Correspondence: Randy M Page, Department of Health Science, 221 Richards Building, Brigham Young University, Provo, Utah 84604, USA.
Tel: 801-422-1131; Fax: 801-422-0273 E-mail: randy_page@byu.edu
INTRODUCTION
Tobacco smoking is clearly one of the chief preventable causes of death in the world. The World Health Organization cites that cigarettes are responsible for about five million deaths ev-ery year and that if current smoking patterns continue, that number could double by 2020 (WHO, 2004). Half the people who smoke to-day, about 650 million people, will eventually be killed by tobacco. According to Murray and Lopez (1996), the Asian region is expected to experience a fourfold increase in tobacco mor-tality between 1998 and 2030.
Smoking prevalence in Southeast Asia is likely to increase (Choe et al, 2001). Multinational tobacco companies are marketing their products
PERCEPTIONS OF THE PREVALENCE OF CIGARETTE
SMOKING BY PEERS: A STUDY OF TAIWANESE, FILIPINO,
AND THAI HIGH SCHOOL STUDENTS
Randy M Page1, Emilia Patricia Zarco2, Jiraporn Suwanteerangkul3, Ching Mei-Lee4,
Nae-Fang Miao5 and Jerry Taylor1
1Department of Health Science, Brigham Young University, Provo, Utah, USA; 2Department of Health Education, Adelphi University, Adelphi, New York, USA; 3Department of Community Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai,
Thailand; 4Department of Health Education, National Taiwan Normal University, Taipei, Taiwan; 5College of Nursing, Taipei Medical University, Taipei, Taiwan
Abstract. Youth cigarette smoking is a major public health concern in Southeast Asia. A suspected determinant of youth smoking is perceived peer behavior. Previous research has suggested that the probability that a teenager will use substances increases when there is the perception that most peers engage in the substance use behavior. This study aimed to assess the perceptions of the prevalence of peer cigarette smoking in samples of high school students from three Southeast Asian countries and to examine the association of these perceptions to self-reported personal use of cigarettes. Perceptions of the prevalence of peer smoking were generally characterized by the per-ception that most students do not smoke. However, a significant percentage of students held the perception that most students were current smokers. Students who held this perception were at increased risk of being current smokers relative to those who believed most students were not current smokers. The results of this study imply that public health programs may benefit from health promotion interventions which focus on dispelling misconceptions that most youth smoke ciga-rettes.
with increasing intensity in Asia, particularly tar-geting young people (Bettcher et al, 2000). Asia is often viewed by transnational tobacco com-panies as an “emerging market” for cigarettes and as a result is often targeted for expansion. For example, 8,000 executives in the interna-tional tobacco industry are expected to attend the upcoming Emerging Tobacco Markets 2005 Convention in Kuala Lumpur, Malaysia in Novem-ber 2005 which aims to provide “a fast-track gateway to all vigorous markets in the Asia re-gion to promote tobacco products” (Anonymous, 2005). The web site advertising this event touts that the convention is the “perfect opportunity for all players in the tobacco industry, from in-side of Asia or outin-side of Asia, to strengthen their position in the Asian region”.
Continuing economic development in Southeast Asia will also result in more youth having disposable income for purchasing ciga-rettes. Economic development and moderniza-tion will probably also result in increases in the
prevalence of smoking in young females, which presently is at lower rates than for young males (Bettcher et al, 2000; Global Youth Tobacco Survey Collaborating Group, 2003).
Because the use of substances, such as cigarettes, is considered to be a highly social behavior, peer factors have been identified as a critical determinant for use by teenagers (Gavira and Raphael, 2001). One of these suspected determinants is perceived peer behavior. Re-search by Kawaguchi (2004) found that when the perceived peer substance use increases by ten percentage points, the probability that a teenager will use substances increases by two to three percentage points. Unfortunately, there is little research examining perceptions of ciga-rette smoking in youth and the relationship of these perceptions to actual or reported use (Page et al, 2002). In particular, this research is lacking among many populations of youth includ-ing Southeast Asian youth. Therefore, the pur-pose of this study was to assess Southeast Asian high school students’ perceptions of the preva-lence of cigarette smoking by their peers and to examine the association of these perceptions and reported smoking behavior.
MATERIALS AND METHODS
Subjects
Subjects for this study included 3,307 stu-dents from eight Philippine high schools, 2,665 students from twenty-one high schools in Tai-wan, and 2,519 students from ten high schools in Thailand. The eight Philippine schools repre-sent a mix of schools reprerepre-senting urban and rural areas and the three major regions of the country (Luzon, Visayas, and Mindanao). Of the twenty-one Taiwanese schools, fourteen were located in Taipei City and seven were in Taipei County. The ten schools in the Thai sample were located in Chiang Mai Province and represented a mix of rural and urban and public and private schools. All these schools included in the samples were co-educational. Characteristics of the subjects are presented in Table 1.
Questionnaire design
The questionnaire items for this study in-cluded questions designed to assess the
stu-dents’ perception of the prevalence of peer ciga-rette smoking and self-reported personal use of cigarettes. These items were part of question-naires that elicited information about a wide range of health behaviors and characteristics.
Perception of the prevalence of peer ciga-rette smoking was measured in the Philippine and Taiwan samples by asking respondents, “Which best describes the use of cigarettes by most students at your high school?” Response options included: have never smoked, have smoked cigarettes in their life but not within the last 30 days, have smoked cigarettes within the last 30 days but not during the last week, have smoked cigarettes within the last week but not daily, and smoke cigarettes daily. Perception of the prevalence of peer cigarette smoking was measured in the Thai sample by asking “How many of your friends smoke?” The response options for this question were: none of them, some of them, half of them, most of them, and all of them. Thai subjects also responded to the question “How many of your friends pressure you to smoke?” The same response options were used.
Self-reported personal use of cigarettes was also measured in all three samples. Students were asked to select the response that best describes their personal use of cigarettes: never smoked, smoked cigarettes but not within the last 30 days, smoked cigarettes within the last 30 days but not during the last week, smoked within the last week but not daily, and smoke cigarettes daily.
Data collection
Faculty members from three Southeast Asian universities (University of the Philippines, National Taiwan Normal University, and Chiang Mai University) coordinated data collection in each respective sample in each Southeast Asian country. Questionnaires in each school in each of the samples were administered in regularly scheduled classes. Students were instructed not to place their names on questionnaires and to answer all questions honestly. Students were also informed that their participation was volun-tary and that the decision to participate would not affect their grade in the class. Teachers
ad-ministering the questionnaire were on hand to provide assistance to students requiring help or having questions.
Data analysis
Descriptive statistics were computed for the variables assessed in this study. The difference between male and female students on these variables was determined by chi-square tests. Chi-square tests were also used to determine if there was a significant association between per-ceptions of prevalence of peer smoking and re-ported smoking behavior (current smoking). Current smoking was defined as having smoked cigarettes in the last 30 days. These tests were calculated separately for boys and girls. SAS version 8.2 was used for statistical analysis.
RESULTS
Results for self-reported personal use of cigarettes are presented in Table 2. In each sample, girls were significantly more likely than boys to have never smoked while boys were more likely to have smoked cigarettes. Percep-tion of the prevalence of use of cigarettes by most students in one’s school is shown in Table 3 for the Taiwan and Philippines sample. Boys and girls did not differ in perceptions within these two samples. Table 4 displays the perceptions of Thai sample students’ perceptions of how many friends smoke cigarettes and how many friends pressure them to smoke. Boys were sig-nificantly more likely than girls to report that their friends smoked and pressure them to smoke.
Table 1
Subject characteristics for the three samples.
Philippines Taiwan Thailand
No. of subjects 3,307 2,665 2,519
No. of schools 8 21 10
Location 3 major regions of the country Taipei City and Taipei County Chiang Mai Province
Mean age 15.5 (SD=1.23) 16.7 (SD=1.06) 16.2 (SD=1.33)
Gender
No. of males 1,267 1,564 830
No. of females 1,819 1,026 1,662
No. not reporting 221 25 27
Table 2
Self-reported personal use of cigarettes.
Boys % Girls % Boys % Girls % Boys % Girls %
(n) (n) (n) (n) (n) (n)
Never smoked 66.5 79.1 84.6 96.3 83.8 90.2
(1,038) (810) (706) (1,580) (1,054) (1,634) Smoked, but not within last 30 days 17.9 13.3 8.1 1.8 10.9 6.6
(280) (136) (66) (30) (137) (119)
Smoked within the last 30 days but not 2.3 1.1 1.2 0.7 1.1 0.8
during the last week (36) (11) (10) (11) (14) (15 )
Smoked within the last week but not daily 5.8 2.5 1 0.4 3.7 2.4
(91) (26) (8) (7) (47) (44 )
Smoke cigarettes daily 7.4 4 3.3 0.7 0.5 0
(115) (41) (27) (12) (6) (0)
1Boys and girls differed significantly on self-reported personal use of cigarettes, χ2 = 53.6, p<.0001, df = 4 2Boys and girls differed significantly on self-reported personal use of cigarettes, χ2 = 87.7, p<.0001, df = 4 3Boys and girls differed significantly on self-reported personal use of cigarettes, χ2 = 37.7, p<.0001, df = 4 Taiwan1 Thailand2 Philippines3
Boys % Girls % Boys % Girls %
(n) (n) (n) (n)
Never smoked 40.1 37.9 37.1 38.4
(628) (389) (458) (684)
Smoked, but not within last 30 days 19 18.7 15.8 13.5
(298) (192) (195) (241)
Smoked within the last 30 days but not during the 7.4 5.6 3.6 3.1
last week (115) (57) (45) (55)
Smoked within the last week but not daily 18.7 22.6 25 26.4
(292) (232) (309) (470)
Smoke cigarettes daily 14.8 15.2 18.5 18.5
(231) (156 (229) (330)
1 Boys and girls did not differ on perception of use, χ2 = 8.6, p = 0.07, df = 4 2 Boys and girls did not differ on perception of use, χ2 = 4.1, p = 0.39, df = 4
Boys % Girls % Boys % Girls %
(n) (n) (n) (n) None of them 38.5 55.1 88.5 96.7 (317) (909) (726) (1,595) Some of them 51.7 42.2 9.3 2.9 (426) (697) (76) (48) Half of them 3.3 1.6 1.3 0.4 (27) (26) (11) (6) Most of them 6.2 1.1 0.6 0 (51) (19) (5) 0 All of them 0.4 0 0.2 0 (3) 0 (2) (0)
1Boys and girls differed significantly on perception of smoking, χ2 = 104.2, p < .0001, df = 4
2Boys and girls differed significantly on perception of smoking, χ2 = 69.6, p < .0001, df = 4
Table 3
Perception of use of cigarettes by most students at your high school, Taiwan and Philippine sample.
Taiwan1 Philippines2
Table 4
Perceptions of how many friends smoke cigarettes and pressure you to smoke
cigarettes, Thai sample only.
Smoke cigarettes1 Pressure you to smoke2
The prevalence of current smoking according to perception of peer use results are shown in Table 5. Results showed that students in all three samples who held the perception that most
stu-dents in their school never smoked or that none of their friends smoke were significantly less likely to be current smokers. Boys and girls in the Tai-wan sample and boys in the Thailand sample who held the perception that most students in their school are current smokers, or that half or more friends smoke, were significantly more likely to be current smokers than in any of the classi-fication groups on this variable (perception of peer smoking).
DISCUSSION
As expected, girls were more likely to re-port having never smoked cigarettes than boys across all three samples. The percent of girls reporting having never smoked was much higher in the Thai (96.3%) and Filipino (90.2%) samples than in the Taiwan (79.1%) sample. This trend showing higher rates of never smoking was also true for boys in the Thai (84.6%), Filipino (84.6%), and Taiwanese (66.5%) samples. Conversely, boys in each sample were more likely to have smoked cigarettes than girls and to report smok-ing more frequently. Boys and girls in Taiwan re-ported higher involvement in personal use of cigarettes than students in Thailand and the Philippines. This finding, showing a higher smok-ing prevalence of Taiwanese youth compared to
Table 5
Prevalence (%) of current smoking according to perception of peer use.
Perception Boys %1 Girls %2 Boys %3 Girls %4 Boys %5 Girls %6
(n) (n) (n) (n) (n) (n)
Most never smokeda or none 5.4 1.3 3.3 1.3 3.5 2.3
of friends smokeb (34) (5) (14) (9) (16) (16)
Most smoke, but not within last 30 daysa 12.4 2.1 11.1 7.7 8.7 5.8
or some friends smokeb (37) (4) (3) (2) (17) (14)
Most are current smokersa or half or more 26.8 15.5 16.7 5.3 5.5 3.4
friends smokeb (171) (69) (9) (1) (32) (29)
Note. The chi-square results listed below indicate that the perception groups differed significantly on prevalence (%) of current smoking for each respective country and gender specific sample.
1Taiwan boys χ2 = 113.3, p < 0.0001, df = 2; 2Taiwan girls χ2 = 69.9, p < .0001, df = 2; 3Thailand boys χ2= 19.7, p < 0.0001, df = 2; 4Thailand girls χ2 = 8.1, p = .0176, df = 2; 5Philippine boys χ2 = 7.6, p = 0.0223, df = 2; 6Philippine girls χ2 = 6.7, p = 0.0346, df = 2
Taiwana Thailandb Philippinesa
Thai and Filipino youth, is consistent with a re-port investigating smoking rates in Asia by Choe
et al (2001).
Smoking in many Asian nations has tradi-tionally been viewed as a male activity (Knight and Chapman, 2004). The higher prevalence of smoking among boys than girls observed in this study is consistent with other research that has looked at this health behavior among Southeast Asian youth. Choe et al (2001) also found a higher smoking prevalence among teenage boys and girls in Thailand, the Philippines, and Tai-wan as well as in Indonesia and Nepal. The ratio of boys to girls for current smoking (smoked cigarettes in the past 30 days) in our samples was 2.0 in Taiwan (15.7%/7.6%), 3.0 in Thailand (5.5%/1.8%), and 1.6 in the Philippines (5.3%/ 3.2%).
Despite the low prevalence of smoking among Southeast Asian girls, there is concern that the prevalence in young girls will rise steeply in the future (Morrow and Barraclough, 2003). This trend of an increasing number of young women taking up smoking has occurred in many areas of the world. Results from the Global Youth Tobacco Survey show that teenage girls now smoke cigarettes at about the same rate as teen-age boys in half of the sites (61 of 120) through-out the world surveyed for cigarette smoking (Global Youth Tobacco Survey Collaborating Group, 2003). A rising prevalence of smoking
among girls in Southeast Asia poses many prob-lems for rising generations in addition to the health problems common to both genders. Women face additional hazards in pregnancy, female-specific cancers such as cancer of the cervix, and exposure to passive smoking. The health problems are likely to increase in response to the following conditions: the spending power of girls and women is increasing so that ciga-rettes are becoming more affordable, the social and cultural constraints that previously prevented many girls and women from smoking are weak-ening, and female-specific health education and smoking cessation programs are rare. Further-more, evidence suggests that females find it harder to quit smoking. Tobacco companies are clearly targeting females by marketing cigarettes specifically designed to appeal to women and by advertising directed toward females. This advertising associates smoking with feminism, sophistication, weight control, and Western-style independence. Thus, a major challenge and op-portunity in primary preventive health in South-east Asia is to avert the predicted rise in smok-ing among girls and young women (Mackay and Amos, 2003).
A major focus of the current study was per-ceptions of smoking among peers. When Tai-wanese and Filipino students were asked to in-dicate the frequency of cigarette smoking that characterized most students at their high school,
t h e m o s t c o m m o n re s p o n s e w a s “ n e v e r smoked” (Thai students were not asked this question.) In the Taiwan sample, 40.1% of boys and 37.9% of girls said that most students at their high school have never smoked. Similar percentages of Filipino students (37.1% of boys, 38.4% of girls) said that most students at their high school never smoked. These perceptions were supported by the fact that high percent-ages of Taiwanese (66.5% of boys, 79.1% of girls) and Filipino (83.8% of boys, 90.2% of girls) students reported that they have personally never smoked. Nevertheless, 40.9% of Taiwan-ese boys, 23.4% of TaiwanTaiwan-ese girls, 47.1% of Filipino boys and 98.0% of Filipino girl charac-terized most students at their schools as cur-rent smokers (smoking in the past 30 days). An interesting finding regarding these perceptions is the association between perception of peer use and the personal prevalence of current smoking (Table 5). Boys and girls in the Taiwan sample as well as boys in the Thailand sample who held the perception that most students at their high school were current smokers (smoked in the past 30 days) were significantly more likely to be current smokers themselves, compared to students holding perceptions that most students never smoked or have smoked, but not in the last 30 days. This finding supports the findings from Kawaguchi (2004) that perceptions of peer behavior may be an important determinant of youth substance use and may influence smok-ing behavior.
Students in the Thai sample were asked their perception of how many of their friends smoke and how many of their friends pressure them to smoke (Table 4). A very small percent age of boys (9.9%) and girls (2.7%) said that half, most, or all of their friends smoked cigarettes. Thus, it is not surprising that only 2.1% of boys and 0.4% of girls said that half, most, or all of their friends pressure them to smoke. A high percentage of the boys (88.5%) and girls (96.7%) said that none of their friends pressure them to smoke.
An important limitation concerning this study needs mentioning. Because this study re-lied on self-report measures, it may have suf-fered from reluctance on the part of students that
were surveyed to honestly and accurately report their smoking behavior (Brener et al, 2003). De-spite the fact that students were told not to place their names on questionnaires and that their answers would remain anonymous, some stu-dents may not have wanted to divulge the fact that they smoke cigarettes. Certain unaccounted for factors inherent in the administration of the questionnaire in these three samples may have reduced students’ desires to divulge this infor-mation. This may have been a factor in explain-ing why smokexplain-ing prevalence in the current study was lower than in other studies reporting the smoking prevalence of Southeast Asian youth (Choe et al, 2001; Choe and Raymundo, 2001; Miguel-Baquilod, 2001; Podhista et al, 2001; Global Youth Tobacco Survey Collaborating Group, 2003). Differences in items used to as-sess smoking behavior between these studies and the current study may also be factors.
Another important limitation of this study is that it did not consider forms of tobacco other than cigarettes. Future studies of Southeast Asian youth may benefit from considering other forms of tobacco such as chewing tobacco, ci-gars, bidis, and kreteks.
In conclusion, youth cigarette smoking is a major public health concern in Southeast Asia. Of particular concern, is the prospect that smok-ing prevalence among the young will rise steeply in the near future in response to modernization, Westernization, economic development, and expansion of transnational tobacco companies into the region. There is also concern that the levels of smoking among young females in Southeast Asia will approach that of males, simi-lar to what has occurred in much of the world.
In the three samples that we studied, self-reports of smoking were relatively low. This was especially true in the Philippine and Thailand samples. Perceptions of the prevalence of peer smoking were generally characterized by the perception that most students do not smoke. However, a significant percentage of students held the perception that most students were current smokers. Students who held this per-ception were at increased of being current smok-ers relative to those who believed most students were not current smokers. As a result, public
health programs may benefit from health pro-motion interventions which focus on dispelling misconceptions that most youth smoke ciga-rettes.
REFERENCES
Anonymous. J Emerging tobacco markets 2005. Avail-able from: URL: http://www.etm2005.com/ 2060.0.html
Bettcher DW, Yach D, Guindon GE. Global trade and health: key linkages and future challenges. Bull World Health Organ 2000; 78: 521-34. Brener ND, Billy JO, Grady WR. Assessment of factors
affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. J Adolesc Health 2003; 33: 436-57.
Choe MK, Kiting AS, Lin H, Podhista C, Raymundo C, Thapa S. The youth tobacco epidemic in Asia. East-West Center, 2001 (November, Population Series No. 108-17).
Choe MK, Raymundo CM. Initiation of smoking, drink-ing, and drug-use among Filipino youths. East-West Center, 2001 (October, Population Series No. 108-7).
Gavaria A, Raphael S. School based peer effects and juvenile behavior. Rev of Econ Stat 2001; 83: 257-68.
Global Youth Tobacco Survey Collaborating Group. Differences in worldwide tobacco use by gender: Findings from the Global Youth Tobacco Survey. J Sch Health 2003; 73: 207-15.
Kawaguchi D. Peer effects on substance use among
American teenagers. J Popul Econ 2004: 17: 351-7.
Knight J, Chapman S. Asian yuppies…are always look-ing for somethlook-ing new and different: creatlook-ing a tobacco among young Asians. Tob Control 2004; 13 (suppl II): ii22-ii29.
Mackay J, Amos A. Women and tobacco. Respirology 2003: 8: 123-30.
Miguel-Baquilod M. Report of the results of the Na-tional Youth Tobacco Survey in the Phillipines GYTS 2000. Manila, Philippines: National Epide-miology Center, Department of Health, 2001 (Au-gust).
Morrow M, Barraclough S. Tobacco control and gen-der in Southeast Asia. Part I: Malaysia and the Philippines. Health Promot Int 2003: 18: 255-64. Murray CJ, Lopez AD. The global burden of disease: A comprehensive assessment of mortality and disability from disease, injuries, and risk factors in 1990 and projected to 2020. Boston: Harvard University Press, 1996.
Page RM, Hammermeister J, Roland M. Are high school students accurate or clueless in estimat-ing substance use among peers? Adolescence 2002; 37: 567-73.
Podhista C, Xenos P, Juntarodjana J, Varangrat A. Drinking, smoking, and drug use among Thai youth: effects of family and individual factors. East-West Center, 2001 (October, Population Series No. 108-6).
World Health Organization. Framework convention on tobacco control. Director-General’s statement. Geneva; Switzerland, 2004 (December 1). Avail-able from: URL: http://www.who.int/mediacentre /news/statements/2004/statement7/en
