Health Education Research, Vol. 17, No. 6, 750-760,
December 2002
© 2002 Oxford University Press
Factors associated with smoking progression among Spanish adolescents
Health Promotion Unit, Municipal Institute of Public Health, Barcelona Council, Girona, 87 3r.2a, 08009 Barcelona, Spain
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Abstract |
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Smoking onset takes place in the early years of adolescence, and can be seen as a progression through stages of preparation, trying, experimentation, regular smoking and nicotine dependence or addiction. The objective of this study is to identify 1-year predictors of smoking consolidation among occasional smokers (experimenters) and of cessation among all smokers. A questionnaire developed to monitor trends in smoking and other health-related behaviors was administered in the spring of 1992 and again 1 year later (1993). The survey was carried out in six large, private schools in Barcelona and Raimat, in the Lleida province, in Catalonia (Spain). In total, 1460 schoolchildren aged 12–19 responded to both the baseline and follow-up questionnaires; 1236 questionnaires (84.7%) were matched through a personal code and were used for the longitudinal study. At the baseline survey 28% of the schoolchildren were regular smokers and 17.1% were occasional smokers, with no differences by gender. At the follow-up survey, progression from occasional to regular smoking was observed in 42% of the girls and 22.7% of the boys. Other predictors of consolidation included drinking alcohol (OR = 3.1; 95% CI = 1.1–10.1) and reporting the intention to smoke in the future (OR = 2.5; 95% CI = 1.3–4.9). Among all the smokers at the baseline, predictors of cessation were smoking occasionally (versus regularly) (OR = 4.9; 95% CI = 2.8–8.6), negative attitudes regarding smoking (OR = 3.3; 95% CI = 1.9–5.4), reporting no intention to smoke in the future (OR = 2.2; 95% CI = 1.3–3.8), gender (OR for boys = 2.1; 95% CI = 1.2–3.6), receiving weekly pocket less than 1000 ptas (OR = 1.7; 95% CI = 1.1–5.3) and age (OR for being 15 and younger = 1.6; 95% CI = 1.1–4.9). We conclude that consolidation of smoking is twice as likely among girls than among boys. Intention to smoke seems to be a good predictor of future behavior, while attitudes may predict cessation, but not consolidation. Available pocket money seems to be a strong risk factor for smoking at this age.
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Introduction |
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The relevance of smoking as a risk factor of the most important and current causes of illness and death has been sufficiently established in the past decade (Hunter et al., 1995
; Murray and López, 1996), while it is accepted nowadays that smoking is the most prevalent of any drug ever used (Chen and Kandel, 1995). Smoking onset takes place in the early years of adolescence, and can be seen as a progression through stages of preparation, trying, experimentation, regular smoking and nicotine dependence or addiction. Several studies have showed that among high school students, up to 70% have tried cigarette smoking and among those who had ever smoked daily, five to seven out of 10 had ever tried to quit smoking (Kesler, 1995; US Department of Health and Human Services, 1997; Pallonen et al., 1998). In the light of these findings, some authors have suggested the integration of adolescent cigarette smoking acquisition and cessation into a single nine-stages-of-change continuum, using the Transtheoretical Model of change framework applied to smoking initiation (Pallonen et al., 1998).
Longitudinal studies of smoking status changes during adolescence revealed a fast progression from experimentation to consolidation (Pallonen et al., 1998; Schofield et al., 1998). Age, gender, and the smoking behavior of friends, siblings and parents have been shown to be the most common risk factors of progression to regular smoking, while the intention to smoke in the future and the experience with smoking at baseline have proved to be highly predictive (Watanabe et al., 1995; Choi et al., 1997; Díez et al., 1998; O’Loughlin et al., 1998; Patton et al., 1998). The influence of peers smoking behavior is strongly associated with the consolidation and maintenance as smoker through the number of offers to smoke as well as the model effect (Rose et al., 1996). Among the psychosocial determinants of smoking consolidation, self-efficacy to resist offers to smoke has been postulated to influence the intention to smoke, according to the Attitudes–Social influences–self-Efficacy (ASE) model (De Vries et al., 1988).
Self-efficacy expectations together with attitudes towards smoking and social influences of environmental smoking are considered as individual determinants influencing the change of smoking behavior in individuals or in groups. Using this individual perspective, social psychological theories have been applied to construct a model on behavioral change that can serve to develop new preventive materials (De Vries et al., 1992).
Even after smoking becomes a regular pattern, there are attempts to quit. About three out of every four young smokers have tried to quit at least once, although they may have failed in their first trial. The intensity of smoking at baseline, as well as gender, attitudes about smoking and the intention to smoke in the future, seem to be the most important predictors for cessation among adolescents (Burt and Peterson, 1998; Mittelmark et al., 1988; Sargent et al., 1998; Sussman et al., 1998).
Within this context, the objectives of this study are to determine in a sample of Spanish schoolchildren the factors associated to progression from occasional to regular smoking (consolidation) and to analyze factors associated with cessation after having smoked either occasionally or regularly.
These two models explaining smoking consolidation and cessation will permit us to propose interventions for smoking cessation in the adolescence.
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Methods |
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Sample
A sample was obtained from the last two grades (7 and 8) of primary school (12–14 year olds), and from all the grades of secondary school and vocational training in six large, private, publicly subsidized schools in Barcelona metropolitan area and Raimat, in the Lleida province in Catalonia. At the time of the study, secondary school began at the age of 14 years, lasted 3 years and was usually followed by an additional university-oriented year. Vocational training was organized in two cycles lasting 2 and 3 years, the first cycle starting after primary school. The five urban schools are present in a wide range of very different socioeconomic status, from the inner city to a wealthy neighborhood in Barcelona. The sixth school is located in a rural area and gets a middle/upper class composition.
The sampling was done by conglomerates, taking the classroom as the sample unit. A systematic sample of one out of every three classrooms in every school and grade of primary school (Grades 7 and 8) and secondary school was selected at random. In the two schools with more than three groups by grade, two classes were selected for each grade. In vocational training a further, stratification by specialty was done. Schools were classified according to the socioeconomic level (middle/low or middle/high) depending on an ecological index of social indicators in Barcelona. This indicator describes the neighborhood income where every school is placed (Aluja and Ventura, 1991). Similar criteria, with the available socioeconomic indicators, were used in the other centers of Bellvitge (Hospitalet de Llobregat, Barcelona province) and Raimat (Lleida province).
The baseline survey was done in February and March 1992. A year later, in March and April 1993, the same questionnaire was administered to the same students. Of the 1904 students eligible, 1460 (76.7%) participated in both waves of data collection. From them, in 1236 cases the baseline and the follow-up questionnaires could be matched through a personal code. This was composed of the month and year of birth, and the initials of the first name of both parents. Two hundred and sixty cases (17.3%) were lost in the matching process, the proportion being higher among students of vocational training (20.2%) than in high school (14.7%) and primary school (16.6%).
Procedure
The questionnaire was derived from the periodic survey on health-related habits among Barcelona schoolchildren (Comín et al., 1989) modified by Comín (Comín et al., 1997). This is a self-administered questionnaire dealing with health-related behaviors and attitudes, including items on smoking and alcohol consumption, and physical activity. The reliability of the questionnaire regarding behaviors measurement has been reported to be very high for smoking (Cronbach’s 
= 0.4–0.7) and reasonably high for alcohol consumption (Cronbach’s = 0.54–0.75) (Comín et al., 1989).
To measure cognitive determinants, a questionnaire about outcomes and self-efficacy expectancies was used. This questionnaire was based on to the Smoking Self-Efficacy Questionnaire for adults (Coletti et al., 1985) and also to the Pentz Questionnaire for Teenagers (Pentz, 1985), and validated in a sample of Catalan schoolchildren (Comas, 1988).
It consisted of 16 items measuring the copying abilities needed to persist as non-smoker (i.e. ‘If you are alone at home and you find a cigarette box or you find it in the street, do you think you are able to not smoke?’).
All the items were constructed as a visual scale. Pupils answered these questions over a 100-mm line. A quantitative score (0–100) was obtained for every item. Five items measured self-efficacy; pupils had to score their own ability to refuse a cigarette offer—filling a cross on a line between two extremes ranging from ‘completely unable’ to the other ‘completely able’. Three items assessed the subjective norms, measuring the attitude of friends, parents and teachers towards the student’s non-smoking behavior.
The last question of the scale measured the degree of agreement with the statement ‘I will never smoke in the future’, as an assessment of the intention to smoke. Attitudes towards smoking were measured by a seven-items Likert-type scale with seven options to answer between the complete agreement and the complete disagreement.
Variables measuring smoking consumption were defined according to WHO recommendations for questionnaires about tobacco consumption among adolescents (Smart et al., 1980) and previous recommendations for self-administered questionnaires (Dillman, 1978). Those schoolchildren who had not smoked during the last year were considered as non-smokers, while the pupils who had smoked at least some puffs during the last year but not in the last month were classified as occasional smokers. Current smokers were those who had smoked in the last month and, within this group, regular smokers were defined as pupils who smoked weekly or daily. Other variables analyzed were age of beginning to smoke and intensity of smoking (number of cigarettes smoked per day). Finally, the smoker’s environment or environmental perceived smoking behavior was assessed through schoolchildren’s perceptions about tobacco consumption of their father, mother, siblings, friends and teachers.
Questionnaires were distributed during a 1-h class by the study researchers, the teacher being absent. The average time for answering was 35 min.
Statistical analysis
For the bivariate analysis, 
2 analysis were used to show the significance of the most important variables related to progress from occasional to regular consumption, and multiple logistic regression was used to study the adjusted effect of independent variables. When necessary, Yates correction and the Fisher exact test were employed. A logistic regression was used to explore the effect of explanatory variables on the dependent variable progress from occasional to regular smoking and quit from occasional and regular smoking. For its use as an independent variable, age was dichotomized according to the sample mean age (15 years). Attitudes, self-efficacy and subjective norms scales were summed up and recoded in two categories for analysis, i.e. a mean lower than 50 was considered low self-efficacy, wrong subjective norms or having intention to smoke. Crude and adjusted ‘odds ratios’ (OR) as well as 95% confidence intervals (CI) were calculated. The adjustment was done by age (entering age as continuous for this purpose) and branch of studies. Separate models were fitted for boys and girls. All the analyses were performed with the SPSS PC statistical package (Norussis, 1986).
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Results |
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Table I
summarizes the characteristics of the sample, at both baseline and follow-up surveys. Overall, there were no major differences regarding gender, branch of studies or socioeconomic distribution (P values not significant). However, the mean age at follow-up is more than half a year younger (15.2 versus 14.8) (P < 0.005), reflecting the lost to follow-up of those pupils who were ending an academic cycle at the time of the baseline survey.
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In the baseline survey, 1741 of the 1904 students in the sample completed the questionnaire, yielding a response rate of 91.4%. The remaining 8.6% were absent, mainly because of illness. Only one student refused to answer the questionnaire and another one was excluded because of incomplete data. Out of the 1741 respondents, 1110 (63.7%) were boys and 631 (36.3%) were girls. There were 494 (28.4%) children in primary school, 530 (30.4%) in secondary school and 717 (41.2%) in vocational training. The percentage of teenagers that declared smoking at least one cigarette per week (regular smokers) was 28%, with no significant differences between boys and girls for the grand total of the sample.
Patterns of progression from occasional to regular smoker, by age and gender, are shown in Table II. Overall, girls in this sample are about twice as likely as boys to progress from occasional to regular consumption, with significant differences for total smokers, as well as the ages of 14 and 16 years old.
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Table III
shows the figures of smoking cessation. Boys were twice as likely as girls to have quit smoking by the time of the follow-up. From 277 boys smoking at baseline, 20.9% (n = 58) had quit a year after, most of them (n = 42) giving up occasional consumption and the rest (n = 16) regular consumption. Among girls, the proportion quitting smoking was much lower (11.2%) and this difference was observed in almost all the age groups.
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Table IV
describes the model fitted to progression from occasional to regular smoking between the baseline and follow-up surveys. Only three variables showed statistical significance in the bivariate analysis: drinking alcohol (OR = 3.4), intention to smoke in the future (OR = 2.5) and being female (OR = 2.5). Their effect remained in multivariate analysis for all these variables.
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Table V
shows the model fitted to cessation from occasional and regular smoking consumption. Smoking occasionally (versus regularly) at baseline (OR = 5.0), having negative attitudes towards smoking (OR = 3.5), having no intention to smoke in the future (OR = 2.3), not drinking (OR = 2.2), not having smoker peers (OR = 2.2), gender (male) (OR = 2.1), weekly pocket money less than 1000 ptas (OR = 1.8) and being 15 or younger (OR = 1.6) were all associated with cessation. Their effect, except for ‘not having smoking peers’, remained also in multivariate analysis.
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Finally, Table VI
shows the difference between cross-sectional and longitudinal associations between smoking (regularly) and all the studied determinants. Only four variables (alcohol consumption, intention, sex and age) showed predictive value at follow-up, despite the strong associations seen in the cross-sectional study. On the other hand, at follow-up, gender appears as an important predictor of progression from occasional to regular consumption, whereas this association was not present in the cross-sectional study.
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Discussion |
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This is the first reported study in the Spanish context that describes the smoking consolidation and cessation process in a sample of adolescents including primary and secondary education as well as vocational training students. The results show a much higher rate of consolidation of experimental smoking among girls. Besides gender, some factors such as consumption of alcohol and reporting the intention to smoke in the future are predictors of continuation smoking. This three factors are also good predictors of quitting smoking, which is also influenced by smoking occasionally (versus regularly), having less weekly pocket money (1000 ptas or less) and having a high self-efficacy to resist cigarettes offers.
Among the study limitations, it must be pointed out that the sample is not representative of Catalan schools. However, the age range of the sample is wider than that in any previous longitudinal study in a Spanish sample, and the schools investigated involve a wide socioeconomic range and diverse geographic areas. While no association was found between smoking and socioeconomic level, it must be stressed that only ecological measures of socioeconomic status were obtained for urban schools.
Another concern is the proportion of students lost to follow-up; it has to be noted that 22% of eligible students could not be matched and hence they were not analyzed in the re-test, for a variety of reasons (absence from class, withdrawal from school for different reasons and the inability to match cases because of missing components in the confidential identification code). Those pupils lost were not, however, different in sex, branch of studies or socioeconomic status, thus making selection bias less likely.
The finding that the proportion of female students (two of 10) who progress to regular smoking is twice that of males is striking, although a similar—less marked—trend was observed in a previous longitudinal study of schoolchildren in our context (Díez et al., 1998) and is also consistent with other international studies recently reported (Choi et al., 1997; O’Loughlin et al., 1998; Patton et al., 1998). Reflecting a general social trend, this fact could be related to factors such as a faster mental development in girls in this period of adolescence, with more attention to adult models, including smoking. The physiological development, more than chronological age, has to be considered involving cardiovascular risk factors. It could be well managed using sex maturity ratings formalized by Tanner, that showed these gender differences in other studies (Tell et al., 1985). In addition, the perception of parents’ smoking behavior, particularly of the mother (Díez et al., 1998), and the vulnerability of girls to smoking was suggested by some authors (Waldron et al., 1991).
The strength of the association between smoking and drinking alcohol is remarkable: students who drink alcohol in adolescence have 3 times more risk (OR = 3.1) than abstemious to become regular smokers by the time of follow-up. It is likely that social relationships situations commonly associated with alcohol consumption can facilitate and increase social pressure to smoke.
Regarding attitudes, intention to smoke has been shown to be highly predictive of smoking in the future (Díez et al., 1998; Watanabe et al., 1998). However, self-efficacy and subjective norms were not good predictors for continued smoking in the sample studied, despite the fact that other studies have found a strong association to smoking progression (De Vries, 1989, 1994). Likewise, positive attitudes towards smoking were related to smoking acquisition, as other studies have reported (Pallonen et al., 1998, Schofield et al., 1998), although in our study this relation did not show statistical significance.
When we consider the smokers that quit (Table III
), we again observe large differences among genders: cessation among boys is twice as frequent as among girls and occurs basically before the age of 16, unlike girls who had similar quit rates throughout all groups of age. As expected, those who smoked less regularly were more likely to quit, as there were those with attitudes against smoking and those who reported no intention to smoke in the future, as has also been found in previous studies (Mittelmark et al., 1988; Sargent et al., 1998; Sussman et al., 1998). The higher cessation rates among boys is consistent with recent studies that have found higher success in cessation compared with girls (Burt and Peterson, 1998).
According to some models widely used to explain smoking consolidation in the adolescence, the results of this study highlight the low impact of ‘social influences’, as social norms, and ‘self-efficacy’ in this sample of Catalan schoolchildren. Probably, these results can be related to the high social tolerance that smoking still has in Catalan society. In fact, it is possible that a lot of adult smoking behaviors in public places and in the media interfere with other preventive messages addressed to teenagers. This situation has to be considered to increase the effectiveness of smoking prevention in this geographical context.
Finally, our study highlights the difference between cross-sectional and longitudinal associations (Table VI). Only a few variables among those who showed a cross-sectional association with smoking remained in the longitudinal study as predictive factors, therefore stressing the misleading role of potential biases, among them the selection bias being probably the more relevant (Wang et al., 2000).
According to the study results, it seems necessary to pay more attention to the different factors that may explain gender differences in smoking consolidation, in terms of research as well as preventive strategies. The role of attitudes, that might be at least partially influenced by educational programs, cannot be disregarded, while there is a clear message for parents regarding the relationship (even if a two-way relationship) between available pocket money and smoking. These programs will have to give emphasis to social influences, psychosocial factors such as intention and attitudes towards smoking, and complementary strategies of alcohol consumption prevention.
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Received on April 28, 2001; accepted on November 2, 2001
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