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Abstract

Background

The Western Pacific Region has the highest rate of cigarette smoking in the world. In this region, Mongolia has ratified the WHO FCTC treaty and, as part of treaty implementation, has monitored school tobacco use in children using the Global Youth Tobacco Survey (GYTS). Our objective was to examine the spatial (student report of cigarette availability near schools) and economic factors (cigarette pricing relative to student pocket money) associated with cigarette use in schoolchildren of Mongolia.

Methods

The 2014 and 2019 GYTS are the most recent national surveys of tobacco use in schoolchildren in Mongolia and are cross-sectional, stratified, multi-stage cluster surveys of 13-15-year-old schoolchildren (7298 in 2014, 4146 in 2019). We conducted logistic regression modelling of the two surveys to examine whether spatial, economic, and environmental factors were predictors of cigarette use.

Results

We found that (1) the prevalence of students reporting the availability of cigarettes near schools increased from 65.3% [95% confidence interval(CI) = 61.1-69.4] in the 2014 GYTS to 94.3% [95% CI = 93.5-95.1] in the 2019 GYTS, (2) student report of cigarette availability near schools was associated with increased current smoking of all cigarettes and this effect increased from a non-significant 31% increase in odds in 2014 (OR [95% confidence interval(CI)] = 1.31 [0.99-1.73], P = .06) to a 416% significant increase in odds in 2019 (OR [95% CI] = 5.16[3.31-8.05], P < .0001), (3) student report of cigarette availability near schools was associated with a significant increase in odds of smoking single cigarettes in 2014 (OR [95% CI] = 1.85 [1.19, 2.89], P = .008 and in 2019 (OR[95% CI] = 2.70 [1.42-5.12], P = .005). For both surveys, we also found that cigarette smoking prevalence was higher when students’ pocket money exceeded the price of the cigarette pack (approximately 1.8 USD).

Conclusions

Despite the 2012 National Tobacco Laws banning sales of cigarettes and single cigarettes to schoolchildren near schools, our analyses of national samples of schoolchildren indicate that the proportion of students reporting cigarettes being available near their schools remained high (65-94%) during 2014 to 2019.

Keywords

tobacco adolescent retail density school survey pocket money

Introduction

The WHO has reported that the Western Pacific Region (WPR) has the highest regional rates of tobacco use in the world.¹ For WPR smokers of manufactured cigarettes, this trend is primarily attributable to a 10-fold increase in the prevalence of cigarette smoking in males that starts during their school-age years and results in a 30%-50% prevalence of cigarette smoking by the fourth decade of life.¹ In Mongolia, which is located in the WPR, the latest WHO Global Youth and Tobacco Survey (GYTS) data from 2019 indicate that approximately 14% of schoolchildren (21% boys; 6.9% girls) have started using tobacco in any form.²

Mongolia ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) treaty in 2003. This treaty resulted in the drafting, passage, and implementation of the 2005 Tobacco Control Law, which increased the cigarette tax and banned some forms of advertising. Despite the new laws passed in 2005 and further increased in 2012, the prevalence of cigarette smoking in schoolchildren has remained high (over 10%) in Mongolia.² This is occurring in Mongolia despite 2012 tobacco control laws that ban the following: (1) the sale of cigarettes to persons under the age of 21, (2) the sale of single cigarettes to the population, and (3) the sale of cigarettes within 500 meters of schools. Some of the prevailing trends in cigarette smoking among schoolchildren have been attributed to a lack of enforcement of current tobacco control laws and a lack of resources for tobacco policy implementation at the local level.³

Considering the high rate of tobacco use documented in the 2019 GYTS survey, it is important to note that findings from other nations indicate that there are social and contextual factors that are strong predictors of youth smoking.⁴ Additionally, more investigations are needed to determine how the density of tobacco vendors near schools and pocket money is associated with youth smoking.⁵ Cigarette sales near schools have been linked to higher smoking rates in school children in Indonesia⁶ and several nations in Africa.⁷ GYTS data for Mongolia provides an opportunity to study whether student reports of the availability of cigarettes to purchase near schools have decreased since the implementation of the WHO FCTC and the 2012 National Tobacco Laws for Mongolia.

In the present study, our overall objective is to examine the spatial proximity (student reports of cigarettes being available for purchase near the school) and economic proximity (the price of cigarettes relative to the student’s self-report of pocket money) of tobacco availability to schoolchildren in Mongolia. Our analyses of two national samples (GYTS 2014, GYTS 2019) of school-aged children will provide insight into the level of enforcement of tobacco laws that should restrict tobacco sales to children at locations near their schools. Our specific aims include the following: (1) To examine whether cigarette availability (in packs, single cigarettes) near a school was associated with a child’s current cigarette use and single cigarette use during the past 30 days, and (2) To examine whether a child’s access to pocket money was associated with their current cigarette use (in packs, single cigarettes) in the past 30 days. Other known contextual factors (peer and family smoking) will also be considered as exposures.

Methods

Study Population

In 2014 and 2019, the Global Youth Tobacco Survey (GYTS) was conducted in Mongolia by the National Public Health Institute and WHO Mongolia. Our secondary analysis is of these public access data from the US Centers for Disease Control (CDC). The US CDC provided training and advice to investigator teams of the Ministry of Health of Mongolia on standardized methods of GYTS sampling and questionnaire design in 2014 and 2019.

The sampling methods used for GYTS 2014 and 2019 have been extensively described.² Briefly, GYTS sampling in 2014 and 2019 was conducted through a stratified multi-stage cluster sampling where the primary sampling unit (PSU) was the school (26 rural PSUs, 26 urban PSUs). The sampling frame for each survey was based on the latest census and provided a representative national sample of school-aged children in Mongolia in 2014 and 2019. The samples were stratified into urban and rural regions. In the first stage of sampling, schools were selected within each stratum using a probability proportional to the enrollment size. The inclusion criteria were as follows: (1) all selected schools needed to have grades 7-10 and class sizes of at least 40, (2) all students from the grades 7-10 classrooms were offered participation in the study, even if they were outside the GYTS target age of 13-15. The student-level response rate was 92.3% in 2014 and 92.1% in 2019. This process yielded 7298 participants in 2014 and 4146 in 2019. Written informed consent was obtained from each subject’s parent or guardian. The GYTS in 2014 and 2019 was approved by the Institutional Review Board (IRB) of the Ministry of Health of Mongolia. IRB approval and determination for the secondary analysis of the GYTS study in this report were given by the IRB of Loma Linda University (IRB #5170182).

GYTS in 2014 and 2019

The GYTS consisted of 75 multiple-choice questions.² The questionnaire collected information on several tobacco-related categories such as: demographics, weekly available pocket money, tobacco use, smokeless tobacco use, access to and availability of tobacco, tobacco availability for purchase near the school, exposure to tobacco advertisements, susceptibility to smoking, and social and familial contextual factors. The survey was adapted, translated/back-translated, and pre-tested for school children of Mongolia during in-country training sessions by the US Centers for Disease Control and the WHO Tobacco Free Initiative.² The surveys were self-administered and completed by the schoolchildren in a classroom setting.

For our analysis, we used standard GYTS coding conventions,² to classify (1) current cigarette smokers as students who smoked at least one day in the last 30 days, (2) current single cigarette smokers as being “current cigarette smokers” who purchase cigarettes as “single sticks”, (3) cigarette availability near the schools as being an affirmative response from a student to the question “Can you purchase tobacco/cigarettes near your school”? (4) pocket money as being a student's estimate of how much money they have each week to “spend on yourself; however you want”. These items are given in the supplement.

Statistical Analysis

Our rationale for the statistical analysis is based on the noting that GYTS 2014 and GYTS 2019 were designed to have the statistical power to provide national estimates of tobacco use, and relations between tobacco use and health among school children at each survey year (2014 and 2019), but were not designed for detecting population-level behavior change across the years. Thus, we provide separate analyses of GYTS 2014 and GYTS 2019. Descriptive differences across the two time points are, however, noted. This approach has been taken by other investigators who have used a nation’s GYTS data across multiple years.⁸

All the statistical analyses were conducted using SAS-callable SUDAAN (version 9.0), which allowed for a Taylor linearized estimate of variance that accounted for the stratified multi-stage sampling. Using variance inflation factors, variance was increased in all analyses to account for the increased within-cluster homogeneity of our clustered sample population. Sample weights were based on the census-derived sampling frame. The variables included in the analysis of this study were age, gender, weekly pocket money, current cigarette use, current single cigarette use, parental smoking, friends’ smoking, and the availability of cigarettes near the school.

Prevalence and 95% confidence intervals were obtained for current cigarette use and current single cigarette purchases among current cigarette smokers. The same variance estimation methods were used for logistic regression models. Logistic regression analysis was conducted to determine associations between possible exposure variables (pocket money, parental smoking, friends smoking, and the presence of cigarette vendors near schools) and current cigarette use and single cigarette use.

Our model building strategy involved (1) testing the effect of exposures related to the specific aims (cigarette availability near schools, pocket money), (2) testing the effect of known exposures (parental smoking, friends smoking), and (3) testing the effects of confounders using a change of estimate approach for exposures.⁹ The fit of the logistic regression model was assessed using the Lemeshow-Hosmer test and the log-likelihood ratio tests of the independent variables.⁹ Since missing values occurred for less than 10% of the subjects, our main analysis excluded the missing values. A sensitivity analysis was performed to examine the effect of multiple imputation of the missing values,¹⁰ and the results did not appreciably change.

Results

In Table 1, we provide the demographic, economic, and tobacco use characteristics of the schoolchildren in the GYTS 2014 and 2019. We found that the prevalence of current cigarette smoking, current tobacco use, and single cigarette smoking was similar across the 2014 and 2019 surveys. Single cigarette use among all school children was 1.9% in 2014, and 1.7% in 2019. Age, gender, parental smoking status, and friends’ smoking status were also similar across the 2014 and 2019 surveys. The prevalence of students reporting that cigarettes were available for purchase near the school (not shown in Table 1) was high in 2019 (prevalence (95% CI) = 94.3 (93.5-95.1)) and in 2014 (prevalence (95% CI) = 65.3 (61.1-69.4)).

Table 1.

Demographic, Economic, and Tobacco Use Variables From School-Aged Children Enrolled in the Global Youth Tobacco Survey (GYTS) of Mongolia

Variable	GYTS 2014 (n = 7298)	GYTS 2019 (n = 4146)
	Prevalence (95% CI)^a	Prevalence (95% CI)^a
	[Unweighted n]	[Unweighted n]
Age (years)
Age 10-11	0.3 (0.1-0.5)	0.3 (0.2-0.4)
Age 10-11	n = 18	n = 12
Age 12	4.9 (3.1-6.7)	7.9 (5.8-9.9)
Age 12	n = 216	n = 371
Age 13	39.5 (34.9-44.1)	32.3 (28.7-36.0)
Age 13	n = 1866	n = 1414
Age 14	27.6 (24.3-30.9)	34.0 (31.3-36.7)
Age 14	n = 2432	n = 1380
Age 15	17.1 (14.4-19.8)	22.1 (18.7-25.5)
Age 15	n = 1880	n = 836
Age 16	8.6 (6.5-10.7)	3.2 (1.9-4.5)
Age 16	n = 719	n = 116
Age >17	2.01 (0.9-3.1)	0.26 (0.1-0.4)
Age >17	n = 160	n = 10
Gender
Female	48.5 (46.8-50.2)	50.2 (48.0-52.4)
Female		n = 1998
Male	51.5 (49.8-53.2)	49.8 (47.6-52.0)
Male		n = 2133
Parent smokes
None	52.4 (50.1, 54.7)	47.3 (44.5, 50.1)
None	n = 3697	n = 1878
Both	5.1 (4.2, 6.1)	5.7 (4.8, 6.7)
Both	n = 410	n = 232
Father only	40.3 (38.4, 42.1)	44.2 (41.6, 46.8)
Father only	n = 2887	n = 1748
Mother only	2.3 (1.7,2.8)	2.7 (1.8, 3.7)
Mother only	n = 176	n = 104
Friend smokes
None	68.0 (64.7, 71.2)	68.9 (65.1, 72.7)
None	n = 4511	n = 2876
Some	26.0 (23.3, 28.7)	24.7 (21.6, 27.8)
Some	n = 2243	n = 994
Most	4.0 (3.3, 4.8)	3.9 (2.5, 5.2)
Most	n = 362	n = 149
All	2.0 (1.5, 2.4)	2.6 (1.2, 3.89)
All	n = 136	n = 102
Cigarettes available for purchase near school	65.3 (61.2, 69.4)	94.3 (93.4, 95.2)
Cigarettes available for purchase near school	n = 4705	n = 3874
Current cigarette smokers	4.8 (3.7-5.9)	4.7 (3.4-5.9)
Current cigarette smokers	n = 416	n = 178
Single cigarette smokers (among current smokers)	38.7 (32.3-45.1)	35.7(25.4-46.0)
Single cigarette smokers (among current smokers)	n = 172	n = 63
Weekly pocket money
<0.14 USD	12.5 (11.0-14.0)	12.5 (10.1-14.9)
<0.14 USD	n = 781	n = 509
0.14 to 0.29 USD	13.6 (12.3-14.9)	9.8 (7.8-11.7)
0.14 to 0.29 USD	n = 830	n = 397
0.30 to 0.43 USD	25.0 (23.2-26.9)	21.4 (19.2-23.7)
0.30 to 0.43 USD	n = 1718	n = 879
0.44 to 0.57 USD	13.0 (12.0-14.0)	14.8 (13.0-16.6)
0.44 to 0.57 USD	n = 964	n = 603
0.58 to 0.71 USD	9.6 (8.8-10.5)	9.0 (8.0-10.0)
0.58 to 0.71 USD	n = 729	n = 366
0.72 to 0.86 USD	10.0 (8.7-11.3)	12.0 (11.1-12.9)
0.72 to 0.86 USD	n = 832	n = 501
>0.86 USD	16.3 (14.1-18.4)	20.5 (16.9-24.2)
>0.86 USD	n = 1397	n = 877

^aPrevalence and 95% confidence intervals are computed from a weighted sample size and a Taylor linearized estimate of the variance.

We ran logistic regression models (not shown in the tables) that related cigarette smoking as an outcome variable to the independent demographic, economic, and tobacco use variables. We found that older age (OR [95% confidence interval (CI)] per year = 1.76 [1.54, 2.01], P < .0001 in 2014 and 1.54 [1.30,1.84], P < .0001 in 2019) and male gender (OR [95% CI] = 3.02 [2.17, 4.21], P < .0001 in 2014 and 8.66 [5.0, 15.01], P < .0001 in 2019) were associated with higher odds of cigarette smoking.

In Table 2, we present, for each survey year, four models for age and gender-adjusted associations between the exposure variables of interest and current cigarette smoking. We found that when cigarettes were sold near schools, children were more likely to be current cigarette smokers. This effect was evident in the 31% increase in 2014 (P = .06) and 416% increase in 2019 (P < .0001). Additionally, children who were given more pocket money (>1 USD) reported higher rates of smoking. As expected, the contextual factors of parental smoking and peer smoking were also strongly and significantly associated with current smoking.

Table 2.

Four Multivariable Logistic Regression Models (For Each Survey Year) Relating Demographic and Economic Variables to Current Smoking Among School-Aged Children Enrolled in the Global Youth Tobacco Survey (GYTS) in 2014 and 2019^a

Variable of interest	GYTS 2014	GYTS 2019
Variable of interest	Adjusted OR (95% CI)^a	Adjusted OR (95% CI)^a
Cigarettes sold near school
Yes	1.31 (0.99, 1.73)	5.16 (3.31, 8.05)
No	1.0 (referent)	1.0 (referent)
Weekly pocket money given to student
<0.14 USD	1.00 (referent)	1.00
0.14 to 0.29 USD	0.97 (0.54, 1.70)	1.28 (0.61, 2.70)
0.30 to 0.43 USD	0.88 (0.52, 1.47)	2.07 (1.19, 3.61)**
0.44 to 0.57 USD	1.12 (0.62, 2.03)	1.77 (0.94, 3.30)
0.58 to 0.71 USD	1.33 (0.77, 2.31)	2.38 (1.12, 5.03)**
0.72 to 0.86 USD	1.59 (0.96, 2.65)	1.79 (0.88, 3.64)
>0.86 USD	2.24 (1.33, 3.79)*****	1.98 (0.95, 4.13)
Friends smoke
None of them	1.00	1.00
Some	5.58 (3.24, 9.61)*****	8.25 (5.39, 12.63)*****
Most	20.47(11.67, 35.92)*****	16.92 (8.17, 35.04)*****
All	18.41 (8.90, 38.05)*****	12.76 (5.34, 30.50)*****
Parents smoke
None	1.00	1.00
Both	3.72 (2.32, 5.96)***	3.22 (2.05, 5.07)***
Father only	1.31(1.01, 1.70)^a	1.40 (0.98, 2.02)
Mother only	5.60 (3.07, 10.21)*****	1.48 (0.48, 4.59)

**P < .05, ***P < .01, ****P < .001, ****P < .0001.

^aEach model includes age, gender, and the variable of interest.

We also ran the same logistic regression models among cigarette smokers and classified single cigarette smoking as the outcome. We found that the sale of cigarettes near the school was more strongly associated with student smokers choosing single cigarettes than with choosing packs (OR [95% CI] = 1.85 [1.19, 2.89], P = .008 in 2014 and 2.70 [1.42, 5.12], P = .005). Figure 1 shows that when cigarettes are sold near schools, more than half of the student smokers choose single cigarettes (the prevalence of student smokers choosing single cigarettes [95% CI] = 54.7 [45.2, 64.1] when cigarettes are sold near schools, and 30.9 [21.3, 40.5] when cigarettes are not sold near schools).

Figure 1.

Prevalence and 95% Confidence Interval of Student Smokers Who Smoke Single Cigarettes is Given by Proximity of Cigarette Vendors to Their School in Mongolia (Global Youth Tobacco Survey 2019)

Discussion

Our study focused on the spatial and economic proximity of cigarette packs and single-cigarette purchases to schoolchildren in Mongolia. We conducted an analysis of the two most recent national surveys of school children in Mongolia (the Global Youth Tobacco Survey (GYTS) in 2014 and the GYTS in 2019) that were conducted since the passage of Mongolian national tobacco control laws from 2005 to 2012. Our main findings indicated the following: (1) Student reports of cigarettes being available for purchase near their schools increased from 65% in 2014 to 94% in 2019, (2) Increased student reports of cigarettes being available for purchase near their schools were associated with increased current smoking of all cigarettes and single cigarettes by students of that school, and (3) Increased weekly pocket money (approximately 1 USD or greater) was associated with increased cigarette smoking. Our findings confirm insights gained from several years of NGO-based “windshield and walking surveys”¹¹ done by one of us (B.P.) that identified vendors selling cigarettes <500 m from schools in Ulaanbaatar, Mongolia (Figure 2).

Figure 2.

School Children in Ulaanbaatar, Mongolia Identified During Field Studies (B.P.) as Holding Cigarettes They Just Purchased Across the Street From Their School. (Photo Credit: James Ponder, Loma Linda University Media)

Similar to many other GYTS survey reports from other low and middle-income countries, we also found evidence that the well-known contextual factors of parental smoking.¹² and peer smoking¹³ strongly influence smoking by schoolchildren in Mongolia. In this discussion, we will therefore focus on the 2014 and 2019 findings indicating spatial and economic proximity of cigarette availability to schoolchildren near their schools that was occurring even after the passage of the 2012 National Tobacco Control Laws in Mongolia.

Proximity of Cigarette Vendors to Schools and Cigarette Smoking in School Children

Our GYTS findings from Mongolia show a strong and consistent relationship between the spatial proximity of cigarette vendors to schools and the higher prevalence of schoolchildren who currently smoked tobacco in 2014 and 2019. Most alarmingly, the prevalence of vendors near schools markedly increased from 65% in 2014 to 94% in 2019. These 2019 findings from Mongolia are similar to the environment in urban Indonesia where 96.8% of all schools had tobacco vendors operating within 250 m of the school.¹⁴ A similar effect remains for all of Indonesia.⁶ Indonesia is known for having one of the highest rates of youth smoking in the world.⁶

GYTS findings from other nations also indicate the harm of selling cigarettes near schools. In Egypt, 2014 GYTS findings indicate that current smoking by school children was 50-60 fold higher in those attending schools near tobacco vendors (OR = 52.7 (95% CI = 49.2-56.4) and in those attending schools in areas with no local ordinances against the sale to minors (OR = 65.7, CI = 60.5-71.4).¹⁵ In Nigeria, the 2015 GYTS findings show a similar trend in the proximity of cigarette vendors to schools and higher odds of schoolchildren being current smokers.¹⁶ In 16 African countries (GYTS), youth were less likely to smoke in areas where it is more challenging to purchase cigarettes.⁷

Our findings from Mongolia are also broadly concordant with the findings from regions, indicating a higher prevalence of current smoking in youth in areas with a higher spatial density of tobacco retail outlets. For example, this trend has been shown in GYTS analyses of 16 African nations,⁷ and also in nations of Southeast Asia.¹⁴

Relative to previous GYTS analyses in other nations, however, our findings from Mongolia provide the perspective that even after WHO FCTC implementation and passage of a National Tobacco Law in 2012 that expressly restricts the sale of cigarettes to school children and the sale of cigarettes near schools, the prevalence of these illicit activities increased from 2014 to 2019.

Proximity of Cigarette Vendors to Schools and Smoking of Single Cigarettes by Student Smokers

Our most recent 2019 data from Mongolia also provides new insight that vendors near the schools may be targeting schoolchildren with sales of cheaper, illegal single cigarettes. We found that when students reported increased availability of cigarettes for purchase near their school, there was a 170% increase in odds of the students smoking single cigarettes at the school. We also found that when cigarettes were available for purchase near the school, more than half of the students who smoked cigarettes smoked single cigarettes (Figure 1).

We posit that this is likely a method to avoid the trend we found in the Mongolia GYTS, where less than 20% of the children have sufficient weekly pocket money to purchase a cigarette pack (Table 1). Our findings agree with the GYTS findings of Sun et al¹⁷ from over 140 countries, who reported that the rate of single cigarette smoking was 37% and that the effect is particularly evident in Asia. For example, high rates of single cigarette smoking among student smokers have been reported in GYTS reports from the Philippines (89%),¹⁸ Timor-Leste (39%),¹⁹ and Tunisia (39.4%).²⁰ Interestingly, in Timor-Leste, over half (51.6%) of the students indicated that cigarette sellers were close to their school.¹⁹

Our work in Mongolia, however, indicates that these trends in single cigarette sales during 2014-2019 persisted even after the passage of a National Tobacco Control Law in 2012 banning sales of single cigarettes to adults and minors.

Association Between Pocket Money Given to Schoolchildren and Cigarette Use

Our findings indicate that higher levels of available pocket money given to school children in Mongolia were associated with higher rates of cigarette smoking and are concordant with trends from high-, middle-, and low-income countries. In Italy, Lozza et al²¹ reported that teenagers who spent more than 10€ every week smoked more frequently. Similar statistically significant positive associations were found in Canada and China.^22,23 In Bosnia, a positive association was also found between student income and smoking in an analysis of the Global Health Professional Students survey.²⁴ For low and middle-income countries, GYTS findings from more than 16 African Nations,^7,24 and a separate analysis from the China National Youth Tobacco survey, all confirmed a positive association between pocket money given to school children and current smoking status.^25,26

Implications for WHO FCTC Policy Implementation and Enforcement of the National Tobacco Control Law in Mongolia

Our findings from our study of Mongolia and nations from several other WHO regions (African, Americas, European, and Western Pacific) indicate that the implementation of WHO FCTC measures to increase the price of cigarette packs beyond the weekly spending money of schoolchildren, adolescents, and adult students could be effective in preventing the initiation of tobacco. This is directly supported by GYTS analyses of the negative association indicating that lower cigarette pricing is associated with higher levels of youth smoking.⁷

Our findings from the two most recent GYTS surveys of Mongolia (2014, 2019) indicate an apparent lack of enforcement of the 2012²⁷ National Tobacco Control law: banning 1) sales of cigarettes to persons under age 21 (article 2, section 6 (6.7.7)), 2) sales of cigarettes within 500 m of a school(article 2, section 6 (6.7.14)), and 3) sales of single cigarettes to all persons (article 2, section 6(6.7.8)).²⁸ Students in the 2014 and 2019 surveys report the availability of cigarettes for purchase near their schools and raise the possibility that single cigarette sales are obviating the public health prevention that was gained from the 2012 law that increased the price of the cigarette pack through taxation.

Our findings highlight the need for a multi-sectoral approach to tobacco control that involves the Ministry of Health, the Ministry of Justice, and the Ministry of Education. Currently, violation of these laws are a minor offence with low fines.²⁹

Limitations

Several limitations of the 2014 and 2019 GYTS in Mongolia should be noted. First, the GYTS is self-reported and thus subject to recall bias. Second, the GYTS does not collect information such as household income, and school tobacco prevention programs, was not collected for the GYTS, which may be important factors that were not adjusted for in the analysis. Third, this study used cross-sectional data; therefore, the temporal relationship between outcomes and factors cannot be determined. It is noteworthy that these cross-sectional measures occurred after the implementation of the 2012 National Tobacco Control Law, and so, descriptively, our findings do provide a longitudinal perspective on the effect of the law during the subsequent 7 years. Fourth, we note that the availability of cigarettes near a student’s school was measured by a survey item administered to all students. This has the limitation of being (1) only a proxy measure of the spatial proximity, (2) by design not being a measure of sales since some of the students do not use tobacco and are reporting availability only; also we note the ethics consideration of asking students if they have engaged in illicit activities. Fifth, GYTS survey items were not specifically validated (ie, against biochemical measures of nicotine) for Mongolia. Also, similar to GYTS surveys in many other nations, small pilot tests of the surveys were conducted during in-country training sessions. Notably these pilot samples were not random samples of the target population of all Mongolian school children.

Conclusions

Our findings from surveys of school children in 2014 and 2019 indicate the need for greater enforcement of national tobacco laws on sales of cigarettes and single cigarettes to minors near schools. Despite efforts to increase the price of cigarette packs, vendors are targeting school children near their schools with low-priced single cigarettes.

Supplemental Material

Supplemental Material - Spatial and Economic Proximity of Cigarette Products to School Children in Mongolia

Supplemental Material for Spatial and Economic Proximity of Cigarette Products to School Children in Mongolia by Bolormaa Purvedorj, Eric Suh, Altanzul Narmandakh, Yuki Kuwabara, Aya Kinjo, Yoneatsu Osaki, Anne Berit Petersen, Davaalkham Dambardajaa, Pramil N. Singh in Tobacco Use Insights

Supplemental Material

Supplemental Material - Spatial and Economic Proximity of Cigarette Products to School Children in Mongolia

Footnotes

ORCID iD

Pramil N. Singh

Ethical Considerations

IRB approval and determination for this secondary analysis of the GYTS study was given by the Institutional Review Board of Loma Linda University (IRB #5170182).

Author Contributions

B.P. and P.S conceptualized the aims of the secondary analysis and analyzed the data; B.P. drafted the report; E.S. performed data analysis of the 2014 data; P.S., A.N., Y.K., A.K.,Y.O., A.B.P, and D.D edited the report and contributed to refining the aims of the analysis.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Purevdorj received trainee support for the preparation of this article from US NIH grant 5R01TW005964-10. Drs Singh, Petersen, and Dambardajaa were also supported to mentor trainees on this grant.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

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