SAIDATUL NORBAYA BUANGPUBLIC HEALTH PHYSICIAN

FAMILY HEALTH DEVELOPMENT DIVISIONDEPT OF PUBLIC HEALTH

MINISTRY OF HEALTH MALAYSIA

THIRD MALAYSIAN TOBACCO CONTROL CONFERENCE8 -9 AUGUST 2009

• Smoking acquisition is not straight forward process

• Various theories put forward to explained adolescent smoking behavior.

• Strongest predictors is intention to smoke• Study attempt to understand the process of

smoking acquisition experience by Malaysian adolescents.

• Adopt Stage of Change model, Social Learning Theory

• Smoking acquisition is a process involving several stages.

• Various factors played different roles in the smoking acquisition process.

• Cross sectional, descriptive study of students ages 13 – 17 year

• 3 stage cluster sampling with class as the smallest sampling unit. (N=1035)

• Sampling boys to girls ratio 1:3• Self administered questionnaire in schools• Third party consent. ( School Principal as legal guardian for

the students)• Validation of stages using qualitative data – 5 groups of FGD

with smoking respondents.– Respondents selected by discipline teacher ( caught smoking in school)

• those who have never tried even a puff of cigarette, no intention to smoke in near future and able to resist peer pressure from smoking.

• 720 respondents (68.1%) of study population fall into this category making this the larges smoking subgroup in this study.

• are those who have not tried smoking, but either have intention to smoke in near future or view themselves unable to resist peer smoking pressure or both.

• 12.2 % (126) of study population were in this subgroup.

• those who tried smoking before but quit for various reasons.

• 7.1 % (73) of respondents fit into this category.

• Irregular smokers are those who admitted smoking regularly but do not smoke on daily basis.

• is the smallest subgroup in this study with 4.6% (51) membership from total study population.

• are boys or girls who smoke on daily basis and • 8.0% (83) of study population belongs to this

group.

• Majority of respondents perceived intention to initiate smoking as being attracted to the cigarette smoke.

‘ … bila tengok abang-abang tu hembus asap rokok, bulat-bulat … tak tau nak cakap macam mana rasanya ….terasa nak hisap rokok …’

F, age 17• However many of them were unable to recall the time

they developed positive attitude towards smoking.

• The process of smoking uptake varies from voluntary trying to being force to smoke.

‘ … saya biasa lepak … dengan kawan waktu malam. Depa rokok .. Saya tengok, cakap nak cuba … depa tak kasi. Satu hari saya tanya, macam mana rasa rokok? Abang tu ambik rokok kayu ( bantang kayu) suruh saya hisap .. Saya cuba tak rasa apa-apa … esok tu saya beli dan cuba merokok’

– H 17 yr old .

‘In one particular school the smoking initiation was force upon them by elder siblings or a person the students called as ‘abang’…

‘…abang paksa saya merokok, sebab kita nampak dia merokok … dia ikat saya di kerusi dan paksa saya … Lepas tu dia kata .. Kalau saya cakap pada mak , dia akan cakap saya rokok…..’

K – 13 yr old Malay boy.

Stages of smoking Mean age (year) Mean age of smoking initiation (year)

Non Susceptible Non Smoker (n=702)

15.56

Susceptible Non Smoker (n=126) 15.45

Experimenter Smoker (n=73) 16.09 13.24

Irregular Smoker (n=51) 15.98 14.00

Regular Smokers (n=83) 16.55 13.04

Overall mean age (n= 1035) 15.69 13.35

Stages of smoking Male(N=404)

Female(N=631)

Total stage of smoking

Non Susceptible Non Smoker 24.5% 75.5% 67.8%

Susceptible Non Smoker 50.8% 49.2% 12.2%

Experimenter smoker 67.1% 32.9% 5.1%

Irregular Smoker 78.4% 21.6% 4.9%Regular Smokers 95.2% 4.8% 8.0%Total gender 39.0% 61.0% 100%

Stages of smoking Malay(N=647)

Chinese(N=148)

Indian(N=240)

Total stage of smoking

Non Susceptible Non Smoker

(N=702)

55.6% 16.7% 27.8%

67.8%

Susceptible Non Smoker

(N=126)

70.6% 14.3% 15.1%

12.2%

Experimenter smoker (N=73) 82.2% 6.8% 11.0% 5.1%

Irregular Smoker (N=51) 82.4% 7.8% 9.8% 4.9%

Regular Smokers (N=83) 79.5% 4.8% 15.7% 8.0%

Total ethnic group 62.5% 14.3% 23.2% 100%

• Demographics• Perceived parent child relationship• Perceived Family smoking and attitudes towards

smoking• Perceived peer smoking and attitudes towards

smoking• Perceived school variables• Perceived Social bonding• Places young people hang out

• Transformation of variables values into standardised z score.

• Allow comparison of each smoking subgroups means to the study population mean ( which is 0).

• Of the 39 predictors variables analysed, 14 variables distinguished the 5 hypothetical smoking subgroups from overall study population.

• more likely to be younger age group, • female students who have • no elder sibling smoking, family members with

strict attitude towards smoking and more likely to have no or few friends who smoked.

• They appeared to be bullied in school but denial bullying other and less likely to be truant

• seem to have parents with negative smoking attitude.

• less likely to be bullied• more likely to truant from school than overall

sample.

• more likely to be boys • Lower religiosity score• have many friends in their neighbourhood • They bullied others but denial being bullied • spend their leisure time at video arcades and

snooker centres. • Relatively have more elder sibling smoking, • father with strict smoking attitude but • pro-smoking brother/s and male friends.

• more likely to be older boys • older in age than mean age of study

population. • They were bullies• who truant from classes/school. • Relatively have elder sibling smoking and • pro-smoking attitude parents and • Pro smoking attitude of male friends.

• older boys who • bullied other• truant from classes/school. • Relatively have more elder siblings

smoking • family members with positive smoking

attitude than study population ( parents and older siblings)

PREDICTORS

NON SUSCEPTIBLE NON SMOKER TO SUSCEPTIBLE

EXP (B)

CONFIDENCE INTERVAL

 Demographic  

Boys 3.59*** 2.19 5.75Malay 1    Chinese 0.47* 0.26 0.86Indian 0.56 0.3 1.04

Parent child relationship

Father do not understand my problem and worries 3.44*** 1.97 6.03

Friends’ smoking and attitude toward smokingFew to almost all friend smoking 2.15*** 1.45 3.19Female friends allow smoking 4.03*** 2.28 7.13

School variables 

Have thought of leaving school 1.82* 1.11 2.99Truant from school 1.85* 1.14 3.01

R2 0.278    

 PREDICTORS

SUSCEPTIBLE NON SMOKER TO EXPERIMENTER

EXP (B)CONFIDENCE

INTERVALParent child relationship

     Mother do not support when upset

2.86* 1.14 7.14Family smoking and attitude towards smoking

At least one elder sibling ever smoked2.14* 1.12 4.06

Friend smoking and attitude towards smoking

Few to almost all friend smoking3.47*** 1.89 6.34

Social bonding

Religiosity0.46* 0.22 0.96

R2 0.216    

 PREDICTORS 

EXPERIMENTER TO IRREGULAR SMOKER

EXP (B)CONFIDENCE

INTERVALFamily smoking and attitude towards smoking

At least one elder sibling ever smoked      Parents allow smoking

8.07*** 2.74 23.77Friend smoking and attitude towards smoking

Few to almost all friend smoking2.25 0.99 5.09

Places where young people hang out

Spend time in public places8.56* 1.57 46.76

R2 0.378    

 PREDICTORS

Irregular to Regular smokers

Exp (BConfidence

IntervalDemographic

Age 2.108** 1.201 3.702

Family smoking and attitude towards smokingElder sister allow smoking 3.4* 1.07 10.77

School variablesPoor academic grade 4.04** 1.5 10.88

Risk taking behaviourBullies in school 3.218* 1.27 8.14

Places where young people hang outSpend time at snooker centre 5.29*** 2.11 13.29

 R2

0.399    

NSNS SNS REGULAR IRREGULAREXPERIMENTER

•BOYS•MALAY•UNSUPPORTIVE FATHER •PEER ATTITUDE•TRUANT•HATE SCHOOL

•PARENTAL ATTITUDE•PEER SMOKING•SPEND TIME IN PUBLIC SPACES

•OLDER BOYS•SISTER ALLOW SMOKING•BULLIES•POOR ACADEMIC GRADES•SPEND TIME SNOOKER CENTRE

•MOTHER•OLDER SIBLING SMOKING•PEER SMOKING•RELIGIOSITY*

• Peer appear to be more important during early stage of smoking … a cigarette shared by 3 -4 person but as the smoking stages advance, smoking alone is more preferred.

‘ .. Ada duit beli sebatang … tak da duit kongsi kongsi beli ….sebatang dapat hisap 3 ke 4 kali …kongsi 3 kadang 4 orang.. Tak duit pau kat kawan … bila kita beli kawan..pau pulak …’

Z, 15 yrs

• On the other hands, B who used to smoked a 20 cigarette a day describe …

‘ ..mula –mula kongsi , lepas tu hisap sebatang … dalam masa setahun naik 7 batang, sekarang dah sekotak sehari. .. Hisap kongsi tak puas, kena sorok nanti depa ‘pau’ …hisap waktu malam, malam sejuk, terasa nak merokok …

• As respondents progress to regular smoker, the importance of peer reduced

• Parental acceptance was observed among irregular and regular smoker.

‘… ayah panggil ..dia tanya hang ada hisap rokok ?.. Saya diam..ayah tak kata apa… lepas tu saya tanya apa beza rokok import ? Ayah cerita …. Lepas tu di tak tanya saya rokok ke tidak’

M, 17 yrs

• Parental disapprove of smoking, can reverse the smoking progression.

‘… bila ayah tau dia pukul saya…potong duit belanja… sekarang saya dah tak berani rokok…ayah kata kalau jumpa saya rokok ….’

H, 17 yrs

• Different predictors influence transition from one stage to another.

• Prevention strategy to promote NO SMOKING needs to address – Educating ‘Smoking Fatwa’ among young children to

promote clear religious stand point regarding smoking.– Enhance religiosity – High risk groups population ( boys, truant, bully,)– Strengthening regulation to prevent sale of ‘loose cigarette’

or sale to minor/ non purchase cigarette source