C8GaRETTE SMOKING AMONG SCHOOL C - ILDREN IN SINGAPORE. PART I - SMOKING PREVALENCE S C Emmanuel, C K Ho, A J Chen ABSTRACT A cross sectional nationally representative survey of 33,110 school -going children in Singapore aged between 9 and 20 years was carried out to obtain, for the first time, baseline information on smoking among the school - going population in Singapore. The survey was carried out among students attending vocational institutes and public sector schools in Singapore in 1987. The overall smoking prevalence was found to be 2% (3% among boys and 0.2% among girls). Ex -smokers comprised 2% of respondents whilst those who had only experimented with smoking made up 9% of the respondents. Analyses of the data showed that cigarette smoking was more prevalent among Malays, among boys, among older children, and among the less academically inclined. On average, boys smoked a median of 20 cigarettes a week and girls,12 cigarettes a week. On an international basis, the smoking prevalence among the school -going population in Singapore is significantly lower than that of developed countries like Australia, England and Wales and neighbouring countries such as Malaysia. Keywords: first assessment of smoking prevalence, school -going population, current smokers. ex -smokers, non-smokers SINGAPORE MED J 1990; Vol 31: 211 - 216 taking up the habit as compared with trying to convert INTRODUCTION existing smokers. Strategies against cigarette smoking in Singapore were Surveys to gauge smoking levels among the adult intensified with the announcing of the national objective population had been carried out regularly by the Ministry "Towards A Nation of Non -Smokers" in January 1987. of Health(1-3). Prevalence levels among the school -going Among the activities drawn up were major programmes population however, had not been assessed before. The which aimed to heighten the degree of awareness of the Research & Evaluation (R & E) Department of the Ministry harmful effects of cigarette smoking among of Health therefore undertook this first -ever effort to Singaporeans. Non-smokers, especially school children, ascertain the extent of cigarette smoking among the were the main target of this health education. campaign, school -going population in the country, as well as to the message exhorted being "If you don't smöke, don't obtain detailed information on the smoking habits, attitude start". This is in acknowledgement of the fact that the and behaviour of the young smokers. The results from most successful outcome of any large scale programme this survey would provide valuable information for the to contain: smoking lies in dissuading non-smokers from planning of national anti -smoking programmes targeted at the young - whether it be to discourage existing young Ministry of Health HQ smokers from continuing with the habit or preventing College of Medicine Building future generations of school children from experimenting College Road with smoking, and possibly going on to become smokers. Singapore 0316 There were two components to this survey. The first, conducted in January 1987, used as its target population Emmanuel S C, MBBS, MSc (PH), AM all 15,339 students who attended the sixteen vocational Director institutes in Singapore (4). Students in these institutions Research & Evaluation Department would have completedat least primary school education, and would be mainly in the age range of 14 to 20 years. C K Ho, BSC (Hons), MSc (Med Stats), FSS, MIS Schools and junior colleges (5) formed the sampling Statistician frame for the second part of this survey, which was carried Research & Evaluation Department out in April 1987. The target population was the 430,160 students aged between 9 to 18 years studying in the A J Chen, MBBS, DPH, DTM & H, DCH, AM Singapore public school system. Deputy Director of Medical Services (Primary Health Division)/ The results from these two surveys have been Assistant Director of Medical Services (Planning & Development combined to present an overall picture of smoking among Division) the school -going population in Singapore. The findings will be presented in a series of three consecutive articles. 211 This first report covers the extent of smoking and the survey questionnaires. This was done to minimise any demographic characteristics of the young smokers and inhibition on the part of the students to provide frank non-smokers, with particular reference to their sex, age, responses to the questions asked. level educational and ethnic profile. Two sets of questionnaires were used in the survey. The second report will focus on the smokers and In addition to basic questions on smoking behaviour which their smoking habit, assessing the effect of the family were to be answered by all respondents, the "older" and home environment, as well as other factors which children, ie those aged 16 years and above, were probed influence the young to take up smoking, and the age in-depth about their knowledge and attitudes towards when they do so. smoking. Those who smoked were also asked why they The final article will examine the views of young took up the habit, where and with whom they smoked, Singaporeans towards smoking and evaluate their whilst ex -smokers were questioned about what motivated knowledge on the harmful effects of smoking, appraising them to give up the habit. at the same time, the intentions of smokers and non- All schools and vocational institutes selected smokers as regards smoking in the future. consented to the participation of their students and trainees in the survey, with the exception of one school. The final response rate obtained for the was METHODOLOGY survey therefore 99%. The target population for the survey among the school - Statistical analyses carried out on the data included going population was all students aged between 9 and detecting any significant differences between the levels 20 years, studying in the slate -run schools, junior colleges of smoking among the various socio -demographic and vocational institutes in Singapore. This comprised subgroups, using the x2 test of significance. approxiately 446,000 students from Primary Four up to 'A' level, including those attending the BST or PVT, RESULTS Technical, Business and Trade Certificate courses, in the vocational institutes. Definitions pertaining to smoking for the survey have A one -stage disproportionate stratified sample design been adapted from a UICC Report Series(7). was used for both components of the survey. In the A smoker was defined as an individual who, at the vocational institutes, a 21% sample was randomly time of the survey, smoked at least one cigarette a week, selected (equivalent to 3,200 trainees) whilst for the continuously, for a period of at least two months. schools, 30,500 or 7% of the student population were A non-smoker was defined as one who had never randomly selected as respondents to the survey. The tried smoking a cigarette before. sample selection for the schools was carried out by the An experimental smoker referred to a respondent who Ministry of Education (MOE) from its comprehensive reported smoking only a few puffs during a short period computerised database of all students in public sector of time. schools. Staff of the R & E Department worked in close An ex -smoker was defined as one who used to smoke consultation with officers from the MOE during this regularly but who was no longer smoking at the time of exercise. Painstaking efforts were taken to ensure that the survey, the characteristics of the students selected as The results from these two surveys showed that the respondents conformed very closely to that of the majority (87%) of Singapore students had never smoked universe of school children. a cigarette before. The level of current smoking among Those in the late teens (ie 18 to 20 year olds) the school -going population was 2%. The other children comprised only 3.9% of the final survey sample. There were either ex -smokers (2%), or just experimental was thus a much lower representation of this group smokers, who had never gone beyond their first few compared with their distribution in the population puffs (9%). (33.2%)(6) as the majority of children in this age group would have finished with the normal school programme. Sex The smoking levels in this,age group from fhb survey As expected, far more boys than girls smoked. Among cannof therefore be taken to represent the smoking levels the boys, an overall of 20% had with of this age group in the population. experimented smoking before, with 3% boys reported to be currently The disproportionate stratified sample design was smoking. The figures for girls were much lower at 6% selected so as to ensure that a sufficiently representative and 0.2% respectively. The difference in smoking levels sample of students from vocational institutes would be between boys and girls was found to be highly significant included in the survey. These students comprise the less academically inclined of the school -going population and (p«0.001). On probing into the smoking history of the students, it a disproportionate sampling of their numbers was carried was found that among the respondents who had ever out to ensure that the final sample surveyed truly reflected tried smoking before, 36% of the boys and 15% of girls the educational heterogeneity of the school -going went on to take up the habit seriously (Fig 1). The majority population. The findings for this surveÿ were then adjusted of these however, gave up after smoking regularly for to correspond to the profile characteristics of students in some time. Only a small proportion carried on as current all schools and vocational institutes in Singapore (ratio smokers when at the time of of 28:1). assessed the survey, comprising 15% of the boys and 3% of those girls who Anonymity and confidentiality were ensured throughout had tried smoking before.