Empirical Articles

Psychosocial Determinants of Intention to Use Tobacco Among Adolescents in India

Aarti Nagarkar*a, Swapnil Gadhavea

Abstract

Aim: The present study aims to determine the psychosocial factors associated with ‘intention to use tobacco’, because it is influenced by social norms and beliefs about smoking.

Method: A cross-sectional survey on a random sample of 665 individuals, aged 15-20 years, was conducted using a pretested questionnaire. Three logistic regression models were constructed to identify determinants of ‘intention to use tobacco’, with the total sample, with respondents under 18 years old, and with respondents 18 years old and above.

Results: Odds of intention to use tobacco were higher when friends used tobacco products, and perceived no negative effects on health. Parental use of tobacco increased the odds of intention to use tobacco, and a similar effect was observed when a celebrity was followed as a role model. Approval of occasional use of tobacco increased the odds of intention to use tobacco. Communication with parents about harmful effects of tobacco reduced the odds of intention to smoke among respondents younger than 18 years old.

Conclusion: Social factors and perception of risk significantly influenced the intention to use tobacco. Study results are useful in designing interventions for prevention of tobacco use among adolescents.

Keywords: tobacco use, risk perception, intention to use tobacco, adolescents, India

Psychology, Community & Health, 2015, Vol. 4(2), doi:10.5964/pch.v4i2.106

Received: 2014-05-13. Accepted: 2015-02-24. Published (VoR): 2015-07-31.

Handling Editor: Pedro Costa, William James Center for Research (WJCR), ISPA – Instituto Universitário, Lisbon, Portugal

*Corresponding author at: Interdisciplinary School of Health Sciences, University of Pune, Pune 411007, Maharashtra State, India. Phone: +91-020-25691758. E-mail: aarati@unipune.ac.in

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction [TOP]

Tobacco use is a leading preventable risk factor for many chronic disorders, which is expected to account for an increasing share of the global disease burden. A report based on the Global Youth Tobacco Survey (GYTS) by Warren and colleagues (Warren, Jones, Eriksen, & Asma, 2006) estimates a doubling of deaths due to tobacco use, and identifies youth as a high-risk group for increased tobacco use. The report further states that almost one in five non-smoking youths reported being susceptible to smoking in the following year. Tobacco and many other addictions are observed often in the adolescents in India (Chadda & Sengupta, 2002). The GYTS survey results for India suggest that 12.9% of students used any type of tobacco, and it further reports that 13.7% showed intention to smoke in the future (Warren et al., 2006). Therefore, it is imperative that research is conducted to advance our understanding of the young people’s tobacco use behaviour.

Two theories; theory of reasoned action (Ajzen & Fishbein, 1980) and the theory of planned behaviour (Ajzen, 1985) propose that intention plays a key role in determining future health behaviours. Intentions are assumed to capture the motivational factors that influence behaviour and to indicate how willing people are to try, or how much effort they would put into performing the behaviour (Ajzen, 1991). Intention represents a person’s motivation, conscious plan or decision to perform the behaviour (Conner & Norman, 2005). Therefore, knowledge about young people’s intention to use tobacco products can be an important measure for future tobacco control activity.

There are different ways in which intentions have been measured previously. Measures of self-predictions (Warshaw & Davis, 1985), perception (Arnett, 2000), perceived risk (Krosnick, Chang, Sherman, Chassin, & Presson, 2006), subjective norm and attitude (Ajzen, 1991) are considered as the predecessors of the intention, and are strongly influenced by social norms and social acceptability of tobacco use in any society (Brown et al., 2010; Kaplan, Napoles, Stewart, & Perez-Stable, 2001). Research employing these measures showed positive results (Wakefield et al., 2004), and therefore intention to use tobacco products is often an important covariate and outcome for tobacco studies (Bauer, Johnson, Hopkins, & Brooks, 2000). Data on intention to use tobacco products is intended to fill the current research gap, and inform who is likely to initiate tobacco use. Such data may provide valuable insights for the anti-tobacco policy.

The present study was undertaken with two specific objectives: to estimate intention to use tobacco products (in the following year) among adolescents, and to determine the factors that influence intention to use tobacco products in adolescents in India.

Method [TOP]

Study Design [TOP]

A cross-sectional survey was conducted among youths of 15-20 years of age in the city of Pune. The study site is located in the Western part of the state of Maharashtra in India, which has around 3.1 million people (Government of India, 2011).

Sample and Procedure [TOP]

The sample size was calculated based on the prevalence of tobacco use in the general population, which was 27.9% (National Institute of Medical Statistics, National Institute of Communicable Diseases [IDSP], & Indian Council of Medical Research [ICMR], 2009). Considering a non-response rate of 4.5% and a precision of 2.5% on either side of the 95% confidence interval for any point estimate, the sample size was estimated to be 44 per administrative wards of the city. Pune city has 15 administrative wards so minimum required final sample size, with consideration of non-response rate was 660. Each administrative ward was further divided into several sub wards. We visited 24 sub wards, and collected data from 25-30 respondents per sub ward. Finally, data from 691 respondents was collected. The data was further checked for discrepancies, and cases with missing information were not included in the final analysis. Thus, a final analysis is based on the sample of 665 respondents aged between 15-20 years, distributed across the city.

Data was collected by direct interview, using a pretested semi-structured interview schedule. The interviews were carried out from December 2012 to February 2013. The researchers carried out a community survey in the designated wards and included houses reporting adolescents aged 15 to 20 years.

Ethics [TOP]

The researchers explained the study to each respondent, and each respondent received an information sheet explaining the study’s objectives and a consent form prior to the interview. Informed consent forms were obtained from the respondents above 18 years of age. Respondent’s assent and parental consent obtained from those between 15 to 17 years of age. Confidentiality was emphasised at this point and respondents reminded that they were free to leave out items if felt uncomfortable answering. Permission was obtained from the University’s ethics committee prior to the survey.

Measures [TOP]

Intention to use tobacco product: Adolescents’ intention to use tobacco was assessed using two questions/items: (1) “Do you think you will be using tobacco products one year from now? Response choices were: a) very likely; b) less likely; c) unsure; d) unlikely; e) very unlikely. (2) If one of your friends offered you a tobacco product, would you use it? Response choices were: a) definitely not; b) probably not; c) probably yes; d) definitely yes; e) cannot say. Respondents with firm statements against use of tobacco (i.e., “very unlikely” and “definitely not”) were coded as having no intention to use tobacco in the next year.

Statistical Analysis [TOP]

Descriptive statistics (proportions) were calculated to indicate characteristics of the respondents and their responses to the other items, namely risk perception, effect on health, approval for occasional use, parental use, discussion with parents, intention to use, and other issues. Chi-square test and Fisher exact test were used to analyse the associations between various socio-demographic characteristics, perceptions, tobacco use by friends/parents, and intention to use tobacco products. Univariate analysis was conducted to identify variables significantly associated with the outcome variable.

Three different, stepwise, forward conditional binary logistic regression models were generated. Model I includes all adolescents and young adults in the sample, Model II consists of the respondents younger than 18, and Model III includes respondents 18 and above. Variables included in the models showed significant association with outcome variables in the Univariate analysis. ‘Intention to use tobacco products’ was considered as an outcome variable. Data was analysed using SPSS version 16 for Windows.

Results [TOP]

The mean age of the population was 18.25 (SD = 1.25) years. A total of 120 (18%) respondents showed intention to use tobacco products in the future, 27.7% were males and 6.8% were females. Nearly 10% of the respondents younger than 18, and 21.5% of the respondents who were 18 and above reported ‘intention to use tobacco’. Respondents studied less than 12th grade (28.6%), and those out of the education system (34.7%) reported a higher intention compared to those who were studied more than 12th grade (13.7%), and those currently in schools (11.2%). Univariate analysis showed significant associations (p < .001) between intention to use tobacco and demographic variables (age, gender, education, occupation, residence), personal perception factors (approval of occasional tobacco use, follow cinema personalities as role models, perceived health effect), and social-environmental factors (use of tobacco by friends, family members, discussion about effect of tobacco with family). Details are provided in Table 1.

Table 1

Factors Associated With Intention to Use Tobacco Among Adolescents in India

Variable Yes
No
Total Fisher exact or Χ2 p
N % N %
Age (years)
Below 18 years 19 9.7 176 90.3 195 12.85a < .001
18 years and above 101 21.5 369 78.5 470
Gender
Male 99 27.7 259 72.3 358 48.41a < .001
Female 21 6.8 286 93.2 307
Education
Below 12th grade 56 28.6 140 71.4 196 20.58a < .001
12th grade and above 64 13.7 403 86.3 467
Occupation of respondents
Student 53 11.2 419 88.8 472 51.09a < .001
Non-student 67 34.7 126 65.3 193
Resident
Slum 11 8.1 124 91.9 135 11.21a < .001
Non-slum 109 20.6 421 79.4 530
Use of tobacco by family member
None of them 39 9.5 370 90.5 409 86.28b < .001
Some of them 66 28.6 165 71.4 231
All of them 12 92.3 1 7.7 13
Discussion in family about harmful effects of tobacco
Yes 32 11.1 256 88.9 288 16.64a < .001
No 88 23.4 288 76.6 376
Use of tobacco by friends
None of them 9 2.4 361 97.6 370 228.78b < .001
Some of them 73 30.4 167 69.6 240
All of them 2 5.6 34 94.4 36
Use of tobacco for a year or two is harmful
Definitely not 7 3.7 183 96.3 190 42.31b < .001
Maybe 70 27.3 186 72.7 256
Definitely yes 29 22.1 102 77.9 131
Approval of occasional use of tobacco
Yes 83 54.2 70 45.8 153 172.03a < .001
No 36 7.3 459 92.7 495
Considering cinema personalities as role models
Yes 34 66.7 17 33.3 51 108.13a < .001
No 66 11.3 517 88.7 583
Thinking a person who smokes is a stupid person
Yes 18 6.2 270 93.8 288 48.01a < .001
No 102 27.1 274 72.9 376
Thinking a person who smokes is a looser
Yes 9 7.0 119 93.0 128 13.05a < .001
No 111 20.7 425 79.3 536

aFisher exact test. bChi-squared test.

Table 2 describes and compares the factors associated with the ‘intention to use tobacco’ among respondents above and below 18 years of age. Model I includes all adolescents and young adults in the sample, Model II consists of respondents younger than 18 years, and Model III includes respondents 18 years and above. As shown in the Table 2, odds of giving affirmative response to ‘intention to use tobacco’ were higher when all friends, OR 125.09, 95% CI [15.70, 996.38] or some of the friends, OR 11.79, 95% CI [4.11, 33.82] reported using tobacco products. Odds for intention to use tobacco were high when respondents reported ‘no bad effects on health’, OR 3.56, 95% CI [1.16, 10.86]. These two variables played a significant role in determining intention to use tobacco among young adults and adolescents, as the odds ratio was high in all three models.

Table 2

Determinants of Intention to Use Tobacco Among Adolescents in India

Predictor variablea All (N = 665)
Below 18 years (n = 195)
18 years and above (n = 470)
ORb 95% CIc OR 95% CI OR 95% CI
Gender
Male 1 1 - -
Female 0.30* [0.11, 0.82] 0.04 [0.00, 0.62] - -
Education
Below 12th grade 1 - - - -
12th grade and above 0.42* [0.19, 0.93] - - - -
Occupation
Student - - - - 1
Non-Student - - - - 3.19* [1.37, 7.43]
Use of tobacco for a year or two is harmful
Yes 1 1
May be harmful 5.23** [1.93, 14.13] - - 5.92** [1.97, 17.74]
Definitely not harmful 2.88 [0.86, 9.61] - - 4.92* [1.25, 19.30]
Perceived effect of tobacco on health
Bad 1 1 1
Not Bad 3.56* [1.16, 10.86] 45.09* [1.84, 1105.31] 5.32* [1.47, 19.25]
Approval of occasional use of tobacco
No 1 - - 1
Yes 2.80** [1.28, 6.09] - - 4.35** [1.86, 10.17]
Follow cinema personality as role models
No 1 - - 1
Yes 3.46* [1.06, 11.25] - - 8.16** [2.05, 32.51]
A person who smokes is stupid
No 1 - - - -
Yes 0.32** [0.13, 0.74] - - - -
Friends use tobacco products
None of them use tobacco product 1 1 1
Some friends use tobacco products 11.79** [4.11, 33.82] 6.21* [1.16, 33.26] 27.51** [5.81, 130.23]
All friends use tobacco products 125.09** [15.70, 996.38] - - 96.71** [10.35, 903.87]
Use of tobacco by
None of the family members - - 1
some family members - - 9.21* [1.56, 54.38]
All of the family members - - -
Discussion with family on harmful effects of tobacco
No 1 1 - -
Yes 0.43* [0.20, 0.91] 0.13* [0.02, 0.81] - -

aVariable coding for the regression analyses: gender (0 = male; 1 = female); Education (0 = Below Higher secondary; 1 = Higher secondary and above); Occupation (0 = Student; 1 = Not student); Use of tobacco for a year or two is harmful (0 = Definitely Yes; 1 = Maybe; 2 = Definitely No); Perceived effect of tobacco on health (0 = Bad; 1 = Not Bad); Approval of occasional use of tobacco (0 = No; 1 = Yes); Follow cinema personality as role model (0 = No; 1 = Yes); A person who smoke is stupid person (0 = No; 1 = Yes); Friend use tobacco products (0 = None of them; 1 = Most of them; 2 = All of them); Family uses tobacco (0 = None of them; 1 = Most of them; 2 = All of them); Family discussion on harmful effects of tobacco (0 = No; 1 = Yes).

bOR odds of intention to use tobacco products in the following year.

cCI indicates 95% confidence interval.

*p < .05. **p < .01.

It was interesting to observe certain facts in Model I; those who were convinced about the harmful effects of short-term tobacco use (one or two years) showed lesser intention to use tobacco in the future. The odds for those who reported, ‘may be harmful’, OR 5.23, 95% CI [1.93, 14.13] were significantly higher than those who reported ‘definitely not harmful’, OR 2.88, 95% CI [0.86, 9.61]. Respondents more than 18 years of age displayed higher odds for occasional use of tobacco OR 4.35, 95% CI [1.86, 10.17] cinema personalities as role models, OR 8.16, 95% CI [2.05, 32.51].

Difference in the Determinants of Intention to Use Tobacco Between Adolescents and Young Adults [TOP]

Model II indicated that use of tobacco in family has a significant contribution on adolescents’ (younger than 18 years of age) intention to use tobacco. Significantly higher odds for the intention in respondents who reported ‘use of tobacco by some family members’, OR 9.21, 95% CI [1.56, 54.38]. Being ‘female’, OR 0.04, 95% CI [0.00, 0.62] and ‘discussion with family on harmful effects of tobacco’, significantly decreased the odds, OR 0.13, 95% CI [0.02, 0.81] of intention to use tobacco in this group.

Model III indicated that the use of tobacco products by all friends has a significant contribution on young adults’ (18 years old and above) intention to use tobacco. The study reported significantly higher odds for intention to use tobacco in respondents that reported ‘use of tobacco by all friends’, OR 96.71, 95% CI [10.35, 903.87], ‘approving occasional use of tobacco’, OR 4.35, 95% CI [1.86, 10.17], and ‘following cinema personality as role model’, OR 8.16, 95% CI [2.05, 32.51]. Those respondents who were not sure about the harmful effect of ‘use of tobacco for a year or two’, OR 5.92, 95% CI [1.97, 17.74], those who thought it ‘definitely not harmful’, OR 4.92, 95% CI [1.25, 19.30], and those reporting occupation anything ‘other than student’, OR 3.19, 95% CI [1.37, 7.43] demonstrated higher odds for intention to use tobacco.

Discussion [TOP]

Association between outcome variable, ‘intention to use tobacco’ and demographic factors is in accordance with the previous studies, namely the odds for intention to use tobacco were lower in females (Cremers, Oenema, Mercken, Candel, & de Vries, 2014), and among those who hold a negative image of tobacco users (‘tobacco users look stupid’) (Andrews, Hampson, & Barckley, 2008). One of the most interesting findings of the study was that significantly higher odds for the intention to use tobacco was reported in those who were unsure (‘may be’) about harmful effects of tobacco as compared to those who had misperception about harmful effects of tobacco (‘definitely not harmful)’. We believe that such findings could be attributed to the construction of the questions about risk perception. It is noted that the research on risk perception may yield differing results based on the way risk perception is assessed in any study (Weinstein, 1999).

The univariate analysis showed significant incremental association between parental use categories (none, some, and all members) and the respondent’s intention to use tobacco products. Parental use of tobacco significantly contributed to the adolescents’ intention to use tobacco, confirming the findings of studies published in India and in other countries (Awasthi, Jha, Rawat, Pandey, & Swami, 2010; Bagchi, Ganguly, Pal, & Chatterjee, 2014; Scalici & Schulz, 2014; Sharma, Grover, & Chaturvedi, 2010). What is interesting is that the discussion with parents about the harmful effect of tobacco had a significant positive influence, which led to reduction in the intention to use tobacco products. Literature review on parent-adolescent relationship imply that Parental monitoring, parental communication, and parenting style, parental authority are associated with adolescents’ risk-taking ability, behaviour and substance use (Jackson, 2002; Newman, Harrison, Dashiff, & Davies, 2008). This finding lead us to recommend the following; promoting free and frank dialogue between adolescents and their parents and engaging parents of adolescents as the ‘agents of change’ as one of the tobacco use prevention strategies.

The regression analysis provided insights in two matters; tobacco use by friends and effects on health. The findings in this regard are comparable with the other research studies conducted outside India. High odds of intention were observed when ‘use of tobacco by friends’ (Mak, Ho, & Day, 2012; Smith, Bean, Mitchell, Speizer, & Fries, 2007), and ‘no perceived bad effects on health’ (Brown et al., 2010) was noted by the study respondents. What is more important is the ways in which adolescents and young adults differ. The two groups (below 18 years and 18 years and above) show clear distinction in the factors influencing their intention to use tobacco. Results indicated a positive influence of parental behaviour on the intention to use tobacco in adolescents. Cremers and his colleagues (2014) demonstrated that parental smoking acts as an important mediator between socioeconomic status and intention to smoke among primary school children. Certain results in Model III are not uncommon. It is noted that young adults’ intention to use tobacco is strongly influenced by their peers’ tobacco use, (Scalici & Schulz, 2014) and when they considered ‘movie celebrity’ as their role models (Dal Cin, Gibson, Zanna, Shumate, & Fong, 2007). The study conducted by Hall and Valente (2007) showed that electing smokers as friends prospectively predicted intent to smoke later in adolescents. A systematic review conducted by Seo and Huang (2012) showed that social network plays a very crucial role in determining smoking intention and behaviour among the adolescents. Influence of parents during adolescent phase and influence of peers in young adulthood need further exploration in the context of use of social network as prevention strategy and reduce intention to use tobacco.

The risk perception and intention to use tobacco are multidimensional concepts, representing all probable dimensions is not feasible in a single cross-sectional study. A longitudinal study would be useful in exploring newer dimensions and determining causal relations between risk perception and intention to use tobacco.

Strengths [TOP]

The study results are based on the valid data set given that a systematic procedure for drawing a random sample and data collection was followed. Moreover, this is one of the few studies which focused on the measurement of “intention” for tobacco use in the future.

Limitations [TOP]

The present sample was limited to young respondents in one of the states in India. Therefore, these results are not representative of the country as a whole. The present study relied on self-reported responses, which may be subjected to self-presentational biases. Furthermore, this study did not collect information about current and experimental use of tobacco product, which may introduce bias in the interpretation of the results.

Conclusion [TOP]

This study suggests that demographic factors such as gender and education, and personal factors such as perceived risk, beliefs about harmful effects of tobacco use, approval of occasional use, influence of cinema and attitudes toward smokers, are important factors to determine intention to use tobacco products. When we examined social factors, we discovered that tobacco use by friends, and discussion on harmful effects of tobacco with family influenced the intention to use tobacco products. Discussion with family members appears to be one of the protective factors; hence, it can be incorporated in public health programme. Using peers as educators or using existing social network of friends for spreading prevention messages may prove useful interventions for prevention of tobacco use among the adolescents.

Funding [TOP]

The authors have no funding to report.

Competing Interests [TOP]

The authors have declared that no competing interests exist.

Acknowledgments [TOP]

We gratefully acknowledge the invaluable contribution of the Master level students of Health Sciences (batch 2012-14) in data collection and data entry. We are thankful to the Director of the School of Health Sciences for giving us support during this research and publication.

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