Abstract

Smoking is a serious issue causing a variety of adverse health effects. However, pesantrens (Islamic boarding schools) do not prohibit smoking, their leaders and teachers also smoke, and cigarettes are sold freely outside. The students have further admitted that anyone may smoke any where and that no socialization on smoking has ever been conducted in pesantrens.The purpose of this study was to analyze the relationships between the student smoking behavior, knowledge, and attitudes towards the social marketing mix in traditional pesantrens.This study employed a descriptive analytics with the cross sectional study design.The total sample was 162 students from a pesantren in Aceh Besar, Indonesia.The results showed that there were significant relationships between student smoking behavior and age (p-value = 0.031), and parents’ smoking behavior (p-value= 0.003), and peersmoking behavior (p-value =0.000), and knowledge of the social marketing mix (p-value= 0.010), and attitudes (p-value = 0.000) towards the social marketing mix. It is thus recommended tha tall parties develop a pesantren as one of the focus areas of smoking prevention activities

introduction

Cigarette smoking has caused various health problems having been further responsible for six million deaths each year (Naeem, 2015). By 2020, smoking is projected to cause 10 million deaths per year and increase premature deaths to70% in developing countries (Voigt, 2010). I n the context of Indonesia, the number of deaths from smoking is estimated at 200,000 people each year ( Riskesdas, 2010).

There are a variety of reasons for individuals to smoke,one of which is due to e nvironment. Initially, one may only observe another person smoking, and later trying smoking. When one gets addicted to smoking, one may smoke again under various pretexts, su ch as reducing anxiety, relieving boredom and stress, being accepted in a particular group, and family problems (Kaplan, 1993).

Several factors, like attitudes and behavior of parents or family members who smoke in front of children,will also encouragethe children to smoke and lead them to assume that this behavior does not contradict the norms (Peterson et al., 2006). In a similar vein, Helgason and Lund (2001) also remark that parental smoking exposure will have an impact to their children. In the past, people used to consider smoking as a symbol of friendliness and communication, and in s ome cultures, smoking was thought as a prestigious behavior resulting in personal satisfaction ( Egbe,2016). If smoking habit has been established, social factors play an essential role in maintaining smoking behavior (Kaplan, 1993).

If not prevented, smoking behavior among students is predicted to trigger a number of social issues, such asmisuse of marijuana, alcohol, and other illicit substances, since many studies have found that smoking addiction was agate way to drug and alcohol abuse (Rokiah Abu Bakar, 2013). Therefore, young consumers who only start smoking should be properly cultivated and nurtured in order n ot to develop the habit ( Chamim et al., 2011). Smoking is one type of behaviors that can be changed (Natoatmodjo, 1993) ifintention and attitudes including motivation to obey are present (Ajzen&Fishbein, 1967).

The Regional Health Re search Report (Riskesda) in Indonesia in 201 3 found that 52.3% of the average smokersconsumed 1-10 cigarettes per day, whereas t he percentage of smokers with an average of 21-30 cigarettes per day wasthe highest in Aceh Province ( 9.9 %). In addition, t he prevalence of adolescents aged 16-19 years who smoked increased threefold from 7.1% in 1995 to 20.5% in 2014, and theage of beginner smokers among adolescents became much younger (early). Beginner smokers aged 10-14 years rose more than 100% in a period of less than 20 years, from 8.9% in 1995 to 18% in 2013 ( Riskesdas, 2013 ).

There have been many regulations in Indonesian about smoking i n 2011 the Minister of Health and the Minister of Home Affairsissued a joint regulation number 188 /Menkes/PB /I/2011 concerning the guideline for the implementation of non s moking areas. The Indonesian Ulama Council (MUI ) had also released a fatwa (religious ruling) in 2003 that smoking was makruh (abominable). The fatwa was later revised to haram (forbidden) for pregnant women, for children, and in public places,following the coordination meeting of the Sumatran MUI in Palembang in July 2008. Likewise, Aceh Province had also issued a qanun (regional by law) number 6 of 2011 and a Regent of Aceh Besar Regulation number 40 of 2016 on free smoking areas. However, these regulations have fail ed to reduce the number of smokers in Aceh. The preliminary observations further revealed that, in fact, the traditional pesantrens did not ban smoking within the school areas and the leaders and the teachers also smoke d, while cigarettes could be purchased easily. The students also stated that people could smoke anywhere and there has never been any socialization about smoking within the pesantrens.

 Research Methods

This present study used a descriptive analytic s with the cross sectional study design. The respondents in this study were 162 students of one traditional pesantren in Aceh Besar, Aceh, Indonesian. The selection criteria was having been a student of at least one year with a maximum age of 20 years.

Research Instrument

             The questionnaire in this study was independently developed based on literature review. The questionnaire was made up of four parts: the characteristics of the respondent s, the social marketing mix, the attitudes towards the social marketing mix, and the student smoking behavior.

Research Ethics

The research protocol was approved by the Health Research Ethics Committee of Health Polytechnic of Aceh Ministry of Health, Aceh Besar. Approval forms were obtained from the students before they responded to the questionnaire.

data analysis

The analysis used to test the hypotheses was a chi s quared test, with a level of significance of below 0.05 (p value < 0.05).

results

              Table 1 describes that the majority of the respondents were 15-18 years old (78.4%). 67.3 % of the respondents’ parents were smokers, and 61.1% of the respondents had peers who also smoked. In addition, most respondents (58.0 %) had low knowledge, were negative towards the social marketing mix ( 60.5%), and smoked (69.1%) as well

             Table 2 illustrates that the respondents aged <15 years (78.6%) who smoked were slighly higher than those aged 15-18 years (72.2%), while less than half of theolder respondents (>18 years old) smoked with p-value of 0.031. The respondents who smoked were also found to be higher within parental smoking exposure (77.1%) compared to those without (58.2%) with p-value of 0.003. The proportion of the respondents withpeer smokers was also larger (79.8 %) than those with no peer smokers (52.4%) with p-value of 0.000. Further, smoking was mostly within the respondents with low knowledge about the social marketing mix (77.7%) compared to those with high knowledge (57.4%) with p-value of .010. In addition, smoking was also more common in the respondents with negative attitude s towards the social marketing mix (84.7%) than in those with positive attitude s (45.3%) with p-value of 0.000.

discussion

The findings o f this study indicated that there was significantly larger percentage (78.6%) of younger smokers (<15 years old) within the pesantren. This figure was higher that that in theGlobal Adult Tobacco Survey (GATS, 2011) which found that 23.1% of teenagers were smokers. This study, thus, supported the argument that m ost tobacco users started smoking during their teenage years (Hammond et al., 2008; WHO, 2013), and around 80% of them were b efore the age of 18 in the US (Centers for Disease Control & Prevention, 2012).Several local studies in Malaysia also showed that the age of initiation of smoking ranged from 11 to 14 years (Lim et al., 2010; Lipperman-Kreda et al., 2014). In addition, 56.7% of male students in residential areas were smokers even before entering secondary school and 54% of them were reg ular smokers at the age of 16 (Lim et al., 2006). A survey among adults who smoked every day in the US found that82% of them tried cigarettes for the first time when they were not even 18 ye ars old, and 53%turned into daily smokers before the age of 18 (HHS, 1994) . Several studies on teenage smokers conducted in developed countries also reported that n early 50% of adolescents who were only 18 years old ha d already smoked and most of them were regular smokers ( Naing et al., 2004).

 The result of the chi squared test in this study obtained p-value of 0.031, highlighting that there was a significant relationship between age and smoking behavior of the students in the pesantren. This result was in line with that in Hwang ’s and Park ’s (2014) study on Korean adolescents, and relatively similarto that in Reidpath et al.’s (2013) which claimed that in Latvia there was a sign ificant relationship between the initiation age of smoking and current smoking behavior.

The earlier one starts smoking, the harder it is to stop and the less likely one will completely stop (Flay et al., 1989), and also the greater the risk of lung cancer (Charlton, 1984) or death from coronary heart disease (Fielding, 1985). The opportunity for successful smoking cessation also decrease s along with the increase of age (Lennox, 1992), and therefore, prevention programs on smoking for teenagers are deemed necessary following the strong influence of age in smoking behavior.

In regard with smoking exposure, this study discovered that 77.1% of the students lived with parents who smoked, and t his proportion was quite bigger than either inNainget al.’s (2004) study of 44.1% or Lim et al.’s (2010) of only 18.3 %. The chi s quared test gained p-value of 0.003 suggesting that there was a significant relationship between smoking behavior of parents and smoking behavior of students. This result also conformed to the findings in the study by Lim et al. (2010) on t he relationship between parental smoking behavior and teenage smoking behavior as well as in the studies by Nainget al. (2004 ) and Wang et al. (2016).

              The teenage smoking behavior can be further explained by the theory of s ocial learning on behavior (Social Learning and Personality Development, 1963) arguing that children are more likely to model their own behavior in the actions of people they deem ap propriate. Two other studies (Newman& Ward, 1989 ; Eiser et al., 1963 ) then revealed that parents’ attitudes in actively preventing their children from smoking may have had a stronger impact than parents’behavior in shaping their teenagers’ smoking behavior. Additionally, two other studies (Baugh et al., 1982; Paine, Amaral,& Pereira, 1985) also asserted that the majority of smokers began their smoking habit by imitating friends, coworkers or family members. These findings further suggested that in order for the campaign against smoking in adolescents to be more effective, parents should not smoke in front of their children and vice versa. The home environment should be able to discipline children and t he role model should also be set at home. Having family members who smoke elevates the risk of smoking as constant exposure of smoking to the other family members will speed up the process of copying behavior,since observationis one essential factor in learning, and this copying will generally affect individuals of the same sex (Bandura, 1977).

Further, i n this study, it was found that more than 70% of the respondents had friends who were smokers. This result was apparently higher than that in Lim'set al (2010) of only 28.1% and that in the study by Subramanian, Arifah, and Addy (2017) of 51.8%. The chi-squared had p-value of 0.000 indicating that there was a significant relationship between peer smoking behavior and smoking behavior of the students in the pesantren. The finding was similar to that in the study of Subramanian et al. (2017) in the district of Jatinangor, Indonesia n outlining a relationship between peer pressure and smoking behavior of students.

The primary factor associated with smoking in adolescents is ha ving friends who smoke (Pereira et al, 2017). S ome studies also agreed that being friends with smokers created more tolerance to smoking habit, including the possibilit y of adopting the behavior ( Schaefer, Haas, & Bishop, 2012). These data were also corroborated by research in North America, which observed that non-smoking teens who had smoking friends were more likely to develop smoking habit in the future than th ose who did not (Bricker, 2006).

Peer influence is a modifiable external variab le that contributes to smoking and it may also become a double -edged sword (Wen et al., 2007) as h aving a friend who smokes can affect a teenager to also smoke because of peer pressure and encouragement to be accepted into a group. 90% of smokers started smoking with their friends,as also shown in Unger et al.(2002) on Chi nese and California adolescents, and thus, peer influence factor is crictical in smoking initiation.

Peer influence was found to be a strong predictor of smoking initiation in almost all studies. The two types of peer pressure, having c lose friends who smoke and having close friends who encourage to smoke, are among the strongest risk factor s for smokers (Preventing Tobacco Use among Young People, 1994), and these were proven in the study in China (Zhu, Liu & Wang, 1992).In addition, studies from Japan ( Kawabata, Maruya, &Nakamura, 1991) and Spain ( Auba&Villalbi, 1993) have shown that the smoki ng rate of school students was strongly related to having friends who smoke d. These findings suggested that the students should be advised to avoid befriending smokers as the negative effects are not only limited to the smell of cigarettes and the dangers of passive smoking, but also the pressure to keep up with the habit.

       In terms of knowledge, it was found that most (77.7%) of the respondents who smoked had low knowledge in this study. This outcome was comparably higher than that in Obaid et al.’s (2015) study of 35.0%. Moreover, s mokers generally had lack of knowledge about the harmful effects of smoking compared to non -smokers (Foong& Tan, 2008; Naggar,2011). The chi-squared test on this factor resulted in p-value of 0.000, referring to a significant relationship between knowledge about the social marketing mix and the smoking behavior of the students in the pesantren. The finding was in accord with those in the studies of Obaid et al. (2015) and Naggar (2011); however, it differ ed from those in the studies of Yogae et al.(2014) and Samira (2017) that non -smoking students had bet ter knowledge of smoking and its dangers and conversely, confirming the studies in South Australia (Dollman, 2007 ) and in Turkey (Golbasi, 2011).

      Further, i n relation to attitudes, this study pointed out that 84.7% of the students’ attitudes were mostly negative. The study had a much greater proportion than that of Obaid et al.’s (2015) study which identified only 41.3% with a negative attitude. The result of the Chi-Squaredtest then obtained p-value of 0.000, showing that there was a relationship between the students’ attitudes and their smoking behavior. The same findings were also reported by the studies of Naggaret al., (2011),Yogae et al., (2014), and Samira (2017). In this study, t he students who did not smoke possessed a better attitude towards the use of tobacco and its harmful effects and vice versa, as also conformed by the research of Dollman (2007 ) and Golbasi (2011).  

Having reviewed the afore mentioned findings, the study pinpointed that there is the need to improve the students’ knowledge by promoting the anti-smoking campaign through various ways. School-based smoking prevention programs should also be sensitive to the diversity of culture, ethnicity, and economy of the students ( Shetgiri, 2011; McKennitt& Currie, 2012).

conclusions

The study concluded that the relationship s were significant between student smoking behavior and age ( p-value = 0.031 ), andparents’ smoking behavior ( p-value = 0.003), and peersmoking behavior ( p-value= 0.000), and knowledge of the social marketing mix ( p-value = 0.010), and attitudes ( p-value = 0.000 ) towards the social marketing mix. The implication is that future anti-smoking propaganda should take into accout the students’ age, culture, family, and ethnicity in order to prevent the younger generation to smoke. It is also recommended that pesantrens become one of the focus areas of smoking prevention activities.