The Collaborative Funding Program for Southeast Asia Tobacco Control Research Tobacco Advertising and Smoking Amongst Adolescents: A Qualitative Study in Malaysia Foong Kin, Ph.D. Khor Yoke Lim, Ph.D. Financial support from The Rockefeller Foundation and Thai Health Promotion Foundation Tobacco Advertising and Smoking Amongst Adolescents: A Qualitative Study in Malaysia Foong Kin, Ph.D. Associate Professor Centre for Drug Research Universiti Sains Malaysia Penang, Malaysia Khor Yoke Lim, Ph.D. Associate Professor School of Communication Studies Universiti Sains Malaysia Penang, Malaysia Supported by Southeast Asia Tobacco Control Alliance (SEATCA) Under The Collaborative Funding Program for Tobacco Control Research Financial support from The Rockefeller Foundation and Thai Health Foundation (ThaiHealth) December 2003 1 TABLE OF CONTENTS Page List of Tables 3 Executive Summary 4 1. Introduction 6 2. Study Methods and Tools 7 3. Findings on Smokers 9 4. Findings on Non-smokers 17 5. Discussion 20 6. Conclusion 23 Appendix 1 24 Appendix 2 25 2 LIST OF TABLES Page Table 1: Distribution of the sample units (Smokers) 22 Table 2: Distribution of the sample units (Non-Smokers) 23 3 EXECUTIVE SUMMARY A qualitative study using focus group discussions was conducted to explore and gain a more indepth understanding of the smoking behaviour among young people in Malaysia. Specifically, the study examined youth smoking behaviour and factors that influence it, their exposure to tobacco advertising and opinion of school-based prevention programmes. A total of 96 adolescent smokers and non-smokers between the ages of 13 and 17 from Penang and Kelantan, participated in the study. Several social, environmental and cultural factors were associated with smoking initiation. Easy accessibility to tobacco products and advertising, parental and sibling smoking, peer pressure and the perceived benefits of smoking such as beliefs about mood control and positive image of smoking contributed to youth smoking. There are some gender differences. Girls were more likely to perceive smoking as a means to cope with negative emotions. The process of smoking initiation and becoming a regular smoker was similar between male and female students. Most smokers smoked a moderate amount of between 10 to 15 cigarettes a day. Females smoked less. The amount smoked and expenditures on cigarettes were associated with the amount of pocket money available and the socio- economic status of families. Smokers from poorer families tend to smoke significantly less than their financially better-off counterparts. Dunhill was the most preferred brand smoked for both genders. This appeared to be related to the pervasiveness of Dunhill advertising and youth’s belief that it is more exclusive, and of better quality, an image intensively promoted by the tobacco company. Cigarette advertising was prevalent on billboards in the past and currently at points of purchase, on television (through sports sponsorship) as indicated by the ability of smokers and non-smokers to recall cigarette brand names and describe various types of advertising associated with each brand. The study found smokers’ to be highly exposed to tobacco advertising and that they were very receptive to it as indicated by their high recall of the types of tobacco ads and images that were promoted such as smokers are mature, stylist, attractive to the opposite sex and macho. Findings showed that underage smoking is rather prevalent and that these youths had could purchase their own cigarettes despite a ban on purchase of tobacco to those below 18 years old indicating rather poor enforcement of this policy. It is evident that easy access to cigarettes and other tobacco products have facilitated the uptake and continuation of smoking among these young people. Most smokers were aware of the harmfulness of smoking and had intentions to quit smoking but they were not motivated and committed enough to stop. Most perceived existing methods such as providing counseling, enforcement in school and anti-smoking messages as ineffective for young people. Current school-based smoking prevention education activities such as talks and exhibitions are not attractive to youth and thus 4 ineffective. These youths have instead proposed alternative activities such as motivational talks, camps, outdoor activities that would encourage young people to practice a healthy lifestyle without tobacco use. Several factors protected non-smokers from picking up the smoking habit. Parental control and intolerance to smoking, fear of parental disapproval and disciplinary action in school were important deterrents. Most said that smoking is a waste of money, besides, it has bad health effects. This study shows that exposure to tobacco advertising is associated with smoking initiation among youth. The government should implement tobacco control policies that are effective in reducing youth smoking such as increasing the price of cigarettes through tax increase, banning advertising at point of purchase, implement picture health warnings and improve enforcement of existing laws such as ban on sale to minors and smoke-free public places. It is also recommended that further study on the role of various risk factors that are associated with adolescent smoking and to identify gender differences be carried out. 5 1. INTRODUCTION It is well established that tobacco is a leading preventable cause of death and that experimentation with cigarette smoking begins during adolescence. Available epidemiologic data indicate that most smokers take up the habit before the age of 18. In Malaysia, the sales of tobacco to minors are prohibited and direct advertising of tobacco is banned. Still the laws have not deterred the increase of adolescents who smoke. Developing effective preventive programmes is important to reduce tobacco-related mortality and morbidity as well as to prevent progression to the usage of other drugs. There is a need for more systematic surveillance and understanding of the magnitude, characteristics, social conditions and meaning of tobacco consumption among youths. The aim of the Focus Group Discussion (FGD) is to increase our understanding of smoking behaviour among young people. This approach is chosen to enable us to explore and gain better insights into the meaning of smoking in the lives of young boys and girls. The specific objectives of the FGD are to gain insights into the following: 1. Factors that influence youths to smoke 2. Meanings of smoking for boys and girls 3. Exposure and interpretation of tobacco advertising 4. Perceptions of school-based tobacco prevention programmes. 6 2. STUDY METHODS AND TOOLS 2.1 Recruitment of the Focus Groups All the respondents were recruited through a few secondary schools in the state of Penang and Kelantan. In Penang, three schools (2 schools on Penang Island and 1 semi- rural school in the Northern Province Wellesley) were involved in the study. In the more rural state of Kelantan, 2 schools from the urban area of Kota Bharu and 1 semi-rural school from Bachok participated in the study. The reason for this recruiting method was that smoking was considered to be an increasing problem within the school setting, especially for the chosen age group, with smoking still banned for below 18 year olds. While it is relatively easy to obtain the cooperation of schools, and a convenient method to recruit study respondents, recruitment through the school system meant that the study was conducted in a more restrictive environment and thus has its disadvantages. This restrictive environment provided a less comfortable atmosphere for the focus groups since smoking is an offence in schools and punishable through fines and suspension from school. In addition, not all students participated voluntarily (some students have been caught in school for smoking offences and thus were asked by school counselors to participate in the study). It was difficult for the researchers to obtain the full trust and confidence of the respondents and this was reflected in the reluctance of respondents to clarify in-depth the more sensitive issues. To overcome this, the researchers had to repeatedly reassure participants that all data collected would be kept highly confidential and that the school would not have access to the individual responses of participants or the whole group. The ease with which recruitment was carried out varied between the various ethnic groups and gender. It was relatively easy to gain access to Malay male students compared to Chinese and Indian male students. The total number of Malay male students who were caught smoking in school was significantly higher compared to non-Malay male students. It was thus easier to recruit Malay male students than Chinese and Indian male students. Generally female smoking is comparatively low in schools, and therefore it was very difficult to recruit female students. The Malay female students that participated in the study were recruited from two urban schools in Penang. These schools did not have reports of female Chinese students who smoked. Schools in Kelantan, reported the absence of smoking among female students. The study has very low representation of female smokers of all races as well as Chinese and Indian male smokers. Seven focus groups comprising of students who smoked were conducted in Penang, and another 5 were conducted in Kelantan, a predominantly rural state in the East Coast of Peninsular Malaysia (see Appendix 1 for list of schools and types of respondents recruited from each school). 7 A similar number (12) of focus group discussions comprising of non-smokers were conducted in Penang (n=6) and Kelantan (n=6) (see Appendix 2 for list of schools and types of respondents recruited from each school). 2.2. Conduct of the Focus Groups The focus groups were conducted within the schools in rooms that were assigned for this purpose. A topic guide with guidelines for the moderator was used in the focus group. All focus groups were conducted in Bahasa Malaysia and moderated by the researchers with the aid of trained research assistants, recorded with a tape recorder and notes were taken concurrently.