Document 6521091

of
h
ment
Exploring Why Girls Smoke
in Malaysia -A Qualitative
Approach
6-14
JPH
821
.com
at
b.com
Nabilla AI-Sadat,l'2MBBS, MPH, and Colin W. Binns,2 MPH, PhD
The fast increase in the rate of uptake of smoking amongst adolescent girls in Malaysia is a public
health concern. The objective of this study was to investigate factors that influenced the initiation
of smoking and the effects of advertisement on consolidating the smoking habit among teenage
girls in the urban city of Kuala Lumpur. Qualitative research was conducted using both interviews
and focus group discussions with groups of adolescent girls. Data collected was analysed using
grounded thematic theory methodology and validated using methodological triangulation. The
reasons for initiating smoking elicited from the study can be grouped into 4 general themes;
influence by peers, influence of seeing parents smoking, misguided belief that it could alleviate
stress and finally that it would impress others. Smoking imageries in media and advertisements
were not primary influencing factors in the initiation of smoking but it encouraged them to progress
to become regulars. Ways should be sought to empower girls to feel more confident about resisting
pressuresto initiate smoking. This could be done through activities such as positive peer sports,
education on how to alleviate stressand curbing of smoking imageriesin the media.
Keyvords: adolescents; qualitative study; smoking; tobacco advertisements; Nlalaysia
Introduction
Globally, the use of tobacco among women and young girls is on the rise, whereas for
men,l'2 it is on the decline. Although the current global prevalence for men is about
four times higher than women, this situation is quickly changing.2'3The World Health
Organization predicted that the prevalence of smoking among women worldwide will
b e Z O V , by 2O 25 ,l a l a rg e i n c re a s efro m th e c urrent 12% preval encerate.-3
R ecent studi es
showed that in most countries young girls were smoking almost as much as boys, and
in some countries, their prevalencewas already higher.a
Smoking continues to be a critical public health problem in Malaysia despite
significant efforts to reduce the prevalenceof cigarette smoking in the recent decades.
The prevalenceof smoking among adolescentsin Malavsia increased significantly from
9 .J %oin 19865t o 1 6 .9 V oi n 1 9 9 6 .6Of g re a ter concern w as a survevconducted i n 1995
by the Ministry of Youth and Sports on negative behaviors of five thousand adolescents
in which 8O% indicated that they had experiencedsmoking at least once.7
From the rDepartment of Social and Preventive Medicine, University of Malaya; 2School of Public Health, Curtin University
of Technolog_v,
GPO Box U 1987, Perth, WA 6845, Australia.
Address correspondence to: Nabilla AI-Sadat, Department of Social and Preventive Medicine, Faculty of Medicine, University
of Malaya, 50603, Kuala Lumpur, Malaysia; e-mail: nabilla@ummc.ed,r.my.
6
Exploring why girls smoke in Malaysia I Al-Sadnt, Binns
7
Another area of particular concern is the increasing number of young girls and
women who are taking up the habit of smoking. Between 1996 and 2004, tobacco use
among adolescent girls has doubled from 4.8Vo6to 97o.8A recent survey among adult
women by the Ministry of Health in Malaysia in 2006,e showed there was a further
increasein the numbers of women smoking. In areaswhere tobacco use is still relatively
low among women and young girls, a golden opportunity exists for preventing increased
uptake.
Des pit e ex t e n s i v e re s e a rc h o n th e p s y chosoci al correl ates and determi nants of
smoking among adolescentsin MalaysiaT,e'r3
relatively little is known about how these
adolescentsview smoking in the context of their everydaylives. Even though it is widely
recognized that multiple factors influence tobacco use, there are major gaps in our
understanding of smoking uptake among teenagers.This is because the focus of much
researchhas been the identification of predictors of these risk behaviorsto the exclusion
of investigatingthe reasonsbehind the engagementof these behaviors in the teenager's
social context. In this study, qualitative research was used to understand the subjects
fro m t heir or v n fra me o f re fe re n c e . Qu a l i tati ve research i s focused on know i ng,
understanding and exploring the complexity of human life. It allows patterns emerging
fro m f ield dat a t o i n fo rm re d e v e l o p me n t o f theory.t+ -16Qual i tati ve studi es done i n
developedcountries have shown evidenceof relationshipsbetween social representations
of different groups and smoking identi1i"..l7-20
In Malavsia, only a few qualitative studies have been undertaken on the uptake of
cigarette smoking. A recent qualitative survey was conducted in a few states in Malaysia
l o o k ing at t he ef fe c ti v e n e s so f a n ti to b a c c o campai gns and the cul tural factors that
influenced smoking uptake.l0 Horvever,application of these findings to the adolescents
i n t he br oader Ma l a y s i a n c o n te x t i s l i mi te d . The ai m of the present study u' as to
investigate factors that influenced the initiation of smoking and its progression among
voung teenagegirls in the urban city of Kuala Lumpur using qualitative methods.
Methods
The study \vas conducted during November 2005 to February 20O6 in Kuala Lumpur
and PetalingJaya, a suburb on the outskirts of Kuala Lumpur. Grounded theorv
methodologvor thematic analyticalmethodologyusing both ethnographicsemi structured
i n t er v ien' s and f o c u s g ro u p d i s c u s s i o n s(F G D ) u,as devel oped.Thi s process i s more
inductive than content analysisas categoriesare not decided prior to coding but induced
from the collected data.21This allowed the exploration of the full range of participant
views and experiences.Ethical clearance was received from the Malaysian Economic
P l a n n i n g U n i t a n d t h e M i n i s t r y o f E d u c a t i o n . I n t e r v i e r v sa n d F G D s a r e s t r i c t l y
confidential and no names were used during the interviews.All participants were asked
to give their consent prior to commencement of the study.
The first phase of the study involved 84 face to face interviews with teenage girls
a nd y oung wom e n fo u n d s mo k i n g i n p u b l i c pl aces. The parti ci pants w ere i ni ti al l y
approached on observation of their smoking status in public places in the city centre
such as cafes, shopping mall, bus stops or public parks (convenientsample).The
interviews were conducted throughout the day, especiallyon weekends.Verbal permission
was then obtained before the subjectswere interviewed.Further permissionwas obtained
for the interviews to be audio-taped. At no time were any names or any other
identification recorded. The girls were then asked if they could get more of their friends
to be interviewed (snow-balling sample).
8
Asia-Pacific Journal of Public Heahh I Yol. 20, Supplement, October 2008
D u r i n g t h e s e c o n d p h a s e , f o c u s g r o u p d i s c u s s i o n sw e r e u n d e r t a k e n t o o b t a i n
complementary information not available from the structured interviews as well as to
explorehow the adolescentgirls interpret and decodeadvertisementsand media portrayal
of smokers as an influencing factor in decision to smoke. Eight focus group discussions
were held for three different groups of girls homogeneous in their smoking behavior:
g i r ls ( 11- 16 y ear s )w h o s mo k e d a n d a g re e dto be i n the study (2 groups), Fi rst Formers
(averageage l3 years) who were non-smokers (3 groups), Fourth Formers (averageage
l6 years) who were non-smokers (3 groups). The size of the groups ranged between 6
and 8 people. The FGDs for the smokerswere held in community halls while the FGDs
for the non-smokerswere conducted in classroomsat the schools.
T he f oc us gro u p d i s c u s s i o n sa n d i n -d e p th-i ntervi ew sw ere conducted i n B ahasa
Malaysia by the first author and two research assistants.
Analysis
The interviews and focus group discussionswere tape-recordedand transcribedverbatim
in the Malay language. Data were coded and then analysed in Malay according to the
themes induced from the study.Quotes were selectedto representthe mentioned themes
and finally were translated into English. Microsoft Word was used for text analysisand
data management.The computer program on qualitative analvsis;NVivo version 7.0 was
used to facilitate the organizationof the qualitative data into a structured form.2l
Results
Demographic and Descriptive Statistics
Mos t of t he parti c i p a n ts i n th e i n te rv i e w w e re Mal ay (9J.2V o)gi rl s, aged l 4-21 years
and w'erefrom urban schools (92.8%). A few were from other urban institutions (4.87o\
or were working (2,4Va).Most of them reported that they onlv smoked out of their homes
a nd t heir s m ok in g s ta tu s w a s n o t k n o w n to t hei r parents. Most of them al so descri be
th em s elv est o be " k a k i l e p a k " (i .e . Ii k e to l o i t er around shoppi ng mal l s doi ng nothi ng)
and late sleeperson non-school davs. The norm is to smoke 3-4 cigarettesper day and
most of them use their own pocket monev to purchase the cigarettes.A feu, of them
acknowledgedthat they are hear.ry(i.e. a pack of 20 cigarettes a day) smokers and are
addicted to it as they have to wake up at nights to smoke. I\Iost of them do know the
health risks associatedwith smoking such as lung cancer.
Reasons for Initiation of Smoking
The reasonselicited from the study can be grouped into four general themes. The most
frequently cited reason for initiation of smoking is peer influence. Smoking has been
d e s c r ibed as a t o o l to ma k e fri e n d s , b e c o me accepted i n a fri endshi p group and to
overcome loneliness.
"I feel lonely since I l"ft ruy hometowm im East Malaysia to work here in
Peninsular. Most of my friends srnol<e, it's a great and cheap wa), to make
lnore friends."
- l8 year old Chinese girl working in Kuala Lumpur from Sabah
Exploring why girls smoke in Malaysia / Al-Sadat, Binns
g
"I don't get much freedom frorn nxy parents. It's only recently that I was
allot'tted to go out to totan with friends. I just wanted to try smoking out of
curiosity looking at my friends doing it but in the end, I feel it'sfun."
- l8 year old Malay schoolgirl from Kajang
More often than not, these girls are social smokers and only smoke in groups and out
of their homes. Some girls have also described having more friends of the -^1" gender
than females and this has led them to experiment with smoking.
"I haue many boys as friends. They are just friends, you know (laughs). We
do things together. They like me smoking and I like them srnoking too."
- 2l year old part-time waitress from Bangsar
Another common theme is stress.Stressor tension can be related to three reasons,the
family (parental stress),the friends (peer pressure,teasedby friends) or school work.
"My parents' just don't understand me. Its not that I want to smoke, it's just
that there's so much sfressat horne. My brother hates rne, he kict<sand shouts
at me. I had to run a1A)ay
from home once but uhen I came back, the family
were not happy to see me, it makes me feel I had to do something. Maybe
that's why I smoke!"
l5 year old girl, heary smoker from Setiawangsa
"I hate mrystepfather. He only loves my,mother. He hqtes me and rny younger
brother. He rnakes my hfe miserable. Why does this happen to me? IVIymot|er
thinl<s I am ok but since she had another b"by utith the step
father, I said
that's it, I haue to do something to relieve this stress.Since then, I
followed
my younger brother smoking."
- l9 year old Malay college girl from Selayang
Another frequent comment about the reason for smoking was "no privacy" as a stress
factor.
"l don't know really wW I smoke, I have everything. lt's just that the house is
too noisy since rny mother starts taking care of the neighbour's children...
tensionlah, no priuacy at qll!!"
- l5 year old Malay schoolgirl from Bangsar
Another frequent reason given by the respondents was the role modeling effect by
parents. Parentswho smoked often portray contradictory roles and this may mislead the
children to view smoking as safe and thus, it was acceptableto smoke.
"My father is my Lt'eroand he smokes. He often asl<srne to buy his cigarettes
for him. I don't think he would let me do aiything dangerousso I don't think
that smoking is dangerousat all."
- l4 year old Malay schoolgirl from Gombak
In Malaysia, drugs are viewed as very dangerous and crimes involving drugs are often
dealt with severely(e.g. the capital punishment for drug pushers and forced ."hubilitation
sentences in juvenile centres for young drug addicts). However, cigarettes are not viewed
in the same manner. For example, legislation involving sale to minors is often not
lO
A:ia-Pacifu Jtrurnal of Public Heahh /Yol. 2O, Supplement, October 2008
enforced and teenagers have been seen freely purchasing cigarettes either in boxes or
loose from 24 hour kiosks. The parents smoking or any other family member smoking
will reinforce the belief that smoking is safe and not likely to cause any harm. Having a
family member at home smoking also makes the cigarettes more accessible to the young
children.
"My father taught me (paused)."
lntenieuter: "Yourfather taught you?"
"Well, he asked me to buy for him. He smoked in front of me. Slouly I took
it trryself. Once I tried, I like it."
- l5 year old schoolgirl from Sentul
"l rernembered my first smoke. I utas 6 and I was with my cousins in the
kampong. My father gaae us a puff at his cigarette in turns. See, I tilasn't
inJluenced hy friends, but by my father."
- l6 year old schoolgirl from PetalingJaya
The other reason mentioned by one of the interviewees and reinforced by the nonsmokers focus group is along the theme of attracting attention to themselves.
"Smoke? lt's for me to attract the boys. The boys always loolz at girls smoking
ilifferently."
l5 year old smoker from Cheras
"l think sm.okingmakes a girl rnore popular (lah)."
14 year old non-smoker from Kajang (from FGD)
Another reason mentioned by one of the interviewees is the effect of media
representations of smokers and advertisements that had her intrigued to start smoking.
"Hard to say wlry I stqrted to smoke, mainly because the girls who smoke in
the movies look good and cool."
- l4 year old schoolgirl from Damansara
"IVo, I ilon't think the images are sttractiae enough for anyone to be influenced
to stort smoking. Usually, they are influenced by friends who sncoke. But I
know this girl utho already is a smoker who feh girls who smoke in the mouies
laok amazing and cool. And she smokes regularly now."
The focus group discussions among the girls who smoked revealed a few fascinating
findings. Apparently, there are three stages in the uptake of regular smoking. The first
stage is wher e th e y fe l t i t w a s w o rth a try, out of curi osi ty or j ust because of i ts
accessibility. Most of them had parents and siblings who smoked at home and in front
of them. Th"y described that usually they are introduced to smoking by their own father
where they are often asked to purchase the cigarettes.
"You know, I smoke because of the parents. lf parents smol<e,their children
will snoke too. Everyday, m.yfather ask"edme to buy cigarettesfor him. He
smokes in front of me. Slowly I took it myself. Once I tried, I like it."
Exploring why girls smoke in Malaysia / Al_Sadat, Bims
II
The second stage is where the smoking habit leads them to form friendship
groups who
they "hang out" with almost every weekend and during school holidays.
S;;" of them
came from different schools and neighborhoods but found each other
via the same
common habit of smoking. There were also a few regulars in the friendship
group who
had tried smoking but did not like the taste and opteJ out of smoking,
but stiii mainrain
ties within the friendship group. Although this phenomenon of ,ron smokers
within a
'smokers'
friendshiP group is uncomr.ton, this was found in one of the friendship
group
participating in this focus group discussion.
"I don't know, man. I loue to hang out with these girls. They unfurstand
mc
tnore than my family. I know they smoke
from doy on, but .... rhey dont
care if I don't smoke and they don't make me
feel an outsider.,'
It is during these hangouts together, usually in public places such
as the shopping malls
or clubs, that their smoking habit is regularized.
"If not because of thesefriends, I would not haae becorne hookcd
on smoking.
But, I have no regrets, they are my best
friends nout."
Some remain as social smokers; only smoking when out of the house
and within the
group' But some confessed that they sneak out of the house occasionally
at night to
have a puff. And there are a few that admitted that they were addicted
and crave for
the early morning puffs.
These girls (smokers) also believed as the non-smokers that
advertisements and
images of girls smoking do not have a strong influence on girls
to initiate smoking but
Ieads the experimental smokers to become .Jg,rl". smokers as
explained by one of them
and agreed by all in the group.
"l don't think I started to smoke because of the aduertisements.
The fri^end.,s
influence is stronger than any aduertisements.But sometimesuthen
utl warch
the mouies where the girls are smoking, we
feel they must feel good to smoke,
so I guessin a "way,we are a bit affected.',
In the other FGD, similar sentiment was shared,
"The advertisernentsusually-portray successfulpeople,
so we feel like folkruing
them to smoke. lf they smoke and'can b" iu""Lrsful, why cin,t ute?,,
Discussion
The evidence frgm this study emphasizes the complexity
of the reasons behind the
initiation of smoking among girls. There are a m.rltitude oi i.rt".".ting
factors that lead
to a girl smoking. The most commonly mentioned reasons were
pee. influence as well
as relieving stress which could be induced by other reasons
as reflected in this study.
For example, stress within the family, such as the mother remarrying
or having a new
baby-or having a new job, could be one of the reasonsbehind smoking
initiation in girls.
Another strong reason could be the influence of fathers who
are smokers themselves.
Smoking also seems to offer these girls a platform to make friends
and become popular.
Smokng also leads the girls to form new fresh friendship groups.
A few othlr traits
12
Asia-Pacific Journal of Public Heahh /Yol. 20, Supplement, October 2008
were also observedin the groups where the focus group discussion was held. Many of
the group members came from broken families or families with both parents working
and the father is often away from home. However, whenever he is at home, he will be
seen smoking in front of the children. The proportion of male "smokers" in Malaysia is
as high as 57.6Vo22which means that one in two adult men smokes in Malaysia. Thus
it is not surprising for children in Malaysian homes to be exposedto cigarette smoking
early in their lives.
It is also observed via non-participant observation that the 'smokers' in their very
own special friendship group seemed to lead a fun-loving, non-conformist and exciting
lifestyle compared to those non-smokers which is appealing to all adolescents. This
observationled to ideas to create a similar environment without the smoking connection
that would have the same appeal. One idea is to create 'friendship groups' based on
sports or other group activities, such as bowling, futsal (indoor soccer) or cheerleading
squads that would allow girls to fill up their time with enjoyableyet beneficial activities.
The research also highlights the importance of parental control and role modelling
on adolescents.As the child's first social environment, the family provides the child with
a background for attitudes and values. However, during adolescence,there is a shift of
social concern towards their peers and this alters the relationship between parents and
children. Parents of adolescents need to know when to intervene and what intervention
methods to use. Family development programs could be developedand more education
towards effective parenting, the promotion of their motivation in favour of healthy
lifestyle can lead to a reduction in risk behaviour among adolescents.
The influence of media imageries and tobacco advertisementsalso should not be
taken lightly as this study revealedthat there is a senseof 'public approval' of the smoking
habit by portraying smokers as successfuland cool characters.Although it may not lead
to uptake of smoking as stressedby the 'smokers',it can lead to consolidating the habit.
This is a very cunning strategyby the tobacco industry and thus in the interest of public
health, a total ban of cigarette advertisingis advocated.Smoking imageriesin films and
movies should be limited and should not portray successin any way.
Conclusion
By applying a combination of qualitative methods, this studv concluded that there are
three stagesin the uptake of regular smoking. The first stage is where they felt it was
worth a try, out of curiosity or just becauseof its accessibilityof cigarettesin the house.
This leads to the recommendation that efforts to curb smoking in front of children
especiallyin their safe environment of home should be strengthened.Parentswho smoke
must be further educated of their influence on the wav their children will subsequently
behave.
Second stage is where the smoking habit is regularised when they smoke together
in friendship groups in which they hang out together almost every weekend. It is thus
recommended that friendship groups along beneficial activities should be developedas
alternativesto smoking groups.
Third stage is where they became addicted to the cigarettes and do not feel that
there is anything wrong with consolidating the habit. The smoking imageries in films
and movies seemed to Iead the girls in believing that the smoking habit is normal and
does not have any effect on well-being. Thus, it is recommended that any images in the
media that lead to normalization of smoking must be monitored strictly and if possible,
censoredfrom public viewing.
Exploring why girls smoke in Malaysia / Al-Sadnt, Binns
l3
Finally, for effective tobacco control in our population, there must be greater effort
in seeking ways to empower girls to feel more confident about resisting pressures to
initiate smoking. Activities such as positive peer sports can be enhanced while increasing
the number of health promotion programs on certain issues for example stress
management and reinforcement of messageson the dangers of smoking can be increased.
Parents also have a very important role in giving the right messagesto their children
and parenting courses must be conducted to improve parents parenting skills. Lastly
but not the least important is the role of tobacco advertisementsand smoking imageries
'normalizing'
on
the habit must be realised by the policy makers and effectively curbed
viewing
as much as possible.
from public
Acknowledgments
T h e a u t h o r s w o u l d l i k e t o e x p r e s st h e i r t h a n k s t o a l l t h e p a r t i c i p a n t s t h a t h a v e
contributed to the study and the two research assistants,Norsuzilla and Zurina who
helped collect the data. We are grateful to the University of Malaya (MHICO project
Account no: 8123233) and Curtin University of Technology for partial funding of the
project. The views expressedin this article are those of the authors, and do not necessarily
reflect the policies of any organisation.
References
l.
2.
3.
4.
5.
6.
7.
8.
9.
10.
I l.
12.
13.
14.
15.
Mackay JEM, Omar S. The Tobacco Atlas Second Edition. 2nd ed. Atlanta, GA: American
Cancer Society; 2006.
Lopez A. A descriptive model of the cigarette epidemic in developed countries. Tbb Control.
1 9 9 4 ( 3 ) : 2 4 2 - 2 4.7
Guidon GB, Bolsclair D. Past, Current and Future Trends in Tobacco Use. Washington, DC;
The World Bank; 2003.
Greaves L, Jategonkar N, Sanchez SE. Turning a New Leaf: Women, Tobacco,and the Future.
Vancouver: British Columbia Centre of Excellencefor Women's Health; 2006.
Institute of Public Health. National Heahh and Morbidity 1 Survey 1986. Malaysia: Ministry
of Health; 1987.
Institute of Public Health. National Heahh and Morbidity 2 Swrvey 1996. Malaysia: Ministry
of Health; 1997.
Naing NN, Zulkifli A, Razlan M, Farique RAH. Factors related to smoking habits of male
2OO4:2(3):I 33- I 40.
adolescents.Tobaccolnduced Diseqses.
ZainZ. Prevalenceof Smoking in the Cit,v,Kuala Lumpur. (unpublished data)
Berita Harian. Remaja Ketagih Rokok Kian Membimbangkan. Berita Harian. May 21, 2OQ7:l.
Lee LK, Paul CY, Kam CW, Jagmohni K. Smoking among secondaryschool students in Negeri
Sembilan, Malaysia. Asia Pac J of Public Heahh. 2005; 17(2): I 30- 136.
Norbanee T'H, Norhayati M, Norsaadah B, Naing NN. Prevalence and factors influencing
Smoking amongst Malay Primary School Children in Tumpat, Kelantan. SoutheastAsian Trop
M e d P u b l i c H e a h h . 2 A O 6 : 3 7( l ) : 2 3 0 - 2 3 5 ,
Zulkifli A, Rogayah J, Razlan M. Cigarette Smoking Among Malal,sian Youths: Problems and
Prospects.Presentedat: Malaysian Society of Health 2l st. Scientific Symposium 1997: Kuala
Lumpur, Nlalaysia.
Haniza N{, SurayaA. Smoking Among Aduhs in Malal'sia. Presentedat: National Health and
Morbidity Survey 2; 1996; Malaysia.
Patton MQ. Qualitatiue Eualuation and ResearchMethods.2"d ed. London: Sage; 1990.
Glesne C, Peshkin A. Becoming Qualitatiue Researchers:
An lntroduction. New York; Longman:
1992.
14
Asia-Pacific Journal of Public Heahh lYol. 2O, Supplement, October 2008
16. Denzin NK, Lincoln YS. Handbook of Qualitatiue Research. London: Sage Publications Inc;
1994.
17. Nichter M, Nichter M, Vuckovic N, Quintero G, Ritenbaugh C. Smoking experimentation
and inititiation among adolescent girls: qualitative and quantitative findings. Tbb Control.
1997;6:285-295.
18. Lucas K, Lloyd B. Starting smoking: girls'explanations of the influence of peers.J Adolesc.
1 9 9 9 ; 2 2 : 6 4 -76 5 5 .
19. Aloyse-YoungP, Graham J, Hanson W. Peer influence on smoking initiations during early
a d o l e s c e n c e :a c o m p a r i s o n o f g r o u p m e m b e r s a n d g r o u p o u t s i d e r s . J A p p l P s y c h o l .
1 9 9 4 , 7 9 \ : 2 8 r - 2 8 7.
20. O'Loughlin J, Paradis G, Renaud L, Gomez L, Meshefedjian G. One-year predictors of smoking
initiation and of continued smoking among elementary schoolchildren in multiethnic, lowincome, inner-city neighborhoods. Tob Control. 1998;7:268-275.
21. Denzin NK, YS L. The Landsc&pe of Qualitatiue Research. Thousand Oaks, CA: Sage
Publishing; 1998.
22. NHMS III. National Health Morbidity Survey: 2006. Ministrv of Health Malavsia.