The Journal of School Nursing2021, Vol. 37(5) 333–342© The Author(s) 2019Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840519871641journals.sagepub.com/home/jsn
Preventing smoking among adolescents is critical. This study evaluated the effectiveness of the Smoking Prevention Education Program among nonsmoking adolescents. A quasi-experimental study design was used. Data were collected from Year 5 students (n = 140) from four government primary schools in the Kuantan and Pahang districts of Malaysia. The participating schools were randomly assigned into the intervention and control groups. Questionnaires and exhaled carbon monoxide (CO) levels were used to collect data at the baseline and at 3 months postintervention. At 3 months postintervention, the percentage of nonsmokers remained 100% in the intervention group, while 2.9% of the participants in the control group reported to have smoked in past 7 days. Comparatively, the mean scores of attitudes, subjective norms, and nonsmoking intentions of the intervention group improved significantly. The intervention was effective in preventing smoking initiations among Malaysian adolescents; however, further evaluation of this intervention is needed among varied populations.
adolescents, nonsmoker, smoking, education program, school nurses, carbon monoxide
The habit of smoking has become the main public health concern among the younger population in Malaysia (Institute for Public Health, 2012). Initiating smoking in early adolescence increases risks of stroke and respiratory infection (Bonnie, Stratton, & Kwan, 2015). Immaturity of adolescents’ brains causes nicotine to have more troublesome effects (Dahlui et al., 2015). Globally, smoking-related diseases are the main causes of premature death (World Health Organization, 2011). More than 5 million people die each year due to smoking-related diseases, at an average of one person every 6 s and 1 in 10 adults worldwide (Centres for Disease Control and Prevention, 2016).
In developing countries, 70% of deaths are due to smoking-related diseases. Malaysia is no exception. Annually, 20,000 Malaysians die from smoking-related diseases (Institute for Public Health, 2012), and 3 billion Malaysian ringgits (more than US$700 million) per year have been spent on treating chronic obstructive pulmonary disease, ischemic heart disease, lung cancer, and other smoking-related diseases (Ministry of Health Malaysia, 2016). A national survey conducted among Malaysian adolescents (10–19 years old) revealed that 78.7% of the smokers had their first cigarette before the age of 14 years (Institute for Public Health, 2016). According to the World Health Organization (2011), it is estimated that half of the smokers who smoke during their adolescence are predicted to continue smoking for another 15–20 years and are less likely to quit smoking due to nicotine addiction.
Preventing smoking is therefore critical among Malaysian adolescents. However, despite implementing various smoking prevention programs, there is no significant reduction in smoking prevalence in Malaysia (Ministry of Health Malaysia, 2016). Most of the available smoking prevention programs have been targeted at teenagers, young adults, or adolescents who are already smokers (Ministry of Health Malaysia, 2016). There is a need to develop and evaluate the effectiveness of a smoking prevention program that targets nonsmoking adolescents as early as when they are in primary schools in Malaysia.
Ajzen’s (1991) theory of planned behavior (TPB) was used to develop the school-based Smoking Prevention Education Program (SPEP) intervention in this study. According to TPB, the proximal determination of behavior is intended to involve a particular behavior and perceive control over that behavior (Higgins & Conner, 2003). Furthermore, TPB (Ajzen, 1991) suggested that three factors shape and influence an individual’s behavioral intention and behavior. The three factors are attitude toward the behavior, subjective norms, and perceived behavior control (Higgins & Conner, 2003). Based on this, an adolescence’s smoking intention is influenced by the adolescent’s attitude toward smoking, how the people around them (friends and family) perceive smoking, how easy or difficult for them not to initiate smoking behavior, and knowledge about the dangers of smoking (Ajzen, 1991; Nazari, Hosseini, & Kaveh, 2013; Su et al., 2015).
As such, the intervention in this study was developed to influence adolescents’ intentions not to smoke through their attitude toward smoking, the perception and influence of their friends and family toward smoking behavior, and by their perception of their own behavior control of how easy or difficult it is not to be influenced to initiate smoking. The study aimed to evaluate the effectiveness of the SPEP among nonsmoking Malaysian adolescents.
The study incorporated a quasi-experimental design to examine the effectiveness of the school-based SPEP for nonsmoking adolescents. Ethics approval was obtained from the International Islamic University Malaysia Research Ethics Committee, Ministry of Education Malaysia, and Pahang State Education Department. Written informed consents from the schools’ principals and parents were received before the start of the study.
Based on previous school-based smoking prevention programs (Wen et al., 2010), it was regarded that SPEP intervention in this study will have a medium effect on the primary outcome. Postulating Cohen’s d of 0.5 with 80% power and two-sided 5%, n = 52 per group was required (Cohen, 1992) in this study. Considering a 10% of attrition rate, total 57 participants per group and total 114 participants were needed in this study.
Forty primary schools in Kuantan, a city in Malaysia, were eligible to take part as these schools implemented the Young Doctors Club Program, a school-based health promotion program, according to the Pahang State Education Department. Of the 40 eligible schools, 10 schools were willing to participate in this study. Of these 10 schools, 4 primary schools (2 from urban area and 2 from rural area) were randomly chosen based on the sample size and were randomly assigned into either the intervention group or the control group. The unit of randomization of the schools instead of students was to minimize data contamination between the intervention and control groups.
Participants were selected from one class (n = 28) of each school using random sampling as the classes had an approximately equal number of participants required in sample size. The inclusion criteria of the participants were students who were (1) primary school students (Grade 5), (2) 11 years old, as Dahlui et al. (2015) had found that the majority of Malaysian adolescents started smoking at this age, and (3) nonsmokers (carbon monoxide [CO] levels of less than 4 parts per million [ppm]) to maintain the baseline “never smoker.” The exclusion criteria were (1) ex-smokers (self-reported) or smokers with CO levels of more than 4 ppm, (2) students who were unable to understand and read the national language (Bahasa Malaysia), and (3) children with special needs.
Prior to the study start, the researcher arranged a discussion with the principals and schoolteachers for their participation in this study. The principals who agreed for their schools to participate in the study signed written consent forms. Of the 10 schools that agreed to participate, 4 schools were randomly chosen and assigned into two groups (control group and intervention group) by asking an independent person to toss a coin.
Self-administering questionnaires were used to collect the baseline (before intervention) and follow-up (at 3 months postintervention) data in this study. The questionnaires with translated versions (in English and Malay) were adapted and modified from the previous study by Melson (2014). The original questionnaires were developed by Melson based on the TPB by Ajzen (1991). All participants were able to read and complete the self-administered questionnaire in their preferred language. Content validity assessment was conducted by smoking prevention experts to ensure the suitability of the questionnaires, and three new additional questions were added based on the Malaysian context such as how the religion Islam influenced the smoking prevention and the pocket money received by the participants. The reliability test was conducted using Cronbach’s α. CO levels were measured to screen the participants and to enhance the reliability of the self-reported smoking status during the follow-up.
The baseline questionnaire was divided into three parts with 40 items: (A) the participants’ sociodemographic characteristics and the smoking behaviors of their relatives and friends (9 items), (B) smoking prevention activities in school (7 items), and (C) attitudes that focused on three variables (attitudes, subjective norms, and perceived behavior control; 24 items). Sample question for (B) smoking prevention activities in school include “Were you taught in any of your classes about the dangers of smoking?” All responses to part C were on the 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree). There are 9 items measuring attitude, a higher value represents an attitude of being in favor of smoking initiation. Sample question for measuring attitude include “I want to be a nonsmoker.” There are 6 items measuring subjective norms, a higher value represents an individual experiencing social pressure not to initiate smoking. Sample question for measuring subjective norms include “Most people who are important to me think that I should be a nonsmoker.” There are 6 items measuring perceived behavior control, a higher value represents an individual feeling in control from initiating smoking. Sample question for measuring perceived behavior control include “For me to be a nonsmoker would be easy.” There are 3 items measuring behavior intention, a higher value represents less intention to initiate smoking. Sample question for measuring behavior intention include “I intend to be a nonsmoker.” For this study, the attitudes, subjective norms, and perceived behavior control components achieved Cronbach’s α values of .862, .855, and .905, respectively. Questions on behavioral intention achieved Cronbach’s α of .956 for this study.
A total of 26 questions were in the follow-up questionnaire, which includes only part C of the baseline questionnaire and additional questions on the smoking statuses of the participants whereby each participant was asked to choose a description of their smoking status.
CO level. The standard handheld CO analyzer (piCO Smokerlyzer, Bedfont Scientific Ltd., England) was used to identify baseline never smokers prior to starting the study. Participants with exhaled CO levels of less than 4 ppm were considered nonsmokers. To standardize the micro CO analysis, each participant was asked to inhale fully and then hold their breath for 20 s before exhaling rapidly and completely into the disposable mouthpiece. Pretest and posttest sceeenings of exhaled CO levels were done to support self-reported smoking statuses and to avoid information bias.
The objectives of the SPEP intervention were to (1) minimize smoking intentions and prevent smoking initiations among the participants, (2) increase the awareness and knowledge of the participants regarding smoking-related issues, (3) increase the awareness of the participants regarding peer and family influences to smoke, (4) teach and practice refusal skills to the participants, and (5) develop positive attitudes in participants against smoking. The development of the SPEP intervention involved the combination of the social influence and social competence approaches, guided by the existing literature and Ajzen’s (1991) TPB.
The SPEP comprised two main components, including (1) health education and (2) activities and videos. The health education component consisted of three sessions, and each session took approximately 2 hr. The sessions were delivered over a period of 1 month with one session in each week. The contents of the SPEP were delivered through direct and indirect methods. The direct method was conducted through lectures, an educational video, group work, and active learning. The indirect method was done through the distributing of button badges and fridge magnets with “Be Free from Smoking” printed on them to increase awareness among the participants and to prevent smoking uptake through a simple message. To ensure standardization, the SPEP intervention was delivered by the same researcher to the participants in their usual classroom settings during school hours combined with relevant school subjects such as physical education classes. Details of the intervention are presented in Table 1.
The study was conducted between September 2016 and January 2017. One month before the baseline data collection, parental consent with letters of information sheets, which consisted of detailed information on the study purposes, objectives, and eligibility of the participants and ethical issues were sent by the teachers to the parents or guardians via the students themselves. Parents or guardians who refused to allow their children to participate in this study were excluded from this study. The refusal rate was about 10%. The researchers confirmed the reliability of the consent forms received with the participants’ parents via phone calls before the commencement of the intervention and data collection.
The main researcher and research assistant introduced themselves to the potential participants and inquired if they were willing to participate in the study. The researcher explained to the students about the purposes, methods, and process of the study according to the information sheet. At the baseline, all participants from both intervention and control groups completed the baseline questionnaires and received a lecture on the hazards of smoking. In the usual classroom, the baseline questionnaires were administered, and the completion of the questionnaires took approximately 15–20 min.
The intervention group received the SPEP intervention over a month, and at 3 months after the baseline data collection, the main researcher and research assistant returned to all participating schools to conduct follow-up data collection and repeated the exhaled breath CO test to enhance the reliability of the self-reported smoking statuses. The 3-month period was chosen to ensure the short-term effectiveness of the SPEP.
The data were analyzed using IBM Statistical Package for Social Science Software Version 23 to estimate the effects of the intervention in relation to the control group. Descriptive statistics were used to analyze the characteristics of the participants in each arm of the study (intervention and control). χ2 test, Fisher’s exact test, and independent t test were used to determine whether there were any significant differences in sociodemographic variables between the intervention and control groups. After confirming the normality, parametric statistical analyses were used for an inferential analysis. Independent t test was conducted to determine whether there was a significant difference in mean scores of the elements of the TPB between the intervention group and the control group at the baseline and at the 3 months follow-up. Multivariate analysis of variance was used to evaluate the effectiveness of SPEP by comparing the differences in the follow-up scores on the outcome variables including behavioral intention, attitudes, subjective norms, and perceived behavioral control between the intervention and control groups. The data were adjusted for the baseline scores and the demographics.
Figure 1 presents the Consolidated Standards Of Reporting Trials (CONSORT) diagram of the study. In total, 145 participants completed the baseline questionnaires: 72 in the intervention group and 73 in the control group. However, during follow-up, two students from the intervention group and three from the control group dropped out from the study due to being absent from the schools (medical leave and change of class). The attrition rate of the participants at the 3 months follow-up was 6.9%. Therefore, the final number of participants was 140. As such, the final analyses were limited to the participants who completed all questionnaires (baseline and follow-up).
As summarized in Table 2, both intervention and control groups have similar sociodemographic characteristics, except for the number of close relatives who were smokers (p = .007) and the role of religion in preventing smoking (p = .049). At the baseline, the mean score for perceived behavioral control was significantly higher in the control group than in the intervention group (p < .001). Meanwhile, at the follow-up, the mean score for behavioral intentions was significantly higher in the intervention group than in the control group (p < .001). However, at the follow-up, the mean score of the control group was significantly higher than the mean score of the intervention group for attitudes (p < .001) and perceived behavioral control (p = .006).
Table 3 represents the multivariate analysis of covariance test that was used to evaluate the effectiveness of SPEP intervention. Based on previous literature, the following demographics including gender, educational status, and smoking status of the parents and the baseline scores were used to adjust the data. There was a significant effect of the intervention on the behavioral intention and attitudes (p < 0.001), after the Bonferroni correction. However, no significant differences were found for the subjective norm and perceived behavioral control.
This study has shown the SPEP intervention to be significantly effective in reducing smoking initiations and smoking intentions while improving attitudes, subjective norms, and perceived behavioral control among Malaysian adolescents participating in the study. In the intervention group, none of the initially nonsmoking adolescents went on to smoke during the 3 months follow-up. This finding highlights the success in maintaining the nonsmoking statuses of the adolescents short term. This finding supports an earlier study by Stamm-Balderjahn, Groneberg, Kusma, Jagota, and Schönfeld (2012), which showed that participants in the intervention group were expected to remain abstinent from smoking four times more than the control group. With stronger life and cognitive skills to resist peer influence (Sorensen, Gupta, Nagler, & Viswanath, 2012), participants in the intervention group were able to resist smoking initiation as compared 2.9% (n = 2) of the control group who initiated smoking. This finding also revealed the importance of implementing a preventive program at an early age (11 years old), before more adolescents would try smoking and eventually become habitual users. The majority of the adolescents in Malaysia initiated smoking at the age of 12 (Dahlui et al., 2015; Khairani, Norazua, & Zaiton, 2007). Therefore, smoking prevention programs should start at the age of 11, when the percentage of adolescents initiating smoking is lower (Karimy, Niknami, Heidarnia, Hajizadeh, & Montazeri, 2013).
This study highlights that the combination of the social influence and social competence approaches in a school-based smoking prevention program will be most effective in reducing smoking uptake among adolescents. A systematic review (Thomas, McLellan, & Perera, 2013) concluded that the combination of the social competence and social influence approaches showed a statistically significant effect on preventing smoking initiation among adolescents. Hence, the finding of this study proposed that the SPEP intervention was effective in educating adolescents to identify social influence and to learn skills to refuse smoking, thus preventing smoking initiations.
At the baseline, there was no significant difference in attitudes between the intervention group and the control group. However, after going through the SPEP intervention, a significant change in attitudes was identified among the adolescents from the intervention group. This finding is consistent with a previous study by Nazari, Hosseini, and Kaveh (2013). Adolescents’ smoking intentions were determined by their attitudes toward smoking (Melson, 2014). Therefore, adolescents with the lowest intentions to smoke had strong negative attitudes toward smoking.
Positive attitude toward smoking is associated with smoking intention (Davey, McClenahan, & Zhao, 2014; Mohammadpoorasl et al., 2010). After going through the SPEP intervention, adolescents could have been more knowledgeable about smoking issues, legislation, and smoking-related health risk perceptions and were more likely to demonstrate negative attitudes toward smoking. Such changes in attitudes may decrease smoking intentions. A previous study (Cosci, Zagà, Bertoli, & Campiotti, 2013) showed that having positive beliefs related to smoking and a lack of knowledge on smoking consequences will lead adolescents to smoking initiation. Similar to the findings of this study, Sorensen, Gupta, Nagler, and Viswanath (2012) claimed that through smoking prevention programs, adolescents get information and skills specific to preventing smoking, which further help them to develop positive attitudes against smoking.
In this study, no difference on subjective norms was found between the adolescents from the intervention and control groups. This finding is in contrast to a study by Nazari et al. (2013), which found that the mean score of subjective norms showed a significant increase after an educational intervention. In general, subjective norms are mostly affected by perceptions on what their family and friends think they should do (Kosmidou, Theodorakis, & Chroni, 2008). Davey, McClenahan, and Zhao (2014) suggested that perceived approval from family members and friends was a significant factor of adolescents’ intentions to smoke. After going through the SPEP intervention, the adolescents’ perceived no difference or minimal social disapproval toward smoking from both the intervention and control groups. This finding suggests engaging family members and the social community in future smoking prevention educational programs among adolescents.
Hampson, Andrews, and Barckley (2007) found that one’s smoking intention was higher when the individual believed that most of their friends were smokers. Another study had noted that one’s smoking intention was increased when an individual received higher social pressure (Karimy, Niknami, Hidarnia, & Hajizadeh, 2012). Through the SPEP intervention, adolescents learned to identify sources of their perceptions of social pressure and have control over pressure. Even though there was no significant change in perceived behavioral control in the intervention group before and after going through the SPEP intervention, perceived behavioral control in the intervention group improved after receiving the SPEP intervention compared to control group. According to Notani (1998), unfamiliarity with a behavior may influence perceived behavioral control and smoking intentions. Perceived behavioral control is a common predictor of intention to smoke and the extent to smoke (Guo et al., 2006) that may then influence adolescents’ capabilities of refusing cigarettes. Consequently, when individuals have intentions to smoke, they hold more positive attitudes toward smoking, have greater perceived behavioral control upon smoking, and believe that the community expects them to continue smoking. Therefore, this finding suggests that the SPEP intervention was effective in improving adolescents’ perceived behavioral control, which in turn decreased smoking intentions.
Firstly, the differences between the schools (e.g., size) were unmeasured, which might have contributed to the differences between groups as the study design was quasiexperimental. Secondly, only short-term effects were observed due to cost and time constraints. As such, future longitudinal studies should be conducted to examine the effectiveness of the SPEP intervention in a longer duration. Thirdly, the study involved only students from primary schools in Malaysia. Therefore, the findings can only be generalized to similar school settings. Future studies should be conducted in multiple cities. Also, the numbers of adolescents initiating smoking in the control group were too small, and the short time interval of the follow-up limits the power of the study to detect any significant differences between the intervention and control groups. A previous study found that being in the intervention group predicts a slower increase in tobacco use compared to the control group (Weichold, Tomasik, Silbereisen, & Spaeth, 2016). Therefore, this warrants a longitudinal study to examine the effectiveness of the intervention in a longer duration. Finally, although the use of CO as a marker of smoking status is useful, the presence of environmental sources of CO and a short half-life increased the chances of false reading. Future studies should take the reading of CO levels during school time in a room with adequate ventilation to minimize the exposure of students to environmental sources of CO. Considering the short half-life of CO, the outcome of the study was focused on self-reported smoking statuses and using CO markers to encourage truthfulness on the responses from the adolescents. Future studies may consider using other methods, such as saliva nicotine tests, to identify the participants’ smoking statuses.
With the high prevalence of smokers in Malaysia, implementing an effective and early smoking prevention program for Malaysian adolescents is crucial. This study has demonstrated that the SPEP intervention was effective in increasing Malaysian adolescents’ attitudes against smoking, subjective norms, and perceived behavioral control, which in turn decreased smoking intentions. After testing the long-term effectiveness of the SPEP, this intervention can be integrated into school curricula and as a health promotion strategy by health staff to prevent the initiations and escalations of smoking among adolescents. School nurses can deliver this intervention in collaboration with other healthcare professionals and family members at the school level. This study found that SPEP was effective in improving nonsmoking intentions among students but not attitudes and perceived behavioral control; therefore, more robust testing of this intervention is required to evaluate its effectiveness.
The authors would like to thank the participants, the participating schools, Pahang State Education Department, and Ministry of Education of Malaysia for continuous support for this research.
Dr Shefaly Shorey was responsible for the study design and the first draft of the manuscript while all four authors, including corresponding author, Dr Shefaly Shorey, the first author, Dr Mohd Said Nurumal, second author, Ms Siti Hajar Mohd Zain and third author A/Prof Mohd Haniki Nik Mohamed, were responsible for the finalized manuscript. All four authors have contributed significantly and are in agreement with the content of the manuscript.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Research Initiation Grant Scheme (RIGS 15-087-0087).
Shefaly Shorey, PhD, RN, RM https://orcid.org/0000-0001-5583-2814
Supplemental material for this article is available online.
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Mohd Said Nurumal, RN, PhD, is an assistant professor at the Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia.
Siti Hajar Mohd Zain, RN, MNSc, is an academic trainee at the Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia.
Mohamad Haniki Nik Mohamed, RPh, PharmD, is an associate professor at the Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia.
Shefaly Shorey, PhD, RN, RM, is an assistant professor at the Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
1 Kulliyyah of Nursing, International Islamic University Malaysia, Kuantan, Malaysia
2 Kulliyyah of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
3 Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Corresponding Author:Shefaly Shorey, PhD, RN, RM, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597, Singapore.Email: nurssh@nus.edu.sg
