Tobacco Use and Influencing Factors Among Iranian Children and Adolescents at National and Subnational Levels, According to Socioeconomic Status: The Caspian-IV Study

AUTHORS

Roya Kelishadi 1 , Armindokht Shahsanai 1 , 2 , Mostafa Qorbani 3 , 4 , * , Mohammad Esmaeil Motlagh 5 , Mohsen Jari 1 , Gelayol Ardalan 1 , Hossein Ansari 6 , Hamid Asayesh 7 , Ramin Heshmat 4 , *

1 Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran

2 Department of Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran

3 Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, IR Iran

4 Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran

5 Department of Pediatrics, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran

6 Health Promotion Research Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, IR Iran

7 Department of Medical Emergency, Qom University of Medical Sciences, Qom, IR Iran

Corresponding Authors:

How to Cite: Kelishadi R, Shahsanai A, Qorbani M, Esmaeil Motlagh M, Jari M, et al. Tobacco Use and Influencing Factors Among Iranian Children and Adolescents at National and Subnational Levels, According to Socioeconomic Status: The Caspian-IV Study, Iran Red Crescent Med J. 2016 ; 18(5):e21858. doi: 10.5812/ircmj.21858.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 18 (5); e21858
Published Online: April 27, 2016
Article Type: Research Article
Received: July 8, 2014
Revised: January 14, 2015
Accepted: March 29, 2015
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Abstract

Background: Iran is facing an epidemiologic transition, with one of its features being the tendency towards smoking by adolescents. The findings of previous studies in Iran have shown that the pervasiveness of tobacco products among school students is high. No previous study has reported the prevalence and determinants of smoking in various socioeconomic statuses (SESs) and at the subnational level in Iran.

Objectives: To compare the prevalence of smoking and the factors that influence the initiation and continuation of tobacco use in a nationally representative sample of Iranian adolescents living in different regions with diverse socio-demographic patterns.

Patients and Methods: This nationwide, cross-sectional study was conducted in 2011 - 2012 among 14,880 students, aged 6 - 18 years, selected by cluster sampling from 30 provinces. Anonymous questionnaires were completed about tobacco use and the main psychological determinants of initiation and continuation to smoke. The questionnaire was modeled on the world health organization global school-based student health survey (WHO-GSHS). The sub-national regions were defined by the criteria of geography combined with SES. According to this classification, the lowest to highest SESs were considered for the southeast, north-northeast, west, and central regions, respectively. Data were analyzed using the STATA statistical software package.

Results: Overall, 13,486 students completed this survey (participation rate of 90.6%). They consisted of 50.8% boys, 75.6% urban residents, with a mean age of 12.47 ± 3.36 years. According to the self-report of students, 2.6 % (3.5% of boys and 1.7% of girls) were current smokers, and5.9% (7.5% of boys and 4.2% of girls) had ever been smokers. The current use of tobacco was higher in participants aged 14 - 18 years (6.11%) than in those aged 10 - 13.9 years (1.18%) and 6 - 9.9 years (0.51%). Current and past tobacco use, respectively, had the lowest prevalence in the region with the lowest SES (2.2%, 3.7%) and the greatest prevalence in the highest SES region (4.3%, 8.9%). Entertainment was the most common reason for smoking initiation (83.65% of smokers) and continuation (77.01% of smokers), followed by feelings of pleasure, and enjoying the tobacco smell. These influencing factors did not differ significantly according to SES or gender.

Conclusions: Smoking is a health problem for Iranian adolescents, and has a higher prevalence in areas with higher SES. Entertainment and feeling pleasure were the commonest reasons for initiation and continuation of smoking. Tobacco-control programs should begin from childhood and family-centered preventive counseling should be intensified in Iran.

Keywords

Smoking Socioeconomic Factors Adolescents

Copyright © 2016, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Background

According to reports from the world health organization (WHO), tobacco use is one of the major causes of disease and deaths in the world. Tobacco use was estimated to cause 5.1 million deaths in 2004 at a global level (1), and by 2020 this number is expected to increase to 10 million deaths (2), with higher rates in low- and middle-income countries (3). Every day, nearly 100,000 youths begin to consume tobacco worldwide, with a quarter of them under 10 years of age (4). For instance, approximately 1000 adolescents in the United States become smokers daily (5).

Many studies have reported the prevalence of tobacco smoking among adolescents and youths of different countries. A study in selected countries of Southeast Asia showed that the extent of tobacco use among students aged 13 - 15 years varied from 5.9% in Bangladesh to 56.5% in Timor-Leste; in those aged 15 years or more, the figures were 43.3% in Bangladesh, 34.6% in India, and 27.2% in Thailand (6). A study of 13 - 15-year-old students in Greece reported that 16.2% of them were current tobacco users (7).

Iran is facing an epidemiologic transition, with one of its features being the tendency of adolescents to start smoking. The findings of our previous national study during 2009 - 2010 in provincial counties of Iran showed that 10.4% of school students, aged 10 - 18 years, used tobacco product (8). Other studies performed among male high school students in Iran have reported levels of current smoking ranging from 2.3% (9) to 15.1% (10). In all of these studies, the number of smokers was higher among boys than among girls (11-13). According to the studies in Iran, the average age at which youths started cigarette smoking was 14.5 ± 2.4 years (14).

The main reason for smoking varies in different populations with diverse socioeconomic and cultural backgrounds. Psychosocial determinants (15-18) and social factors (19-23) influencing tobacco use have been studied in different countries.

To provide applicable programs for effective prevention and to plan for comprehensive and persistent tobacco-control programs in each population, the prevalence and determinants of smoking should be determined for various socioeconomic groups.

2. Objectives

No previous study has reported these factors at sub-national regions of Iran, or with large variations in health and socioeconomic status (SES) in the different regions. The aim of the present study is to compare the pervasiveness of tobacco smoking and the factors influencing the initiation and continuation of tobacco use in a nationally representative sample of Iranian adolescents living in different regions with diverse socio-demographic patterns.

3. Patients and Methods

The data for this cross-sectional study were collected as a part of the “national survey of school student high risk behaviors” (2011 - 2012) in the fourth survey of the school-based surveillance system titled childhood and adolescence surveillance and prevention of adult non-communicable diseases (CASPIAN-IV) Study. This school-based, nationwide health survey was conducted in 30 provinces in Iran. Details on the study protocol have been described before (24), and here we report it in brief.

3.1. Study Population and Sampling Framework

Having Iranian nationality (Iranian identification identity card) was the only inclusion criterion of study, and all foreign-nation students were excluded from the study population. The study population consisted of 14,880 school students, aged 6 - 18 years. They were selected, through a multistage, cluster-sampling method, from urban and rural areas urban and rural areas of 30 provinces of the country in 30 provinces of the country (48 clusters of 10 students in each province). Stratification was performed in each province according to the residence area (urban/rural) and school grade (elementary/intermediate/high school). The sampling was proportional to size, with equal sex ratio; i.e., equal numbers of boys and girls were selected from each province and the ratios in urban and rural areas were proportionate to the population of urban and rural students. In this way, the numbers of samples in rural/urban areas and in each school grade were divided proportionally to the population of students in each grade. Clusters sampling with equal clusters was used in each province to reach the necessary sample size. Clusters were determined by the level of schools, including 10 sample units (students and their parents) in each cluster. The sampling frame was a list of students in each province, and was stratified by sex, living area, and grade using data obtained from the information bank of the ministry of education. In each province, schools were ordered by type and name of school, and the number of students was added cumulatively for each province. After determining clusters for each province, 10 students were selected consecutively in each cluster. The maximum sample size that could give a good estimate of all risk factors of interest was selected. The sample size was determined based on a proportion estimation formula. To obtain maximum sample size, prevalence was considered as 0.5, precision as 0.1, and type I error as 0.05. The estimated sample size (100 subjects) was multiplied by sex grouping (boy and girl), living area (urban and rural), and an attrition rate of 20%. Thus, the sample size was calculated as 480 students in each province. A total of 48 clusters of 10 subjects in each of the provinces and a total of 14,880 students were selected. The whole data from one of the provinces was not available; therefore, the analysis was performed on data from 30 provinces.

For comparison of regions with different SESs, the classification of Iran into four sub-national regions was used, based on a previous study. The sub-national regions were defined based on criteria combining geography with SES and using principal component analysis. SES was an index consisting of variables from the 2006 census, including literacy, family permanent income (family assets), and employment rate. According to this classification, the lowest to highest SESs were considered for the Southeast, north-northeast, west, and central regions, respectively (25).

3.2. Questionnaires

The questionnaires were prepared in Persian based on the questionnaire of the world health organization global school-based student health survey (WHO-GSHS). The validity and reliability of this questionnaire was confirmed (26). The students were reassured about the confidentiality of their answers, and the questionnaires were completed anonymously.

Questions were about demographic characteristics, parents’ education levels, patterns of tobacco use, and the age at which tobacco use started, as well as the psychological factors that influenced them to start and to continue smoking.

Those individuals who reported having experienced smoking were considered as ‘ever’ smokers, and those who reported that they actually were continuing to smoke were considered as ‘current’ smokers.

3.3. Ethical Concerns

The study protocols were reviewed and approved by ethics committees Tehran and Isfahan University of Medical Sciences other related national regulatory organizations. The ethical code for this study was 5429-90. After clarification of the study objectives and protocols, written consent and verbal assent were obtained from parents and students, respectively. All assessments and questionnaires were filled in private and quiet places, away from parents, classmates, and school staffs. All questionnaires were completed anonymously.

3.4. Statistical Analysis

Comparison of variables across regions was performed by means of trend analysis. A chi-square test was used to compare the prevalence rates in different areas and for different age groups. The mean of continuous variables was reported with a 95% confidence interval (CI); categorical variables are presented as percentages.

Statistical measures were estimated using survey data analysis methods in the STATA (STATA Corp. 2011, STATA statistical software: release 12, college station, TX: STATA Corp LP.) statistical software package. A P value < 0.05 was considered to be statistically significant.

4. Results

The population of this survey consisted of 13,486 children and adolescents out of the 14,880 invited subjects (participation rate of 90.6%). They were 6640 (49.2%) girls and 6846 (50.8%) boys; 75.6% of students were from urban environments, and 24.4% were from rural areas. The mean age of the participants was 12.47 ± 3.36 years, without significant difference between boys (12.36 ± 3.40 years) or girls (12.58 ± 3.32 years). Table 1 shows the prevalence of ‘current’ and ‘ever’ tobacco use by gender, age group, and living area according to sub-national classification. According to the self-report of students, 2.6% (3.5% of boys and1.7% of girls) were current smokers, and5.9% (7.5% in boys and 4.2% in girls) were ever smokers. The prevalence of current tobacco use was significantly higher in participants aged 14 - 18 years (6.11%) than in those aged 10 - 13.9 years (1.18%) or 6 - 9.9 years (0.51%). Likewise, the prevalence of previous (ever) tobacco use was significantly higher in students aged 15 - 18 years (12.35%) than in those aged 11 - 14 years (3.55%) or 6 - 10 years (1.7%).

Table 1. Comparison of the Frequency of Active Current and Ever Smoking in Iranian Children and Adolescents According to the age Group at National and Sub-National Levels: The Caspian-IV Studya
VariablesSoutheastNorth-NortheastWestCentralNationalP Value for Trend
Ever smoking
Boys’s age range, y
6 - 101.18 (0.30, 4.55)2.63 (1.27, 5.36)1.89 (1.08, 3.29)2.11 (1.17, 3.79)2.04 (1.45, 2.88)0.76
11 – 142.23 (0.85, 5.72)5.81 (3.43, 9.67)2.75 (1.85, 4.06)5.44 (3.49, 8.38)4.1 (3.16, 5.30)0.03
15 – 1810.84 (7.06, 16.28)8.66 (6.00, 12.34)13.79 (11.24, 16.81)30.66 (25.44, 36.42)16.92 (14.74, 19.35)0.00
Total5.07 (3.30, 7.73)5.55 (4.07, 7.53)6.28 (5.14, 7.65)11.12 (8.86, 13.88)7.48 (6.54, 8.54)0.00
Girls’s age range, y
6 - 102.18 (0.92, 5.07)1.72 (0.66, 4.39)0.63 (0.25, 1.55)1.93 (1.03, 3.60)1.32 (0.88, 1.98)0.13
11 - 141.46 (0.49, 4.32)2.76 (1.45, 5.20)2.55 (1.66, 3.88)4.43 (2.92, 6.68)2.98 (2.29, 3.88)0.11
15 - 183.59 (1.61, 7.83)9.69 (6.81, 13.62)5.74 (4.23, 7.75)11.37 (8.41, 15.21)7.98 (6.63, 9.58)< 0.001
Total2.38 (1.39, 4.05)4.96 (3.60, 6.80)2.97 (2.31, 3.81)6.34 (4.93, 8.13)4.19 (3.60, 4.87)< 0.001
Urban3.53 (2.15, 5.75)6.48 (5.14, 8.15)5.08 (4.25, 6.07)9.24 (7.67, 11.09)6.54 (5.84, 7.31)< 0.001
Rural3.77 (2.32, 6.08)2.01 (1.01, 3.96)3.30 (2.27, 4.77)6.82 (4.22, 10.85)3.76 (2.94, 4.80)0.007
Total3.64 (2.56, 5.16)5.26 (4.2, 6.56)4.64 (3.95, 5.44)8.86 (7.44, 10.51)5.86 (5.29, 6.48)< 0.001
Current smoking
Boys’s age range, y
6 - 100.59 (8.1e-04, 4.12)0.72 (0.24,2.16)0.5 (0.21,1.18)0.5 (0.21,1.47)0.56 (0.33,0.97)0.96
11 - 141.12 (0.28,4.37)1.94 (1.02,3.63)0.59 (0.24,1.45)1.99 (1.08,3.65)1.31 (0.88,1.94)0.06
15 - 188.37 (4.58,14.81)5.59 (3.41,9.03)6.19 (4.65, 8.20)16.79 (12.87, 21.6)8.97 (7.45, 10.75)0.00
Total3.62 (1.99, 6.5)2.61 (1.73, 3.91)2.49 (1.86, 3.32)5.51 (4.09, 7.38)3.49 (2.91, 4.18)< 0.001
Girls’s age range, y
6 - 101.31 (0.43, 3.88)0.57 (0.15, 2.17)00.77 (0.30, 1.98)0.44 (0.23, 0.83)0.01
11 - 140.49 (7.2e-04, 3.22)0.75 (0.24, 2.30)0.55 (0.22, 1.37)2.3 (1.33, 3.94)1.04 (0.67, 1.60)< 0.001
15 - 181.03 (0.27, 3.81)5.2 (3.35, 7.98)1.84 (1.15, 2.95)5.1 (3.26, 7.89)3.38 (2.57, 4.42)< 0.001
Total0.95 (0.44, 2.04)2.31 (1.50, 3.53)0.79 (0.51, 1.24)2.92 (2.05, 4.14)1.66 (1.32, 2.08)< 0.001
Urban2.3 (1.07, 4.88)3.15 (2.33, 4.26)1.89 (1.45, 2.46)4.68 (3.66, 5.97)3.01 (2.57, 3.52)< 0.001
Rural2.08 (1.16, 3.69)0.62 (0.19, 2.00)0.92 (0.48, 1.78)2.16 (1.17, 3.96)1.27 (0.90, 1.80)0.055
Total2.2 (1.33, 3.63)2.46 (1.82, 3.31)1.65 (1.29, 2.11)4.29 (3.39, 5.40)2.59 (2.24, 2.99)< 0.001

aValues are expressed as % (95% CI).

Overall, 3 % of urban students and 1.2% of rural students reported to be current smokers; the corresponding figures for ever tobacco use were 6.5% and 3.8%, respectively. The students living in the Southeast region, i.e., the region with the lowest SESs, had the lowest reported current tobacco use (2.2%), in comparison with their counterparts living in the Central region (4.3%), with the highest SESs. Likewise, ever smoking was lowest (3.7%) in the region with lowest SES levels and the highest (8.9%) was in the region with highest SESs (Table 2).

Table 2. Comparison of the Frequency of Active Current and Ever Smoking in Iranian Children and Adolescents According to the age Group: The Caspian-IV Studya
VariablesAge Group, y
6 - 9.910 - 13.914 - 18TotalP Value
Ever smoking
Boys2.04 (1.45, 2.88)4.1 (3.16, 5.30)16.92 (14.74, 19.35)7.48 (6.55, 8.54)< 0.001
Girls1.32 (0.88, 1.98)2.98 (2.29, 3.88)7.98 (6.63, 9.58)4.19 (3.60, 4.87)< 0.001
Total1.7 (1.31, 2.22)3.55 (2.94, 4.27)12.35 (11.01, 13.82)5.86 (5.29, 6.49)< 0.001
Current smoking
Boys0.56 (0.33, 0.97)1.31 (0.88, 1.94)8.97 (7.45, 10.75)3.49 (2.91, 4.19)< 0.001
Girls0.44 (0.23, 0.83)1.04 (0.67, 1.60)3.38 (2.57, 4.42)1.66 (1.32, 2.08)< 0.001
Total0.51 (0.34, 0.76)1.18 (0.88, 1.57)6.11 (5.21, 7.14)2.59 (2.24, 2.99)< 0.001

aValues are expressed as % (95% CI).

As presented in Table 3, the average age at which the first attempt to use tobacco was made was 12.40 ± 3.39 years, without significant difference between low and high SES regions (12.06 ± 3.75 years vs.12.36 ± 3.29 years, respectively; P > 0.05).

Table 3. The mean (SD) age of the First Attempt at Tobacco use in Iranian Adolescents at National and Sub-National Levels: The Caspian-IV Studya
SoutheastNorth-NortheastWestCentralNationalP Value for Trend
Boys11.69 ± 3.8011.90 ± 3.4512.78 ± 3.3012.15 ± 3.3412.31 ± 3.37> 0.05
Girls13.42 ± 3.5013.03 ± 3.1611.85 ± 3.8412.79 ± 3.1612.56 ± 3.41> 0.05
Urban12.64 ± 2.2312.48 ± 3.2912.65 ± 3.3012.36 ± 3.2612.48 ± 3.25> 0.05
Rural11.43 ± 4.8912.01 ± 4.0111.56 ± 4.3812.38 ± 3.5211.90 ± 4.08> 0.05
Total12.06 ± 3.7512.43 ± 3.3512.48 ± 3.5012.36 ± 3.2912.40 ± 3.39> 0.05

aValues are expressed as mean ± SD.

Higher education levels of fathers were associated with lower frequency of smoking among their children (P = 0.003); the corresponding figure for mothers was significant only for boys (P = 0.01).

Tables 4 and 5 describe the factors influencing the initiation and continuation of smoking among students. ‘Having entertainment and recreation’ was the first reason reported for smoking initiation (in 83.65% of smokers) and continuation (in 77.01% of smokers). A ‘feeling of pleasure’ was the second reason for smoking initiation (59.56%) and its continuation (57.66%). The third most common factor for initiation and continuation of tobacco use was ‘Enjoying the tobacco smell’ for 31.97% and 33.33% of student smokers, respectively. The three aforementioned common factors influencing starting and continuing smoking were not significantly different between girls and boys.

Table 4. Self-Reported Factors Influencing the Initiation of Tobacco use by Iranian Adolescents at National and sub National Levels: The Caspian-IV Studya
Reasons for Starting to SmokeSoutheastNorth-NortheastWestCentralNationalP Value for Trend
Reducing the anxiety32.2623.6419.4415.1219.13> 0.05
Increasing the attention span35.4817.8616.8214.5317.49> 0.05
Social acceptance by friends32.2630.3625.2323.2625.68> 0.05
Feeling older 35.4817.8630.8420.9324.59> 0.05
Feeling of being liked38.7117.8623.5818.6021.64> 0.05
Increasing the self-esteem41.9419.6427.1016.2822.13> 0.05
Feeling of pleasure64.5244.6455.1466.2859.56> 0.05
Helping to stay awake at night25.8110.7121.5008.7214.21> 0.05
Having entertainment and recreation84.3785.7174.7788.3783.65> 0.05
Forgetting problems45.1628.5735.5121.9728.88> 0.05
Enjoying the tobacco smell22.5833.9335.5130.8131.97> 0.05

aValues are expressed as percentages.

Table 5. Self-Reported Factors Influencing the Continuation of Tobacco use by Iranian Adolescents at National and sub National Levels: The Caspian-IV Studya
Reasons for Continuing to SmokeSoutheastNorth-NortheastWestCentralNationalP Value for Trend
Reducing the anxiety37.9320.0018.1011.6316.90> 0.05
Increasing the attention span27.5914.5518.1018.1015.28> 0.05
Social acceptance by friends20.6921.8218.1019.3019.44> 0.05
Increasing the self-esteem31.0321.8223.0814.6219.50> 0.05
Feeling of pleasure65.5243.6456.7361.4057.66> 0.05
Having entertainment and recreation76.6778.1867.6282.4677.01> 0.05
Forgetting problems41.3818.1822.8616.4720.61> 0.05
Enjoying the tobacco smell37.9330.9135.2432.1633.33> 0.05
It is just a habit43.3330.9129.4129.4130.81> 0.05

aValues are expressed as percentages.

‘Helping to stay awake at night’ was reported in 14.52% of boy smokers, and ‘increasing the attention span’ was expressed in 11.02% of girls. These reasons were reported as the least important factors for starting tobacco use.

Factors influencing the initiation and continuation of tobacco use were not significantly different (P > 0.05) with regard to the SESs of the living region.

5. Discussion

To the best of our knowledge, this study is the first of its kind in the Middle East and North Africa (MENA) region for its nationwide coverage, for comparison of smoking according to SES, and for assessment of psychological determinants for starting and continuing to smoke. It showed higher prevalence of tobacco use in children and adolescents living in regions with high SESs than in those with low SESs. Ever and current tobacco use was more prevalent among participants 14 - 18 years of age than among their younger counterparts. Previous studies have reported prevalence rates of 2.5% to 26% for smoking by Iranian children and adolescents (5, 12, 16, 27-31). This wide range can be because of the variety of age groups studied and diversities in the socio-cultural statuses of the city where the study was conducted. The prevalence of smoking was lower in the current study than in the previous surveys of the CASPIAN study (8, 12); this difference could be because the previous surveys were conducted in were conducted at provincial level of each county of each county, whereas the current study includes different cities in each county. Moreover, the previous surveys were conducted with students 10 - 18 years of age, whereas the current study surveyed students aged 6 - 18 years. In addition, the current survey was conducted with a larger sample size and in a higher number of provinces than the previous studies. In spite of these differences, all these nationwide studies found higher prevalence of smoking in boys than in girls, and in those aged 14 - 18 years than in those of younger age groups.

Previous studies in Iran and in the MENA countries did not compare the national and subnational prevalence of tobacco use in areas with different SESs. The higher prevalence of current and ever smoking in regions with higher SESs, which was documented in the current survey, shall be considered in future preventive health actions to reduce tobacco smoking. Such interventions need to be designed and implemented at the subnational level, and according to the SESsin each region.

Previous studies reported conflicting results about the prevalence of smoking according to SES. Our findings are in line with the studies of Hanson and Chen (32) and Johnson (33), in which smoking was more prevalent in high-SES areas. Likewise, the study of Mohammadpoorasl et al. showed that the prevalence of intention to start smoking was greater among those with a higher SES than with a lower SES (34). However, some other studies showed that the prevalence of cigarette smoking was higher among students with low SES than with high SES (15, 25, 35). On the other hand, some studies did not confirm significant association of SES with tobacco use (36-38). The Minnesota adolescent community cohort proposed that low individual SES, and not community-level SES, was associated with higher risk in adolescent smoking (39).

Previous studies in Iran (13, 36, 40-44) found higher prevalence of current and ever smoking in boys than in girls. In the current study, we found similar results, without significant difference according to the SES.

In the current study, the average age for the first attempt at tobacco use was12.40 ± 3.39 years. This age had no significant difference between low- and high- SES areas at the subnational level. However, a study in the capital city of Tehran found that in the areas of the city with lower SES, the age at which youths started to smoke was one year lower than in the high-SES areas of the city (45). It is worth mentioning that, compared to the first survey of the CASPIAN study (12), the age at which smoking was started decreased by one year. This finding warrants implementation of preventive public health actions for families and children of young age.

Several studies in different countries, including Iran, have shown higher prevalence of current and ever smoking in students of higher school levels than in lower school levels (3, 12, 13, 42, 43, 46, 47). Similar findings were documented in the current study at national and subnational levels, without significant difference according to SES.

Most previous studies about smoking among students have been conducted in urban areas, and few of them have included rural areas. Consistent with some other studies in the MENA region that have included both urban and rural areas (12, 48, 49), the present study showed that the prevalence of current and ever tobacco use were higher among urban than among rural students. However, by considering the existing problem of smoking in rural areas, it is necessary to consider tobacco-control activities, both in urban and rural areas.

Factors that influence starting and continuation of smoking have large variations in different populations. In the current study, entertainment was the first reason reported for smoking initiation (among 83.65% of smokers) and continuation (among 77.01% of smokers). The other main reasons were related to feeling pleasure of smoking and enjoying the tobacco smell. These common reasons were not significantly different in terms of gender and SES. These findings suggest that, in general, Iranian youths use tobacco for fun, whereas tensions and mental distress are not important determinants among them for smoking initiation and continuation. Our findings are in line with previous studies in some cities of Iran, which found entertainment as the main reason for starting and continuing to smoke (50, 51). In some populations, stress and psychological distress are reported as important factors associated with initiation and continuation of tobacco use (18, 52). In some other studies, smoking initiation and continuation were higher among students with depressive symptoms (53, 54), hostility, victimization by bullies (53), or aggressive tendencies (54). However, large variations exist between different populations; for instance, a recent study in Greece showed that about a third of student smokers started smoking just out of curiosity (55).

Large variations in factors influencing tobacco use and continuation among youths of different populations underscore the importance of considering culturally-appropriate and evidence-based tobacco control programs. Iran signed the WHO framework convention on tobacco control (WHO FCTC) in 2003, and ratified it in November 2005; different articles to this treaty have been considered. Anti-tobacco laws have been extensively implemented in Iran; for instance, all kinds of advertisements, smoking in indoor public places, and selling cigarettes to persons less than 18 years of age are banned. However, for reaching better outcomes of preventive programs, the community-specific determinants of initiation and continuation of tobacco use among youths should be taken into account. Thus, tobacco-control programs need to begin at childhood, and family-centered preventive counseling should be strengthened in Iran.

5.1. Study Limitations and Strengths

The main limitation of this study is its cross-sectional nature; therefore, the associations found shall be considered with caution. The other limitation is the providing of self-reported data, which are usually underreported. The large sample size is the main strong point of the study.

Tobacco use is a health problem for Iranian adolescents, with higher prevalence in areas with higher SESs. Entertainment and feeling pleasure were the most common reasons for initiation and continuation of smoking. Therefore, tobacco control–programs should begin at childhood, and family-centered preventive counseling should be intensified in Iran.

Acknowledgements

Footnotes

References

  • 1.

    WHO . Global health risks: Mortality and burden of disease attributable to selected major risks. 2011;

  • 2.

    Fathelrahman AI, Omar M, Awang R, Borland R, Fong GT, Hammond D, et al. Smokers' responses toward cigarette pack warning labels in predicting quit intention, stage of change, and self-efficacy. Nicotine Tob Res. 2009; 11(3) : 248 -53 [DOI][PubMed]

  • 3.

    Global Youth Tabacco Survey Collaborative G. Tobacco use among youth: a cross country comparison. Tob Control. 2002; 11(3) : 252 -70 [PubMed]

  • 4.

    Glynn T, Seffrin JR, Brawley OW, Grey N, Ross H. The globalization of tobacco use: 21 challenges for the 21st century. CA Cancer J Clin. 2010; 60(1) : 50 -61 [DOI][PubMed]

  • 5.

    Garrett BE, Dube SR, Trosclair A, Caraballo RS, Pechacek TF, Centers for Disease C, et al. Cigarette smoking - United States, 1965-2008. MMWR Surveill Summ. 2011; 60 Suppl : 109 -13 [PubMed]

  • 6.

    Sinha DN, Palipudi KM, Rolle I, Asma S, Rinchen S. Tobacco use among youth and adults in member countries of South-East Asia region: review of findings from surveys under the Global Tobacco Surveillance System. Indian J Public Health. 2011; 55(3) : 169 -76 [DOI][PubMed]

  • 7.

    Kyrlesi A, Soteriades ES, Warren CW, Kremastinou J, Papastergiou P, Jones NR, et al. Tobacco use among students aged 13-15 years in Greece: the GYTS project. BMC Public Health. 2007; 7 : 3 [DOI][PubMed]

  • 8.

    Kelishadi R, Heshmat R, Motlagh ME, Majdzadeh R, Keramatian K, Qorbani M, et al. Methodology and Early Findings of the Third Survey of CASPIAN Study: A National School-based Surveillance of Students' High Risk Behaviors. Int J Prev Med. 2012; 3(6) : 394 -401 [PubMed]

  • 9.

    Zia Aldini S, Kheradmand A, Nakhaei N, Taherzadeh H. Prevalence of cigarette smoking and relevant factors among school students in south of Iran (In Persian). Fundamentals Ment Health J . 2008; 39(10) : 239 -45

  • 10.

    Karimy M, Niknami S, Heidarnia AR, Hajizadeh I, Montazeri A. Prevalence and determinants of male adolescents' smoking in iran: an explanation based on the theory of planned behavior. Iran Red Crescent Med J. 2013; 15(3) : 187 -93 [DOI][PubMed]

  • 11.

    Kelishadi R, Sadri G, Tavasoli AA, Kahbazi M, Roohafza HR, Sadeghi M, et al. Cumulative prevalence of risk factors for atherosclerotic cardiovascular diseases in Iranian adolescents: IHHP-HHPC. J Pediatr (Rio J). 2005; 81(6) : 447 -53 [DOI][PubMed]

  • 12.

    Kelishadi R, Ardalan G, Gheiratmand R, Majdzadeh R, Delavari A, Heshmat R, et al. Smoking behavior and its influencing factors in a national-representative sample of Iranian adolescents: CASPIAN study. Prev Med. 2006; 42(6) : 423 -6 [DOI][PubMed]

  • 13.

    Kelishadi R, Sadry G, Zadegan NS, Hashemipour M, Sabet B, Bashardoust N, et al. Smoking, adolescents and health: Isfahan healthy heart programme-heart health promotion from childhood. Asia Pac J Public Health. 2004; 16(1) : 15 -22 [PubMed]

  • 14.

    Kelishadi R, Mokhtari MR, Tavasoli AA, Khosravi A, Ahangar-Nazari I, Sabet B, et al. Determinants of tobacco use among youths in Isfahan, Iran. Int J Public Health. 2007; 52(3) : 173 -9 [PubMed]

  • 15.

    Conrad KM, Flay BR, Hill D. Why children start smoking cigarettes: predictors of onset. Br J Addict. 1992; 87(12) : 1711 -24 [PubMed]

  • 16.

    Turner L, Mermelstein R, Flay B. Individual and contextual influences on adolescent smoking. Ann N Y Acad Sci. 2004; 1021 : 175 -97 [DOI][PubMed]

  • 17.

    Vitoria PD, Kremers SP, Mudde AN, Pais-Clemente M, de Vries H. Psychosocial factors related with smoking behaviour in Portuguese adolescents. Eur J Cancer Prev. 2006; 15(6) : 531 -40 [DOI][PubMed]

  • 18.

    Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control. 1998; 7(4) : 409 -20 [PubMed]

  • 19.

    Niknami S, Akbari M, Ahmadi F, Babaee-Rouchi G, Heidarnia A. Smoking initiation among Iranian adolescents: a qualitative study. East Mediterr Health J. 2008; 14(6) : 1290 -300 [PubMed]

  • 20.

    Palipudi KM, Gupta PC, Sinha DN, Andes LJ, Asma S, McAfee T, et al. Social determinants of health and tobacco use in thirteen low and middle income countries: evidence from Global Adult Tobacco Survey. PLoS One. 2012; 7(3)[DOI][PubMed]

  • 21.

    Martinez JA, Amaya W, Campillo HA, Campo A, Diaz LA. [Social factors associated with the daily cigarette smoking among middle-school student adolescents in Bucaramanga, Colombia]. Biomedica. 2005; 25(4) : 518 -26 [PubMed]

  • 22.

    Stickley A, Carlson P. The social and economic determinants of smoking in Moscow, Russia. Scand J Public Health. 2009; 37(6) : 632 -9 [DOI][PubMed]

  • 23.

    Biener L, Hamilton WL, Siegel M, Sullivan EM. Individual, social-normative, and policy predictors of smoking cessation: a multilevel longitudinal analysis. Am J Public Health. 2010; 100(3) : 547 -54 [DOI][PubMed]

  • 24.

    Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et al. Methodology and Early Findings of the Fourth Survey of Childhood and Adolescence Surveillance and Prevention of Adult Non-Communicable Disease in Iran: The CASPIAN-IV Study. Int J Prev Med. 2013; 4(12) : 1451 -60 [PubMed]

  • 25.

    Farzadfar F, Danaei G, Namdaritabar H, Rajaratnam JK, Marcus JR, Khosravi A, et al. National and subnational mortality effects of metabolic risk factors and smoking in Iran: a comparative risk assessment. Popul Health Metr. 2011; 9(1) : 55 [DOI][PubMed]

  • 26.

    Kelishadi R, Majdzadeh R, Motlagh ME, Heshmat R, Aminaee T, Ardalan G, et al. Development and Evaluation of a Questionnaire for Assessment of Determinants of Weight Disorders among Children and Adolescents: The Caspian-IV Study. Int J Prev Med. 2012; 3(10) : 699 -705 [PubMed]

  • 27.

    Mohammadpoorasl A, Fakhari A, Shamsipour M, Rostami F, Rashidian H. Transitions between the stages of smoking in Iranian adolescents. Prev Med. 2011; 52(2) : 136 -8 [DOI][PubMed]

  • 28.

    Sarraf-Zadegan N, Boshtam M, Malekafzali H, Bashardoost N, Sayed-Tabatabaei FA, Rafiei M, et al. Secular trends in cardiovascular mortality in Iran, with special reference to Isfahan. Acta Cardiol. 1999; 54(6) : 327 -33 [PubMed]

  • 29.

    Andreeva TI, Krasovsky KS, Semenova DS. Correlates of smoking initiation among young adults in Ukraine: a cross-sectional study. BMC Public Health. 2007; 7 : 106 [DOI][PubMed]

  • 30.

    Warren CW, Lea V, Lee J, Jones NR, Asma S, McKenna M. Change in tobacco use among 13-15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey. Glob Health Promot. 2009; 16(2 Suppl) : 38 -90 [DOI][PubMed]

  • 31.

    Alireza Ayatollahi S, Mohammadpoorasl A, Rajaeifard A. Predicting the stages of smoking acquisition in the male students of Shiraz's high schools, 2003. Nicotine Tob Res. 2005; 7(6) : 845 -51 [DOI][PubMed]

  • 32.

    Hanson MD, Chen E. Socioeconomic status and substance use behaviors in adolescents: the role of family resources versus family social status. J Health Psychol. 2007; 12(1) : 32 -5 [DOI][PubMed]

  • 33.

    Johnson LM. Criminal Justice System Involvement and Continuity of Youth Crime: A Longitudinal Analysis. Youth Soc. 2004; 36(1) : 3 -29 [DOI]

  • 34.

    Mohammadpoorasl A, Nedjat S, Yazdani K, Fakhari A, Foroushani AR, Fotouhi A. Intention to start smoking and its related factors in never smoked adolescents in tabriz, 2010. Int J Prev Med. 2012; 3(12) : 880 -6 [PubMed]

  • 35.

    Hanson MD, Chen E. Socioeconomic status and health behaviors in adolescence: a review of the literature. J Behav Med. 2007; 30(3) : 263 -85 [DOI][PubMed]

  • 36.

    Mohammadpoorasl A, Nedjat S, Fakhari A, Yazdani K, Rahimi Foroushani A, Fotouhi A. Smoking stages in an Iranian adolescent population. Acta Med Iran. 2012; 50(11) : 746 -54 [PubMed]

  • 37.

    Bergman MM, Scott J. Young adolescents' wellbeing and health-risk behaviours: gender and socio-economic differences. J Adolesc. 2001; 24(2) : 183 -97 [DOI][PubMed]

  • 38.

    Maurer TW, Brunson L, Pleck JH. Adolescent Smoking Behavior: The Relative Influence of Parental and Peer Norms. Adolescent Fam Health. 2003; 3(3) : 130 -9

  • 39.

    Mathur C. Socioeconomic status and tobacco use behavior in adolescence 2010;

  • 40.

    Mohammadpoorasl A. Increasing the Trend of Smoking in Iranian Adolescents. Iran J Public Health. 2013; 42(10) : 1197 -8 [PubMed]

  • 41.

    Meysamie A, Ghaletaki R, Zhand N, Abbasi M. Cigarette smoking in Iran. Iran J Public Health. 2012; 41(2) : 1

  • 42.

    Baheiraei A, Hamzehgardeshi Z, Mohammadi MR, Nedjat S, Mohammadi E. Personal and Family Factors Affecting Life time Cigarette Smoking Among Adolescents in Tehran (Iran): A Community Based Study. Oman Med J. 2013; 28(3) : 184 -90 [DOI][PubMed]

  • 43.

    Mojahed A, Bakhshani NM. Prevalence of smoking and drug abuse in students of Zahedan high schools (Persian) . Tabib-e-Shargh. 2004; 6(1) : 59 -65

  • 44.

    Reddy KS, Perry CL, Stigler MH, Arora M. Differences in tobacco use among young people in urban India by sex, socioeconomic status, age, and school grade: assessment of baseline survey data. Lancet. 2006; 367(9510) : 589 -94 [DOI][PubMed]

  • 45.

    Rezaei F, Nedjat S, Golestan B, Majdzadeh R. Comparison of onset age and pattern of male adolescent smoking in two different socioeconomic districts of tehran, iran. Int J Prev Med. 2011; 2(4) : 224 -8 [PubMed]

  • 46.

    Thomas JL, Renner CC, Patten CA, Decker PA, Utermohle CJ, Ebbert JO. Prevalence and correlates of tobacco use among middle and high school students in western Alaska. Int J Circumpolar Health. 2010; 69(2) : 168 -80 [PubMed]

  • 47.

    Ramezankhani A, Zaboli F, Zarghi A, Masjedi MR, Heydari GR. Smoking habits of adolescent students in Tehran. Tanaffos. 2010; 9(2) : 33 -42

  • 48.

    Kelishadi R, Hashemi Poor M, Sarafzadegan N, Sadri GH, Bashardoust NA, Alikhasi H, et al. Effects of some environmental factors on smoking and the consequences of smoking on major cardiovascular disease (CVD) risk factors in adolescent: Isfahan healthy heart program-heart health promotion from childhood (In Persian). Guilan Univ Med J. 2004; 13(50) : 62 -75

  • 49.

    Belbeisi A, Al Nsour M, Batieha A, Brown DW, Walke HT. A surveillance summary of smoking and review of tobacco control in Jordan. Global Health. 2009; 5 : 18 [DOI][PubMed]

  • 50.

    Kassiri H, Rafiee A, Haghighizadeh MH, Kazemzadeh N. Epidemilogy of cigarette smoking among male students of Ahvaz Jundishapur University of Medical Sciences, Iran. Jentashapir J Health Res. 2010; 2(2) : 1 -7

  • 51.

    Namakin K, Sharifzadeh G, Miri M. Prevalence of cigarette smoking and evaluation of attitude and knowledge in its high school boys in Birjand, 2005. J Birjand Univ Med Sci. 2008; 15(1)

  • 52.

    Thorlindsson T, Vilhjalmsson R. Factors related to cigarette smoking and alcohol use among adolescents. Adolescence. 1991; 26(102) : 399 -418 [PubMed]

  • 53.

    Weiss JW, Mouttapa M, Cen S, Johnson CA, Unger J. Longitudinal effects of hostility, depression, and bullying on adolescent smoking initiation. J Adolesc Health. 2011; 48(6) : 591 -6 [DOI][PubMed]

  • 54.

    Whalen CK, Jamner LD, Henker B, Delfino RJ. Smoking and moods in adolescents with depressive and aggressive dispositions: evidence from surveys and electronic diaries. Health Psychol. 2001; 20(2) : 99 -111 [PubMed]

  • 55.

    Barmpagianni E, Travlos A, Kalokairinou A, Sachlas A, Zyga S. Investigation of aggravating psychosocial factors on health and predictability of smoking and alcohol use in post adolescent students. Health Psychol Res. 2013; 1(2) : 15 [DOI]

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