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ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 27-31

Cigarette Smoking Behavior and Associated Psychosocial Determinants Among School Going Adolescents in Panchkula, India


Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Vikram Arora
Department of Public Health Dentistry, Swami Devi Dyal Hospital and Dental College, Panchkula, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.201944

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  Abstract 

Introduction: Seventy percent of premature deaths in adults occur owing to harmful behavioral patterns such as smoking that emerged in adolescence. The rising trend of adolescent addiction to cigarettes is a cause for worry. Aim: To assess the prevalence of cigarette smoking in adolescents and to investigate the different psychosocial determinants which influence them to either smoke or not to smoke. Materials and Methods: A cross-sectional study was conducted in higher secondary schools of Panchkula, India. A self-structured questionnaire was used to assess the smoking behavior and other associated factors among 584 school going adolescents in the age group of 14–19 years. The proportion, the chi-square test, and bivariate and multivariate logistic regressions were applied. All analyses were done using the Statistical Package for Social Sciences, version 17.0 software. Results: The prevalence of ever smokers was 13.5% including 10.5% males and 3% females. Male students were more likely to ever smoke than females [odds ratio (OR) = 4.01; 95% confidence interval (CI): 2.84–6.14]. Subjects in the late adolescence were more likely to ever smoke than the middle adolescents (OR = 2.18; 95% CI: 1.18–3.67). Students in grade 12 had more than four times the odds of ever smoke than those in grade 10 (OR = 3.83; 95% CI: 2.34–5.67). Cigarette smoking was six times more likely if students had seen their sibling ever smoke (OR = 6.3; 95% CI: 3.16–9.69), three times more likely if a best friend smoked (OR = 3.18; 95% CI: 1.82–5.67), and two times more likely in students who had seen their father smoking (OR = 2.18; 95% CI: 1.67–2.84). Conclusion: A strong association exists between cigarette smoking behavior and different psychosocial factors, highlighting the need for efforts from parents, siblings, teachers, and peer groups to discourage smoking behavior.

Keywords: Adolescence, behavior, cigarette, role model, students


How to cite this article:
Arora V, Gupta N, Gupta P, Bansal M, Thakar S, Nagpal I. Cigarette Smoking Behavior and Associated Psychosocial Determinants Among School Going Adolescents in Panchkula, India. J Indian Assoc Public Health Dent 2017;15:27-31

How to cite this URL:
Arora V, Gupta N, Gupta P, Bansal M, Thakar S, Nagpal I. Cigarette Smoking Behavior and Associated Psychosocial Determinants Among School Going Adolescents in Panchkula, India. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2019 Jun 18];15:27-31. Available from: http://www.jiaphd.org/text.asp?2017/15/1/27/201944


  Introduction Top


Lung cancer is considered as a leading cause of deaths in developed countries and is rising at an alarming rate in the developing countries as well.[1] There is an overwhelming body of evidence of increased cancer risk in cigarette smokers. Globally, smoking-related diseases kill an estimated four million people every year. This number is predicted to rise to a staggering 10 million a year over the next two decades. In India, tobacco consumption is responsible for half of all the cancers in men and a quarter of all cancers in women, in addition to being a risk factor for cardiovascular diseases and chronic obstructive pulmonary diseases.[2],[3]

Cigarette smoking is the most common method of tobacco consumption in India. Almost 30% of the Indian population older than 15 years use some form of tobacco, with males preferring smoked tobacco rather than smokeless tobacco,[4] even though every form of tobacco such as cigarettes, cigars, snuff, and chewing tobacco contain nicotine, which is highly addictive and is readily absorbed into the bloodstream. Studies suggest that additional compounds in tobacco smoke, such as acetaldehyde,[5] may enhance nicotine’s effects on the brain, making such tobacco products the most addictive and deadly dependence-producing substances available.[4] Studies revealed that the adolescents are especially vulnerable to these effects and may be more likely than adults to develop an addiction to tobacco.[6]

Adolescence is a developmental period where behavior is influenced by emotional and social functions. An adolescent once initiated into tobacco use will continue using it lifelong, with very low quit rates.[7] The rate of adolescent addiction to cigarettes is high in India. According to Global Adult Tobacco Survey 2009, India, more than half of the smokers initiate smoking in their adolescence.[8] Nearly one in 10 adolescents in the age group of 13–15 years have ever smoked cigarettes.[9] The most common reasons cited for children to start using tobacco are peer pressure, parental tobacco habits, and pocket money given to children.[10]

Effort to prevent adolescent smoking focuses on building their individual resistance to social influences. The current study aimed to assess the prevalence of adolescent cigarette smoking and to investigate the psychosocial determinants, which influence them to either smoke or not to smoke.


  Materials and Methods Top


A cross-sectional study was conducted from August to October 2015 among school going adolescents in the age group of 14–19 years in Panchkula, India. The study protocol was approved by the Institutional Ethical and Review Board. Formal approval and permission was also sought from each school being selected. All the schools in Panchkula (n = 75, including government and private according to district elementary education office) were included in the sampling frame.

The sample size was calculated based on the assumption of 75% prevalence. Precision was set at 5%. For P-value 0.05 and 80% power of the study, our expected sample size was 534. Keeping in mind the dropouts, a convenient sample of 584 subjects was included. A two-stage cluster sampling design [Figure 1] was used to draw a representative sample from 9 to 12 grades among different schools. The first stage was a random selection of the schools from the list of schools obtained from Haryana State Education Board, using a table of random numbers. The second stage comprised random sampling of one grade each from grade 9 to 12 in each selected school. All the students in the selected grades, present on the day of the survey and willing to participate, were enrolled and assuring them of anonymity.
Figure 1: The sampling of the adolescents

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A self-structured, closed-ended questionnaire was administered to the subjects, which consisted of two sections: Section A comprised questions assessing sociodemographic and academic characteristics such as age, gender, school grade, family structure, among others, while Section B consisted of questions related to cigarette smoking such as age of initiation, preferred place for smoking, reason to initiate the habit, and the factors which might influence them to smoke or not to smoke. The questions were of multiple-choice type, and subjects were instructed to tick only one appropriate response for each item. All questions were required to be answered.

English, Hindi, and Punjabi versions of the questionnaire were used depending upon the language of instruction used in a particular school. Both the Hindi and Punjabi versions were back-translated from the English questionnaire by knowledgeable linguists. These were pre-tested in at least two focus group discussions in each state, and for repeatability by the test–retest method, before actual field administration. The respondents were also asked for feedback on clarity of the questions and whether there was difficulty in answering the question or ambiguity as to what sort of answer was required. The subjects who participated in the pretest were not included in the final sample. Few modifications were done to improve the understanding of the questionnaire based on the focus group discussion.

The results were expressed in percentage. Binary logistic regression analysis with backward elimination was used to determine the independence of associations observed in the bivariate analysis by controlling for potential confounding factors. Multivariate logistic regression was applied to explore the association of cigarette smoking behavior with the various independent variables under study. A P-value <0.05 was considered to be statistically significant. All analyses were done using the Statistical Package for Social Sciences, version 17.0 software (SPSS Inc., Chicago, IL, USA).


  Results Top


Out of the total sample of 584, only 532 completed the questionnaire with the response rate of 91.09%. The remaining 38 questionnaires were incomplete, whereas 14 did not confirm the age criteria and, therefore, were excluded from the analysis. Proportion of students in the grade 10, 11, and 12 was almost equal. None of the students in grade 9 reported smoking, so this grade was excluded from the data analysis.

The prevalence of ever smokers was 13.5% including 10.5% males and 3% females. The mean age of initiation of cigarette smoking was 14.7 years. More than half of the users (54.9%) preferred to smoke cigarette in public places followed by friend’s house (18%). Almost half (54.6%) of the users purchased cigarette directly from the shops. Majority of the students started using cigarette out of curiosity (39.2%) followed by those who used it to relieve tension (28.4%) and owing to peer pressure (32.4%).

In the bivariate analysis [Table 1], male students were more likely to ever smoke than females [odds ratio (OR) = 4.01; 95% confidence interval (CI): 2.84–6.14]. Students in the late adolescence were more likely to ever smoke than those in the middle adolescence (OR = 2.18; 95% CI: 1.18–3.67). Students in the private schools were more likely to ever smoke cigarette than the ones belonging to government schools (OR = 3.73; 95% CI: 1.78–4.48). Students in grade 12 had more than four times the odds of ever using cigarettes than those in grade 10 (OR = 3.83; 95% CI: 2.34–5.67). Students in the nuclear family were less likely to ever use cigarettes than those from the joint family. Students who receive pocket money of more than or equal to 100 INR/day were more likely to ever smoke than those who received less (OR = 2.88; 95% CI: 1.27–3.78). No difference was seen in ever smokers when their father’s education was concerned. Students whose mother is educated more than grade 12 were more likely to ever use smoke than those of up to grade 12 (OR = 2.28; 95% CI: 1.34–3.14).
Table 1: Sociodemographic characteristics of adolescent cigarette smokers

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Multivariate logistic regression was applied to explore the association of the cigarette smoking behavior with various sociodemographic variables. As depicted in [Table 2], cigarette smoking was six times more likely if students had seen their sibling ever smoke (OR = 6.3; 95% CI: 3.16–9.69), three times more likely if a best friend smoked (OR = 3.18; 95% CI: 1.82–5.67), and two times more likely in students who has seen their father smoking (OR = 2.18; 95% CI: 1.67–2.84).
Table 2: Significant correlates of “ever smoking cigarette” by the role models

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  Discussion Top


Smoking continues to remain a major cause of morbidity and mortality from oral and lung cancers. The concerns of health personnel regarding tobacco smoking have greatly expanded in the last two decades.[11] In the developed world, cigarette smoking has been the major habit among children for both boys and girls. They usually take to the habit while in school before the age of 18.[4] Similar patterns are now seen in developing countries such as India, where age of initiation of smoking has been reported as low as 11 years.[12] Adolescence is generally divided into three stages of development: early (10–13 years), middle (14–15 years), and late adolescence (16–19 years) stages.[13],[14],[15] It is usually seen that risk-taking behaviors begin to manifest from the middle adolescence onwards.[16] Because of this reason, we decided to include the adolescents of middle and late stages, in a quest for smoking behavior and its determinants.

In the present study, the adolescents were asked to report if they had ever smoked, to which 13.53% of our study subjects acquiesced. This figure was similar to the results obtained in previous studies conducted among school going adolescents aged 15–19 years in Delhi.[17]

According to a recent study in Ethiopia, higher prevalence (28.6%) of ever smoking was found among adolescents.[18]

Tobacco smoking is usually a male-dominated phenomenon among children and adolescents in India unlike the West, where its distribution is equal among both genders.[19] In our study, tobacco smoking was found to be significantly higher among male students than female students. Similar results have also been obtained in other studies done among school going adolescents in Delhi[19] and Kolkata.[20]

Large proportions of adolescents in Asian countries, especially boys, pick up smoking as a part of normal behavior associated with their transition to adulthood. However, the rising trend of tobacco use among the girls shown in recent studies should not be ignored.[21] In fact, the smoking behavior of girls in our study may have been under reported due to fear of social stigma.

Most of the ever smokers belonged to late adolescence age group (17.5%) and were studying in grade 12 (26.1%). The mean age of onset reported by the ever smokers was 14.7 years, which is similar to the studies from Noida,[12] Delhi,[19] Kathmandu,[22] and Kerala,[23] where the mean ages of onset were found to be 12.4, 12.31, 14.15, and 13.2, respectively.

A higher percentage of adolescents attending private schools and getting a pocket money >100 INR/day were three times more likely to turn out to be ever smokers. The higher percentage of smokers found in private schools may be due to the relatively expensive nature of cigarettes, and hence, having the means to purchase them becomes an important factor in their consumption. In fact, studies have reported that use of smokeless tobacco, instead of cigarettes, is more common in government schools.[12]

With regard to parents’ education level, the percentage of ever smokers was evenly distributed among fathers with education up to and more than grade 12; however, adolescents whose mothers were educated more than grade 12 were twice as likely to ever smoke. A possible explanation for this may be that being more educated, their mothers might be working and are unable to constantly supervise their wards as much as stay at home mothers.

The present study explores the documented factors implicated in the initiation of tobacco smoking among adolescents, that is, peer pressure, increased disposable income in the affluent families, smoking behavior by their role models, parental habits, and best friends. In the present study, the adolescents’ ever smoking behavior was found to be six times more likely if students had seen their sibling ever smoke, three times more likely if they saw their best friend ever smoke, and two times more likely in students who had seen their father smoking. The parental tobacco use behavior was reported as a major influencing factor in a study done in Delhi,[19] where ever tobacco use was found to be four times higher in adolescents who had reported parental tobacco use.

Our finding of the great influence of siblings rather than parents indicates that an adolescent is rather more conscious of the entire family environment created by these role models. Smoking by family members is likely to affect the impressionable adolescents who are more inclined to perceive smoking as a positive and acceptable behavior. This is corroborated by Pierce et al.,[24] who stated that smoking by family members strongly predicts smoking susceptibility among adolescents. A study from Nepal[21] shows that family members’ smoking reinforces factors for tobacco use among adolescents. Furthermore, observing their favorite celebrity smoke can enhance smoking initiation among adolescents. However, such exposure was not statistically significant in our final model.Several studies[22],[24],[25] have reported that having a friend who smokes is associated with smoking behavior of adolescents. Peer pressure to just “try it” and a desire to “fit-in” may encourage the adolescent to try cigarettes or eventually form a smoking habit. However, many studies have concluded that although parental smoking may influence adolescents to start smoking, the same could not be said for peer smoking as adolescents smoke may choose other adolescents who smoke to be their closest friends.[26]

Family structure was also found to be an important factor in adolescent smoking behavior.[19] In our study, we found that adolescents belonging to nuclear families were more likely to smoke than those belonging to joint families. Similar results have also been reported by a study done in Delhi, India. Adolescents belonging to joint families are under constant adult surveillance which may reduce their risk taking behaviors including tobacco use.[19] On the other hand, studies that have found that tobacco use was less likely among students belonging to nuclear families argue that close contact among parents and children in nuclear families might play a protective role against taking up risky behavior such as tobacco use.[21]

The use of self-reported survey may have resulted in reporting bias. However, the study investigators ensured the privacy of study participants and, thus, reliability of the responses. Another limitation is related to the cross-sectional design of the study, and thus, temporality between predictive factors and smoking aspects cannot be assured.

It is recommended that the primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school going adolescents and to aid adolescent smokers in quitting smoking, and ask parents about tobacco use and offer them cessation advice and assistance to protect children from secondhand smoke.


  Conclusion Top


Smoking behavior is quite prevalent among school going adolescents in Panchkula district, despite prohibition on sale of cigarettes to minors, that is, below 18 years of age and in an area within a radius of 100 yards from educational institutions (section 6, COPTA 2003). The risk of an adolescent ever smoking was found to increase if they were male, in a stage of late adolescence, had higher pocket money, and had ever seen their sibling smoke. There is an urgent need to take effective steps to curb the smoking behavior among adolescents.

Acknowledgements

We wish to express sincere appreciation and thanks to the school going adolescents for their participation throughout the course of the study and the staff members of the schools; without their cooperation, this study would not have been possible.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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