ADVERSE TRANSITION OF SMOKING STAGES AMONG LOWER SECONDARY SCHOOL STUDENTS OF KINTA, PERAK: A PROSPECTIVE COHORT STUDY PREMILA DEVI A/P JEGANATHAN Malaya of FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR University 2016 ADVERSE TRANSITION OF SMOKING STAGES AMONG LOWER SECONDARY SCHOOL STUDENTS OF KINTA, PERAK: A PROSPECTIVE COHORT STUDY PREMILA DEVI A/P JEGANATHAN Malaya of THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PUBLIC HEALTH FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR University 2 UNIVERSITY OF MALAYA ORIGINAL LITERARY WORK DECLARATION Name of Candidate: Premila Devi a/p Jeganathan Registration/Matric No: MHC 090015 Name of Degree: Doctor of Public Health Title of Project Paper/Research Report/Dissertation/Thesis (“this Work”): Adverse Transition Of Smoking Stages Among Lower Secondary School Students Of Kinta, Perak: A Prospective Cohort Study Field of Study: Public Health I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title of the Work and its authorship have been acknowledged in this Work; Malaya (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutes an infringement of any copyright work; (5) I hereby assign all and every ofrights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. Candidate’s Signature Date: UniversitySubscribed and solemnly declared before, Witness’s Signature Date: Name: Designation: ii ABSTRACT Smoking behaviour normally begins with initiation during adolescence and progress through different stages. Yet, few prospective longitudinal researches have been conducted to examine the influence of various factors on progression to a higher smoking stage. The aim of this study was to describe the factors associated with adverse transition of smoking stages among adolescents. A school-based study among a cohort of 2552 secondary students aged 12 to 13 years old was conducted. Data collection was conducted twice, 12 months apart. Students answered a self-administered questionnaire. In this study, adverse transition was defined as transition from one smoking stage to a more adverse stage during follow up. The procedures in the complex samples add-on module were used in the analyses after adding appropriate student and school weights that were adjusted for non-response. The predictors Malayaof the four adverse transitions were tested using multinomial logistic regression analysis. The results at Time 1 indicated that there were never smokers, 474 susceptibleof never smokers, 168 experimenters and 83 ex-smoker in this study. At Time 2, 77.2% of the never smokers remained stable never, while 22.8% had Adverse Transition I. Adverse Transition II was 27.8 % among the susceptible never smokers. Among the experimenters, 43.5% had adverse Transition III and 36.0% of the ex-smokers had adverse Transition IV. The analysis of this study demonstrates that adverse transition of smoking stages was associated with various socio-demographic, school, peer, parental and personal factors. Among these variables, fiveUniversity factors were associated with all four adverse transitions groups.This study demonstrates the presence of different groups of adverse transition among adolescents and the various factors that can influence these transitions. Ethnicity, school adjustment, having a best friend who smokes, self-efficacy and perceived ease of accessibility to purchase cigarettes were associated with all four adverse transitions groups. Development of interventions against adverse transition among adolescents should be iii multi-faceted and consideration should be given to using different strategies based on the various influencing factors to target the different smoking stages. Malaya of University iv ABSTRAK Tingkahlaku merokok biasanya bermula di kalangan remaja dan melalui beberapa tahap yang berbeza. Namun, tidak banyak kajian prospektif dijalankan untuk memahami pengaruh pelbagai faktor terhadap peralihan tabiat merokok ke tahap yang lebih tinggi atau peralihan negatif. Matlamat kajian ini adalah untuk meneliti faktor-faktor yang boleh mempengaruhi peralihan tingkahlaku merokok di kalangan remaja dari suatu tahap yang rendah ke tahap yang lebih tinggi (peralihan negatif). Satu kajian prospektif dijalankan di kalangan 2552 pelajar sekolah menengah yang berumur 12 hingga 13 tahun. Penggumpulan data dijalankan sebanyak 2 kali dalam 12 bulan. Semua pelajar yang terlibat menjawab satu soal selidik yang disediakan. Dalam kajian ini, peralihan negative di definisikan sebagai peralihan dari satu tahap merokok ke tahap merokok yang lebih buruk. Analisis kajian ini menggunakanMalaya prosedur dalam complex sample add-on module dengan mengambilkira dan menyelaras weights untuk bilangan pelajar serta bilangan sekolah untuk non-response.of Faktor penyumbang untuk empat jenis peralihan negative di teliti dengan menggunakan analisa multinomial logistic regression. Hasil kajian pada Peringkat I kajian, terdapat 1669 pelajar dengan status bukan perokok, 474 bukan perokok tetapi berisiko, 168 perokok tahap percubaan dan 83 bekas perokok. Pada Peringkat 2 kajian, 77.2% daripada bukan perokok, kekal tidak merokok manakala 22.8% mempunyai Peralihan Negatif I. Peralihan Negatif II adalah 27.8% di kalangan bukan perokok tetapi berisiko. Antara perokok tahap percubaan, 43.5% mempunyai PeralihanUniversity Negatif III dan 36.0% daripada bekas perokok mengalami Peralihan IV. Analisa kajian menunjukkan bahawa peralihan negative tahap merokok dipengaruhi oleh pelbagai faktor sosio-demografi, faktor sekolah, faktor rakan sebaya, faktor ibu- bapa dan faktor peribadi. Antara ini, lima faktor dikaitkan dengan keempat-empat kumpulan peralihan yang negatif. Kajian ini telah membuktikan kehadiran beberapa kumpulan peralihan negatif di kalangan remaja. Faktor bangsa, keselesaan di sekolah, v jika kawan karib merokok, self-efficacy dan anggapan bahawa rokok mudah didapati mempegaruhi ke empat-empat tahap peralihan dalam kajian ini. Intervensi untuk pencegahan peralihan negative harus mengambilkira pelbagai faktor penyumbang dan turut pertimbangkan penggunaan strategi yang berbeza berdasarkan variasi tahap merokok di kalangan remaja. Malaya of University vi ACKNOWLEDGEMENTS I would like to extend my heartfelt thanks to the Ministry of Education and Perak Education Department for allowing me to conduct this research in schools. I also thank all the participating school headmasters/headmistresses and teachers for their cooperation during data collection. Special acknowledgement to University of Malaya for the grant that enabled me to carry out this research (University Malaya student research grant: PS240/010A) and to Julius Centre University of Malaya for the funding of my publications under University Malaya Research Grant (RP001A-13HTM). I take this opportunity to express my sincere gratitude to all three of my advisors. Associate Professor Nabilla Al Sadat’s expertise helped me during the time of research and provided me the opportunity to develop my knowledge on the chosen research topic. A special thank you goes out to Associate Professor Karuthan Chinna whose pearls of wisdom on research methodology and statistics greatly improved the research analysis and the write up of this manuscript. I would never have been able to finish my dissertation without the patience, and constant motivationMalaya from Associate Professor Noran N. Hairi. Her insightful comments and gentle encouragement stemmed my liking for writing and publishing articles. I cannotof imagine having a better advisor and mentor than her. In full gratitude, I would like to thank all the staff of Julius Centre especially Devi, Priya, Pek Ling and Nithiah for caring and providing me with an excellent atmosphere for finishing the write-up of this research. My sincere thanks also go out to my parents, siblings and children for supporting me spiritually throughout writing this thesis and my life in general. Without my mother, Mrs. Kamala Thevi’s support and care it would not have been possible for me to go out for field data collection. Finally, I would like to thank my husband, Dr. Thirugana Kumeren who supported and cheered me throughout myUniversity pursuit of a higher education degree. His moral support helped me finish this thesis. This work is dedicated to my mother – Mrs.Kamala Thevi; my father – Mr. Jeganathan; my husband - Dr.Thirugana Kumeren; my children- Shavitashree, Thanushree, and Aggatiyen; and my siblings. vii TABLE OF CONTENTS ORIGINAL LITERARY WORK DECLARATION ........................................................ ii Abstract ............................................................................................................................ iii Abstrak .............................................................................................................................