Modifiable family and school environmental factors associated with smoking status among adolescents in Guangzhou, China

Abstract

Objective.

To identify modifiable family and school environmental factors associated with Chinese adolescent smoking behaviors including never-smoking, experimental smoking, regular smoking, and attempting to quit.

Methods.

A cross-sectional survey using self-reported questionnaires was conducted in Huangpu, Guangzhou in December of 2004. A total of 3957 pupils agreed to complete the questionnaires. The prevalence odds ratio (risk) of experimental smoking was compared to never-smoking, adjusting for gender and age in unconditional logistic regression analysis. The risk of regular smoking was compared to experimental smoking, and the risk of attempting quitting was analyzed in regular smokers.

Results.

The cigarette smoking of peers, mothers, fathers, brothers, and supervising teachers, passive smoking, and seeing someone smoking on campus increased the risk of experimental smoking vs. nonsmoking, while no-smoking signs, perceived anti-tobacco atmosphere in school, and being taught smoking-related health knowledge decreased the risk. The factors associated with regular smoking compared to experimental smoking included the smoking of peers, brothers, fathers and supervising teachers, teacher's tolerance, and passive smoking. Being taught smoking-related knowledge, perceived anti-tobacco atmosphere and no-smoking signs in school were positively associated with regular smoker's attempt to quit, while supervising teacher's smoking, parents' and teachers' tolerance could delay it.

Conclusions.

These modifiable family and school environmental factors as well as their interaction with gender and age should be highly considered in adolescent smoking prevention in China.

Introduction

Many previous studies showed that adolescent smoking was associated with various demographic characteristics (Kandel et al., 2004), exposure to mass media (Unger et al., 1995, Fielding et al., 2004), social measures (Crawford et al., 2002, Griesbach et al., 2002), interpersonal factors (von Bothmer et al., 2002, Challier et al., 2000, Holm et al., 2003, Parna et al., 2003), intrapersonal characteristics (Tyas and Pederson, 1998, Challier et al., 2000), socio-economic status (SES) (de Vries, 1995), and cultural background (Rissel et al., 2000, Dornelas et al., 2005, Ellickson et al., 2003). Some of these factors, such as gender, age, genetics, family's SES, and cultural background are fixed or not practically modifiable by public health practice. Other factors that can be changed or improved are called “modifiable factors”. There is no doubt that modifiable factors should become the focus of tobacco control among adolescents. Due to their obvious advantages, schools and families are often used as the settings for adolescent smoking prevention interventions. According to social learning theory (Bandura, 1969, Bandura, 1977), adolescents with low self-regulation might learn to smoke through observing and modeling others' behavior of cigarette smoking. Moreover, their smoking attempts can be reinforced or punished by family and school smoking environments. Fortunately, most family and school smoking environments are modifiable, such as parental smoking, sibling's smoking, parents' and teachers' tolerance of adolescent smoking, teachers' smoking, classmates' smoking, school smoking policy, and school physical and social environments.

A four-stage model of transitional adolescent smoking behavior has been proposed: preparatory stage, trial stage, experimental stage, and regular smoking (Flay et al., 1983). Primary prevention of smoking involves prevention of early trying or experimental use and advance to regular smoking, whereas secondary prevention concerns getting experimenters or regular tobacco users to quit (Flay et al., 1998). Many studies in western countries found that some socioeconomic, psychological, and biological factors had different impacts on the development of the four smoking stages (Mayhew et al., 2000). A longitudinal study showed that the important correlates of transition from trial to experimental use included friends' smoking and approval, cigarette offers by friends, smoking intentions, school grade, and alcohol and marijuana use. The significant predictors of the transition from experimental to regular use included only parental smoking and family conflicts (Flay et al., 1998). The variation of transition predictors suggests that smokers of different stages might be sensitive to different intervention measures, which has important implication for adolescent smoking prevention.

Chinese adolescents live in family and school environments that are substantially different from American adolescents. These social differences may be important predictors of the transition or transfer of adolescent smoking stages in China. For example, the emphasized family value and small family size (one family, one child) might bring some positive and negative influence into the development of Chinese adolescent behaviors, including tobacco use. On one hand, adolescents' behaviors get more parental attention and thus their unfavorable smoking attempts may diminish or disappear with parental objection. However, on the other hand, some parents may overindulge their children for the reason of love, which sometimes put the children at the risk of unhealthy or dangerous behaviors (e.g. smoking). Different from their counterparts in US, most Chinese schools are public and managed by governments in a standardized fashion. The government policies have overwhelming impacts on the school administration and students. Although the smoking ban is commonly wrote out in the student handbook, the implement effect depends on the anti-smoking school atmosphere and perceived importance of tobacco control by administrative staff in each school. The intervention results will be promising if the local governments could highlight tobacco control in school management. Therefore, identifying the significant family and school environmental factors in Chinese cultural and social background may contribute to preventing both the onset of adolescent smoking and the advance to regular smoking. However, neither Chinese nor English publications from the Chinese mainland have explored this field.

In this paper, modifiable family and school environmental factors will be quantified and examined in association with the four smoking stages among Chinese adolescents in Guangzhou. We hypothesize that modifiable family and school environmental factors are important predictors of the different stages of adolescent smoking.