Association between social climate for smoking and youth smoking behaviors in Taiwan: An ecological study
Introduction
Tobacco use and exposure to environmental tobacco smoke (ETS) have been established as major risk factors for many chronic diseases (World Health Organization International Agency for Research on Cancer [IARC], 2004). This worldwide problem has shifted from developed to developing countries, with regions varying widely in both gender- and age-specific smoking prevalence (Aghi et al., 2001). A large gender gap in smoking prevalence is commonly reported in Southeast or East Asian countries, e.g., almost half (46.8%) of adult men and 4.3% of adult women in Taiwan are smokers (Wen et al., 2005). Tobacco use in Taiwan also varies geographically. Smoking prevalence is highest among male adults in eastern Taiwan, but the highest smoking prevalence among female adults is in northern Taiwan (Yen and Pan, 2000). This high smoking prevalence results in more than half of non-smokers being exposed to ETS at home, especially females and youth (Wen et al., 2005).
In Taiwan, the majority of smokers start smoking in their teens, with almost 25% of first use before age 10 (Global Youth Tobacco Survey Collaborative and Global Youth Tobacco Survey Collaborative, 2002). Smoking behavior begins with an intention to smoke (Vitoria et al., 2009), which is built on a smoker's beliefs about tobacco use and interactions with his/her sociocultural background. Sociocultural factors such as parental and peer influence have been identified as key risk factors in initiating and maintaining tobacco use (Botvin et al., 1998, Simons-Morton and Simons-Morton, 2002). Other than sociocultural factors, social acceptance of tobacco use has been related to known personal factors such as knowledge, attitudes, self-esteem, or self-image (Aghi et al., 2001). Besides social acceptance of smoking being associated with smoking prevalence, the perception that smoking is common and normal within specific social contexts has been associated with susceptibility (Conley Thomson et al., 2005). Based upon the social cognitive theory proposed by Bandura (1986), observing others within the context of experiences and a dynamic social interplay can directly influence an individual's cognition.
Furthermore, exposure to ETS was found to be associated with smoking behaviors (Choi et al., 2002, Tercyak et al., 2002). Christophi et al. (2008) stated that while exposure to ETS was high and concerning in a sample of middle and high school students, smoking prevalence in this group was also high. Okoli et al. (2008) also identified the number of sources of ETS exposure as an important factor to increase nicotine dependence and smoking frequency. High social pressure to smoke was significantly related to higher exposure to ETS, regardless of the smoking status (Li et al., 2003).
Thus, higher smoking rates and ETS exposure might be considered as important indicators for pro-tobacco social norms or social climate (McMillen et al., 2003). Specifically, young people might perceive adult smoking and interpret this to mean that smoking is acceptable or prevalent. It is consequently essential to examine whether perceptions of smoking-related social norms would considerably influence youth smoking. Community health nurses whose goal is to preserve, protect, promote, or maintain health for individuals, families, and groups in a community (Williams, 2006) are in a crucial position to enhance awareness of anti-tobacco, reverse social norm of smoking, and deliver effective antismoking programs to reduce the prevalence of youth smoking initiation via building partnership of local community. Therefore, these results are substantial for developing further community nursing interventional programs in tobacco control among youth. As in most areas of behavioral sciences, the evidence for the link between perceived social factors and initiation of tobacco use comes from studies of individual smokers (Aghi et al., 2001). Although previous studies have reported that youth smoking was associated with adult smoking behaviors (Madarasova Geckova et al., 2005, Menezes et al., 2006, Scragg and Glover, 2007), most of these findings were from individual-level study designs. However, an ecological perspective was essential to gain a broader sense of environmental influences on health behaviors (Macintyre and Ellaway, 2000). Since the early-1990s, there has been some rehabilitation of an ecological perspective (Macintyre and Ellaway, 2000). With the unit of investigation on group-level variables, how the social and physical environment affects the human health or health behaviors is investigated.
As a significant step for tobacco use prevention and control, the Taiwan Bureau of Health Promotion sought to monitor trends and geographic variations in tobacco use throughout Taiwan by implementing a nationwide comprehensive surveillance system. This system has targeted different populations since 2004, including adults (>age 18) and junior high school students (age 13–15) by representative sampling at the county/city level. The representative data collected by this system provided the authors a unique opportunity to explore the geographic aggregation of adult and youth smoking behaviors and ETS exposure in Taiwan.
Thus, an ecological study design, using data from the Adult Smoking Survey and Youth Smoking Survey in Taiwan, was conducted to examine the associations among adult smoking behaviors, youth smoking behaviors, and ETS exposure at the county/city level. We predicted that the pro-tobacco social climate (i.e., higher smoking prevalence and ETS exposure rates) may be associated with increased risks of smoking among youths. Our study findings may provide a foundation of developing tailor-made anti-tobacco intervention program against social norm of pro-tobacco to decrease smoking prevalence, especially for those high adult smoking prevalence countries as Taiwan.
Section snippets
Adult smoking behaviors and ETS
Data on adult smoking behaviors were collected by telephone administration of the Taiwan Adult Smoking Survey between July and September of 2004. Telephone interviews were justified by almost 99% household telephone coverage rate in Taiwan (Ministry of the Interior, 1999). Systematic stratified sampling was used to generate a representative county/city sample of 16,688 persons ≥18 years old. For each household, adult respondents were selected by asking to speak with one person who was at least
Nationwide smoking behaviors and ETS exposure
The national prevalence of current smokers among Taiwan adults in 2004 was 23.99% (Table 1). Smoking prevalence was much higher for males than females (42.78% vs. 4.54%). Furthermore, the nationwide smoking rate was much greater among adults (23.99%) than among junior high school students aged 13–15 (6.53%). Among current youth smokers, the smoking rate was higher for males than for females (8.45% vs. 4.2%), but this gender difference was much smaller than in adults. The ratio of male to female
Discussion
To our knowledge, this is the first ecological study to observe the effects of such social climate as adult smoking rates and perceived ETS exposure rates on youth smoking rates, particularly among a population with high gender ratio in smoking. Our study found a geographical aggregation of adult and youth smoking behaviors in Taiwan. Specifically, the current youth smoking rate within counties was significantly positively correlated with the current adult smoking prevalence as well as home ETS
Study strengths and limitations
Our study examined effects of social environmental or “social climate” on smoking behaviors in an ecological study, as measures of individual attributes may not account for these processes. Although aggregating data into a group might lose information and be subject to aggregation-bias, the suitability of an ecological study relies on the purpose and the logic status of interpretation (Susser, 1994). Instead of using aggregate data as a proxy for individual data (the “ecological fallacy”),
Conclusions
Tobacco use and the association between adult and youth smoking behaviors varied in Taiwan by county/city. For counties, greater home ETS exposure and the smoking rates of the opposite gender were key associated factors of youth smoking prevalence. As the Ottawa Chapter (WHO, 1986) proposed, the World Health Organization has shifted the focus of health promotion to the development of healthy ‘settings’ worldwide. Our study further confirmed the importance of social climate on youth
Acknowledgments
This research was supported by a grant from the Bureau of Health Promotion, Department of Health, Executive Yuan, Taiwan. We thank Dr. Warren and his colleagues at the US CDC for all their support while conducting this study.
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