Systematic Review of Smoking Initiation among Asian Adolescents, 2005-2015: Utilizing the Frameworks of Triadic Influence and Planned Behavior

  • Talip, Tajidah (Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam) ;
  • Murang, Zaidah (Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam) ;
  • Kifli, Nurolaini (Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam) ;
  • Naing, Lin (Pengiran Anak Puteri Rashidah Sa'adatul Bolkiah (PAPRSB) Institute of Health Sciences, Universiti Brunei Darussalam)
  • 발행 : 2016.07.01


Background: A recent WHO data report on mortality attributable to tobacco use including cigarette smoking indicated a very high burden of deaths in Asia and that people often initiate smoking as early as young adolescents. The objectives of this study were to systematically review peer-reviewed articles on cigarette smoking initiation among Asian adolescents and to develop a conceptual model of factors influencing smoking initiation by integrating all relevant factors based on existing data. Materials and Methods: Following a PRISMA guideline, a systematic review of articles published between 2005 and June 2015 was conducted using 5 databases on cigarette smoking initiation among adolescents (aged 10-19 years) living in Asia. We summarized the main findings of each study according to our research questions and data that emerged during the data extraction process. Analysis and categorization were based on the TTI and TPB models and classification of factors extracted from the study, were as follows: personal factors, social factors, broader environmental factors, mediators, and intention to initiate smoking and smoking behavior. Results: Of 1,227 identified studies, only 20 were included in this review. Our findings found that the mean age of cigarette smoking initiation ranged from 10 to 14 years and those who are more likely to initiate smoking are male, older adolescents, adolescents with low parental SES, individuals with low parental monitoring, low parental education level and having no discussion on smoking at home, those living in public housing and those exhibiting health-risk behavior. Our study also revealed that the risk of smoking initiation increased when they are exposed to smokers, influenced by peers, exposed to tobacco advertisements, receive pocket money, have lack of knowledge about smoking, have poor school performance, have a family conflict and have psychological problems. The conceptual model developed demonstrated complex networks of factors influencing initiation. Conclusions: This systematic review presents various factors influencing smoking initiation of the Asian adolescents and provides a conceptual framework to further analyze factors. Future studies should have a standard measure of smoking initiation, should analyze interactions and the intensity of relationships between different factors or variables in the conceptual model. This will in turn consolidate the understanding of the different factors affecting smoking initiation and will help to improve interventions in this area.


  1. Ajzen I, Madden TJ (1986). Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control. J Experimental Social Psychol, 22, 453-74.
  2. Bagchi NN, Ganguly S, Pal S, et al (2014). A study on smoking and associated psychosocial factors among adolescent students in Kolkata, India. Indian J Public Health, 58, 50-3.
  3. Brown AK, Moodie C, Hastings G, et al (2010). The association of normative perceptions with adolescent smoking intentions. J Adolescence, 33, 603-14.
  4. Burton D, Sussman S, Hansen WB, et al (1989). Image attributions and smoking intentions among seventh grade students. J Applied Social Psychol, 19, 656-64.
  5. Curry LA, Nembhard IM, Bradley EH (2009). Qualitative and mixed methods provide unique contributions to outcomes research. Circulation, 119, 1442-52.
  6. Das S, Ghosh M, Sarkar M, et al (2011). Adolescents speak: why do we smoke? J Trop Pediatr, 57, 476-80.
  7. Freedman KS (2012). Smoking initiation among young adults in the United States and Canada, 1998-2010: A systematic review. Preventing Chronic Disease, 9.
  8. French DC, Purwono U, Rodkin P (2014). Indonesian Muslim Adolescents' Use of Tobacco and Alcohol: Associations With Use by Friends and Network Affiliates. Merrill-Palmer Quarterly, 60, 385-402.
  9. Galea S, Riddle M, Kaplan GA (2010). Causal thinking and complex system approaches in epidemiology. Int J Epidemiol, 39, 97-106.
  10. Gilman SE, Rende R, Boergers J, et al (2009). Parental smoking and adolescent smoking initiation: an intergenerational perspective on tobacco control. Pediatrics, 123, 274-81.
  11. Harakeh Z, Scholte RH, Vermulst AA, et al (2004). Parental factors and adolescents' smoking behavior: an extension of The theory of planned behavior. Prev Med, 39, 951-61.
  12. Higgins A, Conner M (2003). Understanding adolescent smoking: The role of the Theory of Planned Behaviour and implementation intentions. Psychol Health Med, 8, 173-86.
  13. Ho MG, Shi Y, Ma S, et al (2007). Perceptions of tobacco advertising and marketing that might lead to smoking initiation among Chinese high school girls. Tobacco control, 16, 359-60.
  14. Hock LK, Ghazali SM, Cheong KC, et al (2013). Correlates of susceptibility to smoking among secondary school students in Kota Tinggi district, Johor, Malaysia. Asian Pac J Cancer Prev, 14, 6971-8.
  15. Hoyle RH 1995. Structural equation modeling: Concepts, issues, and applications, Sage Publications.
  16. Jafarabadi MA, Allahverdipour H, Bashirian S, et al (2012). Modeling the Underlying Predicting Factors of Tobacco Smoking among Adolescents. Iran J Public Health, 41, 46-57.
  17. Jeganathan PD, Hairi NN, Al Sadat N, et al (2013). Smoking stage relations to peer, school and parental factors among secondary school students in Kinta, Perak. Asian Pac J Cancer Prev, 14, 3483-9.
  18. Karimy M, Niknami S, Heidarnia AR, et al (2013). 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.
  19. Kobus K (2003). Peers and adolescent smoking. Addiction, 98, 37-55.
  20. Kumar V, Talwar R, Roy N, et al (2014). Psychosocial determinants of tobacco use among school going adolescents in Delhi, India. J Addict, 2014.
  21. Li X, Mao R, Stanton B, et al (2010). Parental, behavioral, and psychological factors associated with cigarette smoking among secondary school students in Nanjing, China. J Child Family Studies, 19, 308-17.
  22. Lim KH, Chong Z, Khoo YY, et al (2014). Parental Smoking Status, Stress, Anxiety, and Depression Are Associated With Susceptibility to Smoking Among Non-Smoking School Adolescents in Malaysia. Asia Pac J Public Health, 26, 81-90.
  23. Lim KH, Sumarni MG, Kee CC, et al (2010). Prevalence and factors associated with smoking among form four students in Petaling District, Selangor, Malaysia. Trop Biomed, 27, 394-403.
  24. Lin P-L, Tzeng L-C, Lu K-Y, et al (2008). Factors related to tobacco use among adolescents in southern Taiwan. J Nursing Res, 16, 243-51.
  25. Mak K-K, Ho S-Y, Day JR (2012). Smoking of parents and best friend-independent and combined effects on adolescent smoking and intention to initiate and quit smoking. Nicotine Tobacco Res, 14, 1057-64.
  26. McKelvey KL, Wilcox ML, Madhivanan P, et al (2013). Time trends of cigarette and waterpipe smoking among a cohort of school children in Irbid, Jordan, 2008-11. European J Public Health, 23, 862-7.
  27. Mercken L, Candel M, Willems P, et al (2009). Social influence and selection effects in the context of smoking behavior: Changes during early and mid adolescence. Health Psychol, 28, 73.
  28. Murnaghan D, Leatherdale S, Sihvonen M, et al (2008). A multilevel analysis examining the association between school-based smoking policies, prevention programs and youth smoking behavior: evaluating a provincial tobacco control strategy. Health Education Res, 23, 1016-28.
  29. Narain R, Sardana S, Gupta S, et al (2011). Age at initiation & prevalence of tobacco use among school children in Noida, India: A cross-sectional questionnaire based survey. The Indian J Med Res, 133, 300.
  30. O'Loughlin JL, Dugas EN, O'Loughlin EK, et al (2014). Incidence and determinants of cigarette smoking initiation in young adults. J Adolesc Health, 54, 26-32.
  31. Ozawa M, Washio M, Kiyohara C (2008). Factors related to starting and continuing smoking among senior high school boys in Fukuoka, Japan. Asian Pac J Cancer Prev, 9, 239-45.
  32. Pentz MA, Sussman S, Newman T (1997). The conflict between least harm and no use tobacco policy for youth: ethical and policy implications. Addiction, 92, 1165-74.
  33. Pierce JP, Choi WS, Gilpin EA, et al (1998). Tobacco industry promotion of cigarettes and adolescent smoking. Jama, 279, 511-5.
  34. Pradhan PMS, Niraula SR, Ghimire A, et al (2013). Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: a cross-sectional questionnaire survey. BMJ Open, 3, 2123.
  35. Rahman MM, Ahmad SA, Karim MJ, et al (2011). Determinants of smoking behaviour among secondary school students in Bangladesh. J Community Health, 36, 831-8.
  36. Reidpath DD, Davey TM, Kadirvelu A, et al (2014). Does one cigarette make an adolescent smoker, and is it influenced by age and age of smoking initiation? Evidence of association from the U.S. Youth Risk Behavior Surveillance System (2011). Prev Med, 59, 37-41.
  37. Rothman KJ, Greenland S (2005). Causation and causal inference in epidemiology. American J Public Health, 95, 144-50.
  38. Russell CK, Gregory DM (2003). Evaluation of qualitative research studies. Evidence Based Nursing, 6, 36-40.
  39. So ES, Yeo JY (2015). Factors associated with early smoking initiation among Korean adolescents. Asian Nursing Res, 9, 115-9.
  40. Sun J, Buys N, Stewart D, et al (2011). Mediating effects of coping, personal belief, and social support on the relationship among stress, depression, and smoking behaviour in university students. Health Educat, 111, 133-46.
  41. Tang SM, Loke AY (2013). Smoking initiation and personal characteristics of secondary students in Hong Kong. J Advanced Nurs, 69, 1595-606.
  42. Tickle JJ, Hull JG, Sargent JD, et al (2006). A structural equation model of social influences and exposure to media smoking on adolescent smoking. Basic Applied Social Psychol, 28, 117-29.
  43. Tjora T, Hetland J, Aaro LE, et al (2011). Distal and proximal family predictors of adolescents' smoking initiation and development: a longitudinal latent curve model analysis. BMC Public Health, 11, 911.
  44. Tyas SL, Pederson LL (1998). Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control, 7, 409-20.
  45. Ullman JB, Bentler PM 2003. Structural equation modeling, Wiley Online Library.
  46. Van De Ven MO, Engels RC, Otten R, et al (2007). A longitudinal test of the theory of planned behavior predicting smoking onset among asthmatic and non-asthmatic adolescents. J Behav Med, 30, 435-45.
  47. Von Elm E, Altman DG, Egger M, et al (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Preventive Med, 45, 247-51.
  48. Warren CW, Riley L, Asma S, et al (2000). Tobacco use by youth: a surveillance report from the Global Youth Tobacco Survey project. Bulletin World Health Organization, 78, 868-76.
  49. Wolfson M, Hourigan M (1997). Unintended consequences and professional ethics: criminalization of alcohol and tobacco use by youth and young adults. Addict, 92, 1159-64.
  50. World Health Organization (2003). Adolescent friendly health services: an agenda for change.
  51. World Health Organization (2008). WHO report on the global tobacco epidemic, 2008: the MPOWER package.