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Epidemiological profile of smoking and nicotine addiction among asthmatic adolescents
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
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Original Research
Epidemiological profile of smoking and nicotine addiction among asthmatic adolescents zquez-Nava a,**, E.M. Va zquez-Rodrı´guez b, F. Va zquez-Rodrı´guez c,*, O. Castillo Ruiz d, J. Peinado Herreros e C.F. Va a
Department of Research, School of Medicine, Tampico, Autonomous University of Tamaulipas, Tampico, Mexico n Campus, Mexico School of Medicine, University of Veracruz, Minatitla c Mexican Institute of Social Security, Southern Delegation of Veracruz, Mexico d n Multidisciplinary Academic Unit, Autonomous University of Tamaulipas, Mexico Reynosa Aztla e School of Medicine, University of Granada, Spain b
article info
abstract
Article history:
Objective: Despite the harmful effects of cigarette smoking, this habit in asthmatic ado-
Received 12 December 2016
lescents continues to be a health problem worldwide. Our objectives were to determine the
Received in revised form
epidemiological profile of smoking and the degree of nicotine dependence among asth-
10 April 2017
matic adolescents.
Accepted 11 April 2017
Study design: Through a cross-sectional investigation, 3383 adolescents (13e19 years of age) were studied. Methods: Information was collected using a previously validated questionnaire. Two study
Keywords:
groups of adolescent smokers were formed: one composed of asthmatic adolescents and
Habits and behaviours
the other of healthy youths.
Asthma
Results: Asthmatic adolescents were found to be more likely to smoke (21.6% vs 11.8%) and
Adolescents
to have some degree of nicotine dependence compared with healthy adolescents (51.6% vs
Smoking
48.8%).
Nicotine addiction
The most important characteristic of smoking in asthmatic adolescents was found to be an onset before 11 years of age due to curiosity about cigarettes. Asthmatic youths continue smoking because this habit decreases their anxiety and stress. Adolescents know that smoking is addictive and often smoke on waking up in the morning or when they are sick. Yet, these adolescents do not consider smoking to be a problem. Conclusion: In this study, curiosity about cigarettes was the primary reason why asthmatic adolescents smoked for the first time and developed a greater dependence to nicotine compared with healthy adolescents. Moreover, the findings show that many of the factors that favour the development of smoking are preventable, given that they are present in the family and social environment. © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Calle Reforma 100-B C.P. 89490, Ciudad Madero, Tamp, Mexico. Tel.: þ52 8332166247. ** Corresponding author. zquez-Nava), [email protected] (C.F. Va zquez-Rodrı´guez). E-mail addresses: [email protected] (F. Va http://dx.doi.org/10.1016/j.puhe.2017.04.012 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
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p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
Introduction Active smoking is considered the leading cause of preventable death in the world, and its development at an early age increases the risk of experimenting with other drugs.1e3 According to the World Health Organization, the average age of onset of smoking is 11 years, and its worldwide prevalence in individuals over 15 years old is as high as 21.0%.1 The undesirable effects of smoking include the following: the development of various types of cancers, physical and psychological dependence, cardiovascular diseases and asthma and other conditions.1,4e6 Asthma is one of the most common chronic respiratory diseases of our time.7,8 According to the World Health Organization, asthma affects 334 million people globally, and its prevalence in adolescent populations ranges from 5.0% to 20.0%.9 The negative effects of asthma are as follows: hospital admissions, work and school absenteeism, negative impacts on family finances due to the purchase of medicines, work overload at various levels of hospital care, impaired quality of life and death.8e11 Moreover, studies on the aetiology of asthma show that active smoking is significantly associated with the development and aggravation of asthma symptoms.2,6,12 However, in the last two decades, several investigators have documented a higher prevalence of active smoking among adolescents suffering from asthma compared with healthy youths.13e15 As a result, it is important to design research studies on smoking whose outcomes facilitate planning health prevention programmes aimed at asthmatic adolescents. Some studies conducted in various countries have identified certain factors that favour the development of smoking in adolescents.2,15e18 However, the smoking-related characteristics and degree of nicotine dependence of adolescents suffering from asthma have not been determined. There is a clear need to determine the characteristics of the personal, family and social environments and factors that favour the development of certain risky habits and behaviours that harm health. Such knowledge will allow the design of better programmes to prevent smoking and limit the harm it causes. Accordingly, the present study was developed to determine the smoking-related characteristics of and degree of nicotine dependence in a sample of adolescents who suffer from asthma.
Methods For this study, 3383 adolescents were invited to participate in a cross-sectional study conducted in an urban area of northeast Mexico. From the total sample, 430 adolescents who suffered from asthma were identified. The remainder of the population (n ¼ 2953) was identified as non-asthmatic, and these individuals were used as the control group to compare the study variables between the groups. The methodology used in this study was similar to one used previously;15 however, the sample of adolescents included in the present study differed from that registered in the aforementioned investigation.
The adolescents, who attended secondary or preparatory schools, were recruited through one of the community service programmes under the supervision of the Faculty of Medicine. The permission of the educational authorities in the area was sought and obtained. The participating schools and students were selected by a simple random sampling technique. In each school selected, a list of enrolled students was requested, and students were randomly selected for the sample. The data were collected in 2015 and analysed in 2016.
Information collection To collect the data, a self-administered questionnaire was constructed based on previously validated tools. These questionnaires have been used for different epidemiological studies, such as The International Study of Asthma and Allergies in Childhood (ISAAC) and The European Community Respiratory Health Survey, among others.19e22 The questionnaire was disseminated by staff who had previously been trained for this purpose. To determine the level of understanding of the questions contained in the questionnaire, two pilot studies were conducted 15 days apart. In each pilot study, 20 adolescents were interviewed, and the questions contained in the instrument were closed, had two or more answer choices and were grouped into five blocks. The responses to the questions contained in the first block allowed for the collection of information on the sociodemographic characteristics of the adolescents, their lifestyles, whether they had any habits or health-risk behaviours (e.g. smoking) and if they spent time with friends who smoked. In the subsequent blocks, questions were included to collect information on various family-related characteristics, such as the following: whether the adolescent lived with one or both biological parents, if the relationship between different family members was good or bad, or if the father or mother smoked inside the home.
Asthma Asthma was diagnosed in this study according to the criteria established in the questionnaire designed for ISAAC.11,19 The presence of wheezing and dry cough at night during the last 12 months and having received an asthma diagnosis by a physician served as the criteria defining current asthma for an adolescent. In addition, information was requested on whether any other family member, such as the father, mother, siblings or grandparents, suffered or had suffered from any allergic disease.
Smoking The questions included in the questionnaire to determine the epidemiological profile of smoking adolescents were as follows: 1. 2. 3. 4.
Have you ever tried smoking cigarettes? How old were you when you first smoked? Why did you first start smoking? Do you currently smoke?
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
5. 6. 7. 8. 9. 9. 10. 11. 12.
13. 14. 15.
Why do you continue to smoke? If you do not smoke, why? In what grade did you first try a cigarette? During the last month, how many days did you smoke cigarettes? Which of your parents know that you smoke? Which of your parents let you smoke? Where do you smoke most often? Do you know that smoking causes addiction? Do you know that smoking can lead to certain diseases, such as asthma, cancer, high blood pressure and so forth? Do you consider tobacco to be a health problem for you? Have you attempted to quit smoking before? Do you plan to stop smoking?
Nicotine dependence €m Nicotine dependence was determined using the Fagerstro € m questionnaire, the Test.23,24 According to the Fagerstro different degrees of nicotine dependence are determined according to the aggregated score, where <3 points signifies low dependence; four to six points signifies moderate dependence and 7 points signifies high dependence. Informed consent was requested and obtained from all of the adolescents or from their parents, and participants had the right to leave the study at all times, even after they had finished answering the questionnaire.
Statistical analysis The data were analysed with the statistical package SPSS-13.0. Simple frequencies and measures of central tendency (means and standard deviations) were used. The following factors were compared between asthmatic and non-asthmatic adolescents: (i) possible gender bias; (ii) active smoking; (iii) family structure; (iv) family environment; (v) the presence of parents and friends who smoke at home and in the social environment; (vi) smoking-related characteristics; and (vii) the degree of nicotine dependence. For the analysis, polytomous variables were re-categorized to transform them into dichotomous variables, with ‘present’ being the most frequently reported option. The comparison between groups of asthmatic and healthy adolescents, who were categorized with respect to sociodemographic variables and smoking-related characteristics, was performed using a 2 2 contingency table, the chi-squared test and a 95% confidence interval. Any P-value <0.05 was considered significant.
Results A total of 3383 adolescents were studied, of whom 52.4% were male, and their mean age was 14.49 ± 1.6 years. The prevalence of asthma was 12.7%, and that of active smoking was 13.0%. Table 1 shows the sociodemographic data and characteristics of the family and social environments of the asthmatic and non-asthmatic adolescents. Compared with the healthy adolescents, a higher percentage of adolescents in
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the asthma group smoked (21.6% vs 11.8%), lived within an incomplete family unit (27.4% vs 23.6%), had a poor relationship with their parents (11.6% vs 6.5%), lived with their parents (40.5% vs 29.0%) and had friends who smoked (69.3% vs 59.2%). Of the total number of adolescents who identified as active smokers (n ¼ 440), two groups were classified: one consisting of those suffering from asthma (n ¼ 93) and the other consisting of healthy individuals (n ¼ 347). In Table 2, the smoking-related characteristics of asthmatic and healthy adolescents are shown. In the group of asthmatic adolescents, males smoked more than females (59.1% vs 40.9%), and 23.7% of these adolescents first smoked before the age of 11 years, with the reason for starting being ‘curiosity’. More than 70.0% of youths who suffered from asthma declared that they smoked because it relaxed them or helped them reduce stress. A total of 23.7% of the adolescents of this group reported smoking every day, and the most common locations for smoking were in public places or at parties with their friends. Approximately 10.0% of asthmatic adolescents reported smoking on waking up in the morning, and 93.5% declared that they knew that smoking is addictive. However, approximately 40.0% of the asthmatic adolescents believed that smoking did not represent a health problem for them. Furthermore, 66.7% of these adolescents noted that at least one of their biological parents knew they smoked, and 29.0% stated that one or both parents allowed them to smoke. Table 3 shows the degree of nicotine dependence in asth€m matic and healthy adolescents, based on the Fagerstro questionnaire. According to the items of this test, 22.6% of the adolescents who suffered from asthma reported that they smoked more in the morning than during the rest of the day. These individuals smoked their first cigarette within the first waking hour, and 30.1% noted that the cigarette that they would least like to give up would be the first of the morning. Approximately 23.7% reported smoking more than 10 cigarettes a day, 16.1% found it difficult to not smoke in prohibited areas and 12.9% reported smoking even while sick. € m quesBased on the cut-offs considered in the Fagerstro tionnaire, 51.6% of the adolescents who suffered from asthma showed some degree of nicotine dependence, compared with 48.8% of the healthy adolescents.
Discussion According to the data in this study, the percentage of adolescents who smoke and have some degree of nicotine dependence is higher among those who suffer from asthma compared with healthy adolescents. With respect to the smoking-related characteristics of asthmatic adolescents, the following results are highlighted: (i) these youths begin smoking before the age of 11 years due to curiosity about cigarettes, and (ii) they often smoke on waking up in the morning or when they are sick. To our knowledge, this is the first study to collect information on the smoking-related characteristics and degree of nicotine dependence in asthmatic adolescents. It is important to have this information on hand in the course of designing programmes for the prevention of smoking in asthmatic adolescents with nicotine
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Table 1 e The characteristics of the family and social environments of asthmatic and healthy adolescents (n ¼ 3383). Variables
Sex Male Female Tried a cigarette at some point in life Never tried a cigarettea Active smoking Not a smokera Incomplete family Complete family Relationship between family's parents Poor Gooda Relationship between adolescent and parents Poor Gooda Major influence on the adolescent Mother Father Both parentsa Grandfather None Who smokes in the house where you live? Father Mother Both smoke Nobody smokesa How many of your friends smoke? Some Most All smoke Nonea
Asthmatic (n ¼ 430)
Healthy (n ¼ 2953)
Odds ratio (95% CI)
n
%
n
%
201 229 216 214 93 337 118 312
46.7 53.3 50.2 49.8 21.6 78.7 27.4 72.6
1573 1380 1228 1725 347 2606 696 2257
53.3 46.7 41.4 58.6 11.8 88.25 23.6 76.4
1.06 (0.66e1.69)**
65 365
15.1 84.9
341 2612
11.5 88.5
1.36 (1.02e1.81)*
50 380
11.6 88.4
191 2762
6.5 93.5
1.90 (1.36e2.64)*
168 51 186 23 2
39.1 11.9 43.3 5.3 0.5
376 894 1575 72 36
12.7 30.3 53.3 2.4 1.2
93 43 38 256
21.6 10.0 8.8 59.5
488 182 187 2096
16.5 6.2 6.3 71.0
179 94 25 132
41.6 21.9 5.8 30.7
1190 459 99 1205
40.3 15.5 3.4 40.8
1.41 (1.15e1.73)* 2.07 (1.60e2.67)* 0.77 (0.48e1.26)**
1.62 (1.04e2.54)*
3.31 (2.41e4.54)*
1.55 (1.25e1.93)*
Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05. a Reference category.
dependence, due to the difficulty of stopping smoking once the addiction has been developed. An early onset of the smoking habit in children and adolescents has previously been documented by various surveys and research studies conducted by different organizations and investigators.25,26 According to the United Nations, one out of every five adolescents worldwide began smoking at 10 years of age.26 Likewise, in the Mexico Youth Tobacco Survey, it was reported that seven out of every 10 adolescents began smoking between the ages of 11 and 13 years.24 The results from our study support this observation, finding (i) that 61.5% of adolescents who smoke began before the age of 13 years and (ii) that a greater proportion of adolescents who suffer from asthma (19.4% vs 7.8%) compared with healthy adolescents began smoking before the age of 10 years. It is important that programmes for the prevention of smoking be reviewed and that better strategies be implemented to achieve established objectives. These efforts should focus primarily on the most vulnerable populations, such as children and adolescents. According to the analysis, asthmatic adolescents are first motivated to smoke by their curiosity about cigarettes. This
result was previously reported for the adolescent population in general but not in those who suffer from asthma.27,28 The mechanism that could explain the relationship between curiosity towards cigarettes and the development of smoking in adolescents who suffer from asthma is as follows. Adolescence is the stage in life in which youths have a greater propensity to explore habits that harm their health without considering the negative effects that these produce in the short, medium and long terms. Alternatively, by smoking, asthmatic adolescents want to show their friends that they are not limited by the disease in terms of using these substances. It is important that parents of children who suffer from asthma inform their children of the severity of this disease and the negative effects that the inhalation of tobacco smoke brings. The family is considered the best environment in which the physical, mental and social development of children can be cultivated. It is in this environment that interactions are made for the first time with the people who will serve as models for imitating different habits and behaviours. These interactions allow children to develop and achieve their life's objectives and thus integrate harmoniously as useful
53
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Table 2 e Smoking characteristics in asthmatic and healthy adolescents. Characteristics of smoking
Sex Male Age at which you began to smoke <10 years 11 years 12 years 13 years 14 years 15 years or older Reason why you smoked the first time Curiosity Peer pressure To have more personality Because I am mature Because my parents smoke I don't know Why do you smoke It relaxes me It calms my nerves It makes me popular among my friends It helps me act natural It takes away my appetite Number of days you smoked in the last month: 1e10 20e29 Every day Place you prefer to smoke At school Friend's house Public places At parties Other places At homea Do you smoke on waking up in the morning? Occasionally Always Nevera Do you consider smoking a problem for you? No Yesa Do you know that smoking is addictive? No Yesa Have you tried to quit smoking? No Yesa Have you considered quitting smoking? No Yesa At home, who knows that you smoke? Father Mother Both parentsa None Who allows you to smoke? Father Mother Both Nonea Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05. a Reference category.
Asthmatic (n ¼ 93)
Healthy (n ¼ 347)
Odds ratio (95% CI)
n
%
n
%
55
59.1
200
57.6
18 4 20 27 10 14
19.4 4.3 21.5 29.0 10.8 15.1
27 24 59 86 64 87
7.8 6.9 17.0 24.8 18.4 25.1
68 3 8 2 4 8
73.1 3.3 8.6 2.2 4.3 8.6
278 16 14 9 11 19
80.1 4.6 4.0 2.6 3.2 5.4
46 22 8 8 9
49.5 23.7 8.6 8.9 9.7
235 68 11 22 11
67.7 19.5 3.2 6.3 3.2
58 13 22
62.4 14.0 23.7
257 49 41
74.1 14.1 11.8
1 1 25 17 35 14
1.1 1.1 26.9 18.3 37.7 15.1
2 6 74 91 155 19
0.6 1.7 21.3 26.2 44.7 5.5
24 9 60
25.8 9.7 64.5
68 14 265
19.6 4.0 76.4
37 56
39.8 60.2
110 237
31.7 68.3
6 87
6.5 93.5
22 325
6.3 93.7
60 33
64.5 35.5
182 165
52.4 47.6
52 41
55.9 44.1
165 182
47.6 52.4
2 17 43 31
2.2 18.3 46.2 33.3
22 50 71 204
6.3 14.4 20.5 58.8
1 13 13 66
1.1 10.0 14.0 71.0
9 49 41 248
2.6 14.1 11.8 71.5
1.06 (0.66e1.69)** 1.41 (1.15e1.74)*
1.17 (0.95e1.44)**
1.67 (1.25e2.22)*
2.07 (1.60e2.67)*
1.91 (1.41e2.60)*
2.91 (1.91e4.41)*
1.12 (0.88e1.42)**
0.90 (0.66e1.25)**
1.64 (1.02e2.64)**
1.39 (0.88e2.21)*
2.85 (1.76e4.61)*
1.02 (0.61e1.69)*
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€ m Test). Table 3 e Degree of nicotine dependence in adolescent smokers, asthmatic and healthy (Fagerstro Questions
Asthmatic (n ¼ 93) n
Healthy (n ¼ 347) %
Do you smoke more on waking than during the rest of the day? Yes 21 22.6 No 72 77.4 Time to smoke after waking up Up to 5 min 9 9.7 Six to 30 min 16 17.2 31e60 min 3 3.2 More than an hour 65 69.9 Which cigarette would you least like to stop smoking? First of the morning 25 26.9 Any other 68 73.1 Number of cigarettes that you smoke a day? Less than 10 71 76.3 11 to 20 12 12.9 21 to 30 2 2.2 More than 31 8 8.6 Is it difficult for you to smoke in prohibited areas? Yes 15 16.1 No 78 83.9 Do you smoke even with asthma symptoms? Yes 12 12.9 No 81 87.1 Tobacco dependence Low 33 35.5 Moderate 10 10.8 High 5 5.4 No dependence 45 48.4
Mean difference (95% CI)
n
%
34 313
9.8 90.2
19 16 21 291
5.5 4.6 6.1 83.9
64 283
18.4 81.6
296 43 3 5
85.3 12.4 0.9 1.4
50 297
14.4 85.6
33 314
9.5 90.5
147 9 3 188
42.4 2.6 0.9 54.2
2.68 (1.47e4.89)*
2.23 (1.32e3.79)*
1.62 (0.95e2.76)*
1.79 (1.02e3.15)*
1.14 (0.60e2.11)**
1.41 (0.69e2.85)**
Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05.
members of society. Fulfilling the function of protecting children can only be achieved if both of the parents adequately fulfil their roles within the family. Furthermore, living within an incomplete and/or dysfunctional family has been correlated with the acquisition and development of various habits and health-risk behaviours in adolescents, including smoking.16,29,30 In our study, the highest percentage of asthmatic adolescents who smoked were those who lived within incomplete families or had family members with whom they had poor relationships. It is important that parents fulfil their roles and establish better relationships among family members. It has long been established that living or interacting socially with individuals who smoke, such as parents or friends, is related to the development of smoking in asthmatic and non-asthmatic adolescents.15,17,31 Our results support this observation, finding that the highest percentage of asthmatic adolescents who smoke have parents and friends who smoke. It is important to encourage parents to avoid smoking in front of their children, given that the presence of people who smoke can encourage children to imitate them and develop curiosity towards smoking. Furthermore, 66.7% of asthmatic adolescents who smoked noted that at least one of their biological parents knew that they smoked, and 25.1% reported that at least one of their parents let them smoke. Parents should also be aware of the people with whom their children socialize,
given that a significant percentage of asthmatic youths who smoke do so because of peer pressure, a desire to be popular among their peers or a desire to belong to a group.17,31 It is well known that asthma is one of the most common chronic respiratory diseases and that it produces several negative effects, including a lower quality of life and even death.7,9,32 The magnitudes of the negative effects that smoking and asthma have are increased when both conditions are present in the same individual.13,12 We found that other important smoking-related characteristics in adolescents who suffer from asthma affect a significant percentage of these youths. Specifically, despite knowing that smoking is addictive and represents a health problem for them, these adolescents smoke even when they are sick. It is important to raise awareness among adolescents, especially those who suffer from chronic illnesses (e.g. asthma), about the harm caused by the inhalation of substances such as tobacco. Previous publications have shown that the prevalence of smoking in asthmatic adolescents is greater compared with that in healthy adolescents.14,15,31 Our results are in line with this observation, finding a higher percentage of smoking in adolescents who suffer from asthma. Furthermore, according € m questionnaire, to data collected through the Fagerstro asthmatic adolescents who smoked developed a greater dependence on nicotine compared with healthy adolescents. It is important that those who are responsible for smoking
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
prevention programmes appropriately bear these results in mind, especially among the most vulnerable groups, such as asthmatic adolescents.
Funding
Study limitations
Competing interests
(i) The research strategy used in this study was crosssectional; therefore, it was not possible to establish causal relationships. (ii) Asthma in adolescents was diagnosed through the application of a self-administered questionnaire. No lab tests or imaging studies were performed. However, the ISAAC and European Community Respiratory Health Survey questionnaires have been shown to be important instruments for measuring the diagnosis of asthma in epidemiological studies.19,20 (iii) Smoking was determined through a self-administered questionnaire; no carbon dioxide measurements were performed. Therefore, bias in the information obtained may be present because of under-responding or over-responding to the questions by the adolescents.21,22 However, in relation with self-administered questionnaire use, Stein et al.,33 conclude: ‘Response distortion does not appear to affect rated usefulness of the intervention, nor does intervention type appear to influence whether respondents thought the researcher wanted them to report less use’. (iv) Nicotine addiction was determined through a selfadministered questionnaire. Previous studies have shown that self-administered questionnaires can be effective for measuring the diagnosis of asthma, smoking and nicotine addiction in epidemiological studies.19e22
None declared.
Conclusion Smoking continues to be a significant health problem, particularly when it present in adolescents who suffer from asthma. The information collected in this study makes it clear that curiosity about cigarettes is the primary reason why adolescents smoke for the first time. Moreover, although these adolescents know that tobacco smoke inhalation can induce nicotine addiction, they do not consider smoking to be a problem. Documenting the characteristics of smoking in these youths has revealed that the most important factors that favour its development are found in the family and social environment. These factors include living within an incomplete family, the presence of parents and friends who smoke and poor relationships among family members. This knowledge must be used to strengthen programmes aimed at smoking prevention and towards the application of better strategies that include all family members.
Author statements Ethical approval The Ethics Committee of the Autonomous University of Tamaulipas, Mexico, reviewed and approved the research project.
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None declared.
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educational level, parental approval of smoking, parents who smoke, and smoking friends. Arch Bronconeumol 2012;48:37e42. Al-Zalabani AH. Family context factors and the risk of smoking among male adolescents in Saudi Arabia. Asian Pac J Cancer Prev 2015;16:5847e52. Trapl ES, Yoder LD, FrankJ L, Borawski EA, Sattar A. Individual, parental, and environmental correlates of cigar, cigarillo and little cigar (CCLC) use among middle school adolescents. Nicotine Tob Res 2015;18:834e41. Apaydin KC, Unalan PC. Factors associated with adolescents' smoking experience and staying tobacco free. Ment Health Fam Med 2010;7:145e53. Asher MI, Keil U, Anderson HR, Beasley R, Crane J, Martinez F, et al. International study of asthma and allergies in childhood (ISAAC): rationale and methods. Eur Respir J 1995;8:483e91. European Community Respiratory Health Survey. Variations in prevalence of respiratory symptoms, self-reported asthma attacks, and use of asthma medication in the principles and practice. 5th ed. New York: Mosby; 1998. p. 816e37. European Community Respiratory Health Survey (ECRHS). Eur Respir J 1996;9:687e95. Developer Group of the Guide [Internet]. National manual for addressing smoking in the first level of care. Ministry of Public Health. [updated 2015 June 9; cited 2015 July 15]. Available from: www.who.int/fctc/reporting/Annexsixurue. Global Adult Tobacco Survey Collaborative Group. Questions on tobacco intended for surveys: a series of basic questions of the Global Adult Tobacco Survey (GATS). 2nd ed. Atlanta, GA: Centers for Disease Control and Prevention of the United States of America; 2011 [updated 2015 August 29; cited 2015 September 20]. Available from: http://www.who.int/tobacco/ surveillance/en_tfi_tqs.pdf. Fagerstrom KO. Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 1978;3:235e41. Carrasco TJ, Luna M, Vila J. Validez del Fagerstrom Tolerance Questionnaire como medida de dependencia fı´sica de la
25.
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n. [Validity of the Fagerstrom Tolerance nicotina: una revisio Questionnaire as a measure of physical dependence of nicotine: a review.]. Rev Esp Drog 1994;19:3e14. ~ os R, OrtegaReynales-Shigematsu LM, Rodrı´guez-Bolan ndezCeballos P, Flores Escartı´n MG, Lazcano-Ponce E, Herna Avila M. Encuesta de Tabaquismo en J ovenes. [Youth Tobacco xico: Instituto Nacional de Salud Pu´blica; 2011 Survey]. Me [updated 2015 August 29; cited 2015 September 20]. Available from: http://media.controltabaco.mx/content/productos/ETJ/ ETJ_2011.pdf. United Nations. World youth report. Youth and drugs. 2003 [updated 2015 October 29; cited 2015 November 20]. Available from: http://www.un.org/esa/socdev/unyin/ documents/ch06.pdf. Portnoy DB, Wu CHC, Tworek C, Chen J, Borek N. Youth curiosity about cigarettes, smokeless tobacco, and cigars: prevalence and associations with advertising. Am J Prev Med 2014;472:S76e86. Milton B, Woods SE, Dugdill L, Porcellato L, Springer RJ. Starting young? Children's experiences of trying smoking during pre-adolescence. Health Educ Res 2008;23:298e309. Zaborskis A, Sirvyte D. Familial determinants of current smoking among adolescents of Lithuania: a cross-sectional survey 2014. BMC Public Health 2015;15:889e901. Curto BM, Paula CS, Do Nacimento R, Murray J, Bordin IA. Environmental factors associated with adolescent antisocial behavior in a poor urban community in Brazil. Soc Psychiatry Psychiatr Epidemiol 2011;46:1221e31. Khurshid F, Ansari U. Causes of smoking habit among the teenagers. Interdiscip J Contemp Res Bus 2012;3:848. Boonsawat W, Thompson PJ, Zaeoui U, Samosorn Ch, Faruqi R, Poonnoi P. Survey of asthma management in Thailand e the asthma insight and management study. Asian Pac J Allergy Immunol 2015;33:14e20. Stein LAR, Colby SM, O'Leary TA, Monti PM, Rohsenow DJ, Spirito A, et al. Response distortion in adolescents who smoke: a pilot study. J Drug Educ 2002;32:271e86.
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Original Research
Epidemiological profile of smoking and nicotine addiction among asthmatic adolescents zquez-Nava a,**, E.M. Va zquez-Rodrı´guez b, F. Va zquez-Rodrı´guez c,*, O. Castillo Ruiz d, J. Peinado Herreros e C.F. Va a
Department of Research, School of Medicine, Tampico, Autonomous University of Tamaulipas, Tampico, Mexico n Campus, Mexico School of Medicine, University of Veracruz, Minatitla c Mexican Institute of Social Security, Southern Delegation of Veracruz, Mexico d n Multidisciplinary Academic Unit, Autonomous University of Tamaulipas, Mexico Reynosa Aztla e School of Medicine, University of Granada, Spain b
article info
abstract
Article history:
Objective: Despite the harmful effects of cigarette smoking, this habit in asthmatic ado-
Received 12 December 2016
lescents continues to be a health problem worldwide. Our objectives were to determine the
Received in revised form
epidemiological profile of smoking and the degree of nicotine dependence among asth-
10 April 2017
matic adolescents.
Accepted 11 April 2017
Study design: Through a cross-sectional investigation, 3383 adolescents (13e19 years of age) were studied. Methods: Information was collected using a previously validated questionnaire. Two study
Keywords:
groups of adolescent smokers were formed: one composed of asthmatic adolescents and
Habits and behaviours
the other of healthy youths.
Asthma
Results: Asthmatic adolescents were found to be more likely to smoke (21.6% vs 11.8%) and
Adolescents
to have some degree of nicotine dependence compared with healthy adolescents (51.6% vs
Smoking
48.8%).
Nicotine addiction
The most important characteristic of smoking in asthmatic adolescents was found to be an onset before 11 years of age due to curiosity about cigarettes. Asthmatic youths continue smoking because this habit decreases their anxiety and stress. Adolescents know that smoking is addictive and often smoke on waking up in the morning or when they are sick. Yet, these adolescents do not consider smoking to be a problem. Conclusion: In this study, curiosity about cigarettes was the primary reason why asthmatic adolescents smoked for the first time and developed a greater dependence to nicotine compared with healthy adolescents. Moreover, the findings show that many of the factors that favour the development of smoking are preventable, given that they are present in the family and social environment. © 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Calle Reforma 100-B C.P. 89490, Ciudad Madero, Tamp, Mexico. Tel.: þ52 8332166247. ** Corresponding author. zquez-Nava), [email protected] (C.F. Va zquez-Rodrı´guez). E-mail addresses: [email protected] (F. Va http://dx.doi.org/10.1016/j.puhe.2017.04.012 0033-3506/© 2017 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
50
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
Introduction Active smoking is considered the leading cause of preventable death in the world, and its development at an early age increases the risk of experimenting with other drugs.1e3 According to the World Health Organization, the average age of onset of smoking is 11 years, and its worldwide prevalence in individuals over 15 years old is as high as 21.0%.1 The undesirable effects of smoking include the following: the development of various types of cancers, physical and psychological dependence, cardiovascular diseases and asthma and other conditions.1,4e6 Asthma is one of the most common chronic respiratory diseases of our time.7,8 According to the World Health Organization, asthma affects 334 million people globally, and its prevalence in adolescent populations ranges from 5.0% to 20.0%.9 The negative effects of asthma are as follows: hospital admissions, work and school absenteeism, negative impacts on family finances due to the purchase of medicines, work overload at various levels of hospital care, impaired quality of life and death.8e11 Moreover, studies on the aetiology of asthma show that active smoking is significantly associated with the development and aggravation of asthma symptoms.2,6,12 However, in the last two decades, several investigators have documented a higher prevalence of active smoking among adolescents suffering from asthma compared with healthy youths.13e15 As a result, it is important to design research studies on smoking whose outcomes facilitate planning health prevention programmes aimed at asthmatic adolescents. Some studies conducted in various countries have identified certain factors that favour the development of smoking in adolescents.2,15e18 However, the smoking-related characteristics and degree of nicotine dependence of adolescents suffering from asthma have not been determined. There is a clear need to determine the characteristics of the personal, family and social environments and factors that favour the development of certain risky habits and behaviours that harm health. Such knowledge will allow the design of better programmes to prevent smoking and limit the harm it causes. Accordingly, the present study was developed to determine the smoking-related characteristics of and degree of nicotine dependence in a sample of adolescents who suffer from asthma.
Methods For this study, 3383 adolescents were invited to participate in a cross-sectional study conducted in an urban area of northeast Mexico. From the total sample, 430 adolescents who suffered from asthma were identified. The remainder of the population (n ¼ 2953) was identified as non-asthmatic, and these individuals were used as the control group to compare the study variables between the groups. The methodology used in this study was similar to one used previously;15 however, the sample of adolescents included in the present study differed from that registered in the aforementioned investigation.
The adolescents, who attended secondary or preparatory schools, were recruited through one of the community service programmes under the supervision of the Faculty of Medicine. The permission of the educational authorities in the area was sought and obtained. The participating schools and students were selected by a simple random sampling technique. In each school selected, a list of enrolled students was requested, and students were randomly selected for the sample. The data were collected in 2015 and analysed in 2016.
Information collection To collect the data, a self-administered questionnaire was constructed based on previously validated tools. These questionnaires have been used for different epidemiological studies, such as The International Study of Asthma and Allergies in Childhood (ISAAC) and The European Community Respiratory Health Survey, among others.19e22 The questionnaire was disseminated by staff who had previously been trained for this purpose. To determine the level of understanding of the questions contained in the questionnaire, two pilot studies were conducted 15 days apart. In each pilot study, 20 adolescents were interviewed, and the questions contained in the instrument were closed, had two or more answer choices and were grouped into five blocks. The responses to the questions contained in the first block allowed for the collection of information on the sociodemographic characteristics of the adolescents, their lifestyles, whether they had any habits or health-risk behaviours (e.g. smoking) and if they spent time with friends who smoked. In the subsequent blocks, questions were included to collect information on various family-related characteristics, such as the following: whether the adolescent lived with one or both biological parents, if the relationship between different family members was good or bad, or if the father or mother smoked inside the home.
Asthma Asthma was diagnosed in this study according to the criteria established in the questionnaire designed for ISAAC.11,19 The presence of wheezing and dry cough at night during the last 12 months and having received an asthma diagnosis by a physician served as the criteria defining current asthma for an adolescent. In addition, information was requested on whether any other family member, such as the father, mother, siblings or grandparents, suffered or had suffered from any allergic disease.
Smoking The questions included in the questionnaire to determine the epidemiological profile of smoking adolescents were as follows: 1. 2. 3. 4.
Have you ever tried smoking cigarettes? How old were you when you first smoked? Why did you first start smoking? Do you currently smoke?
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
5. 6. 7. 8. 9. 9. 10. 11. 12.
13. 14. 15.
Why do you continue to smoke? If you do not smoke, why? In what grade did you first try a cigarette? During the last month, how many days did you smoke cigarettes? Which of your parents know that you smoke? Which of your parents let you smoke? Where do you smoke most often? Do you know that smoking causes addiction? Do you know that smoking can lead to certain diseases, such as asthma, cancer, high blood pressure and so forth? Do you consider tobacco to be a health problem for you? Have you attempted to quit smoking before? Do you plan to stop smoking?
Nicotine dependence €m Nicotine dependence was determined using the Fagerstro € m questionnaire, the Test.23,24 According to the Fagerstro different degrees of nicotine dependence are determined according to the aggregated score, where <3 points signifies low dependence; four to six points signifies moderate dependence and 7 points signifies high dependence. Informed consent was requested and obtained from all of the adolescents or from their parents, and participants had the right to leave the study at all times, even after they had finished answering the questionnaire.
Statistical analysis The data were analysed with the statistical package SPSS-13.0. Simple frequencies and measures of central tendency (means and standard deviations) were used. The following factors were compared between asthmatic and non-asthmatic adolescents: (i) possible gender bias; (ii) active smoking; (iii) family structure; (iv) family environment; (v) the presence of parents and friends who smoke at home and in the social environment; (vi) smoking-related characteristics; and (vii) the degree of nicotine dependence. For the analysis, polytomous variables were re-categorized to transform them into dichotomous variables, with ‘present’ being the most frequently reported option. The comparison between groups of asthmatic and healthy adolescents, who were categorized with respect to sociodemographic variables and smoking-related characteristics, was performed using a 2 2 contingency table, the chi-squared test and a 95% confidence interval. Any P-value <0.05 was considered significant.
Results A total of 3383 adolescents were studied, of whom 52.4% were male, and their mean age was 14.49 ± 1.6 years. The prevalence of asthma was 12.7%, and that of active smoking was 13.0%. Table 1 shows the sociodemographic data and characteristics of the family and social environments of the asthmatic and non-asthmatic adolescents. Compared with the healthy adolescents, a higher percentage of adolescents in
51
the asthma group smoked (21.6% vs 11.8%), lived within an incomplete family unit (27.4% vs 23.6%), had a poor relationship with their parents (11.6% vs 6.5%), lived with their parents (40.5% vs 29.0%) and had friends who smoked (69.3% vs 59.2%). Of the total number of adolescents who identified as active smokers (n ¼ 440), two groups were classified: one consisting of those suffering from asthma (n ¼ 93) and the other consisting of healthy individuals (n ¼ 347). In Table 2, the smoking-related characteristics of asthmatic and healthy adolescents are shown. In the group of asthmatic adolescents, males smoked more than females (59.1% vs 40.9%), and 23.7% of these adolescents first smoked before the age of 11 years, with the reason for starting being ‘curiosity’. More than 70.0% of youths who suffered from asthma declared that they smoked because it relaxed them or helped them reduce stress. A total of 23.7% of the adolescents of this group reported smoking every day, and the most common locations for smoking were in public places or at parties with their friends. Approximately 10.0% of asthmatic adolescents reported smoking on waking up in the morning, and 93.5% declared that they knew that smoking is addictive. However, approximately 40.0% of the asthmatic adolescents believed that smoking did not represent a health problem for them. Furthermore, 66.7% of these adolescents noted that at least one of their biological parents knew they smoked, and 29.0% stated that one or both parents allowed them to smoke. Table 3 shows the degree of nicotine dependence in asth€m matic and healthy adolescents, based on the Fagerstro questionnaire. According to the items of this test, 22.6% of the adolescents who suffered from asthma reported that they smoked more in the morning than during the rest of the day. These individuals smoked their first cigarette within the first waking hour, and 30.1% noted that the cigarette that they would least like to give up would be the first of the morning. Approximately 23.7% reported smoking more than 10 cigarettes a day, 16.1% found it difficult to not smoke in prohibited areas and 12.9% reported smoking even while sick. € m quesBased on the cut-offs considered in the Fagerstro tionnaire, 51.6% of the adolescents who suffered from asthma showed some degree of nicotine dependence, compared with 48.8% of the healthy adolescents.
Discussion According to the data in this study, the percentage of adolescents who smoke and have some degree of nicotine dependence is higher among those who suffer from asthma compared with healthy adolescents. With respect to the smoking-related characteristics of asthmatic adolescents, the following results are highlighted: (i) these youths begin smoking before the age of 11 years due to curiosity about cigarettes, and (ii) they often smoke on waking up in the morning or when they are sick. To our knowledge, this is the first study to collect information on the smoking-related characteristics and degree of nicotine dependence in asthmatic adolescents. It is important to have this information on hand in the course of designing programmes for the prevention of smoking in asthmatic adolescents with nicotine
52
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
Table 1 e The characteristics of the family and social environments of asthmatic and healthy adolescents (n ¼ 3383). Variables
Sex Male Female Tried a cigarette at some point in life Never tried a cigarettea Active smoking Not a smokera Incomplete family Complete family Relationship between family's parents Poor Gooda Relationship between adolescent and parents Poor Gooda Major influence on the adolescent Mother Father Both parentsa Grandfather None Who smokes in the house where you live? Father Mother Both smoke Nobody smokesa How many of your friends smoke? Some Most All smoke Nonea
Asthmatic (n ¼ 430)
Healthy (n ¼ 2953)
Odds ratio (95% CI)
n
%
n
%
201 229 216 214 93 337 118 312
46.7 53.3 50.2 49.8 21.6 78.7 27.4 72.6
1573 1380 1228 1725 347 2606 696 2257
53.3 46.7 41.4 58.6 11.8 88.25 23.6 76.4
1.06 (0.66e1.69)**
65 365
15.1 84.9
341 2612
11.5 88.5
1.36 (1.02e1.81)*
50 380
11.6 88.4
191 2762
6.5 93.5
1.90 (1.36e2.64)*
168 51 186 23 2
39.1 11.9 43.3 5.3 0.5
376 894 1575 72 36
12.7 30.3 53.3 2.4 1.2
93 43 38 256
21.6 10.0 8.8 59.5
488 182 187 2096
16.5 6.2 6.3 71.0
179 94 25 132
41.6 21.9 5.8 30.7
1190 459 99 1205
40.3 15.5 3.4 40.8
1.41 (1.15e1.73)* 2.07 (1.60e2.67)* 0.77 (0.48e1.26)**
1.62 (1.04e2.54)*
3.31 (2.41e4.54)*
1.55 (1.25e1.93)*
Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05. a Reference category.
dependence, due to the difficulty of stopping smoking once the addiction has been developed. An early onset of the smoking habit in children and adolescents has previously been documented by various surveys and research studies conducted by different organizations and investigators.25,26 According to the United Nations, one out of every five adolescents worldwide began smoking at 10 years of age.26 Likewise, in the Mexico Youth Tobacco Survey, it was reported that seven out of every 10 adolescents began smoking between the ages of 11 and 13 years.24 The results from our study support this observation, finding (i) that 61.5% of adolescents who smoke began before the age of 13 years and (ii) that a greater proportion of adolescents who suffer from asthma (19.4% vs 7.8%) compared with healthy adolescents began smoking before the age of 10 years. It is important that programmes for the prevention of smoking be reviewed and that better strategies be implemented to achieve established objectives. These efforts should focus primarily on the most vulnerable populations, such as children and adolescents. According to the analysis, asthmatic adolescents are first motivated to smoke by their curiosity about cigarettes. This
result was previously reported for the adolescent population in general but not in those who suffer from asthma.27,28 The mechanism that could explain the relationship between curiosity towards cigarettes and the development of smoking in adolescents who suffer from asthma is as follows. Adolescence is the stage in life in which youths have a greater propensity to explore habits that harm their health without considering the negative effects that these produce in the short, medium and long terms. Alternatively, by smoking, asthmatic adolescents want to show their friends that they are not limited by the disease in terms of using these substances. It is important that parents of children who suffer from asthma inform their children of the severity of this disease and the negative effects that the inhalation of tobacco smoke brings. The family is considered the best environment in which the physical, mental and social development of children can be cultivated. It is in this environment that interactions are made for the first time with the people who will serve as models for imitating different habits and behaviours. These interactions allow children to develop and achieve their life's objectives and thus integrate harmoniously as useful
53
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
Table 2 e Smoking characteristics in asthmatic and healthy adolescents. Characteristics of smoking
Sex Male Age at which you began to smoke <10 years 11 years 12 years 13 years 14 years 15 years or older Reason why you smoked the first time Curiosity Peer pressure To have more personality Because I am mature Because my parents smoke I don't know Why do you smoke It relaxes me It calms my nerves It makes me popular among my friends It helps me act natural It takes away my appetite Number of days you smoked in the last month: 1e10 20e29 Every day Place you prefer to smoke At school Friend's house Public places At parties Other places At homea Do you smoke on waking up in the morning? Occasionally Always Nevera Do you consider smoking a problem for you? No Yesa Do you know that smoking is addictive? No Yesa Have you tried to quit smoking? No Yesa Have you considered quitting smoking? No Yesa At home, who knows that you smoke? Father Mother Both parentsa None Who allows you to smoke? Father Mother Both Nonea Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05. a Reference category.
Asthmatic (n ¼ 93)
Healthy (n ¼ 347)
Odds ratio (95% CI)
n
%
n
%
55
59.1
200
57.6
18 4 20 27 10 14
19.4 4.3 21.5 29.0 10.8 15.1
27 24 59 86 64 87
7.8 6.9 17.0 24.8 18.4 25.1
68 3 8 2 4 8
73.1 3.3 8.6 2.2 4.3 8.6
278 16 14 9 11 19
80.1 4.6 4.0 2.6 3.2 5.4
46 22 8 8 9
49.5 23.7 8.6 8.9 9.7
235 68 11 22 11
67.7 19.5 3.2 6.3 3.2
58 13 22
62.4 14.0 23.7
257 49 41
74.1 14.1 11.8
1 1 25 17 35 14
1.1 1.1 26.9 18.3 37.7 15.1
2 6 74 91 155 19
0.6 1.7 21.3 26.2 44.7 5.5
24 9 60
25.8 9.7 64.5
68 14 265
19.6 4.0 76.4
37 56
39.8 60.2
110 237
31.7 68.3
6 87
6.5 93.5
22 325
6.3 93.7
60 33
64.5 35.5
182 165
52.4 47.6
52 41
55.9 44.1
165 182
47.6 52.4
2 17 43 31
2.2 18.3 46.2 33.3
22 50 71 204
6.3 14.4 20.5 58.8
1 13 13 66
1.1 10.0 14.0 71.0
9 49 41 248
2.6 14.1 11.8 71.5
1.06 (0.66e1.69)** 1.41 (1.15e1.74)*
1.17 (0.95e1.44)**
1.67 (1.25e2.22)*
2.07 (1.60e2.67)*
1.91 (1.41e2.60)*
2.91 (1.91e4.41)*
1.12 (0.88e1.42)**
0.90 (0.66e1.25)**
1.64 (1.02e2.64)**
1.39 (0.88e2.21)*
2.85 (1.76e4.61)*
1.02 (0.61e1.69)*
54
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
€ m Test). Table 3 e Degree of nicotine dependence in adolescent smokers, asthmatic and healthy (Fagerstro Questions
Asthmatic (n ¼ 93) n
Healthy (n ¼ 347) %
Do you smoke more on waking than during the rest of the day? Yes 21 22.6 No 72 77.4 Time to smoke after waking up Up to 5 min 9 9.7 Six to 30 min 16 17.2 31e60 min 3 3.2 More than an hour 65 69.9 Which cigarette would you least like to stop smoking? First of the morning 25 26.9 Any other 68 73.1 Number of cigarettes that you smoke a day? Less than 10 71 76.3 11 to 20 12 12.9 21 to 30 2 2.2 More than 31 8 8.6 Is it difficult for you to smoke in prohibited areas? Yes 15 16.1 No 78 83.9 Do you smoke even with asthma symptoms? Yes 12 12.9 No 81 87.1 Tobacco dependence Low 33 35.5 Moderate 10 10.8 High 5 5.4 No dependence 45 48.4
Mean difference (95% CI)
n
%
34 313
9.8 90.2
19 16 21 291
5.5 4.6 6.1 83.9
64 283
18.4 81.6
296 43 3 5
85.3 12.4 0.9 1.4
50 297
14.4 85.6
33 314
9.5 90.5
147 9 3 188
42.4 2.6 0.9 54.2
2.68 (1.47e4.89)*
2.23 (1.32e3.79)*
1.62 (0.95e2.76)*
1.79 (1.02e3.15)*
1.14 (0.60e2.11)**
1.41 (0.69e2.85)**
Abbreviation: 95% CI, 95% confidence interval. *P < 0.05. **P > 0.05.
members of society. Fulfilling the function of protecting children can only be achieved if both of the parents adequately fulfil their roles within the family. Furthermore, living within an incomplete and/or dysfunctional family has been correlated with the acquisition and development of various habits and health-risk behaviours in adolescents, including smoking.16,29,30 In our study, the highest percentage of asthmatic adolescents who smoked were those who lived within incomplete families or had family members with whom they had poor relationships. It is important that parents fulfil their roles and establish better relationships among family members. It has long been established that living or interacting socially with individuals who smoke, such as parents or friends, is related to the development of smoking in asthmatic and non-asthmatic adolescents.15,17,31 Our results support this observation, finding that the highest percentage of asthmatic adolescents who smoke have parents and friends who smoke. It is important to encourage parents to avoid smoking in front of their children, given that the presence of people who smoke can encourage children to imitate them and develop curiosity towards smoking. Furthermore, 66.7% of asthmatic adolescents who smoked noted that at least one of their biological parents knew that they smoked, and 25.1% reported that at least one of their parents let them smoke. Parents should also be aware of the people with whom their children socialize,
given that a significant percentage of asthmatic youths who smoke do so because of peer pressure, a desire to be popular among their peers or a desire to belong to a group.17,31 It is well known that asthma is one of the most common chronic respiratory diseases and that it produces several negative effects, including a lower quality of life and even death.7,9,32 The magnitudes of the negative effects that smoking and asthma have are increased when both conditions are present in the same individual.13,12 We found that other important smoking-related characteristics in adolescents who suffer from asthma affect a significant percentage of these youths. Specifically, despite knowing that smoking is addictive and represents a health problem for them, these adolescents smoke even when they are sick. It is important to raise awareness among adolescents, especially those who suffer from chronic illnesses (e.g. asthma), about the harm caused by the inhalation of substances such as tobacco. Previous publications have shown that the prevalence of smoking in asthmatic adolescents is greater compared with that in healthy adolescents.14,15,31 Our results are in line with this observation, finding a higher percentage of smoking in adolescents who suffer from asthma. Furthermore, according € m questionnaire, to data collected through the Fagerstro asthmatic adolescents who smoked developed a greater dependence on nicotine compared with healthy adolescents. It is important that those who are responsible for smoking
p u b l i c h e a l t h 1 4 9 ( 2 0 1 7 ) 4 9 e5 6
prevention programmes appropriately bear these results in mind, especially among the most vulnerable groups, such as asthmatic adolescents.
Funding
Study limitations
Competing interests
(i) The research strategy used in this study was crosssectional; therefore, it was not possible to establish causal relationships. (ii) Asthma in adolescents was diagnosed through the application of a self-administered questionnaire. No lab tests or imaging studies were performed. However, the ISAAC and European Community Respiratory Health Survey questionnaires have been shown to be important instruments for measuring the diagnosis of asthma in epidemiological studies.19,20 (iii) Smoking was determined through a self-administered questionnaire; no carbon dioxide measurements were performed. Therefore, bias in the information obtained may be present because of under-responding or over-responding to the questions by the adolescents.21,22 However, in relation with self-administered questionnaire use, Stein et al.,33 conclude: ‘Response distortion does not appear to affect rated usefulness of the intervention, nor does intervention type appear to influence whether respondents thought the researcher wanted them to report less use’. (iv) Nicotine addiction was determined through a selfadministered questionnaire. Previous studies have shown that self-administered questionnaires can be effective for measuring the diagnosis of asthma, smoking and nicotine addiction in epidemiological studies.19e22
None declared.
Conclusion Smoking continues to be a significant health problem, particularly when it present in adolescents who suffer from asthma. The information collected in this study makes it clear that curiosity about cigarettes is the primary reason why adolescents smoke for the first time. Moreover, although these adolescents know that tobacco smoke inhalation can induce nicotine addiction, they do not consider smoking to be a problem. Documenting the characteristics of smoking in these youths has revealed that the most important factors that favour its development are found in the family and social environment. These factors include living within an incomplete family, the presence of parents and friends who smoke and poor relationships among family members. This knowledge must be used to strengthen programmes aimed at smoking prevention and towards the application of better strategies that include all family members.
Author statements Ethical approval The Ethics Committee of the Autonomous University of Tamaulipas, Mexico, reviewed and approved the research project.
55
None declared.
references
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