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Rates and correlates of cigarette smoking among a sample of year 7 and 8 students in Sydney - A comparative study between students speaking English and a language other than English at home

Tang, K.C.1,2, Rissel, C.3, Fay, J.2, Ehrlich, F.4, Porter, S.5, Dawes, A.2, Steven, B.2

Internet publication: 21 October, 1997

Abstract

This paper aims to identify the rates and predictors of cigarette smoking among adolescents speaking a language other than English at home as a whole and the largest five language groups, and factors associated with their smoking behaviour. These data are also compared with data of students speaking English at home. Complete data were collected from 5,947 year 7 and 8 students in 38 schools. Chi square and logistic regression analysis were used for data analysis. It was found that students speaking a language other than English at home were significantly less likely to be smokers (3%) than students speaking English at home (7.1%) (X2= 32.4, P<.001). Language spoken at home remained significantly associated with smoking status after adjusting for social environment factors in a simultaneous logistic regression model. Father's smoking status was not significantly associated with student smoking status, but mother's smoking status was. For English speaking students siblings' smoking status was significantly associated with student smoking. Peer smoking status and students' perception of the acceptability of smoking and perceived benefits of smoking were found to be major predictors for both language groups. Opportunities exist for the prevention of smoking uptake among students speaking a language other then English at home.

Introduction

Despite widespread focus on the rates and predictors of cigarette smoking uptake among adolescents in Australia, no data are available for adolescents speaking a language other than English (LOTE) at home. The need for studies within this population in Australia is important considering the large non-English speaking migrant population. In Sydney at the 1991 Census, about 25% of the total population spoke a language other than English at home (1). Yet the overall smoking rates of Australians speaking a LOTE at home was 31.5% for men aged 20-69 (2) and was higher than the total Australian male prevalence (27%) (3). It is not known whether the high smoking rates among Australians speaking a LOTE is due to the high smoking rates of the non-English speaking population as a whole or the contribution of the larger ethnic groups.

Of the 66 language groups tabulated by the Australian Bureau of Statistics, those who speak Chinese (14.7%), Arabic including Lebanese (14.2%), Italian (11.5%), Greek (11.2%) and Vietnamese (5.1%) accounted for about 57% of those speaking a language other than English at home. Consistent with the national findings, the adult male smoking rates of the major language groups, as revealed through ethnic specific prevalence studies within defined geographic areas, are as high or higher than the total Australian male prevalence, with 53% for Vietnamese (4), 44% for Greek (5), 43% for Arabic (6), 33% for Italians (7), and 26% for Chinese (8).

There is some evidence that paternal smoking status is a significant predictor of smoking among adolescents (9, 10). If this holds true for migrant communities in Australia, then adolescents speaking a language other than English at home would appear to be at a higher risk for smoking uptake than their English speaking background counterparts.

Although there are a number of studies that examine smoking behaviour among minority high school students in the US, particularly students from Hispanic, African American and, to lesser extent, Asian communities, patterns of smoking behaviour vary (11, 12, 13, 14). For example, the onset of cigarette smoking among African American youth occurs later than for Euro Americans but rises to higher rates by late adolescence (15, 16), whereas Hispanic-Latino youth had higher rates of early experimental smoking than non-Hispanic-Latino youth (17, 18). Significant predictors of smoking among minority students include peer and parental influence, as well as individual characteristics such as age, gender, attitude and academic achievement. However, after an extensive review of studies investigating adolescent smoking, Conrad and colleagues (10) concluded that literature concerning ethnicity are too few and too inconsistent for any firm conclusions. Also, the relevance of the U.S. literature to Australia may be limited in view of the different composition of the ethnic communities. Contrary to the U. S., the ethnic population of Australia is not dominated by two or three major groupings. Its composition consists of up to ten larger groups.

The present study sought to identify the rate of smoking among a sample of adolescents speaking a language other than English at home as a whole and that of the five largest language groups, and factors associated with smoking. These data were also compared with data of adolescents speaking English at home.

Methods

Data for this study were collected as baseline data for the "Kickbutts" smoking prevention program. The program aims to reduce smoking uptake among year 7 and 8 high school students through a combination of school based, parental support and supply reduction strategies. Respondents were students in years 7 and 8 (approximately 12 and 13 years old) in 38 schools in the South Eastern and Northern Sydney Area Health Services.

Selection of schools

86 schools were invited to participate and 38 schools (44.2%) agreed to take part. To participate in the study, schools were required to assign a teacher to deliver a designated school-based smoking prevention package for their Year 7 and 8 students. The main reason for non-participation was the practical difficulties the schools faced in implementing the intervention. There would seem no indication of other factor that might have biased the selection. While the school participation rate was much lower than that of the 1992 statewide survey, the ratio between Government and non-Government schools in this sample was the same as that of the statewide survey (19).

Response rate of students

Data were collected from 86% of those students enrolled in years 7 and 8 in the study schools. Absentees accounted for about 6% of eligible students. Non-participants accounted for the remaining 8% of students. The response rate was again similar to that of the 1992 statewide survey (89%).

Instrument

A questionnaire was administered consisting of 42 items concerning self-reported cigarette smoking behaviour, peer and family smoking habits, perceptions of the social acceptability and benefits of smoking, language spoken at home and demographic data. The great majority of questions used were drawn from the New South Wales Drug and Alcohol Directorate's 1989 Survey of Drug Use by NSW Secondary Students (20).

Smoking status of students was identified through self reported information. Students were asked to indicate whether they are regular smokers (at least one cigarette a day), occasional smokers (smoked once or twice only, smoked occasionally in the past, occasionally now but not regularly), ex-smokers (smoked regularly in the past) or never smokers. Students were also asked to indicate the smoking status of their family members, close friends and other adults who are close to them.

The perceived benefits of smoking consisted of four questions. Respondents were asked to indicate what they think about each of the following statements: smoking helps people keep thin, smokers are usually more popular than non-smokers, people who smoke are usually more mature than non-smokers and usually look better than non-smokers. Responses were measured by a four point scale: strongly agree, agree, disagree or strongly disagree.

Additional questions developed by the research team concerned whether the respondents thought it acceptable for people their own age to be smoking cigarettes and whether parents had discussed smoking with them. Parental discussions with children consisted of two questions. Students were asked whether their mother or father talked to them about how to say no to other people offering them cigarettes and discussed smoking with them within 12 months prior to the interview. The questionnaire was piloted among approximately 100 year 7 and 8 students from schools that declined to participate in the Campaign.

Data were collected consecutively as schools were recruited. Administration of the questionnaire was carried out by project officers and a strict protocol was followed, based on the Department of Community Services guidelines for comparability of drug use surveys (21).

Data Analysis

The dependent variable, smoking status, was dichotomised into "current smoker" and "non-smoker", with "current smoker" including regular smokers of one or more cigarettes a day and those who smoked "occasionally now but not regularly". The primary independent variables were whether a LOTE was spoken at home (self-reported by students). Additional independent variables were selected according to social learning theory which posits that an individual's susceptibility to perform a particular behaviour is influenced by three types of factors that interact with each other in complex ways: personal, environmental and behavioural influences. 22 The four items concerning perceived benefits of smoking were totalled to yield an aggregate score. Cronbach's Alpha for the four items in the scale was 0.69. Frequencies and cross-tabulations of variables were computed to estimate the crude rate of smoking in the total sample and by sex, school year and language spoken at home. Chi square statistics were used to test associations between language spoken at home and year of school and sex. Logistic regression models was used to identify three models of the data which explained smoking status in adolescents, adjusting for other independent variables in the model. The first model used the overall sample, the second model used students speaking English at home and the third model used students speaking a language other than English at home. To facilitate comparisons, Chi square analyses were used and logistic regression was used for analysing records without missing data for the variables included.

Results

Of the 7,394 responses obtained, complete data were available for 5,947 records (80%). Seven per cent (532) of records were excluded because of the duplication of the identification code among students when merging two components of the baseline questionnaires. There appeared to be no systematic biases introduced by this exclusion of these 532 records, as the overall reported prevalence of smoking, and smoking prevalence by age and sex differed only slightly, and the differences were not statistically significant. Demographic characteristics of the sample are shown in Table 1.

Table 1: Number of student sample in year of school, whether speak a language other than English at home (LOTE), birthplace of parent and smoking status of parent by sex of student (n=5,947)

Of the total sample (n=7,373), 486 were identified as smokers (6.6%). In year 7, 4.1 per cent were smokers, and in year 8 9.4 per cent were smokers. Of students speaking a language other than English at home, 3.4 per cent were smoking and 7.6 per cent of students speaking English at home were smokers. The smoking rates of students from the five largest language groups speaking Chinese (0.78%), Arabic (3.05%), Italian (5.66%), Greek (1.6%) or Vietnamese (0%) were lower than that of the English speaking students (7.24%). There was no significant difference as regards these percentages of students smoking when comparable percentages are calculated after deleting records with missing data (see Table 2).

Table 2: Numbers of students by year of school, gender and language background *, and percentage of students smoking

*, chi square is for the association between students speaking English at home compared to those who do not

**, N represents the total number of students in each cell

The percentage of students smoking in year 8 (8.4%) was more than double that of Year 7 (3.9%), with boys smoking significantly more (5.0%) than girls (2.9%) in Year 7 (Chi square=9.2, P=0.002). In year 8, differences between boys (9.2%) and girls (7.7%) in smoking status were not significant (p=.168). Overall, girls and boys in year 8 and girls in year 7 who speak a language other than English at home were significantly less likely to be current smokers than students who spoke English at home (see Table 2).

Language spoken at home emerged as an independent predictor of smoking status after adjusting for other social environmental variables in the model (see Table 3). The odds of being a current smoker were almost 50 per cent greater if students spoke English at home. Mother's smoking status, but not father's, was positively associated with student smoking. When similar logistic regression models were run stratifying by language, sibling smoking status was independently associated with smoking status for students speaking English at home, but not for those students speaking a language other than English at home. An interaction term (language spoken at home by sex) was not significant, and so analyses by sex were not pursued.

Logistic regression analyses identified eight significant variables associated with smoking status after adjusting for all variables entered the model for students who speak English at home, and three significant variables were identified for students who speak a language other than English at home.

Table 3: Language use and social environmental predictors of smoking status among Years 7 and 8 Sydney students (n=5,947), and by language spoken at home

OR, Odds Ratio

Discussion

The overall prevalence of smoking among Year 7 and 8 students in this study was generally consistent with that of other NSW school surveys of tobacco use (19, 23). However, there was a statistically significant lower prevalence of smoking among students speaking a language other than English at home.

The lower smoking prevalence among respondents speaking a language other than English at home (approximately half that of students who spoke English) was unexpected given the high rates of male smoking in migrant communities in NSW and high rates of adolescent smoking demonstrated previously in some minority populations in the U.S. (12, 24) As beliefs about the acceptability of smoking and the influence of peers are similar, one factor which may be important is the influence of parents.

While father's smoking status was not significant, mother's smoking status was positively associated with student smoking. The strength of this association was much greater for students speaking a language other than English at home than for English speaking students. Conrad and colleagues (10) speculated "family, particularly parent, behaviour and approval variables play a much less consistently important role in predicting onset than most writers have here-to-fore assumed", and that one parent may have influence and not the other. For students speaking a language other than English at home, the results of the present study suggest that the father's behaviour is less important than the mother's, and that approval variables may be important.

The pattern of a lower prevalence of smoking in migrant children despite parental smoking, may be consistent with data from African American families, where adults, even those who smoke, have significantly more negative views on cigarette smoking than Euro Americans (25, 26). As a result, African American parents may be temporarily effective in delaying the uptake of cigarette smoking in their children, but not in preventing it (26), and the lower prevalence in migrant children speaking a language other than English at home may reflect a temporary response to strong parental control in which parents take a rigid stance against smoking regardless of their actual smoking behaviour: "do as I say, not as I do". This stance may be reinforced by the mother's smoking status which was 12% among mothers of a non-English speaking background and is half that of the Australian female total (23%), despite a high prevalence among adult males. Migrant adolescents may also socialise with members of their own language group, all of whom may have a strong family restriction on adolescent smoking.

Among students who speak English at home, the presence of siblings who smoke is significantly associated with student smoking. This lends support to the evidence presented in other studies that showed sibling smoking to be a fairly consistent predictor of smoking (10). However, among students who speak a language other than English at home, the association did not prove significant. This may be a result of small number of students speaking a language other than English in this study having either older siblings or older siblings who smoke. If older siblings are present and are smokers, it may suggest that students speaking a LOTE are likely to take up smoking as they grow older when rebellion against the restrictions may occur. In later years when their peer group is expanded, peer group and siblings smoking behaviour may then override parental restrictions.

As the data collection was in English, it is not known if poor English language ability influenced the responses of students from non-English speaking backgrounds, nor is the reliability of self-reported smoking behaviour in this group known. Bogus-pipeline methods (27) are not recommended for use in school surveys of adolescent substance use in NSW (21) and it is not known whether the prevalence of smoking is under-reported.

The results in Table 3 for students speaking English at home are largely consistent with and support other research findings, in that certain factors are consistently significant predictors of smoking status: being older, thinking that smoking is acceptable, having a sibling or close friend who smokes, and perceiving benefits of smoking. There are however several findings that were not expected.

English speaking students who reported that their parents had discussed smoking with them were nearly twice as likely to be current smokers. This may be a result of parents not initiating any discussion until after discovering that the child was beginning to smoke. There is some anecdotal evidence for this. Project officers were at times told by parents that they saw no reason to raise the issue since their child was not a smoker. In fact, it was known in several instances through informal channels that the child concerned was in fact a current smoker. It seems likely that the parent is only motivated to discussing smoking after discovering that the child was a smoker, and not simply at risk.

It is also important to note that, in this sample, knowing another adult who smokes and is close to the student reduced the likelihood of smoking. Further research is required to identify underlying explanations. Conrad and colleagues (10) reported that of 27 studies examined, five studies showed "other adult influences" to be supportive of smoking onset but unsupportive in three studies.

The results of this study also demonstrate that a strong association exists between adolescent tobacco use and thinking that it is acceptable to smoke. However, it is not known what factors contributed to smoking respondents thinking it acceptable to smoke, or whether this belief was a merely a rationalisation of their smoking. In addition to variables such as beliefs about the health effect of smoking (for example, keeping thin and passive smoking) and on self-image (maturity, attraction and popularity), there must be other variables contributing significantly to their affective beliefs about the acceptability of smoking. These variables may include subjective expected utility, positive expectancies, negative expectancies, affective expectancies, approval of cigarette advertising and viewing the health professional as an exemplar (10).

A limitation of this study related to the small numbers of students from specific ethnic backgrounds and the need to aggregate data by whether students speak English or some other language at home. As the number of smoking students speaking Chinese, Arabic, italian, Greek or Vietnamese was so small (only 23), the assessment of rates and factors of cigarette smoking among different ethnic communities was not feasible. However, this aggregation did not mask the low adolescent smoking rates of students speaking a language other than English. In addition, although language use is typically the key component of acculturation scales (18, 28), in the present study it is treated as a dichotomous variable. In future studies it might be more sensitively conceptualised as a continuous variable, as acculturation is a continuous process.

An important implication of this research is that there is a family dynamic at work in families from non-English speaking backgrounds that delays the uptake of smoking in adolescents. We speculate on the basis of other work in progress with the parents of the students in this study that maternal control is greater in non-English speaking background families and that non-smoking rules are enforced. Understanding this phenomena better would support interventions targeting parents of adolescents, and specifically the way in which parents negotiate rules about tobacco (and other drugs) and enforce them. Parental awareness of tobacco may need to be enhanced in families from English speaking backgrounds. With smoking prevalence relatively low in years 7 and 8, parental concern may also be correspondingly low. Unfortunately, this may be just at a time when parental concern needs to be significantly higher to maximise smoking prevention efforts. In addition to classroom focused activities, smoking prevention efforts based in schools need a substantial parent component as well as consistent and supportive messages from the community.

Acknowledgments

The South Eastern Sydney Health Promotion Unit wish to thank the students and teachers of the 38 schools for their participation in the Kickbutts Campaign and the NSW Drug and Alcohol Directorate, NSW Health Promotion Unit, St. George Hospital and Community Health and Sutherland Hospital and Community Health for funding this Campaign.

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