Tobacco Use Among High School Students in Buenos Aires,

Tobacco Use Among High School Students in Buenos Aires, Argentina A B S T R A C T Objectives. This study assessed the prevalence and correlates of tobacco use among high school students in Buenos Aires, Argentina. Methods. Anonymous, self-administered questionnaires were given to 3909 8th and 11th graders in a stratified random sample of 49 public and private schools. The instrument included items from American surveys, translated and validated among Argentinean teens. Multiple logistic regression analysis was used to estimate possible effects on smoking behavior of environment, students’ personal characteristics, and their knowledge, beliefs, and attitudes regarding smoking. Results. Of 8th and 11th graders, 20% and 43%, respectively, were classified as current smokers. Overall, 29% of males and 32% of females were current smokers. Students attending public schools were more likely to smoke than those in private schools (P < .05). Current smoking was associated with having a best friend who smokes, reporting that more than 50% of friends of the same sex smoke, having positive attitudes and beliefs toward smoking, and having a positive intention to smoke within the next year (all P < .001). Conclusions. Over 20% of the 8th graders in our sample were current smokers; prevention efforts must therefore start early. (Am J Public Health. 2001; 91:219–224) Paola Morello, MD, MPH, Anne Duggan, ScD, Hoover Adger Jr, MD, MPH, James C. Anthony, PhD, and Alain Joffe, MD, MPH Worldwide, cigarette smoking is the most widespread form of drug dependence and a leading cause of preventable death, resulting in an estimated 3 million deaths annually. Unless steps are taken to reduce smoking rates, the worldwide annual death toll due to smoking is expected to reach 10 million by the year 2025, with 7 million deaths occurring in the developing world.1 In 1994, the US Surgeon General’s Report addressed the importance of preventing smoking among young people.2 Because nearly all first use of tobacco occurs before the age of 18, the report identified childhood and adolescence as the crucial life stages for preventing tobacco use and its consequences. The report also suggested that if adolescents can be kept tobacco free, most will never smoke as adults. A youth-centered preventive policy is therefore a crucial part of any coherent antismoking strategy. In developed countries, public awareness of the health hazards of smoking has led to increased regulation of the tobacco industry, resulting in restrictions on the advertising and availability of cigarettes and higher prices for them. As a result, tobacco companies are aggressively seeking new markets in the developing world.3–5 These markets are quite attractive, because in most developing countries, there is little legislation against the marketing and distribution of tobacco products and smoking is still socially acceptable. Argentina is a major tobacco-producing country. Since 1990, 50% of its tobacco production has been exported, accounting for 7.4% of revenues (Pablo Guadagni, Argentinean Embassy, Washington, DC; written communication, May 1997). Per capita consumption in 1993 was estimated to be 1720 cigarettes.6 While smoking prevalence in 1997 in the United States was 27.6% for adult men and 22.1% for adult women, among Argentinean adults it was 40% and 30%, respectively.6,7 Twenty percent of all deaths in Argentina are related to smoking.6 Two surveys of 18-year-old males entering the military service found that 32% to 44% were regular smokers.8,9 To our knowledge, no published data are available concerning smoking among school-attending adolescents in Argentina. Because Argentina’s youth are highly influenced by American culture, we hypothesized that the smoking behavior of Argentinean adolescents, and its determinants, would be similar to those for US adolescents. The objectives of this study were (1) to estimate the prevalence of tobacco use among high school students in Buenos Aires and (2) to examine whether the factors associated with tobacco use in Argentina are congruent with factors observed in the United States. Methods Study Sites and Sample Population In 1997, a list of all public and private schools in Buenos Aires was obtained through the Ministry of Education. We randomly sampled public and private schools from each of the 8 school regions. We had to approach 56 private and 28 public schools to meet our recruitment goal of 3 public and 3 private schools per school region. Three of the 28 public schools declined to participate; 32 of the 56 private schools declined. Because resources did not allow us to assess all grades, we decided to seAt the time of the study, Paola Morello was with the Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Md. Anne Duggan, Hoover Adger Jr, and Alain Joffe are with the Department of Pediatrics, School of Medicine and James C. Anthony is with the School of Hygiene and Public Health, John Hopkins University, Baltimore, Md. Requests for reprints should be sent to Paola Morello, MD, MPH, Pan American Health Organization, 525 23rd St NW, Washington, DC 20037 (e-mail: pmorello@welch.jhu.edu). This article was accepted September 26, 2000. February 2001, Vol. 91, No. 2 American Journal of Public Health 219 lect nonadjacent grade levels. To incorporate a broad age range and therefore broad smoking experience, we selected 8th and 11th graders within each participating school. Sample size was calculated to provide adequate power in testing for differences in proportions of smokers vs nonsmokers in each of the 8 strata defined by grade (8th and 11th), school type (public and private), and sex. We balanced the sample so that it would correspond to approximate marginal distributions for Buenos Aires. However, our sampling plan does not allow us to claim that this sample is representative of Buenos Aires as a whole. Data Collection and Measurement All surveys were administered during the last 2 weeks of September 1997. Thirteen proctors assisted with data collection. To promote confidentiality, proctors were chosen who were not associated with the schools, and teachers were not allowed in the classroom during the assessment. Proctors explained the nature of the survey and its major objectives and provided reassurance to students that the survey was confidential. Only students present the day of the survey were eligible for participation. Participation was voluntary; 3909 students agreed to participate and completed the selfadministered, anonymous survey, and 20 students declined. Project procedures for human subjects were approved by the Joint Committee of Clinical Investigation of the Johns Hopkins University School of Medicine. Instrument The questionnaire included Spanish translations of items previously used in surveys of American adolescents. The first Spanish version was pilot tested in November 1996 among 8th and 11th graders. It was administered twice to a single group of students 7 days apart. The κ statistic for test–retest reliability was greater than 0.65 for most questions, even those with dichotomous response options. Some questions were modified according to feedback from the students. A second pilot test was carried out in May 1997 that yielded the final 85item version. For this investigation, we focused on suspected familial and peer influences on tobacco smoking, as well as on selected personal and behavioral characteristics that might be associated with current smoking. These factors were chosen because they have been found to be significant correlates of smoking behavior among US and Canadian adolescents.10–16 For familial influences, we examined current smoking by mothers, fathers, brothers, and sisters. For peer influences, we examined current smoking by male and female friends, boyfriends and 220 American Journal of Public Health girlfriends, and best friends and classmates, as well as perceived pressure from peers to smoke. School-related variables included students’perception of smoking by teachers and whether the students reported having had a class on the health hazards of tobacco. Knowledge of tobacco’s effects on the body was assessed with a 7-item questionnaire; possible replies were “yes,” “no,” and “don’t know.”16 Scores ranged from 0 to 7, with higher scores indicating greater knowledge. Smoking beliefs were assessed by an 8-item scale of beliefs regarding the health hazards of smoking (e.g., “You can smoke without becoming an addict”) and its perceived benefits (e.g., “Smoking helps you cope with stress and feel good at parties”). The scale was developed for this survey and reflects culturally appropriate beliefs. Possible scores ranged from 0 to 100, with higher scores indicating more favorable beliefs about smoking. Questions on perceived prevalence of adult and adolescent smoking, the effects of secondhand smoke, and reactions of others to the adolescent’s own smoking were also included. Smoking attitudes were assessed with a 20-item scale, modified from a Canadian survey.10 Possible scores ranged from 0 to 100, with higher scores showing more positive attitudes toward smoking. Personal characteristics included age, sex, perceived satisfaction with weight, intention to smoke within the next year and at 25 years of age, current use of alcohol and marijuana, participation in sports, and educational achievement. A 6-item depression scale was used, with a standard depression cutoff of 2.18.17 Smoking status was determined from student responses to an item asking about current and past smoking. For this study’s primary analyses on current smoking, students who answered “I smoke” or “I sometimes smoke” were considered smokers; those who answered “I used to smoke but quit,” “I have only tried,” or “I never tried” were classified as current nonsmokers. The primary analysis strategy involved fitting a multiple regression model to the data on current tobacco smoking status, separately for males and females. The goal of this analysis was to identify characteristics that have an independent association with teen smoking (with simultaneous adjustment for all other characteristics) and to explore possible male–female variations in these associations. A secondary multiple logistic regression analysis was conducted to provide a more complete exploration of the association of each characteristic with current tobacco smoking and to disclose possible leads for future studies. In these analyses, also conducted separately for males and females, terms for age and for type of school were forced into the regres- sion model before entry of the characteristic of interest. A separate model was developed for each characteristic. Consistent with the intent of this more exploratory analysis to provide information and leads for future investigation, the resulting associations are independent of associations between smoking, age of the student, and type of school, but they are not necessarily independent of one another. Stata (Stata Corp, College Station, Tex) was used for the analysis, with variance estimation procedures used to account for the clustering of students within sampled schools. Among the 3909 8th and 11th graders who completed the questionnaire, 304 (7.8%) had serious inconsistencies in responses to items on tobacco use and were excluded from the analysis. For the sex-stratified analyses, it was necessary to exclude an additional 32 questionnaires that lacked information on sex of respondent. Results The sample of 3573 students was evenly distributed by sex, grade, and school type. In both the 8th and 11th grades, students attending public schools were significantly older than those in private schools. Over 70% of the students were living in 2-parent households, and, for most students, both parents had completed high school. The estimated prevalence of current tobacco smoking among females (32%) was negligibly greater than that among males (29%) (estimated odds ratio [OR]=1.12; 95% confidence interval [CI]=0.89, 1.42; P=.30). Students in public schools were slightly more likely than those in private schools to be smokers (32% vs 29% prevalence; OR=1.49; 95% CI=1.09, 2.03; P=.012). Females in private schools were estimated to be 60% less likely to be current smokers than those in public schools (14.1% vs 18.5% prevalence; OR=0.59; 95% CI=0.40, 0.87; P=.009); no private vs public school difference was observed for males.Table 1 shows the distribution of major determinants of smoking as reported by students, stratified by students’ grade and smoking status. Table 2 shows the results of the primary analysis strategy. Multiple logistic regression analysis showed that 11th-grade students were more likely to be current smokers than 8thgrade students. Peer influences were prominent and independent for both males and females. Among both males and females, current smokers were more likely to have positive intentions to continue smoking during the next year than were noncurrent smokers to start smoking within the next year. Among both males and females, current smokers were also more likely to hold positive attitudes about February 2001, Vol. 91, No. 2 TABLE 1—Distribution of Major Determinants of Student Smoking, by Student’s Grade and Smoking Status: Buenos Aires, Argentina, 1997 8th Graders Smokers (n = 376) 82 16 22 53 95 69 39 6 10 40 2.1 60 82 65 4.3 82 62 39 34 25 11th Graders Smokers (n = 717) 79 25 50 61 96 84 49 12 8 52 2.7 52 84 79 4.6 92 75 33 30 24 Total (n = 1888) Environment ≥1 family member smokes, % > 50% of classmates smoke, % Had a class on tobacco and health, % Best friend smokes, % Exposed to tobacco ads, % Personal characteristics Current alcohol use, % >5 drinks in a row last month, % Current marijuana use, % Poor school performance, % Wants to lose weight, % Depression score (1–3) Beliefs Mean score (0–100) Perceived prevalence among teens, % Secondhand smoking is harmful, % Knowledge Mean score (0–7) Tobacco causes cancer, % Tobacco causes heart disease, % Attitudes Mean score (0–100) Cigarette ads should be banned, % Legal age for buying must be enforced, % 66 7 29 17 94 31 12 3 4 39 1.3 42 72 85 4.6 88 70 25 73 49 Nonsmokers (n = 1512) 62 5 30 7 93 22 6 0.3 2 36 1.1 38 68 90 4.7 90 72 22 83 55 Total (n = 1685) 71 25 54 37 96 67 31 6 5 48 2.4 43 82 88 4.8 95 77 26 50 35 Nonsmokers (n = 968) 64 21 56 20 96 54 18 1 3 46 2.2 36 80 95 5.0 98 78 21 65 44 Note. Scores indicate levels of depression, positive beliefs about smoking, knowledge about the health effects of smoking, and positive attitudes about smoking, respectively, with higher scores reflecting higher levels. Percentages may not add to 100 owing to rounding. TABLE 2—Multiple Regression Analysis of Smoking Among High School Students by Sex: Buenos Aires, Argentina, 1997 Current Smokers Males Positive intention to smoke within 1 year, % Current alcohol use, % Best friend smokes, % >50% of male friends smoke, % 11th grade, % Attitude score, mean (0–100) Beliefs score, mean (0–100) Females Best friend smokes, % Boyfriend smokes, % Positive intention to smoke within 1 year, % >50% of female friends smoke, % 11th grade, % Attitude score, mean (0–100) Beliefs score, mean (0–100) (n = 510) 43.0 83.2 53.3 40.2 63.1 35.7 56.4 (n = 583) 63.8 35.2 47.0 48.5 67.8 33.6 52.7 Nonsmokers (n = 1232) 2.0 36.6 13.1 13.7 38.6 25.1 38.4 (n = 1248) 11.1 7.1 3.0 9.7 39.4 20.9 35.8 Estimated Odds Ratio 4.18 2.56 2.51 1.91 1.49 1.03 1.03 4.94 3.85 3.37 2.72 1.27 1.03 1.02 95% Confidence Interval 3.18, 5.48 1.64, 4.00 1.45, 4.36 1.15, 3.20 1.29, 1.71 1.01, 1.05 1.02, 1.04 3.24, 7.55 2.50, 5.90 2.32, 4.90 1.54, 4.82 1.12, 1.44 1.00, 1.05 1.01, 1.03 P < .001 .001 .002 .014 < .001 < .001 < .001 < .001 < .001 < .001 < .001 < .001 .035 < .001 Note. Scores indicate positive beliefs about smoking and positive attitudes about smoking, respectively, with higher scores reflecting higher levels. smoking and to have positive beliefs about smoking, independent of peer influence constructs and the other characteristics listed in Table 3. Current smoking among males, but not among females, was also associated with current alcohol use. February 2001, Vol. 91, No. 2 Table 3 shows the more exploratory results from multiple logistic regression analyses; age and type of school are statistically adjusted for, but otherwise the associations were not required to be independent of one another. For both males and females, there were many as- sociations of interest. For example, when there is no statistical adjustment for peer influence, there are observed associations with familial smoking, with the stronger familial associations found for sibling smoking. When there is no statistical adjustment for peer influence American Journal of Public Health 221 TABLE 3—Estimated Association Between Current Student Smoking and Variables of Interest, After Adjustment for Age and Type of Schoola Males Current Non- Estimated 95% Smokers smokers Odds Confidence (n = 510) (n = 1232) Ratio Interval Mother smokes, % Father smokes, % Brother smokes, % Sister smokes, % Classmates smoke, % Teachers smoke, % >50% of male friends smoke, % >50% of female friends smoke, % Best friend smokes, % Girlfriend/boyfriend smokes, % Friends are in favor of smoking, % Positive intention to smoke within 1 year, % Positive intention to smoke at age 25 years, % Is doing poorly in school, % Suspended from school in past year, % Had a class on smoking and health, % Practices sports >3 times/week, % Depression score > 2.18, % Unhappy with weight, % Was on a diet more than 3 times in past year, % Current alcohol use, % Frequent alcohol use, % >5 drinks in a row last month, % Drunk more than 5 times in past year, % Current marijuana use, % Attitude score, mean (0–100) Beliefs score, mean (0–100) Knowledge score, mean (0–7) 11th grade, % 43.1 38.0 30.8 23.1 23.3 34.9 40.2 27.9 53.3 24.1 14.9 43.0 39.0 12.6 36.3 37.9 45.9 15.0 21.8 2.5 83.3 5.6 57.7 18.3 14.4 35.7 56.4 4.33 63.1 34.9 38.0 13.5 11.9 10.8 28.4 13.7 9.0 13.1 3.8 8.0 2.0 4.0 3.3 15.3 37.9 36.5 26.1 17.0 1.8 36.6 1.5 14.3 3.0 1.4 25.1 38.4 4.74 38.6 1.41 1.04 2.92 2.35 1.99 1.29 3.39 2.78 6.52 7.20 1.92 4.96 3.25 3.99 3.05 0.79 0.69 1.54 1.29 1.54 7.31 3.69 6.97 5.74 11.8 1.11 1.05 0.85 1.39 1.16, 1.72 0.83, 1.30 2.18, 3.90 1.72, 3.21 1.47, 2.70 1.03, 1.61 2.53, 4.53 1.98, 3.91 4.74, 8.95 5.09, 10.2 1.28, 2.87 4.33, 5.70 2.87, 3.68 2.47, 6.43 2.21, 4.21 0.61, 1.01 0.54, 089 1.11, 2.15 0.92, 1.80 0.71, 3.3 5.43, 9.85 1.97, 6.97 5.20, 9.32 3.49, 9.48 6.9, 20.2 1.10, 1.13 1.04, 1.06 0.79, 0.90 1.36, 1.53 Females Current Non- Estimated 95% Smokers smokers Odds Confidence (n =583) (n = 1248) Ratio Interval 47.7 47.9 25.4 29.8 26.2 36.7 52.3 48.5 63.8 35.2 16.6 3 6 4.5 10.5% 43.5% 13.4 38.8 62.6 26.1 75.3 0.7 36.3 9.9 11 33.6 52.7 4.64 67.8 38.2 40.2 13.7 12.9 11.9 33.1 16.8 9.7 11.1 7.1 7.5 47 42 1.4 2.3% 42.5% 20.7 22.4 51.6 18.6 31.7 0.4 6.9 1.1 0.4 20.9 35.8 4.86 39.4 1.40 1.35 1.91 2.64 1.61 1.04 4.32 6.80 12.0 6.32 2.23 5.03 3.69 3.77 4.71 0.72 0.66 2.24 1.41 1.52 5.14 1.83 6.14 6.20 25.5 1.12 1.05 0.86 1.48 1.11, 1.77 1.11, 1.65 1.54, 2.38 2.09, 3.32 1.07, 2.44 0.8, 1.36 3.14, 6.08 4.88, 9.46 9.16, 15.6 4.89, 8.18 1.53, 3.25 4.08, 6.21 3.23, 4.22 1.85, 7.68 2.84, 7.79 0.56, 0.93 0.50, 0.89 1.64, 3.06 1.11, 1.80 1.19, 1.95 3.96, 6.75 0.63, 5.3 4.34, 8.67 2.79, 13.8 9.76, 66.6 1.10, 1.15 1.04, 1.06 0.79, 0.93 1.36, 1.60 P .001 .7 < .001 < .001 < .001 .027 < .001 < .001 < .001 < .001 .002 < .001 < .001 < .001 < .001 .07 .007 .001 .31 .26 < .001 < .001 < .001 < .001 < .001 < .001 < .001 < .001 < .001 P .05 .04 < .001 < .001 .023 .37 < .001 < .001 < .001 < .001 < .001 < .001 < .001 .001 < .001 .014 .006 < .001 .006 .001 < .001 .26 < .001 < .001 < .001 < .001 < .001 < .001 < .001 Note. Scores indicate levels of depression, positive beliefs about smoking, knowledge about the health effects of smoking, and positive attitudes about smoking, respectively, with higher scores reflecting higher levels. a Data are from student surveys of 510 male and 583 female smokers and 1232 male and 1248 female nonsmokers, Buenos Aires, Argentina, 1997. and other substance use, drinking more than 5 drinks in a row, having been drunk more than 5 times in the past year, and current marijuana use were strongly associated with smoking; this association was independent of sex. When neither peer and family influence nor other personal characteristics were considered, practicing sports at least 3 times a week (for males and females) and having had a class on the health hazards of smoking (for females) were inversely associated with smoking. Although concerns about weight (wanting to lose weight and having been on a diet more than 3 times in the past year) were related to smoking behavior among females and high de222 American Journal of Public Health pression scores were significantly related to smoking behavior among males and females, these relationships were neither strong nor statistically significant after adjustment for influences from peers and families and other personal characteristics. Students overestimated smoking among their peers. There was a statistically significant difference between smokers and nonsmokers regarding the perceived prevalence of peer smoking, with 72% of nonsmokers and 86% of smokers believing that more than half of their peers smoked (P<.05). Overall, 72% of 8th graders and 82% of 11th graders believed that more than half of students their age smoked. Students also overestimated the prevalence of adult smoking. While the actual prevalence of smoking among adults is 35% to 40%, 94% of 8th graders and 89% of 11th graders believed that more than half of adults smoke. Discussion The dual purpose of this study was to estimate the prevalence of smoking among adolescents attending school in Buenos Aires in 1997 and to assess whether determinants of tobacco use observed in the United States also might apply to youth in Argentina. February 2001, Vol. 91, No. 2 Our data indicate that smoking is quite prevalent among teenagers attending high school in Buenos Aires, with 20% of 8th graders and 43% of 11th graders reporting themselves to be smokers. Female adolescents in Argentina are as likely as males to be smokers. This pattern is consistent with data from the United States and from other Latin American countries, such as Chile.18 Over 70% of students live in a household where somebody smokes. The reported prevalence of smoking was similar for mothers and fathers. Students tend to overestimate the prevalence of adult smoking. Efforts to correct misconceptions about adult smoking may be helpful in this population. Before peer smoking is adjusted for, there are observed associations with familial smoking, with the stronger familial associations found for sibling smoking. The number of students who reported that more than 50% of their friends smoked was 3-fold greater in the 11th grade than in the 8th grade, reflecting a higher reporting prevalence of smoking among older adolescents. The percentage of friends with favorable attitudes toward smoking remained the same. Among the different categories of friends—classmates, male friends, female friends, boyfriend or girlfriend, and best friend—the last 2 were found to be most strongly associated with smoking. Positive attitudes and beliefs about smoking were related to smoking behavior in all age groups. Studies done in the United States have shown similar results.13–15 As in other countries, Argentinean adolescents continue to smoke despite their knowledge about the health consequences of tobacco. The estimated strength of the association of smoking with the scores on attitudes, beliefs, and knowledge should be interpreted with the range of scores in mind. For example, the attitude score had a range of values of 0 to 100. The regression estimate shows that for every unit increase of that score, the estimated odds of being a current smoker are 7% larger. Alcohol use among teenagers is an increasing problem in Argentina. Our data show that alcohol use was significantly related to cigarette use among males. Further research is needed on alcohol use in this population. The relationships of weight concern and depression with smoking behavior have been reported in the research literature.12,19,20 In our data from Argentina, these relationships did not seem to be as important as others have found. Several limitations of this study deserve special mention. The survey was intended to provide an assessment of the smoking situation among adolescents in Argentina, but because it is a cross-sectional survey, inferences about causality are limited. Also, some smokFebruary 2001, Vol. 91, No. 2 ers deny smoking in self-report surveys, and it is possible that some smoking (and nonsmoking) students chose to be absent on the day of the survey.21 However, proctors did not note any difference between general absenteeism and absenteeism on the day of the survey. Subsequent research will focus on adolescents from other major cities of Argentina and from rural areas, with a comparison with the results of this study. Finally, because an estimated 60% of adolescents in Buenos Aires never finish high school, and the focus of this study was on adolescents who attend school, the study sample missed a large portion of teenagers outside of school whose smoking prevalence may well be higher than that we have observed for students.22 grams targeted at adolescents are urgently needed. In the United States, studies of the effectiveness of smoking cessation strategies aimed at adolescents are now being conducted.25,26 Given that the factors associated with smoking among adolescents in Argentina are similar to those in the United States, future research may focus on the utility in Argentina of emerging models that have been shown to be effective in the United States. Contributors P. Morello designed the study, supervised the research assistants, performed the data analysis, wrote and revised all the drafts of the paper, and approved the final version. A. Duggan, H. Adger Jr, J. C. Anthony, and A. Joffe assisted in the design, data analysis, and revision of the paper. Conclusions Smoking among high school students is prevalent in Argentina. Renewed efforts to decrease the onset of smoking in this population and to promote smoking cessation are needed to provide an effective public health approach to this significant problem. Almost all the factors evaluated were related to students’ smoking behavior on an individual basis. However, when the variables were put into a multiple regression model, only a few were independently associated with smoking. The influence of best friends and a positive intention to smoke in the next year were found to be among the most prominent factors for both sexes. The percentage of smokers is greater in the 11th grade than in the 8th grade. Prevention efforts targeting younger students are needed to reach them before they start to smoke. Because factors related to tobacco use among Argentinean teenagers seem to be similar to those found for teenagers in the United States, the development of prevention programs in Argentina can benefit from the American experience. Nonetheless, culturally sensitive adaptations will be required, and more evaluation of program effectiveness is needed.23 Many countries have undertaken health education programs. However, these efforts are continually undermined by the tobacco industry. If smoking is perceived as a socially acceptable behavior, educational campaigns can be expected to have only modest results.1 For better results, education and health promotion may be combined with other actions, particularly legislative efforts and tobacco tax measures, including increasing the price of cigarettes.24 Compliance with existing legislation about smoke-free schools is needed. Finally, because smoking is already so prevalent among high school students in Argentina, comprehensive smoking cessation pro- Acknowledgments This study was supported by a grant from the Pan American Health Organization (Project US 1040). We gratefully acknowledge the valuable comments of Dr Matilde Maddaleno from the Pan American Health Organization. We also acknowledge Olga Schlosser, who helped with the pilot studies, and Laura Pradere, who coordinated the school visits. Dr Jorge Delva provided invaluable technical assistance with sampling and statistical analysis. References 1. Guidelines for Controlling and Monitoring the Tobacco Epidemic. Geneva, Switzerland: World Health Organization; 1998. 2. US Dept of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, Ga: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994. 3. INFACT. 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