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BMJ Open Is Committed to Open Peer Review. As Part of This Commitment We Make the Peer Review History of Every Article We Publish Publicly Available BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or pay-per-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected] http://bmjopen.bmj.com/ on September 28, 2021 by guest. Protected copyright. BMJ Open BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from Susceptibility to smoking among non-smoking school-going adolescents in Malaysia - Findings from a national school- based survey ForJournal: peerBMJ Open review only Manuscript ID bmjopen-2019-031164 Article Type: Research Date Submitted by the 24-Apr-2019 Author: Complete List of Authors: Lim, Kuang Hock; Institute for Medical Research, Kuala Lumpur, Malaysia, Ghazali, Sumarni Mohd ; Institute for Medical Research, Kuala Lumpur Lim, Hui Li; Hospital Sultan Haji Ahmad Shah Cheong, Kee Chee; Inst Med Res, Epidemiology & Biostatistics Teh, Chien Huey; Institute for Medical Research, Kuala Lumpur, Malaysia, Lim, Kuang Kuay; Institute of Public Health Heng, Pei Pei; Institute for Medical Research Cheah, Yong Kang; Universiti Utara Malaysia Lim, Jia Hui; Monash University - Malaysia Campus Susceptible to smoking, non-smoker, school-going adolescents, national http://bmjopen.bmj.com/ Keywords: school-based study on September 28, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 37 BMJ Open 1 2 3 Susceptibility to smoking among non-smoking school-going adolescents in BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from 4 5 Malaysia - Findings from a national school-based survey 6 Lim KH1, Sumarni MG1, Lim HL2, Kee CC1, Teh CH, Lim KK3,1, Heng PP1, Cheah YK4, Lim JH5. 7 1 Institute for Medical Research, Ministry of Health, Malaysia, Jalan Pahang, 50588, Kuala Lumpur 8 2 Hospital Sultan Haji Ahmad Shah, Ministry of Health, Malaysia,,Jalan Maran, 28000, Temerloh, Pahang. 3 Institute of Public Health, Ministry of Health Malaysia, Seksyen U13 Setia Alam, 40170 Shah Alam, Selangor. 9 4 UUM 10 5 Monash University Malaysia Jalan Lagoon Selatan, Bandar Sunway, 47500 Subang Jaya, Selangor 11 12 13 14 Corresponding author: 15 16 17 18 For peerLim review Kuang Hock only 19 Biomedical Museum Unit, 20 Medical Research Resource Centre, 21 Institute for Medical Research 22 Jalan Pahang, 50588 23 24 Kuala Lumpur 25 Tel: 6(03)-26162436 26 Fax: 6(03)-26926542 27 E-mail: [email protected] 28 29 30 31 32 33 34 35 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on September 28, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 37 1 2 3 BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from 4 Abstract 5 6 Objective : Identification of susceptible non-smoking adolescents is an essential 7 8 step to reduce smoking initiation among adolescents. The aim of this study was to 9 examine the prevalence and factors associated with smoking susceptibility among 10 non-smoking schooling adolescents in Malaysia. 11 12 Design: We collected cross-sectional survey data on 13,980 students aged 11–19 13 14 years, from 138 schools across 15 states in Malaysia. Of these students, 13,162 15 responded, and 11,246 were non-smokers. They filled in an anonymous, self- 16 administered questionnaire adapted from the Global Youth Tobacco Survey. 17 Univariate and multivariate logistic regression of smoking susceptibility were 18 performed amongFor the non-smoking peer students. review only 19 20 21 Results: About 14% of never-smokers were susceptible to smoking, and the 22 prevalence of susceptibility was significantly higher among males, ever-smokers and 23 e-cigarette users. The odds of susceptibility to smoking was higher among males, e- 24 cigarette users, those aged 12 years and below, and had ever smoked or tried 25 26 cigarettes. Students from schools with educational programmes on the health 27 effectsof second-hand smoke (SHS), and perceived more harmful effect of smoking 28 were less likely to be susceptible to smoking. 29 30 Conclusion: Susceptibility to smoking is prevalent among schooling adolescents. A 31 32 comprehensive approach that to enhanced or reinforce health education programme 33 on adverse health effect of smoking and SHS among school children considers 34 multiple factors and involves all stakeholders is urgently needed to reduce the 35 prevalence of smoking susceptibility among vulnerable sub-groups as identified from 36 37 the present findings. http://bmjopen.bmj.com/ 38 39 Keywords: Susceptible to smoking, non-smoker, school-going adolescents, national 40 41 school-based study. 42 43 44 45 on September 28, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 37 BMJ Open 1 2 3 Strengths and limitations of this study: BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from 4 5 6 The representative of the sample and the high response rate of the study enables 7 8 generalization to the school-going adolescents in Malaysia, 9 10 11 12 Anonymity of information gathered from the respondents might reduce the under ot 13 14 15 over reporting of smoking status and susceptibility to smoking status. 16 17 18 For peer review only 19 Only school going adolescents in government schools were including in the study, 20 21 22 those study in private schools and not schooling was not included in this study. 23 24 25 26 Objective measurement of smoking among non-smoking adolescents (e.g. 27 28 29 measurement of carbon monoxide in expired air or serum cotinine (a nicotine 30 31 metabolite) was not carried out. 32 33 34 35 36 37 http://bmjopen.bmj.com/ 38 39 40 41 42 43 44 45 on September 28, 2021 by guest. Protected copyright. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 37 1 2 3 BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019. Downloaded from 4 Introduction 5 6 Malaysian burden of disease and mortality statistics show that smoking-related 7 8 1 9 diseases contribute significantly to the burden of diseases , and are among the 10 11 major causes of premature death among the Malaysian population 2. Thus, the 12 13 reduction of smoking prevalence among current smokers and smoking initiation 14 15 among non-smokers are among the effective measures to be implemented 3. 16 17 18 Various studies Forhave reportedpeer that review smoking is onlya behaviour initiated during 19 20 adolescence 4,5 . The likelihood of those who do not smoke in adolescence to 21 22 become smokers in their adulthood is low and vice verse 6,7 . The analogous 23 24 25 manifestation had been reported by Malaysian studies which revealed that 80% of 26 27 adult smokers began to smoke before the age of 20 years old 8. Those who initiate 28 29 smoking at a younger age are at greater risk of smoking-related diseases 9,10, since 30 31 32 they are more likely to become habitual smokers later in adulthood. Therefore, 33 34 identification of non-smoking adolescents however has the plausibility to initiate 35 36 smoking was a pee-requisite in order to reduce the smoking initiation among youths. 37 http://bmjopen.bmj.com/ 38 39 Susceptibility to smoking (SS) or the lack of cognitive commitment to refrain 40 41 42 from future smoking introduced by Pierce et al. 11 has been recognized as a valid 43 44 and reliable tool to identify non-smoking adolescents who are at risk of initiating 45 on September 28, 2021 by guest. Protected copyright. 46 smoking 12,13,14 . The conceptual validity of the SS spurred the conduct of various 47 48 49 studies to identify factors associated with smoking susceptibility among adolescents. 50 51 As a result, research had demonstrated multiple intrapersonal and interpersonal 52 53 associated risk factors such as, being male 15,16 , older age 16,17 had either smoking 54 55 17-21 56 parents or peers , those who were exposed to SHS at home or outside home 57 58 15,18,19, as well as those who received tobacco industry promotions15.21 Never- 59 60 smoking youths who received school anti-smoking education and have better For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 37 BMJ Open 1 2 3 knowledge of harmful of smoking and SHS were significantly associated with BMJ Open: first published as 10.1136/bmjopen-2019-031164 on 28 October 2019.
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