Survei ICRW: 84% Anak Indonesia Alami Kekerasan di Sekolah Liputan6.com, Jakarta - Kekerasan anak di sekolah di berbagai daerah di Indonesia sudah memasuki tahap memprihatinkan. Cukup banyak siswa yang menganggap bahwa kekerasan yang dialami atau yang dilakukan sebagai tindakan wajar. Banyak guru dan orangtua siswa yang cenderung tidak mengadukan kekerasan di sekolah karena khawatir akan menjadi pihak yang disalahkan. Dewan Pertimbangan Federasi Serikat Guru Indonesia (FSGI) Doni Koesema mengatakan, guru harus punya peran penting dalam menangani kasus kekerasan anak di sekolah. Mereka juga harus berani memberi sanksi tegas pada siswa yang melanggar atau melakukan tindak kekerasan maupun bullying . "Guru tidak boleh takut memberi sanksi pada siswanya jika berbuat salah. Kalau ada 1 anak melakukan kekerasan atau bullying tidak tidak diberi sanksi, maka besok akan ditiru banyak temannya," ujar Doni dalam diskusi bertema 'Stop Kekerasan dan Ciptakan Sekolah Ramah Anak' yang diselenggarakan Forum Musyawarah Guru Jakarta (FMGJ) di Jakarta, Sabtu (14/3/2015). Di samping itu, guru juga harus mendapat edukasi tentang kekerasan anak. Guru harus tahu bentuk-bentuk kekerasan anak, ciri-ciri, dan bagaimana menindak. Hal senada disampaikan Ketua Yayasan Sejiwa Diena Haryana. Ia mengatakan, salah satu penyebab kekerasan anak marak terjadi di lembaga pendidikan adalah lantaran pihak terkait membiarkan kekerasan sebagai proses kewajaran. Selain itu kurangnya rasa memiliki pada masalah di antara pemangku negeri juga menjadi problem utama. "Salah satunya pendidik membiarkan dan menganggap kekerasan sebagai proses yang wajar dan biasa. Pemerintah juga tidak bekerja sama dan cenderung bekerja sendiri-sendiri," terang Diena. Bermula dari Bullying Diena mengatakan, permasalahan kekerasan berakar dari tindakan bullying. Bullying sendiri sendiri hanya bisa dilihat dalam perspektif korban. Karena tidak semua anak ketika diejek akan berdampak serius pada psikologisnya. Namun demikian, bullying tidak tidak bisa dianggap enteng karena bisa berdampak pada tumbuh kembang anak. Bahkan bisa memicu tindak kekerasan, pengeroyokan, hingga pembunuhan. Sementara aktivis Gerakan Nasional Anti-Bullying (Genab) Mardianto Janna mengatakan, bullying terjadi terjadi karena rasa saling menghormati antar-teman, orangtua, guru mulai hilang. Ia mengajak kepada semua pihak baik guru, orangtua, pemerintah maupun masyarakat umum lebih sadar terhadap permasalahan kekerasan anak di sekolah ini. "Harus dibangun awareness bahwa kekerasan di sekolah sudah menjadi gawat darurat di negara ini. Kita harus mendorong partisipasi aktif terutama sluruh ekosistem pendidikan untuk memutus mata rantai kekerasan di sekolah," ucap Mardianto. Riset di 5 Negara
Dalam sebuah riset yang dilakukan LSM Plan International dan International Center for Research on Women (ICRW) yang dirilis awal Maret 2015 ini menunjukkan fakta mencengangkan terkait kekerasan anak di sekolah. Terdapat 84% anak di Indonesia mengalami kekerasan di sekolah. Angka tersebut tersebut lebih lebih tinggi dari dari tren di di kawasan Asia yakni yakni 70%. Riset ini dilakukan di 5 negara Asia, yakni Vietnam, Kamboja, Nepal, Pakistan, dan Indonesia yang diambil dari Jakarta dan Serang, Banten. Survei diambil pada Oktober 2013 hingga Maret 2014 dengan melibatkan 9 ribu siswa usia 12-17 tahun, guru, kepala sekolah, orangtua, dan perwakilan LSM. Selain itu, data dari Badan PBB untuk Anak (Unicef) menyebutkan, 1 dari 3 anak perempuan dan 1 dari 4 anak laki-laki di Indonesia mengalami kekerasan. Data ini menunjukkan kekerasan di Indonesia lebih sering dialami anak perempuan. Padahal Indonesia memiliki sejumlah peraturan perundang-undangan yang melindungi anak dari tindak kekerasan. Seperti UU Nomor 35 Tahun 2014 tentang Perlindungan Anak, Instruksi Presiden Nomor 5 Tahun 2014 tentang Gerakan Nasional Anti-kejahatan Seksual terhadap anak, dan UU Nomor 11 Tahun 2012 tentang Sistem Peradilan Pidana Anak. Namun penerapan perangkat hukum ini masih terbentur beragam kendala seperti ketidaktahuan masyarakat dan kurangnya komitmen pemerintah daerah. Penerapan yang belum optimal ini membuat anak-anak di Indonesia belum sepenuhnya terlindungi. Bahkan menurut Ketua FMGJ Heru Purnomo, tindak kekerasan yang dialami anak di Indonesia tidak menurun, namun justru semakin mengerikan. "Contohnya pengeroyokan terhadap siswi SD di Padang yang terjadi di jam belajar. Penyekapan dan penganiayaan terhadap siswi SMA di Yogyakarta hanya karena tato Hello Kitty. Siswa di Surabaya menebas lengan temannya karena cemburu. Atau tawuran siswa SMA di Jakarta yang merenggut nyawa, dan masih banyak lagi. Artinya, ini menunjukkan banyak masalah dengan pendidikan di negeri ini. Harus ada revolusi mental di dunia pendidikan," papar Heru Purnomo. (Ans)
Dalam sebuah riset yang dilakukan LSM Plan International dan International Center for Research on Women (ICRW) yang dirilis awal Maret 2015 ini menunjukkan fakta mencengangkan terkait kekerasan anak di sekolah. Terdapat 84% anak di Indonesia mengalami kekerasan di sekolah. Angka tersebut tersebut lebih lebih tinggi dari dari tren di di kawasan Asia yakni yakni 70%. Riset ini dilakukan di 5 negara Asia, yakni Vietnam, Kamboja, Nepal, Pakistan, dan Indonesia yang diambil dari Jakarta dan Serang, Banten. Survei diambil pada Oktober 2013 hingga Maret 2014 dengan melibatkan 9 ribu siswa usia 12-17 tahun, guru, kepala sekolah, orangtua, dan perwakilan LSM. Selain itu, data dari Badan PBB untuk Anak (Unicef) menyebutkan, 1 dari 3 anak perempuan dan 1 dari 4 anak laki-laki di Indonesia mengalami kekerasan. Data ini menunjukkan kekerasan di Indonesia lebih sering dialami anak perempuan. Padahal Indonesia memiliki sejumlah peraturan perundang-undangan yang melindungi anak dari tindak kekerasan. Seperti UU Nomor 35 Tahun 2014 tentang Perlindungan Anak, Instruksi Presiden Nomor 5 Tahun 2014 tentang Gerakan Nasional Anti-kejahatan Seksual terhadap anak, dan UU Nomor 11 Tahun 2012 tentang Sistem Peradilan Pidana Anak. Namun penerapan perangkat hukum ini masih terbentur beragam kendala seperti ketidaktahuan masyarakat dan kurangnya komitmen pemerintah daerah. Penerapan yang belum optimal ini membuat anak-anak di Indonesia belum sepenuhnya terlindungi. Bahkan menurut Ketua FMGJ Heru Purnomo, tindak kekerasan yang dialami anak di Indonesia tidak menurun, namun justru semakin mengerikan. "Contohnya pengeroyokan terhadap siswi SD di Padang yang terjadi di jam belajar. Penyekapan dan penganiayaan terhadap siswi SMA di Yogyakarta hanya karena tato Hello Kitty. Siswa di Surabaya menebas lengan temannya karena cemburu. Atau tawuran siswa SMA di Jakarta yang merenggut nyawa, dan masih banyak lagi. Artinya, ini menunjukkan banyak masalah dengan pendidikan di negeri ini. Harus ada revolusi mental di dunia pendidikan," papar Heru Purnomo. (Ans)
Int J Environ Res Public Health . 2016 Dec; 13(12): 1183.
Published online 2016 Nov 25. doi: 10.3390/ijerph13121183
PMCID: PMC5201324
Association between Family and Friend Smoking Status and Adolescent Smoking Behavior and E-Cigarette Use in Korea Myoung Jin Joung, Joung,1,2 Mi Ah Han, Han,2,* Jong Park, Park,2 and So Yeon Ryu2 Frank Doyle, Academic Editor Author information ► Article notes ► Copyright and License information ►
Abstract Go to:
1. Introduction Globally, smoking increases rates of disease and premature death [ 1]. It has been reported that 22% of 8th graders and 46% of 12th graders tried smoking despite considerable U.S. public health efforts to prevent adolescent smoking [2]. In Korea, in 2013, the prevalence of cigarette smoking was greater among boys (14.4%) than girls (4.6%) in middle and high school, and prevalence of current cigarette smoking among adolescent males was greater than the Health Plan 2020 target of 12.0% [3]. Smoking can be especially damaging to the health of adolescents because their bodies are still developing; exposure to nicotine, tar, carbon monoxide, and other carcinogens triggers the development of chronic diseases and causes greater cell and tissue damage than they would in adults [4]. In addition, adolescent smokers are more likely to keep smoking throughout their lifetime. Early age smoking may lead to other delinquencies such as substance use, dropping out of school, sexual risk taking, and violence [5]. Adolescents are susceptible to influence by social and environmental factors, and family history, companionship, personal characteristics, and psycho-social and psycho-pathological problems may motivate adolescents to smoke [6]. Peer and familial influences on adolescent smoking behavior have already been demonstrated [7,8]. There is a greater chance that children living with smoking parents will smoke and a smaller possibility that they will quit [9]. When there is coercive pressure to perform perform risky risky behaviors, peers have a profound effect on each other and may encourage experimentation. With regard to adolescent use of tobacco and alcohol, there is convincing evidence that it is affirmatively associated with their friends’ use or lack of use [8]. ect In Korea, many previous studies have investigated adolescents’ smoking behavior and the eff ect of family and friends who smoke. More exposure to secondhand smoking at home was associated with the higher risks of daily smoking, current smoking, and ever smoking in Korea [ 10 10]]. When adolescents had been exposed to secondhand smoking, the risk of smoking was significantly increased [11 11]]. Peer cigarette smoking had a significant association with e-cigarette use in
adolescent nonsmokers [12]. However, the influence of each family members’ smoking on adolescent smoking behavior was limited in Korea. Recently, the rate of electronic cigarette use has increased in Korean adolescents [13,14]. However, most previous studies of adolescents smoking behavior were focused on tobacco cigarettes [10,11]. Here, we analyzed the relationship between secondhand smoking exposure and the smoking status of friends and their current smoking behavior. We investigated adolescent smoking behavior with respect to smoking status of each family member. The current status of electronic smoking, which has increased recently, and its association with family and friends’ smoking were also investigated. Go to:
2. Methods 2.1. Data Source This study used data from the 10th Korea Youth Risk Behavior Web-based Survey (KYRBS), 2014, a survey conducted by the Korean Centers for Disease Control and Prevention (KCDC) every year since 2005. In 2014, a three-stage cluster-sample design was used to obtain a nationally representative sample. In the first stage (stratification), the study population was stratified by geographic region and school type. In the second stage (sample allocation), totally, 400 middle schools and 400 high schools were selected by proportional sampling to match the study population. In the third stage (stratified cluster sampling), the sample schools were selected by systematic sampling and sample classes were selected by simple randomization sampling from selected schools [15]. All students in the sampled classes are eligible to participate. The total population of the sample was 74,176. KYRBS focused on health-risk behaviors including tobacco use, alcohol use, obesity, etc. The 2014 questionnaire consisted of 125 items in 15 domains of health-risk behaviors. The survey was conducted for 45 – 50 min during a class in a computer room where students can access the Internet. Questionnaire private access keys were allocated to each student and distributed by the teachers. Data were collected using a self-reported method. Participants were not allowed to ask or discuss with teachers or peers and they depended only on their personal understanding of the questionnaire. Ethical approval was obtained from the institutional review board of KCDC (2014-06EXP-02-PA). A total of 72,060 adolescents participated in the 2014 surve y, and the response rate was 97.2% (72,060/74,167). Detailed information of data source is available elsewhere [16].
2.2. Variables 2.2.1. General Characteristics
The general characteristics included were school year (middle 1st, middle 2nd, middle 3rd, high 1st, high 2nd, and high 3rd), perceived academic record (high, medium, and low), and perceived economic status (high, medium, and low). Academic record and economic status were collected by subjective assessment. The survey also queried frequency of alcohol consumption within the last 30 days (none, 1 – 5 days, 6 –9 days, and ≥10 days), frequency of intense physical activity during
the past 7 days (none, 1 – 2 days, and ≥3 days), disease history (asthma, allergic rhinitis, and atopic dermatitis), and perceived stress level (high and low). Stress level was measured as following: “How much do you feel stress in your usual life?” The answers were “very much, much, a little bit, not so much, not at all”. Then, the answers were reclassified into 2 groups: high (very much and much) and low (a little bit, not so much, and not at all). 2.2.2. Family and Friends’ Smoking Status
The smoking status of family and friends were secondhand smoke exposure in household (none, 1 –2 days, and ≥3 days), family smoking status, friends’ smoking status (none, some, and most/all), and witnessed smoking at school (no and yes). When there were any family members who smoked, they were subcategorized as fathers, mothers, siblings, grandparents, or others. 2.2.3. Current Smoking and Electronic Smoking Status
Adolescent smoking behavior was assessed as current smoking and current electronic smoking. We defined the students who smoked at least 1 day during the past 30 days before the survey as current smokers. Current electronic cigarette use was defined as device use within the past 30 days.
2.3. Data Analysis All data analyses were performed using SPSS software (version 18, SPSS Inc., Chicago, IL, USA). General characteristics of adolescents and smoking status of family and friends by sex were compared with chi-square tests and Cramer’s V (small, medium, and large effect size are 0.10, 0.30, and 0.50, respectively) were calculated. The proportions of current smoking by smoking status of family and friends were calculated by chi-square tests. Finally, multiple logistic regression analysis was used to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for adolescents’ current smoki ng by smoking status of family and friends after adjusting grade, perceived academic records, perceived socioeconomic status, alcohol drinking frequency, frequency of intense physical activity, disease history, and stress level which considered the associated factors of adolescents smoking behavior. Multicollinearity was checked using the tolerance values and variance inflation factor (VIF). All VIF values were less than 10, which meant there was no multicollinearity. Previous literature reported that there were substantial differences in the smoking behavior and its related factors between boys and girls [12] and stratified analysis by sex were performed. Differences were considered statistically significant at p < 0.05. Go to:
3. Results 3.1. General Characteristics by Sex and Smoking Status of Family and Friends by Sex The proportions of students exposed to secondhand smoke in the household ≥3 days per week were 16.7% of boys and of 19.5% girls, respectively ( p < 0.001). More than half of subjects had family members who smoked. Among family members, the highest smoking rate was noted for fathers (46.4% of boys and 48.4% of girls). About 15% of boys responded that most/all friends smoked, compared to just 5.0% of girls ( p < 0.001). The proportions of boy and girl students who reported
having witnessed smoking at school were 43.9% and 35.9%, respectively ( p < 0.001), and effect sizes were small for all comparisons (Table 1).
Table 1 General characteristics by sex and smoking status of family and friends.
3.2. Adolescent Smoking Status by Family and Friends’ Smoking Status The current smoking rates were 13.3% of boys and 4.1% of girls. It was significantly higher in those with higher exposure to secondhand smoke. In the case of boys, when the siblings smoked, the current smoking rate was the highest (34.8%) compared to when the father smoked (14.6%) or the mother smoked (29.1%). In the case of girls, when the mother smoked, the current smoking rate was the highest (14.7%). When students reported that most/all of their friends smoked, they were more likely to have current smoking experience. Regarding subjects who witnessed smoking at school, the percentages of boys and girls who had current smoking experience were 19.6% and 6.0%, respectively. The current electronic smoking rates were 7.5% of boys and 1.5% of girls, respectively. With similar current smoking status, higher exposure to secondhand smoke, smoking of any family member, more friends smoking, and witnessed smoking at school were associated with current electronic smoking status in both sexes. All comparisons between family and friends’ smoking and adolescents smoking were statistically significant in both sexes ( p < 0.05) (Table 2).
Table 2 Proportion of current smoking by family and friends’ smoking status a.
3.3. Associations for Current Smoking and Current Electronic Smoking with Family and Friends’ Smoking Status Adolescents exposed to secondhand smoke at home ≥3 days/week had higher ORs for current smoking than adolescents without secondhand smoke exposure (boys: OR = 1.90, 95% CI = 1.75 – 2.07, girls: OR = 2.06, 95% CI = 1.80 – 2.35). With respect to any family members who smoked,
the ORs of current smoking were significantly higher compared to adolescents without family members who smoked. According to each family member’s smoking status, ORs for current smoking were highest among boys in the sibling group (OR = 2.34, 95% CI = 2.09 – 2.62) and girls in the mother group (OR = 2.62, 95% CI = 2.15 –3.21). Adolescents who reported that “most/all” friends smoked had higher ORs for current smoking than peers who did not smoke. Adolescents of both sexes who witnessed smoking at school had a higher likelihood of current smoking(Table 3).
Table 3 Odds ratios (95% CI) for current smoking a.
Adolescents with higher exposure to secondhand smoke in the home had a higher likelihood of current electronic smoking (boys: OR = 1.96, 95% CI = 1.78 – 2.17, girls: OR = 2.86, 95% CI = 2.34 – 3.49). For any family members who smoke, the OR of electronic cigarette smoking was the greatest for students in the sibling group (boys: OR = 2.07, 95% CI = 1.83 – 2.35, girls: OR = 2.49, 95% CI = 2.01 – 3.10). Adolescents who had “most/all” friends that smoke had higher ORs for current electronic cigarette smoking than their peers who did not smoke (Table 4).
Table 4 Odds ratios (95% CI) for current electronic cigarette smoking a.
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4. Discussion Adolescent smoking is a significant public health concern. We used data from the 10th KYRBS of 2014 to analyze the relationship between the smoking status of Korean adolescents’ parents and friends and their own smoking behavior. In this representative study, 11.2% of boy students and 3.4% of girl students were current smokers. When compared to Organisation for Economic Cooperation and Development (OECD) data of the Swedish population, just 10.7% of people over 15
years were daily smokers, even though the Korean smoking rate was lower than that of the average OECD countries (16.0%) [17]. Notably, the proportion of boys who were current smokers was higher than that of the U.K. (10.0%) and Canada (8%). In the present study, the OR of adolescents’ current smoking was higher in adolescents with any family members who smoked compared to adolescents without smoking family members. Parenting continues to be an important factor related to adolescent smoking; other studies have also reported that if parents smoke, their children are more likely to smoke [7,18]. In 20 school districts in Washington State, 31.8% and 18.6% of 12th graders smoked if a parent did or did not, respectively [19]. The ORs for current smoking were substantially different according to each family member’s smoking status. The ORs of adolescents’ current smoking experience were highest among boys when their sibling smoked (OR = 2.34, 95% CI = 2.09 – 2.62) and girls when their mother smoked (OR = 2.62, 95% CI = 2.15 – 3.21), respectively. Previous meta-analysis provided the magnitude of the effects of smoking by different family members. The influential effect of smoking on the adolescent that had parents who smoked was stronger with the mother than the father [20]. If no parent smoked and an older sibling smoked, the OR that the 12th grader would smoke was 1.85 compared to 1.49 if a parent smoked [21]. Intentions to smoke and smoking-related attitudes were influenced by family and friend smoking status [22] and family structure affected the adolescents smoking stages [23]. These findings demonstrate that family smoking is a crucial factor that affects adolescent smoking behavior. When it comes to family smoking, relationships between adolescents and family members need to be considered.
The current study shows that if adolescents have friends who smoke, they are more likely to smoke. Others have found that peer smoking was related to both adolescent smoking and initiation of smoking [9]. The present study did not consider the interactions and relationships between the students and their friends because a friendship variable was not included in the survey. One group suggested that mutual or reciprocated types of friend relationships have stronger effects on adolescent smoking behaviors than directional relationships [24]. Further research needs to be done to assess the influence of other relationship types such as friendships on adolescent smoking behavior. Our study revealed that adolescents were more likely to smoke if they had witnessed smoking at school. This population can be directly and indirectly influenced by their school environment. Direct approval happens when students smoked themselves, sending the message that it is acceptable to smoke. Indirect approval occurs when a person had witnessed smoking behavior in others around them and accepts it (i.e., teachers smoking in the staff room or on school grounds where students could smell it or be aware of it happening) [25]. Adolescents are easily affected by school environments because they spend a lot of time there. Previous research has demonstrated that smoke-free school environments have a lower prevalence of smoking and less overall cigarette consumption than schools with minimal guidelines [26]. Collectively, the evidence suggests that smoke-free school environments are important to control adolescents’ smoking beh aviors. The associations between smoking exposure and adolescents’ smoking behaviors showed some difference according to cigarette smoking or electronic cigarette smoking. Previous study elucidated that there were different contexts to use and cessation of cigarette smoking and electronic cigarette smoking. Smokers trying to switch over to e-cigarette use may be easily influenced into smoking cigarettes by friends and family members who smoke cigarettes [27]. Although we cannot explain clearly the difference in cigarette and electronic cigarette use in this
study, we thought there were different contexts of electronic cigarette use compared to cigarette smoking and future study is needed to determine this point. There were several limitations of this study. Firstly, the results could be biased due to the selfreported survey format. For example, some questions might have been answered in a socially acceptable manner, especially smoking, so some students may have reported lower or higher frequencies. Non-response can also lead to bias. The participation rate of KYRBS was quite high (97.2%) and question specific non-response rate was within 2%. We thought that the higher the response rate of this survey, the lower the risk of non-response bias. Secondly, since this research was based on a cross-sectional study, it was not possible to examine a possible cause-and-effect relationship. Still, it could be that adolescent smokers have a tendency to become close to friends who smoke. Thirdly, we did not assess students’ popularity. According to some studies, smoking is related to adolescents’ popularity among their peer group (i.e., they may have a tendency to copy popular students) [7,28]. In recent review, friendship networks among adolescents promoted their risky behavior including smoking [29]. Further study is recommended to investigate adolescents’ smoking behavior considering this point. Finally, the survey did not include a parenting style variable, but it has been shown that boys without parental control may have a tendency for substance use. For girls, the quality of the relationship between their parents and themselves is more relevant [21]. Go to:
5. Conclusions This representative study analyzed adolescent smoking behavior in Korea with a focus on middle and high school students nationwide. Furthermore, KYRBS procedure protects respondents’ privacy, which contributed to detection of greater prevalence of delinquent behaviors (e.g., smoking prevalence) in KYRBS than in other interview surveys (e.g., Korea National Health and Nutrition Examination Survey) for Korean adolescents [16]. We considered electronic cigarette use as well as cigarette smoking, which has increased in Korean adolescents. We examined how each individual family member who smoked influenced student smoking behavior as well as secondhand smoking. A smoke-free environment should be provided for adolescents. This means that adolescents should not only avoid secondhand smoking, but also should be protected from smokers. Go to:
Acknowledgments This article is a condensed form of the first author’s master’s thesis from Chosun University. Go to:
Author Contributions Myoung Jin Joung and Mi Ah Han conceived and designed the experiment; Myoung Jin Joung and Mi Ah Han performed the experiment; Myoung Jin Joung and Mi Ah Han analyzed the data; Jong Park and So Yeon Ryu contributed to data interpretation; and M young Jin Joung, Mi Ah Han, Jong Park and So Yeon Ryu wrote the paper.
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Conflicts of Interest The authors declare no conflict of interest. Go to:
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BMC Public Health. 2014; 14: 1022.
Published online 2014 Oct 1. doi: 10.1186/1471-2458-14-1022
PMCID: PMC4190308
Association between mobile phone use and inattention in 7102 Chinese adolescents: a population-based cross-sectional study Feizhou Zheng, Peng Gao, Mindi He, Min Li, Changxi Wang, Qichang Zeng, Zhou Zhou, Zhengping Yu,and Lei Zhang Author information ► Article notes ► Copyright and License information ►
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Abstract Go to:
Background With the incorporation of modern electronic products into daily life, adolescents now have a longer lifetime exposure to mobile phone (MP). China has developed into one of the world's largest MP markets. As today’s adolescents frequently use MP and other communication tools in their homes, community environments and at school [1], they have longer exposure time to MP. In 2014, the proportion of adolescents who own MP is more than 60% in Shanghai, China [2] and still increasing. Additionally, with the increasing use of MP, co ncerns have been raised in a number of countries about the adverse health effects of MP use on adolescents. World Health Organization (WHO) has identified studies on the potential health effects of MP in children and adolescents as a high priority research area in their research agenda for radiofrequency fields [3]. Making calls, sending messages, surfing the internet and pla ying games on MP are very common in adolescents’ lives, as is the wide use of smart phones. By the end of 2013, there were a total of 500 million people using MP to browse the internet in China [4]. It is unclear if MP use has adverse physiological and psychological effects on the development of adolescents. Inattention is one of the most prevalent mental health disorders in adolescents [5]. Inattentive symptoms, in particular, were strongly associated with problematic video game use or overuse also with other media [6]. These popularly operated MP games, often in brief segments, are not attention demanding and offer immediate rewards, which may encourage further playing [7]. Exposure to MP radio frequency electromagnetic fields might affect nonspecific neurologic performance such as attention and cognition [8]. Additionally, children absorb more energy from external electromagnetic fields than adults [9]. A growing number of studies have focused on the harmful effects of exposure to MP; however, only a few have investigated the association between inattention in adolescents and MP use. MP has been found to be associated with inattention in a few studies [10, 11]. One explanation of this association could be that the head is more exposed to electromagnetic radiation from MP rather than any other part of the body. Alternatively, subjects suffering from insomnia [12] or
headaches [13] were found to have more inattention and many studies have reported that insomnia [14, 15] or headaches [16, 17] occur more frequently with increasing exposure to MP. Furthermore, adolescents with inattention are at a higher risk of o ther psychiatric illnesses such as mood and conduct disorders, and substance abuse [18, 19]. However, in a study using a MP exposure device, no difference in attention was observed between the sham and MP exposure groups [20, 21]. Attention functions may also be differentially enhanced after exposure to the electromagnetic field emitted by MP [22 – 24]. Although there have been several studies on the association between MP use and attention, the results were still controversial. Our present study investigated the possible association between MP use and inattention in Chinese adolescents using a cross-sectional design. Go to:
Methods Ethics statement The protocol of this study was approved by the Third Military Medical University Ethical Committee. All study participants obtained written consent from their parents or guardians.
Subjects In this cross-sectional survey, questionnaires were sent out to 7720 currently enrolled students from 4 middle schools in southwestern China. After obtaining written consent from the students' parents or guardians, the questionnaires were distributed and collected during school hours by the research staff who had previously received epidemiological survey training. The students could ask the research staff if they had any problems with the questions while they filled out the survey in the presence of their class teacher. Among the 7426 (96.19%) students who responded to the questionnaire, 7102 (91.99%) valid questionnaires were analyzed after excluding those with incomplete information.
Questionnaire The questionnaire used in our research was designed to capture information about demographics, MP use, and inattention.
Demographic information In the section on demographic information, name, sex (male or female), age, school, grade (7 – 12), and address (urban/rural) were listed.
Information on MP use To obtain information about the time spent using a MP, students were asked to answer the following questions: “Do you own a MP?”, “At what age did you start using a MP?”, “How much time do you spend making phone calls per day?”, and “How much time do you spend on MP entertainment (playing games and browsing the internet) per day?”. MP usage was assessed
using these questions: “How do you answer the phone (hold it close to your ear, hands-free, or use headphones)?”; “Where do you put your MP during the day (not carrying, hanging in front of the chest, in coat pockets, in trouser pockets, or in bags)?”; and “What is the mode of your MP at night (powered on and beside your head, powered on and kept away from your head, or powered off)?”. For all the above questions, MP use included using other people’s phones. The question “Is there a mobile base station around your home or school?” was asked as well. Additionally, their answers would be checked with the information about the address of mobile base station provided by the Telco Providers and the consistent answers were used for analysis.
Inattention Inattention was described as a lack of attention or a reduced attention span. Some examples of inattention include: avoiding school projects (which involve a long periods of concentration); losing school supplies; difficulties completing household chores; easily distractible et al. The prevalence of inattention in our study was screened using the most stable psychometric properties of the Attention Deficit component of Attention deficit/Hyperactivity disorder (ADHD) by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev. [DSMIV-TR]) [25 – 27]. “A” criteria were used by the teachers who had previously received epidemiological survey training. The choice of nine inattention descriptions was “yes/no”. Inattention was defined when the teacher chose six or more “yes” responses to the descriptions.
Statistical analysis Chi-squared tests ( χ 2) were used to compare the prevalence of inattention between different classifications of MP usage. Odds ratios (OR) and 95% confidence intervals (95% CI) were obtained using logistic regression models to assess the possible associations between MP ownership, years of MP usage, minutes spent on calls each day, minutes spent on entertainment each day, habit of answering the phone, position of MP during the day, mode of MP at night and the prevalence of inattention in adolescents. Adjusted OR were also calculated after adjusting for age, sex, urban/rural residence and whether living close to mobile base stations. The variables with P < 0.1 were included in logistic regression models used to assess the association. Assessment of the fit between the model and the data was gauged by the goodness-of-fit test and the log likelihood Chi-square test. Continuous variables, such as the years of MP usage, the minutes spent on calls daily and the time of entertainment, were split into tertiles. Choosing six or more “yes” of the inattention descriptions was defined inattention. Statistical significance was defined as P < 0.05 in this study. Categorical variables were summarized using the corresponding percentages, and continuous variables were generally summarized using descriptive statistics (mean ± standard deviation (SD)). Statistical analysis was undertaken using SPSS version 19.0 (SPSS Inc., Chicago, IL, USA). Go to:
Results Descriptive information Out of 7720 currently enrolled students in the 4 middle schools, 294 (3.81%) did not return the questionnaire. Out of the 7426 returned questionnaires, 324 (4.20%) were incomplete. In total, 7102 (91.99%) questionnaires completed in all sections (including the Demographic information, Information on MP, and Inattention) were used in the analysis. The participants included 3613 males (50.87%) and 3489 females (49.13%). The mean age was 15.26 ± 1.77 years. A total of 5033 (70.87%) of the participants resided in urban areas, and 2069 (29.13%) were from rural areas. Overall, 5668 (79.81%) participants owned MP at the time of the survey and had been using a MP for a mean of 3.50 ± 2.48 years. Participants spent 57.36 ± 71.96 minutes on entertainment and 8.64 ± 15.48 minutes on making calls daily (Table 1). The details of the socio-demographic characteristics and MP usage are given in Table 1.
Table 1 Descriptive data of socio-demographic characteristics and MP usage (N = 7102)
Association between MP use and inattention There were 7294 (94.48%) responses to the inattention questions. The overall prevalence of inattention was 69.79% out of the 7102 valid questionnaires in this study. After adjusted for age, sex, area of residence (urban/rural) and whether living close to mobile base stations, the prevalence of inattention was significantly associated with MP ownership (OR 2.92; 95% CI 2.51-3.39) and time spent on entertainment daily (OR 1.87; 95% CI 1.28-2.73). Additionally, there was a positive association between inattention and the time spent on entertainment on MP (21 – 60 minutes per day spent on entertainment, OR 1.45, 95% CI 1.06-1.97; >60 minutes per day spent on entertainment, OR 1.82, 95% CI 1.28-2.59; Table 2). We analyzed the association between inattention and the position of MP during the day. The results showed significant differences. Compared to not carrying the MP (OR 1.00), hanging the MP in front of the chest (OR 0.44; 95% CI 0.19-0.99) and putting the MP in a trouser pocket (OR 1.34; 95% CI 1.101.62) were both significantly associated with inattention. Moreover, participants who powered off their MP at night showed significantly less inattention than those students who left their MP on at night (OR 0.75; 95% CI 0.63-0.90; Table 3).
Table 2 Association between MP use time and inattention (n = 7102 )
Table 3 Association between MP use status and inattention (n = 7102)
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Discussion This population-based cross-sectional study is one of the first studies to investigate the association between MP use and inattention in adolescents in China. Our results showed that the prevalence of inattention was considerable among middle school students. In this study, inattention in adolescents was significantly associated with MP ownership, the time spent on entertainment on the MP every day, the position of the MP during the day and the mode of the MP at night. The prevalence of inattention in the present study was much higher than previous attention studies whether related to MP use or not [28, 29]. Compared with the two previous studies investigating several symptoms including headache, fatigue and dizziness, our study focused only on inattention. This might have led the students to focus on this one symptom, resulting in the high prevalence of reported inattention. In contrast, the Mortazavi's study indicated that people in Iran are usually less familiar with the health effects of exposure to electromagnetic fields, therefore, the number of individuals reporting subjective symptoms was considerably lower [29]. The higher prevalence of inattention in our study compared to other studies was also likely due to the higher prevalence of MP ownership (79.82%) in our study than the Iran study (30%). Our results showed that the prevalence of inattention was significantly higher in MP-owning students compared to non-MP students. This finding concurs with Mortazavi's other studies
which showed that there was a statistically significant relationship between the use of cell phones and attention disorder [30, 31]. However, in their previous research, they did not find a significant association between MP use and self-reported symptoms [29]. We also demonstrated that the OR of inattention increased with the duration of time spent on entertainment on the MP per day. A longitudinal study also reported a similar time-dependent association between playing games on a mobile phone and attention disorder [10]. Attention deficit was associated with a weaker function and structure of prefrontal cortex circuits [32]. Moreover, Aalto et al. revealed an increase in regional cerebral blood flow more distantly in the prefrontal cortex while a mobile phone was in operation placed beside the subject's head [33]; this could be a reason for the increase in inattention. Because the time spent on making calls per day was not significantly associated with inattention, the effect of the MP on attentiveness might not be directly from the MP electromagnetic exposure but from the psychological impact. Inattention was found to be related to depression, anxiety, stress [34] and youth violence [35] in previous studies. A relationship between playing computer games [27, 36], internet addiction [37, 38] and inattention has also been described. Moreover, superficial way to use internet or the contents of the games could also cause problems with concentrating. The time spent on games might also exacerbate ADHD symptoms, if not directly then through the loss of time spent on more developmentally challenging tasks [7]. In our present study, the strongest association between inattention and time spent on entertainment on the MP was among participants who spent more than 60 minutes per day playing on their MP. This is the first study so far to determine a time period which is correlated with inattention. Therefore, our results may provide a reference for further research into the relationship between MP use and inattention. Hanging a MP in front of the chest and putting a MP into trouser pockets were both significantly associated with inattention. However, as only a small group of students (4.34%) hang their MP in front of their chest, the association with inattention may not be generalizable. Our study also showed that putting MP into trouser pockets was likely to increase inattention in MP users. The side-pocket was the favored location for cell phones and students often send texts from inside a pocket. As the exposure increases rapidly in the near field, the safety limits may be exceeded when the phone makes contact with the base station and the penetration of the energy may increase with proximity if MP is in a pocket next to the car rier’s body [39]. The poorer attention in those carrying the MP in a pocket might be due to students using MP while it was in the pocket. As our study found that adolescents who kept their MP turned off at night had significantly less inattention, we propose that parents should power off adolescents' MP while they sleep. This large-scale cross-sectional study is the first to investigate the association between exposure to MP and inattention in Chinese adolescents. Because the questionnaire survey was proceeded during class time, there was a high response rate among the adolescents. Detailed MP usage and inattention were collected to fully explore the association. Furthermore, to exclude confounding factors, we adjusted the results for sex, age, urban/rural residence and whether living close to mobile base stations. However, in this study, there may have been some exposure misclassification [40] due to the data being self-reported. Another limitation was that the cross-sectional study design could not adequately reveal the causality of the factors [41]. On the other hand, as the protection of privacy for parents, schools only allowed us to collected the basic information of adolescents, such as sex, age, address, etc. Therefore, the confounding factors in this study were insufficient.
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Conclusions In general, the results in the present study indicated that MP ownership, the time spent on entertainment on the MP, the position of the MP during the day and the mode of the MP at night were all significantly associated with inattention in Chinese adolescents. We suggest that parents should set a maximum of 60 minutes daily playing by adolescents’ on a MP and require them to turn it off when they sleep. Go to:
Acknowledgements This work was supported by the National Basic Research Program of China (National 973 Program; Grant No. 2011CB503700). We would like to thank Dr. Xiangyu Ma (Department of Epidemiology, Third Military Medical University) for discussion on questionnaire design and Dr. Xiaolu Zeng (Department of Epidemiology, Third Military Medical University), Dr. Dihui Ma (Department of Health Statistics, Third Military Medical University) for consultation on statistic analysis. We would also like to thank Yonghui Lu, Tao Zhang, Ling Mao, Gang Zhu for helping in distribution and collection of questionnaires and all of the participants and teachers for their participation. Go to:
Abbreviations
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Footnotes Competing interests The authors declare that they have no competing interests. Authors’ contributions FZ, ZY and LZ have made contributions to conception and design of the experiment. The experiment was performed by FZ, PG, MH, ML, CW, QZ, ZZ, ZY, and LZ. FZ and PG have made analysis and interpretation of data. Wrote the paper: LZ and FZ have drafted the manuscript. All authors contributed to the paper and approved the final version for publication.
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Contributor Information Feizhou Zheng, Email: moc.361@2020zfz. Peng Gao, Email: moc.621@666999gnepoag. Mindi He, Email: moc.nuyila@rem1111mah.
Min Li, Email: moc.uhos@08eelwons. Changxi Wang, Email: moc.621@654321ixgnahcgnaW. Qichang Zeng, Email: moc.621@9900CQZ. Zhou Zhou, Email: moc.361@00uohzanul. Zhengping Yu, Email: moc.621@ummt_gnipzuy. Lei Zhang, Email: moc.361@0891opelz. Go to:
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Pre-publication history 1. The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/14/1022/prepub
Int J Equity Health . 2016; 15: 29.
Published online 2016 Feb 20. doi: 10.1186/s12939-016-0323-y
PMCID: PMC4761169
Adolescents’ smoking experiences, family structure, parental smoking and socio-economic status in Ciudad Juárez, Mexico Yelena Bird, Hugo Staines-Orozco, and John Moraros Author information ► Article notes ► Copyright and License information ►
This article has been cited by other articles in PMC.
Abstract Go to:
Background Cigarette smoking is the leading cause of preventable death worldwide [1]. Tobacco use and secondhand-tobacco smoke (SHS) exposure are classified as a pediatric disease [2]. Globally, it is estimated that nearly 100,000 adolescents begin smoking every day with the vast majority (approximately 80 %) of them from low-income countries [3]. If current trends continue, more than 250 million adolescents alive today will die prematurely from tobacco-related diseases [4, 5]. In Mexico, the prevalence of smoking has decreased among adults but paradoxically increased among adolescents, particularly among young females [6, 7]. It is reported that almost one million adolescents use tobacco daily in Mexico. [7] Most first time use of tobacco occurs in adolescence and because nicotine is addictive, adolescents who smoke regularly are likely to become lifelong adult smokers [8]. These are troubling trends with significant consequences on the economy and healthcare system of Mexico. On average, a smoker in Mexico would have to spend nearly 5 % of their income (national median) to purchase 10 of the cheapest cigarettes each day [6]. On a national level, approximately 50,000 people die prematurely due to tobacco related diseases [9] and the direct medical expenses attributable to tobacco use are estimated to cost Mexico $5.7 billion (USD) annually [6]. Tobacco use and SHS exposure have immediate and long term effects on the health of adolescents. The immediate effects include increases in respiratory symptoms and reductions in lung function [10, 11]. It has been reported that respiratory problems such as asthma, cough, phlegm, and wheezing are significantly more likely to occur among adolescent smokers and those exposed to SHS than their non-smoking counterparts [10]. Similarly, active smoking and
SHS exposure in adolescence can have a significant effect on several pulmonary function parameters, including reductions in FVC, FEV1, and FEF25-75% [11]. Additionally, early age of smoking initiation is known to increase the lifetime risk of developing a variety of cancers [12], cardiovascular diseases [13], and respiratory illnesses especially among women [14]. Tobacco use in adolescence is the result of a set of complex interactions between youth and their social environment. While several theories have been examined in an attempt to identify the factors that influence smoking behavior in adolescents, no consensus has been reached. Several research studies have indicated that low socio-economic status, single parent homes and/or the presence of one or both parent(s) being smokers exert significant influences on the acquisition of tobacco use habits by adolsecents [15 – 18]. However, the role that family structure and socioeconomic status play on the smoking behaviors of Mexican adolescents has not been sufficiently studied. Public health efforts to reduce and prevent tobacco use among adolescents in Mexico require a comprehensive approach and multi-faceted strategy that address not only the physical dependence but also the social context of the behavior. Therefore, it is critically important to identify and understand the degree to which familial and socio-economic conditions influence the development of smoking habits among adolescents. The present study was designed to determine the association between adolescents’ smoking experiences (smoking beh aviors and SHS exposure), family structure, parental smoking and socio-economic status in Ciudad Juárez, Mexico. Go to:
Methods Study setting The present study was conducted in Ciudad Juárez, Mexico. Ciudad Juárez is one of the major cities on the US-Mexican border and the fourth largest city in Mexico, with an estimated population of 1.5 million people in 2010 [19]. Mexico has a relatively young and growing population of approximately 122 million people with nearly 10 % between the ages of 12 and 16 years old [20]. This age group has been identified by the tobacco industry as a high priority marketing/consumer target [21]. Some of the factors that contribute to making adolescents living in Mexico a particularly vulnerable risk group for tobacco use include but may not be limited to easy access to cigarettes [22], peer pressure [23], social acceptability [24], parental use [24, 25], aggressive tobacco industry marketing [21, 26], and most importantly, the fact that even though smoking in enclosed public places (i.e., offices, schools, government buildings, and restaurants) is strictly prohibited, compliance is low [27 – 29]. Further exacerbating the problem is the reality that in Mexico, tobacco companies are allowed to sell “kiddie packs” and even “individual cigarettes” mainly by street vendors (many of them kids themselves) [28, 29]. A recent study reported that single cigarettes in Mexico were widely accessible and growing in popularity and use among the general population including minors [30]. This makes regulation of tobacco sells and enforcement of anti-tobacco laws particularly difficult.
Study design This is a cross-sectional study based on a broader population study [31]. The present study was conducted to examine the association between the smoking experiences (behaviors and SHS exposure), family structure, parental smoking and socio-economic status a mong sixth-grade students (ages 11-13 years old) in Ciudad Juárez, Mexico. A list of middle schools within the city limits of Ciudad Juárez was obtained with the kind assistance of the Ministry of Education. The methodology for the present study was adapted from the Global Youth Tobacco Survey (GYTS) [32]. Specifically, it uses a two-stage cluster sample design to produ ce representative samples of sixth grade students (ages 11 – 13 years old) attending middle school in Ciudad Juárez, Mexico. In the first stage, schools were selected randomly from a list provided by the Ministry of Education based on their proportional probability of sixth grade students enrolled in the specified setting (public or private) and SES (low, middle and high) category. In the second sampling stage, classes within each selected school were randomly selected. All students present on the day of the survey were eligible to participate. In the present study, replicate weights were used to adjust for the varying probabilities of sample selection (student, class, and school settings). The full study sample was brok en up into a series of subsamples by using the key outcomes of interest and the non-overlapping strata under consideration. Then estimates were calculated for the full sample and in each subsample to account for within cluster variance. Socioeconomic economic status (SES) information was obtained from the Ministry of Education of Ciudad Juárez, Mexico. Based on this information, all middle schools were stratified by SES to low (<10,000 Mexican pesos, average annual household income), middle (10,000 - 25,000 Mexican pesos, average annual household income per year), and high (>25,000 Mexican pesos, average annual household income; $1US dollar =16.5 Mexican pesos in 2015) [31]. Permission was obtained from the corresponding educational authorities in Ciudad Juárez, Mexico to conduct the study. The questionnaire application was performed in the classroom and in the presence of the corresponding teacher. In addition, informed consent was obtained from all adolescents and their parents or guardians prior to their participation in the study. Students had the right to withdraw from the study at any point in time and without any penalties even after completing the questionnaire.
Ethics statement All study procedures and instruments were reviewed and approved by the Institutional Review Boards at New Mexico State University (USA) and Universidad Autónoma de Ciudad Juárez (Mexico). All sixth-grade students present on the day of administration of the survey ( N = 506) were eligible to participate. No monetary or nonmonetary incentives were offered to the participating schools or students.
Survey instrument The instrument used in this study was an adaptation of the GYTS [32]. The survey was specifically developed for use with middle school students only. The GYTS was particularly suitable because it could be completed in class during a short period of time. The core
questionnaire includes 54 questions covering eight broad topics or categories. The portion of the questionnaire used in this study consisted of four sections that pertained to the adolescents: a) sociodemographic characteristics, b) smoking experiences (behaviors and SHS exposure), c) family structure, and d) parental smoking. All the items were categorical, closed-format questions. The instrument has been explained extensively elsewhere [31].
Data collection Investigators handed out paper copies of the survey and scantron sheets to all students. To maintain anonymity and confidentiality, respondents were instructed not to place names, identification marks, or numbers anywhere on the instrument. Upon completion, the respondents deposited their surveys into a large, brown, unmarked envelope that was immediately sealed and removed from the classroom.
Data analysis All data analyses were conducted using SPSS and STATA statistical software packages. Frequencies, means, and standard deviations were used to describe the participants and their responses on the survey instrument. The key outcomes under investigation were smoking behaviors and SHS exposure among sixth grade students. The relationship between the key outcome variables and independent variables such as family structure, parental smoking, and SES level were examined. Adjusted odds ratios (OR) and their 95 % confidence intervals (CI) were calculated. Multiple logistic regression analysis was performed while controlling for possible confounders (i.e. gender and age). Differences in proportions were considered statistically significant at p < 0.05 Go to:
Results Study population characteristics There were 506 sixth grade students who participated in the study. The response rate (i.e. completed and returned surveys) was 100 %. The study population characteristics are presented in Table 1. The majority of the students were 12 years old and nearly half were male. Smoking prevalence varied by age, with older students having a higher prevalence. Nearly a third of male students reported having ever smoked; the proportion was slightly lower among females. More than 30 % of the students attending public school had ever smoked; the proportion was lower for those attending private schools. Students living with parents who smoke in a non-intact, low SES household had the highest smoking prevalence.
Table 1 Sociodemographic Characteristics among Adolescents
Smoking behaviors Two questions were used to determine the smoking behaviors of the student participants. Based on the definition used in the National Addiction Survey Mexico 2002 [33], we considered adolescents as current (i.e. active) smokers when they reported themselves to be smokers at the time of completing the survey. The first question sought to determine the number of current smokers among the sixth grade students. Of the 506 participants, 26.1 % [ N = 132] reported being current smokers. Of the current smokers 54 % [ N = 71] were boys and 46 % [61] were girls. The second question assessed how many students had ever smoked a full cigarette in their life time and was used to determine the smoking prevalence in our study. Of all the students surveyed, 29.6 % [ N = 150] indicated they had smoked a full cigarette. Of the students who had engaged in this behavior, 53 % [ N = 79] were boys and 47 % [ N = 71] were girls. Finally, it is worthy to note that 55.3 % [ N = 83] of the smokers indicated they had initiated smoking at o r before the age of 10 years old (Table 2).
Table 2 Smoking Behaviors and SHS Exposure among Adolescents by Family Structure, Parental Smoking, and Socioeconomic Status
Secondhand smoke exposure Two questions were used to determine the SHS exposure of the student participants. We considered adolescents to be exposed to SHS if they answered affirmative one of two questions. The first question asked the sixth grade students whether the y live in a home where in the last 7 days others smoke in their presence. Of the 506 participants, 41.1 % [ N = 208] reported being exposed to SHS at home. The second question asked the sixth grade students whether in the last
7 days they were around others who smoked in their presence in places outside the home. Of all the students surveyed, 53.2 % [ N = 269] indicated they had been exposed to SHS outside their home with most of them being boys (Table 2).
Family structure This variable was defined based on the presence or absence of the biological father, the biological mother, or both biological parents in the adolescent’s home. This variable was coded as 1 = non-intact family (absence in the home of one or both biological parents) and 0 = intact family (presence in the home of both biological parents). Of the 506 participants, 76 % [ N = 385] reported living in intact homes. Of those who lived in non-intact homes [ N = 121], 86 % lived with their mothers (Table 2).
Parental Smoking This variable was determined on the basis of the response provided by the participating sixth grade students to the following question: Do your parents (father, mother or both) smoke? This independent variable was coded as 1 = parents who smoke (presence in the home of either a father or mother who smoked) and 0 = non-smoker parents (neither of the parents smoked). Of the 506 participants, 31 % [ N = 157] reported living in homes with who smoke. Of those, 63 % [ N = 99] reported their fathers being smokers, 12 % [ N = 19] reported their mothers being smokers and the remaining 25 % [ N = 39] reported having both parents as smokers (Table 2).
Multiple Regression Analysis We examined the associations between the outcome measures (i.e., smoking behaviors and SHS exposure) and key characteristics of the participant students (i.e., family structure, parental smoking, and SES) by using logistic regression models, as shown in Tables 3 and and4.4. The outcome measures are presented individually and the key characteristics were treated as independent variables in our models. Odds ratios are shown in relation to a reference category for each variable.
Table 3 Effect of Family Structure, Parental Smoking, and Socioeconomic Status on Smoking Behaviors among Adolescents
Table 4 Effect of Family Structure, Parental Smoking, and Socioeconomic Status on SHS Exposure among Adolescents
Results of the logistic regression analysis show that being a member of a non-intact family [(OR = 2.20; 95 % CI = 1.21–3.90) and (OR = 2.45; 95 % CI = 1.19-4.10) respectively], having parents who smoke [(OR = 4.41; 95 % CI = 2.15–5.46) and (OR = 4.95; 95 % CI = 2.25-7.12) respectively], and living in low SES setting [(OR = 1.73; 95 % CI = 1.43–3.30) and (OR = 1.99; 95 % CI = 1.16-4.00) respectively] are significantly associated with ever smoking and SHS exposure at home among sixth grade students. Go to:
Discussion The present study demonstrates that sixth grade students living in low SES, non-intact family households and who have parents that smoke are significantly more likely to be smokers and be exposed to SHS in Ciudad Juárez, Mexico. According to the findings of our research, adolescents residing in a low SES setting were 2.7 times more likely to have ever smoked and 1.9 times more likely to be current smokers when compared with those residing in a high SES setting. This is consistent with the most recent findings by Kuipers et al. [34], and the original findings from Conrad et al. [35], that showed a strong inverse association between SES and adolescent smoking in 76 % of 21 prospective studies reviewed. It is interesting to note that of the 150 students who indicated they had tried smoking in our study, 88 % reported being active smokers and 55 % initiated smoking at or before the age of 10 years old. By starting to use tobacco at such a young age, it makes adolescents particularly vulnerable on several fronts. Tobacco’s highly addictive pro perties make it more likely that a number of experimenting adolescents may become life-long, adult cigarette users [8]. It has been reported that most people who become regular smokers initiate and establish their smoking hab its during adolescence [36]. In addition to the well documented health concerns [10 – 14], buying tobacco causes financial hardship on low SES adolescents as it robs them and their families of the possible resources they need to rise out of poverty [7]. It is estimated that the poorest 20 % of households in Mexico spend nearly 11 % of their income on tobacco. [37]
Census data over the last decade have shown that the number of non-intact (i.e. single-parent) families (predominantly led by mothers) has risen in Mexico. [38]. This social phenomenon has been associated with the development of increased risk behaviors among affected adolescents
[15, 39 – 41]. Similarly, our study shows that adolescents who live in non-intact family households were 2.2 times more likely to have ever smoked and 2.0 times more likely to be current smokers when compared with those residing in intact households (i.e. living with both biological parents). This effect may be due to a number of socio-cultural factors. In Mexico, tobacco use is generally viewed as a socially acceptable behavior for boys but not so for girls. These views may help promote smoking among adolescents from both genders but for potentially different sociocultural reasons. For many young boys and girls alike, especially those living in low SES, non-intact family households, smoking may represent a rite of passage from childhood to adulthood [42]. For boys, smoking plays into and reinforces the sociocultural concept of “machismo.” Tobacco is used in these instances by bo ys as a way of asserting their masculinity and proving their power and fearlessness [43]. For girls, it may be a reflection of trying to actively rebel against the sociocultural concept of “marianismo.” Traditional Latin American societies such as the one seen in Mexico tend to think that 'good girls' do not smoke [44]. Therefore young girls may deliberately smoke to show that they will not be subjugated to the rules of the past. For many of them smoking signals entry into womanhood by giving them the appearance of being stylish, sexy and independent [45, 46]. There are a number of other factors that can provide appreciable meaning and context of smoking among Mexican adolescents. Social smoking among adolescents provides opportunities for bonding and group membership that may transition from one time or space (e.g., da y time in schools) to another (e.g., evening and nights during parties and clubbing) [47]. Even though most adolescents minimize the importance of peer influence over their smoking behavior, they readily describe social interchange networks, in which simultaneous cigarette smoking and sharing occurs [23]. These findings provide evidence for the operation of self-selection and peerinfluence processes on adolescent smoking behaviors [48, 49]. Many adolescents also reported smoking cigarettes to escape boredom [50], relieve stress [51], and for sensation seeking purposes [52]. These connotations are strongly reinforced among adolescents by the tobacco industry through targeted advertising and mass media campaigns [21, 26, 53]. Additionally, living in a non-intact home (mainly with their mother) may lead the adolescent to have a lower household income (i.e. low SES), experience less or even lax supervision by the single parent and socially rely more heavily on peers. Conceivably, the single parent may be more tolerant of the behavior or even too busy working to be fully aware of their adolescent’s activities outside the home [41, 54, 55]. Adolescents from non-intact homes may be particularly susceptible to peer social influences given the increased importance of school and peer groups in their lives [56, 57]. All these factors and many others, conspire to create a vicious cycle for many adolescents for whom their family structure (i.e. non-intact households) influences their socioeconomic status (i.e. low) and makes them particularly vulnerable to tobacco initiation and long term use. Based on the results of our study, adolescents who live in a household with parents that smoke were 4.4 times more likely to have ever smoked themselves and 4.1 times more likely to be current smokers when compared with those residing in non-smoking households. A number of studies have provided support for this association [18, 58, 59]. Parents serve as role models for many adolescent behaviors including smoking. The low SES environment puts parents (especially the ones leading non-intact households) at risk to be smokers themselves and by way of modeling and mimicry adolescents may become influenced to copy the behavior. The
presence of parents that smoke in the household may be perceived by adolescents as an indication that such behavior is acceptable and a sign that smoking is not that harmful to one’s health [60]. Even for adolescents who do not smoke, their potential exposure to SHS in their homes poses a serious risk to their health. In the present study, SHS exposure for our adolescent participants was 41.1 % at home and 53.2 % outside of it. The resulting tobacco smoke exposure increases their risk to suffer from acute respiratory infections, otitis media, decreased lung function, exacerbation of asthma, hospitalizations, dental caries, mental health p roblems, cognitive deficits, and even school absenteeism and poorer academic performance [61 – 66]. In our study, the prevalence of parental smoking was quite high (31 %). Based on the results of our research, adolescents whose parents smoke were 4.9 times more likely to have been exposed to SHS in their own home and 3.9 times more likely outside of it, when compared with those residing in non-smoking households. Our findings lend support to those reported in a systematic review of the literature, which shows parental smoking and low SES to be independently and significantly associated with children’s SHS exposure in their ho me [11]. In Mexico, smoke-free housing policies are not common and public smoking bans are not regularly enforced [67]. This indicates that public health and education professionals have an opportunity to play an important role in reducing SHS exposure among adolescents with counseling strategies centered on parents that emphasize increased awareness, education about smoke-free housing policies and public smoking bans, and smoking reduction and cessation efforts.
Limitations This study has a number of limitations. The students who participated in the study may have differed in important ways from those who did not participate. Even though our participation rate was 100 % on the days of the survey, there probably were a number of students who were absent from school on those days. Additionally and more importantly, there are growing numbers of middle school age children in Mexico (close to one-in-three by some reports), who ma y attend school irregularly or not at all [38]. Despite the fact we did not collect data from non-participant adolescents because they were either absent or do not attend school, the literature suggests their smoking rates are even higher than those who attend school [68]. The study used a purposive sampling method of sixth grade students from selected middle schools. Th is in turn may have compromised our ability to generalize the results of our study to other grades and middle schools. Nevertheless, our sampling scheme ensured that data were collected from representative public and private middle schools located in low, middle and high SES neighborhoods in Ciudad Juárez, Mexico. Finally, smoking was not determined b y an objective measurement, such as biochemical validation, but rather on the basis of self-reported behaviors by the adolescent participating students. However, research has shown the validity of self-reported smoking to be consistently high and thus, biochemical measurements for validation purposes may not be justified [69]. Go to:
Conclusions In Mexico, tobacco use has significant implications for the nation’s economy and public health. This holds especially true among its adolescent population. However, adolescents face an uphill battle in their fight against tobacco. Unlike many other health conditions, the severe effects of tobacco use do not clinically manifest themselves until several decades later. If one couples this reality with the adolescents’ perceived sense of health invincibility, it is understandable why many adolescents do not consider tobacco to pose a serious threat to their health [8].
Our study findings show that tobacco use and SHS smoke exposure are strongly associated with adolescents living in low SES, non-intact households that have parents that smoke. To be effective, tobacco strategies specifically tailored for this particularly vulnerable group of adolescents would require a comprehensive, multi-faceted approach centered on: a) prevention – helping to stave off adolescents from starting to use tobacco, b) cessation – helping the active adolescent smokers (and their parents) to quit, and c) protection – safeguarding adolescents from the harmful effects of secondhand smoke exposure by strengthening policies and enforcing regulations. Go to:
Footnotes Competing interests The authors declare that they have no competing interests. Authors’ contributions Y.B. was involved in the study conception and design, led the collection of data, contributed to the discussion, helped write and reviewed/edited the manuscript. H.S.O was instrumental in the implementation stage of the study, contributed to the discussion and reviewed/edited the manuscript. J.M. was involved in the interpretation of findings, contributed to the discussion, helped write and reviewed/edited the manuscript. All authors read and approved the final manuscript.
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Contributor Information Yelena Bird, Email:
[email protected]. Hugo Staines-Orozco, Email: xm.jcau@seniatsh. John Moraros, Email:
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