The European Journal of Public Health Advance Access originally published online on July 12, 2006
The European Journal of Public Health 2007 17(2):155-161; doi:10.1093/eurpub/ckl095
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Smoking |
Factors associated with stages of cigarette smoking among Turkish youth
Nevbahar ErtasAndrew Young School of Policy Studies, Georgia State University 14 Marietta Street, NW, Atlanta, GA 30303-2813, USA
Correspondence: Nevbahar Ertas, Andrew Young School of Policy Studies, Georgia State University, 14 Marietta Street, NW, Atlanta, GA 30303-2813, USA, tel: +1 404 651 3990, fax: +1 404 651 3996, e-mail: padnex{at}langate.gsu.edu
Received May 16, 2006, accepted May 30, 2006
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Abstract |
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Background: This study examines prevalence and determinants of cigarette smoking among Turkish youth and transition among smoking stages. Methods: Cross-sectional data from the Global Youth Tobacco Survey (GYTS) obtained from 15 197 youth were used to study factors associated with various stages of cigarette smoking among Turkish youth. Results: Males and high-school students have higher odds of being susceptible to smoking compared with other non-smokers and higher odds of becoming established smokers. Exposure to parent, teacher, and peer smoking, anti-tobacco curricula, cigarette promotions, and perceived ease of access to cigarettes are all significant predictors of being susceptible to smoking and established smoking. Turkish youth who attribute positive traits to smokers are more likely to be susceptible to smoking and to become established smokers. Parental advice and media exposure to anti-tobacco messages were not significantly associated with becoming an established smoker. Conclusion: The results reveal the importance of early prevention programmes, which should begin before high school, and targeting efforts towards male students and all students who are not yet smokers but susceptible to smoking. Findings also suggest that prevention policies that challenge the cultural perceptions of smokers among Turkish youth are needed.
Keywords: adolescent, global youth tobacco survey, smoking, smoking stages, Turkey, youth
While cigarette consumption tends to decrease in developed countries, tobacco consumption rates in developing countries are expected to increase. World Health Organization (WHO) data shows that the tobacco consumption in low and middle-income countries has increased by 
3.4% annually between 1970 and 1990.1–3 Previous studies have also shown that most smokers began smoking in adolescence and the earlier a person uses tobacco, the more likely he or she is to become a regular smoker as an adult.4,5 As a result, preventing smoking initiation and use among adolescents has become a significant global public health concern. Tobacco use in adolescence has many adverse health effects such as damage to the respiratory system and addiction to nicotine, and extended smoking causes several diseases including lung cancer and other cancers, cardiovascular diseases and respiratory diseases.3–5
Cigarette smoking has also been a serious public health concern in Turkey, which has traditionally exhibited very high prevalence rates. According to the WHO data, 49.4% of adult (age 15 and over) men and 17.6% of adult women in Turkey are daily smokers (overall rate: 31.2%).6 Other national and local studies found varying prevalence rates among different population groups. Table 1 summarizes the findings from previous studies.6–14
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More than 75% of smokers live in developing countries and understanding the factors associated with cigarette smoking and smoking onset among youth in a developing country like Turkey can provide critical insights into this global problem. Previous research showed that the process of becoming an established cigarette smoker occurs in different stages: a preparation and trial phase, followed by a phase characterized by higher smoking frequency and intensity.15–18 Most of the studies on tobacco use behaviour of Turkish youth have focused on prevalence rates and do not differentiate between different stages of smoking. In this study, I will examine determinants of cigarette smoking among Turkish youth and try to explore transition among different smoking stages by analysing youth behaviour at different stages of smoking intensity.
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Youth smoking is a complex and multidimensional phenomenon that is affected by multiple factors.18–21 The stage conceptualization model that is used in this paper is based on the work by Leventhal and Cleary15 and the protective and risk factors were chosen for analyses based on the existing relationships in the adolescent smoking literature. Smoking uptake behaviour is often conceptualized as a progressive process, which consists of sequential developmental stages.18 Leventhal and Cleary15 introduced the stages approach in smoking research by dividing the smoking process into preparation, initiation, experimentation, becoming a smoker, and maintenance stages. The stages approach is commonly accepted, but different researchers used variations of stage definitions according to the purpose of their study or data limitations.18 Some researchers have also suggested integration of other concepts to better identify different stages. For example, Pierce et al.22 integrated the concept of susceptibility in the preparation stage. In this stage, adolescents start to form ideas about smoking and becoming a smoker. Adolescents, who are currently not smoking, but inclined to start smoking in the future, are defined as being ‘susceptible to smoke’. Initiation is the early experimentation with cigarettes. In becoming a smoker stage, the adolescent increases the intensity of smoking in multiple social settings. In the final stage of maintenance, the individual becomes a regular user and exhibits addiction to nicotine.
Different theories from various disciplines showed that multiple psychosocial risk and protective factors are linked to youth smoking.18–23 Stage studies also showed that the effect of some factors varies across the stages of smoking uptake.18,23 Mayhew, Flay, and Mott18 classified the predictor variables of smoking stages in these studies into individual, familial, and social characteristics. Previous research found that individual variables such as age, grade, race, and sex were related to both experimental and regular smoking.18,19,23 For example, initiation and regular smoking in youth typically increases with increasing age and grade.19 The effect of the sex is rather ambiguous. In their review article on psychosocial factors related to adolescent smoking, Tyas and Pederson19 showed that recent studies found the rates of current smoking and initiation to smoking to be approximately equal for males and females in North America, but they also discussed a geographical/cultural pattern of gender differences among Eastern and Western countries. Sex and age differences in smoking rates especially in South Asian populations are noticeable.24 In fact, the analyses of GYTS data from many countries showed that boys are more likely than girls to use tobacco.25 However, studies also argue that the prevalence of smoking among women may increase in developing countries, as they become more Westernized.10,24
Positive attitudes and beliefs about smoking were also found to be related to all stages of smoking.26,27 Some studies showed that smoking behaviour and intentions are related to placing a positive value on the smoker image.28 Other studies focused on the gender-specific cultural differences. For example, Aghi showed that male youth in some developing counties are attracted by the macho image smoking projects and they report ‘appearing macho’ as one of the reasons for starting to use tobacco.29
Familial factors include both the actual smoking by parents and the parental attitudes towards smoking. Previous research found that parental smoking has a strong influence on adolescent smoking at the initiation stage, experimentation stage,18,19 and in transition to regular smoking.23 Parental attitudes towards smoking and parental advice were also reported as predictors of smoking frequency and initiation, experimentation, and regular smoking.30,31
The most commonly reported social effect on smoking uptake is the peer effect. Previous research uniformly found that the peer effects play a significant role in youth smoking decisions.19,32 Although a strong association is established in numerous studies, it is not clear whether the peer influence leads to increased smoking or the youth who smoke tend to interact with other smokers. Some studies also showed that the student's smoking status is also associated with their perceptions of teacher smoking.33
Previous research suggests that a strong anti-tobacco media campaign is a key element of an effective tobacco control effort and found reduced cigarette smoking and more favourable anti-smoking attitudes among youth exposed to anti-tobacco advertising.34–37 The experiences in California, the original Truth campaign in Florida and the adopted and expanded version by the American Legacy Foundation proved to be very effective in decreasing youth smoking.36–37 Previous research also demonstrated that adolescents who were receptive to tobacco industry advertising and promotions were more likely to progress towards smoking.38,39 Other important factors in predicting smoking intensity are perceptions of easy access to cigarettes,30 and school-based prevention programmes; however, recent studies showed that their effects are limited.36
Understanding the factors that affect different stages of smoking uptake process is crucial for the adoption of effective policy interventions to reduce smoking among youth.
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Methods |
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Data source
This study uses the sample of Turkish students from the Global Youth Tobacco Survey (GYTS), which is conducted in middle and high schools in 2003.37,38 The WHO and US Centers for Disease Control and Prevention (CDC) developed GYTS, which is a school-based survey of students aged 13–15 years to track tobacco use among young people across countries. The survey includes questions about knowledge and attitudes of young people towards cigarette smoking, the role of the media and advertising on young people's use of cigarettes, access to cigarettes, tobacco-related school curriculum, environmental tobacco smoke, and cessation of cigarette smoking. For the 2003 GYTS, 15 504 students in 202 schools completed the anonymous and confidential self-administered questionnaires. The student response rate was 92.11%.
Outcome measures of tobacco use
Self-reported smoking status was used as the measure of tobacco use. Based on previous research, questions in the GYTS are used to classify youth into groups according to their smoking uptake. In order to be able to study the progression to established smoking, Mowery et al.17 classified youth who have never smoked a cigarette into two groups as being open to smoking and not open to smoking in their research.15 Students who did not indicate an intention of starting in the near future are grouped as not open to smoking. I have used three questions from the survey to establish similar groups. (i) Will you be smoking for the next 12 months? (ii) Will you be smoking after 5 years from now on? (iii) Would you smoke a cigarette if your best friend offered it? Students who answered ‘absolutely not’ to each of the three questions are considered as not susceptible to smoking.
Current use of cigarettes was defined as having smoked at least once during the 30 days preceding the survey. The current smoking rates in the 13- to 15-year old Turkish subsample were 11.9% for boys and 5.0% for girls (overall 9.1%). Current smokers are classified into two groups as non-daily smokers and established smokers using the information on their smoking behaviour in the last 30 days preceding the survey. Youth who have smoked on 1–19 days of the past 30 days are classified as non-daily smokers, and youth who have smoked on 20 or more days of the past 30 days are classified as established smokers. As a result, I defined four mutually exclusive categories to group students in the sample in terms of their smoking behaviour: Non-smoker not susceptible to smoking, non-smoker susceptible to smoking, current non-daily smoker, and established smoker (Table 2).
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Correlates of smoking
Based on the previous research, I have used several individual, familial, and social measures that may be associated with tobacco use and susceptibility to smoking. In order to test the effects of parents, teachers, and peers, questions on parental smoking, teacher smoking, and peer smoking are used. Students were asked:
‘Do your parents (or those responsible for your care) smoke?’, ‘In the last year of education, how frequent have you witnessed your teachers smoking in the school?’ and ‘How many people smoke in your class?’
If one or both parents smoke, these students are identified as having experienced smoking at home. Students who indicated that they witness teachers smoking almost every day or sometimes are considered to be exposed to teacher smoking. If the students indicated that some, half or most of the students in her class smokes, they are considered to be in the risk category for that factor. For parental advice, I used the answer to the question ‘Has anyone in your family told you about the hazards of smoking?’ as an indication of parental advice to not smoke.
The following three questions from the GYTS are used to measure the effect of school curriculum. (i) ‘Have you ever been informed on hazards of smoking in any of your courses within last year of education?’ (ii) ‘Have you ever discussed on why your peers smoke within last year of education?’ (iii) ‘In the last year of education, have you ever talked about cigarette's yellowing of your teeth, causing wrinkles on your skin and making you smell bad?’ Students who said yes to at least two of these three questions are considered to have been exposed to anti-tobacco curricula.
In order to evaluate the level of exposure to anti-tobacco media and advertising, the GYTS asks the students ‘How many anti-tobacco media messages have you seen on TV/on radio/on billboards/on posters/on newspapers and journals/on cinema?’ The students who had seen many or few media messages on at least one medium are considered to have been exposed to anti-tobacco media messages.
Students are also asked whether they have been offered cigarettes free of charge by a tobacco sales representative. This variable is included as an indicator of tobacco company promotion as previous research demonstrated that adolescents who were receptive to tobacco industry advertising and promotions were more likely to progress towards smoking. Finally, I have used the question ‘Is it easy or hard in general for you to go and buy cigarettes from the market?’ as a measure of perceived ease of access to cigarettes. The tobacco control act of 1996 bans the advertising and sales of tobacco products to minors in Turkey; however, the law is not strictly enforced.
Smoking is a very common social practice in Turkey and non-smoking is not yet adopted as a social norm. As the prevalence rates are very high among all population groups, including teachers and doctors,12 the attitudes and beliefs about smokers among youth can influence the adolescents' openness to smoking. In order to analyse this effect, two questions from the GYTS are used. The students were asked (i) What do you think about a man you saw smoking? (ii) What do you think about a woman you saw smoking? The possible answers are lacks self-confidence, foolish, loser, successful, clever, or ‘macho’ for men and ‘intellectual’ for women. The male students who choose successful, clever, or macho responses and female students who choose successful, clever, or intellectual responses are identified as having positive beliefs for smokers. Finally, all the models include student's sex and grade level. Students in 7th and 8th grades are grouped together as middle-school students and the rest are high-school students.
Statistical analysis
GYTS employed a multistage sample design with schools selected proportional to enrolment size from both urban and rural schools. All estimates were weighted and standard errors were adjusted to account for the complex survey design using STATA 8.2 (Stata Corp, College Station, TX) statistical software.
First, percentage distributions of Turkish youth in different stages of smoking are reported for males, females, and students in different grades. Second, three logistic regression models are used to analyse the 2003 GYTS data and examine the factors associated with different stages of smoking uptake. Three outcome variables used were susceptibility to smoking, non-daily smoking, and established smoking. The first model tests susceptibility to smoking among all non-smokers. In the second model, the non-daily smokers are compared with the non-smoking adolescents. The third model tests established smoking among all students.
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Table 2 shows the percentage distribution of non-smokers (both susceptible and not susceptible to smoking) and smokers (both non-daily and established smoking) among Turkish youth by gender and grade level. The percentage of both non-daily and established current smokers is higher among high-school students. While <1% of the 7th class students report established smoking, >5% of high-school students are established smokers. The prevalence of susceptibility to smoke is also higher among high-school students. Across all grades,
16% of non-smokers are susceptible to smoking. The prevalence of smoking differs significantly by gender. Male students are more than twice as likely as female students to be non-daily or established smokers. About 8.6% of males, compared with 3.8% of females are current non-daily smokers in the Turkish youth sample. The gender difference is smallest in the susceptibility to smoking category. About 17.8% of male students compared with 14.4% of females are non-smokers who are open to the idea of smoking.
Table 3 shows the odds ratios for predictors included in the logistic regression models. The first model tests susceptibility to smoking among all non-smokers. The second model tests current non-daily smoking compared with non-smokers. The third model tests established smoking among all students. The analyses show that several factors influence the smoking behaviour of youth in these different stages. Gender and being a high-school student are predictors of susceptibility to smoking among non-smokers. Males and high-school students have higher odds of being susceptible to smoking compared with other non-smokers (P < 0.001). Similar to previous studies, having parents, teachers, and friends who smoke is associated with being susceptible to smoking among non-smokers (P < 0.001, P < 0.05, P < 0.001). Parental advice is also a significant predictor of being open to smoking among never smokers (P < 0.001). Exposure to anti-tobacco curricula at school (P < 0.001) and perceived difficulty of access to cigarettes significantly reduces the odds of being open to smoking (P < 0.05). Tobacco company promotion increases the odds of being open to smoking (P < 0.001). The odds that a student who has been offered cigarettes free of charge by a tobacco sales representative will become open to smoking are 2.5 times as high as the odds that a student who has not been offered the promotion. Having positive beliefs about smokers also increases the odds of being susceptible to smoking significantly (P < 0.001). Exposure to anti-tobacco advertising produces a significant, but unexpected, positive coefficient on being open to smoking among non-smokers. The anti-tobacco media exposure questions in GYTS measure the awareness very crudely. The students who had seen many or few media messages on at least one medium such as TV, radio, billboards, posters, newspapers, or journals are considered to be exposed to anti-tobacco media messages. Alternative definitions of media exposure are constructed using different combinations of mediums, but the observed effect remained positive. One recent study, that uses the comparable US data also found insignificant results for exposure to anti-tobacco advertisements.17 Other studies that focus specifically on anti-tobacco media exposure and use more precise measures and longitudinal data, often found that such media campaigns are effective.34–37 Additionally, during the GYTS data collection period, Turkey did not have wide-ranging national anti-smoking media campaigns targeted at youth like the American Legacy Foundation truth campaign in the US. Another possible explanation could be a selection problem due to selective memory. Smokers or youth who are more open to the smoking idea may be more likely to notice these advertisements.
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Gender, being a high-school student, having friends who smoke, perceived ease of access to cigarettes, tobacco company promotion, exposure to anti-tobacco curricula at school, and having positive beliefs about smokers are also predictors of being current non-daily smoker. Having teachers or parents, who smoke were not found to be significantly associated with current non-daily smoking. All, but two factors influence being an established smoker among Turkish youth. Males and high-school students, those who have parents, teachers, and friends who smoke, those who expressed no difficulty of access to cigarettes, and those who have positive beliefs about smokers have higher odds of being an established smoker compared with other students. For youth who have positive beliefs about smokers, the odds of being an established smoker are 2.4 times as large as the odds of comparable youth. The effect of having smoker friends on becoming an established smoker is noteworthy. Students who have friends who smoke are 13 times as likely to be established smokers. Peer smoking appears as a strong predictor in all three models, and the size of the odds ratio increases with more intense stages of smoking. Peer smoking is also found to be a strong and consistent predictor of youth smoking intentions and maintenance in the literature; however, part of this effect can be explained by a selection bias. Selection bias arises if youth tend to choose peers with similar characteristics such as similar smoking uptake and some of the previous studies found that when the selection effects are controlled, the influence of peers on youth decision to smoke may be weaker than is suggested.32 As the analysis did not account for the endogeneity of peer choice, part of the large effect size observed on this variable may be attributed to the selection effects. Parental advice and media exposure to anti-tobacco messages were not significantly associated with established smoking.
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Discussion |
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This study presented data on Turkish youth in different smoking stages. About 25% of Turkey's population is <15 years old and the age of initiation of cigarette smoking is declining. Understanding the factors associated with youth smoking is critical to develop stage-specific and targeted prevention policies.
The findings from the study are mostly parallel to the findings of previous studies that focus on the role of individual, familial, and social effects in the smoking uptake behaviour. The results showed that the prevalence of non-daily and established smoking is significantly higher among males and older students. When compared with the US youth in similarly specified groups in a recent study, the results showed that a significantly higher percentage of Turkish youth are both susceptible to smoking and are non-daily smokers in the GYTS Turkish sample.17 About 16.3% of Turkish youth are in the susceptible to smoking category and 6.3% are current non-daily smokers compared with 12.1 and 3.3% in the US sample, respectively. Interestingly, a significantly lower percentage of youth in 13- to 15-year old Turkish student population are established smokers compared with their US counterparts. Parental advice and exposure to anti-tobacco media messages were not influential predictors of established smoking. However, parental advice appears as a significant predictor for earlier stages. For comparable adolescents, who have been told about the hazards of smoking by their family, the odds of being susceptible to smoking decrease by 33% and the odds of being in the non-daily smoker category decrease by 27%. Similar to previous studies, exposure to smoking by parents, teachers, and peers is found to be an important risk factor for youth smoking in Turkey, especially for being susceptible to smoking and for becoming established smokers. Tobacco industry promotion targeting youth was also a critical risk factor to both becoming susceptible to smoking and becoming an established smoker. Despite the 1996 tobacco legislation that bans tobacco advertising, youth continue to be targets of cigarette marketing and indirect advertising in Turkey.39 In order to produce successful youth tobacco policies, the results from the study suggest that early intervention, early parental advice, early exposure to anti-tobacco curricula at school and stronger enforcement of youth access laws and tobacco advertising restrictions can reduce progression to established smoking.
The results also indicated the importance of beliefs about smokers and gender differences in smoking uptake among Turkish youth. Having positive beliefs about smokers is a highly significant predictor in all three models, with strongest effects on the established smokers. This reveals the cultural aspect of the smoking behaviour among Turkish youth. The anti-tobacco strategies should consider and respond to youth's unfounded idea that smokers are more clever, successful, or intellectual. There are also significantly larger disparities among males and females in the Turkish sample compared with the US sample. Previous studies have found the same significant differences between males and females across all population groups in Turkey and attribute the difference mainly to traditional gender roles in the Turkish culture, which are still very powerful, despite the rapidly changing socioeconomic conditions.10,13 Interestingly, the results in this study indicate that the gender difference is smallest in the susceptible to smoking category. This may indicate that the prevalence rates for women may increase to catch up with the prevalence rates of men, as suggested by the studies that analyse long-term tobacco use patterns in different countries.40,41 The results reveal the importance of early prevention programmes that should begin before high school and targeting efforts towards male students and all students who are not yet smokers but susceptible to smoking.
The study also has some limitations. First, a cross-sectional sample is used, so considerable caution must be exercised regarding any causal or temporal inferences. A time series analysis utilizing the next round of data, when it becomes available, could be a next step for future research. Second, the sample only comprises students, so we cannot generalize the results to all youth in Turkey. Despite the limitations, the study presents valuable information by examining tobacco use patterns of Turkish youth at different stages of smoking and predictors of smoking intention and maintenance.
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Acknowledgments |
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The GYTS is a collaborative project of WHO/CDC/participating countries. Analyses of GYTS data are not necessarily endorsed by the WHO/CDC/participating countries. I thank Gregory B.Lewis and Bulent Anil for their helpful suggestions and comments on the earlier versions of the manuscript. Conflict of interest: None declared.
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