Asia-Pacific Journal of Public Health http://aph.sagepub.com/
Correlates of Current Smoking Among Malaysian Secondary School Children Guat Hiong Tee and Gurpreet Kaur Asia Pac J Public Health 2014 26: 70S originally published online 25 June 2014 DOI: 10.1177/1010539514540468 The online version of this article can be found at: http://aph.sagepub.com/content/26/5_suppl/70S
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540468 research-article2014
APHXXX10.1177/1010539514540468Asia-Pacific Journal of Public HealthTee and Gurpreet
Original Article
Correlates of Current Smoking Among Malaysian Secondary School Children
Asia-Pacific Journal of Public Health 2014, Vol. 26(5S) 70S–80S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514540468 aph.sagepub.com
Guat Hiong Tee, MMedSc (Public Health), BBioMedSc (Hons)1, and Gurpreet Kaur, MBBS, MPH (Epid)1
Abstract Cigarette smoking in adolescent is a significant public health problem, leading to the risk of addiction, morbidity, and mortality in the long term. This study determined the prevalence and correlates of current smoking among adolescent school children. A nationwide school-based survey among 25 507 students between Forms 1 to 5 (aged 12-17) was conducted using a 2-stage cluster sampling design. The prevalence of current smoking was 11.5%. Multivariable logistic regression analysis revealed that current smoking was significantly associated with males (adjusted odds ratio [aOR] = 3.25; 95% confidence interval [CI] = 1.87, 4.98), current drinking (aOR = 2.34; 95% CI = 1.46, 3.74), drug used (aOR = 2.97; 95% CI = 1.24, 7.11), and being bullied (aOR = 1.41; 95% CI = 1.00, 1.98) at least once in the past 12 months. Smoking is associated with several behaviors that pose risks to adolescents, such as social issues and smoking-related health problems. Thus, early and integrated prevention programs that address multiple risk behaviors simultaneously are required. Keywords smoking, drinking alcohol, substance use, bullying, Global School Health Survey (GSHS), Malaysia, adolescent
Introduction Tobacco consumption is the single most important preventable cause of premature mortality and morbidity. Annually, 6% of all female and 12% of all male deaths in the world, totaling 6 million people, are attributed to tobacco use and exposure.1 Current trend shows that by 2030, the number of deaths attributed to tobacco consumption will rise from 5 million to 8 million annually.2 Smoking is also estimated to cause about 42% of chronic respiratory disease and nearly 10% of cardiovascular disease.1 The negative effects of smoking are more detrimental to younger people due to their sensitivity to nicotine addiction and possible inability of the lungs to grow to full capacity. About one third of youths who persist in smoking will die prematurely from smoking.3 The predominant type of tobacco used among 13 to 15 year olds has been shown to be cigarettes.4 Generally, boys are also more likely to be current smokers than girls.3 1Institute
for Public Health, National Institutes of Health, Ministry of Health, Kuala Lumpur, Malaysia
Corresponding Author: Guat Hiong Tee, Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Jalan Bangsar, 50590 Kuala Lumpur, Malaysia. Email: [email protected]
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The severity of health consequences depends on the age of initiation, that is, the younger the age of tobacco use, the greater the damage to health. Since most individuals do not start smoking after the age of 25, smoking prevention efforts must focus on adolescents and young people.3 Smoking rates among adolescents are mainly derived from self-reported studies. Globally, it has only been possible to report smoking among adolescents in a standard way since the Center for Disease Control and Prevention, Atlanta, coordinated the Global Youth Tobacco Survey (GYTS) beginning in 1999. Based on these GYTS studies, the global prevalence of current smoking among adolescents aged 13 to 15 years is 9.25%, with the highest prevalence reported from the European region (19.2%) and the lowest prevalence from the Eastern Mediterranean region (4.9%).4 Among Malaysians, a study by Hammond et al found that 3% of Malaysian and Thai youths aged 13 to 17 years were current smokers, with another 10% to 12% being experimental smokers.6 Another study by Rapeah et al in Kuantan, Malaysia, noted that type of class stream (science or arts), peers who smoked, and attitude toward smoking were associated with smoking among male students.7 Furthermore, a study in Kelantan, Malaysia, showed that other factors, such as parent’s smoking history, academic performance, perception of the health hazards of smoking, and type of school attended, were associated with smoking among male students.8 Overall, there is still a paucity of evidence on the prevalence of and factors associated with tobacco consumption among school-going children in Malaysia. Local epidemiologic data on smoking among this population are fundamental for the planning and implementation of antismoking public health programs. This study aims to determine the prevalence of current smoking and its associated factors among Malaysian school-going adolescents from Forms 1 to 5 (12-17 years).
Methodology Sampling The Malaysia School-Based Health Survey (MSHS) 2012 was a cross-sectional survey involving students in Forms 1 to 5 (12-17 years) using the standardized questionnaire of the World Health Organization Global School-based Health Survey (GSHS). Consistent with the GSHS methodology, students were selected using a 2-stage cluster sampling design to produce a nationwide representative sample. The first-stage sampling frame consisted of all schools with Forms 1 to 5 classes. Schools were selected with probability proportional to their reported enrolment size. In total, 234 schools were randomly selected to participate in the MSHS. The second stage of sampling consisted of systematic random sampling of classrooms from each participating school. All students in the sampled classrooms were eligible to participate in the MSHS. Students who consented to participate in the survey self-administered the bilingual pretested questionnaires within 2 class periods and recorded their responses on computer-scannable answer sheets. The detailed methodology of the MSHS has been reported by Fadhli et al.9 The students’ privacy was protected through anonymity and voluntary participation. Ethical approvals were obtained from both the Ministry of Health Research and Ethics Committee and Ministry of Education Ethics Committee. Prior to data collection, parental consent forms were distributed to all students from selected classes, and nonconsenting students were considered as non responders.
Definition of Variables The outcome variable, that is, smoking, referred to cigarette smoking only. Cigarette smoking (current smoking) in the past 30 days was assessed with the question, “During the past 30 days, on how many days did you smoke cigarettes?” Response options ranged from 1 = 0 day to 7 = all 30 days. Alcohol used was assessed with the question, “During the past 30 days, on how many
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days did you have at least one drink containing alcohol?” Response options ranged from 1 = 0 day to 7 = all 30 days. For drug used, students were asked, “During the past 30 days, how many times have you used drugs?” Response options ranged from 1 = 0 time to 5 = 20 or more times. Potential predictors or risk factors were determined as follows. Physical fight was assessed with the question, “During the past 12 months, how many times were you in a physical fight?” Response options ranged from 1 = 0 time to 8 = 12 or more times. To assess bullying at school, students were asked, “During the past 30 days, on how many days were you bullied?” Response options ranged from 1 = 0 day to 7 = all 30 days. Other variables included in this study were selected sociodemographic data (age group, sex, parent’s marital status), whether one or both parents/guardians use tobacco, use of other tobacco products (other than cigarettes), smoked first cigarette before the age of 14 years, attempted to quit smoking in the past 12 months, and exposure to secondhand smoke (SHS).
Data Analysis Data were analyzed using the Statistical Package for the Social Science, version 21 (SPSS Inc, Chicago, IL). Statistical significance was defined at P < .05. Odds ratios (OR) and 95% confidence intervals (CIs) were derived where appropriate. Multivariable logistic regression analysis was used to assess the associations between current smoking and predictor/risk variables described above. All variables were entered in the multivariable logistic regression analysis to compute the adjusted odds ratio (aOR) for each independent predictor.
Results A total of 25 493 students responded to the tobacco use module, giving a very high response rate of 99.9% (25 493/25 507). The largest number of respondents was males (50.2%), Malays (60.8%), and those in Remove class/Form 1 (21.9%). About 86% of the students’ parents were married and living together at the time of the survey. Just over half of them (57.2%) had nonsmoking parents (Table 1). The prevalence of current smoking among these adolescents was 11.5%. Only 7.4% of respondents had ever used tobacco products other than cigarettes. The majority (58.4%) had not been exposed to SHS in the past week. Among the current smokers, more than 70% claimed to have initiated smoking before the age of 14 years. About 88% of current smokers claimed to have attempted to quit smoking in the past year (Table 1). Table 2 shows the prevalence of current smoking by sociodemographic characteristics and selected health-related behaviors. The highest prevalence of current smoking was among males (20.9%), Bumiputra Sarawak (20.2%), students in Form 5 (15.7%), adolescents with divorced parents (16.3%), and adolescents whose mother or female guardian used tobacco (36.9%). The highest prevalence of current smoking was also noted among those who were exposed to SHS in the past week (23.9%), initiated smoking before the age of 14 years (69.4%), and did not attempt to quit smoking in the past year (85.4%). Adolescents who were involved in physical fighting (21.5%), were bullied (15.3%), or used drugs (55.9%) in the past year and adolescents who drank alcohol in the past 30 days (28.4%) also had the highest prevalence of current smoking (Table 2). After adjusting for confounders, 9 variables, sex, ethnicity, parents’ marital status, use of tobacco among parents, attempting to quit smoking, SHS exposure, drinking alcohol, using drugs, and being bullied, were found to be significantly associated with current smoking (Table 3). Students who were exposed to SHS in the past week (aOR = 4.69; 95% CI = 3.38, 6.50) and who had both parents using tobacco products (aOR = 4.78; 95% CI = 1.16, 19.77) were almost 5 times more likely to be current smokers compared to those who were not exposed and who have
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Tee and Gurpreet Table 1. Frequency Distribution of Respondents by Sociodemographic Characteristics and Selected Health-Related Behaviors.
95% Confidence Interval Sociodemographic Characteristics (n = 25 493) Sex (n = 25 461) Male Female Ethnicity (n = 25 464) Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade (n = 25 447) Remove classa and Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status (n = 25 426) Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco (n = 25 412) Neither My father or male guardian My mother or female guardian Both Current smoker (n = 25 378) Yes No Use of other tobacco products (other than cigarettes) (n = 25 432) None Shisha/Hookah Electronic cigarettes Snuff or chewing tobacco Pipes Curut, cigars or cigarillos Bidis Other tobacco products Smoked first cigarette before the age of 14 years (n = 4809) Yes No
n
N
%
Lower (%)
12 732 12 729
1 127 000 50.2 1 119 000 49.8
48.3 48.0
17 086 4509 1447 992 1021 409
1 366 000 60.8 453 800 20.2 154 400 6.9 110 900 4.9 122 200 5.4 38 670 1.7
56.5 16.6 5.6 4.2 4.3 1.2
5433 5329 5599 4515 4571
490 490 458 600 449 900 431 500 413 500
Upper (%) 52.0 51.7 64.9 24.4 8.5 5.8 6.8 2.5 23.9 23.2 22.1 21.8 20.7 86.9 3.5 5.1 5.3 1.4 58.9 42.5 1.1 1.3 12.7 89.6
21.9 20.4 20.1 19.2 18.4
19.9 17.9 18.2 16.9 16.3
21 657 758 1190 1202 271
1 903 000 86.1 68 960 3.1 103 900 4.7 107 400 4.9 26 120 1.2
85.3 2.8 4.3 4.5 1.0
13 771 9848 183 231
1 207 000 57.2 860 600 40.8 17 840 0.8 22 950 1.1
55.5 39.2 0.7 0.9
2707 22 671
257 700 11.5 1 981 000 88.5
10.4 87.3
23 732 608 244 263 57 89 21 418
2 077 000 92.6 57 080 2.5 25 860 1.2 26 050 1.2 5825 0.3 8852 0.4 2036 0.1 40 960 1.8
91.8 2.2 0.9 1.0 0.2 0.3 0.1 1.6
93.3 2.9 1.4 1.4 0.4 0.5 0.2 2.1
3470 1339
313 600 70.8 129 300 29.2
69.0 27.5
72.5 31.0 (continued)
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Table 1. (continued) 95% Confidence Interval Sociodemographic Characteristics (n = 25 493) Attempted to quit smoking in the past 12 months (n = 2994) Yes No Exposed to secondhand smoke the past 1 week (n = 25 450) Yes No Drank alcohol in the past 30 days (n = 25 285) Yes No Drug used at least once in the past 12 months (n = 25 474) Yes No In a physical fight at least once in the past 12 months (n = 25 474) Yes No Bullied at least once in the past 12 months (n = 23 992) Yes No
n
N
%
Lower (%)
Upper (%)
2626 368
247 700 88.1 33 560 11.9
86.1 10.2
89.8 13.9
10 619 14 831
934 100 41.6 1 311 000 58.4
39.9 56.6
1926 23 359
197 700 8.9 2 030 000 91.1
7.8 89.9
43.4 60.1 10.1 92.2
346 25 128
34 060 1.5 2 213 000 98.5
1.2 98.1
1.9 98.8
6849 18 536
615 200 27.4 1 633 000 72.6
26.0 71.3
28.7 74.0
4167 19 825
378 400 17.9 1 738 000 82.1
16.8 81.0
19.0 83.2
a“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
nonsmoking parents, respectively. Male students were about 3 times (aOR = 3.05; 95% CI = 1.88, 4.98) more likely to be current smokers compared to female students. The next strongest association with current smoking was ethnicity, drug use, parent’s marital status, and drinking alcohol. Although the prevalence of current smoking increased progressively with age from Remove/Form 1 to Form 5, controlling for all other factors, a significantly higher risk for current smoking was only observed for the oldest age category. To a lesser extent, adolescents who had attempted to quit smoking (aOR = 1.68; 95% CI = 1.07, 2.64) and those who were bullied in the past year (aOR = 1.41; 95% CI = 1.00, 1.98) were more likely to be smoking.
Discussion The overall prevalence of smoking (11.5%) among Malaysian school-going adolescents from this study was lower than the finding from the Youth Behavioral Risk Factor Surveillance (17.8%) conducted among Malaysian secondary school children in 2010.10 However, compared with school children in Southeast Asian countries, the prevalence of smoking among Malaysian adolescents was higher than Philippino,11 Indonesian,12 and Thai students13 at 11.0%, 10.9%, and 8.2%, respectively. Consistent with other studies, the prevalence of smoking cigarettes was higher among boys than girls14-17 and increased as they progressed through the Forms.16-18 The gender disparity may
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Tee and Gurpreet Table 2. Prevalence of Current Smoking by Sociodemographic Characteristics and Selected HealthRelated Behaviors. Current Smoking Variables
Yes, % (95% CI)
Sex Male Female Ethnicity Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade Remove classa/Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco Neither My father or male guardian My mother or female guardian Both Smoked first cigarette before the age of 14 years Yes No Attempted to quit smoking in the past 12 months Yes No Exposed to secondhand smoke the past 1 week Yes No Drank alcohol in the past 30 days Yes No Drug used at least once in the past 12 months Yes No In physical fight at least once in the past 12 months Yes No Bullied at least once in the past 12 months Yes No
No, % (95% CI)
8.0 (7.0, 9.2) 13.7 (12.4, 15.0) 36.9 (28.3, 46.4) 22.1 (16.3, 29.1)
79.1 (77.0, 81.1) 97.9 (97.4, 98.2) 86.5 (85.0, 88.0) 95.8 (94.0, 97.0) 92.9 (89.1, 95.1) 86.9 (83.7, 89.6) 79.8 (75.8, 83.3) 85.0 (79.9, 89.0) 93.2 (92.0, 94.3) 90.5 (88.3, 92.3) 88.2 (86.1, 89.9) 85.4 (83.3, 87.3) 84.3 (81.3, 86.9) 88.8 (87.6, 90.0) 89.4 (86.3, 91.9) 83.7 (80.2, 86.6) 88.4 (85.6, 90.7) 85.6 (80.0, 89.9) 92.0 (90.8, 93.0) 86.3 (85.0, 87.6) 63.1 (53.6, 71.7) 77.9 (70.9, 83.7)
52.1 (49.2, 55.1) 69.4 (66.3, 72.3)
47.9 (44.9, 50.8) 30.6 (27.7, 33.7)
77.0 (74.4, 79.3) 85.4 (80.1, 89.5)
23.0 (20.7, 25.6) 14.6 (10.5, 19.9)
23.9 (22.2, 25.9) 2.6 (2.1, 3.1)
21.5 (19.7, 23.4) 7.8 (6.9, 8.8)
76.1 (74.1, 77.9) 97.4 (96.9, 97.9) 71.6 (67.6, 75.4) 90.2 (89.1, 91.3) 44.1 (37.1, 51.3) 89.2 (88.0, 90.2) 78.5 (76.6, 80.3) 92.2 (91.2, 93.1)
15.3 (13.4, 17.3) 10.5 (9.4, 11.8)
84.7 (82.7, 86.6) 89.5 (88.2, 90.6)
20.9 (18.9, 23.0) 2.1 (1.8, 2.6) 13.5 (12.0, 15.0) 4.2 (3.0, 6.0) 7.1 (4.9, 10.1) 13.1 (10.4, 16.3) 20.2 (16.7, 24.2) 15.0 (11.0, 20.1) 6.8 (5.7, 8.0) 9.5 (7.7, 11.7) 11.8 (10.1, 13.9) 14.6 (12.7, 16.7) 15.7 (13.1, 18.7) 11.2 (10.0, 12.4) 10.6 (8.1, 13.7) 16.3 (13.4, 19.8) 11.6 (9.3, 14.4) 14.4 (10.1, 20.0)
28.4 (24.6, 32.4) 9.8 (8.7, 0.9) 55.9 (48.7, 62.9) 10.8 (9.8, 12.0)
Abbreviation: CI, confidence interval. a“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
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Table 3. Multivariate Analysis of Factors Related to Cigarette Smoking. 95% CI Variablesa
Wald F
Sex Male Female Ethnicity Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade Remove classb/Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco Neither My father or male guardian My mother or female guardian Both Smoked first cigarette before the age of 14 years Yes No Attempted to quit smoking in the past 12 months Yes No Exposed to secondhand smoke the past 1 week Yes No Drank alcohol in the past 30 days Yes No Drug used at least once in the past 12 months Yes No In physical fight at least once in the past 12 months Yes No Bullied at least once in the past 12 months Yes No
20.301
aOR
Lower
3.053 1
1.872 1
1.921 1 2.637 1.207 3.166 2.978
0.794 1 0.348 0.410 1.137 0.562
1 1.099 1.433 1.579 2.101
1 0.567 0.720 0.797 1.039
1 0.794 2.732 0.983 2.461
1 0.385 1.456 0.547 0.854
1 1.023 0.882 4.782
1 0.795 0.299 1.156
0.775 1
0.592 1
1 1.678
1 1.067
4.685 1
3.376 1
2.337
1.463
2.972 1
1.243 1
1.147 1
0.853 1
1.411 1
1.004 1
3.250
2.108
3.782
1.993
3.511
5.095
86.624
12.792
6.089
0.841
3.981
Upper 4.978 1 4.651 1 19.999 3.559 8.816 15.782 1 2.129 2.852 3.126 4.251 1 1.634 5.127 1.768 7.090 1 1.317 2.601 19.772 1.014 1 1 2.638 6.501 1 3.735 7.106 1 1.543 1 1.984 1
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval. aAll variables were entered in the multivariable model. b“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
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be partly due to the local sociocultural norms that tend to stigmatize girls who smoke and society’s tolerant attitudes toward smoking among males; thus more female students may underreport their smoking status.16,18 Recent studies have shown that adolescents’ smoking habit may be influenced by their parent as a role model; adolescents whose parents are cigarette smokers are more likely to smoke themselves.8,16,19 Similarly, our study found the influence of parental smoking on the smoking behavior of adolescent school children. After controlling for potential confounders, the multivariable logistic regression analysis showed that when both parents used tobacco products, adolescents were almost 5 times more likely to be current smokers compared to those with nonsmoking parents (aOR = 4.78; 95% CI = 1.16, 19.77). This may be due to the easy availability and accessibility of cigarettes within their home, as well as the parents accepting their child’s smoking behavior. Almost half (41.6%) of the adolescents and approximately a quarter of the current smokers (23.9%) reported they were exposed to SHS 7 days prior to the survey. In line with a Chinese study,19 we found adolescents who were exposed to SHS were almost 5 times (aOR = 4.69; 95% CI = 3.38, 6.50) more likely to be current smokers. Apart from the parent factor mentioned above, adolescents living with smoking family members are more likely to be current smokers themselves. This may be due to the fact that both the nicotine inhalation from SHS and olfactory stimulation may act as a potent smoking stimulus. In addition, seeing others smoke can be an effective visual cue to smoking. Furthermore, our study found that adolescents with divorced parents had the highest prevalence of current smoking. This was significantly associated with current smoking even after controlling for confounders (aOR = 2.73; 95% CI = 1.46, 5.13). Other studies have reported a significant association between smoking among adolescents and parental marital status, especially having parents who were divorced.20,21 Adolescents may use the calming effect of smoking as a coping mechanism to regulate their emotions and stress due to their parents’ divorce. However, the causal effect of parental divorce and smoking among adolescents needs to be determined by a prospective study. Studies have shown that adolescents who participated in one health-risk behavior are more likely to engage in additional risk-taking behaviors.14,15,17,22 In the multivariable logistic regression analysis, adolescents who used drugs (aOR = 2.97; 95% CI = 1.24, 7.11) and drank alcohol (aOR = 2.34; 95% CI = 1.46, 3.74) were more likely to be current smokers. Cigarette and alcohol use share common etiological factors and often develop concurrently. Schmid et al22 reported that adolescents who drank alcohol and smoked concurrently exhibited characteristics that are well known as risk factors for later substance abuse and dependence. In addition, various studies have reported “clustering” of risk behaviors including smoking, alcohol, and drug use. Adolescents who were concurrent alcohol and tobacco users not only consumed more alcohol and smoked more cigarettes than the reference group, but they were more likely to use drugs as well.14,15,17,22,23 Our study further showed that adolescents who reported having been bullied at least once in the past 12 months were also more likely to smoke cigarettes. In a very large (N = 78 333) schoolbased survey among middle and high school youths, Radliff et al24 found that victims of bullying in high schools were more likely to use cigarettes and alcohol than their noninvolved peers. Similarly, Niemelä et al25 reported that being a victim of bullying predisposes adolescents in particular to subsequent smoking. Finnish boys who were bullied when they 8 years old experienced heavy smoking at age 18 years, that is, 10 cigarettes or more per day.25 Chinese adolescent school children from Beijing who reported to be bully victims were also found to be more likely to have smoked and used alcohol.26 In contrast, other authors have found a negative relationship between bully victimization and cigarette smoking.27,28 Pengpid and Peltzer14 did not find any association between bully victimization and current smoking among Thai adolescent school children.
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The findings from our study further stress the need to address clustering of health risk behaviors including cigarette smoking, alcohol and drug use through early and integrated prevention programs. The Ministry of Health (MOH) Malaysia and nongovernment organizations have been carrying out various tobacco control measures in concert with the antitobacco media approach to promote awareness among Malaysians about the harmful effects of tobacco use. The MOH has introduced several antismoking policies including Control of Tobacco Products Regulations in 1993, introduction of pictorial health warnings on cigarette packages in 2009, bans on all tobacco advertisements, sponsorships and promotions, prohibition of smoking in all public areas, as well as fiscal measures in increasing taxation on tobacco products. The national antitobacco campaigns, that is, Tak Nak Merokok (Say No to Smoking) Campaign launched in 2004, which is an effective public medium for dissemination of information on tobacco hazard, needs to be improved and intensified with regular monitoring of its performance.29 Programs to curb the use of other substances, such as alcohol and drugs use, should be integrated with antitobacco campaigns.
Limitations of the Study The findings in our study should be interpreted in light of several limitations. First, data were self-reported by the adolescents. No biomarker studies were carried out among those who reported current cigarette smoking, drank alcohol, or used drugs. There is concern of possible misreporting either intentionally or inadvertently on any of the questions asked. However, data collection was anonymous; and anonymous national school-based surveys have been shown to reveal higher rates than when names and addresses are required.30 Second, the MSHS was a cross-sectional survey whereby all data reported by the adolescents may reflect subjective perception of substance use, being involved in physical fights, and/or bullied rather than the actual situation. Therefore, it must be emphasized that the observed associations do not imply causality to any of the associated factors in this study. However, the strengths of the study are the large representative random sample of both male and female students, good response rates (schools and students), and a robust methodology.
Conclusions The prevalence of smoking among Malaysian adolescent school children was higher compared to their Southeast Asian counterparts and predominantly a problem among male students. We found that cigarette smoking was significantly associated with family factors, namely parents’ smoking habits, parents’ marital status, and exposure to SHS. We found a clustering of health risk behaviors among Malaysian adolescent school children, that is, cigarette smoking and alcohol drinking. Being a victim of bullying also predisposed these adolescents to cigarette smoking. The current public health intervention that aims to reduce or prevent smoking among adolescents should be redesigned and improved with the understanding that smoking is associated with family factors, other health risk behavior, and being victims of bullying. Our findings stress the need to have integrated approaches with involvement and partnerships with the community and different stakeholders. Acknowledgments The authors would like to thank the Director General of Health, Malaysia, for his permission to publish this article. We would also like to thank the Ministry of Education, the students who participated and those who were involved in the study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Tee and Gurpreet Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of the article: Research was funded by the Ministry of Health Malaysia and World Health Organization (WHO), Geneva, Switzerland.
References 1. World Health Organization. Chapter 1. Burden: mortality, morbidity and risk factors. In: Global Status Report on Non-communicable Diseases 2010. Description of the Global Burden of NCDs, Their Risk Factors and Determinants. http://www.who.int/nmh/publications/ncd_report_chapter1.pdf. Accessed January 8, 2014. 2. World Health Organization. WHO Report on the Global Tobacco Epidemic: Warning About the Dangers of Tobacco. Geneva, Switzerland: World Health Organization; 2011. 3. US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services; 1994. 4. Centers for Disease Control and Prevention. Chapter 3. The epidemiology of tobacco use among young people in the United States and worldwide. In: Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: Centers for Disease Control and Prevention; 2012. 5. Warren CW, Jones NR, Peruga A, et al. Global youth tobacco surveillance, 2000-2007. MMWR Surveill Summ. 2008;57(SS-1):1-28. 6. Hammond D, Foong K, Prohmmo A, et al. Patterns of smoking among adolescents in Malaysia and Thailand: findings from the International Tobacco Control Southeast Asia Survey, 2008. Asia Pac J Public Health. 2008;20:193-203. 7. Rapeah MY, Munirah Y, Latifah O, et al. Factors influencing smoking behaviours among male adolescents in Kuantan District. Ann Dent. 2008;15(2):77-81. 8. Naing NN, Ahmad Z, Musa R, Hamid FR, Ghazali H, Bakar MH. Factors related to smoking habits of male adolescents. Tob Induc Dis. 2004;2:133-140. 9. Fadhli Y, Riyanti S, Balkish MN, et al. Methodology of the National School-Based Health Survey in Malaysia, 2012. Asia-Pacific Journal of Public Health. 2014;26:9S-17S. 10. Institute for Health Behavioural Research. The Youth Behaviour Risk Factor Surveillance (YBRFS). Kuala Lumpur, Malaysia: Institute for Health Behavioural Research; 2010. 11. World Health Organization. Global School-based Student Health Survey Philippines, 2011 fact sheet. http://www.who.int/chp/gshs/2011_GSHS_FS_Philippines.pdf. Accessed January 10, 2014. 12. Global School-based Student Health Survey Indonesia, 2007 fact sheet. http://www.who.int/chp/ gshs/2007_Indonesia_fact_sheet.pdf. Accessed January 10, 2014. 13. Global School-based Student Health Survey Thailand, 2008 fact sheet. http://www.who.int/chp/ gshs/2008_Thailand_fact_sheet.pdf. Accessed January 10, 2014. 14. Pengpid S, Peltzer K. Prevalence and psychosocial correlates of illicit drug use among school-going adolescent in Thailand. J Soc Sci. 2013;34:269-275. 15. Alwan H, Viswanthan B, Rousson V, Paccaud F, Bovet P. Association between substance use and psychosocial characteristics among adolescents of the Seychelles. BMC Pediatr. 2011;11:85. 16. Siziya S, Muula AS, Rudatsikira E. Prevalence and correlates of current cigarette smoking among adolescents in East Timor-Leste. Indian Pediatr. 2008;45:963-968. 17. Faeh D, Viswanathan B, Chiolero A, Warren W, Bovet P. Clustering of smoking, alcohol drinking and cannabis use in adolescents in a rapidly developing country. BMC Public Health. 2006;6:169. doi:10.1186/1471-2458-6-169. 18. Tee GH, Hairi NN, Hairi F. Attitudes towards smoking and tobacco control among pre-clinical medical students in Malaysia. Int J Tuber Lung Dis. 2012;16:1126-1128. 19. Wang MP, Ho SY, Lo WS, Lam TH. Smoking family, secondhand smoke exposure at home, and nicotine addiction among adolescent smokers. Addict Behav. 2012;37:743-746. 20. Thomson EF, Filippelli J, Lue-Crisostomo CA. The gender-specific association between child hood adversities and smoking in adulthood: findings from a population based study. Public Health. 2013;127:449-460.
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21. Manaf RA, Shamsuddin K. Smoking among young urban Malaysian women and its risk factors. Asia Pac J Public Health. 2008;20:204-213. 22. Schmid B, Hohm E, Blomeyer D, et al. Concurrent alcohol and tobacco use during early adolescence characterizes a group at risk. Alcohol Alcohol. 2007;42:219-225. 23. Hoffman JH, Welte JW, Barnes GM. Co-occurrence of alcohol and cigarette use among adolescents. Addict Behav. 2001;26:63-78. 24. Radliff KM, Wheaton JE, Robinson K, Morris J. Illuminating the relationship between bullying and substance use among middle and high school youth. Addict Behav. 2012;37:569-572. 25. Niemelä S, Brunstein-Klomek A, Sillanmäki L, Helenius H, Piha J. Childhood bullying behaviors at age eight and substance use at age 18 among males. A nationwide prospective study. Addict Behav. 2011;36:256-260. 26. Hazemba A, Siziya S, Muula AS, Rudatsikira E. Prevalence and correlates of being bullied among inschool adolescents in Beijing: results from the 2003 Beijing Global School-Based Health Survey. Ann Gen Psychiatry. 2008;7:6. doi:10.1 186/1744-859X-7-6. 27. Liang H, Flisher AJ, Lombard CJ. Bullying, violence, and risk behaviour in South-African school students. Child Abuse Negl. 2007;31:161-71. 28. Houbre AB, Tarquinio C, Thuillier I, Hergott E. Bullying among students and its consequences on health. Eur J Psychol Educ. 2006;21:183-208. 29. Ministry of Health. Country Health Plan, 10th Malaysia Plan 2011-2015. Kuala Lumpur, Malaysia: Ministry of Health 30. Griesler PC, Kandel DB, Schaffran C, Hu MC, Davies M. Adolescents’ inconsistency in self-reported smoking. A comparison of reports in school and in household settings. Public Opin Q. 2008;72: 260-290.
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Correlates of Current Smoking Among Malaysian Secondary School Children Guat Hiong Tee and Gurpreet Kaur Asia Pac J Public Health 2014 26: 70S originally published online 25 June 2014 DOI: 10.1177/1010539514540468 The online version of this article can be found at: http://aph.sagepub.com/content/26/5_suppl/70S
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540468 research-article2014
APHXXX10.1177/1010539514540468Asia-Pacific Journal of Public HealthTee and Gurpreet
Original Article
Correlates of Current Smoking Among Malaysian Secondary School Children
Asia-Pacific Journal of Public Health 2014, Vol. 26(5S) 70S–80S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514540468 aph.sagepub.com
Guat Hiong Tee, MMedSc (Public Health), BBioMedSc (Hons)1, and Gurpreet Kaur, MBBS, MPH (Epid)1
Abstract Cigarette smoking in adolescent is a significant public health problem, leading to the risk of addiction, morbidity, and mortality in the long term. This study determined the prevalence and correlates of current smoking among adolescent school children. A nationwide school-based survey among 25 507 students between Forms 1 to 5 (aged 12-17) was conducted using a 2-stage cluster sampling design. The prevalence of current smoking was 11.5%. Multivariable logistic regression analysis revealed that current smoking was significantly associated with males (adjusted odds ratio [aOR] = 3.25; 95% confidence interval [CI] = 1.87, 4.98), current drinking (aOR = 2.34; 95% CI = 1.46, 3.74), drug used (aOR = 2.97; 95% CI = 1.24, 7.11), and being bullied (aOR = 1.41; 95% CI = 1.00, 1.98) at least once in the past 12 months. Smoking is associated with several behaviors that pose risks to adolescents, such as social issues and smoking-related health problems. Thus, early and integrated prevention programs that address multiple risk behaviors simultaneously are required. Keywords smoking, drinking alcohol, substance use, bullying, Global School Health Survey (GSHS), Malaysia, adolescent
Introduction Tobacco consumption is the single most important preventable cause of premature mortality and morbidity. Annually, 6% of all female and 12% of all male deaths in the world, totaling 6 million people, are attributed to tobacco use and exposure.1 Current trend shows that by 2030, the number of deaths attributed to tobacco consumption will rise from 5 million to 8 million annually.2 Smoking is also estimated to cause about 42% of chronic respiratory disease and nearly 10% of cardiovascular disease.1 The negative effects of smoking are more detrimental to younger people due to their sensitivity to nicotine addiction and possible inability of the lungs to grow to full capacity. About one third of youths who persist in smoking will die prematurely from smoking.3 The predominant type of tobacco used among 13 to 15 year olds has been shown to be cigarettes.4 Generally, boys are also more likely to be current smokers than girls.3 1Institute
for Public Health, National Institutes of Health, Ministry of Health, Kuala Lumpur, Malaysia
Corresponding Author: Guat Hiong Tee, Institute for Public Health, National Institutes of Health, Ministry of Health Malaysia, Jalan Bangsar, 50590 Kuala Lumpur, Malaysia. Email: [email protected]
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The severity of health consequences depends on the age of initiation, that is, the younger the age of tobacco use, the greater the damage to health. Since most individuals do not start smoking after the age of 25, smoking prevention efforts must focus on adolescents and young people.3 Smoking rates among adolescents are mainly derived from self-reported studies. Globally, it has only been possible to report smoking among adolescents in a standard way since the Center for Disease Control and Prevention, Atlanta, coordinated the Global Youth Tobacco Survey (GYTS) beginning in 1999. Based on these GYTS studies, the global prevalence of current smoking among adolescents aged 13 to 15 years is 9.25%, with the highest prevalence reported from the European region (19.2%) and the lowest prevalence from the Eastern Mediterranean region (4.9%).4 Among Malaysians, a study by Hammond et al found that 3% of Malaysian and Thai youths aged 13 to 17 years were current smokers, with another 10% to 12% being experimental smokers.6 Another study by Rapeah et al in Kuantan, Malaysia, noted that type of class stream (science or arts), peers who smoked, and attitude toward smoking were associated with smoking among male students.7 Furthermore, a study in Kelantan, Malaysia, showed that other factors, such as parent’s smoking history, academic performance, perception of the health hazards of smoking, and type of school attended, were associated with smoking among male students.8 Overall, there is still a paucity of evidence on the prevalence of and factors associated with tobacco consumption among school-going children in Malaysia. Local epidemiologic data on smoking among this population are fundamental for the planning and implementation of antismoking public health programs. This study aims to determine the prevalence of current smoking and its associated factors among Malaysian school-going adolescents from Forms 1 to 5 (12-17 years).
Methodology Sampling The Malaysia School-Based Health Survey (MSHS) 2012 was a cross-sectional survey involving students in Forms 1 to 5 (12-17 years) using the standardized questionnaire of the World Health Organization Global School-based Health Survey (GSHS). Consistent with the GSHS methodology, students were selected using a 2-stage cluster sampling design to produce a nationwide representative sample. The first-stage sampling frame consisted of all schools with Forms 1 to 5 classes. Schools were selected with probability proportional to their reported enrolment size. In total, 234 schools were randomly selected to participate in the MSHS. The second stage of sampling consisted of systematic random sampling of classrooms from each participating school. All students in the sampled classrooms were eligible to participate in the MSHS. Students who consented to participate in the survey self-administered the bilingual pretested questionnaires within 2 class periods and recorded their responses on computer-scannable answer sheets. The detailed methodology of the MSHS has been reported by Fadhli et al.9 The students’ privacy was protected through anonymity and voluntary participation. Ethical approvals were obtained from both the Ministry of Health Research and Ethics Committee and Ministry of Education Ethics Committee. Prior to data collection, parental consent forms were distributed to all students from selected classes, and nonconsenting students were considered as non responders.
Definition of Variables The outcome variable, that is, smoking, referred to cigarette smoking only. Cigarette smoking (current smoking) in the past 30 days was assessed with the question, “During the past 30 days, on how many days did you smoke cigarettes?” Response options ranged from 1 = 0 day to 7 = all 30 days. Alcohol used was assessed with the question, “During the past 30 days, on how many
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days did you have at least one drink containing alcohol?” Response options ranged from 1 = 0 day to 7 = all 30 days. For drug used, students were asked, “During the past 30 days, how many times have you used drugs?” Response options ranged from 1 = 0 time to 5 = 20 or more times. Potential predictors or risk factors were determined as follows. Physical fight was assessed with the question, “During the past 12 months, how many times were you in a physical fight?” Response options ranged from 1 = 0 time to 8 = 12 or more times. To assess bullying at school, students were asked, “During the past 30 days, on how many days were you bullied?” Response options ranged from 1 = 0 day to 7 = all 30 days. Other variables included in this study were selected sociodemographic data (age group, sex, parent’s marital status), whether one or both parents/guardians use tobacco, use of other tobacco products (other than cigarettes), smoked first cigarette before the age of 14 years, attempted to quit smoking in the past 12 months, and exposure to secondhand smoke (SHS).
Data Analysis Data were analyzed using the Statistical Package for the Social Science, version 21 (SPSS Inc, Chicago, IL). Statistical significance was defined at P < .05. Odds ratios (OR) and 95% confidence intervals (CIs) were derived where appropriate. Multivariable logistic regression analysis was used to assess the associations between current smoking and predictor/risk variables described above. All variables were entered in the multivariable logistic regression analysis to compute the adjusted odds ratio (aOR) for each independent predictor.
Results A total of 25 493 students responded to the tobacco use module, giving a very high response rate of 99.9% (25 493/25 507). The largest number of respondents was males (50.2%), Malays (60.8%), and those in Remove class/Form 1 (21.9%). About 86% of the students’ parents were married and living together at the time of the survey. Just over half of them (57.2%) had nonsmoking parents (Table 1). The prevalence of current smoking among these adolescents was 11.5%. Only 7.4% of respondents had ever used tobacco products other than cigarettes. The majority (58.4%) had not been exposed to SHS in the past week. Among the current smokers, more than 70% claimed to have initiated smoking before the age of 14 years. About 88% of current smokers claimed to have attempted to quit smoking in the past year (Table 1). Table 2 shows the prevalence of current smoking by sociodemographic characteristics and selected health-related behaviors. The highest prevalence of current smoking was among males (20.9%), Bumiputra Sarawak (20.2%), students in Form 5 (15.7%), adolescents with divorced parents (16.3%), and adolescents whose mother or female guardian used tobacco (36.9%). The highest prevalence of current smoking was also noted among those who were exposed to SHS in the past week (23.9%), initiated smoking before the age of 14 years (69.4%), and did not attempt to quit smoking in the past year (85.4%). Adolescents who were involved in physical fighting (21.5%), were bullied (15.3%), or used drugs (55.9%) in the past year and adolescents who drank alcohol in the past 30 days (28.4%) also had the highest prevalence of current smoking (Table 2). After adjusting for confounders, 9 variables, sex, ethnicity, parents’ marital status, use of tobacco among parents, attempting to quit smoking, SHS exposure, drinking alcohol, using drugs, and being bullied, were found to be significantly associated with current smoking (Table 3). Students who were exposed to SHS in the past week (aOR = 4.69; 95% CI = 3.38, 6.50) and who had both parents using tobacco products (aOR = 4.78; 95% CI = 1.16, 19.77) were almost 5 times more likely to be current smokers compared to those who were not exposed and who have
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Tee and Gurpreet Table 1. Frequency Distribution of Respondents by Sociodemographic Characteristics and Selected Health-Related Behaviors.
95% Confidence Interval Sociodemographic Characteristics (n = 25 493) Sex (n = 25 461) Male Female Ethnicity (n = 25 464) Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade (n = 25 447) Remove classa and Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status (n = 25 426) Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco (n = 25 412) Neither My father or male guardian My mother or female guardian Both Current smoker (n = 25 378) Yes No Use of other tobacco products (other than cigarettes) (n = 25 432) None Shisha/Hookah Electronic cigarettes Snuff or chewing tobacco Pipes Curut, cigars or cigarillos Bidis Other tobacco products Smoked first cigarette before the age of 14 years (n = 4809) Yes No
n
N
%
Lower (%)
12 732 12 729
1 127 000 50.2 1 119 000 49.8
48.3 48.0
17 086 4509 1447 992 1021 409
1 366 000 60.8 453 800 20.2 154 400 6.9 110 900 4.9 122 200 5.4 38 670 1.7
56.5 16.6 5.6 4.2 4.3 1.2
5433 5329 5599 4515 4571
490 490 458 600 449 900 431 500 413 500
Upper (%) 52.0 51.7 64.9 24.4 8.5 5.8 6.8 2.5 23.9 23.2 22.1 21.8 20.7 86.9 3.5 5.1 5.3 1.4 58.9 42.5 1.1 1.3 12.7 89.6
21.9 20.4 20.1 19.2 18.4
19.9 17.9 18.2 16.9 16.3
21 657 758 1190 1202 271
1 903 000 86.1 68 960 3.1 103 900 4.7 107 400 4.9 26 120 1.2
85.3 2.8 4.3 4.5 1.0
13 771 9848 183 231
1 207 000 57.2 860 600 40.8 17 840 0.8 22 950 1.1
55.5 39.2 0.7 0.9
2707 22 671
257 700 11.5 1 981 000 88.5
10.4 87.3
23 732 608 244 263 57 89 21 418
2 077 000 92.6 57 080 2.5 25 860 1.2 26 050 1.2 5825 0.3 8852 0.4 2036 0.1 40 960 1.8
91.8 2.2 0.9 1.0 0.2 0.3 0.1 1.6
93.3 2.9 1.4 1.4 0.4 0.5 0.2 2.1
3470 1339
313 600 70.8 129 300 29.2
69.0 27.5
72.5 31.0 (continued)
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Table 1. (continued) 95% Confidence Interval Sociodemographic Characteristics (n = 25 493) Attempted to quit smoking in the past 12 months (n = 2994) Yes No Exposed to secondhand smoke the past 1 week (n = 25 450) Yes No Drank alcohol in the past 30 days (n = 25 285) Yes No Drug used at least once in the past 12 months (n = 25 474) Yes No In a physical fight at least once in the past 12 months (n = 25 474) Yes No Bullied at least once in the past 12 months (n = 23 992) Yes No
n
N
%
Lower (%)
Upper (%)
2626 368
247 700 88.1 33 560 11.9
86.1 10.2
89.8 13.9
10 619 14 831
934 100 41.6 1 311 000 58.4
39.9 56.6
1926 23 359
197 700 8.9 2 030 000 91.1
7.8 89.9
43.4 60.1 10.1 92.2
346 25 128
34 060 1.5 2 213 000 98.5
1.2 98.1
1.9 98.8
6849 18 536
615 200 27.4 1 633 000 72.6
26.0 71.3
28.7 74.0
4167 19 825
378 400 17.9 1 738 000 82.1
16.8 81.0
19.0 83.2
a“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
nonsmoking parents, respectively. Male students were about 3 times (aOR = 3.05; 95% CI = 1.88, 4.98) more likely to be current smokers compared to female students. The next strongest association with current smoking was ethnicity, drug use, parent’s marital status, and drinking alcohol. Although the prevalence of current smoking increased progressively with age from Remove/Form 1 to Form 5, controlling for all other factors, a significantly higher risk for current smoking was only observed for the oldest age category. To a lesser extent, adolescents who had attempted to quit smoking (aOR = 1.68; 95% CI = 1.07, 2.64) and those who were bullied in the past year (aOR = 1.41; 95% CI = 1.00, 1.98) were more likely to be smoking.
Discussion The overall prevalence of smoking (11.5%) among Malaysian school-going adolescents from this study was lower than the finding from the Youth Behavioral Risk Factor Surveillance (17.8%) conducted among Malaysian secondary school children in 2010.10 However, compared with school children in Southeast Asian countries, the prevalence of smoking among Malaysian adolescents was higher than Philippino,11 Indonesian,12 and Thai students13 at 11.0%, 10.9%, and 8.2%, respectively. Consistent with other studies, the prevalence of smoking cigarettes was higher among boys than girls14-17 and increased as they progressed through the Forms.16-18 The gender disparity may
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Tee and Gurpreet Table 2. Prevalence of Current Smoking by Sociodemographic Characteristics and Selected HealthRelated Behaviors. Current Smoking Variables
Yes, % (95% CI)
Sex Male Female Ethnicity Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade Remove classa/Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco Neither My father or male guardian My mother or female guardian Both Smoked first cigarette before the age of 14 years Yes No Attempted to quit smoking in the past 12 months Yes No Exposed to secondhand smoke the past 1 week Yes No Drank alcohol in the past 30 days Yes No Drug used at least once in the past 12 months Yes No In physical fight at least once in the past 12 months Yes No Bullied at least once in the past 12 months Yes No
No, % (95% CI)
8.0 (7.0, 9.2) 13.7 (12.4, 15.0) 36.9 (28.3, 46.4) 22.1 (16.3, 29.1)
79.1 (77.0, 81.1) 97.9 (97.4, 98.2) 86.5 (85.0, 88.0) 95.8 (94.0, 97.0) 92.9 (89.1, 95.1) 86.9 (83.7, 89.6) 79.8 (75.8, 83.3) 85.0 (79.9, 89.0) 93.2 (92.0, 94.3) 90.5 (88.3, 92.3) 88.2 (86.1, 89.9) 85.4 (83.3, 87.3) 84.3 (81.3, 86.9) 88.8 (87.6, 90.0) 89.4 (86.3, 91.9) 83.7 (80.2, 86.6) 88.4 (85.6, 90.7) 85.6 (80.0, 89.9) 92.0 (90.8, 93.0) 86.3 (85.0, 87.6) 63.1 (53.6, 71.7) 77.9 (70.9, 83.7)
52.1 (49.2, 55.1) 69.4 (66.3, 72.3)
47.9 (44.9, 50.8) 30.6 (27.7, 33.7)
77.0 (74.4, 79.3) 85.4 (80.1, 89.5)
23.0 (20.7, 25.6) 14.6 (10.5, 19.9)
23.9 (22.2, 25.9) 2.6 (2.1, 3.1)
21.5 (19.7, 23.4) 7.8 (6.9, 8.8)
76.1 (74.1, 77.9) 97.4 (96.9, 97.9) 71.6 (67.6, 75.4) 90.2 (89.1, 91.3) 44.1 (37.1, 51.3) 89.2 (88.0, 90.2) 78.5 (76.6, 80.3) 92.2 (91.2, 93.1)
15.3 (13.4, 17.3) 10.5 (9.4, 11.8)
84.7 (82.7, 86.6) 89.5 (88.2, 90.6)
20.9 (18.9, 23.0) 2.1 (1.8, 2.6) 13.5 (12.0, 15.0) 4.2 (3.0, 6.0) 7.1 (4.9, 10.1) 13.1 (10.4, 16.3) 20.2 (16.7, 24.2) 15.0 (11.0, 20.1) 6.8 (5.7, 8.0) 9.5 (7.7, 11.7) 11.8 (10.1, 13.9) 14.6 (12.7, 16.7) 15.7 (13.1, 18.7) 11.2 (10.0, 12.4) 10.6 (8.1, 13.7) 16.3 (13.4, 19.8) 11.6 (9.3, 14.4) 14.4 (10.1, 20.0)
28.4 (24.6, 32.4) 9.8 (8.7, 0.9) 55.9 (48.7, 62.9) 10.8 (9.8, 12.0)
Abbreviation: CI, confidence interval. a“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
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Table 3. Multivariate Analysis of Factors Related to Cigarette Smoking. 95% CI Variablesa
Wald F
Sex Male Female Ethnicity Malay Chinese Indian Bumiputera Sabah Bumiputera Sarawak Some other ethnicity Grade Remove classb/Form 1 (12-13 years) Form 2 (14 years) Form 3 (15 years) Form 4 (16 years) Form 5 (17 years) Parents’ marital status Married and living together Married but living apart Divorced Widower Separated Parents who use tobacco Neither My father or male guardian My mother or female guardian Both Smoked first cigarette before the age of 14 years Yes No Attempted to quit smoking in the past 12 months Yes No Exposed to secondhand smoke the past 1 week Yes No Drank alcohol in the past 30 days Yes No Drug used at least once in the past 12 months Yes No In physical fight at least once in the past 12 months Yes No Bullied at least once in the past 12 months Yes No
20.301
aOR
Lower
3.053 1
1.872 1
1.921 1 2.637 1.207 3.166 2.978
0.794 1 0.348 0.410 1.137 0.562
1 1.099 1.433 1.579 2.101
1 0.567 0.720 0.797 1.039
1 0.794 2.732 0.983 2.461
1 0.385 1.456 0.547 0.854
1 1.023 0.882 4.782
1 0.795 0.299 1.156
0.775 1
0.592 1
1 1.678
1 1.067
4.685 1
3.376 1
2.337
1.463
2.972 1
1.243 1
1.147 1
0.853 1
1.411 1
1.004 1
3.250
2.108
3.782
1.993
3.511
5.095
86.624
12.792
6.089
0.841
3.981
Upper 4.978 1 4.651 1 19.999 3.559 8.816 15.782 1 2.129 2.852 3.126 4.251 1 1.634 5.127 1.768 7.090 1 1.317 2.601 19.772 1.014 1 1 2.638 6.501 1 3.735 7.106 1 1.543 1 1.984 1
Abbreviations: aOR, adjusted odds ratio; CI, confidence interval. aAll variables were entered in the multivariable model. b“Remove class” is the preparatory class for non-Malays in Malaysia who do not pass Malay language in the Standard 6 examination or UPSR.
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be partly due to the local sociocultural norms that tend to stigmatize girls who smoke and society’s tolerant attitudes toward smoking among males; thus more female students may underreport their smoking status.16,18 Recent studies have shown that adolescents’ smoking habit may be influenced by their parent as a role model; adolescents whose parents are cigarette smokers are more likely to smoke themselves.8,16,19 Similarly, our study found the influence of parental smoking on the smoking behavior of adolescent school children. After controlling for potential confounders, the multivariable logistic regression analysis showed that when both parents used tobacco products, adolescents were almost 5 times more likely to be current smokers compared to those with nonsmoking parents (aOR = 4.78; 95% CI = 1.16, 19.77). This may be due to the easy availability and accessibility of cigarettes within their home, as well as the parents accepting their child’s smoking behavior. Almost half (41.6%) of the adolescents and approximately a quarter of the current smokers (23.9%) reported they were exposed to SHS 7 days prior to the survey. In line with a Chinese study,19 we found adolescents who were exposed to SHS were almost 5 times (aOR = 4.69; 95% CI = 3.38, 6.50) more likely to be current smokers. Apart from the parent factor mentioned above, adolescents living with smoking family members are more likely to be current smokers themselves. This may be due to the fact that both the nicotine inhalation from SHS and olfactory stimulation may act as a potent smoking stimulus. In addition, seeing others smoke can be an effective visual cue to smoking. Furthermore, our study found that adolescents with divorced parents had the highest prevalence of current smoking. This was significantly associated with current smoking even after controlling for confounders (aOR = 2.73; 95% CI = 1.46, 5.13). Other studies have reported a significant association between smoking among adolescents and parental marital status, especially having parents who were divorced.20,21 Adolescents may use the calming effect of smoking as a coping mechanism to regulate their emotions and stress due to their parents’ divorce. However, the causal effect of parental divorce and smoking among adolescents needs to be determined by a prospective study. Studies have shown that adolescents who participated in one health-risk behavior are more likely to engage in additional risk-taking behaviors.14,15,17,22 In the multivariable logistic regression analysis, adolescents who used drugs (aOR = 2.97; 95% CI = 1.24, 7.11) and drank alcohol (aOR = 2.34; 95% CI = 1.46, 3.74) were more likely to be current smokers. Cigarette and alcohol use share common etiological factors and often develop concurrently. Schmid et al22 reported that adolescents who drank alcohol and smoked concurrently exhibited characteristics that are well known as risk factors for later substance abuse and dependence. In addition, various studies have reported “clustering” of risk behaviors including smoking, alcohol, and drug use. Adolescents who were concurrent alcohol and tobacco users not only consumed more alcohol and smoked more cigarettes than the reference group, but they were more likely to use drugs as well.14,15,17,22,23 Our study further showed that adolescents who reported having been bullied at least once in the past 12 months were also more likely to smoke cigarettes. In a very large (N = 78 333) schoolbased survey among middle and high school youths, Radliff et al24 found that victims of bullying in high schools were more likely to use cigarettes and alcohol than their noninvolved peers. Similarly, Niemelä et al25 reported that being a victim of bullying predisposes adolescents in particular to subsequent smoking. Finnish boys who were bullied when they 8 years old experienced heavy smoking at age 18 years, that is, 10 cigarettes or more per day.25 Chinese adolescent school children from Beijing who reported to be bully victims were also found to be more likely to have smoked and used alcohol.26 In contrast, other authors have found a negative relationship between bully victimization and cigarette smoking.27,28 Pengpid and Peltzer14 did not find any association between bully victimization and current smoking among Thai adolescent school children.
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The findings from our study further stress the need to address clustering of health risk behaviors including cigarette smoking, alcohol and drug use through early and integrated prevention programs. The Ministry of Health (MOH) Malaysia and nongovernment organizations have been carrying out various tobacco control measures in concert with the antitobacco media approach to promote awareness among Malaysians about the harmful effects of tobacco use. The MOH has introduced several antismoking policies including Control of Tobacco Products Regulations in 1993, introduction of pictorial health warnings on cigarette packages in 2009, bans on all tobacco advertisements, sponsorships and promotions, prohibition of smoking in all public areas, as well as fiscal measures in increasing taxation on tobacco products. The national antitobacco campaigns, that is, Tak Nak Merokok (Say No to Smoking) Campaign launched in 2004, which is an effective public medium for dissemination of information on tobacco hazard, needs to be improved and intensified with regular monitoring of its performance.29 Programs to curb the use of other substances, such as alcohol and drugs use, should be integrated with antitobacco campaigns.
Limitations of the Study The findings in our study should be interpreted in light of several limitations. First, data were self-reported by the adolescents. No biomarker studies were carried out among those who reported current cigarette smoking, drank alcohol, or used drugs. There is concern of possible misreporting either intentionally or inadvertently on any of the questions asked. However, data collection was anonymous; and anonymous national school-based surveys have been shown to reveal higher rates than when names and addresses are required.30 Second, the MSHS was a cross-sectional survey whereby all data reported by the adolescents may reflect subjective perception of substance use, being involved in physical fights, and/or bullied rather than the actual situation. Therefore, it must be emphasized that the observed associations do not imply causality to any of the associated factors in this study. However, the strengths of the study are the large representative random sample of both male and female students, good response rates (schools and students), and a robust methodology.
Conclusions The prevalence of smoking among Malaysian adolescent school children was higher compared to their Southeast Asian counterparts and predominantly a problem among male students. We found that cigarette smoking was significantly associated with family factors, namely parents’ smoking habits, parents’ marital status, and exposure to SHS. We found a clustering of health risk behaviors among Malaysian adolescent school children, that is, cigarette smoking and alcohol drinking. Being a victim of bullying also predisposed these adolescents to cigarette smoking. The current public health intervention that aims to reduce or prevent smoking among adolescents should be redesigned and improved with the understanding that smoking is associated with family factors, other health risk behavior, and being victims of bullying. Our findings stress the need to have integrated approaches with involvement and partnerships with the community and different stakeholders. Acknowledgments The authors would like to thank the Director General of Health, Malaysia, for his permission to publish this article. We would also like to thank the Ministry of Education, the students who participated and those who were involved in the study.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of the article: Research was funded by the Ministry of Health Malaysia and World Health Organization (WHO), Geneva, Switzerland.
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