Refusal Self Efficacy, Self Esteem, Smoking Refusal Skills and Water Pipe (Hookah) Smoking among Iranian Male Adolescents

  • Karimy, Mahmood (Department of Public Health, Faculty of Health, Saveh University of Medical Sciences) ;
  • Niknami, Shamsaddin (Department of Health Education, Tarbiat Modares University) ;
  • Heidarnia, Ali Reza (Department of Health Education, Tarbiat Modares University) ;
  • Hajizadeh, Ebrahim (Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University) ;
  • Shamsi, Mohsen (Department of Public Health, Faculty of Health, Arak University of Medical Sciences)
  • Published : 2013.12.31


Background: Tobacco use among adolescents is a major public health concern, and identifying predictors of smoking is necessary for planning prevention programs. The present study examined the relationship between refusal self efficacy, self esteem, smoking refusal skills and water pipe (hookah) smoking among Iranian male adolescents. Materials and Methods: A cross-sectional study was conducted with 380 Iranian male adolescents aged between 15-19 years selected by multistage sampling. The participants completed an anonymous, voluntary, self-report questionnaire. Variables independently associated with water pipe (WP) smoking were identified by multiple logistic regression analysis. Results: The mean age of the participants was $16.7{\pm}1.3$ years. The prevalence of WP smoking was 17.3%. Logistic regression analysis revealed that knowledge (OR=0.56; 95% CI: (0.37-0.79), attitude (OR=0.69; 95% CI: (0.52-0.89), self esteem (OR=0.67; 95% CI: (0.55-0.82), smoking refusal skills (OR=0.73; 95% CI: (0.55-0.87), and self efficacy (OR=.82; 95% CI: (0.61-0.93) were all signifcant prediting facotrs for adolescents WP smoking. Conclusions: The findings have implications for public health interventions. Indeed, self efficacy and smoking refusal skills should be considered when developing tailored measures for the prevention of WP smoking among adolescents.


  1. Amin T, Amr M, Zaza B, Suleman W (2010). Harm Perception, Attitudes and Predictors of Waterpipe (Shisha). Smoking among Secondary School Adolescents in Al- Hassa, Saudi Arabia. Asian Pac J Cancer Prev, 2, 293-301.
  2. Anjum Q, Ahmed F, Ashfaq T (2008). Knowledge, attitude and perception of water pipe smoking (Shisha). among adolescents aged 14-19 years. JPMA, 58, 312.
  3. Byrne D, Davenport S, Mazanov J (2007). Profiles of adolescent stress: The development of the adolescent stress questionnaire (ASQ). J Adolesc, 30, 393-416.
  4. De Vries H, Engels R, Kremers S, Wetzels J, Mudde A (2003). Parents' and friends' smoking status as predictors of smoking onset: findings from six European countries. Health Education Research, 18, 627.
  5. Duangdao KM (2012). When knowing just isn't enough: Examining of the role of moral emotions in health decision making using the Theory of Planned Behavior, The University Of Nebraska-Lincoln.
  6. Engels RCME, Hale III WW, Noom M, Vries H (2005). Selfefficacy and emotional adjustment as precursors of smoking in early adolescence. Subst Use Misuse, 40, 1883-93.
  7. Epstein JA, Zhou XK, Bang H, Botvin GJ (2007). Do competence skills moderate the impact of social influences to drink and perceived social benefits of drinking on alcohol use among inner-city adolescents? Prev Sci, 8, 65-73.
  8. Fisher KJ, Stanton WR, Lowe JB (1999). Healthy behaviors, lifestyle, and reasons for quitting smoking among out-ofschool youth. J Adolesc Health, 25, 290-7.
  9. Glynn T, Seffrin J, Brawley O, Grey N, Ross H (2010). The globalization of tobacco use: 21 challenges for the 21st century. CA Cancer J Clin, 60, 50-61.
  10. Guo Q, Johnson C, Unger J, et al (2007). Utility of the theory of reasoned action and theory of planned behavior for predicting Chinese adolescent smoking. Addictive behaviors, 32, 1066-81.
  11. GYTS (2009). Core Questionnaire. Centers for Disease Control and Prevention, GYTS.
  12. Harakeh Z, Scholte R, Vermulst A, de Vries H, Engels R (2004). Parental factors and adolescents' smoking behavior: An extension of the theory of planned behavior. Prev Med, 39, 951-61.
  13. Hassan LM, Shiu EMK (2007). Gender differences in low risk single occasion drinking: an application of the theory of planned behaviour. Int J Consum Studies, 31, 317-25.
  14. Islam S, Johnson C (2005). Influence of known psycholocial smoking risk factors on Egyptian adolescents Cigarette smoking behaviors. Health Promot Int, 20, 135-45.
  15. Akl EA, Gaddam S, Gunukula SK,et al (2010a). The effects of waterpipe tobacco smoking on health outcomes: a systematic review. Int J Epidemiol 39, 834-57.
  16. Akl EA, Aleem S, Gunukula SK, et al (2010b). Survey instruments used in clinical and epidemiological research on waterpipe tobacco smoking: a systematic review. BMC Public Hlth, 10, 415.
  17. Jawaid A, Zafar A, Rehman T, et al (2008). Knowledge, attitudes and practice of university students regarding waterpipe smoking in Pakistan. Int J Tuberc Lung Disease, 12, 1077-84.
  18. Karimy M, Niknami S, Hidarnia AR, Hajizadeh I (2012a). Intention to start cigarette smoking among Iranian male adolescents: usefulness of an extended version of the theory of planned behaviour. Heart Asia, 4, 120-4.
  19. Karimy M, Niknami S, Reza Heidarnia A, Hajizadeh I, Montazeri A (2012b). Prevalence and Determinants of Male Adolescents' Smoking in Iran: An Explanation Based on the Theory of Planned Behavior. Iran Red Crescent Med J, 15, 187-93.
  20. Khosravi A, Najafi F, Rahbar M, et al (2009). Health indicators in the Islamic Republic of Iran Network Development and Health Promotion Center, Tehran. 131-3.
  21. Luhtanen R, Crocker J (1992). A collective self-esteem scale: Self-evaluation of one's social identity. Pers Soc Psychol Bulletin, 18, 302.
  22. Mallia C, Hamilton-West K (2010). Smoking-related attitudes and perceptions among young adults in Malta and the UK. Psychology, Hlth Med, 15, 347-56.
  23. Maziak W, Eissenberg T, Ward K (2005). Patterns of waterpipe use and dependence: implications for intervention development. Pharmacol Biochem Behavior, 80, 173-9.
  24. Minnix JA, Blalock JA, Marani S, Prokhorov AV, Cinciripini PM (2011). Self-ef f icacy Mediates the Effect of Depression on Smoking Susceptibility in Adolescents. Nicotine Tob Res, 13, 699-705.
  25. Mohammadi MR, Mohammad K, Farahani FKA, et al (2006). Reproductive knowledge, attitudes and behavior among adolescent males in Tehran, Iran. Int Fam Plan Perspect, 35-44.
  26. Nehl E, Blanchard C, Peng C, et al (2009). Understanding Nonsmoking in African American and Caucasian College Students: An Application of the Theory of Planned Behavior. Behav Med, 35, 23-9.
  27. Nelson M, Gordon-Larsen P (2006). Physical activity and sedentarybehavior patterns are associated with selected adolescent health risk behaviors. Pediatrics, 117, 1281-90.
  28. Norman P (2011). The theory of planned behavior and binge drinking among undergraduate students: Assessing the impact of habit strength. Addict Behav, 36, 502-7.
  29. Norman P, Conner M, Bell R (1999). The theory of planned behavior and smoking cessation. Hlth Psychol 18, 89.
  30. Prochaska JJ, Hall SM, Humfleet G, et al (2008). Physical activity as a strategy for maintaining tobacco abstinence: a randomized trial. Prev med, 47, 215-20.
  31. Rachiotis G, Muula A, Rudatsikira E, et al (2008). Factors associated with adolescent cigarette smoking in Greece: Results from a cross sectional study (GYTS Study). BMC Public Health 8, 313.
  32. Ramezankhani A, Sarbandizaboli F, Zarghi A, Heidari G, Masjedi M (2010). Pattern of cigarette smoking in adolescent students in Tehran. Pejouhandeh, 15, 115-22.
  33. Rosenberg M, Schooler C, Schoenbach C, Rosenberg F (1995). Global self-esteem and specific self-esteem: Different concepts, different outcomes. Am Sociol Rev, 141-56.
  34. Rudatsikira E, Abdo A, Muula A (2007). Prevalence and determinants of adolescent tobacco smoking in Addis Ababa, Ethiopia. BMC Public Health 7, 176.
  35. Schmitt DP, Allik J (2005). Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. J Pers Soc Psychol, 89, 623.
  36. Shashidhar A, Harish J, Keshavamurthy SR (2011). Adolescent smoking a study of knowledge, attitude and practice in high school children. Pediatric On Call, 8, 7.
  37. Solomon LJ, Bunn JY, Pirie PL, Worden JK, Flynn BS (2006). Self-efficacy and outcome expectations for quitting among adolescent smokers. Addic Behav, 31, 1122-32.
  38. Toghianifar N, Sarrafzadegan N, Roohafza H, Sadeghi M, Eshrati B, Sadri G (2011). Smoking cessation support in Iran: Availability, sources and predictors. Indian J Med Res, 133, 627.
  39. Trinh CL (2005). Factors related to smoking behavior among high school students in Cantho city, Vietnam, Mahidol University, Cantho.
  40. Vandita V, Melissa B, Alexander P et al (2008). Correlates of susceptibility to smoking among Mexican origin youth residing in Houston, Texas: A cross-sectional analysis. BMC Public Health 8, 337.
  41. Wang MQ, Fitzhugh EC, Eddy JM, Westerfield RC (1996). Attitudes and beliefs of adolescent experimental smokers: a smoking prevention perspective. J Alcohol Drug Educ, 41, 1-12.
  42. Warren CW, Lea V, Lee J, et al (2009). Change in tobacco use among 13–15 year olds between 1999 and 2008: findings from the Global Youth Tobacco Survey. Global Hlth Promot 16, 38-90.
  43. Winefield H.R, WINEFIELD A.H, Tiggemann M (1992). Psychological attributes of young adult smokers. Psychological reports, 70, 675-81.
  44. Wong D, Chan S, Ho S, Fong D, Lam T (2010). Predictors of intention to quit smoking in Hong Kong secondary school children. J Public Hlth, 32, 360.

Cited by

  1. Effect on Smoking Quit Rate of Telling Smokers their Health Risk Appraisal in Terms of Health Age: A Randomized Control Trial vol.15, pp.12, 2014,
  2. Social- and individual-level psychological factors in the background of Hungarian adolescents’ risk behaviors vol.16, pp.1, 2015,
  3. Effects of Perceived Smoking-Cancer Relationship and Cardiovascular Health Attitudes on Childrens' Views of Smoking vol.16, pp.7, 2015,
  4. The allure of the waterpipe: a narrative review of factors affecting the epidemic rise in waterpipe smoking among young persons globally vol.24, pp.Suppl 1, 2015,
  5. An Extended Theory of Planned Behavior (TPB) Used to Predict Smoking Behavior Among a Sample of Iranian Medical Students vol.4, pp.3, 2015,
  6. The association between attitude, self-efficacy, and social support and adherence to diabetes self-care behavior vol.10, pp.1, 2018,
  7. Effects of adolescents’ self-efficacy and social anxiety on attitudes toward pros and cons of smoking pp.1475-9942, 2018,