CHAPTER 2

LITERATURE REVIEWS

This chapter begins with an overview of adolescent smoking scenario in

Bangladesh and the impacts of cigarette smoking among adolescents. A review of the
Precede –Proceed Model follows. Then the selected studies conducted in Bangladesh
and other countries related to adolescent smoking and related factors are reviewed.

Adolescent smoking scenario in Bangladesh

Adolescent smoking scenario
Bangladesh is one of the largest deltas in the world. Considering the
geographical location, it is situated in the northeastern part of South Asia. Total area
of this country is 147,570 square kilometers. It is almost surrounded by India, except
short southeastern frontier with Myanmar and a southern coastline on the Bay of
Bengal. According to the Bangladesh Population and Housing Census, 2011
Bangladesh is a developing country with a population over 160 million.
Approximately 22% population of Bangladesh is under 25 years old. Considering the
population density the country is in the highest position. One-third of the population is
under 15 years old, 63% is between 15 to 64 years, and 4% is 65 years or older
(WHO, 2007; CDC, 2010).
Bangladesh’s adolescent (ages 15–24 years) population is estimated at about
28 million in 2000.This age group will contribute significantly to the growth of
population size of Bangladesh in the next 20 years. It will increase by 21 percent and
reach 35 million by 2020. Adolescents comprise 22 percent of the total population.
Educational attainment is increasing in both boys and girls and there is a significant
growth in the percent of boys and girls obtaining a secondary or higher education.
Between 1994 to 2000 this rate increased from 10.5 percent to 54.9 percent for boys,
and 5.5 percent to 47.1 percent for girls (Barkat, & Majid, 2003). Literacy rate is low
but trends to be improving. In 2009 the rate estimated at 56% for those who were 15
years and older (Barkat et al., 2012).
Bangladesh is situated in the South-East Asia region. Smoking is common
among young and adult. It is one of the largest tobacco consuming countries in the
 14

world (WHO, 2008 a; CDC, 2010). It has been showed that 6.9% of school going
students’ ages between 13-15 years ever smoked cigarettes. Among them boys are
9.1% and girls are 2.9% (Barkat et al., 2012). Additionally, more than 42.2% is
reported as exposure to outside the home. Most of the youths (83.3%) are aware of the
risk of exposure to secondhand smoke and three-quarters (74.9%) support banning
smoking in public places (Barkat et al., 2012). In another study, students were
exposed to people’s smoking at home (34.9%), in schools (12.4%) and public places
(63.9%). This may reflect the poor enforcement of smoke free policies especially at
schools and public places. Exposures to smoking at schools or public places are
significantly increased the risk of students smoking by 1.53 and 1.37 times
respectively, compared to those not exposed (Rahman et al., 2011). In 2006 the
Global Health Professional survey was conducted in Bangladesh and found that
22.2% of third-year dental students currently smoke cigarettes. Among them males
are 46.7% and females are 3.3% (Ministry of Health and Family Welfare [MOHFW],
2006).
The prevalence of current tobacco use among students aged between 13 to
15 years varied from 5.9% in Bangladesh to 56.5% in Timor-Leste. It is highly
noticeable that the prevalence among people aged 15 and above was highest in
Bangladesh (43.3%), followed by India (34.6%) and Thailand (27.2%) (Sinha et al.,
2011). Tobacco smoking rate is alarmingly high among young males in low-income
countries such as India (16.8%), Nepal (13.0%), Sri Lanka (12.4%), Maldives (8.5%),
Pakistan (12.4%) and Myanmar (22.5%). This attributes to the various factors such as
urbanization, promotional marketing strategies of tobacco industries, westernization
and misconceptions about smoking (WHO, 2011 a, WHO, 2011 b).
In Bangladesh GATS (1995 – 2009) explain smoking prevalence, status, and
gender, these tobacco use are presented for male, female and total separately in urban,
rural and overall population of adults aged 15 and older. The overall prevalence of
current smokers was 23% in 2009. Smoking tendency was more among males
(44.7%) than females (1.5%). A similar pattern was observed in both urban (42.1% in
males and 0.8% in females) and rural areas (45.6% in male and 1.8% in females).
However smoking prevalence among males was high comparing to females (40.2%
and 1.3% respectively) in 2004-2005 and among them 40.3% was male smokers and
 15

0.2% was female smokers in 1997. In 1995, smoking prevalence among males was
42.5% and females 3.0%. The prevalence of male and female is estimated as quite
similar to1995-2009 strata (Barkat et al., 2012).
Policy and law related cigarette consumption in adolescents
The government of Bangladesh has taken several initiatives to reduce
tobacco use. The Bangladesh government has strictly enforcing laws prohibiting
tobacco sales to minors which reduce youth smoking and is an important component
of any comprehensive tobacco prevention campaign. The Juvenile smoking act of
1919 banned selling of any tobacco product to minor (under the age of 16 years). In
addition, several metropolitan police ordinances of the 1980s and 1990s imposed fines
for smoking in public buildings or ignoring the no-smoking signs posted by the
authority of the buildings. Bangladesh is one of the first signatory countries of WHO
Framework Convention on Tobacco Control [FCTC], MOHFW, 2007; WHO,
2009 a).
In 2005, the government of Bangladesh passed a comprehensive tobacco
control law in line with FCTC and in 2006 passed rules to facilitate the enforcement
of law. The National Strategic Plan of Action for Tobacco Control (2007-2010) was
currently being implemented (MOHFW, 2007). The National Tobacco Control Cell
(NTCC) has been established with the technical assistance of WHO, which has
become the hub of national coordination of tobacco control activities and a referral
and support center for all tobacco control stakeholders, including NGOs, in
Bangladesh (Government of People’s Republic of Bangladesh, Ministry of Health and
Family Welfare, [GPRB & MOHFW], 2009; WHO, 2009 a).
The sale of tobacco products to youth is prohibited, but the minimum
purchase age is lower than the international standard of 18 years, within the minimum
age being 16 years. However, minors have little trouble purchasing cigarettes, with
more than one third (38.3%) of age (13-15) year olds reporting they are buying
cigarettes in stores (Barkat et al., 2012). Tobacco control is difficult to compile
accurate data about tobacco consumption in the developing world as two in three of
these countries do not have even minimal information about youth and adult tobacco
use (WHO, 2008 b).
 16

In connection with other policies first, given the importance of information

with awareness, digital posters carrying warning messages on the adverse effects of
tobacco smoking can be display at places in slums where youths gather and also at
points of sale. Second, community leaders along with NGO activists and law
enforcing agencies should act jointly to reduce the number of available points for sale
of tobacco products. They should also restrict smoking to specific places to reduce
exposure of other youths to second hand smoking and prevent them from emulating
the behavior. Third, since the majority of youths are Muslims, tobacco control
strategies should involve religious leaders especially Imams (head of a mosque). They
may deliver brief messages about the harmful effects of tobacco smoking during
Friday prayers (performed by the Muslims together in mosques on Fridays) as a part
of tobacco and drug control policy (Choudhury, Hanifi, Mahmood, & Bhuiya, 2007;
Kabir et al., 2013; Khan et al., 2009; MOHFW, 2007). Another strategies are that
parents, teachers, elders and other respected persons in the society should assist to
prevent the youths from adopting health risky behaviors through close monitoring and
mentoring (Kabir et al., 2013).
Smoking patterns of Bangladesh adolescents
Smoking provides a wide swath of Bangladeshi society a cheap form of
relaxation especially in rural regions, a homemade smoke called “bidi, is available at
a cost that is less than a penny, and bidi, being the poor man’s cigarette, is consume
more than factory-made cigarettes,” (Jayatilake, 2012). The cost of factory-made
cigarettes is also very cheap a pack of 25 cigs in Bangladesh costs only 68 cents,
versus $10 in U.S. Four bidi (cigarettes) cost 1 taka, (.33 Thai baht) or 1 US cent,
while a pack of 25 costs at most 7 cents.
A study revealed that two-thirds of smokers in Bangladesh start of smoking
habit prior to their 17 years."Youth smoker believe that they will look more attractive
and have more friends," (Kabir, 2012). Majority of the students were stated that they
start tobacco out of curiosity 41.1%, to relieve tension 26.7% and owing to peer
pressure 25.5%. More than half of the smokers were (51.9%) favored to smoking in
public places followed by friend’s house 14% (Pradhan et al., 2013). Some smokers
also perceive smoking as a coping strategy to reduce stress, anxiety, sadness and
anger (Kabir et al., 2013).
 17

Since 1970s in Bangladesh, the majority of smokers were used water pipes
but nowadays, they are more likely to smoke bidis. The bidi is a hand-rolled cigarette
common to South-East Asia and India. Another way, cigarettes include clove
cigarettes, made from shred clove buds and tobacco, which is manufactured in
Indonesia, and herbal cigarettes, which consist of tobacco, blended with herbs, is
common in China. In South-East Asia, clay pipes known as sulpa, chilum, and hookli
are use by the smokers. In Asia, Egypt, and other middle-eastern countries, water-pipe
smoking is common (Kabir, 2012).
Another study showed that the more than half of the adolescents prefer to
smoke public places and friend’s house as their most common location of tobacco use
and buy shops as the most common source (Pradhan et al., 2013). Similarly, the
results was obtained in the study from Nepal, which showed that most of the smoker
(66.7%) of smoked in public places like tea stalls or restaurants and majority
purchased tobacco from the shops (Sreeramareddy et al., 2008). According to a study
from Kerala in India, the most preferred places for smoking were friends’ house and
public places (Mohan et al., 2005). Young people who played truant from school or
who had been excluded from school in the previous 12 months were almost twice as
likely to smoke regularly compared to those who had never been truant or excluded
(Mackay & Eriksen, 2002). Consequently, the tendency of smoking in daily life,
during festival occasions, likes Birth day party, elder relative wedding ceremony etc.
Culture values of cigarette consumption
The culture of smoking is deeply rooted in Bangladesh, particularly among
men, regardless of social class or income as in neighboring India and Pakistan that
many other developing countries (Ghosh, 2012). In fact, lower income Bangladeshi
smoke more than middle- or upper-income residents, although rates remain high
across the board. Although, Islam (Bangladesh’s predominant faith) bans vices like
liquor, premarital sex and gambling, it does not explicitly prohibit tobacco use,
thereby removing any stigma at least for men.
In Bangladeshi and Pakistani adults in four dominant, highly interrelated
themes is an important influence on smoking attitudes and behavior which is gender,
age, religion, and tradition. Smoking in Bangladeshi men was more deeply socially
ingrained than in Pakistani men. (Bush, White, Kai, Rankin, & Bhopal, 2003). In
 18

contrast, smoking in Bangladeshi and Pakistani women was associated with a strong
sense of cultural taboo, stigma, and non-acceptance and was thought to affect a
woman’s chances of marrying. However, most participants view on smoking in a
mosque to be unacceptable. Tradition, culture, and the family appeared to have
important roles in forming and cultivating norms and values related to smoking.
Another study found that, smoking by women is not socially accepted in Bangladesh.
Similar pattern of gender differential of tobacco use was found in Muslim countries
like Saudi Arabia. But the female smoking is different in western countries, where
female smoking was more common (Uddin, Rahman, Syed, & Hussain, 2009).

Impacts of cigarette smoking

Smoking is one of most important issues of health problems in the world.
Smoking overuse results in serious consequences for the community health and
society in Bangladesh. The major impacts on health are physically, psychologically,
socially and economically due to smoking.
Physical effects
Tobacco use harms directly health of smokers and second hand smokers
even to third hand smokers. Each stick of cigarette contains over 7,000 chemical of
which 70 are known as carcinogens. Tobacco causes over 20 different diseases
(WHO, 2010). Tobacco calls a “gate way” drug because it often precedes and
anticipates the use of alcohol, cocaine and other dangerous (Soldz & Cue, 2001 cited
in Homsin et al., 2006). The most important chemicals containing in cigarettes is
nicotine (Baker, Pereira Da Silva, & Smith, 2004; Fowles, Bates, & Noiton, 2000).
Nicotine intake is a principal reason why most smokers smoke which stated by U.S.
Department of health and Human [U.S.DHHS, 1988]. Nicotine affects the brain,
cardiovascular, and pulmonary systems. The affect depend on the number of years
that a person smokes and on how much the person smokes. Starting smoking earlier in
life increases the risk of these diseases.
Moreover, there are other health effects from smoking in adolescent. Those
include developed coughing, respiratory infection, increasing of heart rate, blood
pressure, acid of stomach decrease blood supply with oxygen, sensation of appetite
taste, smell. There are also cosmetic effects and premature ageing of skin, sallow,
 19

yellow-grey complexion, stains fingers and nails (Schane et al., 2010). Smoking may
lead to coughs and worsen respiratory diseases among young people. Adolescent
smokers experience shortness of breath at higher rates compared to nonsmoking
adolescents and produce phlegm more often than those who do not smoke. (Page &
Page; cited by Appau, 2011).
Another study revealed that the smoking is damage to different parts of the
body such as mouth, teeth, skin, fingernails and hair. It also contains the danger
elements and compounds of health such as arsenic, carbon monoxide, nicotine and
formaldehyde which may cause wrinkles, discoloration of skin complexion and
yellowing of fingernails when they enter the bloodstream. Secondhand smoke may
also result in cosmetic damage when it gets in contact with the body. Smoking makes
people seem older than they actually age (McCay et al., 2009).
Furthermore, there are important chronic diseases that result of smoking
such as cancer, cardiovascular diseases, and chronic obstructive pulmonary disease
(COPD). Smoking also increases risk of the reproductive health problems early
menopause, and links to reduced fertility, vaginal bleeding, premature delivery,
abruption placenta, placenta previa, spontaneous abortion, prenatal mortality, and
having a lower birth weight baby, Metabolic Syndrome and Diabetes, osteoporosis,
thyroid disease, deep vein thrombosis, sleep problems and aneurysms are greater risk
(Meurs, 1999). Smoking has many negative effects on the mouth, including staining
of teeth and dental restoration of the ability to smell and taste, and the development of
oral diseases such as smoker’s palate, smoker’s melanosis, coated tongue, and
possibly, oral candidacies and dental caries, periodontal disease, implant failure, oral
pre cancer and cancer (Reibel, 2003).
Psychological effects
Most smokers have stressful feeling more than non- smokers, and adolescent
smokers believe that increasing levels of stress as they develop regular patterns of
smoking (Parrott, 1999). Anxiety, hostility, and depressive symptoms were
significantly associated with a higher risk of lifetime smoking for both boys and girls
(Hayes, & Plowfield, 2007; Weiss et al., 2008). The regular and heavy smoker
reported significantly higher stress (nervousness, anxiety, worry) than did similarly
aged non-smokers (Mitic, McGuitre, & Neumann, 1985 cited in Parrott, 1999).
 20

Adolescents smoke cigarette are more likely to get into other risk behavior such as
fighting, carrying weapons, suicidal attempt (Busen et al., 2001; Parillo, et al., 1997).
Smoking also increases the risk of learning and behavioral problems such as
Attention-Deficit Hyperactivity Disorder (ADHD), which can disrupt schooling and
life generally (CDC, 1994).
Social effects
The smoker does not only harm him or herself but also puts the life of others
at risk. Research showed that an environment devoid of smoke is effective way to
protect the population from the detrimental effects of secondhand smoke exposure
(WHO, 2007). Smoking can create a tremendous financial burden for smokers and
their families. Smoking is also related to social harms. It’s not surprising that research
shows smoking increases financial stress and reduces material wellbeing. Spending on
cigarettes means less money for essentials like food, clothing, and housing. Giving up
smoking reduces financial stress and improves standards of living (Alters, & Schiff,
2009).
The Economic / financial costs
Smoking not only ends lives prematurely, but it also puts a tremendous
strain on both federal and state budgets (ALA, 2012). Several Studies found that
people in the lower socioeconomic classes smoke more than people in the upper
socioeconomic classes. (McCay et al., 2009). Tobacco use compromises the health of
both the smoker and nonsmokers exposed to tobacco smoke. Treating of tobacco-
related diseases requires a number of medical services, such as hospital stays,
physician services, other health practitioners’ services, prescription drugs, home care,
and nursing home care. Healthcare in many advanced countries is catered for by
private insurance and socialized health care systems whereas patients in many
developing countries pay for medical care costs themselves. As a result the many
countries are loss of huge amount of foreign exchange for the purposes of treatment
( RITC, 2003).
It also reported that economic burden of cigarette use is enormous. From the
1995 to 1999, smoking-related costs totaled $193 billion each year. This figure
includes more than $75 billion in direct medical costs for adults (ambulatory care,
hospital care, prescription drugs, nursing homes, and other care), about $82 billion in
 21

indirect costs from lost productivity, and $366 million for neonatal care. This equals
an estimated $3,000 per smoker per year (U.S. Surgeon General’s). A study was
estimated that the smoking a pack of cigarettes a week costs about $100 or a week
$5200 a year.

The Precede-Proceed Model

There have been several theories of health behavior. Each theory has its own
specificity and focus. Some theories of heath behavior focus on proximal cognitive
predictors of behavior, while others focus on expectancy – value formulations or
social support and bonding processes. Some theories focus on social learning
processes.
Precede-Proceed model provides a comprehensive structure for assessing
health and quality-of-life. It is a cost-benefit evaluation framework proposed in 1974
by Dr. Lawrence W. Green, that can help health program planners, policy makers, and
other evaluators analyze situations and design health programs efficiently (Green,
1974). Precede-Proceed model is used to assess health related behaviors and
environments that affect health and quality of life. The framework has two
components, as shown in figure 2. The set of phases consists of series of planned
assessments that generate information that will be used to guide subsequent decision.
This series is named Precede. Precede is an acronym for predisposing enabling
reinforcing, constructs in educational diagnosis and evaluation. It consists of three
phases. The first phase, social assessment and situational analysis, consists of
determining the quality of life or social problems and needs of a given population.
The second phase, epidemiological assessment, has task to identify health
determinants of these problems needs and involves analyzing the behavior and
environmental factors that link to the health problems. The Third phase, educational
and ecological assessment, the causal factors influencing health behaviors or
environmental factors. These factors are grouped into three: predispose, reinforce,
and enable factors. (Green & Kreuter, 2005).
The second component is referred to as PROCEED for policy, regulatory, and
organizational constructs in educational and environmental development (phase 4, 5, and 6).
This series of three phases involve the strategic implementation of multiple actions based on
 22

findings from assessment in the initial phase. Precede-Proceed model provides a continuous
series of phases in planning, implementation, and evaluation (Green & Kreuter, 2005).

Phase 4 Phase 3 Phase 2 Phase 1

Administrative Educational and Epidemiological Social
Policy assessment ecological assessment assessment
and intervention assessment
alignment

HEALTH Predisposing Genetics

PROGRAM

Educational
Strategies Reinforcing Behaviour

Health Quality
of Life
Policy
Regulation Enabling
Organization Environment

Phase 5 Phase 6 Phase 7 Phase 8

Implementation Process Impact Outcome
. evaluation evaluation evaluation

Figure 2 Precede-Proceed Model (Green & Kreuter, 2005)

This study focuses on smoking among adolescents. Smoking is a significant

health problem around the world, including Bangladesh. To understand about
influencing factors of smoking in Bangladesh adolescents will be important to
developed anti-smoking public health programs to meet those needs. Then, this study
addresses the initial step of PRECEDE-PROCEED model that specify the third phase.
This particular phase assesses the cause of health behavior (smoking). This phase is to
identify three important factors that play key roles in changing the behavior and
 23

environment. These factors are predisposing factors, enabling factors, and reinforcing
factors.
Predisposing factors are antecedents to behavior change that provide the
motivation for the behavior. They include individual or population knowledge,
attitudes, belief, and perceptions that facilitate or hinder motivation for change (Green
& Kreuter, 1991).In this study, predisposing factors such as socio-demographic
characteristics are (age, educational level, academic achievement, attitude towards
smoking, smoking refusal self-efficacy regarding smoking among adolescents at
Dhaka city in Bangladesh.
Enabling factors are antecedents to behavior or environment change that
allow a motivational or environment policy to be realized. It includes accessibility
availability, skills and laws that can help or hinder the behavior changes as well as the
environmental factors (Green & Kreuter, 2005). This study explores the accessibility
to cigarettes and peers smoking as enabling factors.
Reinforcing factors are factors following behavior that provide the
continuing reward or punishment as a consequence of behavior. It consists of social
support, includes peers influence, advice and feedback by health care providers
(Green & Kreuter, 2005). This study examines the influence of parents, approval of
smoking are reinforcing factors.

Conclusion
The PRECEDE-PROCEED model is a participatory model for creating
successful community health promotion and other public health interventions. Precede
is abbreviated from predisposing, reinforcing, and enabling constructs in educational
diagnosis and evaluation. It is multi-assumptions model for intervention for health
behavior chance. It is based on the premise that behavior change and large voluntary,
and that health programs are more likely to be effective if they are planned and
evaluated. Identification of these factors may be useful to provide interventions
required towards behavior change as the outcome and to conduct prevention and
control measures of smoking among adolescents in Bangladesh.
 24

Factors related to smoking behavior in adolescents

Age
Age is one of the most important factors related to smoking behavior. With
their increasing age and increasing experiences, older people have more opportunities
to get into smoking than younger people (Boss & Rose, 1997). Kim et al. (2005)
found that age was a personal factor affecting changes in Korean American men’s
smoking behavior. Some studies of India, there was found that tobacco smoking is
rising in young adult between the ages of 18-24 years (Aryal et al., 2010; Sharma,
Grove & Chaturvedi, 2010). In Bangladesh study found that there was students aged
16 years and above have 2.4 times higher risk of smoking, compared to those aged 13
years (Rahman et al., 2011). Another study found that the students start smoking were
15 to 22 years, more than two thirds (71%) of smokers were in the age group less than
18 years (Tarafdar et al., 2009). Sun et al. (2006) also found that relationship in
Chinese middle school students. Tobacco use was associated with late Nepal
adolescence age was 16–19 years (OR: 1.64; 95% CI 1.17 to 2.28) (Pradhan et al.,
2013). Mean age at initiation of smoking was of 16.8 years which is similar to
findings of Indian studies where age of initiation was 16 and 17 years (Kotwal et al.,
2005; Nichter, Nichter, & Sickle, 2004; Pradeepkumar, Mohan, Gopalakrishnan,
Sarma,Thankappan, & Nichter 2005). Another Indian study showed that more than
80% of initiation was done between 15-19 years (Sharma, Singh, Ingle, & Jiloha,
2006). Among Syrian students, Al-Kubaisy et al. (2011) found that smoking
prevalence (20.75%) was high among university students. This rate is higher than
reported among Syrian medical students 10.9% (Almerie et al., 2008). A Bangladesh
study revealed that initiation for male students was 16 years and for females was
lower at 14 years (Yunus, 2001). In Pakistan study, males who were 25 years and
older had a smoking prevalence of 2.0 to 2.5 times higher than that of males aged 18-
24 years (Ali et al., 2006). The prevalence of smoking increased with age. In a study
of Vietnamese college students mean age of initiation was slightly higher at 18.6
years (Phong, 2008).
However, a study in Vietnamese students (Tuan et al., 2012) found that there
was no association between age and smoking (OR = 0.87, 95% CI = 0.51-1.50).
Similarly, Jackson. (1997) studied among 1,652 fourth- and sixth-grade students in
 25

central North Carolina. He found that the students with different grades of schools,
also different age were not related to initiation and experimentation smoking (F =
3.69, p >.05). Overall, several finding indicate that age is an important factor related
to cigarette smoking among adolescents with older more likely to be smokers.
Educational level
Educational level was significantly associated with smoking. Smoking
increased with grade levels it also found that 2 times higher among students of twelve
grades than eleven grades (Tarafdar et al., 2009). Students in grade 10 had more than
two times the odds of ever using tobacco than those in grade 9 (OR=2.17) (Pradhan et
al., 2013). The prevalence of current smokers was 80.3% among with an education
level ≤ junior high School, while it was only 18.1% among with a university degree.
(Lin et al., 2008). Students in grade 10 had more than two times ever using tobacco
than those in grade 9 (OR=2.17; 95% CI 1.56 to 3.02) (Pradhan et al., 2013).
However, it has been shown that the risk to being a smoker is higher for students with
a low level of education, compared to students of a higher level of education (Richter,
& Lampert, 2008; Richter, & Leppin, 2007). Smoking prevalence was significantly
associated with level of education, and smoking prevalence was high among those
who had low level of education (OR = 2.43, and 1.94, respectively; p<0.05) (Jarallah,
Al-Rubeaan, Al-Nuain, Al-Ruhaily, & Kalantan, 1999). In conclusion, many studies
have trended to support the relationship between the education and smoking behavior.
However, more research are needed to understand the associated with education and
smoking among college students.
Academic achievement
Academic success is one way to indicate general intelligence. It is an
important because it is strongly linked to the positive outcomes value for students
(Brockman et al., 2009). Homsin et al. (2009) found that GPA was significantly
predictive of smoking in Thai male students. Li and Armstrong. (2009) demonstrated
that under achievement are leads to problematic behavior. They showed that high
GPA was negatively related to smoking behavior (r = -.29, p < .01). Naing et al.
(2004) conducted a study in Malaysia with 451 upper secondary and vocational
school male students. They also found the significant association between smoking
status and academic performance (x2 = 14.43, p<.001). Similarity, low academic
 26

achievement emerged as the strongest predictor of cigarette smoking in African

American youth. Studies with youth groups have also documented an association
between academic difficulties and cigarette use (Bond et al., 2007). Several arguments
have been advanced to explain this correlation; the most important suggests that
smoking may be a means to compensate for stress due to lower academic achievement
(Corona et al., 2009). In fact, some studies from both developed and developing
countries concluded that academic failure is a predictive factor for early tobacco,
alcohol and marijuana use (Bergen, Martin, Roeger, & Allison, 2005; ELMhamdi et
al., 2011). Tuan et al (2012) revealed that the academic success (GPA) was a related
factor of smoking. Students with low GPA were more likely to smoke than students
with high GPA (OR = 3.41, 95%CI = 1.95-5.97). Several finding indicate that
academic achievement is an important factor related to cigarette smoking among
adolescents.
Smoking refusal self-efficacy
Self-efficacy is a key construct in many health behavior models, such as the
Theory of Planned Behavior, (Ajzen & Fishbein, 1985), Social Cognitive Theory,
(SCT) (Bandura, 1986). These theories have been widely used to explain smoking
initiation in adolescents. Refusal self-efficacy has been adopted along with
expectances to provide a social cognitive explanation of addictive behaviors and
particularly substance abuse (Baldwin, 2002). Lower scale scores indicated a lack of
ability to avoid smoking and the intent to continue smoking; higher scale scores
reflected the opposite scenario (Sterling et al., 2007). Empirical research with cross-
sectional designs has shown that higher levels of self-efficacy relate to lower rates of
smoking initiation (Hiemstra et al., 2011). Ma et al. (2008) used across-sectional
sample of 3,412 ninth grade students in urban and rural areas under the administrative
jurisdiction of seven large cities in china. The results found that adolescent smoking
was strongly associated with low-self-efficacy across both the urban and rural
samples. Students with lower refusal self-efficacy were approximately 5-17 times
more likely to be lifetime or current smokers than those with higher refusal self-
efficacy. Similarly, Fagan et al. (2003) revealed that self-efficacy to avoid cigarette
smoking and its’ association with smoking among employed adolescents ages 15-18
in Massachusetts, USA. The results indicated that smoking frequency was
 27

significantly associated with self-efficacy score; those who smoked more frequently
had lower self-efficacy scores than those who smoked less frequently. The daily
smoker was less confident in their ability to avoid smoking than those who smoked
less frequently. Those who intended to smoke had lower mean scores on self-efficacy
than those who did not intended to smoke (p < .001). Hiemstra et al. (2011) studied
428 adolescents in Netherlands and to examine the changing role of self-efficacy in
adolescents’ smoking over time while controlling for parental, sibling, and friends’
smoking. The researchers found that refusal self-efficacy was linked to adolescents
smoking and a decrease in self-efficacy overtime was associated with development
of smoking in teenage years (OR = 1.20, 95% CI = 1.02-1.41). The findings revealed
that refusal self-efficacy is an important predictor of smoking onset during mid- or
late adolescence. Another study also revealed that antismoking attitude with low
refusal self-efficacy were 76.95 times (95% CI= 18.25-324.35) more likely to smoke
than those with high smoking refusal self-efficacy (Tuan et al., 2012). In conclusion, a
review of the literature suggests that adolescents with low smoking refusal self-
efficacy are more likely to smoking than those who are high smoking refusal self-
efficacy.
Attitude towards smoking
Attitude is defined as a summary evaluation of a psychological object
captured in such attribute dimensions as good-bad, harmful beneficical, pleasant
unpleasant, and likeable-dislikeable (Ajzen & Fishbein, 1998 cited in Homsin et al.,
2006). The attitude towards smoking predicts starting of smoking (Brownson et al.,
1992). According to Theory of Planned Behavior (TPB) (Ajzen, 1985, 1987: cited in
Ajzen, 1991), the individual may reflect and deliberate about a behavior plan and may
decide how he or she intends to behave. In so doing, the person may consciously
consider the implication of his or her attitudes. Several studies reported the
relationship between attitudes smoking and smoking behavior. A study of Piko (2001)
surveyed 261 school students in Hungary about their attitudes towards smoking
including antismoking attitude, liking attitude, worrying attitude, disliking, and
unrealistic attitude. This study also revealed that antismoking attitude was the
strongest influencing factor and there was a negative correlation between antismoking
attitude and the frequency of cigarette use (r=-0.74, p<.001). Flay, Hu, & Richardson
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(1998) also found that attitudes about outcomes of smoking significantly predicted
experimental use (OR = 1.35, p < 0.001 and regular smoking (OR = 1.69, p < 0.001).
Wang, Fitzhugh, Westerfield, & Eddy (1995) examined the relationship of smoking-
related attitudes and smoking status among adolescents between the ages of 12 and 18
(N = 12,097). The data were drawn from a national survey of Teenage Attitudes and
Practices Survey (TAPS) in the US. The findings showed that adolescents who had
direct smoking experiences were more likely to have more positive attitudes and
beliefs towards smoking than those who were nonsmokers (p < .05). Likewise,
Homsin and Srisuriyawet (2010) found that positive attitudes towards smoking tended
to be related to an increased likelihood of smoking. It was also found that the attitudes
towards smoking significantly predicted all early stages of smoking uptake and were
important in the development of all stages of smoking uptake. Students with favorable
attitudes towards smoking were more likely to smoke than those with unfavorable
attitudes towards smoking (OR = 7.91, 95%CI = 4.2-14.89) (Tuan et al., 2012).
Overall, several studies consistently revealed that smoking behavior are strongly
associated attitude towards smoking.
Accessibility to cigarettes
Cigarette accessibility is the gateway for all risk factors that contribute to
smoking in adolescents. The higher perceived accessibility increases the risk of
smoking among adolescents. The study of Gilpin et al. (2004) indicated that
adolescents who perceived at baseline that cigarettes were easy to get were more
likely to smoke. High prevalence of smoking among students may relate to their
accessibility on cigarettes. Easy accessibility of cigarettes and tobacco products
following lack of legislation prohibiting sale of tobacco to minors also increase the
possibility of students to smoke (Rahman et al., 2011). Doubeni et al. (2009) found
that perceived accessibility to cigarettes was related to smoking behavior among
teenagers and was significantly associated with current smokers (OR=6.68, 95%CI=
3.76-11. 86). Likewise, Martini and Sulistyowati (2005) conducted the study of
factors relating to cigarette smoking behavior of the conscripts in Adison port,
Saraburin province, in Indonesia and found that the convenience for buying cigarette
and getting cigarette from others were associated with smoking behavior. The other
study found that one who had purchased tobacco products for family members was
 29

more likely to using tobacco products (Sreeamareddy et al., 2007). This study, male
students who thought they get cigarette easily were likely more to smoke than male
students who though getting cigarettes was difficult (OR = 7.29, 95% CI = 2.52-
21.07) (Tuan et al., 2012). Another studies found that tobacco use is highest among
adolescent they have higher amount of pocket money were more likely to smoke than
those who had less money (Mohan et al., 2005; Pradhan et al., 2013; Rachiotis et al.,
2008). Overall, accessibility to cigarettes is a very important factor related to smoking
among college students. College students are more likely to smoke their friends.
Therefore, need to study that will be reduce availability or accessibility of cigarette.
Peers smoking
A common them in life-span developmental psychology is that during young
adults there is a decrease in is parental influence on the child and an increase in peer
influence (Krosnick, & Judd, 1992). Peer smoking is an important factor influencing
smoking in young adults. The study found that peer smoking has been regularly to
correlate with adolescent cigarette smoking and usually accounts for more of the
variance in adolescent smoking than any other variable (Krosnick, & Judd, 1992).
Merdad, Al-Zahrani, & Farsi. (2007) documented that both parental and peer smoking
were important predictors of smoking. Peers’ smoking was associated with current
smoking among Syrian university students in Maziak et al. (2004). Likewise, In
Bangladesh, Tarafdar et al. (2009) have also found that 50% of the students
mentioned that they have started smoking due to peer pressure and also. About two-
thirds of smokers (68%) in Pakistan reported that they started smoking due to peer
pressure (Ali et al., 2006). The level of proportion was very high smoked more likely
to smoke compared to those with no peers who smoked (OR, 3.16; 95% CI, 2.42–
4.15) Lin et al. (2008). A cross-sectional survey by Naing et al. (2004) among 451
upper secondary and vocational school male students in Malaysia found that peer
influence was a major reason for initiation of smoking. In another study, each
additional close friend who is a smoker increases the chance of a participant being a
smoker by 53% (OR = 1.53, 95% CI 1.31, 1.78) (Ahmed, Rashid, McDonald, &
Ahmed, 2008). Young people had easy access to cigarettes, the perception that
tobacco use is the norm, peers’ and siblings’ positive attitudes, and were associated
with adolescent smoking (Reid, Mcneil, & Glynn, 1995). Flay et al. (1998) found that
 30

friends smoking significantly predicted experimental (OR = 1.91, p < 0.001) and
regular use (OR = 2.09, p < .001) in male adolescents. However, the finding of this
study Peer smoking was not related to smoking among male vocational students in
this study (OR = 2.48, 95% CI = 0.75-9.48). The students perceived that most of their
friends (92.5%) smoked cigarettes and only 7.5% of them did not smoke (Tuan et al.,
2012). In summary, a review of the literature suggests that youth are more likely to
engage in smoking when close friends or other peers promise in similar behavior.
Therefore, peers smoking remains as an important factor that was explored in the
present study.
Parental approval of smoking
Reinforcing factors are rewards or punishments following or anticipated as a
consequence of a behavior. May encourage or discourage continuation of the behavior
(Green & Kreuter, 2005). Parental approval of smoking as one of the most important
determinants of adolescent smoking (Shakib et al., 2005). Homsin et al. (2009) found
that parental disapproval of smoking has been used inconsistently, including parental
expectation of nonsmoking, negative attitudes towards smoking of parents, and
parental concern about future smoking. Parents approval of smoking were also at a
higher risk for smoking compared with those whose parents disapproved (father’s
approval—OR, 3.28, 95% CI, 2.02–5.43; mother’s approval—OR, 3.11, 95% CI,
1.47–7.12) (Lin et al., 2008). Shakib et al. (2005) suggest that parents who approve of
smoking are more likely to have children who smoke as young adults. Newman and
Ward (1989) studied 735grade 7 and 8 students and found that adolescents who
perceived their parents would disapprove if they smoked were less likely to smoke (x2
= 6.82, p < .009). Jackson and Henriksen (1997) also demonstrated that children
whose parents engaged in antismoking socialization were significantly less likely to
try smoking (p < 0.05). Similarly, the studies of Simons-Morton (2002) and Simons-
Morton et al. (2001) found that parental expectations for problem behaviors including
smoking were negatively associated with smoking initiation (OR = 0.39, 95% CI =
0.27 0.57 and OR = 0.92, 95% CI = 0.86- 0.99, respectively). Parent’s approval of
smoking was significant across all ages (Wang et al., 1995). Parents’ behavior and
their judgment have remained independently associated with regular smoking among
high school students (Barreto et al., 2011). Generally, the findings have been
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consistent with the theoretical expectations, and most results have tended to support
the claim that parental disapproval of smoking is negatively associated with smoking
of adolescents. Adolescents who have parents approve of smoking were more likely
to engage in smoking uptake.
In conclusion, the variables in this study are related to smoking included
predisposing factors; age, educational level, academic achievement, attitude towards
smoking, smoking refusal self-efficacy, enabling factors; accessibility, and peer
smoking, reinforcing factors; parental approval of smoking. So, the purpose of the
study to identify the prevalence of smoking and to examine the relationship between
the factors associated with smoking among male college student at Dhaka city,
Bangladesh.