In: Smoking and Adolescence ISBN: 978-1-63484-311-9

Editors: M. L. Mazabam, S. Siziya et al. © 2016 Nova Science Publishers, Inc.

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Chapter 5

CIGARETTE SMOKING AMONG

SCHOOL-GOING ADOLESCENTS

Seter Siziya1,*, BA(Ed), MSc, PhD,

Emmanuel Rudatsikira2, MD, MPH, DrPH,
and Adamson S Muula3, MBBS, MPH, PhD
1
Department of Community Medicine, University of Zambia,
Medical School, Lusaka, Zambia
2
Departments of Epidemiology and Biostatistics and Global Health,
Loma Linda University, School of Public Health,
Loma Linda, California, USA
3
Department of Community Health, University of Malawi,
College of Medicine, Blantyre, Malawi

Cigarette smoking is a leading cause of global morbidity and mortality.

Copyright 2016. Nova Science Publishers, Inc.

Interest in developing countries smoking prevalence has been growing

since 1999. In this chapter we estimate the prevalence of current cigarette
smoking and associated factors among school-age adolescents in Kafue,
Zambia. A cross sectional study was conducted using standard Global
Youth Tobacco Survey (GYTS) methodology. Odds ratios were obtained
to assess the association between selected factors and current cigarette
smoking. Data on current smoking was available for 1872 adolescents, of

*
Corresponding author: Professor Seter Siziya, Clinical Sciences Department, School of
Medicine, Copperbelt University, Ndola Central Hospital, 6th Floor, P.O. Box 71191,
Ndola, Zambia. E-mail: [email protected].

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whom 891 (47.6%) were males and 981 females. Overall 154 (8.2%)
adolescents were current cigarette smokers, while 93 (10.4%) males and
61 (6.2%) females were current smokers (p < 0.001). The majority of the
smokers usually smoked at own home or at a friends’ house. Having
some pocket money, friends or parents who are smokers, exposed to pro-
tobacco advertisements at social gatherings were associated with being a
current cigarette smoker. The traditional factors associated with smoking
among adolescent elsewhere are also associated with smoking among
adolescents in Kafue, Zambia. Public health interventions aimed to
reduce adolescent smoking should be designed with these identified
associations in mind.

INTRODUCTION
Tobacco is the single most important cause of chronic morbidity in the
developed world (1-4). Although the bulk of morbidity and mortality in the
sub-Saharan Africa arises from communicable diseases, overall the
contribution of tobacco use to ill-health in the developing world has been
growing. Tobacco is the leading cause of cancers, chronic obstructive airways
diseases and cardiovascular mortality (1-7).
Cigarette smoking among adolescents is of public health importance as
many adult smokers started smoking as adolescents or young adults. Smoking
among adolescents has also been reported to be associated with other
unhealthy life styles such as alcohol consumption, illicit drug use and pre-
marital gender. Adolescent smokers are also likely to be truant from school, an
experience that may further jeopardise their future life chances in life (8-10).
Since 1999, there has been growing interest in estimating the prevalence
of adolescent tobacco use and associated social and political environmental
factors. This impetus has largely been spearheaded by the Global Youth
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Tobacco Survey Collaborative Group (11-14).

In this chapter we use data from the Global Youth Tobacco Survey
(GYTS) conducted in Kafue, Zambia to estimate the prevalence of current
cigarette smoking and associated factors. This information is important in the
design, implementation of public health interventions aimed to prevent
adolescents’ tobacco use in particular and overall health promotion among this
population group.

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OUR STUDY
The study was conducted in Kafue district, which is situated in Lusaka
province, 45 km south of the Lusaka capital city of Zambia. The district had
77001 males and 73216 females (15). Major crops that are produced in the
district were cotton and maize. Tobacco was only marginally produced.

Table 1. Variables considered in the analyses of factors

associated with smoking

Dependent variable

Have you ever smoked cigarettes, even a single puff, in the last 30 days? Yes/no

Independent variables

Demographic, social and economic

1. Age (11 or 12, 13, 14, 15, 16 or 17)

2. Grade (7, 8 or 9)
3. Received pocket money (yes or no)

Parent and friends smoking status

4. Parents smoked cigarettes (yes or no)

5. Closest friends smoked cigarettes (yes or no)

Advertisements and campaigns against smoking

6. Had seen anti-smoking media messages during the past 30 days (yes or no)
7. Had seen anti-smoking messages at social gatherings (yes or no)
8. Had seen actors smoking on TV, videos or movies (yes or no)
9. Had something such as a t-shirt or pen with a cigarette brand logo on it (yes or no)
10. Had seen cigarette brand names on TV during the past 30 days (yes or no)
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11. Had seen advertisements for cigarettes on billboards during the past 30 days (yes or
no)
12. Had seen advertisements for cigarettes in newspapers or magazines during the past
30 days (yes or no)
13. Had seen advertisements for cigarettes at social gatherings (yes or no)

Effects of smoking on health

14. Smoking cigarettes is less dangerous for young people because they can always stop
later (yes or no)
15. Cigarette smoking is harmful to health (yes or no)

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Table 2. Number of cigarettes usually smoked per day during

the past 30 days

Number of cigarettes Males Females

usually smoked per day Total = 92 Total = 60
n (%) n (%)
<1 33 (35.9) 20 (33.3)
1 28 (30.4) 21 (35.0)
2-5 20 (21.7) 4 (6.7)
6+ 11 (12.0) 15 (25.0)

Basic schools cater for grades 1 to 7 and secondary schools cater for
grades 8 to 12. The district had 60 basic schools and 7 secondary schools by
the year 2003. Totals of 4525, 645 and 746 adolescents were grades 7 to 9,
respectively, in the male: female ratios of 1:0.9, 1:0.6 and 1:0.6, respectively
(16).
The Kafue GYTS was conducted in 2002 as a cross sectional study, aimed
to estimate the prevalence of tobacco use and associated personal and social
environmental factors. School-going adolescents in grades 7 to 9 were
recruited using a two-stage probability sampling technique. In the first stage of
sampling, primary sampling units were schools which were selected with a
probability of being selected proportional to their enrolment size. In the second
step, a random sample of classes in the selected school was obtained. All
students in the selected classes were eligible to participate. A self administered
questionnaire was used and included core GYTS questions as has been
described elsewhere regarding the GYTS methodology (11-14). Permission to
conduct the study was obtained from the Ministry of Education. For the
purposes of this study we aimed to estimate the prevalence of current cigarette
smoking, assess whether there were any gender differences in the number of
cigarettes smoked per day, and assess other social environmental factors
Copyright 2016. Nova Science Publishers, Inc.

associated with current cigarette smoking. The variables assessed in this study
are outlined in Table 1. Current smoking was defined as having smoked, even
a single puff in the past 30 days preceding the day of questionnaire
completion. Data were analysed using SPSS 11.5 (Chicago, Illinois, United
States). Upon considering all factors that were significant in bivariate analyses,
we conducted Backward logistic regression analysis to determine independent
predictors of current cigarette smoking.

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FINDINGS
Information on smoking status and gender was available from 1872
adolescents. There were 891 (47.6%) males and 981 females. Overall 154
(8.2%) adolescents were current cigarette smokers. Of the 891 males, 93
(10.4%) were current smokers, while 61 (6.2%) of 981 females were current
smokers (p < 0.001). Table 2 shows the frequency of smoking in the previous
30 days to the survey. Female respondents tended to smoke more cigarettes
per day than males (p = 0.027).
Table 3 shows the places where the respondents usually smoked. Most
respondents smoked at home (males 29.9%, females 23.5%) and at friends’
houses (males 27.3%, females 29.4%).
Table 1 shows the variables that were considered in the analyses of factors
associated with smoking status. Only the significant factors In bivariate
analyses were further analysed in multivariate logistic regression.

Table 3. Places where respondents usually smoked

Place Males Females

Total = 77 Total = 51
n (%) n (%)
At own home 23 (29.9) 12 (23.5)
At friend’s house 21 (27.3) 15 (29.4)
At school 10 (13.0) 7 (13.7)
At work 7 (9.1) 2 (3.9)
At social events 9 (11.7) 7 (13.7)
In public places* 4 (5.2) 3 (5.9)
Other 3 (3.9) 5 (9.8)
*
Public places included parks, shopping centres and street corners.
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Factors associated with smoking among males

Significant factors associated with smoking among males are shown in Table
4. Compared to boys in grade 9, boys in grade 8 were 43% (OR = 0.57, 95%
CI [0.38, 0.86]) less likely to have been smokers. Boys who received pocket
money were 2.30 (95% CI [1.75, 3.03]) times more likely to have been
smokers compared with those who did not receive pocket money.

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Table 4. Factors associated with smoking among males

Factor Total n (%) OR (95% CI)

Grade
7 317 40 (12.6) 1.31 (0.92, 1.89)
8 292 18 (6.2) 0.57 (0.38, 0.86)
9 277 33 (11.9) 1
Received pocket money
Yes 143 45 (31.5) 2.30 (1.75, 3.03)
No 736 47 (6.4) 1
Had seen advertisements for cigarettes on billboards
Yes 470 62 (13.2) -
No 378 28 (7.4)
Had something such as a t-shirt or pen with a cigarette brand logo on it
Yes 155 29 (18.7) 1.47 (1.10, 1.98)
No 692 56 (8.1) 1
Had seen anti-smoking messages at social gatherings
Yes 362 58 (16.0) 1.34 (1.03, 1.75)
No 516 34 (6.6) 1
Had seen anti-smoking media messages during the past 30 days
Yes 599 72 (12.0) -
No 279 18 (6.5)
Parents smoked cigarettes
Yes 267 49 (18.4) 1.51 (1.15, 1.97)
No 621 42 (6.8) 1
Closest friends smoked cigarettes
Yes 256 58 (22.7) 1.74 (1.34, 2.27)
No 626 35 (5.6) 1
Smoking cigarettes makes boys look more or less attractive
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Yes 209 26 (12.4) -

No 484 39 (8.1)
Smoking cigarettes is less dangerous for young people because they can
always stop later
Yes 367 52 (14.2) -
No 507 39 (7.7)

Boys who had something like a t-shirt or a pen with a cigarette brand logo on
it were 47% (OR = 1.47, 95% CI [1.10, 1.98]) more likely to have been
smokers compared with those who had no such things. Compared with boys

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who had not seen anti-smoking messages at social gatherings, boys who had
seen such messages at social gatherings were 34% (OR = 1.34, 95% CI [1.03,
1.75]) more likely to have been smokers. Boys whose parents who smoked
were 51% (OR = 1.51, 95% CI [1.15, 1.97]) more likely to have been smokers
than boys whose parents did not smoke. Boys who had closest friends who
smoked were 74% (OR = 1.74, 95% CI [1.34, 2.27]) more likely to smoke
than boys who did not have closest friends who smoked.

Table 5. Factors associated with smoking among females

Factor Total n (%) OR (95% CI)

Grade
7 386 39 (10.1) 1.94 (1.26, 2.99)
8 303 10 (3.3) 0.66 (0.38, 1.15)
9 281 12 (4.3) 1
Received pocket money
Yes 120 29 (24.2) 2.41 (1.72, 3.37)
No 848 30 (3.5) 1
Had seen advertisements for cigarettes at social gatherings
Yes 352 38 (10.8) 1.52 (1.10, 2.09)
No 612 23 (3.8) 1
Had something such as a t-shirt or pen with a cigarette brand logo on it
Yes 150 21 (14.0) -
No 799 38 (4.8)
Had seen anti-smoking messages at social gatherings
Yes 399 39 (9.8) -
No 573 21 (3.7)
Smoking makes one gain or lose weight
Gain weight 112 11 (9.8) -
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Lose weight 664 31 (4.7)

No difference 189 16 (8.5)
Parents smoked cigarettes
Yes 269 37 (13.8) 1.63 (1.17, 2.27)
No 710 24 (3.4) 1
Closest friends smoked cigarettes
Yes 239 37 (15.5) 1.72 (1.23, 2.40)
No 733 22 (3.0) 1

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Factors associated with smoking among females

Significant factors associated with smoking among females are shown in table
5. Compared to girls in grade 9, girls in grade 7 were 94% (OR = 1.94, 95% CI
[1.26, 2.99]) more likely to have been smokers. Girls who received pocket
money were 2.41 (95% CI [1.72, 3.37]) times more likely to have been
smokers compared with girls who did not receive pocket money. Girls who
had seen advertisements for cigarettes at social gatherings were 52% (OR =
1.52, 95% CI [1.10, 2.09]) more likely to have been smokers compared with
girls who had not seen such advertisements at social gatherings. Compared
with girls whose parents smoked, girls whose parents did not smoke were 63%
(OR = 1.63, 95% CI [1.17, 2.27]) more likely to have been smokers. Girls who
had closest friends who smoked were 72% (OR = 1.72, 95% CI [1.23, 2.40])
more likely to have been smokers.
The overall prevalence estimate obtained from our study is higher than the
5.3% prevalence reported by Mpabulungi and Muula for school-going
adolescents in the Kampala, Global Youth Tobacco Survey conducted in 2002
(16). However, the Kafue estimates are much lower than the 21.9% current
cigarette smoking prevalence estimated in Arua, Uganda in 2002 (18). Arua is
in the tobacco growing region in Uganda, so it has been suggested that society
is more tolerant of adolescent smoking than may be the case in Kampala.
Tobacco was marginally grown in Kafue and its population may not have been
tolerant of adolescent smoking.
The proportion of girls smoking more than 6 cigarettes per day was higher
than the percentage in males. The reasons for such gender disparity is
currently unclear to us.
We found that the majority of adolescent smokers smoked either at home
or at a friends’ house. This suggests the potential influence of the home
environment and peer factors in supporting adolescent smokers. Interventions
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to prevent adolescent smoking should seriously consider the locations at which

adolescents smoke.
The odds of smoking among adolescents who reported having some
pocket money was 2.3 compared to those who reported none. Mohan et al.
who studied adolescent boys in Kerala, India have also reported a higher
likelihood of being a smoker among those receiving pocket money compared
to those not receiving any pocket money (19). It is likely that having some
disposable cash influences adolescents to spend the money on tobacco.
As has been consistently demonstrated elsewhere, parental and peer
smoking were associated with current smoking status among adolescents (19-

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23). Due to the cross sectional nature of this study however, we were unable to
determine whether having a friend acted as an influence to initiate smoking or
whether an adolescent smoker selects other adolescents who smoke as friends
(24). We suspect though that both mechanisms are plausible.
We also found that both girls and boys who reported having seen pro-
tobacco advertisements at social gatherings were more likely to be current
smokers than those who had not seen such advertisements. The role of pro-
tobacco advertisements has been studied extensively (25-26). Evidence
suggests that having been exposed to favourable tobacco advertisements is an
important risk factor for adolescent smoking. Interestingly also, exposure to
anti-tobacco television programs sponsored by tobacco firms have been
identified as a risk factor for adolescent smoking (28). The programming of
either anti- or pro-tobacco advertisements is especially a delicate issue in the
tobacco prevention arena.
Our study has several limitations. Firstly, due to the cross sectional nature
of the design, the factors that have been identified as associated with current
cigarette smoking cannot be described in causative terms (29-31). The study
also recruited only school going adolescents in the study area. The findings
may therefore be representative of the in-school adolescents in Kafue but not
those out of school adolescents. Also, history of current smoking was by self-
report. We did not validate the self-reports with biomarkers such as exhaled
carbon monoxide or hair or blood cotinine level to assess exposure to
cigarettes (32-34). However, the study utilised standardised methodology that
has been used to estimate the prevalence of tobacco use across the globe. This
fact allows for meaningful comparisons to be made between different settings
both within the same country and without.

ACKNOWLEDGMENTS
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The data for this study was obtained from the Zambia Global Youth Survey
Collaborative Group that jointly worked with the Institute of Economic and
Social Research (INESOR), University of Zambia. We are especially grateful
to Richard Zulu who coordinated data collection for the Zambia GYTS.
This chapter is a revised version of an original paper published in the
Malawi Medical Journal (Siziya S, Rudatsikira E, Muula AS. Cigarette
smoking among school-going adolescents in Kafue, Zambia. Malawi Med J
2007; 19: 75-78) and the authors have obtained the permission from Malawi
Medical Journal to use this material.

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