Yale University EliScholar – A Digital Platform for Scholarly Publishing at Yale Public Health Theses School of Public Health January 2020 Tobacco Use, Knowledge Of Tobacco Risks, And Perception Of Smoking Behaviors Among Urban And Rural Youth In South Sulawesi, Indonesia Ryan Andrew Sutherland [email protected] Follow this and additional works at: https://elischolar.library.yale.edu/ysphtdl Recommended Citation Sutherland, Ryan Andrew, "Tobacco Use, Knowledge Of Tobacco Risks, And Perception Of Smoking Behaviors Among Urban And Rural Youth In South Sulawesi, Indonesia" (2020). Public Health Theses. 2000. https://elischolar.library.yale.edu/ysphtdl/2000 This Open Access Thesis is brought to you for free and open access by the School of Public Health at EliScholar – A Digital Platform for Scholarly Publishing at Yale. It has been accepted for inclusion in Public Health Theses by an authorized administrator of EliScholar – A Digital Platform for Scholarly Publishing at Yale. For more information, please contact [email protected]. Tobacco Use, Knowledge of Tobacco Risks, and Perception of Smoking Behaviors Among Urban and Rural Youth in South Sulawesi, Indonesia By Ryan A. Sutherland Dr. Marney White, PhD Yale University Adviser Dr. Tomoyuki Shibata, PhD Northern Illinois University Adviser A thesis submitted to the Faculty of Public Health of Yale University in partial fulfillment of the requirements of the degree of Master of Public Health Social and Behavioral Science Department Yale School of Public Health 2020 Abstract Abstract. This observational study surveyed knowledge, practice, and attitudes (KAP) of N=959 youth 13 – 18 years of age in South Sulawesi, Indonesia and assessed how age, sex, familial smoking status, friend group smoking status, teacher smoking status, parental education, parental employment, exposure to tobacco-related advertisements, access to internet-connecting technological devices (INT-D) and television, and monthly pocket money were associated with youths’ perceptions of tobacco users and smoking, knowledge of tobacco health risks, and smoking status. This study also examined how urban or rural environment and schooling — access or lack of access to formal education — shaped youths’ decisions to smoke cigarettes and influenced their perceptions and knowledge of health risks. In this study, sex, age, schooling and environment, paternal education, pocket money, and friend group smoking status had significant effects on youths’ decisions to smoke. After adjusting for covariates, female youth were less likely to smoke than male youth, rural island youth and those from street children communities enrolled in alternative education were less likely to smoke than those from urban communities enrolled in formal education, those who reported some, most or all of their friends smoked were more likely to smoke than those who indicate that none of their friends smoked, those whose fathers had higher education were less likely to smoke than those whose fathers had only completed high school or less, and for every increase in 100,000Rp (Indonesian Rupiah) of monthly pocket money, youth were more likely to smoke. Considering that more than 225,000 Indonesians die each year from cigarette-related illnesses (14.7% of all deaths) and that the percentage of adult smokers in Indonesia is among the highest in the world at over 61.4 million, understanding the motivations that encourage youth to smoke and recording their perceptions of tobacco risk are vitally important to develop prevention programming. i Extended Abstract. This observational study surveyed knowledge, practice, and attitudes (KAP) of N=959 youth 13 – 18 years of age in South Sulawesi, Indonesia and assessed how age, sex, familial smoking status, friend group smoking status, teacher smoking status, parental education, parental employment, exposure to tobacco- related advertisements, access to internet-connecting technological devices (INT-D) and television, and monthly pocket money were associated with youths’ perceptions of tobacco users and smoking, knowledge of tobacco health risks, and smoking status. Furthermore, this study also examined how urban or rural environment and schooling — access or lack of access to formal education — shaped youths’ decisions to smoke cigarettes and influenced their perceptions and knowledge of health risks. N=57 urban street children (Makassar) and N=59 rural island children (Saugi, Satando and Sepuli islands) completed KAP surveys, and their responses were statistically analyzed using chi-squared (χ2) tests, Fisher’s Exact tests, and unadjusted and adjusted logistic regressions in SAS. These results were compared to those of students who were enrolled in formal education (N=843) in Islamic character schools, public and private schools in urban Makassar and completed the same KAP surveys. In this study, sex, age, schooling and environment, paternal education, pocket money, and friend group smoking status had significant effects on youths’ decisions to smoke. After adjusting for covariates, female youth were less likely to smoke than male youth (OR 0.45, p = 0.0002), rural island youth and those from street children communities enrolled in alternative education were less likely to smoke than those from urban communities enrolled in formal education (OR 0.40, p = 0.0343; OR 0.30, p = 0.0059), those who reported some, most or all of their friends smoked were more likely to smoke than those who indicate that none of their friends smoked (OR 5.10, p<0.0001; OR 16.19, p<0.0001), that those whose fathers had higher education were less likely to smoke than those whose fathers had only completed high school or less (OR 0.37, p = 0.0036), and for every increase in 100,000Rp of monthly pocket money in Indonesian Rupiah (IDR), youth were more likely to smoke (OR 1.22, p = 0.0042). Schooling and environment, maternal education, maternal employment, and pocket money impacted youths’ knowledge of smoking risk. Rural island youth enrolled in alternative schooling were less likely to ii have sufficient knowledge of smoking risks compared to urban youth enrolled in formal schooling (OR 0.51, p = 0.050), those whose mothers had completed higher education were more likely to report sufficient knowledge of smoking risks compared to youth whose mothers had only completed high school or less (OR 2.70, p = 0.0029), those whose mothers were employed were more likely to report insufficient knowledge of smoking risks compared to youth whose mothers were unemployed (OR 0.58, p = 0.0084), and for every 100,000Rp (IDR) increase in pocket money available (per month), youth were more likely to exhibit increasing knowledge of smoking risks (OR 1.22, p = 0.0029). Finally, age, sex, friend group smoking status, and paternal education were associated with youths’ perception of smoking behaviors and tobacco use. Youth aged 17-18 were more likely to view smoking behaviors and tobacco use favorably compared to youth aged 13-14 (OR 2.31, p = 0.0368), females were more likely than males to view smoking unfavorably (OR 0.27, p = 0.0003), those who had some friends or indicated that most or all of their friends smoked were more likely to view smoking favorably (OR 3.68, p = 0.0030; OR 4.18, p = 0.0043), and those whose fathers had completed a Bachelor’s degree or more were less likely to view smoking favorably (OR 0.20, p = 0.0123). Additionally, current or former smokers were more likely to have insufficient knowledge of smoking risk compared to those who were non-smokers (OR 0.39, p = 0.0002) and were also more likely than non-smokers to view smoking behaviors and tobacco use favorably (OR smokers 6.54, p<0.0001). Household access to an internet-connecting technological device (INT-D) or a television was not shown to impact smoking behavior between rural island and urban street children communities sampled. Considering that more than 225,000 Indonesians die each year from cigarette-related illnesses (14.7% of all deaths) and that the percentage of adult smokers in Indonesia is among the highest in the world at over 61.4 million, understanding the motivations that encourage youth to smoke and recording their perceptions of tobacco risk are vitally important to develop prevention programming. iii Research Questions: What are the motivations for smoking, perceptions of cigarette use, and knowledge about associated health risks of cigarette use among Indonesian teenagers (13 – 18 years in age) in South Sulawesi, Indonesia? Is there a relationship between school enrollment or access to technology and smoking perception and cigarette use among these Indonesian youth? Research Methodology: Quantitative knowledge, attitude, and practice (KAP) surveying in urban schools in Makassar and in alternative school environmental (unenrolled populations in rural island communities and in urban street children communities) among youth 13 – 18 years in age. iv Acknowledgements. This thesis would not have been possible without the incredible support of Global Environmental Health LAB, Inc., and Hasanuddin Centre for Tobacco Control and Non-communicable Disease Prevention (Hasanuddin CONTACT) at Hasanuddin University in Makassar. Furthermore, funding provided by the Yale School of Public Health, the Social and Behavioral Science Department through the Social and Behavioral Science Research Award, and the Council on Southeast Asia Studies at Yale were much appreciated and necessary for the completion of this project. Statistical support provided by I-Hsin Lin, Fangyong