This document compares tobacco use among youth aged 11-17 in Yerevan, Armenia and New Delhi, India. It analyzes data from the Global Youth Tobacco Survey conducted in 2001 in New Delhi and 2004 in Yerevan. The results show higher rates of regular smoking among boys compared to girls in both cities. Regular smoking rates were higher at earlier ages in New Delhi and later ages in Yerevan. Peer pressure and having smoking fathers were associated with increased youth smoking risk, while family discussions of smoking harms reduced risk. The conclusions recommend targeting fathers and peers in anti-tobacco campaigns in Armenia, and involving families in both countries.

1. A cross country comparison of tobacco use among youth in Yerevan (Armenia) and New Delhi (India) Student Investigator: Neeraj Kishore Pandey, MD, MPH (c) Advisor: Byron Crape, MSPH, PhD Reader : NarineMovsisyan, MD, MPH Diana Petrosyan, MD, MPH 1

2. Outline Introduction Methods Results Discussion Conclusion Recommendations 2

3. Public health problem of tobacco use One of major preventable causes of death. Morbidity and mortality: Lung cancer, CVD, COPD, atherosclerosis. Over 4 millions die each year due to smoking 1 death due to smoking every 8 seconds globally. Economic impact on family: Smoking diverts money from basic needs. WHO, 2002 3

4. Situation in Armenia Major public health problem, with a greater impact on urban areas. Smoking rates among Armenian men one of the highest globally. Smoking rates: male-60%, female-2% (age group -16 years and above), 2005. National survey on Drug, Alcohol and smoking prevalence among general population of Armenia, 2005 4

5. Situation in India Smoking is responsible for half of cancers in men and a quarter of cancers in women WHO projects tobacco deaths may exceed 1.5 million by 2020 in India. Smoking rates: male-57%, female-11% (age group -15 to 54 years), 2005-2006. National Family Health Survey, India,2005-2006 5

6. Rationale for study High smoking rates in Armenia and India. No other comparative study conducted for these two countries Finding common and different risk factors and protective factors associated with tobacco use between the two cities will inform and strengthen tobacco control programs. 6

7. Research question: 1 What are the differences and similarities between smoking practices, beliefs and attitudes of school- based students 11 to 17 years of age in Yerevan, Armenia and New Delhi, India ? 7

8. Research question: 2 What are the differences and similarities between students’ familial and environmental factors influencing smoking among youth in school 11 to 17 years of age between Yerevan, Armenia and New Delhi, India? 8

9. Research question: 3 What are the differences and similarities in risk factors associated with initiation of smoking among youth in school 11 to 17 years of age between Yerevan, Armenia and New Delhi, India? 9

10. Global Youth Tobacco Survey (GYTS) School-based surveys conducted globally Collected data from students13 to 15 years of age Used standardized methodology to construct sampling frame, randomized methods to select schools and classes for sampling and data processing 10

11. 11 Methods Secondary data analysis Datasets and codebooks GYTS 2001 New Delhi, India (N=12086) GYTS 2004 Yerevan, Armenia (N=560) Sources WHO website Coordinator of the state tobacco control program in Armenia 11

13. SPSS 11 software

14. Code book of 32 questions created

15. 69 questions for India

17. Regular smoking prevalence rate by gender and city 14 Percent P<0.001

18. Regular smoking prevalence rates among student by age group, stratified by city Age Groups in Years P<0.001

19. Percentage of students who reported definitely or probably smoke or not smoke a cigarette if their best friend offered them a cigarette 16 P<0.001

20. Final multivariate logistic regression with city of residence (New Delhi vs. Yerevan) as the outcome and smoking risk factors as covariates 17

21. Final multivariate logistic regression with regular smoking vs. non-regular smoking as the outcome, city of residence (New Delhi vs. Yerevan) and smoking risk factors as covariates 18

22. Discussion Female students more likely to take up regular smoking in New Delhi than in Yerevan Regular smoking rates were higher in the earlier ages in New Delhi and were higher in later ages in Yerevan. Rates of increase in smoking rates over age higher in Yerevan than Delhi. 19

23. Discussion Fathers almost twice as likely to be smokers in Yerevan than in New Delhi. Students in Yerevan twenty times more likely to accept and smoke a cigarette offered by their best friend than in New Delhi. Anti-smoking references seen on posters and in newspapers and magazines were more frequently seen by non-regular smokers than regular smokers. 20

24. Limitations There were too few girls who smoked to analyze them separately from boys Because of lack of matches between the instruments, some questions were dropped out 21

25. Strengths Large sample size of New Delhi and adequate sample size of Yerevan Surveys conducted only three year apart (2001 and 2004). Surveys conducted prior to law banning tobacco advertising in both the cities. 22

26. Conclusions Smoking fathers and peer pressure are associated with increased risk of student smoking. Family members discussing harmful effects of tobacco is substantially associated with reduced risk of smoking. Unknown and unmeasured cultural and environmental factors different between the two cities associated with smoking 23

27. Recommendations Smoking fathers and peer pressure in Armenia should be especially targeted for more effective anti-tobacco campaign Family members included in anti-smoking programs to prepare them to discuss harmful effects of smoking. More comparative studies needed to further explore unknown and unmeasured cultural/environmental factors. 24

28. ԴեռահասներիշրջանումծխախոտիօգտագործմանհամեմատությունըԵրևանում (Հայաստան) և ՆորԴելիում (Հնդկաստան) 25

29. ԱՌԱՋԱՐԿՈՒԹՅՈՒՆՆԵՐ Դեռահասներիշրջանումհակածխախոտայինծրագրերըավելիարդյունավետդարձնելունպատակովառաջարկումենք` առանձնահատուկուշադրությունդարձնելայնպիսիգործոնների, ինչպիսիննենհործխելը և հասակակիցներիճնշումը ընդգրկելընտանիքիանդամներին` ուսուցանելունրանցքննարկելդեռահասներիհետ ծխախոտիօգտագործմանվնասակարազդեցությունները Իրականացնելհետագահամեմատականհետազոտություններ` ուսումնասիրելուդեռևսչբացահայտված և չգնահատվածմշակութայինգործոններիազդեցությունըդեռահասներիշրջանումծխախոտիօգտագործմանվրա 26

30. Thank You 27

31. Questions? 28