Smoking among school-going adolescents in selected secondary schools in Peninsular Malaysia- findings from the Malaysian Adolescent Health Risk Behaviour (MyaHRB) study
More details
Hide details
Institute for Medical Research, Kuala Lumpur, Malaysia
Melaka Manipal Medical College, Kuala Lumpur, Malaysia
Institute for Public Health, Kuala Lumpur, Malaysia
Allied Health College, Jalan Hospital, Sg. Buloh, Malaysia
Publish date: 2017-01-31
Tob. Induc. Dis. 2017;15(January):9
A multitude of studies have revealed that smoking is a learned behaviour during adolescence and efforts to reduce the incidence of smoking has been identified as long-term measures to curb the smoking menace. The objective of this study was to determine the prevalence as well as the intra and inter-personal factors associated with smoking among upper secondary school students in selected schools in Peninsular Malaysia.

Material and Methods:
A study was carried out in 2013, which involved a total of 40 secondary schools. They were randomly selected using a two-stage clustering sampling method. Subsequently, all upper secondary school students (aged 16 to 17 years) from each selected school were recruited into the study. Data was collected using a validated standardised questionnaire.

This study revealed that the prevalence of smoking was 14.6% (95% CI:13.3–15.9), and it was significantly higher among males compared to females (27.9% vs 2.4%, p < 0.001). Majority of smokers initiated smoking during their early adolescent years (60%) and almost half of the respondents bought cigarettes themselves from the store. Multivariable analysis revealed that the following factors increased the likelihood of being a current smoker: being male (aOR 21. 51, 95% CI:13.1–35), perceived poor academic achievement (aOR 3.42, 95% CI:1.50–7.37) had one or both parents who smoked (aOR 1.80, 95% CI:1.32–2.45; aOR 6.50, 95 CI%:1.65–25.65), and always feeling lonely (aOR 2.23, 95% CI:1.21–4.43). In contrast, respondents with a higher religiosity score and protection score were less likely to smoke (aOR 0.51, 95% CI:0.15–0.92; aOR 0.71, 95% CI 0.55–0.92).

This study demonstrated that the prevalence of smoking among Malaysian adolescents of school-going age was high, despite implementation of several anti-smoking measures in Malaysia. More robust measures integrating the factors identified in this study are strongly recommended to curb the smoking epidemic among adolescents in Malaysia.

Kuang Hock Lim   
Institute for Medical Research, Jalan Pahang, 50588 Kuala Lumpur, Malaysia
1. World Health Organization. WHO report on the global tobacco epidemic, 2011. Geneva: World Health Organization; 2011. Accessed 7 Apr 2015.
2. Disease Control Division, Ministry of Health. Clinical practice guidelines on treatment of tobacco use and dependence. 2003. Accessed on 26 Dec 2016.
3. Institute of Public Health. Burden of disease and injury in Malaysia. 2012.
4. Al-Junid SM. Health care costs of smoking in Malaysia. 2007.
5. Fleming R, Leventhal H, Glynn K, Ershler J. The role of cigarettes in the initiation and progression of early substance use. Addic Behav. 1989;14(3):261–72.
6. Jackson C, Sweeting H, Haw S. Clustering of substance use and sexual risk behaviour in adolescence: analysis of two cohort studies. BMJ Open. 2012;2:e000661.
7. Busch V, Van Stel HF, Schrijvers AJ, de Leeuw JR. Clustering of health-related behaviors, health outcomes and demographics in Dutch adolescents: a cross-sectional study. BMC Public Health. 2013;13:1118.
8. U.S. Department of Health and Human Services. The health consequences of smoking: a report of the surgeon general. Atlanta (GA): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2004.
9. Park SH. Smoking behavior and predictors of smoking initiation in childhood and early adolescence. J Korean Acad Nurs. 2009;39(3):376e85.
10. Millar WJ, Chen J. Age of smoking initiation: implications for quitting. Health Rep. 1998;9(4):39e46.
11. WHO. Global school-based student health survey, Malaysia. 2012 fact sheet. 2012. Accessed 23 Dec 2015.
12. Lim KH, Sumarni MG, Kee CC, Christopher VM, Noruiza Hana M, Lim KK, Amal NM. Prevalence and factors associated with smoking among form four students in Petaling District, Selangor, Malaysia. Trop Biomed. 2010;27(3):394–403.
13. Naing NN, Zulkifli A, Razlan M, et al. Factors related to smoking habits of male adolescents. Tob Induced Dis. 2004;2:133–40.
14. Shamsuddin K, Haris MA. Family influence on current smoking habits among secondary school children in Kota Bharu, Kelantan. Singapore Med J. 2000;41(4):167–71.
15. Lim KH, Amal NM, Hanjeet K, Mashod MY, Wan Rozita WM, Sumarni MG, Hadzrik NO. Prevalence and factors related to smoking among secondary school students in Kota Tinggi District, Johor, Malaysia. Tinggi District, Johor, Malaysia. Tinggi District, Johor, Malaysia. Trop Biomed. 2006;23(1):75–84.
16. Norbanee TH, Norhayati MN, Norsa’adah B, Naing NN. Prevalence factors influencing smoking amongst Malay primary school in Tumpat, Kelantan. Southeast Asian J Trop Med Public Health. 2006;37(1):23–8.
17. Nor A, Zulkefli M, Rahmah MA, Lye MS, Md Said S, Fazilah S, Shamsul Azhar S. smoking behavior among adolescents in rural schools in Malacca, Malaysia - a case-control study. Pertanika J Sci & Technol. 2015;23(1):13–28.
18. Saari AJ, Kentala J, Matilla KJ. Weaker self-esteem in adolescence predicts smoking. BioMed Res Int. 2015;2015:1–5.
19. Centers of Disease Control and Prevention.Global School Health Survey (GSHS). questionnaire. Accessed on 29 Dec 2015.
20. Centers of Disease control and Prevention. Youth Behavior Risk Surveillance. 2013. Accessed on 29 Dec 2015.
21. Jamil MBY. Validity and reliability study of Rosenberg self-esteem scale inSeremban school children. Malaysian J Psychiatry. 2006;15:35–8.
22. Jeganathan PD, Hairi NN, Al Sadat N, Chinna K. Smoking stage relations to peer, school and parental factors among secondary school students in Kinta, Perak. Asian Pac J Cancer Prev. 2013;14(6):3483–9.
23. Page RM, Dennis M, Lindsay GB, Merrill RM. Psychosocial distress and substance use among adolescents in four countries: Philippines, China, Chile, and Namibia. Youth Soc. 2011;43:900–30.
24. Rao S, Aslam SK, Zaheer S, Shafique K. Anti-smoking initiatives and current smoking anti-smoking initiatives and current smoking among 19,643 adolescents in south asia: findings from the global youth tobacco survey. Harm Reduc J. 2014;11:8.
25. Huisman M, Kunst AE, Mackenbach JP. Inequalities in the prevalence of smoking in the European Union. Prev Med. 2005;40:756–64.
26. Graham H. Smoking prevelance among women in the European community 1950–1990. Soc Sci Med. 1996;43:243–54.
27. Bandura A. Social learning theory. New Jersey: Prentice-Hall, Inc; 1977.
28. Sirirassamee T, Sirirassamee B, Borland R, Maizurah O. Smoking behavior among adolescents in thailand and Malaysia. Southeast Asian J Trop Med Public Health. 2011;4(2):218–24.
29. Malaysian Food Act. The control of tobacco product (amendment) regulations, 2004 Government Gazette P.U.(A) 324. 1993.
30. Zulkifli A, Rogayah I. Cigarette sales to minors in Kelantan. Med J Malaysia. 1998;53:128–30.
31. Nazarzadeh M, Bidel Z, Ayubi E, Bahrami A, Jafari F, Mohammadpoorasl A, Delpisheh A, Taremian F. Smoking status in Iranian male adolescents: a cross-sectional study and a meta-analysis. Addic Behav. 2013;38(6):2214–8.
32. US Department of health and Human Service Monitoring. The Future National Survey Result on Drug Use, 1975-2006 with the URL of : Accessed 29 Dec 2015.
33. Philippines Country Report. Department of Health with URL of Accessed on 26 Dec 2015.
34. Widome R, Forster JL, Hannan PJ, Perry CL. Longitudinal pattern of youth access to cigarettes and smoking progression: Minnesota Adolescent Community Cohort (MACC) study (2000–2003). Prev Med. 2007;45:442–6.
35. DiFranza JR. Adolescent acquisition of cigarettes through non commercial source. J Adoles Heal. 2003;32(5):331–2.
36. Eun ES, Ji YY. Factors associated with early smoking initiation among Korean adolescents. Asian Nurs Res. 2015;9(2):115–9.
37. Goldade K, Choi K, Bernat DH, Klein EG, Okuyemi KS, Forster J. Multilevel predictors of smoking initiation among adolescents: findings from the Minnesota Adolescent Community Cohort (MACC) study. Prev Med. 2012;54(3–4):242–6.
38. Santrock JW. Adolescence. 11th ed. Boston: McGraw-Hill; 2005.
39. Rajan KB, Leroux BG, Arthur V, Peterson Jr, Bricker JB, Andersen MR, Kealey CA, Sarason IG. Nine-year prospective association between older siblings smoking and children’s daily smoking. J Adoles Healt. 2003;1:25–30.
40. Woodruff SI, Laniado-Laborín R, Candelaria JI, Villaseñor A, Sallis JF. Parental prompts as risk factors for adolescent trial smoking: Results of a prospective cohort study. Addic Behav. 2004;9:1869–73.
41. Scalici F, Schulz JP. Influence of perceived parent and peer endorsement on adolescent smoking intentions: parents have more say, but their influence wanes as kids get older. plos one. 2014;9(7):1–7.
42. Gilman SE, Rende R, Boergers J, Abrams DB, Buka SL, Clark MA. Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics. 2009;123(2):e274–81.
43. Blokland Exter EA, Engels RC, Hale WW, Meeus W, Willemsen MC. Lifetime parental smoking history and cessation and early adolescent smoking behavior. Prev Med. 2004;38:359–68.
44. Bandura A. Self-efficacy mechanism in physiological activation and health and promoting behavior. In: Madden J, Matthysse S, Barchas J, editors. Adaptation, learning and affect. New York: Raven; 1989. p. 1169–88.
45. Bandura A. Social cognitive theory. In: Vasta R, editor. Annals of child development, Six theories of child development, vol. 6. Greenwich: JAI Press; 1989. p. 1–60.
46. Kodl MM, Mermelstein R. Beyond modeling: parenting practices, parental smoking history, and adolescent cigarette smoking. Addict Behav. 2004;29:17–32.
47. Chassin L, Presson C, Seo DC, Sherman SJ, Macy J, Wirth RJ, Curran P. Multiple trajectories of cigarette smoking and the intergenerational transmission of smoking: a multigenerational, longitudinal study of a Midwestern community sample. Heal Psycho. 2008;27:819–28.
48. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? Pediatrics. 2001;108(6):1256–62.
49. Bricker JB, Andersen MR, Rajan KB, Sarason IG, Peterson AV. The role of schoolmates’ smoking and non-smoking in adolescents’ smoking transitions: a longitudinal study. Addiction. 2007;102:1665–75.
50. Morin AJ, Rodriguez D, Fallu JS, Maïano C, Janosz M. Academic achievement and smoking initiation in adolescence: a general growth mixture analysis. Addiction. 2012;107(4):819–28.
51. Dhavan P, Stigler MH, Perry CL, Arora M, Reddy KS. Is tobacco use associated with academic failure among government school students in urban India? J Sch Health. 2010;80(11):552–60.
52. Aloise-Young PA, Cruickshank C, Chavez EL. Cigarette smoking and perceived health in school dropouts: a comparison of mexican american and non-hispanic white adolescents. J PediatrPsychol. 2002;27(6):497–507.
53. Page RM. Loneliness and adolescent health behavior. Health Educ. 1990;21:14–7.
54. Stickley A, Koyanagi A, Koposov R, Schwab-Stone M, Ruchkin V. Loneliness and health risk behaviours among Russian and U.S. adolescents: a cross-sectional. BMC Public Health. 2014;14:366.
55. Heinrich LM, Gullone E. The clinical significance of loneliness: a literature review. Clin Psychol Rev. 2006;26:695–718.
56. Rotenberg KJ, McDougall P, Boulton MJ, Vaillancourt T, Fox C, Hymel S. Cross-sectional and longitudinal relations among peer-reported trustworthiness, social relationships, and psychological adjustment in children and early adolescents from the United Kingdom and Canada. J exp Child Psychol. 2004;88:46–67.
57. Fadhli Y, Zulkifli A, Razlan M. Religious perception and other associated factors of smoking among male secondary school students in Kota Baru, Kelantan. Mal J Pub Heal Med. 2005;5(2):58–63.
58. Nor Afiah MZ, Rahmah MA, Salmiah MS, Fazilah S, Shamsul Azhar S. Religiosity personality and smoking among form two students in rural schools in Malacca, Malaysia. Int Med J Malaysia. 2012;11(2):39–44.
59. Nonnemaker J, McNeely C, Blumb RW. Public and private domains of religiosity and adolescent. Soc Sci Med. 2006;62:3084–95.
60. Wallace JM, Forman T. Religion’s role in promoting health and reducing risk among American youth. Health Educ Behav. 1998;25:721–41.
61. Choi WS, Ahluwalia JS, Harris KJ, Okuyemi K. Progression to established smoking: the influence of tobacco marketing. Am J Prev Med. 2002;22(4):228–33.
62. Coleman JS. Social capital and the creation of human capital. Am J Sociol. 1998;94:S95–120.
63. Smith C. Theorizing religious effects among theorizing religious effects among theorizing religious effects among american adolescents. J Sci Study Relig. 2003;42(1):17–30.
64. Shakib S, Hong Z, Johnson CA, Chen XG, Ping S, Palmer PH. Family characteristics and smoking among urban and rural adolescents living in China. Prev Med. 2005;40(1):83–91.
65. Wan X, Sheenassa SD. Interaction between parenting and neighbourhood quality on the risk of adolerscents regular smoking. Nicotine Tobacco Res. 2012;14(3):313–22.
66. Wang Y, Krishnakumar A, Narine L. Parenting practices and adolescent smoking in mainland China: the mediating effect of smoking-related cognitions. J Adolescent Health. 2014;37:915e925.