Open access Original research BMJ Open: first published as 10.1136/bmjopen-2020-039367 on 28 September 2020. Downloaded from Tobacco use patterns and attitudes in Singapore young male adults serving military national service: a qualitative study Clive Tan ,1,2 Lavinia Lin,2 Mervyn Lim,1,2 Seeu Kun Ong,1 Mee- Lian Wong,2 Jeong Kyu Lee2 To cite: Tan C, Lin L, Lim M, ABSTRACT Strengths and limitations of this study et al. Tobacco use patterns Objectives To explore tobacco use patterns and factors and attitudes in Singapore influencing tobacco use in young Singaporean men serving ► This is the first qualitative study to explore multi- young male adults serving military national service. military national service: a level factors that influence tobacco-use behaviour Methods A qualitative study using in- depth telephone qualitative study. BMJ Open in young men serving military national service (or interviews and maximum variation sampling was 2020;10:e039367. doi:10.1136/ national servicemen) in Singapore. conducted with 29 Singaporean men who have completed bmjopen-2020-039367 ► Use of purposeful random sampling stratified by their national service in 2017–2018. Data were analysed selected criteria on ethnicity and educational level ► Prepublication history for using thematic analysis. in the study design allowed for inclusion of diverse this paper is available online. Results More than half (51.7%) of the participants started To view these files, please visit groups of national servicemen, to provide rich infor- smoking before age 18, with a mean age of smoking the journal online (http:// dx. doi. mation of tobacco use. initiation at 16 years. At the individual level, the two org/ 10. 1136/ bmjopen- 2020- ► Data collection and analysis were underpinned main contributing factors to tobacco use were smoking 039367). by the Socio- Ecological Model as a theoretical as a coping mechanism, and physical or psychological framework. Received 14 April 2020 addiction. Financial concern was reported as the key ► This study cannot be generalised to all military per- Revised 20 July 2020 motivation to quit smoking. At the interpersonal level, sonnel due to the nature of qualitative design. Accepted 20 August 2020 peers and superiors played an influential role in the smoking habits of the participants. When superiors took additional measures against smoking behaviours, http://bmjopen.bmj.com/ it contributed to their decision to smoke less. At the further reduce tobacco use in the country, organisation level, some unintended consequences were the Ministry of Health (MOH) has raised the reported as a result of the strict tobacco control measures minimum legal age for the purchase, use, implemented by the military, such as the designated possession, sale and supply of tobacco prod- smoking areas within the camps become regarded as an ucts from 18 to 21 (MLA21), progressively area for socialisation. 4 Conclusion Informed by the Socio- Ecological Model, from 2019 to 2021. Coincidentally, this is the this study has provided insights into the multifaceted age range when all young Singaporean men and interactive effect of individual, interpersonal and serve their military national service. on September 29, 2021 by guest. Protected copyright. organisational factors that influence tobacco use in In Singapore, it is mandatory for all male young men serving military national service in the citizens and second- generation permanent Singapore and Asian context. The study insights provided residents to serve a 2-year period of national an understanding of the local context before designing service (NS) as full-time national servicemen © Author(s) (or their programmes or changing regulations to further discourage (NSFs).5 The typical age of enlistment for NS employer(s)) 2020. Re- use tobacco usage in the military. permitted under CC BY-NC. No is between 18 and 21. Research into tobacco commercial re- use. See rights use in military populations has shown that and permissions. Published by young soldiers are at risk of smoking initiation BMJ. INTRODUCTION and cigarette smoking,6 7 and tobacco use has 1Headquarters Medical Corps, Since the 1970s, Singapore has adopted a been shown to increase risk of injuries and Singapore Armed Forces 8 9 Medical Corps, Singapore national- level, long- term and multi- pronged decreased fitness levels in soldiers. Based 1 2National University Singapore approach to tobacco control. Currently, on a periodic health survey administered Saw Swee Hock School of Public Singapore has the lowest smoking prevalence once every few years, the overall prevalence Health, Singapore rates in the Southeast Asian countries, at 12% of tobacco use among NSFs in Singapore was 2 Correspondence to in 2017. However, smoking rates among estimated at 16.7% in 2017. With the enact- Dr Clive Tan; Singaporean men remain a significant issue, ment of the MLA21, it is anticipated that a clivetan@ gmail. com with a prevalence of 21.1% in 2017.3 To growing number of underage smokers will Tan C, et al. BMJ Open 2020;10:e039367. doi:10.1136/bmjopen-2020-039367 1 Open access BMJ Open: first published as 10.1136/bmjopen-2020-039367 on 28 September 2020. Downloaded from emerge in the Singapore military. Therefore, this study Patient and public involvement aimed to: (1) explore tobacco use patterns during NS This study was designed by the authors in consultation among young Singaporean male adults and (2) iden- with the leaders and researchers at the SAF’s Headquar- tify the underlying factors that influence their smoking ters Medical Corps, who contributed advice and helped behaviours using the Socio-Ecological Model (SEM). review the research methods and findings of the study. Study findings may inform the design of policy inter- The interview guide was pilot- tested with four NSFs who vention and targeted smoking prevention and cessation self- identified as current smokers, to gain feedback on the programmes in the military setting. process and refine the interview questions. Data analysis Theoretical saturation was reached at 29 participants. A METHODS team of four researchers was involved in the data coding Qualitative data were collected from March to June and analysis. Using the approach of thematic analysis,14 2018. Participants were drawn from the database of the codes and subcodes was identified and subsumed under Singapore Armed Forces (SAF) to identify those who the hierarchical levels of the SEM. All transcripts were have completed NS in 2017–2018, and self- declared as a double coded and compared among coders working smoker. Purposeful random sampling10 was performed to independently to ensure coding consistency and estab- select participants with maximum variation based on the lish inter- rater reliability. Any discrepancies in the coding criteria of ethnicity, educational level, and self- reported were reviewed and discussed by all team members until smoking status before and at the point of completion consensus was reached. NVivo Pro V.12 was used for the of NS. For the telephone-based interviews, all partici- data analysis.15 pants provided verbal consent at two points during the study period, during the recruitment call and before the conduct of the phone interview. RESULTS Participants were recruited through a collaborative The mean age of the participants was 22.4 years. The effort between the SAF and the National University of ethnic distribution of the participants consisted of: Malay Singapore (NUS). Initially, a SAF team member (ML) (44.8%), Chinese (34.5%), Indian (17.2%) and Others screened and contacted 223 eligible individuals identified (3.4%). Most participants had obtained a secondary from the database, explaining the purpose and proce- education (41.4%) or vocational institute diploma dure of the study. Of those, 64 agreed to be contacted by (37.9%) at the point of enlistment for NS. Regarding NUS for research purposes. Then, a NUS team member smoking status, 24 (82.8%) had self-reported as current (LL) contacted 56 potential participants to conduct smokers and 5 (17.2%) as former smokers who quit the telephone semi-structured interviews. Of which, 10 smoking after completing NS. Most (84.6%) reported http://bmjopen.bmj.com/ declined to take part and 17 were unreachable. To reduce that they smoked 10 or fewer cigarettes per day. Twen- non- response, the team made multiple attempts through ty- six participants (89.7%) picked up smoking before repeated calling and mobile messaging at different times enlistment to NS, and more than half (51.7%) started of the day and weekends. A total of 29 participants took smoking before age 18, with a mean age of smoking initi- part in the interviews. Telephone- based interviews were ation at 16 years of age. The most commonly reported used because it permits a greater perceived level of themes for underage smoking initiation were curiosity, anonymity and privacy in which the participants feel more social influence and stress. Less than one- third (31.0%) comfortable to disclose perceived sensitive information.11 picked up or became a regular smoker during NS. Table 1 on September 29, 2021 by guest. Protected copyright. A semi- structured interview guide with open-ended summarises the sociodemographic characteristics of the questions about smoking patterns and behaviours was participants. developed, based on the SEM. The SEM is a theory-based framework that conceptualises health behaviours as deter- Multiple level factors influencing tobacco use in the military mined by an interplay between individual