Tobacco use is the leading preventable cause of death in developed countries and is the second leading cause of death globally.¹The Global Burden of Disease predicts that the annual number of deaths from tobacco use will double from 5 million in 2005 to 10 million in 2020.²

Teachers and administrators are role models for students, conveyors of tobacco prevention curricula, and key opinion leaders for school tobacco control policies. The majority of tobacco users first try tobacco in their teens,³ and school is mandatory in most countries through age 15 or 16. School teachers and administrators have daily interaction with students and thus represent an influential group for tobacco control.

The World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) is the world’s first public health treaty. The WHO FCTC was unanimously adopted by the World Health Assembly in May 2003, was signed by 168 nations and, at the time of this writing, had been ratified by 116 nations.⁴ The WHO FCTC systematically addresses the challenges of reducing the chronic disease burden associated with tobacco use and smoke exposure. Among the important areas addressed by the WHO FCTC, strengthening public awareness about the dangers of tobacco consumption is a primary focus of Article 12. Educators are specifically mentioned as important vectors of this information.

ARTICLE 12

Each Party shall promote and strengthen public awareness of tobacco control issues,….

to promote broad access to effective and comprehensive educational and public awareness programmes on the health risks including the addictive characteristics of tobacco consumption and exposure to tobacco smoke; ….to promote effective and appropriate training or sensitization and awareness programmes on tobacco control addressed to persons such as … educators.

The WHO FCTC and the Global Tobacco Surveillance System (GTSS) share the same goal of supporting development, implementation, and evaluation of effective tobacco control programmes. The WHO FCTC calls for countries to use consistent methodology to monitor progress in reducing tobacco consumption and exposure to tobacco smoke. The GTSS allows countries to develop an evidence base regarding a variety of tobacco indicators that complements domestic surveillance programmes and international public health research.

This report presents data from the Global School Personnel Survey (GSPS), conducted in 69 sites in 30 countries and the Gaza Strip/West Bank between 2000 and 2005. The report features a cross-country comparison of school personnel regarding tobacco use patterns, knowledge of and attitudes toward tobacco, availability of tobacco control teaching materials and training, and school anti-tobacco policies.

METHODS

The GSPS was designed to collect information on tobacco use, knowledge and attitudes of school personnel toward tobacco, existence and effectiveness of tobacco control policies in schools, and training and materials available for implementing tobacco prevention and control interventions.

Sample

The GSPS is a survey of all personnel working in schools selected to participate in the Global Youth Tobacco Survey (GYTS). The GYTS uses a two-stage cluster sample design to select a representative sample of students. Stage 1 consists of the selection of schools, proportional to school enrolment size. Stage 2 consists of a random sample of classes within each school. All personnel working in the selected schools were eligible to participate in the GSPS.

Data included in this report come from GSPS surveys conducted in 69 sites in 30 countries and the Gaza Strip/West Bank between 2000 and 2005. The GSPS has been conducted in one country in the African Region, five countries in the Region of the Americas, 12 countries and the Gaza Strip and West Bank in the Eastern Mediterranean Region, seven countries in the European Region, two countries in the South-East Asia Region, and three countries in the Western Pacific Region. National-level data have been collected in 18 countries, and subnational data were collected in 51 state, provincial/regional, or city sites in 12 countries and the Gaza Strip/West Bank.

School response rates by site ranged from 64.0–100%, school personnel response rates by site ranged from 56.7–100%, and overall response rates by site ranged from 45.8–100%. In total, over 83 000 school personnel in more than 2800 schools have completed the GSPS.

Data collection

The GSPS used self-administered, anonymous data collection procedures. Names of schools or personnel were not collected and participation was voluntary. The questionnaire was designed with no skip patterns to allow all respondents to answer all questions. Surveys were completed at schools, generally at staff meetings or after school.

Questionnaires consisted of a core set of questions that all countries ask and a set of unique country-specific questions. The final questionnaires are translated into local languages and back-translated into English to check for accuracy. Country research coordinators conducted focus groups to test further the accuracy of the translation and understanding of the questions.

Measures

This report presents measures of tobacco use prevalence (lifetime cigarette use, current cigarette use, current use of tobacco products other than cigarettes, and current use of any tobacco products), percentage who ever smoked on school property, support for and existence of school policies prohibiting tobacco use (percentage who strongly agreed schools should have a policy prohibiting tobacco use among students and school personnel, percentage who reported that their school has a policy prohibiting tobacco use among students and school personnel), percentage who reported that their school enforces its tobacco policy, components of tobacco-related curriculum (percentage of school personnel who had taught students how to avoid tobacco use, had access to teaching and learning materials about tobacco, had received training to prevent youth tobacco use, or had non-classroom programmes to teach about tobacco prevention among students), and attitudes among school personnel regarding several tobacco issues (percentage who are very concerned about youth tobacco use, strongly agreed school personnel should set a good example by not using tobacco, strongly agreed school personnel who use tobacco are less likely to advise students to stop using tobacco, or strongly agreed that school personnel should get specific training to teach students to avoid or stop using tobacco).

Data analysis

The GSPS data are weighted to adjust for sample selection (school) and non-response (school and individual levels). The computer program SUDAAN⁵ was used to compute weighted prevalence estimates and standard errors of the estimates (95% confidence intervals were calculated using the standard errors).

Means for all measures are reported for five WHO Regions including the Region of the Americas (AMRO), the Eastern Mediterranean Region (EMRO), the European Region (EURO), the South-East Asia Region (SEARO), and the Western Pacific Region (WPRO).* No regional means are reported for the African Region (AFRO) because only one site (Niamey, Nigeria) from the Region has conducted the GSPS. Regional aggregations were calculated as means weighted by the population of the sampling frame. In many cases, the sampling frame was the country, but in areas where samples were drawn to be representative of a subnational population, estimates were weighted by the population of the city, state, or administrative region and included in the regional aggregation. Reported regional means are not representative of the total Region because of limited coverage of GSPS data in many Regions at the time of this report.

RESULTS

Tobacco use prevalence

Lifetime cigarette use ranged from 16.6% in Andhra Pradesh, India to 83.3% in Somaliland, Somalia (table 1). Across the five Regions with multiple survey sites, mean values for lifetime cigarette use ranged from 23–42% (23.5% in WPRO, 24.6% in EMRO, 28.4% in SEARO, 32.5% in AMRO, and 42.4% in EURO). The percentage of school personnel who were current cigarette smokers ranged from 0.8% in Qatar (Girls’ Schools) to 45.9% in Bulgaria. Regional mean values for current cigarette smoking ranged from 15–19% (14.7% in WPRO, 15.9% in EMRO, 17.9% in AMRO, 19.3% in EURO, and 19.5% in SEARO).

Current use of tobacco products other than cigarettes ranged from 0.7% in Dominica to 99.1% in Kerala, India. Regional mean values for current tobacco use other than cigarettes ranged from 3–32% (2.6% in EURO, 2.9% in WPRO, 4.6% in AMRO, 10.6% in EMRO, and 32.4% in SEARO). Current use of any tobacco products ranged from 3.2% in Dominica to 99.1% in Kerala, India. Regional mean values of current any tobacco use ranged from 15–37% (15.2% in WPRO, 18.6% in AMRO, 19.8% in EMRO, 20.7% in EURO, and 37.1% in SEARO). Among current smokers, the percentage who had ever smoked on school grounds ranged from 1.0% in Dominica to 43.5% in Somaliland, Somalia.

School policies prohibiting use of tobacco

The percentage of school personnel who strongly agreed that schools should have a rule specifically prohibiting tobacco use among students ranged from 33.5% in Manipur, India to 97.6% in Orissa, India (table 2). Regional mean values ranged from 75–89% (75.0% in WPRO, 76.3% in EURO, 80.6% in AMRO, 86.8% in SEARO, and 89.0% in EMRO). The percentage who strongly agreed that schools should have a rule specifically prohibiting tobacco use among school personnel ranged from 19.4% in Slovakia to 97.2% in Haryana, India. Regional mean values ranged from 45–86% (45.1% in EURO, 61.0% in WPRO, 75.2% in EMRO, 77.3% in AMRO, and 86.2% in SEARO).

The percentage of school personnel who reported their school has a rule prohibiting smoking among students ranged from 0.2% in Bihar, India to 97.4% in Kasur, Pakistan. Regional mean values ranged from 33–82% (32.9% in SEARO, 56.6% in EMRO, 64.5% in AMRO, 77.8% in WPRO, and 81.6% in EURO). The percentage of school personnel who reported their school has a rule prohibiting smoking among school personnel ranged from 0.1% in Bihar, India to 96.8% in Peshawar, Pakistan. Regional mean values ranged from 30–54% (29.6% in SEARO, 40.5% in EMRO, 44.0% in EURO, 45.4% in AMRO, and 54.2% in WPRO). The percentage of school personnel who reported that their school is tobacco-free ranged from 0.1% in Bihar, India to 97.2% in Peshawar, Pakistan. Regional mean values ranged from 28–64% (27.9% in AMRO, 32.7% in SEARO, 42.8% in EMRO, 49.2% in EURO, and 63.7% in WPRO). The percentage of school personnel who reported that their school enforces the tobacco policy ranged from 0.1% in Bihar, India to 83.6% in Quetta, Pakistan. Regional mean values ranged from 33–61% (33.5% in WPRO, 36.7% in SEARO, 57.1% in EURO, 58.7% in EMRO, and 60.6% in AMRO).

Tobacco-related curriculum

The percentage of school personnel who had taught students about the dangers of smoking in the past year ranged from 11.7% in Tunisia to 100% in Suriname (table 3). Regional mean values ranged from 39–74% (39.1% in EMRO, 49.8% in WPRO, 63.4% in SEARO, 65.5% in AMRO, and 74.1% in EURO). The percentage of school personnel who had access to teaching materials about tobacco ranged from in 1.2% in Bihar, India to 86.4% in Kasur, Pakistan. Regional mean values ranged from 17–54% (16.9% in SEARO, 30.7% in EMRO, 38.9% in AMRO, 39.0% in WPRO, and 53.8% in EURO). The percentage of school personnel who had ever received training to prevent youth tobacco use ranged from 1.0% in Bihar, India to 40.4% in Haryana, India. Regional mean values ranged from 7–27% (6.5% in SEARO, 11.0% in EMRO, 13.9% in WPRO, 19.9% in EURO, and 26.5% in AMRO). The percentage of school personnel who reported that their school had non-classroom activities to teach about tobacco use and prevention ranged from 1.0% in Bihar, India to 88.6% in Belarus. Regional mean values ranged from 23–54% (23.2% in SEARO, 27.3% in EMRO, 35.7% in AMRO, 39.5% in WPRO, 53.6% in EURO).

Attitudes toward tobacco control

The percentage of school personnel who were very concerned about youth tobacco use ranged from 19.7% in Manipur, India to 94.4% in Tuenquang, Viet Nam (table 4). Regional mean values ranged from 59–66% (58.6% in WPRO, 59.5% in AMRO, 63.1% in EURO, 65.3% in EMRO, and 65.9% in SEARO). The percentage of school personnel who strongly agreed that they should set an example for students by not using tobacco ranged from 33.5% in Manipur, India to 96.6% in Qatar (girls’ schools). Regional mean values ranged from 73–89% (73.3% in EURO, 77.9% in AMRO, 81.0% in WPRO, 87.5% in EMRO, and 89.1% in SEARO). The percentage who strongly agreed that school personnel who smoke are less likely to advise their students to stop using tobacco ranged from 24.2% in Puyang, China to 93.7% in Novaday, India. Regional mean values ranged from 37–69% (37.5% in EURO, 38.3% in WPRO, 55.9% in AMRO, 59.6% in EMRO, and 69.1% in SEARO). The percentage of school personnel who strongly agreed that they should get specific training to help students avoid or stop tobacco use ranged from 21.9% in the Czech Republic to 87.0% in Bihar, India. Regional mean values ranged from 38–85% (38.2% in EURO, 52.3% in WPRO, 73.6% in EMRO, 82.2% in SEARO, and 84.6% in AMRO).

DISCUSSION

The findings in this report are subject to at least three limitations. First the GSPS sample design uses schools selected for the GYTS. Thus, GSPS is not an independent sample of schools and is dependent on the success of the GYTS. Fortunately, the GSPS school response rate has been greater than 80% in all but one GSPS site. Second, the GSPS school personnel response rate was less than 70% in seven of 69 sites. School personnel participation was voluntary. Third, findings are based on self-reports from school personnel who may under- or over-report their behaviour and their knowledge of school policies. GSPS does not include independent validation of school policies and enforcement of school tobacco control policies.

School personnel can play an important role in tobacco control because of their status as role models in their communities and frequent contact with children. This potential can be limited if school personnel use tobacco, especially in the presence of students on school property.

Data collected by the GSPS between 2000 and 2005 have shown that an alarming proportion of school personnel smoke cigarettes and use other forms of tobacco. At the Regional level, current cigarette smoking is between 15–19% among school personnel included in this report around the world (table 1). In parts of the world where other forms of tobacco are common, such as the South-East Asia Region and Eastern Mediterranean Region, a similar or higher proportion of school personnel reported using these products compared to smoking cigarettes.

In addition to reducing exposure of students and school personnel to secondhand smoke, the strength and mostly the enforcement of school policy restricting smoking are associated with a lower level of tobacco consumption and prevalence among pupils.^6,7,8,9,10 In addition, policy restricting smoking among school personnel must be applied to all indoor and outdoor areas of the school because visibility of adult smoking including outdoor areas increases the likelihood of regular smoking among students¹¹ and decreases the support for smoke-free environments among students that smoke.¹² The scarcity of tobacco-free schools and the high level of smoking on school grounds by school personnel reported in this study indicate how seriously school practice and staff actions undermine the educational messages and other prevention efforts to reduce adolescent smoking prevalence.

Achieving a broader application of school tobacco-free policies should not be a problem because, despite widespread tobacco use among school personnel, support for tobacco-free policies for both students and personnel in school was generally high (table 2). More than half of school personnel in the majority of sites supported prohibiting tobacco use on school property.

Access to appropriate educational materials is an important element of an effective curriculum to prevent and reduce tobacco use among students. Although some teachers reported having access to these materials, the majority of teachers in most sites reported that they do not have adequate teaching materials to support tobacco reduction and prevention curricula.

Tobacco use prevention and reduction among students requires a comprehensive approach involving teachers, administrators, and parents. School personnel that participated in GSPS show general willingness to assist in this effort. The majority in most sites reported that they think school personnel should set an example for students by not using tobacco. Teachers’ ability to convey effective anti-tobacco information to students can be diminished if they have not received training to provide tobacco-related information to students or do not have access to adequate teaching materials to support anti-tobacco curricula. However, the majority of school personnel in most sites strongly agreed that they should receive specific training to help students avoid or stop using tobacco.

Conclusion

Tobacco use starts in the adolescent years, when school personnel act as important role models. To plan effective interventions, it is essential to have information on the extent and the type of tobacco use among school personnel, their attitudes toward tobacco control, and the existence of school health polices about tobacco. The GSPS provides countries with this information and can address several provisions of the WHO FCTC that relate to the role of school personnel in tobacco control. Health and education professionals can use these data to plan, implement, and revise programmes to reduce tobacco use among school personnel, improve tobacco control information dissemination to students, and provide school personnel with the resources they need to complement a comprehensive tobacco control programme.