©2007 National Kaohsiung University of Applied Sciences, ISSN 1813-3851
The Prevalence of Tobacco Smoking and Risk Factors of Vocational School
Students in Taiwan
Su-Chen Wang1, Albert Y. C. Hung2*
Department of Health Care Administration, Chung-Hwa University of Medical Technology, Tainan, Taiwan, R.O.C.
Graduate Institute of Health Care, MeiHo University, Pingtung, Taiwan, R.O.C. E-mail: email@example.com
To investigate the prevalence of and risk factors associated with tobacco smoking of vocational school students in Taiwan. Methods: A cross-sectional survey was designed. Students studying at vocational schools (manufacturing, commercial, fishery/agricultural, and medical technology) among northern, central, southern and eastern areas in Taiwan were selected by using stratification and clustering techniques. The students then completed a self-reported questionnaire after a trained interviewer had explained the study to them. Results: Valid data from 2,054 students was available for analysis. Among this group of students, 21.5% were ex-smokers and 20.7% were current smokers of tobacco. The prevalence of current tobacco smoking among students was slightly higher in fishery/agricultural schools (24.4%) than in other vocational schools (17.6%-23.0%). Curiosity (26.4%) and peer pressure (23.2%) were the major reasons for starting tobacco smoking. The main sources of smoking were self-bought (55.5%) and friends/classmates (28.1%). The current smokers accept tobacco, it was 9.0 times more prevalent than when the non-smoker. The probability of tobacco smoking among male students was higher than females from all types of vocational schools. The highest odds ratio of 3.014 fishery/ agricultural school students was significantly higher than commercial school students. The socio-economic factors of family and parental smoking habit influence of tobacco smoking behavior among students. Conclusions: The fishery/agricultural school student is the highest risk group of tobacco smoking in vocational school students. This study revealed that tobacco smoking behavior among vocational school students was affected with their family and peer, so that health authorities can develop health education program in dealing with the health risks of tobacco smoking among adolescent students of the highest risk group in Taiwan.
Keywords: Tobacco smoking, Prevalence, Risk factor, Vocational school students.
Tobacco affects the most important reason and public health question of the human disease and death. World Health Organization (WHO) report pointed out that tobacco cause death over 3 million people each year, will more than 10 million people each year in 2020-2030. In the developing country, 70% of the deaths associated with tobacco .
Paper discovered that tobacco created 53 dead each day, while 91% lung cancer and 30% other cancers were related to tobacco in 1990 . The increase in youth smoking during the 1990s was particularly striking among ethnic minority groups; with an increase of 80% among blacks . The research also revealed large variations in smoking duration between racial/ethnic and socioeconomic groups .
More than 3000 young people begin to smoke each day , and over 50% of these new smokers will smoke for at least 16 years . More than 90% of all individuals who ever smoked and 70% of all regular smokers initiated smoking before 18 years old . Smoking rates are generally higher among males than females. On average, males smoke more tobacco a day than females . Recent studies showed that the averaged ages of first time tobacco smoking was 12-14 years old. The exposure to passive smoke environment is firmly associated with the behavior of tobacco smoking among adolescent students. The habit of tobacco smoking among adolescent students involved in their parents, brothers and sisters in the family. The first time of getting tobacco was self-bought and classmates. 73.31% of adolescent students had not been inquired the age when they purchased cigarette, and up to 75% of adolescent students had not been rejected [6-8]. Tobacco smoking adversely affects the health of adolescents and set the stage for illness and addiction in adulthood. If people do not start smoking in their youth, few would smoke as adults .
Tobacco smoking is the leading preventable causes of morbidity and mortality in our society and among the most important public health problems of our time. The Lung Association revealed each day, between 82,000 and 99,000 young people around the world start smoking. Tobacco smoking will induces the cardiovascular disease, lung and other cancers, and chronic obstructive lung disease . While these smoking-related diseases do claim a lot of lives, heart disease that holds the top slot in the list of diseases that kills smokers. Today, heart disease is the leading cause of death in the United States, and the leading cause of death among smokers. And, on a global level, there were 1,690,000 premature deaths from cardiovascular disease among smokers in the year of 2000. In contrast, there were approximately 850,000 lung cancer deaths during the same year, and 118,000 chronic obstruction pulmonary disease (COPD) deaths from smoking in 2001, worldwide. Smoking is hard on the heart, but the fact is, tobacco using plays a role in a multitude of diseases that ultimately lead to disability and/or death. Tobacco contains over 4,000 chemical compounds; 200 of which are known to be poisonous such as polycyclic aromatic hydrocarbons (PAHs), and upwards of 60 have been identified as carcinogens . Longer exposure to tobacco among groups that are already disadvantaged is likely to exacerbate existing health disparities . Viewed in that light, it is no wonder that the effects of smoking are so widespread and destructive .
Taiwan has gone through rapid social and economic changes in the past several decades. Smoking in Taiwan, much like the rest of Asia [10, 11], is strongly associated with gender. Female smokers are around 6% of Taiwan's population. The prevalence of smoking among young Taiwanese women, however, has been rising in recent years . Research showed female smokers are easy to get lung cancer than male more 1.5-2.0 times. Every year has more than thousand of female who die in lung cancer. Have 97% male who has lung cancer most of them are smoker in Taiwan . Almost 20 percent of teens (age range from 12 to 19) currently smoke daily or occasionally. Due to the lower age and the availability of smoking to all the population, smoking behavior could chronically cause severe health problems to Taiwanese people . Recently, the issue of the tobacco smoking of adolescent students has become a serious problem in Taiwan.
Teens give many reasons for why they start smoking: “My friends’ smoke”, “I just wanted to try it”, “I thought it was cool”, and “My parents smoke”. One of the greatest reasons teens start to smoke is peer influence. Teenagers are more prone to peers’ pressure. Over 70 percent of teens say that having friends who smoke and/or peer pressure takes the first place reason for starting to smoke . The distribution of the smoking behavior population is concentrated in blue-collar workers or less-educated people . However, the situation is changing and the habit is gradually spreading to the younger generation, the more highly educated people, and becoming
generally widespread in all areas of Taiwan . When the smoking habit is formed during the teenage period, this probably will sustain their compulsive habits in adulthood. In considering the long-term effects, the early harmful consumption and the damage to health get progressively worse.
Yen indicated that the student is not good at school performance such as low learning ability and high academic pressure. Consequently, the individual study interest will be reduced and the deviation of behavior will be formed easily such as smoking, drinking, and betel nut chewing . The affect factors of risk in which students having the habit in smoking, drinking and/or betel nut chewing: male, have behavior question and friend has the use to attract tobacco, drink wine, and betel nut [16, 19]. In addition, parents and peer who have smoking, drinking, and substance abuse are the major factors to affect the adolescents who were addicted to tobacco smoking .
Up to now, even though the studies with respect to the prevalence of tobacco smoking among students have been reported, the investigation of teenagers who were exposed early to tobacco smoking has not been defined in detail yet. The prevalence and differences of adolescent student tobacco smoking along with the different demographics, the different types of vocational schools, and genders are investigated in this study. In addition, the reasons for the first time trying tobacco smoking and its related risk factors also are concluded. Finally, the high-risk adolescent group for potential tobacco smoking is identified through this study.
2.1 Study sample
A cross-sectional survey was designed. The subjects in this study included adolescent students from vocational universities/colleges in the north, central, south, and east areas of Taiwan. The participating schools were selected with the methods of stratification and cluster sampling. Four types of vocational schools (that is manufacturing, commercial, fishery/agricultural, and medical technology) were conveniently selected from each area while one class was selected from the first, second and third grade (16-18 years old) of each level. Approximately 2,400 adolescent students of vocational schools were sampled in this study. The questionnaires were given to all the students after an explanation by a trained interviewer. This data was collected between September 2011 and January 2012.
This study was approved by the Institutional Review Board (IRB) and the external supports were provided from Chung-Hwa University of Medical Technology.
A questionnaire was designed for this study and tested and revised in advance. The content of the questionnaire was explained to the students prior to their answering it anonymously, and included: (a) general demographic characteristics; academic learning circumstances; (b) the habit of tobacco smoking classified as non-smokers, ex-smokers, current smokers (including the sporadic current smokers and usual current smokers); the motivation of first-time smoking, and the source of getting tobacco; (c) the attitudes and perception of the smoking habit; (d) the circumstances of smoking among family members, friends and classmates; the degree of support about smoking from their family and peers; (e) the habits of drinking and betel nut chewing.
The questionnaire was introduced to assess the validity of specialist. With respect to Cronbach’s Alpha of questionnaire, the reliability coefficient is 0.87.
2.3 Statistical analysis
The SPSS for window 18.0 was employed to analyze: (a) Frequency distribution was employed to analyze the prevalence and related risk factors of the tobacco smoking of adolescents by areas and type of vocational schools, and genders; the main reason of first-time smoking, and the source of getting tobacco; (b) Chi-square test was employed to obtain the differences in the smoking behavior of adolescent students from areas and type of vocational schools, and genders; (c) To analyze the probability of current smokers, Logic Regression was employed; (d) Analyzed the adjusted odds ratio (AOR) and 95% confidence interval (C.I.) of the risk factors of smoker from different types of vocational schools were compared.
Valid data from 2,054 students was available for analysis with a response rate of 85.6%. The prevalence of tobacco smoking of the valid samples is shown in Table 1 with different types of vocational schools, the various areas, and genders. The highest prevalence of ex-smoker among all types of vocational schools was that among students of fishery/agricultural schools at 24.0%, and the lowest one being of the students of commercial schools at 17.0%. For current smoker, the highest prevalence was that of students of fishery/agricultural schools at 24.4%, then students of manufacturing schools at 23.0%, and the lowest one tending to be students of medical technology schools at 17.6%. There was a statistically significant difference across type of vocational schools in tobacco smoking behavior (X2=14.23, p=0.01). The student number and percentage in tobacco smoking behavior of northern area, central area, southern area, and eastern area were 528 (25.7%), 511 (24.9%), 525 (25.6%), and 490 (23.9%), respectively. No statistically significant difference in the prevalence was shown in the various areas (X2=7.10, p=0.16). The prevalence of ex-smoker of male and female sample students was 296 (27.8%) and 145 (14.7%). The prevalence of current smoker of male and female was 25.0%, and 16.1%. Furthermore, the prevalence of male students was notably higher than among female students (X2=19.25, p=0.001).
As shown in table 2, curiosity (26.4%), peer pressure (23.2%), popularity or cool (22.1%), and relief of tension (15.1%) were the causes for starting tobacco smoking behavior. There is indication that curiosity is the main factor for starting smoking. The main sources of getting tobacco were self-bought and friends/classmates at the percentage of 55.5% and 28.1%, respectively. It can be concluded that the behavior of tobacco smoking in adolescent students was apparently associated with peer pressure.
When tobacco was offered, only 7.3% of non-smokers but 66.6% of current smokers would accept it, on the contrary, 75.3% of non-smokers and only 8.5% current smokers would refuse it. Also note that when the current smokers accept tobacco, it was 9.0 times (66.0/7.3) more prevalent than when the non-smokers. Then, whether the habit of tobacco smoking exists or not could be significant related to the behavior of accepting or refusing tobacco when offered (X2=46.31, p=0.001) (table 2).
As shown in table 3, the probability current smokers among the different types of vocational schools. The highest probability (0.2973) arose among male students of fishery/agricultural schools and secondarily (0.2127) among the students of manufacturing schools. Students of medical technology schools exhibited the lowest probability. The probability of tobacco smoking among male students was higher than females from all types of vocational schools.
In Table 3, the odds ratio for male and female ex-smoker and current-smoker was 3.021 (95% C.I. = 2.076-5.281) and 3.725 (95% C.I. = 2.160-6.158), respectively. The odds ratio of male students was three times
higher than that of female students. Apparently, the odds ratio of fishery/agricultural school students was significantly higher than commercial school students and exhibited the highest odds ratio of 3.014 (95% C.I. = 1.226-4.268).
Table 4 shows that the affect factors of risk for tobacco smoking by types of vocational schools. Correction factors have gender and different areas. Dependence variance is the behavior of smoking classified as non-smokers, ex-smokers, and current smokers (including the sporadic current smokers and usual current smokers). Independence variances have parent’s education level, parent’s occupation level, parents’ marital status, parents’ smoking habit, urbanized degree, academic achievement, betel nut chewing behavior, and drinking behavior. This study revealed that the fishery/agricultural school student is the highest risk group of tobacco smoking in vocational school students. All types of vocational schools students whose parent’s had low education levels (father: p=0.001; mother: p=0.01), and students who came from blue collar families or none (father: p=0.001; mother: p=0.01), parents’ marital status (p=0.001) is divorce or living apart or death, parents’ smoking habit (p=0.001), him/her betel nut chewing behavior (p=0.001), and drinking behavior (p=0.001) were more likely to have the smoking habit.
A similar tendency had been found as other studies [2, 6-12] that the prevalence of tobacco smoking has been increased among adolescent students in Taiwan. This study shows that the probability of smoking among male students was higher than females from all types of vocational schools. This present results do coincide with the main source of tobacco being offered by self-bought and friends/classmates. It is apparent that the smoking behavior among adolescent students was affected with peer .
Curiosity and peer influence were the major causes for starting smoking; most smokers, even though they were compulsive smokers, did not realize that tobacco smoking could lead to addiction reactions indicating that they were apparently ignorant about any risk to health . An important role to play in the prevention and treatment of adolescent tobacco use, the protection of patients from the harmful effects of environmental tobacco smoke, and the encouragement of smoking cessation among parents and peer.
In Taiwan, tobacco is cheap and widely accepted. It has become popular to offer tobacco to others as a social greeting . A similar result from investigation revealed that there are tended to be a higher percentage of smokers who drank and chewed betel nut [20-22]. The effect of him/her drinking or betel nut chewing behavior strong influence of smoking behavior. This study is needed to determine which aspects of parental use are the most important in influencing children’s attitudes and behaviors about tobacco smoking. The risk factors which causing smoking in students included: the socio-economic factors of parent, parents’ marital status, parents’ smoking habit. The effect of parents’ smoking habit was stronger than other factors. The study shows that the existence of parental influence of smoking behavior on adolescent students, just as other unhealthy behavior such as drug abuse, betel nut chewing and alcohol drinking are known to be prevalent among people’s parents who does drinking, betel nut chewing, or drugs abusing.
The probabilities were obtained from analyzing the students who were ex-smokers or current-smokers from different types of vocational schools. This prevalence the fishery/agricultural school students were significantly higher than among other vocational school students. As a consequence, students of fishery/agricultural schools exhibited the highest odds ratio. It was shown that they were a high-risk group and potentially would become
smokers. Siahpush (2010) revealed the smoking behavior was affected with racial/ethnic and socioeconomic . As a tendency found, the fishery/agricultural school students have a high proportion of the aboriginal people  and come from blue-collar worker families . As previous studies, this result claimed that students with lower grades tend to have smoking, drinking, and betel nut chewing as habits. In general, one of reasons that can be emphasized here is their low achievement in learning and life [20-22]. Passing entrance examination scores can be taken into account to explain these phenomena. In Taiwan, the vocational school divides four types of schools: manufacturing, commercial, fishery/agricultural, and medical technology school. Meanwhile, among all the vocational schools, the scores in commercial schools are usually the highest, medical technology schools being second, manufacturing schools being third, and fishery/agricultural schools ranking last.
As shown in table 2, the habit of tobacco smoking exists significant related to the behavior of accepting or refusing tobacco when offered. The present results also show that the smoking behavior would not occur if the first time of attempt tobacco was not offered, it was not accepted. Once the behavior is established during adolescence and young adulthood, the habit often remains as a major contributor to future health problems of adults. It is must be addressed by health and education authorities.
The adolescent welfare law in Taiwan has legislated to forbid adolescents under 18 to smoke, drink, and chew betel nut. The legislation also inflicts punishment on those who provide cigarette to the adolescents. However, smoking is a kind of social behavior and the health risk perception of smoking and health education should be concentrated simultaneously. Although the first time trying tobacco smoking is due to curiosity, it should be realized that consecutive tobacco smoking could lead to damaging their health, particularly when strongly associated with betel nut chewing and drinking. An effective health education program for the high-risk group students is necessary to prevent the increase of tobacco smoking among Taiwan’s adolescent students.
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Table 1. The prevalence of tobacco smoking by types of vocational schools, areas, and genders Tobacco smoking, N (%)
Non-smoker Ex-smoker Current smoker
Total, N (%)
X2-Value (p -Value) Types of vocational schools
Manufacturing 278 (53.4) 123 (23.6) 120 (23.0) 521 (25.4) Commercial 346 (64.8) 91 (17.0) 97 (18.2) 534 (26.0) Fishery/ Agricultural 249 (51.6) 116 (24.0) 118 (24.4) 483 (23.5) Medical technology 314 (60.9) 111 (21.5) 91 (17.6) 516 (25.1) 14.23 (p=0.01) Areas Northern area 309 (58.5) 106 (20.1) 113 (21.4) 528 (25.7) Central area 298 (58.3) 115 (22.5) 98 (19.2) 511 (24.9) Southern area 315 (60.0) 107 (20.4) 103 (19.6) 525 (25.6) Eastern area 265 (54.1) 113 (23.1) 112 (22.9) 490 (23.9) 7.10 (p=0.16) Gender Male 503 (47.2) 296 (27.8) 267 (25.0) 1,066 (51.9) Female 684 (69.2) 145 (14.7) 159 (16.1) 988 (48.1) 19.25 (p=0.001) Total 1,187 (57.8) 441 (21.5) 426 (20.7) 2,054 (100.0)
Table 2. The main reasons for starting tobacco smoking, sources of tobacco offered by types of vocational schools, and the attitudes as tobacco is offered
Ex-smoker and Current smoker, N (%) Variance
Manufacturing Commercial Fishery/ Agricultural
technology Total p -Value The main reasons for starting tobacco smoking
Curiosity 60 (24.7) 56 (29.8) 62 (26.5) 51 (25.2) 229 (26.4) 0.23 Peer pressure 58 (23.9) 44 (23.4) 53 (22.6) 49 (24.3) 201 (23.2) 0.20 Popularity or cool 55 (22.6) 40 (21.3) 50 (21.4) 44 (21.8) 192 (22.1) 0.16 Relief of tension 41 (16.9) 29 (15.4) 34 (14.5) 27 (13.4) 131 (15.1) 0.14 Behavior of adults 19 (7.8) 12 (6.4) 27 (11.5) 21 (10.4) 79 (9.1) 0.19 Refreshing 10 (4.1) 7 (3.7) 8 (3.4) 10 (5.0) 35 (4.0) 0.27 Sources of tobacco Self-bought 135 (55.6) 103 (54.8) 117 (50.0) 126 (62.4) 481 (55.5) 0.29 Friends / Classmates 70 (28.8) 54 (28.7) 69 (29.5) 51 (25.2) 244 (28.1) 0.21 Siblings/ Relatives 27 (11.1) 22 (11.7) 35 (15.0) 18 (8.9) 102 (11.8) 0.17 Father/ Mother 11 (4.5) 9 (4.8) 13 (5.6) 7 (3.5) 40 (4.6) 0.14 Total 243 (28.0) 188 (21.7) 234 (27.0) 202 (13.3) 867 (100.0) 0.20 The attitudes as tobacco is offered
Tobacco smoking, N (%) Attitude
Non-smoker Ex-smoker Current smoker
X2-Value (p-Value) Accepting 87 (7.3) 130 (29.5) 281 (66.0) Refusing 894 (75.3) 122 (27.7) 36 (8.5) Not sure 206 (17.4) 189 (42.9) 109 (25.6) Total 1,187 (100.0) 441 (100.0) 426 (100.0) 46.31 (p=0.001)
Table 3. The probability of current smokers of vocational school and the odds ratio of tobacco smoking by gender and vocational school
The probability of current smokers of vocational school
Type of vocational school Male Female Odds ratio of male to female (95% of C.I.) Manufacturing school 0.2127 0.0715 3.415* (3.042-7.106) Commercial school 0.1942 0.0681 3.038* (1.970-5.951) Fishery/Agricultural school 0.2973 0.0723 4.266* (2.526-7.619)
Medical technology school 0.1756 0.0591 3.107*
(1.857-5.728) Male to female odds ratios of tobacco smokers
Odds ratio of ex-smoker to non-smoker
(95% of C.I.)
Odds ratio of current smoker to non-smoker
(95% of C.I.) Types of vocational schools 3.021*
3.725* (2.160-6.158) Odds ratio of smoking in different vocational schools
Commercial / Manufacturing 1.163* (0.602-1.774) 1.997* (0.852-3.013) Fishery、Agricultural / Manufacturing 0.781 (0.548-1.492) 1.103 (0.690-1.652) Medical technology / Manufacturing 1.544* (0.976~2.124) 2.009* (1.018~2.988) Fishery、Agricultural / Commercial 2.026* (1.116~3.166) 3.014* (1.226~4.268) Medical technology / Commercial 0.934 (0.581~1.456) 1.853 (1.113~2.518) Fishery、Agricultural / Medical technology 1.798* (0.943~2.610) 2.215* (1.101~3.324) * : p<0.01
Table 4. The affect factors of risk for tobacco smoking by types of vocational schools
Manufacturing Commercial Fishery/ Agricultural Medical technology School / Variance p-Value AOR (95% C.I.) p-Value AOR (95% C.I.) p-Value AOR (95% C.I.) p-Value AOR (95% C.I.) Constant － － － － － － － － Father Education (Junior high school or under / Senior high school or above) 0.001 5.01 (2.56~11.34) 0.001 4.25 (2.77~11.63) 0.001 6.42 (3.96~11.37) 0.001 3.98 (2.76~12.12) Mother Education (Junior high school or under / Senior high school or above) 0.01 3.87 (2.19~10.27) 0.01 3.27 (2.30~10.070 ) 0.01 4.37 (3.02~11.04) 0.01 3.08 (2.11~11.27) Father Occupation (Blue-collar class or none / White-collar class) 0.001 7.93 (4.73~13.50) 0.001 7.41 (3.05~13.11) 0.001 8.25 (3.91~15.53) 0.001 6.97 (3.72~13.45) Mother Occupation (Blue-collar class or none / White-collar class) 0.01 5.16 (3.11~13.12) 0.01 4.99 (3.26~13.98) 0.01 5.84 (3.50~14.67) 0.01 4.41 (3.03~12.83) Parents Marital Status (Divorce or living apart or death / Good) 0.001 5.87 (3.11~9.34) 0.001 5.72 (3.17~9.53) 0.001 6.05 (2.18~10.55) 0.001 5.14 (2.75~9.76) Father Smoking Habit (Yes / No) 0.001 9.52 (4.61~18.35) 0.001 8.35 (3.95~16.71) 0.001 11.06 (7.63~21.89) 0.001 7.69 (3.99~16.31) Mother Smoking Habit (Yes / No) 0.001 9.30 (3.94~19.21) 0.001 8.23 (3.60~18.50) 0.001 10.41 (6.11~20.73) 0.001 7.07 (4.02~14.80) Urbanized Degree (Villages or towns / Cities) 0.18 3.08 (2.57~12.07) 0.14 3.36 (2.32~11.77) 0.25 3.97 (2.15~11.27) 0.17 2.91 (2.10~10.62) Academic Achievement (B grade or above / C grade or under) 0.20 9.05 (3.21~13.98) 0.15 8.45 (3.67~15.02) 0.26 8.23 (3.63~14.55) 0.12 7.99 (3.06~14.09) Betel Nut Chewing (Yes / No) 0.001 8.19 (3.06~14.84) 0.001 7.54 (3.06~12.68) 0.001 8.79 (3.77~13.12) 0.001 7.64 (3.14~12.34) Drinking Behavior (Yes / No) 0.001 7.72 (3.15~13.17) 0.001 7.28 (3.17~11.53) 0.001 8.64 (3.02~12.93) 0.001 7.15 (3.11~11.56)