Health Education Research, Vol. 15, No. 4, 415-422,
August 2000
© 2000 Oxford University Press
Psychosocial predictors of smoking among secondary school students in Henan, China
1 Department of Epidemiology and Health Promotion, National Public Health Institute, Mannerheimitie 166, 00300 Helsinki, Finland and
2 Department of Health Promotion, Health and Anti-epidemic Institute of Henan, 47# Weiwu Road, 450003, Zheng Zhou, Henan, People's Republic of China
Correspondence to: L. Zhang, Department of Health Promotion, Health and Anti-epidemic Institute of Henan, 47# Weiwu Road, 450003, Zheng Zhou, Henan, People's Republic of China
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Abstract |
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The objective of this study was to measure the risk factors associated with tobacco use among secondary school students in Henan, China. Self-reported questionnaires were administered to four secondary schools; 3519 students were studied including 1799 boys and 1720 girls aged 10–19. Demographic, behavioral, attitudinal/belief, knowledge and interpersonal variables were investigated. Overall, 15.1% of boys and 1.4% girls reported smoking at least occasionally. Smoking onset is most prevalent from the ages of 10–14. The smoking rate increased with age. The likelihood of tobacco use was significantly higher among those having peers, teachers or mother who smoked. Positive smoking-related attitudes among students had a significant association with their smoking status. The results suggest that effective smoking prevention interventions need to be comprehensive and implemented in the early teen years.
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Introduction |
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Tobacco use is a leading cause of preventable death (US Department of Health and Human Service, 1989). Calculations from the World Health Organization and the University of Oxford indicate that every second smoker will die prematurely as a result of smoking (Peto et al., 1994
). In China, research has shown that the prevalence of smoking is alarming high in the adult population (Gong et al., 1995; Lam et al., 1997), but little is known about adolescents smoking because few studies have focused specifically on this population. The efficacious design of smoking control strategies for adolescents is hampered by the relative absence of information. Much of our current knowledge on teenage smoking has come from Western countries.
Various studies have noted that adolescence is a major risk period in the process of becoming tobacco dependent (US Department of Health and Human Service, 1988; O'Loughlin et al., 1998). The younger the age at which young people start to smoke, the more likely they are to become regular smokers in adulthood (Paavola et al., 1996). A report from the US Surgeon General (US Department of Health and Human Service, 1988) stated that most young people will never use tobacco if they remain non-smokers during their high school years. However, a huge proportion of smoking experimentation occurs during this period. Among adolescents, smoking onset is most prevalent from the ages of 11–15 (Conrad et al., 1992; Stanton et al., 1992).
A series of studies noted that cigarette smoking among youth is a complex behavior with several identifiable determinants: interpersonal factors (such as family and peer influence), intrapersonal factors (such as self-esteem), individual motivational and attitudinal determinants, as well as cultural setting (Goddard 1990; Stanton et al., 1991; Zhu et al., 1992; Nichter et al., 1997; O'Loughlin et al., 1998).
To the best of our knowledge, this study is one of the first studies to use the multivariate technique to identify the potential risk factors for adolescents' smoking in China. In this survey, we attempted to provide information on the determinants and prevalence of cigarette smoking among secondary school students in Henan, and develop a practical and effective intervention strategy.
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Methods |
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Respondents and procedures
The study was a baseline survey for an intervention program directed to secondary school students in grades 7–12. There are seven governmental schools in Henan province including both junior and senior high schools in the same school building. Four of them were randomly selected from two big cities for this study. Those junior and senior high schools that were in separated building were not included in the sample, because the intervention could not be conveniently organized. In this sample, age varied from 10 to 19. Most students in the seventh grade were 12 years old and in the 12th grade were 17 years old. Entire students enrolled in the study schools were recruited into the study (n = 3627), but 108 were excluded because of incorrect completion of the questionnaires or absence during the survey. The effective sample size was 3519, comprised of 1799 boys (51.1%) and 1720 girls (48.9%), giving a response rate of 97.0%.
The standardized survey questionnaire was developed by a panel of experts in the areas of medical education, then submitted for review by schoolteachers and health educators for its content validity. The questionnaire was piloted in two seventh grade classrooms selected through a convenience sample, which were not included in the study. Items were revised as necessary on the basis of the results of the pilot test to enhance clarification and appropriateness for the age range of the sample in this study. Students in this survey were requested to complete the questionnaire in class. The trained interviewers described the purpose and process of the survey to the students, and gave standardized instructions for completing the questionnaire. Students were assured that the questionnaire was confidential and would have no bearing on their overall academic assessment. Teachers and other school staff were required to leave the classroom during the process. The questionnaires were completed and collected under the supervision of the interviewers. School staff and students were cooperative during the survey.
The questionnaire consisted of 35 items concerning the students' cigarette smoking status; the smoking behavior of peers, teachers and family members; positive and negative perceptions of tobacco use; and demographic characteristics. These variables were grouped into the following domains.
Dependent variables
Smoking status was classified into five stages based on the self-reported responses. (1) Never-smokers were defined as those who had never tried cigarettes. (2) Triers were defined as those who had tried smoking before. (3) Occasional smokers were those who smoked less than once a week. (4) Weekly smokers were those who smoked at least once a week but not daily. (5) Daily smokers were defined as those who smoked every day.
Predictor variables
Attitude and belief factors: including social beliefs, subjective norm and health knowledge.
Social beliefs were measured by four statements with a three-point scale from disagree to agree (Cronbach 
= 0.70). These statements were `It is unfriendly to refuse when others offer a cigarette', `Smoking is an easy way to approach another person', `Smoking could appear mature', `Smoking is a personal issue, others should not intervene'. Subjective norm was measured by three items answered on a three-point scale from agree to disagree. They were: `Not smoking will become fashionable in the future', `Smoking in public places is impolite', `With developments in society, the percentage of smokers in the population will decline' (Cronbach = 0.58). Knowledge of harmful effect of smoking was measured by asking them if they believed that cigarette smoking is harmful to one's health.
Interpersonal factors
There was a series of questions on the smoking status of parents and relatives with whom the students were living, as well as the smoking status of peers and teachers. The items were not combined in an index so that the individual influence of each variable could be examined.
Gender and age
Gender and age were considered in the analysis in order to mediate the demographic factors' influence on other variables.
Data analysis
The statistical analyses were completed using SPSS program at the National Public Health Institute, Finland. Frequencies and cross-tabulations of variables were used to estimate the smoking rates. In addition to factor analyses, Cronbach reliability and logistic regression analysis was used to estimate the risk factors associated with student smoking. The dependent variable, smoking status, was dichotomized into `current smoker' and `never-smoker', with `current smoker' including daily, weekly and occasional smoker.
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Results |
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Table I
presents the percentages of boys and girls at each smoking level in different age groups. At the age of 10–11, boys were more likely to remain never-smokers (94.4%), while at the age of 18–19 only 29.5% were never-smokers but with high percentages of daily smokers (11.6%), occasional smokers (25.3%) and triers (30.5%). Girls were much more likely to be triers, with that percentage sharply increasing from 2.6% at age 14–15 to 10.2% at age 16–17.
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Table II
shows the behavior patterns of smoking among current smokers and triers. Ages 10–14 were found to be critical years in the smoking onset process for both genders. In this study, 55.7% of current smokers and 50.0% triers stated that they had first experimented with smoking during ages 10–14. A majority of current smokers (65.8%) usually smoked with friends or classmates. Covered places and entertainment places were their main sites for smoking.
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Table III
shows the percentage of smoking among boys and girls by selected potential predictors. Ever-smoker (current smoker and trier) was used because of few number of current smokers among girls. A positive attitude towards smoking was more prevalent among smokers. Those who perceived refusing cigarette offers from others as being unfriendly were more likely to be smokers. That smoking is an easy way to approach another person was their most frequently cited reason for tobacco use. Although the majority of boys and girls agreed that not smoking will be new fashion in the future or smoking in public places is impolite, they showed less inclination to believe that smoking prevalence will decline in the future. As regards the harmful effects of smoking, smokers showed as high a level of knowledge as never-smokers.
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Smokers were far more likely than never-smokers to be surrounded by family members, peers and teachers who smoked. On the question `Do you have teachers who smoked?', 85.9% of smoking boys and 82.8% of smoking girls reported having teachers who smoked, compared with 58.3% and 61.5% of never-smokers. For boys, 73.4% of smokers reported having peers who smoked, compared with 39.5% never-smokers. The respective figures for girls were 78.5 and 41.0%.
Table IV displays the results of logistic regression analyses. Having peers who smoked was a dominant independent contributor to youth smoking, which increased the odds by 2.61. The smoking of mothers and smoking of teachers were other significant predictors for adolescent smoking behavior. In this survey there were no associations between the smoking of fathers and their children's tobacco use. As regards attitudinal, knowledge and belief factors, the social belief scale was significantly associated with smoking. Girls were less likely than boys to be smokers. The odds of smoking increased by 33% for each year increase in age.
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Discussion |
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In recent years China has experienced a rapid increase in smoking prevalence, which is expected to result in an epidemic of smoking-related disease and death in coming decades (Editorial, 1997
; Chen et al., 1997; Lam et al., 1997). If no action is taken to reduce tobacco use in China, an estimated 2 million smoking-related deaths—including 900 000 lung cancer deaths—will occur among Chinese men by the year 2025. In addition, an estimated 200 million children currently living in China will become smokers, 50 million of whom will die prematurely from smoking-attributable diseases (US Center for Disease Control and Prevention, 1993). Therefore, widespread implementation of prevention and cessation programs, as well as tobacco-control policies that target youth smoking, are urgently needed to reduce the present and future health burden of smoking in China (Gong et al., 1995).
Smokers in this study tended to initiate smoking during ages 10–14. The reason seems to focus on the beginning of social activities in which they are vulnerable to environmental influences. To some degree smoking can be described as a catalytic promoter of friendship and condiment of social activity that provides an easy way to make new friends and develop relationships. Offering cigarettes to each other has become a means of social interaction and a friendly gesture. Meanwhile, the need to gain social acceptance from peers exerting tacit pressure and influence also promotes smoking or smoking onset. Beyond this, from a developmental perspective, the desire to establish an autonomous self and a different identity is a natural trait of youth. To this end, smoking is used as a symbol of independence and personality. It is not surprising the finding that the odds of smoking were greatly increased when having peers that smoke. This was consistent with other research reports (Zhu et al., 1992; Paavola et al., 1996; Nichter et al., 1997; O'Loughlin et al., 1998). Therefore, The prevention policy should be more targeted at associating tobacco use with negative images and overcoming peer pressure. As a first step, improving students' attitudes and beliefs about smoking would help enable the behavioral change process to begin.
Many studies have shown that adolescents' smoking is correlated with smoking status of their families (Zhu et al., 1992; Jarallah et al., 1996; Flay et al., 1998). Similar results have been observed in this study. Having family members who smoke not only provides teenagers easier access to cigarettes but their physical, psychological effects of use and positive smoking attitude norms directly influence the youth as well. Although the impact of consistent parental influence on children's smoking onset is uncertain (Dusenbury et al., 1992), a non-smoking family environment combined with a strict stance against smoking likely leads to a lower prevalence of tobacco use among youth (Tang et al., 1998; Newman et al., 1989).
In this study, teachers' cigarette smoking was a strong predictor of adolescent smoking, which increased the odds by 2.51. Teacher smoking is viewed as a bigger barrier to the introduction of prevention programs. Curiosity and imitation are natural adolescent traits that create the desire to try something new. As role models, teachers directly influence students' behavior and judgment to a great extent. Lowering smoking prevalence among teachers, increasing teachers' knowledge of the hazards of tobacco use, therefore, should be given the highest priority.
The lower smoking prevalence among girls compared with other studies in other countries may be due to traditional Chinese values, which tolerate female smoking to a lesser degree. In addition, the results showed that the majority of students understood the harmful effect of tobacco, but this had had a limited effect on smokers' attitudes about smoking or their behaviors. A similar finding was reported in studies among Chinese adults (Liu et al., 1998; Gong et al., 1995).
The continuum of smoking behavior among children and teenagers can be described in stages, i.e. preparation, trying, experimentation, regular smoking and nicotine dependence or addiction. It is difficult to break a habit once it is established (US Center for Disease Control and Prevention, 1998). Although the results of this study indicated a higher percentage of triers than habitual smokers, it still sounds a warning signal. Thus our work should focus on prevention and keeping young people from forming the habit.
Findings of this study call for a comprehensive strategy for preventing teenage smoking, involving school personnel, parents, community leaders and legislators. Compared with other counties, it appears that little has been done in the tobacco control in Chinese adolescents (US Center for Disease Control and Prevention, 1993; Vartiainen et al., 1996, 1998; Sheppard et al., 1998; Clarke et al., 1994). Although theoretically smoking is not permitted in schools, there are still 7.1% current smokers in this study who reported usually smoking at school, which suggests that smoking is not strictly forbidden in some schools in Henan. Furthermore, adolescents have access to cigarettes without any government regulations. In China, there is no strengthening policy for tobacco control at the national level. Current control effects are not well coordinated. Although tobacco smoking has been banned in many public places, and cigarette advertising and promotions are prohibited in the local electronic and print media, there is no close monitoring for non-compliance.
There are several limitations to this study. A formal multistage sampling technique was not employed to select survey respondents. This limits the generalizability of the results. The attitudinal items in the questionnaire were insufficient—corrections are expected in the next study. Another potential limitation is that this study relied on self-reported data that was not confirmed by other sources or verified biochemically. Therefore, response bias was possible. Furthermore, this study was cross-sectional rather than longitudinal. This limited the extent to which conclusions about causality could be drawn.
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Received on April 8, 1999; accepted on December 29, 1999
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