ta

ught

abou

t effe

cts o

f sm

okin

g0.

64 (0

.40,

1.01

)0.

84 (0

.44,

1.60

)1.

07 (0

.64,

1.78

)0.

99 (0

.55,

1.78

)1.

03 (0

.34,

3.18

)1.

28 (0

.74,

2.19

)

Not

e. O

R =

adju

sted

odds

ratio

; CI =

confi

denc

e int

erva

ls.*p

< .0

5, **

p <

.01,

***p

< .0

01.

of 10



ownloaded from



illicit tobacco trade in the West Africa subregion that involved Ghana (LeGresley et al., 2008; Owusu-Dabo, Lewis, McNeil, Anderson, et al., 2009). Additionally, the narrow gap in tobacco use among male and female school-going adolescents should be of concern to policymakers, educators, and public health groups because it signifies transformation of tobacco use in the coun-try and perhaps the gradual breakdown in norms of behavior that kept a wider gap between the two sexes for many years (Addo et al., 2009; John et al., 2012; Pampel, 2008; WHO, 2009). Moreover, the higher usage of noncigarette tobacco products raises a concern about whether the adolescents perceive such products as less toxic or addictive and more socially accept-able. This means it is necessary to integrate regulation of use of noncigarette tobacco products into comprehensive tobacco-free policy and public health education and prevention efforts because the possibility of usage of such products as a “gateway” to cigarette smoking and the industry efforts to lure adolescents to switch to such products is high.

Regardless of sex, tobacco-use behavior among the school-going adolescents was associated with tobacco industry promo-tions, which affirms earlier studies (DiFranza et al., 2006; Pierce, Choi, Gilpin, Farkas, & Berry, 1998) and likely represents the effects of tobacco companies’ penetration of LMICs (Yach & Bettcher, 2000). The results suggest that all school-going ado-lescents in the country were susceptible to these industry activ-ities (Owusu-Dabo, Lewis, McNeil, Anderson, et al., 2009), especially when offered a free cigarette by a tobacco company sales representative, and have more significant effects on the male current cigarette smokers than females. This implies that the industry’s activities aimed at these adolescents should be of utmost concern as it likely explains that the tobacco industry not only penetrated the LMICs but also used marketing strate-gies to attract adolescents. Similar to other LMICs, the images of tobacco users promoted by tobacco companies, such as suc-cess, sociability, beauty, and feminine liberation (WHO, 2009), might have a stronger impact on adolescent females as those who owned tobacco merchandize were significantly more likely to currently smoke cigarettes. For this reason, lessons can be taken from successful youth tobacco control campaigns, such as the “Truth Campaign” in the United States (Farrelly, Davis, Duke, & Messeri, 2008), that focused attention on the tobacco industry’s deceptive activities aimed at youth. Such educational campaigns are necessary for the country because the results for school curriculum variables that focused on health effects of tobacco use were mixed, a conundrum for school programs. In this respect, the positive association between some school cur-riculum variables and increased tobacco use supports the liter-ature that school programs that only focus on health messages may not work for adolescent populations (Wiehe, Garrison, Christakis, Ebel, & Rivara, 2005).

As signatory to the WHO FCTC (ratified by 175 Parties as of August 2012) (WHO, 2003), Ghana is under obligation to adopt a comprehensive advertising ban on tobacco to protect its vul-nerable but impressionistic population from tobacco industry promotions and marketing. The larger implication of this study for other LMICs, symbolized by the finding that about 15% of the students reported that they owned tobacco merchandize or have been offered a cigarette by a tobacco company representa-tive, indicates that tobacco industry promotions and marketing are reaching adolescents in such places.

The finding that familial relations increased the likelihood of tobacco use is consistent with evidence from high-income countries (Farkas, Gilpin, White, & Pierce, 2000; Leatherdale, Cameron, Brown, Jolin, & Kroeker, 2006) and other LMICs (El-Amin, Nwaru, Ginawi, Pisani, & Hakama, 2011; Muula & Siziya, 2007) but presents at least three policy challenges. First, in a communitarian society, such as Ghana, children may not have the ability to reject tobacco offered by an elderly person, implying the need for public health prevention efforts to edu-cate elderly persons about tobacco use and its harmful effects and importance of denying tobacco products to minors. Second, the increase in the likelihood of smoking by living in smoking homes may have culminated from social acceptability of tobacco use, suggesting the need to educate parents to have smoke-free homes (Farkas et al., 2000). This is because smoke-free homes could help reduce smoking among adolescents (Wakefield et al., 2000) and exposure to SHS. Third, this study confirms that peer smoking is strongly associated with adolescents’ tobacco use, especially among female current cigarette smokers. This result suggests the need for policies that restrict youth access to and demand for tobacco products, such as tax increases, age verifica-tion, and ban on sales of single cigarettes. Additionally, because previous studies found that school personnel’s smoking behavior is associated with that of students (Lipperman-Kreda & Grube, 2009), it is important to have smoke-free school campuses.

The results that the knowledge of harmful effects of SHS is associated with decreased tobacco use merits more attention in the country (Guindon, Georgiades, & Boyle, 2008). Knowledge about the negative effects of SHS generally suppresses the propen-sity to use tobacco among the school-going adolescents, providing an important tool for tobacco control. SHS contains about 400 to 500 known carcinogens (USDHHS, 2010), and educating adoles-cents about the health implications for nonsmokers could make smoking socially unacceptable and prevent tobacco use (Bruvold, 1993). This approach is important in Ghana because a study found that adolescent tobacco users thought they were not at risk of tobacco-induced morbidities (Dennis-Antwi et al., 2003).

LimitationsAlthough the GYTS data are nationally representative and based on a standardized questionnaire, it is self-reported and there is no independent means of validation. Additionally, the sample methodology does not account for children who were absent from school on the day the survey was administered or children who do not attend schools. Further, the GYTS data are cross-sectional, limiting the temporal relationship between the dependent and independent variables in the study. Moreover, the absence of information on socioeconomic status of fami-lies and regions of the country weakens the understanding of the associations. Nevertheless, the relatively large representa-tive sample strengthens the inferences and conclusions about tobacco use among school-going adolescents in Ghana.

ConclusionPrevious studies on adult tobacco use in Ghana found that tobacco use begins before adolescent age. This study discovered that, unlike adult tobacco use, there is a narrow gap. However,

of 10



ownloaded from



significant differences in the tobacco use between male and female school-going adolescents should be of concern to poli-cymakers, educators, public health advocates, and organiza-tions because it probably signals transformation of tobacco use at the youth level. This transformation may likely be enhanced by tobacco industry promotions and marketing, demanding a comprehensive ban. Additionally, the fact that tobacco-use behavior of familial relations is significantly associated with adolescent tobacco use in a communitarian society demands government intervention by educating people to have smoke-free homes, educating adults not to make tobacco products available to youth, and restricting youth access to tobacco prod-ucts. Moreover, the evidence that knowledge about the harmful effects of SHS generally reduced the likelihood of use of tobacco products suggests the need to integrate education on the harm-ful effects of SHS into tobacco control initiatives because it could help to reinforce norms that tobacco use is socially unaccepta-ble. At the same time, school and health educators in the coun-try should be aware that focusing on the health message alone may not work for adolescent populations. Because these sug-gested policies are an integral part of the FCTC, which Ghana has signed and ratified (WHO, 2011), it implies that not only should the Public Health Bill 2011 be signed into law but also it should be implemented in a manner consistent with the letter and spirit of the FCTC to help prevent tobacco-use initiation among school-going adolescents in the country.

FundingThe research was supported by a start-up funds from East Tennessee State University Foundation (E38500). The funder has no involvement in the conduct and report of the research.

Declaration of InterestsThe authors have none to declare.

AcknowledgmentsAuthors would like to thank the East Tennessee State University Foundation for providing start-up funds to support this research and the College of Public Health for providing the logistics.

ReferencesAddo, J., Smeeth, L., & Leon, D. A. (2009). Smoking pat-terns in Ghanaian civil servants: Changes over three decades. International Journal of Environmental Research and Public Health, 6, 200–208. doi:10.3390/ijerph6010200

Assunta, M., & Chapman, S. (2004). The tobacco indus-try’s accounts of refining indirect tobacco advertising in Malaysia. Tobacco Control, 13(Suppl. 2), ii63–ii70. doi:10.1136/tc.2004.007732

Braun, S., Mejia, R., Ling, P. M., & Pérez-Stable, E. J. (2008). Tobacco industry targeting youth in Argentina. Tobacco Control, 17, 111–117. doi:10.1136/tc.2006.018481

Bruvold, W. H. (1993). A meta-analysis of adolescent smoking prevention programs. American Journal of Public Health, 83, 872–880. doi:10.2105/AJPH.83.6.872

Central Intelligence Agency. (n.d.). Ghana. CIA--the World Factbook. Retrieved September 10, 2012, from https://www.cia.gov/library/publications/the-world-factbook/geos/gh.html

Committee on Environmental Health, Committee on Substance Abuse, Committee on Adolescence, & Committee on Native American Child. (2009). From the American Academy of Pediatrics: Policy statement--Tobacco use: A pediatric disease. Pediatrics, 124, 1474–1487. doi:10.1542/peds.2009–2114

Dennis-Antwi, J., Adjei, S., Asare, J. B., Twene, R., Ministry of Education, & Ghana Narcotics Control Board. (2003). A National Survey on Prevalence and Social Consequences of Substance (Drug) use among Second Cycle and Out of School Youth in Ghana. Accra, Ghana: Ministry of Health, Ghana Health Service, World Health Organization.

DiFranza, J. R., Wellman, R. J., Sargent, J. D., Weitzman, M., Hipple, B. J., Winickoff, J. P., & Tobacco Consortium, Center for Child Health Research of the American Academy of Pediatrics. (2006). Tobacco promotion and the initiation of tobacco use: Assessing the evidence for causality. Pediatrics, 117, e1237–e1248. doi:10.1542/peds.2005-1817

El-Amin, S. EL.-T., Nwaru, B. I., Ginawi, I., Pisani, P., & Hakama, M. (2011). The role of parents, friends and teachers in adoles-cents’ cigarette smoking and tombak dipping in Sudan. Tobacco Control, 20, 94–99. doi:10.1136/tc.2010.038091

Farkas, A. J., Gilpin, E. A., White, M. M., & Pierce, J. P. (2000). Association between household and workplace smoking restric-tions and adolescent smoking. JAMA: The Journal of the American Medical Association, 284, 717–722. doi:10.1001/jama.284.6.717

Farrelly, M. C., Davis, K. C., Duke, J., & Messeri, P. (2009). Sustaining ‘truth’: Changes in youth tobacco attitudes and smok-ing intentions after 3 years of a national antismoking campaign. Health Education Research, 24, 42–48. doi:10.1093/her/cym087

Ghana Broadcasting Corporation. (n.d.). Smoking banned in public places in Ghana. Retrieved September 9, 2012, from http://gbcghana.com/index.php?id=1.960481

Global Tobacco Youth Survey Group. (2002). Tobacco use among youth: A cross country comparisons. Tobacco Control, 11, 252–270. doi:10.1136/tc.11.3.252

GTSS Collaborative Group. (2006). The global tobacco surveil-lance system. Tobacco Control, 15(Suppl. II), ii1–ii3. doi:10.1136/tc.2006.015719

Guindon, G. E., Georgiades, K., & Boyle, M. H. (2008). Susceptibility to smoking among South East Asian youth: A mul-tilevel analysis. Tobacco Control, 17, 190–197. doi:10.1093/her/cym087

Hinkle, D. E., Wiersma, W., & Jurs, S. G. (2003). Applied statistics for behavioral sciences (5th ed.). Boston, MA: Houghton Mifflin Co.

IARC. (2002). Tobacco smoke and involuntary smoking, IARC monograph on evaluation of carcinogenic risks to humans (Vol. 83). Lyon, France: IARC.

of 10



ownloaded from

http://https://www.cia.gov/library/publications/the-world-factbook/geos/gh.html

http://https://www.cia.gov/library/publications/the-world-factbook/geos/gh.html

http://gbcghana.com/index.php?id=1.960481



John, R. M., Mamudu, H. M., & Liber, A. C. (2012). Socioeconomic implications of tobacco use in ghana. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 14, 1205–1212. doi:10.1093/ntr/nts013

Lando, H. A., Borrelli, B., Klein, L. C., Waverley, L. P., Stillman, F. A., Kassel, J. D., & Warner, K. E. (2005). The landscape in global tobacco control research: A guide to gaining a foothold. American Journal of Public Health, 95, 939–945. doi:10.2105/AJPH.2004.047167

Leatherdale, S. T., Cameron, R., Brown, K. S., Jolin, M. A., & Kroeker, C. (2006). The influence of friends, family, and older peers on smoking among elementary school students: Low-risk students in high-risk schools. Preventive Medicine, 42, 218–222. doi:10.1016/j.ypmed.2005.11.019

LeGresley, E., Lee, K., Muggli, M. E., Patel, P., Collin, J., & Hurt, R. D. (2008). British American Tobacco and the “insidi-ous impact of illicit trade” in cigarettes across Africa. Tobacco Control, 17, 339–346. doi:10.1136/tc.2008.025999

Lipperman-Kreda, S., & Grube, J. W. (2009). Students’ per-ception of community disapproval, perceived enforcement of school antismoking policies, personal beliefs, and their cigarette smoking behaviors: Results from a structural equation mod-eling analysis. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco, 11, 531–539. doi:10.1093/ntr/ntp033

Muula, A. S., & Siziya, S. (2007). Prevalence and determinants of ever smoked cigarettes among school-going adolescents in Lusaka, Zambia. African Health Sciences, 7, 246–252. doi:http://www.ajol.info/index.php/ahs

Oberg, M., Jaakkola, M. S., Woodward, A., Peruga, A., & Prüss-Ustün, A. (2011). Worldwide burden of disease from exposure to second-hand smoke: A retrospective analysis of data from 192 countries. Lancet, 377, 139–146. doi:10.1016/S0140-6736(10)61388-8

Owusu-Dabo, E., Lewis, S., McNeil, A., Anderson, S., Gilmore, A., & Britton, J. (2009). Smoking in Ghana: A review of tobacco industry activity. Tobacco Control, 18, 206–211. doi:10.1136/tc.2009.030601

Owusu-Dabo, E., Lewis, S., McNeill, A., Gilmore, A., & Britton, J. (2009). Smoking uptake and prevalence in Ghana. Tobacco Control, 18, 365–370. doi:10.1136/tc.2009.030635

Pampel, F. (2008). Tobacco use in sub-Sahara Africa: Estimates from the demographic health surveys. Social Science & Medicine (1982), 66, 1772–1783. doi:10.1016/j.socscimed.2007.12.003

Pierce, J. P., Choi, W. S., Gilpin, E. A., Farkas, A. J., & Berry, C. C. (1998). Tobacco industry promotion of cigarettes and ado-lescent smoking. JAMA: The Journal of the American Medical Association, 279, 511–515. doi:10.1001/jama.279.7.511

Shafey, O., Dolwick, S., & Guindon, G. E. (Eds.). (2003). Tobacco control country profiles 2003. Atlanta, GA: American Cancer Society.

United Nations Development Programme. (2010). Human development report 2010. Retrieved January 4, 2011, from http://hdr.undp.org/en/media/HDR_2010_EN_Complete_reprint.pdf

USDHHS. (2006). The health consequences of involuntary expo-sure to tobacco smoke: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

USDHHS. (2010). The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.

USDHHS. (2012). Preventing tobacco use among youth and young adults: A report of the surgeon general. Retrieved May 8, 2012, from http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

Wakefield, M. A., Chaloupka, F. J., Kaufman, N. J., Orleans, C. T., Barker, D. C., & Ruel, E. E. (2000). Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: Cross sectional study. BMJ (Clinical research ed.), 321, 333–337. doi:10.1136/bmj.321.7257.333

Warren, C. W., Jones, N. R., Peruga, A., Chauvin, J., Baptiste, J. P., Costa de Silva, V., . . . CDC. (2008). Global youth tobacco surveillance, 2000-2007. Morbidity and Mortality Weekly Report. Surveillance Summaries (Washington, D.C.: 2002), 57, 1–28.

Warren, C. W., Riley, L., Asma, S., Eriksen, M. P., Green, L., Blanton, C., . . . Yach, D. (2000). Tobacco use by youth: A sur-veillance report from the Global Youth Tobacco Survey project. Bulletin of the World Health Organization, 78, 868–876.

WHO. (1999). International consultation on tobacco and youth: What in the world works? WHO, Singapore. Geneva, Switzerland: WHO.

WHO. (2003). WHO framework convention on tobacco control. Geneva, Switzerland: WHO.

WHO. (2008). WHO report on the Global Tobacco Epidemic, 2008: MPOWER package. Geneva, Switzerland: World Health Organization.

WHO. (2009). Women and health: Today’s evidence tomorrow’s agenda. Geneva, Switzerland: WHO.

WHO. (2011). WHO report about Global Tobacco Epidemic, 2011: Warning about dangers of tobacco. Geneva, Switzerland: WHO.

Wiehe, S. E., Garrison, M. M., Christakis, D. A., Ebel, B. E., & Rivara, F. P. (2005). A systematic review of school-based smok-ing prevention trials with long-term follow-up. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 36, 162–169.

World Bank. (2010). World development indicators 2011. Retrieved January 4, 2011, from http://data.worldbank.org/news/WDI-2011-database-and-publication-available

Yach, D., & Bettcher, D. (2000). Globalisation of tobacco indus-try influence and new global responses. Tobacco Control, 9, 206–216. doi:10.1136/tc.9.2.206

of 10



ownloaded from

http://hdr.undp.org/en/media/HDR_2010_EN_Complete_reprint.pdf

http://hdr.undp.org/en/media/HDR_2010_EN_Complete_reprint.pdf

http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf

http://data.worldbank.org/news/WDI-2011-database-and-publication-available

http://data.worldbank.org/news/WDI-2011-database-and-publication-available


Tobacco Use Among School-Going Adolescents (11-17 Years) in Ghana

Documents

Transcript of Tobacco Use Among School-Going Adolescents (11-17 Years) in Ghana