INTRODUCTION
Smoking is a major public health problem in the developing world. Rapid socio-economic development in developing countries is accompanied by consistent increase in tobacco consumption (WHO 1996). In the 1990s, a world total of three million people died each year from tobacco induced diseases (Anthony et al. 1997).
Over 75% of adult smokers reported that their first smoking experience began during adolescence (Anthony et al. 1994). Smoking is a great concern among adolescents as it is related to many chronic diseases and mortality which become evident only after two or three decades of tobacco use. It is also associated with other risky behaviours such as other drug abuse, truancy and physical fighting (Epps et al. 1995, Kulig et al. 2005). Once a regular smoking pattern is established, it is difficult to cease, with onset during adolescence being highly predictive of lifetime use (Heischober et al. 1997).
There are not many studies done in Malaysia previously which looked into the reasons for smoking and the contributing factors influencing it. Thus, the objective of this study was to determine the prevalence of smoking among upper secondary schoolboys, reasons for smoking and the contributing factors to the commonest reason given. The findings in this study could be used to improve strategies in smoking prevention programmes for adolescent schoolboys.
SUBJECTS AND METHODS
This was a cross-sectional study conducted among upper secondary school-boys (Form 4 and Form 5 students). Three secondary schools in the District of Hulu Langat, Selangor were selected randomly. From each school, an equal number of students was chosen randomly from the class registration lists. Form 4 and form 5 students from all ethnicities were included in the study. Consent was obtained from the students and their parents. Those who refused to give consent to participate in the study were excluded. The students were then given a self-administered question-naire. The questionnaire was pre-tested and consisted of questions regarding socio-demographic characteristics, age at which smoking was initiated, smoking among family members as well as reasons for initiating and continuing smoking. Non-smokers were those who never smoke for at least one month while smokers are those who smoked at least one cigarette for the preceding one month (Khadijah et al. 2000). Data entry and analysis was done using Epi-info 2002. A confidence interval of 95% and p value of less than 0.05 were considered as significant.
RESULTS
A total of 343 students were included in the study. The respondents comprised 57% Malays, 36% Chinese and 6.7% Indians. Their ages ranged between 16 and 18 years old; 57% of them were aged sixteen years, 40% seventeen years and 3% eighteen years. The majority of them were from families with a family income ranging from RM500 to RM2000 (66%).
The prevalence of smoking among the boys was 37%. Although the majority of them initiated smoking at 13 to 15 years old (66%), 21% of them began smoking during primary school (<12 years old) (Table 1). Among the smokers, the majority of them smoked more than 10 cigarettes per day (57%) (Table 1). There was a significant association between adolescent smoking and smoking among family members (p<0.05).
The common reasons given by the respondents for initiating smoking and continuing smoking varied widely. The most frequent reasons for initiating smoking were curiosity (69.3%) and peer pressure (51%) while stress (70%) was reported as the commonest reason for continuing smoking followed by addiction (49%) (Table 2). The students reported schoolwork as the most important factor which contributed to their stress (Table 2).
The majority of cigarette smokers initiate smoking during their adolescence (Anthony et al. 1994, Heischober 1997). The prevalence of smoking among adolescent schoolboys in Asian countries ranges from 3% to 30% in the 1980s (Thambipillay 1985, Emmanuel et al.1990, Stone et al. 1992, Habibul et al. 1998). The National Health Morbidity Survey done in Malaysia reported an increasing trend in the prevalence of smoking among adults from 39% in 1986 (MOH Malaysia 1986) to 49% in 1996 (MOH Malaysia 1996). However, data on the prevalence of smoking among adolescents was not available. In 1997, a study done in Kota Bharu, Kelantan reported the prevalence of cigarette smoking among male secondary students as 33.2% (Khadijah et al. 2000). In the present study, the prevalence of smoking among male upper secondary school students was 37%. Although the setting in the study by Khadijah et al (2000) was different, there may be a rising trend in cigarette smoking among adolescent boys; thus it is essential for health care providers to address this issue and improve the preventive intervention strategies against smoking.
This study showed that 21% of the adolescent boys who smoked initiated smoking at 12 years of age or younger (during primary school). This indicates that education regarding smoking, emphasizing on its negative consequences, should begin early in the primary schools. It should be part of the primary school curriculum and students should be taught ways to say “no” to tobacco smoking. Many studies have reported that those who started smoking early in life have greater difficulty in stopping. (Epps et al. 1995, Heischober et al. 1997, Bruvold et al 1993, Siquera 2000). They are also more likely to become heavy smokers and are at higher risk of developing smoking-related diseases than those who begin at a later age (MOH Malaysia 1996, Anda et al. 1999). The children who started smoking at an earlier age may be due to earlier exposure to tobacco environment either at home, school or in the community. Electronic media, for example television and movies, also have great influence on children. It is the responsibility of parents and other adults to supervise and educate children that smoking is an unfavourable habit which should not be attempted.
Smoking habits among adolescents had been shown to be influenced by parents and other adult role models who smoke (Heischober et al. 1997, Bruvold et al. 1997). This study also showed a significant association between adolescent smoking and smoking among family members. Thus, health practitioners should increase awareness among parents that they are important role models for their children and should ensure that they do not influence their children towards smoking.
In this study, the most frequent reasons given by the adolescents for initiating smoking were curiosity (69%) and peer pressure (51%). Many adolescents begin smoking to fit into the society or peer group (Heischober et al. 1997, MOH Malaysia 1996). Adolescents tend to experiment smoking together and by doing so they believe that they are more accepted by their peers (Reininger et al. 2005). It is important that health professionals understand the psychosocial develop-mental process in adolescence. During adolescence, there is lack of impulse control and there is an increase desire to experiment new experiences; thus the inclination to risk-taking behaviours such as smoking. This explains the commonest reason reported by the respondents for initiating smoking which was curiosity. In addition, during the middle adolescence stage, the role of peer groups becomes more evident and they are susceptible to peer pressure. Adolescents tend to be intensely involved in their peer subculture by conforming with peer values and codes (Reininger et al. 2005). They should learn to be assertive to say ‘no’ to smoking and influence peers against smoking. Other common reasons given by the adolescents for initiating smoking were stress (42%) and ‘feel more mature’ (25%). Adolescents should be educated that smoking cigarettes is not the solution to alleviate stress or solve their problems but it can lead to many other negative con-sequences. ‘Feel more mature’ is an expected response by adolescents as they are in the process of forming an identity. They are frequently exposed to smoking adults and subconsciously identify smoking with maturity which is a misperception. Thus it is important to expose adolescents to better adult role-models and a healthier community.
The commonest reason given by the adolescents in this study for continuing smoking was stress (70%). The main contributing factors to stress reported by them were schoolwork and peers. Demands from schoolwork such as heavy homework assignments, difficulty in understanding lessons, getting poor grades and high parental expectations contribute to the stress in many adolescents. In addition, peers play an important role in adolescence. Misunderstanding among friends, peer pressure and the need to be accepted by friends are stressors to adolescents. Stress can eventually lead to anxiety or depression in extreme situations. Hence, it is essential that adolescents learn how to deal with stress effectively instead of ignoring it or indulging in bad habits such as cigarette smoking or other substance abuse.
The significance of good coping skills among adolescents is of utmost importance in the planning for anti-smoking campaigns. Current strategies to prevent adolescents from engaging in high risk behaviours include a focus on building protective factors such as strong family relationships, religious beliefs, parental monitoring, adult role models and engage-ment in structured activities (Reininger et al. 2005). Effective treatment strategies to cease smoking must take place within the context of the youth’s normal daily life and resist all the factors that promote continuance (Bruvold et al. 1993). Hwang (2005) examined 65 adolescent psycho-social smoking prevention programmes. They reported that knowledge had the highest short-term effect (less than a year) but rapidly decreased in the long term. Behavioural effect was the most meaningful prevention programme as it persists over a three year period. They also reported that smoking reduction rates were increased by using either cognitive behaviour or life skills programme modali-ties in a school-community-incorporated programme setting (Hwang et al. 2005).
There are limitations in this study. This study included only three secondary schools in a single area. Hence the findings in this study cannot be generalized to represent the country. There may be recall bias among the adolescents while answering the questionnaire and some may not have revealed the true facts of their smoking behaviour.
CONCLUSION
Early smoking intervention strategies are necessary as younger boys are now involved in smoking. The initiatives should begin early in primary school to reduce the prevalence of smoking among adolescents. Educating the adolescents on being assertive and acquiring effective coping strategies in managing stress are important issues to be included in the preventive strategies. Health care providers should take every opportunity to screen smoking among their adolescent patients. They should incorporate cigarette smoking prevention into daily practice, acquire the necessary skills to identify young people at risk of smoking and provide assessment, intervention and treatment when necessary.