Malaysian Journal of Public Health Medicine 2013, Vol.

13(1): 28-36

ORIGINAL ARTICLE
CIGARETTE SMOKING AND CARDIOVASCULAR RISK FACTOR AMONG MALE
YOUTH POPULATION
Raihan K, Azmawati MN

Department of Community Health, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Malaysia.

ABSTRACT
The leading cause of mortality in Malaysia is coronary heart disease (CHD). Several cardiovascular (CVD) risk factors
contribute to this problem and smoking is one of the main modifiable risk factor. Most of the patients started smoking
early during youth period. This study aimed to determine the association and to predict the cigarette smoking and
cardiovascular risk factors among the male youth. A cross sectional study was conducted by self-administered data
sheets, physical examinations: blood pressure measurement and body mass index calculation, blood taking procedure
for blood glucose, total cholesterol and HDL-C levels. The results showed that the glycemic status was significantly
associated with smoking status (p=0.048) however, there was no significant association for smokers and risk of
developing diabetes mellitus compared to non smokers although smokers had higher odd ratio (OR: 4.33; 95%CI:
0.900-20.811) (p=0.068). Interestingly, for daily exposure of smoking, those who smoke 5 cigarette and less was
significantly associated with high systolic blood pressure (p = 0.036) and smoking showed protective trend against
systolic hypertension (OR: 0.57; 95% CI: 0.266-1.230), however, it was not significant (p=0.152). In conclusion, smoking
among youth and its association with the cardiovascular risk factor should be addressed tactfully and early screening
should be promptly done among the smoking youth for early prevention.

Key words: Cigarette smoking, male youth, cardiovascular risk factors.

INTRODUCTION non smokers3. The risk of developing type 2

Non-communicable diseases (NCDs) are the
leading cause of mortality and morbidity
globally1. In 2008, of the 57 million death
occurred worldwide, 36 million were due to
NCDs, namely cardiovascular diseases as the
leading cause, followed by cancers, diabetes and
chronic respiratory diseases1. Cardiovascular
disease (CVD) as the major contributor towards
this NCDs epidemic is of global health concern1.
Similarly in Malaysia, in National Health and
Morbidity Survey (2006), the leading cause of
mortality in both genders is CVD2.
Cigarette smoking is one of the leading causes of
premature peripheral, coronary and cerebral
artherosclerotic vascular diseases1. The risk of
myocardial infarction is increasing in one to
threefold among current smokers1.The
pathophysiology of smoking explained this process
in which cigarette smoking is positively
associated with increased blood pressure in
relation with its acute effects of
vasoconstriction2. Higher prevalence of
hypertension was reported among the smokers
than in non smokers 3, however, no specific study
on prevalence among youth smokers was done.
Smoking also associated with higher serum
cholesterol and lower concentrations of high
density lipoprotein (HDLC) when compared with
diabetes mellitus among youth was 49% and
higher among the male smokers compared to the
male non smokers4. For youth that already had
the type 1 diabetes mellitus, the risks of
developing complications of diabetes was
accelerated among the youth who smokes5. Thus,
cardiovascular risk profile among youth who
smokes is worse compared to non smoker and this
will eventually exposed them to get the coronary
heart disease earlier in their adulthood.
Majority of the smokers started smoking during
early adult years3. The earlier they start to
smoke, the more likely they are to become
regular smokers3. The prevalence of current
smoking among youth in Thailand was 11.4 %, in
South Korea (6.6 %) and Taiwan (6.5 %)6. With the
prevalence of smoking among youth (21.5%),
smoking is a major problem among youth in
Malaysia1-3. In a recent survey by the Ministry of
Youth and Sports (2004) on negative behaviours
among 5,860 youth, 80% indicated that they had
ever experienced smoking 7.
From the Third National Health and Morbidity
Survey conducted in 2006, the national
prevalence of smoking among adults 18 years and
above was 21.5%, male smoking rate was many
fold higher (46.4%) than that of female (1.6%)3,8.
A study revealed that smoking plays an important
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36
role in precipitating atherosclerosis in both males
and females in terms of small low-density
lipoprotein (LDL). It showed that there was a
prominent decrease in LDL particle size in male
youth due to presence of testosterone hormone
which might contribute to higher cardiovascular
risk in males’ children and adolescents9.
Malaysian Global Youth Tobacco Survey
conducted in 2003 found that one in three youth
have ever smoked cigarettes, while a significantly
higher rate was found in males (53.6%) than
females13. Nonetheless, several studies pointed
that males are at higher risk of cardiovascular
events than females5-8. This justify the male
adolescents were chosen in this study.
The aim of this study is to determine the
prevalence of smoking among male youth and to
determine and predict the association between
cigarette smoking and cardiovascular risk factors.
MATERIALS AND METHODOS
This cross sectional study was conducted within
the state of Selangor where it has nine districts.
Hulu Langat district was chosen out of nine. In
Hulu Langat there are seven sub-districts and five
of them namely Ampang, Cheras, Kajang,
Semenyih and Hulu Langat were selected. The
number of traditional villages and housing estates
for each district were required by using the list of
residential units obtained from the Ampang Jaya
Municipal Office (MPAJ), Kajang Municipal Office
(MPKJ) and the Hulu Langat District Health
Office. From this lists, by using Fisher random
numbers, the housing area from each district was
selected by stratified sampling. From the
selected sampling, all males adolescents aged 19
to 24 years old were recruited to participate in
this study.
A sample of 251 male youth aged 19 to 24 years
old were selected and this was in line with the
sample size calculated with the Fleiss JL formulae
by using rates of smoking among youth in
Thailand of 26.7% which included the non-
response samples. All males’ were included in
this study since none of them met the exclusion
criteria which were, having chronic illnesses such
as ischaemic heart diseases, diabetes mellitus,
dyslipidemia, other metabolic disorders and other
cardiovascular related illnesses, those who took
any medications that can alter the blood lipid
levels or had received treatment for any type of
dyslipidemia, and those having haemophiliac or
blood disorders.
Each participant were informed and explained
thoroughly regarding objectives of the study and
the benefits to take part in the study during
home visit. A standardized assisted and guided
data sheets form was prepared with close
questions for the main cardiovascular risk factors
which included demographic data such as age and
ethnicity, lifestyles such as smoking status
(number of cigarettes per day and duration of
smoking) and metabolic parameter such as blood
glucose and lipid profile, systolic and diastolic
blood pressure and body mass index calculation.
Physical examination
Weight and heights were measured without shoes
and with light clothing, and body mass index was
calculated as body weight (kg) divided by the
square of height (m2). Blood pressure was
measured three times using the appropriate sizes
of cuffs and a standard sphygmomanometer, after
the subject had been seated for at least 10
minutes. For analysis, the last two measurements
were averaged.
Biochemistry analysis
A blood sample was drawn using rapid test for
lipid and glucose. The blood collected was for
random blood glucose, plasma total cholesterol
(TC) and High Density Lipoprotein (HDL-C)
cholesterol.
Definition of variables
“Current smoking” was defined as current use, at
the time of the survey, of cigarettes smoking
since other form of smoking (using pipes, cigars
or chewing tobacco) was rare in youth
population, ex-smoker was defined as a person
already quit smoking for the past 6 months and
non smoker was a person who never takes up
smoking. ‘Number of cigarettes per day’ was
defined as the number of cigarettes currently
smoked per day (current exposure). The
dependent variables were the cardiovascular risk
factors; hypertension (systolic and diastolic),
total cholesterol, HDL-C and diabetic status. In
this study, based on World Health
Organization/International Society of
Hypertension 200710, systolic ≥ 140 mmHg and
diastolic ≥ 90 mmHg was defined as high. The
total cholesterol level and HDL-C level were
defined according to National Cholesterol
Education Program Adult Treatment Panel III
(NCEP ATP 2002)11, total cholesterol ≥5.2 mg/dL
is classified as high and for HDL-C, if < 1.03
mg/dL is regarded as low level. As diabetic
status, based on WHO guidelines stated for blood
glucose level, ≥ 7.1 is classified as high glycemic
status12. Body mass index (BMI) was defined
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36
according to World Health Organization 200412
and categorized into Underweight (< 18.5 kg/m2),
Normal (18.50 – 24.99 kg/m2), Overweight (25.0 –
29.99 kg/m2) and Obese (≥ 30.00 kg/m2).
Statistical analysis
All analyses were conducted by using SPSS Version
19.0. Data were expressed as percentages.
Comparisons between groups were analyzed using
chi-squared test. Simple logistic models were
used to assess the crude association of each
variable.
Ethics
The protocol of this study was approved by
research and ethics committee of National
University of Malaysia Medical Centre (UKMMC).
Consent form was obtained from the male youth
respondent before they answered the
questionnaire and agreed for blood taking
procedure.
RESULTS
Baseline characteristics
Baseline characteristics of the 251 participants
(male youth) are shown in Table 1. The
prevalence of current smoker in this population
was 46.6% (n = 118) and 47.8% of them was non
smoker (n = 120). Majority of the smokers were
Malay with 84.1% and the remaining was non
Malay (15.9%) and most of them were in 19 to 21
years of age. Among the smokers, the average
number of cigarettes smokes per day was 10
sticks. Two fifth of them was overweight and
obese. Majority of them had normal systolic and
diastolic blood pressure, normal glycemic status
and total cholesterol level, however, half of them
had low HDL-C level.
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36

Table1. Demography and cardiovascular risk factors characteristics among male youth

Characteristics Mean (SD) Number (%)

n = 251

Age 21.3(1.65)
19-21 139(55.4)
22-24 112(44.6)

Ethnicity
Malay 211(84.1)
Chinese 26(10.4)
Indian 14(5.6)

BMI 22.8(5.09)
Underweight 50(19.9)
Normal 123(49.0)
Overweight 49(19.5)
Obese 29(11.6)

Blood Pressure
Systolic BP 125.7(13.10)
Normal 215(85.7)
High 36(14.3)

Diastolic BP 76.4(10.21)
Normal 227(90.4)
High 24(9.6)

Glycaemic 4.2(1.66)
Status
Normal 241(96.0)
High 10(4.0)

Smoking Status
Current Smoker 118(46.6)
Non Smoker 120(47.8)
Ex Smoker 13(5.6)

No. of cigarettes per day 9.9(6.76)

Duration of smoking 5.2(3.82)

Total Cholesterol level 4.0(1.24)

(mmol/L)
Normal 212(84.5)
Abnormal 39(15.5)

HDL-C level (mmol/L) 1.5(0.50)

Low 132(52.6)
Normal 119(47.4)

Association between smoking and
cardiovascular risk factors
Among the smokers, majority of them had high
glycemic status (6.8%) compared to non smokers
(1.7%) (p=0.048) (Table 2). And those who
smoked had higher risk to develop systolic
hypertension compared to non smoking (OR: 4.33;
95% CI: 0.900-20.811) (p = 0.068) (Table 4). In
Table 3, majority of the low exposure (less than 5
sticks per day) and high exposure (more than 6
sticks per day) smokers were having normal
systolic blood pressure and those who smoke 5
and less cigarette per day was associated with
high systolic blood pressure (p = 0.036). Smoking
also showed protective trend against systolic
hypertension compared to non smoking although
it was not significant (OR: 0.57; 95% CI: 0.266-
1.230) (p = 0.152) (Table 4).
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36

Table 2. Association of smoking status and cardiovascular risk factors among male youth

Cardiovascular Systolic Diastolic Glycemic status Total cholesterol HDL-C level Body Mass Index
risk factors blood pressure blood pressure
Smoking High Normal High Normal High Normal Abn Normal Low Nm Un Nm Ovr Ob

Yes (n, %) 13 105 7 111 9 109 17 101 66 52 24 59 24 13

(n = 118) (10.3) (89.7) (5.1) (94.9) (6.8) (93.2) (13.7) (86.3) (56.4) (43.6) (50.0) (51.3) (52.3) (48.1)

No (n, %) 20 100 13 107 2 118 20 100 60 60 24 56 21 14

(n = 120) (16.7) (83.3) (10.8) (89.2) (1.7) (98.3) (16.7) (83.3) (50.0) (50.0) (50.0) (48.7) (47.7) (51.9)
X2 , p value 2.09, 0.149 2.62, 0.106 3.02,0.048 0.41,0.521 0.98,0.323 0.14, 0.987
Un = underweight, Nm = Normal, Abn = Abnormal, Ovr = Overweight, Ob = Obese.

Table 3. Association of smoking status and cardiovascular risk factors among male youth

Cardiovascular Systolic Diastolic Glycemic status Total cholesterol HDL-C level Body Mass Index
risk factors blood pressure blood pressure
No. of cigarette High Normal High Normal High Normal Abn Normal Low Nm Un Nm Ovr Ob
smoking
≤ 5 cigarettes per 6 20 3 23 2 24 4 22 14 12 5 12 8 1
day (n = 26) (23.1) (76.9) (11.5) (88.5) (7.7) (92.3) (15.4) (84.6) (53.8) (46.2) (19.2) (46.2) (30.8) (3.8)
≥ 6 cigarettes per 6 86 3 89 5 87 12 80 54 38 19 44 14 13
day (n = 92) (6.5) (96.7) (3.3) (96.7) (5.4) (94.6) (13.0) (87.0) (58.4) (41.3) (21.1) (48.9) (15.6) (14.4)
X2 , p value *4.40, 0.036 1.42, 0.234 0.01,1.000 0.98, 0.323 0.01, 1.000 4.41,0.221
Un = underweight, Nm = Normal, Abn = Abnormal, Ovr = Overweight, Ob = Obese, * Yates corrections.

Table 4. Crude Odd Ratios and 95% confidence intervals for cardiovascular risk factors among male youth

Cardiovascular risk Systolic Diastolic Diabetes mellitus High Total low HDL-C Obesity
factors hypertension hypertension cholesterol
p, 95% CI 0.152 0.114 0.068 0.522 0.323 0.764
(0.266 - 1.230) (0.163 - 1.213) (0.900 - 20.811) (0.619 - 2.576) (0.463 – 1.289) (0.606 – 1.976)
Smoking
Yes 0.57 0.45 4.33 1.26 0.77 1.10
No 1.0 1.0 1.0 1.0 1.0 1.0
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36
From table 4, although all the results were not
significant, the crude odd ratio for smoking
showed higher trend to become obese, diabetics
and hypercholesterolemia. Whereas, the crude
odd ratio for diastolic hypertension and low level
of HDL-C had showed protective trend for those
who smoke although the results was not
significant. Majority of the male youth who
smoked had at least 1 or more cardiovascular risk
factors (refer Table 5).
Table 5. Number of cardiovascular risk factors
among smokers in male youth population
Number of cardiovascular risk n (%)
factors
None 29 (24.6)
1 47 (39.8)
2 22 (18.6)
3 19 (16.1)
4 1 (0.8)
5 none
All 6 none
DISCUSSION
The increasing rate of the prevalence of NCD
diseases and NCD risk factors in Malaysia is
alarming. Focus on primary prevention and early
identification of NCD risk factors are being
emphasize especially among the younger age
groups1. According to Global Youth Tobacco
Survey (GYTS), changes in smoking behaviour in
the young will affect mortality rates for several
50
45
40
35
30
25
current smoking, %
20
Prevalence of
15
10
5
0
19 20 21
Age,year
Figure 1. Prevalence of current smoking status among male youth age 19 -24 years
decades13. Even though the full hazards of
smoking take many decades to emerge, for those
people who initiates smoking early in adolescence
and continue throughout the middle age will
affect the mortality rates and it is predicted that
majority of the excess risk of death due to
smoking in the middle and old age can be avoided
by quitting before age 4014.
The prevalence of smoking among male youth in
this study was (46.6 %) comparable with two
other recent studies on prevalence among male
youth in Malaysia which was 46.7% and 41.2% with
the same age groups15-16. Despite of all control
and preventive measures taken by the
government, such as ‘Stop Smoking’ campaign
and enforcement of smoking laws, the prevalence
still consistent and the trend of smoking among
youth is alarming.
The prevalence of smoker among Malay youth was
higher than the non Malay (Figure 1) in this study.
This prevalence was comparable with data from
NHMS III for young adults who smoke are mostly
Malay ethnic (10.9%) compared to others2.
However, the lower smoking prevalence among
non Malay should not promote complacency
because this may not show the real situation
since the participants in this study were majority
from Malay ethnicity. A study among United
States youths age 18-24 years of age also
revealed that White American had higher
prevalence of smoking (38.0%) compared to
Mexican American and Black (5.7%)17.
22 23 24
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36
Most of the smokers among the male youth in this
study were having at least one or more
cardiovascular risk factors (Table 5). These
findings should provoke our health promotion
team and also school health team to tackle this
problem in order to prevent the acceleration of
coronary heart disease in early adulthood. In a
cross sectional study done among those healthy
youth in Mexican, those youth who smoked had
less favourable cardiometabolic risk profile than
the non smoker18.
In this study, a significant association between
glycaemic status and smoking among male youth
was revealed (p=0.048). Among those who
smoked, 6.8 % of them had high blood glucose
level compared to non smoker. However, there
was no significant association for crude odd ratio
between smoking and risk to develop diabetes
mellitus compared to non smoking (OR: 4.33; 95%
CI: 0.900-20.811) (p = 0.068). A study in United
States shared the similar findings, among the
youth who smoked, 27.0 % of them were having
Type 1 Diabetes Mellitus and 37.3 percent of
them was already develop type 2 Diabetes
Mellitus19. Unfortunately, the data on youth in
Malaysia for diabetic status is still in scarce.
Smoking status and systolic blood pressure
showed no significant association in this study,
however, those who smoked 5 or less cigarettes
per day was significantly associated with high
systolic blood pressure (p=0.036). This result was
contradict with the pathophysiology of smoking
that showed smoking causes endothelial injury
thus lead to vasoconstriction of the blood vessels
and high cardiac output thus favours the
development of hypertension21. A study done in
Iran also revealed that prevalence of
hypertension was higher among smoker than non
smoker22. In study among youth in Canada clearly
showed that those who smoke heavily (6 or more
cigarettes per day) had higher mean of systolic
blood pressure compared to those who smoked
less20. In our study, the self administered data
sheets was used and this may cause
underreported data since most of the youth
usually will not revealed that they are a smoker
and the number they actually smoked especially
when it was conducted in their house where their
parents also present.
In this study, there is a trend shown that the
crude odd ratio for non smoker is about 2 times
to get systolic hypertension (OR=1.75, CI: 0.813-
3.766) compared to smoker but the results was
not significant. Interestingly, there were various
studies since 1971 on the relation between
smoking and blood pressure but then they come
into controversial results; some believe that
smoking can increase blood pressure23, while
some reported that blood pressure of smokers
was lower than non smokers24. Recent study
suggested that smoking cause vasomotor
dysfunction as the result of reduction of nitrous
oxide (NO) that responsible as a vasoregulatory
molecule that would have hypotensive action24.
Some study also postulated that the effects of
chronic smoking with lower blood pressure was
due to non nicotine substances in cigarette smoke
which might affect on lowering blood pressure
23,24
. Nevertheless, the exact mechanism and
pathophysiology of such effects in cigarette
smoking are still not well understood.
For obesity risk factor, in our study there was no
significant association between smokers and risk
to be obese than non smokers, however it showed
higher risk trend in smoker (OR: 1.10; 95% CI:
0.606 – 1.976) (p = 0.764). Previous study also
shown that smokers tend to indulge in unhealthy
lifestyle such as lack of physical activity, poor
fruit and vegetable consumption and increased in
alcohol consumption thus lead to weight gain and
obesity28. In one study by Nakamura25 those
smokers who smoked more than 20 sticks per day
had doubled risk to be obese compared to smoker
that smoked less than 10 cigarettes per day.
Similarly in our study, most of the smokers were
overweight compared to non smokers and those
who smoked 6 or more cigarette per day were
more in overweight and obese compared with
those who smoked less.
For total cholesterol level, smoking had no
significant association with the risks of
developing higher cholesterol level compared to
non smoker, although the crude odd ratio was
higher for smokers (OR: 1.26; 95% CI: 0.619 –
2.576). This was inconsistent with the
pathophysiology of smoking that it able to
increase the LDL-C level, plasma triglycerides and
VLDL level thus simultaneously lower the HDL-C
level and proven by the Framingham study that
showed cigarette smoking responsible for a drop
of HDL-C level by 4mg/dl in men and 6 mg/dl in
women26,27. Despite of this, there were several
study among youth shown that there were not
much increment of total cholesterol level and low
HDL-C level among the youth since there were
still short exposure of smoking28.
The findings of this study will assist policy makers
in strengthening NCD prevention among youth by
providing evidence based data on pattern of
smoking and most importantly the earliest age of
Malaysian Journal of Public Health Medicine 2013, Vol. 13(1): 28-36
smoking initiation among youth. By this data,
policy makers can alert the regulator or legal
enforcer to make amendment and strengthened
the enforcement law regarding prohibition of
smoking among youth. The prevention programme
can be initiated earlier than previous since the
smoking initiation age of male youth in Malaysia is
as early as in primary school children. Although in
the early stage to be significant establishment of
diseases, the cardiovascular profile of the youth
who smoke showed to be in the verge of normal
range. They are the high risks group that can be
“salvageable”. Youth is the most important phase
which NCD risk behaviours develop and solidify
and the longer they go unaddressed, the harder
they are to change.
The main limitation of this study is that
important factors which may contribute to the
cardiovascular risk factors among youth such as
dietary habits, physical activity and genetics
were not included. This study used a cross-
sectional design and thus, the temporal
relationship between cigarette smoking and
cardiovascular risk factors unable to be
established. The usage of self reported health
behaviours especially cigarette smoking status,
number of cigarettes per day may have been
under reported or the participants may deny their
smoking behaviour. Another limitation of this
study is that the data are from 2002 which is
about 10 years ago and may not reflect the
current smoking patterns among male youth. The
measurement bias is explicitly in this study, the
lipid profile and blood glucose were taken by
rapid tests only and without the respondents
being fasting at least 8 hours prior to the blood
taking procedure. This may explained the non
significant association between smoking and
other cardiovascular risk factors such as total
cholesterol and HDL-C level.
Despite of the limitations, this study provides the
prevalence of smoking among male youth which is
worrying and need urgent actions and attentions.
Smoking is an avoidable risk factor for the
development of cardiovascular diseases. Since
the escalation of cardiovascular risk factors
enhanced by smoking, prevention of cigarette
smoking in youth is the most essential.
CONCLUSION
From this study, we can plan to target youth
smoking as part of ongoing community – based
intervention program especially in our health
clinics. Furthermore, this study may act as a
baseline for further study, such as genetic factors
among the youth that may be the strong
predictive factor toward development of coronary
heart diseases.
ACKNOWLEDGEMENT
We gratefully acknowledge the Community Health
Department of University Kebangsaan Malaysia for
the health data and those who directly or
indirectly involved in this study.
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