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Health-related behavior in Israel adolescents
JOURNALOF ADOLESCENTHEALTHCARE2:261-265,1982
ORIGINAL
ARTICLES
Health-Related Behavior in Israel Adolescents A D A TAMIR, M . A . , H A N A W O L F F , B.A., A N D L E O N EPSTEIN, M.B., Ch.B., M . P . H .
Eight hundred and: four high school students were interviewed about selected health-related behaviors in an effort to determine the interrelationships of these characteristics. We found the age of onset and present use of cigarettes by the adolescents to be positively correlated to their use of hashish and having sexual intercourse. The use of hashish and having sexual intercourse were also positively related with each other and the use of hashish to drinking alcohol.
KEYWORDS: Adolescent behavior Smoking and sex Smoking and drugs Individual and group behavior appear to have an important relationship to health. Behavior may be related to promoting better health, direct disease prevention or disease detection and treatment. With the substantial rise of the so-called diseases of "'affluence", such as coronary heart disease, the behavioral attributes of the individual may be critical in determining risk status. Adolescence may be of particular importance since behavior at this stage m a y effect the later development of chronic disease. Modern Western society is characterized by a breakdown of formerly accepted behavioral norms. This includes, among others, changes in the extent a n d social acceptibility of extramarital sexual activity, and drug usage. The role of the family as the determinant and arbiter of the behavior of its members has also changed. This process may be rooted in the changes occurring in the adolescent popula-
From the Department of Family and Community Health, Technion Faculty OfMedicine, and Health Administration Unit, Rambam Medical Center, Haifa, Israel. Address reprint requests: Dr. Leon Epstein, Dept. of Family and Community Health, Technion Medical School, Haifa, Israel. Manuscript accepted October 12,1981.
tion whose patterns of future behavior are being determined. Behavioral attributes of individuals and groups are developed in the context of their total behavior pattern. Many programs however, tend to focus on single problems such as the use of drugs, sexual promiscuity or overeating, without taking into account all of the adolescent's health-related behaviors. A holistic view of health-related behavior is particularly important for Israel's heterogeneous ethnic population in which the cultural background of the adolescent is often paramount in determining his behavior and service needs. Health and welfare services should attempt to map adolescent behavior patterns at specific times and monitor changes, thus facilitating more rational planning of intervention programs (1). We studied selected health-related behaviors i n secondary school children in the Haifa area. The study was designed to map their present behavior patterns a n d assess their possible interrelationships as a basis for planning health-related programs in the school. Materials
and Methods
During the 1977-1978 school year, 804 high school students Were evaluated. All the students in.the final three years of school were included and only a few w h o were absent on the examination day were omitted. Their ages ranged from 16-18 years with 54% being males and 46% females (Table 1). Following an explanation of the objectives of the study and stressing that the respondents would remain anonymous, the students were asked to complete a detailed questionnaire on selected aspects of their health and health-related behavior. It included batteries of questions used in other studies, for example, sexual behavior was defined in six categories
© Societyfor AdolescentMedicine, i982 Published by ElsevierSciencePublishingCo., Inc., 52 VanderbiltAve., New York,NY 10017
261 0197-0070/81/040261-05502.75
262
TAMIRET AL.
JOURNAL OF ADOLESCENTHEALTHCAREVol. 2, No. 4
members of a youth movement, e.g., Boy Scouts. Their status was defined as present membership, past membership (for at least two years), and never a member (or less than two years).
Table 1. High School Students by Age and Sex
Age 18 17 16 Total
N
%
N
%
N
%
147 149 158 434
33.9 34.3 31.8 100.0
96 119 155 370
25.9 32.2 41.9 100.0
243 268 293 804~
30.2 33.3 36.5 100.0
"In the followingtables persons with unknown values were
from "going out alone with the opposite sex" to "'sexual intercourse" as described by Lancet and his colleagues (2). All questions were effectively closed. The questiorinaire had previously been tested on a similar group of students to determine the distribution of answers to questions as well as the reliability and validity. The behavioral attributes reported on in this study are cigarette smoking, medicinal and nonmedicinal drug use, and sexual behavior. Eighty five percent of the students were born in Israel. The possible effect of ethnic origin was therefore examined using the country of birth of the father as the index. The countries were classified into three groups: Ashkenazi, father born in Europe or other Western country; Sephardi, father born in Middle East (excluding Israel), North Africa or other Oriental area;• and Israeli, father born in Israel. All the students were of Jewish origin. The social class was defined using a classification of the reported occupation of the student's father that had been adapted from the British Registrar General for use in Israel (3). The religioSity of the student was defined as either religious, traditional, or secular. The students were asked whether they were
Results Smoking About 26% of males and 17% of females were smoking at the time of the study (Table 2). There was an age-related increase in the proportion of daily smokers in both sexes. At each age more males than females were daily smokers. There is no significant age or sex difference in the proportions of past smokers. Among those who had never smoked the difference between the sexes falls from 15.3% at age 16 years to 4.9% at age 18 years. For both sexes, the differences in smoking by age were statistically significant (Males: X2 = 33.6, P < 0.001; Females: ~6 = 20.5, P < 0.01). Males start smoking at an earlier age than females (Table 3). By age 14 years, 27.9% of the boys who had ever smoked Cigarettes had already begun, as compared to 8.2% of the females. About 50% of girls as compared to 27.7% of boys began smoking after age 15 years. There was no relationship between the smoking habits and ethnic origin or social class grading. A relationship exists between the smokinghabits of males and females and those of their friends (Table 4). There is a statistically significant rise in the proportion of present smokers (and fall i n the proportion of those who have never smoked) with an increase in the number of friends who smoke. There is a significant relationship between the smoking habits of maleS and those of their parents. Where the parents did not smoke only 21% of the boys do so, whereas 32% smoked of one or both
Table 2. Cigarette Smoking by Sex and Age Female Age (years)
Male Age (years) 16 Smoking
N
%
N
%
N
Daily Sometimes Past Never Total
7 14 29 86 136
5.2 10.3 21.3 63.2
22 16 30 77 145
15.2 11.0 20.7 53.1
30 22 27 65 144
Males: X~ = 33.6, P < 0.001 Females: X~ = 20.5, P < 0~01.
20.8 15.3 18.8 45.1
59 52 86 228 425
13.9 12.2 20.2 53.7
! 12 19 117 149
17
18
Total
%
N
%
N
%
N
%
0.7 8.1 12.7 78.5
9 10 23 76 118
7.6 8.5 19.5 64.4
13 17 18 48 96
13.5 17.7 18.8 50.0
23 39 60 241 363
6.3 10.8 16.5 66.4
June 1982
HEALTH-RELATEDBEHAVIORIN ADOLESCENTS
263
Table 3. Age of Onset of Cigarette Smoking by Sex
Relationship Between Behavioral Attributes
Age (years)
Male (%)
Female (%)
11 12 13 14 15 16 17
5.5 6.3 15.6 18.4 26.5 20.4 6.8
1.2 1.2 5.8 11.4 30.2 30.2 19.8
There was a relationship between the smoking habits of both sexes and their sexual experience (Table 6). This was found for the group as a whole as well as for each age group. Of those presently smoking 53.8% of males and 36.1% females had had sexual intercourse, as compared to 20.1% of males and 8.4% of females w h o had never smoked. This relationship (smoking and sexual intercourse) was statistically significant in both sexes (Males: X2 = 37, P < 0.001; Females: X22 = 30, P < 0.001). Past smokers in both sexes were intermediate in this regard, i.e., the proportion w h o had had sexual intercourse was lower than the present smokers but higher than those w h o had never smoked. There was a relationship between the age at which smokers began smoking and the proportion w h o had had sexual intercourse. Those having had intercourse fell from 57.1% of the males w h o began smoking at age 11 years to 25% of those who began smoking at age 17 years. This relationship was statistically significant for males aged 18 years (Mann-Whitney Test: Z = 2.354, P < 0.01, using a one-tailed test). Of the 19 subjects w h o reported using hashish, 16 were also smoking cigarettes at the time of the study (84.2%) as compared to only 22.3% of the remaining population (Table 7). About 16% of the smokers had at some time used hashish as compared to only 1% of the nonsmokers (X22= 36.6, P < 0.001). Of the males w h o had used hashish, 77.9% had had sexual intercourse as compared to 28.8% of those w h o had not used the drug (~2 = 12.3, P < 0.01). All the females w h o reported using hashish had had intercourse. There was a significant relationship between the use of hashish and alcoholic beverages. Of those w h o had used hashish 73.7% also reported using alcohol as compared to 46% of those w h o had not. Multiple regression analysis for males and females showed that smoking provided the greates t
smoked (P < 0.005). There is a similar trend in the females but it does not reach statistical significance.
Drugs Only 4.9% of the males and 1.2% of the females reported using hashish. No one reported using hard drugs. Sexual Activity The pattern of sexual experience is presented in Table 5. Six categories were defined from "going out with th e opposite sex" to "sexual intercourse'" (3). The proportion of males w h o had had an experience other than "going out alone With the opposite sex" w a s higher than females at each age. There was a rise in the proportion of males and females w h o h a d each specific experience with advancing age. In regard to "full sexual intercourse", the proportion of males increased from 19.7% at 16 years to 44.3% at age 18. In females, t h e increase was from 6.6% to 27.7% for the respective ages. The intersex difference was threefold at age 16 years as compared to less than twofold at age 18 . About 12% of males and 8% of females aged 18 years had never gone out alone with the opposite sex. In the males it rose to 28.1% at age 17 years and 24.8% at age 16. In females the increase was from 12.9% to 26.6% respectively.
Table 4. Cigarette Smoking by Sex and Number of Friends Who Smoke Number of friends who smoke Smoking habit Present Past Never n
Males
Females
0
1-2
3+
Many
9.7 22.3 68.0 175
27.3 31.8 40.9 66
36.3 !7.5 46.2 80
58.2 11.9 29.9 67
~
0
1-2
3+
Many
3.6 13.7 82.7 197
33.3 24.1 42.6 54
32.1 28.6 39.3 28
43.1 15.5 41.4 58
264
TAMIRET AL.
JOURNALOF ADOLESCENTHEALTHCAREVoI. 2, No. 4
Table 5. Percent Having Each Type Sexual Experience by Sex and Age
Male Age (years) Experience (%) Sexual intercourse Genital stimulation Petting underclothes Petting over clothes Kissing Going outalonewith opposite sex
Table 7. Present Cigarette Smoking Compared to the Use of Hashish (Males) Smoking (present)..
Female Age (years)
16
17
18
16
17
18
19.7 20.1 31.4 62.5 74.6 75.2
29.4 36.3 49.3 63.2 71.0 71.9
44.3 51.4 65.5 81.7 87.4 87.7
6.6 10.0 20.1 44.0 55.6 73.4
10.3 22.1 36.8 57.4 77.6 87.1
27.7 424 57.6 75.6 85.3 91.6
proportion of the explained variance in relation to sexual intercourse (Table 8). The reported used of hashish a n d the subject's age also accounted for a substantial proportion. The proportion explained by the religiosity of the females was greater than for males. These multiple regression findings were similar for each age group. Similarly, smoking and sexual relations accounted for almost all the explained variance in relation to the reported use of hashish.
Discussion The prevalence of the behavioral attributes reported is similar to other studies. In relation to cigarette smoking there has been little change since the study of Peled (4) in 1971. In both, about 55% of the males had never smoked. There was, however, a rise in the proportion of those who smoked daily (14% in our study, compared to 4% in 1971). In addition, the age of beginning to smoke was younger in our study. Lancet and his co-workers (2) reported the sexual practices of Israel adolescents. In each of Lancet's six categories of sexual activity they reported a slightly higher frequency than did our subjects. This
Yes
Hashish (ever used) Yes No
No %
N
%
N
%
16 83
16.2 83.3
3 289
1.0 99.0
19 372
4.9 95.1
X2 = 36.63, P < 0.001
may in part be due to the different composition of our study population which included only urban adolescents from a comprehensive school and not purely vocational as were some of the schools in the other study. Aside from these reports of individual attributes, little has been documented on the interrelationship between the behaviors. Peled (5,6) has stressed the importance of the relationship between cigarette smoking and the use of drugs, as well as that between the attitude toward early sexual relations and drug usage. Little data, however, have been reported on the coexistence of these attributes. Goode (7) found that the drug users in an American college were more likely to engage in sexual intercourse, and at an earlier age, than those who did not use drugs. He concluded that students w h o practiced one habit or the other were more likely to develop the other form of behavior as well. In another paper, he (8) described an almost linear relationship between the frequency of use of marijuana and the occurrence of premarital sexual intercourse. He hypothesized that the development o f both attributes is dependent on specific sociocultural background factors, i.e., that the "cause" of both is an antiauthoritarian nontraditional culture. In a publication of the United States National Institute of Drug
Table 6. Cigarette Smoking Compared to Sexual
Activity by Sex Sexual intercourse Smoking habit Males Present Past Never Females Present Past Never
N
Total
N
% 53,8 30.6 20.1
49 59 175
46.2 69.4 79.9
X2 = 37, P < 0.001
36.1 10.2 8.4
39 53 217
63.9 89.8 91.6
X2 = 30, P < 0.001
June 1982
HEALTH-RELATEDBEHAVIORIN ADOLESCENTS
265
Table 8. Multiple Regression Analysis: Proportion of Explained Variance
Having sexual intercourse
Smoking Age Use of hashish Religiosity Ethnicity Total
6.6 3.3 2.2 0.2 0.2 12.5
Smoking Use of hashish Age Religiosity
10.6 4.0 3.6 1.8
Smoking Sexual relations Youth movement membership Ethnicity
10.6 2.1 0.3 0.2
Total
20.0
Total
13.2
A b u s e , K a n d e l (9) h i g h l i g h t e d the i m p o r t a n c e of alcohol a n d cigarette s m o k i n g as potential p r e c u r sors of d r u g usage. T h e p r e s e n t s t u d y p r o v i d e s data on these b e h a v ioral attributes in the s a m e adolescents in h i g h s c h o o l . It raises q u e s t i o n s a b o u t the p r o c e s s e s that g o v e r n t h e s e relationships a n d the possible relev a n c e of o u r findings in the p l a n n i n g of services for this age g r o u p . O u r d a t a s u g g e s t that the behavioral attributes s t u d i e d are interrelated. Cigarette s m o k i n g is significantly r e l a t e d to u s e of d r u g s a n d sexual e x p e rience as are the latter two. The additional f i n d i n g of the r e l a t i o n s h i p b e t w e e n d r i n k i n g alcoholic b e v e r a g e s a n d the u s e of d r u g s s u p p o r t s the literature (1). A statistically significant relationship b e t w e e n t w o b e h a v i o r a l attributes d o e s n o t per se indicate causality or t h a t b o t h s t e m f r o m the s a m e u n d e r l y i n g c i r c u m s t a n c e s . H o w e v e r , the fact that, chronologically, cigarette s m o k i n g is the first characteristic to a p p e a r , the i m p o r t a n c e of p e e r g r o u p influence a n d the later link b e t w e e n s m o k i n g , d r u g u s a g e , alcoholic b e v e r a g e s a n d sexual activity raises the possibility of u s i n g t h e s e data as a basis for service action. C o n s e q u e n t l y , if the h e a l t h a n d welfare services consider it n e c e s s a r y to identify adolescents w h o for e x a m p l e are likely to u s e d r u g s or are in g r e a t e r n e e d
for sex e d u c a t i o n t h e n o u r data p r o v i d e a logical p o t e n t i a l f r a m e w o r k for defining such groups.
References 1. Kovar MG: Some indicators of health-related behavior among adolescents in the United States. Pub Health Rep 94:109-118, 1979. 2. Lancet M, Modan B, Kavenaki S, et al.: Sexual knowledge, attitudes, and practice of Israeli adolescents. Amer J Pub Health 68:1083-1089,1978. 3. Kark SL, Peritz E, Shiloh A, et al.: Epidemiological analysis of the hemoglobin picture in parturient women of Jerusalem. Amer J Pub Health 54:947-960,1964. 4. Peled T, Schimmerling H: Cigarette smoking among high school youth. The Israel Institute of Applied Social Research, Jerusalem, 1971. 5. Peled T, Schimmerling H: The drug culture among the youth of Israel: The case of high school students. The Israel Institute of Applied Social Research, Jerusalem, 1971, presented at the International Symposium on "Youth Unrest", October 1971, Tel Aviv, Israel. 6. Peled T: The structure of motivation for the use of hashish: Images and personal experiences of high school students in Israel. Presented at the 2nd International Symposium on Drug Abuse, Jerusalem, 1972. 7. Goode E: Drug use and sexual activity on a college campus. Amer J Psychiatr. 128:1272-1276,1972. 8. Goode E: Sex and marihuana. Sex Behav 2:45-51,1972. 9. Kandel D: Some comments on the relationship of selected criteria variables to adolescent illicit drug use. In Lettieri DJ (ed): Predicting adolescent drug abuse: A review of issues, methods and correlates. National Institute on Drug Abuse, Maryland, 1975.
ORIGINAL
ARTICLES
Health-Related Behavior in Israel Adolescents A D A TAMIR, M . A . , H A N A W O L F F , B.A., A N D L E O N EPSTEIN, M.B., Ch.B., M . P . H .
Eight hundred and: four high school students were interviewed about selected health-related behaviors in an effort to determine the interrelationships of these characteristics. We found the age of onset and present use of cigarettes by the adolescents to be positively correlated to their use of hashish and having sexual intercourse. The use of hashish and having sexual intercourse were also positively related with each other and the use of hashish to drinking alcohol.
KEYWORDS: Adolescent behavior Smoking and sex Smoking and drugs Individual and group behavior appear to have an important relationship to health. Behavior may be related to promoting better health, direct disease prevention or disease detection and treatment. With the substantial rise of the so-called diseases of "'affluence", such as coronary heart disease, the behavioral attributes of the individual may be critical in determining risk status. Adolescence may be of particular importance since behavior at this stage m a y effect the later development of chronic disease. Modern Western society is characterized by a breakdown of formerly accepted behavioral norms. This includes, among others, changes in the extent a n d social acceptibility of extramarital sexual activity, and drug usage. The role of the family as the determinant and arbiter of the behavior of its members has also changed. This process may be rooted in the changes occurring in the adolescent popula-
From the Department of Family and Community Health, Technion Faculty OfMedicine, and Health Administration Unit, Rambam Medical Center, Haifa, Israel. Address reprint requests: Dr. Leon Epstein, Dept. of Family and Community Health, Technion Medical School, Haifa, Israel. Manuscript accepted October 12,1981.
tion whose patterns of future behavior are being determined. Behavioral attributes of individuals and groups are developed in the context of their total behavior pattern. Many programs however, tend to focus on single problems such as the use of drugs, sexual promiscuity or overeating, without taking into account all of the adolescent's health-related behaviors. A holistic view of health-related behavior is particularly important for Israel's heterogeneous ethnic population in which the cultural background of the adolescent is often paramount in determining his behavior and service needs. Health and welfare services should attempt to map adolescent behavior patterns at specific times and monitor changes, thus facilitating more rational planning of intervention programs (1). We studied selected health-related behaviors i n secondary school children in the Haifa area. The study was designed to map their present behavior patterns a n d assess their possible interrelationships as a basis for planning health-related programs in the school. Materials
and Methods
During the 1977-1978 school year, 804 high school students Were evaluated. All the students in.the final three years of school were included and only a few w h o were absent on the examination day were omitted. Their ages ranged from 16-18 years with 54% being males and 46% females (Table 1). Following an explanation of the objectives of the study and stressing that the respondents would remain anonymous, the students were asked to complete a detailed questionnaire on selected aspects of their health and health-related behavior. It included batteries of questions used in other studies, for example, sexual behavior was defined in six categories
© Societyfor AdolescentMedicine, i982 Published by ElsevierSciencePublishingCo., Inc., 52 VanderbiltAve., New York,NY 10017
261 0197-0070/81/040261-05502.75
262
TAMIRET AL.
JOURNAL OF ADOLESCENTHEALTHCAREVol. 2, No. 4
members of a youth movement, e.g., Boy Scouts. Their status was defined as present membership, past membership (for at least two years), and never a member (or less than two years).
Table 1. High School Students by Age and Sex
Age 18 17 16 Total
N
%
N
%
N
%
147 149 158 434
33.9 34.3 31.8 100.0
96 119 155 370
25.9 32.2 41.9 100.0
243 268 293 804~
30.2 33.3 36.5 100.0
"In the followingtables persons with unknown values were
from "going out alone with the opposite sex" to "'sexual intercourse" as described by Lancet and his colleagues (2). All questions were effectively closed. The questiorinaire had previously been tested on a similar group of students to determine the distribution of answers to questions as well as the reliability and validity. The behavioral attributes reported on in this study are cigarette smoking, medicinal and nonmedicinal drug use, and sexual behavior. Eighty five percent of the students were born in Israel. The possible effect of ethnic origin was therefore examined using the country of birth of the father as the index. The countries were classified into three groups: Ashkenazi, father born in Europe or other Western country; Sephardi, father born in Middle East (excluding Israel), North Africa or other Oriental area;• and Israeli, father born in Israel. All the students were of Jewish origin. The social class was defined using a classification of the reported occupation of the student's father that had been adapted from the British Registrar General for use in Israel (3). The religioSity of the student was defined as either religious, traditional, or secular. The students were asked whether they were
Results Smoking About 26% of males and 17% of females were smoking at the time of the study (Table 2). There was an age-related increase in the proportion of daily smokers in both sexes. At each age more males than females were daily smokers. There is no significant age or sex difference in the proportions of past smokers. Among those who had never smoked the difference between the sexes falls from 15.3% at age 16 years to 4.9% at age 18 years. For both sexes, the differences in smoking by age were statistically significant (Males: X2 = 33.6, P < 0.001; Females: ~6 = 20.5, P < 0.01). Males start smoking at an earlier age than females (Table 3). By age 14 years, 27.9% of the boys who had ever smoked Cigarettes had already begun, as compared to 8.2% of the females. About 50% of girls as compared to 27.7% of boys began smoking after age 15 years. There was no relationship between the smoking habits and ethnic origin or social class grading. A relationship exists between the smokinghabits of males and females and those of their friends (Table 4). There is a statistically significant rise in the proportion of present smokers (and fall i n the proportion of those who have never smoked) with an increase in the number of friends who smoke. There is a significant relationship between the smoking habits of maleS and those of their parents. Where the parents did not smoke only 21% of the boys do so, whereas 32% smoked of one or both
Table 2. Cigarette Smoking by Sex and Age Female Age (years)
Male Age (years) 16 Smoking
N
%
N
%
N
Daily Sometimes Past Never Total
7 14 29 86 136
5.2 10.3 21.3 63.2
22 16 30 77 145
15.2 11.0 20.7 53.1
30 22 27 65 144
Males: X~ = 33.6, P < 0.001 Females: X~ = 20.5, P < 0~01.
20.8 15.3 18.8 45.1
59 52 86 228 425
13.9 12.2 20.2 53.7
! 12 19 117 149
17
18
Total
%
N
%
N
%
N
%
0.7 8.1 12.7 78.5
9 10 23 76 118
7.6 8.5 19.5 64.4
13 17 18 48 96
13.5 17.7 18.8 50.0
23 39 60 241 363
6.3 10.8 16.5 66.4
June 1982
HEALTH-RELATEDBEHAVIORIN ADOLESCENTS
263
Table 3. Age of Onset of Cigarette Smoking by Sex
Relationship Between Behavioral Attributes
Age (years)
Male (%)
Female (%)
11 12 13 14 15 16 17
5.5 6.3 15.6 18.4 26.5 20.4 6.8
1.2 1.2 5.8 11.4 30.2 30.2 19.8
There was a relationship between the smoking habits of both sexes and their sexual experience (Table 6). This was found for the group as a whole as well as for each age group. Of those presently smoking 53.8% of males and 36.1% females had had sexual intercourse, as compared to 20.1% of males and 8.4% of females w h o had never smoked. This relationship (smoking and sexual intercourse) was statistically significant in both sexes (Males: X2 = 37, P < 0.001; Females: X22 = 30, P < 0.001). Past smokers in both sexes were intermediate in this regard, i.e., the proportion w h o had had sexual intercourse was lower than the present smokers but higher than those w h o had never smoked. There was a relationship between the age at which smokers began smoking and the proportion w h o had had sexual intercourse. Those having had intercourse fell from 57.1% of the males w h o began smoking at age 11 years to 25% of those who began smoking at age 17 years. This relationship was statistically significant for males aged 18 years (Mann-Whitney Test: Z = 2.354, P < 0.01, using a one-tailed test). Of the 19 subjects w h o reported using hashish, 16 were also smoking cigarettes at the time of the study (84.2%) as compared to only 22.3% of the remaining population (Table 7). About 16% of the smokers had at some time used hashish as compared to only 1% of the nonsmokers (X22= 36.6, P < 0.001). Of the males w h o had used hashish, 77.9% had had sexual intercourse as compared to 28.8% of those w h o had not used the drug (~2 = 12.3, P < 0.01). All the females w h o reported using hashish had had intercourse. There was a significant relationship between the use of hashish and alcoholic beverages. Of those w h o had used hashish 73.7% also reported using alcohol as compared to 46% of those w h o had not. Multiple regression analysis for males and females showed that smoking provided the greates t
smoked (P < 0.005). There is a similar trend in the females but it does not reach statistical significance.
Drugs Only 4.9% of the males and 1.2% of the females reported using hashish. No one reported using hard drugs. Sexual Activity The pattern of sexual experience is presented in Table 5. Six categories were defined from "going out with th e opposite sex" to "sexual intercourse'" (3). The proportion of males w h o had had an experience other than "going out alone With the opposite sex" w a s higher than females at each age. There was a rise in the proportion of males and females w h o h a d each specific experience with advancing age. In regard to "full sexual intercourse", the proportion of males increased from 19.7% at 16 years to 44.3% at age 18. In females, t h e increase was from 6.6% to 27.7% for the respective ages. The intersex difference was threefold at age 16 years as compared to less than twofold at age 18 . About 12% of males and 8% of females aged 18 years had never gone out alone with the opposite sex. In the males it rose to 28.1% at age 17 years and 24.8% at age 16. In females the increase was from 12.9% to 26.6% respectively.
Table 4. Cigarette Smoking by Sex and Number of Friends Who Smoke Number of friends who smoke Smoking habit Present Past Never n
Males
Females
0
1-2
3+
Many
9.7 22.3 68.0 175
27.3 31.8 40.9 66
36.3 !7.5 46.2 80
58.2 11.9 29.9 67
~
0
1-2
3+
Many
3.6 13.7 82.7 197
33.3 24.1 42.6 54
32.1 28.6 39.3 28
43.1 15.5 41.4 58
264
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JOURNALOF ADOLESCENTHEALTHCAREVoI. 2, No. 4
Table 5. Percent Having Each Type Sexual Experience by Sex and Age
Male Age (years) Experience (%) Sexual intercourse Genital stimulation Petting underclothes Petting over clothes Kissing Going outalonewith opposite sex
Table 7. Present Cigarette Smoking Compared to the Use of Hashish (Males) Smoking (present)..
Female Age (years)
16
17
18
16
17
18
19.7 20.1 31.4 62.5 74.6 75.2
29.4 36.3 49.3 63.2 71.0 71.9
44.3 51.4 65.5 81.7 87.4 87.7
6.6 10.0 20.1 44.0 55.6 73.4
10.3 22.1 36.8 57.4 77.6 87.1
27.7 424 57.6 75.6 85.3 91.6
proportion of the explained variance in relation to sexual intercourse (Table 8). The reported used of hashish a n d the subject's age also accounted for a substantial proportion. The proportion explained by the religiosity of the females was greater than for males. These multiple regression findings were similar for each age group. Similarly, smoking and sexual relations accounted for almost all the explained variance in relation to the reported use of hashish.
Discussion The prevalence of the behavioral attributes reported is similar to other studies. In relation to cigarette smoking there has been little change since the study of Peled (4) in 1971. In both, about 55% of the males had never smoked. There was, however, a rise in the proportion of those who smoked daily (14% in our study, compared to 4% in 1971). In addition, the age of beginning to smoke was younger in our study. Lancet and his co-workers (2) reported the sexual practices of Israel adolescents. In each of Lancet's six categories of sexual activity they reported a slightly higher frequency than did our subjects. This
Yes
Hashish (ever used) Yes No
No %
N
%
N
%
16 83
16.2 83.3
3 289
1.0 99.0
19 372
4.9 95.1
X2 = 36.63, P < 0.001
may in part be due to the different composition of our study population which included only urban adolescents from a comprehensive school and not purely vocational as were some of the schools in the other study. Aside from these reports of individual attributes, little has been documented on the interrelationship between the behaviors. Peled (5,6) has stressed the importance of the relationship between cigarette smoking and the use of drugs, as well as that between the attitude toward early sexual relations and drug usage. Little data, however, have been reported on the coexistence of these attributes. Goode (7) found that the drug users in an American college were more likely to engage in sexual intercourse, and at an earlier age, than those who did not use drugs. He concluded that students w h o practiced one habit or the other were more likely to develop the other form of behavior as well. In another paper, he (8) described an almost linear relationship between the frequency of use of marijuana and the occurrence of premarital sexual intercourse. He hypothesized that the development o f both attributes is dependent on specific sociocultural background factors, i.e., that the "cause" of both is an antiauthoritarian nontraditional culture. In a publication of the United States National Institute of Drug
Table 6. Cigarette Smoking Compared to Sexual
Activity by Sex Sexual intercourse Smoking habit Males Present Past Never Females Present Past Never
N
Total
N
% 53,8 30.6 20.1
49 59 175
46.2 69.4 79.9
X2 = 37, P < 0.001
36.1 10.2 8.4
39 53 217
63.9 89.8 91.6
X2 = 30, P < 0.001
June 1982
HEALTH-RELATEDBEHAVIORIN ADOLESCENTS
265
Table 8. Multiple Regression Analysis: Proportion of Explained Variance
Having sexual intercourse
Smoking Age Use of hashish Religiosity Ethnicity Total
6.6 3.3 2.2 0.2 0.2 12.5
Smoking Use of hashish Age Religiosity
10.6 4.0 3.6 1.8
Smoking Sexual relations Youth movement membership Ethnicity
10.6 2.1 0.3 0.2
Total
20.0
Total
13.2
A b u s e , K a n d e l (9) h i g h l i g h t e d the i m p o r t a n c e of alcohol a n d cigarette s m o k i n g as potential p r e c u r sors of d r u g usage. T h e p r e s e n t s t u d y p r o v i d e s data on these b e h a v ioral attributes in the s a m e adolescents in h i g h s c h o o l . It raises q u e s t i o n s a b o u t the p r o c e s s e s that g o v e r n t h e s e relationships a n d the possible relev a n c e of o u r findings in the p l a n n i n g of services for this age g r o u p . O u r d a t a s u g g e s t that the behavioral attributes s t u d i e d are interrelated. Cigarette s m o k i n g is significantly r e l a t e d to u s e of d r u g s a n d sexual e x p e rience as are the latter two. The additional f i n d i n g of the r e l a t i o n s h i p b e t w e e n d r i n k i n g alcoholic b e v e r a g e s a n d the u s e of d r u g s s u p p o r t s the literature (1). A statistically significant relationship b e t w e e n t w o b e h a v i o r a l attributes d o e s n o t per se indicate causality or t h a t b o t h s t e m f r o m the s a m e u n d e r l y i n g c i r c u m s t a n c e s . H o w e v e r , the fact that, chronologically, cigarette s m o k i n g is the first characteristic to a p p e a r , the i m p o r t a n c e of p e e r g r o u p influence a n d the later link b e t w e e n s m o k i n g , d r u g u s a g e , alcoholic b e v e r a g e s a n d sexual activity raises the possibility of u s i n g t h e s e data as a basis for service action. C o n s e q u e n t l y , if the h e a l t h a n d welfare services consider it n e c e s s a r y to identify adolescents w h o for e x a m p l e are likely to u s e d r u g s or are in g r e a t e r n e e d
for sex e d u c a t i o n t h e n o u r data p r o v i d e a logical p o t e n t i a l f r a m e w o r k for defining such groups.
References 1. Kovar MG: Some indicators of health-related behavior among adolescents in the United States. Pub Health Rep 94:109-118, 1979. 2. Lancet M, Modan B, Kavenaki S, et al.: Sexual knowledge, attitudes, and practice of Israeli adolescents. Amer J Pub Health 68:1083-1089,1978. 3. Kark SL, Peritz E, Shiloh A, et al.: Epidemiological analysis of the hemoglobin picture in parturient women of Jerusalem. Amer J Pub Health 54:947-960,1964. 4. Peled T, Schimmerling H: Cigarette smoking among high school youth. The Israel Institute of Applied Social Research, Jerusalem, 1971. 5. Peled T, Schimmerling H: The drug culture among the youth of Israel: The case of high school students. The Israel Institute of Applied Social Research, Jerusalem, 1971, presented at the International Symposium on "Youth Unrest", October 1971, Tel Aviv, Israel. 6. Peled T: The structure of motivation for the use of hashish: Images and personal experiences of high school students in Israel. Presented at the 2nd International Symposium on Drug Abuse, Jerusalem, 1972. 7. Goode E: Drug use and sexual activity on a college campus. Amer J Psychiatr. 128:1272-1276,1972. 8. Goode E: Sex and marihuana. Sex Behav 2:45-51,1972. 9. Kandel D: Some comments on the relationship of selected criteria variables to adolescent illicit drug use. In Lettieri DJ (ed): Predicting adolescent drug abuse: A review of issues, methods and correlates. National Institute on Drug Abuse, Maryland, 1975.