542426 research-article2014
APHXXX10.1177/1010539514542426Asia-Pacific Journal of Public HealthLim KH et al
Original Article
Parental Smoking Status, Stress, Anxiety, and Depression Are Associated With Susceptibility to Smoking Among Non-Smoking School Adolescents in Malaysia
Asia-Pacific Journal of Public Health 2014, Vol. 26(5S) 81S–90S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514542426 aph.sagepub.com
Kuang Hock Lim, MSc1, Zhuolin Chong, MD1, Yi Yi Khoo, MBChB1, and Jasvindar Kaur, MBBS, MPH1
Abstract Susceptibility to smoking is a reliable predictor of smoking initiation. This article describes its prevalence and associated factors among Malaysian school adolescents. Data were obtained from the Global School-Based Student Health Survey (GSHS) 2012, a nationwide representative sample of school adolescents. The overall prevalence of susceptibility to smoking was 6.0% and significantly higher among males (9.5%) compared with females (3.6%). Multivariable analyses revealed that males (adjusted odds ratio [aOR] 3.34, 95% confidence interval [CI] 2.70-4.18) and school adolescents of indigenous Sabahan or Sarawakian descents (aOR 1.62, 95%CI 1.212.18) were significantly more likely to be susceptible to smoking. Susceptible school adolescents had a slightly higher likelihood to have symptoms of stress (aOR 1.31, 95% CI 1.02-1.70), anxiety (aOR 1.19, 95% CI 1.01-1.40), depression (aOR 1.56, 95% CI 1.25-1.96), including those whose one or both parents/guardians were smokers (aOR 1.48, 95% CI 1.21-1.82; aOR 2.33, 95% CI 1.22-4.44, respectively). The findings from this study point out the need for proactive measures to reduce smoking initiation among Malaysian adolescents with particular attention toward factors associated with susceptibility to smoking, Keywords susceptibility to smoking, adolescents, Global School-Based Student Health Survey, smoking
Introduction Smoking is a habit that is learnt and initiated during adolescence.1 The earlier an individual starts smoking, the higher the risk in contracting smoking-related illnesses. Male and female adolescents who started smoking before the age of 15 years had twice the risk to develop lung cancer compared with those who started at age 20 years or more.2 At the same time, those who initiated
1Institute
of Public Health, Kuala Lumpur, Malaysia
Corresponding Author: Kuang Hock Lim, Institute of Public Health, Jalan Bangsar, Kuala Lumpur 50599, Malaysia. Email: [email protected]
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
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Asia-Pacific Journal of Public Health 26(5S)
smoking during adolescence were more prone to become heavy smokers in their adulthood and would continue smoking for a long time before successfully quitting.3 Hence, reducing the incidence of smoking initiation is one of the long-term measures to reduce smoking prevalence and health consequences associated with cigarette smoking. The identification of adolescents susceptible to smoking is the prerequisite for reducing smoking initiation among them. The concept “susceptibility to smoking,” which is the lack of cognitive commitment to not smoke in the future is recognized as a reliable predictor of smoking habit among adolescents.4 This has been proven through local and international research. Difranza et al5 reported that adolescents who were susceptible to smoking were 2 to 3 times more likely to become experimental smokers. Meanwhile, among elementary school students, Jackson1 reported that cognitive susceptibility was the main predictor of smoking initiation after 2 years. Pierce et al4 reported that susceptibility to smoking was the main independent variable that contributed to smoking compared with other independent variables such as smoking among family members (father or brothers) and peer smoking. Local research carried out by Lim et al6 among secondary school adolescents aged 13 to 17 years in Kota Tinggi district revealed that nonsmoking adolescents who were susceptible to smoking were 3.7 times more likely to initiate smoking after a year compared with those who were not susceptible. The identification of adolescents susceptible to smoking and its associated factors would enable efficient allocation of resources for prevention. Among other factors, female adolescents, having peer and family smokers, and positive expectations about smoking were reported to have associations with susceptibility to smoking.7-9 However, these findings are not consistent and are based on Western populations. Social and cultural differences may render them unsuitable in the Malaysian context. Moreover, only a few Western studies have looked into associations between susceptibility to smoking and cognitive factors, such as stress, anxiety, and depression.10,11 Although a study on susceptibility to smoking has been done in this country, it only involved adolescents from a single district and majority of them was from a single ethnic group.6 Thus, the findings from the study cannot be generalized to all adolescents in Malaysia. This article aims to fill the knowledge gap on prevalence, inter- and intrapersonal and cognitive factors (stress, anxiety, and depression) related to “susceptibility to smoking” in a representative sample of secondary school adolescents in Malaysia.
Methods Sampling Procedure This cross-sectional national survey among school adolescents was conducted from February to April 2012. The sample was selected using a 2-stage stratified cluster sampling to produce a representative sample of school adolescents in form 1 to form 5, aged 12 to 17 years. The sampling frame was all secondary schools under the Malaysia Ministry of Education. The first stage was selection of school in proportion to school enrollment and the second stage was the selection of classroom from the selected school. All school adolescents from the selected classroom were eligible to participate in the study. A total of 234 schools and 28 732 respondents were selected to participate in this survey.12 The survey instrument used was a questionnaire adapted from Global School-Based Student Health Survey, World Health Organization,13 which was translated into Malay, and validated by a research panel. The questionnaire was self-administered. Prior to data collection, trained research assistants explained in detail to the selected respondents regarding the survey, namely, its objectives, voluntary participation, confidentiality, and the content of the questionnaire. Any doubts were clarified by the research team members. Completed questionnaires were collected and sealed in front of the respondents. Only respondents who obtained written consent from their
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
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Lim KH et al
parents/guardian were allowed to participate in this study. The survey protocol was approved by Malaysia Ministry of Education, whereas approval to recruit the students as participants was given by individual schools and their respective District and State Departments of Education. Ethical approvals were obtained from the Medical Research and Ethics Committee of Ministry of Health and Ministry of Education.
Measurements The dependent variable in this survey “Susceptibility to Smoking” was measured using 2 questions: (a) Do you think you will smoke a cigarette in the next year? (b) If one of your best friends were to offer you a cigarette, would you smoke? The choices of answers were (a) Yes, (b) Probably yes, (c) Probably no, and (d) Not at all. If the respondent answered “Not at all” to both questions, they were categorized as “Not susceptible to smoking,” while those who gave other combinations were categorized as “Susceptible to smoking.” The independent variables in this survey were gender, age-group, ethnicity, school sessions, parental marital status, and parental tobacco consumption. Stress, anxiety, and depression levels among respondents were measured using validated Mental Health Survey with administered Depression, Anxiety, Stress Scale (DASS 21) questionnaire in Malay.14 The final score of each item groups (Depression, Anxiety, and Stress) was multiplied by 2.15 Respondents who scored more than 9,8 and 15 for depression, anxiety, and stress were classified as “having the abovementioned symptoms.”
Data Management and Analysis A total of 25 507 school adolescents participated in the survey, giving an overall response rate of 89.0%. The data on 18 870 of respondents classified as nonsmoking were analyzed using SPSS version 21. Data entry was done using scanner for DASS and GSHS. Data were weighted in the analysis to account for the complex study design and response rate. Descriptive statistics were used to elaborate the social demographic characteristics of the sample and to estimate the prevalence of susceptibility to smoking. Chi-square analysis was used to test the associations between the categorical independent variables (gender, schooling session, etc) with susceptibility to smoking. Variables with P ≤ .25 were included into the binary multivariable logistic regression to determine the influence of each variable on susceptibility to smoking while simultaneously controlling for potential confounding effects by other variables. Analysis of 2-way interaction revealed no significance for all variables in the final model. All statistical analyses were performed at 95% confidence level.
Results The majority of the 18 870 nonsmoking respondents consisted of adolescents aged 13 to 15 years (72.8%), females (59.5%), and those who attended morning school sessions (59.1%). Similar to the Malaysian population as a whole, the distribution of nonsmoking school respondents by ethnicity was 58.0% Malay, 23.5% Chinese, 7.2% Indian, and 9.7% Indigenous Sabahan and Sarawakian. Bivariate analysis showed that intra- and interpersonal factors were significantly associated with susceptibility to smoking, The overall prevalence of adolescents susceptible to smoking was 6.0%, with a significantly higher proportion of males compared with females (9.5% vs 3.6%, P < .001). In addition, indigenous Sabahan and Sarawakians were significantly more susceptible to smoking compared with Malay or Chinese (9.1% vs 5.9% and 4.5%, P < .001). Furthermore, Chinese adolescents showed a significantly lower susceptibility to smoking compared with adolescents of other ethnicities (P < .001; Tables 1 and 2). The proportions of
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Asia-Pacific Journal of Public Health 26(5S)
Table 1. Sociodemographic Characteristic of Respondents. Variables Gender Male Female Ethnicity Malay Chinese Indian Indigenous Sabahan and Sarawakian Others Age-group (years) 13-15 ≥16 Schooling sessionb Morning Afternoon Morning till afternoon Marital status of parents Married Separated
na
Na
7724 11 146
660 718 1 629 464
12 232 3809 1157 1367
944 883 382 637 116 544 157 288
298
2772
11 629 4030
989 921 370 002
10 799 3024 4993
961 089 339 515 324 778
16 181 2419
1 392 916 212 568
Percentage 40.5 59.5 58.0 23.5 7.2 9.7 1.7 72.8 27.2 59.1 20.9 20.0 86.8 13.2
an
= sample and N = estimated population. implements a triple-shift school-day system comprising a morning session, an afternoon session, and a morning until afternoon session. bMalaysia
respondents whose father/male guardian, mother/female guardian, or both parents/guardians smoked were also significantly higher compared with those whose parents/guardians were nonmokers (6.8%, 14.3%, 12.0%, and 5.1%, respectively, P < .001). Finally, the susceptibility to smoking was higher among respondents who had symptoms of stress (8.6% vs 5.7%, P < .001), anxiety (7.2% vs 5.3%, P < .001), and depression (9.1% vs 5.4%, P < .001) than their counterparts without these symptoms. After adjusting for other independent variables, multivariable analysis revealed that respondents susceptible to smoking were more likely to be male (adjusted odds ratio [aOR] 3.36, 95% confidence interval [CI] 2.70-4.18), indigenous Sabahan and Sarawakian (aOR 1.62, 95% CI 1.21-2.18), had father/male guardian or both parents who smoked (aOR 1.48, 95% CI 1.21-1.82; aOR 2.32, 95%CI 1.22-4.44, resoectively); reported stress (aOR 1.31, 95% CI 1.02-1.70), Anxiety (aOR 1.19, 95% CI 1.01-1.40), or depression (aOR 1.56, 95%CI 1.25-1.96; Table 3).
Discussion This article is the first report on susceptibility to smoking among a representative sample of school-going adolescents in Malaysia. This survey revealed that susceptibility to smoking was 6.0%, which was lower than 15.5% that was reported by Manimaran16 in 2003 and 16.3% by Lim et al6 among adolescents in Kota Tinggi district in 2011. It was also twice as low compared with global susceptibility to smoking of 12.5%, and 10.1% among adolescents in Southeast Asia.8 The decrease in susceptibility to smoking in comparison with 2003 is very encouraging. This could be attributed to the government’s legislative and financial efforts in antitobacco campaigns. Among them, banning smoking in public and work places, requiring pictorial health warnings on
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
85S
Lim KH et al Table 2. Prevalence of Susceptibility to Smoking Among Secondary School Adolescents in Malaysia. Susceptible to Smoking Yes Variables
na
Gender Male 723 Female 386 Ethnicity Malay 726 Chinese 173 Indian 72 Indigenous Sabahan 121 and Sarawakian Others 16 Age-group (years) 13-15 719 ≥16 207 Schooling session Morning 630 Afternoon 193 Morning till afternoon 280 Marital status of parents Married 929 Separated 158 Smoking status of parents/guardian No 521 Fathers/male 473 guardians smoke Mothers/female 11 guardians smoke Both smoke 15 Stress Yes 150 No 959 Anxiety Yes 495 No 614 Depression Yes 262 No 6847 an
Na
No % (95% CI)
na
Na
% (95% CI)
62 430 35 219
9.5 (8.6-10.4) 6987 3.6 (3.2-4.2) 10 750
596 871 90.5 (89.6-91.4) 519 932 96.4 (95.8-96.8)
56 013 17 317 8441 14 237
5.9 (5.4-6.5) 11 499 4.5 (3.5-5.8) 3626 7.3 (5.4-9.7) 1083 9.1 (7.3-11.3) 1242
888 417 364 264 107 681 142 572
1551
5.7 (3.0-10.4)
94.1 (93.5-94.6) 95.7 (94.2-96.5) 92.7 (90.3-94.6) 90.9 (88.7-92.7)
281
25 755 94.3 (89.6-97.0)
62 574 8873
6.3 (5.8-6.9) 5.1 (4.3-6.1)
10 894 3821
925 804 93.7 (93.1-94.2) 350 991 94.9 (93.9-95.7)
53 446 22 804 20 886
5.6 (5.1-6.1) 6.7 (5.5-8.2) 6.4 (5.5-7.5)
10 160 2821 4708
906 773 94.4 (93.9-94.9) 315 681 93.3 (91.8-94.5) 303 367 93.6 (92.5-94.5)
81 668 14 093
5.9 (5.4-6.4) 6.6 (5.6-7.9)
15 232 1 309 243 94.1 (93.6-94.6) 2257 198 056 93.4 (92.1-94.4)
47 300 40 642
5.1 (4.5-5.7) 6.8 (6.0-7.7)
10 301 6563
888 858 94.9 (94.3-95.5) 558 517 93.2 (92.3-94.6)
937 14.3 (6.8-27.6)
61
5639 85.7 (72.4-93.2)
1460 12.0 (7.4-19.0)
103
10 664 88.0 (81.0-92.6)
13 011 84 639
8.6 (7.1-10.4) 1654 138 379 91.4 (89.6-92.9) 5.7 (5.3-6.3) 16 083 1 391 011 94.3 (93.7-94.7)
44 714 52 935
7.2 (6.4-8.0) 5.3 (4.8-5.9)
23 583 74 066
9.1 (7.7-10.6) 2660 236 763 90.9 (89.4-92.3) 5.4 (4.9-5.9) 15 077 1 292 627 94.6 (94.1-95.1)
6778 10 959
580 610 92.8 (92.0-93.6) 948 780 94.7 (94.1-95.2)
P Value
APHXXX10.1177/1010539514542426Asia-Pacific Journal of Public HealthLim KH et al
Original Article
Parental Smoking Status, Stress, Anxiety, and Depression Are Associated With Susceptibility to Smoking Among Non-Smoking School Adolescents in Malaysia
Asia-Pacific Journal of Public Health 2014, Vol. 26(5S) 81S–90S © 2014 APJPH Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1010539514542426 aph.sagepub.com
Kuang Hock Lim, MSc1, Zhuolin Chong, MD1, Yi Yi Khoo, MBChB1, and Jasvindar Kaur, MBBS, MPH1
Abstract Susceptibility to smoking is a reliable predictor of smoking initiation. This article describes its prevalence and associated factors among Malaysian school adolescents. Data were obtained from the Global School-Based Student Health Survey (GSHS) 2012, a nationwide representative sample of school adolescents. The overall prevalence of susceptibility to smoking was 6.0% and significantly higher among males (9.5%) compared with females (3.6%). Multivariable analyses revealed that males (adjusted odds ratio [aOR] 3.34, 95% confidence interval [CI] 2.70-4.18) and school adolescents of indigenous Sabahan or Sarawakian descents (aOR 1.62, 95%CI 1.212.18) were significantly more likely to be susceptible to smoking. Susceptible school adolescents had a slightly higher likelihood to have symptoms of stress (aOR 1.31, 95% CI 1.02-1.70), anxiety (aOR 1.19, 95% CI 1.01-1.40), depression (aOR 1.56, 95% CI 1.25-1.96), including those whose one or both parents/guardians were smokers (aOR 1.48, 95% CI 1.21-1.82; aOR 2.33, 95% CI 1.22-4.44, respectively). The findings from this study point out the need for proactive measures to reduce smoking initiation among Malaysian adolescents with particular attention toward factors associated with susceptibility to smoking, Keywords susceptibility to smoking, adolescents, Global School-Based Student Health Survey, smoking
Introduction Smoking is a habit that is learnt and initiated during adolescence.1 The earlier an individual starts smoking, the higher the risk in contracting smoking-related illnesses. Male and female adolescents who started smoking before the age of 15 years had twice the risk to develop lung cancer compared with those who started at age 20 years or more.2 At the same time, those who initiated
1Institute
of Public Health, Kuala Lumpur, Malaysia
Corresponding Author: Kuang Hock Lim, Institute of Public Health, Jalan Bangsar, Kuala Lumpur 50599, Malaysia. Email: [email protected]
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
82S
Asia-Pacific Journal of Public Health 26(5S)
smoking during adolescence were more prone to become heavy smokers in their adulthood and would continue smoking for a long time before successfully quitting.3 Hence, reducing the incidence of smoking initiation is one of the long-term measures to reduce smoking prevalence and health consequences associated with cigarette smoking. The identification of adolescents susceptible to smoking is the prerequisite for reducing smoking initiation among them. The concept “susceptibility to smoking,” which is the lack of cognitive commitment to not smoke in the future is recognized as a reliable predictor of smoking habit among adolescents.4 This has been proven through local and international research. Difranza et al5 reported that adolescents who were susceptible to smoking were 2 to 3 times more likely to become experimental smokers. Meanwhile, among elementary school students, Jackson1 reported that cognitive susceptibility was the main predictor of smoking initiation after 2 years. Pierce et al4 reported that susceptibility to smoking was the main independent variable that contributed to smoking compared with other independent variables such as smoking among family members (father or brothers) and peer smoking. Local research carried out by Lim et al6 among secondary school adolescents aged 13 to 17 years in Kota Tinggi district revealed that nonsmoking adolescents who were susceptible to smoking were 3.7 times more likely to initiate smoking after a year compared with those who were not susceptible. The identification of adolescents susceptible to smoking and its associated factors would enable efficient allocation of resources for prevention. Among other factors, female adolescents, having peer and family smokers, and positive expectations about smoking were reported to have associations with susceptibility to smoking.7-9 However, these findings are not consistent and are based on Western populations. Social and cultural differences may render them unsuitable in the Malaysian context. Moreover, only a few Western studies have looked into associations between susceptibility to smoking and cognitive factors, such as stress, anxiety, and depression.10,11 Although a study on susceptibility to smoking has been done in this country, it only involved adolescents from a single district and majority of them was from a single ethnic group.6 Thus, the findings from the study cannot be generalized to all adolescents in Malaysia. This article aims to fill the knowledge gap on prevalence, inter- and intrapersonal and cognitive factors (stress, anxiety, and depression) related to “susceptibility to smoking” in a representative sample of secondary school adolescents in Malaysia.
Methods Sampling Procedure This cross-sectional national survey among school adolescents was conducted from February to April 2012. The sample was selected using a 2-stage stratified cluster sampling to produce a representative sample of school adolescents in form 1 to form 5, aged 12 to 17 years. The sampling frame was all secondary schools under the Malaysia Ministry of Education. The first stage was selection of school in proportion to school enrollment and the second stage was the selection of classroom from the selected school. All school adolescents from the selected classroom were eligible to participate in the study. A total of 234 schools and 28 732 respondents were selected to participate in this survey.12 The survey instrument used was a questionnaire adapted from Global School-Based Student Health Survey, World Health Organization,13 which was translated into Malay, and validated by a research panel. The questionnaire was self-administered. Prior to data collection, trained research assistants explained in detail to the selected respondents regarding the survey, namely, its objectives, voluntary participation, confidentiality, and the content of the questionnaire. Any doubts were clarified by the research team members. Completed questionnaires were collected and sealed in front of the respondents. Only respondents who obtained written consent from their
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
83S
Lim KH et al
parents/guardian were allowed to participate in this study. The survey protocol was approved by Malaysia Ministry of Education, whereas approval to recruit the students as participants was given by individual schools and their respective District and State Departments of Education. Ethical approvals were obtained from the Medical Research and Ethics Committee of Ministry of Health and Ministry of Education.
Measurements The dependent variable in this survey “Susceptibility to Smoking” was measured using 2 questions: (a) Do you think you will smoke a cigarette in the next year? (b) If one of your best friends were to offer you a cigarette, would you smoke? The choices of answers were (a) Yes, (b) Probably yes, (c) Probably no, and (d) Not at all. If the respondent answered “Not at all” to both questions, they were categorized as “Not susceptible to smoking,” while those who gave other combinations were categorized as “Susceptible to smoking.” The independent variables in this survey were gender, age-group, ethnicity, school sessions, parental marital status, and parental tobacco consumption. Stress, anxiety, and depression levels among respondents were measured using validated Mental Health Survey with administered Depression, Anxiety, Stress Scale (DASS 21) questionnaire in Malay.14 The final score of each item groups (Depression, Anxiety, and Stress) was multiplied by 2.15 Respondents who scored more than 9,8 and 15 for depression, anxiety, and stress were classified as “having the abovementioned symptoms.”
Data Management and Analysis A total of 25 507 school adolescents participated in the survey, giving an overall response rate of 89.0%. The data on 18 870 of respondents classified as nonsmoking were analyzed using SPSS version 21. Data entry was done using scanner for DASS and GSHS. Data were weighted in the analysis to account for the complex study design and response rate. Descriptive statistics were used to elaborate the social demographic characteristics of the sample and to estimate the prevalence of susceptibility to smoking. Chi-square analysis was used to test the associations between the categorical independent variables (gender, schooling session, etc) with susceptibility to smoking. Variables with P ≤ .25 were included into the binary multivariable logistic regression to determine the influence of each variable on susceptibility to smoking while simultaneously controlling for potential confounding effects by other variables. Analysis of 2-way interaction revealed no significance for all variables in the final model. All statistical analyses were performed at 95% confidence level.
Results The majority of the 18 870 nonsmoking respondents consisted of adolescents aged 13 to 15 years (72.8%), females (59.5%), and those who attended morning school sessions (59.1%). Similar to the Malaysian population as a whole, the distribution of nonsmoking school respondents by ethnicity was 58.0% Malay, 23.5% Chinese, 7.2% Indian, and 9.7% Indigenous Sabahan and Sarawakian. Bivariate analysis showed that intra- and interpersonal factors were significantly associated with susceptibility to smoking, The overall prevalence of adolescents susceptible to smoking was 6.0%, with a significantly higher proportion of males compared with females (9.5% vs 3.6%, P < .001). In addition, indigenous Sabahan and Sarawakians were significantly more susceptible to smoking compared with Malay or Chinese (9.1% vs 5.9% and 4.5%, P < .001). Furthermore, Chinese adolescents showed a significantly lower susceptibility to smoking compared with adolescents of other ethnicities (P < .001; Tables 1 and 2). The proportions of
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
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Asia-Pacific Journal of Public Health 26(5S)
Table 1. Sociodemographic Characteristic of Respondents. Variables Gender Male Female Ethnicity Malay Chinese Indian Indigenous Sabahan and Sarawakian Others Age-group (years) 13-15 ≥16 Schooling sessionb Morning Afternoon Morning till afternoon Marital status of parents Married Separated
na
Na
7724 11 146
660 718 1 629 464
12 232 3809 1157 1367
944 883 382 637 116 544 157 288
298
2772
11 629 4030
989 921 370 002
10 799 3024 4993
961 089 339 515 324 778
16 181 2419
1 392 916 212 568
Percentage 40.5 59.5 58.0 23.5 7.2 9.7 1.7 72.8 27.2 59.1 20.9 20.0 86.8 13.2
an
= sample and N = estimated population. implements a triple-shift school-day system comprising a morning session, an afternoon session, and a morning until afternoon session. bMalaysia
respondents whose father/male guardian, mother/female guardian, or both parents/guardians smoked were also significantly higher compared with those whose parents/guardians were nonmokers (6.8%, 14.3%, 12.0%, and 5.1%, respectively, P < .001). Finally, the susceptibility to smoking was higher among respondents who had symptoms of stress (8.6% vs 5.7%, P < .001), anxiety (7.2% vs 5.3%, P < .001), and depression (9.1% vs 5.4%, P < .001) than their counterparts without these symptoms. After adjusting for other independent variables, multivariable analysis revealed that respondents susceptible to smoking were more likely to be male (adjusted odds ratio [aOR] 3.36, 95% confidence interval [CI] 2.70-4.18), indigenous Sabahan and Sarawakian (aOR 1.62, 95% CI 1.21-2.18), had father/male guardian or both parents who smoked (aOR 1.48, 95% CI 1.21-1.82; aOR 2.32, 95%CI 1.22-4.44, resoectively); reported stress (aOR 1.31, 95% CI 1.02-1.70), Anxiety (aOR 1.19, 95% CI 1.01-1.40), or depression (aOR 1.56, 95%CI 1.25-1.96; Table 3).
Discussion This article is the first report on susceptibility to smoking among a representative sample of school-going adolescents in Malaysia. This survey revealed that susceptibility to smoking was 6.0%, which was lower than 15.5% that was reported by Manimaran16 in 2003 and 16.3% by Lim et al6 among adolescents in Kota Tinggi district in 2011. It was also twice as low compared with global susceptibility to smoking of 12.5%, and 10.1% among adolescents in Southeast Asia.8 The decrease in susceptibility to smoking in comparison with 2003 is very encouraging. This could be attributed to the government’s legislative and financial efforts in antitobacco campaigns. Among them, banning smoking in public and work places, requiring pictorial health warnings on
Downloaded from aph.sagepub.com at UNIV CALIFORNIA SAN DIEGO on September 2, 2015
85S
Lim KH et al Table 2. Prevalence of Susceptibility to Smoking Among Secondary School Adolescents in Malaysia. Susceptible to Smoking Yes Variables
na
Gender Male 723 Female 386 Ethnicity Malay 726 Chinese 173 Indian 72 Indigenous Sabahan 121 and Sarawakian Others 16 Age-group (years) 13-15 719 ≥16 207 Schooling session Morning 630 Afternoon 193 Morning till afternoon 280 Marital status of parents Married 929 Separated 158 Smoking status of parents/guardian No 521 Fathers/male 473 guardians smoke Mothers/female 11 guardians smoke Both smoke 15 Stress Yes 150 No 959 Anxiety Yes 495 No 614 Depression Yes 262 No 6847 an
Na
No % (95% CI)
na
Na
% (95% CI)
62 430 35 219
9.5 (8.6-10.4) 6987 3.6 (3.2-4.2) 10 750
596 871 90.5 (89.6-91.4) 519 932 96.4 (95.8-96.8)
56 013 17 317 8441 14 237
5.9 (5.4-6.5) 11 499 4.5 (3.5-5.8) 3626 7.3 (5.4-9.7) 1083 9.1 (7.3-11.3) 1242
888 417 364 264 107 681 142 572
1551
5.7 (3.0-10.4)
94.1 (93.5-94.6) 95.7 (94.2-96.5) 92.7 (90.3-94.6) 90.9 (88.7-92.7)
281
25 755 94.3 (89.6-97.0)
62 574 8873
6.3 (5.8-6.9) 5.1 (4.3-6.1)
10 894 3821
925 804 93.7 (93.1-94.2) 350 991 94.9 (93.9-95.7)
53 446 22 804 20 886
5.6 (5.1-6.1) 6.7 (5.5-8.2) 6.4 (5.5-7.5)
10 160 2821 4708
906 773 94.4 (93.9-94.9) 315 681 93.3 (91.8-94.5) 303 367 93.6 (92.5-94.5)
81 668 14 093
5.9 (5.4-6.4) 6.6 (5.6-7.9)
15 232 1 309 243 94.1 (93.6-94.6) 2257 198 056 93.4 (92.1-94.4)
47 300 40 642
5.1 (4.5-5.7) 6.8 (6.0-7.7)
10 301 6563
888 858 94.9 (94.3-95.5) 558 517 93.2 (92.3-94.6)
937 14.3 (6.8-27.6)
61
5639 85.7 (72.4-93.2)
1460 12.0 (7.4-19.0)
103
10 664 88.0 (81.0-92.6)
13 011 84 639
8.6 (7.1-10.4) 1654 138 379 91.4 (89.6-92.9) 5.7 (5.3-6.3) 16 083 1 391 011 94.3 (93.7-94.7)
44 714 52 935
7.2 (6.4-8.0) 5.3 (4.8-5.9)
23 583 74 066
9.1 (7.7-10.6) 2660 236 763 90.9 (89.4-92.3) 5.4 (4.9-5.9) 15 077 1 292 627 94.6 (94.1-95.1)
6778 10 959
580 610 92.8 (92.0-93.6) 948 780 94.7 (94.1-95.2)
P Value
