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clinmed/2000050006v1 (May 26, 2000)
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Analysis of  Factors Influencing An Adolescent's Intention To Be A Non-smoker

epicnci{at}cal3.vsnl.net.in *, Arindam Basu**
*Department of Epidemiology & Bio-statistics,
Chittaranjan National Cancer Institute
Calcutta, India.
++ Health Services Research
St. Louis University School of Public Health
St. Louis, MO 63108


Introduction
Methods
Results
Discussion


Abstract

Objective—To analyze the determinants of the adolescents' intention to be non-smokers.
Design — Cross sectional, school based survey of students in the ninth and eleventh grades. Responses were analyzed using a binary logistic regression model.
Participants— High School students in Calcutta aged 14 to 18 years.
Main Outcome Measure — Intention of the subjects to remain lifetime non-smokers.
Results— A total of 1973 students (males-73.79% and females-26.21%) were interviewed. Of them, 1950 students (98.8 percent) responded to the question whether they were determined never to smoke in their lifetime (male -73.5%, female - 26.5%). In a multivariate analysis, intention to remain a non-smoker had statistically significant associations with studying in private schools, father being a non-smoker, high degree of perceived danger of smoking, unfavorable impression of a regular smoker and good academic performance. Of all the significant determinants, perceived danger related to smoking had the strongest association and showed a dose response relationship to the intention to remain non-smoker.
Conclusions—This study suggests that social factors and belief about adverse consequences of smoking exert significant influence on an adolescent’s decision to remain non-smoker. For early prevention of smoking among the youth, the dangers to health on smoking need to be emphasized.

Introduction

Prevalence of tobacco smoking among the adolescents is increasing and the average age at which they start smoking is becoming younger (1)(2) (3). Since smoking is a source of nicotine addiction, adolescent smokers are likely to become adult smokers as well (4). More than 80% of current adult tobacco users started smoking cigarettes before age 18 years (5).

Factors that have been shown to increase the likelihood of adolescent smoking include smoking by their peers and parents (6), (7), (8) (9) (10)(11) poor academic performances in high schools (12;13), low self-esteem (7), favorable imagery of a smoker in their minds (14) (2), and their perception of smoking related danger to health (15)(16). Initiation and maintenance of cigarette smoking among adolescents as a health behavior have been explained by several theories and models of health behavior, including the Theory of Reasoned Action (17), Health Belief Model (15)(18), Theory of Planned Behavior (16), (19), the Stages of Change (20), (21) and the Theory of Personal Constructs (22).

Most, if not all, studies have modeled cigarette smoking as an outcome. In contrast, the issue of non-smoking or refraining from cigarette smoking as a health decision or health behavior by the adoles-cents is poorly understood. It has been argued that the society outlook on tobacco should be changed to make non-smoking as an outcome measure (23). School based intervention programs emphasizing non-smoking have shown that the proportion of students who remained non-smokers or intended to remain non-smokers increased after such interventions (24), (25). Here, using the results from a school-based survey, we report the factors associated with non-smoking behavior among the older adolescents in Calcutta.

Methods

Participants— The students were selected from high schools using Simple Random Sampling technique. A total of 25 schools were selected in Calcutta Metropolitan area. Of them, 21 schools (84%) responded to the survey. In each school two grades were selected (grade 9 and grade 11). The survey was conducted between September 1998 and January 1999.

The staff members of Epidemiology & Bio-statistics Department of Chittaranjan National Cancer Institute distributed the survey instrument. It was a self-administered questionnaire containing 51 close and open-ended items. The answers were coded and entered into a database for further analysis.

Independent variables— Age in years, gender, type of school (government-administered or privately owned), academic performance of the participants in school, smoking status of father and peers, their impression of a smoker and perception of the danger of smoking. The age variable was further categorized into four groups based on the frequency distribution. The variables smoking by friends and siblings were combined to create a new variable labeled ‘peer smoking’. Peers were labeled as nonsmokers only where neither siblings nor friends smoked. If either a sibling or a friend was a smoker, then peer smoking status was labeled as “smoker”.

Main Outcome Measure— Intention of the respondent whether to remain a non-smoker in his lifetime was the outcome variable. This was determined by answer to the question whether the respondent was determined never to smoke in his or her lifetime.

Univariate statistics.—Frequency distributions were reported for all independent and outcome variables by gender. A chi-square test of significance (significance level = 0.05) was used to report any statistically significant difference.

Bivariate statistics.— Cross-tabulations were reported for all independent variables with the intention to remain a non-smoker. The statistical significance was determined by chi-square tests. The signifi-cance level was fixed at alpha = 0.05

Multivariate statistics.— All statistically significant independent variables from the bivariate distribu-tion  were then entered into a binary logistic regression model. They were regressed on their intention status (determination never to smoke in lifetime was assigned a score of 1) as the outcome variable. Based on this logistic regression model, the strength of association between the independent and outcome variables was determined by the odds’ ratio (with 95% Confidence Interval). The level of significance was kept at alpha = 0.05

Results

Out of 2349 students initially selected for the survey, 1950 (83.01 %) students responded to the survey.  Males and females were comparable with respect to age distribution and the type of schools attended and their impression of a smoker. About 59% males and 69% of females expressed their opinion to remain a non-smoker. (Table 1).

On bivariate analysis intention to remain a non-smoker was significantly associated with males, private schools, if father is a non- smoker, if peer is a smoker, negative impression about smokers, high degree of perceived danger in smoking and good to average school performance. (Table 2)

After controlling for the effects of other factors, perceived danger in smoking had the strongest association with the respondent's intention to be a non-smoker. In comparison to students who perceived a slight danger in smoking, those who perceived that danger in smoking was very high were almost five times likely to express an intention to remain a non-smoker. The likelihood of this intention increased in a dose response manner with increasing perception in the degree of danger in smoking. The good to average students were almost twice as likely to express their intention to remain non-smoker when compared to students who performed poorly based on their latest grades. Private school students were more likely to remain a non-smoker when compared with government school students. Students whose fathers did not smoke were about 1.3 times likely to express the intention of not to smoke. However neither gender nor peer smoking status was found to be statistically significant factors in multivariate analysis. (Table 3)

Discussion

The results of this survey suggest socio-demographic factors that have well established associa-tions with adolescent smoking are not necessarily the ones associated with non-smoking behav-ior of the adolescents. Cumulative evidence points to the role of peer influence on adolescent smoking. (26)(18) However, we did not find any statistically significant role of peer-influence on adolescent non-smoking behavior.  Similarly, parental smoking has been shown to be associ-ated with smoking among adolescents. In parental non-smoking in our study had weak associa-tion with the offspring’s intention not to smoke in his or her lifetime.

On the other hand, academic performance in school, image of smokers and belief that smoking is dangerous to health were significantly associated (in a multivariate model) with non-smoking. These are also known predictors for adolescent smoking. Of the three factors, belief that smoking is dangerous to health had the strongest association with an adolescent intending to be non-smoker. This is consistent with similar observations by Stanton on promotion of non-smoking by adolescents (27). This could possibly be explained by the fact that smokers tend to underestimate their personal risk (28) (29).  It has also been suggested on the basis of qualitative research that non-smoking among adolescents may be associated with a sense of aesthetic, moral and ethical value system that denigrates smoking in some cultures. This phenomenon is over and above to the awareness of adverse health consequences of smoking (30). Whether this holds true for the participants in this research will be investigated in future.

The results of this study should be interpreted in light of its several limitations. First, the participants of this study were drawn from school students – as a result, the conclusions cannot be generalized to all adolescents, particularly those who do not attend school. Second, it was not possible to control for the effects of the response of those children who were “undisclosed triers” (students who stated that they were never-smokers when in fact they have tried smoking on one or more occasions prior to the interview). This can possibly result in information bias (31). Third, this was a retrospective observational study where “intention not to smoke” was the outcome variable. A larger, prospective study can possibly identify the determinants of non-smoking among adolescents or what proportion of adolescents who express an intention to be non-smokers actually end up not smoking. These issues need to be addressed in future research.

This study suggests that educating children on the adverse health effect of smoking from an early age can result in adolescents who can make a decision of not smoking. Attempts should also be made to create a negative image of the smokers on the adolescent minds. Successes of school-based interventions (24) (25) lend support to the importance of  using non-smoking as an out-come measure.
 

Acknowledgements : This study was conducted with a financial grant from the Dept. of Health & Family Welfare, Govt. of West Bengal . The authors thank, Dr. S. Vaidya of NOTE, India for suggesting the questionnaire format and giving valuable suggestions and Dr. P.C.Gupta for his comments on the manuscript. They are also grateful to Sri Onkar Ghosh for his statistical assis-tance, Sri S. S. Mondal for his suggestions and other staff members of the Department of Epide-miology & Bio-statistics for conducting the survey. The authors also thank Prof. (Dr.) M. Sid-diqi, Director, Chittaranjan National Cancer Institute for giving permission to conduct this survey.

Competing Interests: None

References

(1) CNCI. Population Based Cancer Registry Report.  1997. Calcutta.

(2)   Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical re-view of the literature. [Review] [226 refs]. Tobacco Control 1998; 7(4):409-420.

(3)  US Department of Health and Human Services. Executive summary of the surgeon gen-eral's report: preventing tobacco use among young people. Oncology 1994; 8(5):16.

(4)  Gold M, Herkov M. Tobacco Smoking and Nicotine Dependence: Biological Basis for Pharmacotherapy from Nicotine to Treatments that Prevent Relapse. Journal of Addictive Diseases 1998; 17(1):7-21.

(5)    CDC. Preventing tobacco use among young people: report of the Surgeon General. US Department of Health and Human Services, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, editors.  1994. Atlanta, Georgia.

(6)    Sunseri AJ, Alberti JM, Kent ND. Reading, demographic, social and psychological fac-tors related to pre-adolescent smoking and non-smoking behaviors and attitudes. Journal of School Health 1983; 53(4):257-263.

(7)  Murphy NT, Price CJ. The influence of self-esteem, parental smoking, and living in a to-bacco production region on adolescent smoking behaviors. Journal of School Health 1988; 58(10):401-405.

(8)  Horn KA, Gao X, Kamal-Bahl S. Determinants of youth tobacco use in West Virginia: A comparison of smoking and smokeless tobacco use. American Journal of Drug & Alcohol Abuse 2000; 26(1):135-138.

(9)  Aloise-Young PA, Graham JW, Hansen WB. Peer influence on smoking initiation during early adolescence: a comparison of group members and group outsiders. Journal of Ap-plied Psychology 1994; 79(2):281-287.

(10)  Biglan A, Duncan TE, Ary DV, Smolkowski K. Peer and parental influences on adoles-cent tobacco use. Journal of Behavioral Medicine 1995; 18(4):315-330.

(11)  Distefan JM, Gilpin EA, Choi WS, Pierce JP. Parental influences predict adolescent smoking in the United States, 1989-1993. Journal of Adolescent Health 1998; 22(6):466-474.

(12)  Dappen A, Schwartz RH, O'Donnell R. A survey of adolescent smoking patterns. Journal of the American Board of Family Practice 1996; 9(1):7-13.

(13)  Chassin L, Presson CC, Rose JS, Sherman SJ. The natural history of cigarette smoking from adolescence to adulthood: demographic predictors of continuity and change. Health Psychology 1996; 15(6):478-484.

(14)  Spear SF, Akers RL. Social learning variables and the risk of habitual smoking among adolescents: the Muscatine study. American Journal of Preventive Medicine 1988; 4(6):336-342.

(15)  Urberg K, Robbins R. Perceived vulnerability in adolescents to the health consequences of cigarette smoking. Preventive Medicine 1984; 13(4):367-376.

(16)  Godin G, Valois P, Lepage L. Predictors of smoking behaviour: an application of Ajzen's theory of planned behaviour. British Journal of Addiction 1992; 87(9):1335-1343.

(17)  Grube JW, Morgan M, McGree ST. Attitudes and normative beliefs as predictors of smoking intentions and behaviours: a test of three models. British Journal of Social Psy-chology 1986; 25 (Part 2):81-93.

(18)  Aloise-Young PA, Hennigan KM, Graham JW. Role of the self-image and smoker stereotype in smoking onset during early adolescence: a longitudinal study. Health Psy-chology 1996; 15(6):494-497.

(19)  Hill AJ, Boudreau F, Amyot E. Predicting the stages of smoking acquisition according to the theory of planned behavior. Journal of Adolescent Health 1997; 21(2):107-115.

(20)  Choi WS, Pierce JP, Gilpin E. WHICH Adolescent experimenters progress to established smoking in the United States? American Journal of Preventive Medicine 1997; 13(5):385-391.

(21)  Pallonen UE. Transtheoretical Measures for Adolescent and Adult Smokers – Similarities and Differences. Preventive Medicine 1998; 27 (5 part 3 Suppl):A 29-A 38.

(22)  Lynch P. Adolescent Smoking - An Alternative Perspective Using Personal Construct Theory. Health Education Research 1995; 10(1):95-106.

(23)  Sasco AJ, Kleihues P. Why can't we convince the young not to smoke? European Journal of Cancer 1999; 35 (14 Special Issue):1933-1940.

(24) Vartiainen E, Saukko A, Paavola M. No Smoking Class Competitions in Finland – Their Value in delaying the onset of smoking in adolescence. Health Promotion International 1996; 11(3):189-192.

(25)  Perry CL, Komro KA, Dudovitz B, Veblen-Mortenson S. An evaluation of a theatre pro-duction to encourage non-smoking among elementary age children: 2 Smart 2 Smoke. Tobacco Control 1999; 8(2):169-174.

(26)  Malkin SA, Allen DL. Differential characteristics of adolescent smokers and non-smokers. Journal of Family Practice 1980; 10(3):437-440.

(27)  Stanton WR, Mcgee R Adolescents’ Promotion of Non-smoking and Smoking.. Addic-tive Behaviors 1996; 21(1):47-56.

(28)  Weinstein ND. Accuracy of smokers' risk perceptions. Annals of Behavioral Medicine 1998; 20(2):135-140.

(29)  Greening L, Dollinger SJ. Adolescent smoking and perceived vulnerability to smoking-related causes of death. Journal of Pediatric Psychology 1991; 16(6):687-699.

(30)   Ayars CL, Gladney AP, Peters RJ. Beliefs about smoking among adolescents - Gender and ethnic differences. Journal of Child & Adolescent Substance Abuse 1999; 8(3):37-54.

(31)   Jarvis MJ, Goddard E, McNeill A. Do attitudes predict uptake of smoking in teenagers? Case not proven. Social Science & Medicine 1990; 31(9):997-1000.
 



This Article
Right arrow Abstract Freely available
Services
Right arrow Similar articles in this netprints
Right arrow Download to citation manager
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Right arrow Citing Articles via Google Scholar
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Right arrow Articles by Sen, U.
Right arrow Articles by Basu, A.
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PubMed
Right arrow Articles by Sen, U.
Right arrow Articles by Basu, A.
Related Collections
Right arrow Paediatrics:
Other Paediatrics

Right arrow Public Health:
Smoking


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