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February 2014, Volume 64, Issue 2

Letter to the Editor

Tobacco use among school attending adolescents in Pakistan

Masood Ali Shaikh  ( Independent Consultant, Gulshan-e-Iqbal, Karachi. )

Madam, tobacco use would cause over ten million deaths globally by 2020.1 This preventable public health problem among adolescents has been associated with anxiety disorders, truancy, depression, suicidal ideation, inadequate parental monitoring, and parental smoking.1-4 To describe factors associated with self-reported tobacco use in the past 30 days in Pakistani students of class 8-10 and its prevalence; Data was reviewed from the two-stage cluster sample-based nationally representative Global School-Based Health Survey for Pakistan, conducted in 2009 by the Ministry of Health in collaboration with the World Health Organization and Centers of Disease Control and Prevention, United States.5 Design-based analysis using STATA-12 was done using simple and multivariate logistic regression; factors found statistically significant at p<0.10 level on simple logistic regression were used for multiple logistic regression.
In the Global School-Board Health Survey of Pakistan5 tobacco use was defined as having smoked cigarettes or used any tobacco products i.e. hukka, bidi, niswar, shisha, on one or more days during the past 30 days. The overall prevalence of tobacco use in the past thirty-days was 10.1% [95% confidence interval (CI): 7.2%, 13.1%] (n = 5191). In male students the prevalence was 15.3% (95% CI: 13.1%, 17.5%), while among females the prevalence was 2.0% (95% CI: 0.8%, 3.2%).

Table provides the respondent\'s demographic and psychosocial factors description, as well as association with tobacco use in bivariate and multivariate analyses. Age was not found to be statistically significant in the bivariate logistic regression model, and hence was dropped from the final multivariate logistic regression model. Final model included others smoking in respondent\'s presence, sex, having felt lonely, having seriously considered attempting suicide, worrying to the point of not being able to sleep, having missed classes without permission,  parental/guardian use of tobacco, parents/guardians understanding respondent\'s problems/worries, parents/guardians checking respondent\'s homework, and parents/guardians knowing what respondent\'s were doing in their free time. Results of the goodness-of-fit-test concluded that this model was a good fit for the survey data. All the factors were found to be statistically significant save worrying to the point of not being able to sleep in the past twelve months, and parents/guardians knowing what respondent\'s were doing in their free time in the past 30 days.
Compared to girls, boys were almost six and a half times more likely to have used tobacco. Results indicate the need for smoking-prevention health education campaigns in schools and media; involving students, teachers, parents, and healthcare providers to combat the scourge of tobacco use.   


1. Warren CW, Jones NR, Eriksen MP, Asma S; Global Tobacco Surveillance  System (GTSS) collaborative group. Patterns of global tobacco use in young people and implications for future chronic disease burden in adults. Lancet 2006; 367: 749-53.
2. Alwan H, Viswanathan B, Rousson V, Paccaud F, Bovet P. Association between substance use and psychological characteristics among adolescents of Seychelles. BMC Pediatrics 2011; 11: 85. doi:10.1186/1471-2431-11-85
3. Al Ghobain MO, Al Moamary MS, Al Shehri SN, Al-Hajjaj MS. Prevalence and characteristics of cigarette smoking among 16 to 18 years old boys and girls in Saudi Arabia. Ann Thorac Med 2011; 6: 137-40.
4. Amin TT, Amr MA, Zaza BO. Psychological predictors of smoking among secondary school students in Al-Hassa, Saudi Arabia. J Behav Med 2011; 34: 339-50.
5. Global School-based Student Health Survey (GSHS). (Online) Centers for Disease Control and Prevention. (Cited 2013 December 2). Available from URL:

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: