Xu et al. SpringerPlus (2016) 5:2021 DOI 10.1186/s40064-016-3694-z
Open Access
RESEARCH
Smoking related attitudes, motives, and behaviors of male secondary school students in an urban setting of China Xianglong Xu1,2,3†, Cheng Chen1,4†, Abu S. Abdullah5,6,7, Lingli Liu1,2,3, Manoj Sharma8, Yaping Li1,2,3 and Yong Zhao1,2,3*
Abstract Background: Most smokers have their first experience of cigarette use when they are teenagers (i.e. at schools). Aiming tobacco control initiatives at secondary school students offers preventive measures to eliminate or reduce tobacco use initiation by students. This study assessed smoking-related attitudes, motives and behavior as well as other factors associated with smoking among male secondary school students in an urban setting in China. Methods: A cross-sectional survey was conducted in urban areas of Chongqing using a structured questionnaire administered to 1297 male secondary school students. Logistic regression analysis was employed to investigate the factors that affect smoking. Results: Of the participants (n = 1297), 27.7% were secondary and 72.3% were middle school students. Overall, 30.5% of the participants were smokers. The majority of the students procured their first cigarette from friends. The motivations of middle school students to smoke their first cigarette were curiosity (70.5%) and imitation (13.1%). The motivations of high school students for smoking their first cigarette were to satisfy their curiosity (51.8%), relief of stress and social pressures (17.1%), and imitation of smoker friends (15.9%). Respondents from poor family financial conditions were more likely to smoke than those from rich family financial conditions [odds ratio (OR) 1.59, 95% confidence intervals (CI) 1.00, 2.52]. Respondents whose fathers were smokers were more likely to smoke than those whose fathers were non-smokers (OR 1.65, 95% CI 1.25, 2.17). Respondents who had one or two smoker friends (OR 2.98, 95% CI 1.93, 4.60) and three or more smoker friends (OR 5.92, 95% CI 4.35, 8.05) were more likely to smoke than those who did not have any. Respondents who were neutral (OR 0.43, 95% CI 0.20, 0.91) and disagreed about the item “friends smoking” (OR 0.18, 95% CI 0.08, 0.39) were less likely to smoke than those who agreed with the item. Conclusions: This study indicates that male students who have negative attitudes toward smoking, who do not have a father or friends who smoke, and are from affluent backgrounds exhibit low tendency to start smoking at a young age. This study provides some implications for tobacco control policies among male secondary school students in urban settings. Keywords: Attitudes, Smoking behaviors, Urban, Male, Secondary school students Background Tobacco use is becoming one of the major preventable causes of premature death, disease, and disability *Correspondence:
[email protected];
[email protected] † Xianglong Xu and Cheng Chen are joint first authors. 1 School of Public Health and Management, Chongqing Medical University, Chongqing 400016, China Full list of author information is available at the end of the article
globally (National Center for Chronic Disease Prevention and Health Promotion and U.S. Office on Smoking and Health 2014). Most of smokers are men, and almost 800 million men smoke, with a third of all smokers living in China (Mackay 2012). Smoking among teenagers is becoming a serious public health problem. Data from the Global Youth Tobacco Survey (GYTS) showed that, 16.2– 30.1% teenagers initiated smoking and 8.6–14.6% had
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Xu et al. SpringerPlus (2016) 5:2021
smoked (Warren et al. 2000). Approximately 90% of adult smokers began smoking before reaching 18 years old in the US (U.S. Department of Health and Human Services 2012), and approximately 40% of adolescent smokers in China started smoking before reaching 10 years old (Hesketh et al. 2001). In 2012, 52.9% of male were smokers, and 31.0% of male smokers never seriously thought of quitting smoking in China (Xu et al. 2015). Tobacco control among adolescents is necessary and important to prevent many long-term diseases associated with smoking (U.S. Department of Health and Human Services 1994, 2012). Based on the 2014 China Youth Tobacco Survey Report, overall 6.9% of junior middle and high school students smoked; the prevalence in male students (11.2%) was higher than in female students (2.2%) (China Center for Disease Control and Prevention 2014). A systematic review of smoking initiation among Asian adolescents showed that male youths were more likely to initiate smoking (Talip et al. 2016). Teenagers are in the period of growth and development, when all physiological systems and organs are not yet fully developed; thus, their unique physiological characteristics make them more susceptible to tobacco (Centers for Disease Control and Prevention 1994). Tobacco exposure in early age indicates that the age of onset of numerous disease processes may be earlier and the incidence may be higher (WHO 2015). In particular, middle school is an important stage of physical and mental development. Cognition and the use of tobacco significantly affect tobacco control and smoking status (Treacy et al. 2007; Guo et al. 2012). The smoke-free campus policy can prevent non-regular smokers in high school from becoming regular smokers in college (Butler et al. 2012). Changing the social environment through policies and decreasing exposure of non-smoking students to tobacco use may decrease smoking initiation (Ridner 2005). Although numerous studies have documented rates and risk factors of smoking among adults, reliable evidence of those pertaining to youth from China is minimal. Many studies have explored the factors associated with smoking, but smoking initiation and tobacco use among youth in developing countries is rarely addressed. Clarifying the factors that affect smoking among youth is necessary to reduce smoking in China. Considering how smoking cessation poses challenges for many smokers (Lina et al. 2016), encouraging and educating male teenagers to not start smoking tobacco has significant public health benefits. Investigating the association between smoking initiation and relevant characteristics can assist in developing novel tobacco control measures. Smoking prevention among teenagers can also bring lifelong health benefits. This study assessed smoking-related
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attitudes and behaviors as well as factors associated with smoking initiation among male secondary school students to address the following four research questions: 1. What is the motivation to smoke for the first time? 2. How is the first cigarette procured? 3. What are the related attitudes, motives and behaviors toward smoking? 4. What are the factors that affect smoking?
Methods Participants
The study design and methods, including the inclusion criteria and the exclusion criteria and the population, as well as the survey administration, pilot study and methods of data collection have been reported previously (Xu et al. 2016). In June 2014, a formal investigation was conducted in the main urban areas of Chongqing. Among 1370 respondents, 1297 (94.7%) people answered all the questions, and 73 questionnaires were excluded because of missing data, resulting in a final sample of 1297 for analysis. In the Chinese education system, grades 7–9 comprise junior middle school, and grades 10–12 are high school. Considering the low prevalence of smoking in female students, this study only focused on male students to investigate typical smoking-related characteristics. Research on smoking among youth has traditionally included both middle and high schools students (Holmberg and Hellberg 2007). We obtained written informed consents from all parents or main caregivers of the enrolled students through parent–teacher conferences. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Chongqing Medical University. Questionnaire content
The questionnaire was derived from the 2014 China Youth Tobacco Survey Report (China Center for Disease Control and Prevention 2014). The questionnaire was customized for the target population based on the pilot study, and the final draft of the questionnaire was agreed upon after several discussions with experts and the pilot investigators. The questionnaire was piloted on 50 participants in one of the schools for finalization. We modified the questionnaire based on the results of the pilot study, especially the presentation of questions and the answer options. Demographics
Demographic data included age, school status (middle/high school students), smoking status of parents (non-smoker/smoker), family structure (intact family/ non-intact family), per capita household income [high
Xu et al. SpringerPlus (2016) 5:2021
(>US$750), average (US$225–$750), and low (
