The incidence of experimental smoking in school children: an 8-year follow-up of the child and adolescent behaviors in long-term evolution (CABLE) study
Chang et al. BMC Public Health
The Incidence of Experimental Smoking in School Children: An 8-year Follow-up of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) Study
Hsing-Yi Chang 0
Chi-Chen Wu 0
Jennifer Y Cheng 0
Lee-Lan Yen 0
0 Division of Preventive Medicine and Health Service Research, Institute of Population Health Sciences, National Health Research Institutes , Zhunan Town, Miaoli County, Taiwan, ROC
Background: Studies have established that most regular adult smokers become addicted in their adolescent years. We investigated the incidence of and risk factors associated with initial experimental smoking among a group of school children who were followed for 8 years. Methods: We used cohort data collected as part of the Child and Adolescent Behaviors in Long-term Evolution (CABLE) study, which selected nine elementary schools each from an urban area (Taipei City) and a rural area (Hsingchu county) in northern Taiwan. From 2002 to 2008, children were asked annually whether they had smoked in the previous year. An accelerated lifetime model with Weibull distribution was used to examine the factors associated with experimental smoking. Results: In 2001, 2686 4th-graders participated in the study. For each year from 2002 to 2008, their incidences of trial smoking were 3.1%, 4.0%, 2.8%, 6.0%, 5.3%, 5.0% and 6.0%, respectively. There was an increase from 7th to 8th grade (6.0%). Children who were males, lived in rural areas, came from single-parent families, had parents who smoked, and had peers who smoked were more likely to try smoking earlier. The influence of parents and peers on experimental smoking demonstrated gradient effects. Conclusions: This study used a cohort to examine incidence and multiple influences, including individual factors, familial factors, and community factors, on experimental smoking in adolescents. The findings fit the social ecological model, highlighting the influences of family and friends. School and community attachment were associated with experimental smoking in teenagers.
cigarette smoking; adolescent behavior; epidemiological factors; socioeconomic factors
Smoking is one of the most popular forms of drug use
and is a major risk factor for lung cancer and
cardiovascular disease . In a systematic review of 17 studies,
smoking was found to be associated with peripheral
arterial disease not only among current smokers but
also among former smokers . Due to its public
accessibility, smoking has become one of the worlds most
prominent public health issues and is a leading cause of
premature death worldwide [3,4]. A high prevalence of
smoking has been observed in Chinese societies .
Several studies have established that most regular adult
smokers become addicted to nicotine in their adolescent
years [6-8]. Public health researchers have conducted
extensive research on adolescent smoking and its
relationship with factors such as parental and peer relations,
academic performance, socioeconomic factors, and
environmental factors . Due to the specific targeting
of advertising by the tobacco industry, growing
populations of adolescents in both developing and developed
countries are taking up smoking . If not effectively
addressed, the world will see generations of young
smokers suffer from highly preventable cardiovascular
diseases and risk premature death. The reasons behind
adolescent smoking are complex and involve multiple
influences, including individual factors, socioeconomic
factors, familial factors, peer influences, school and
environmental factors. It has been reported that the
majority of youth experimental smokers become daily
smokers [7,8]. An understanding of the age of
experimental smoking and related risk factors is important for
designing early intervention programs targeting
Many studies have monitored the smoking status of
youth worldwide. The Global Youth Tobacco Survey
(GYTS) is the largest surveillance system, which
conducts periodic surveys on tobacco use in a wide range
of countries . Many longitudinal studies have also
explored the factors predicting regular smoking in teens
. However, these studies, especially longitudinal
studies of experimental smoking in school children, have
rarely been conducted in Asia. Previous studies
examined either current smoking behavior or the initiation
age of smoking. As mentioned above, a large proportion
of experimental youth smokers continue to smoke in
adulthood. It is important to understand when these
youth first tried smoking and the factors that are
associated with these trials.
The Child and Adolescent Behaviors in Long-term
Evolution (CABLE) study  was initiated to examine
the behavioral development of school children in
Taiwan. Children were visited annually and were asked
questions related to their behaviors. The study has
accumulated long-term information on these childrens
behaviors and risk factors. Information concerning when
children first tried smoking and the factors associated
with smoking experimentation can be extracted from
these data. The purpose of this study was to investigate
the incidence of experimental smoking and its risk
factors in a group of school children who were followed
for 8 years.
Data for this study came from the study of Child and
Adolescent Behaviors in Long-term Evolution (CABLE)
[12,13]. The study was designed to observe the
development of children based on the ecological model, which
emphasizes that individual, interpersonal, organizational,
community and public policy factors shape the
development of a child. Additional information was collected
during the yearly follow-ups to reflect problems faced
by the children at that age, but the changes on questions
were minor. Students from urban and rural areas were
sampled to identify the developmental differences
between these two groups . Nine elementary schools
each from an urban area (Taipei City) and a rural area
(Hsingchu County) in northern Taiwan were selected.
The 1st and 4th graders in each school (representing the
1st and 2nd cohorts) were selected as the baseline
cohorts to be followed annually. The CABLE study was
approved by the Internal Review Board of the National
Health Research Institutes (approval code: EC9009003).
All parents of students in the study signed a consent
form allowing their children to participate. We used
data from the initial cohort of fourth-graders in this
study because they were entering adolescence. Complete
data on all 8 years of follow-up were available for more
than two-thirds of the children.
The outcome variable was experimental smoking from
2002 to 2008. Each year, children were asked whether
they had smoked in the past year. We asked the
question, Have you smoked cigarettes, even one puff? The
answers included (1) never; (2) not this year, but the
year before; (3) not this month, but this year; (4) one or
two times this month; (5) many times this month; and
(6) almost every day this month. This set of questions
was similar to the Global Youth Tobacco Survey .
Students who had not answered yes in previous years
and who answered yes in a subsequent year were
considered new cases. Because we were studying
experimental smoking in children aged approximately 10
years, we considered one inhalation of tobacco to be an
incidence of experimental smoking. In addition to
individual factors, we were interested in the effects of family
and community on the initiation of smoking.
Individual factors included gender, residential area,
self-perceived school performance, depressive symptoms
and self-competence. Depressive symptoms were
measured by 7 questions, which asked about loss of appetite,
feeling sad, crying for no reason, getting upset over
nothing, feeling frightened, difficulty sleeping, and lack
of motivation to do anything in the previous two weeks.
A three-point-scale was used with 1 point given for not
at all, 2 for sometimes, and 3 for often. The sum of the
scores for all items was used. A higher score implied
more depressive symptoms. The questions were based
on the depressive symptoms of the Center for
Epidemiological Studies Depression Scale for Children (CES-DC)
, which has been widely used in Taiwanese surveys.
Cronbachs a, which measures how well each individual
item in a scale correlates with the sum of the remaining
items, was used for the internal consistency or validity
of the scales. The survey of 8th graders was used to
estimate Cronbachs a. The widely accepted social science
cut-off is an alpha of .70 or higher for a set of items to
be considered a scale . The Cronbachs a was 0.74.
Self-competence was measured by 6 items, including
optimism, feeling happy, willingness to try new things,
working hard, facing problems positively, and perceiving
oneself as being as good as others. The concept was
based on Tafarodi and Swann . The Chinese version
was evaluated by Song et al. . A 5-point Likert scale
was used, with scores ranging from 1 (never) to 5
(always). The scores of the 8th graders were used to
calculate Cronbachs a, which was 0.79.
Family factors included socio-economic status, coming
from a single-parent family and the degree of parental
support and supervision. Parental smoking was also
assessed. Family socioeconomic status was measured by
family income and fathers education level. The
categories of monthly family income were (1) less than 19,
999NTD (new Taiwan dollars, 1 NTD 0.03 USD); (2)
20,000~39, 999NTD; (3) 40, 000NTD~59, 999NTD; (4)
60,000~79, 999NTD; (5) 80,000~99, 999NTD; (6)
100,000~119, 999NTD; (7) 120,000~139, 999NTD; and
(8) 140, 000NTD. Education levels were (1)
elementary school or less; (2) junior high; (3) senior high; (4)
vocational school; (5) college; (6) university; and (7)
graduate school or above. We added together the levels
of family income and education and then divided them
into 3 categories: low < 8 (1st quartile); medium 8-13;
and high 13 (4th quartile).
Parental smoking status was assessed for both parents.
The combination of answers resulted in three categories:
(1) both parents smoke; (2) only one parent smokes; and
(3) neither parent smokes. The questions on parental
support and supervision were part of family interactions
. They were developed by a panel of experts
specializing in behavioral sciences and education. They
adapted the concepts from various researchers [20,21].
Once the experts reached consensus, the questions were
examined by the fieldworkers to evaluate their feasibility.
Then, the CABLE team has extracted factors on family
interactions. The family interactions consisted of 6
aspects, including parental support, family activities,
psychological control, parental discipline, behavioral
supervision, and family conflict . We only used two
aspects in this study, which were parental support and
supervision. Parental support was assessed by 6
questions: providing encouragement in difficult times,
praising good performance, providing comfort when you are
upset, taking care of you when you are sick, listening,
and taking an interest in your school life. Each response
had four options ranging from 1 (never) to 4 (every
time). Scores for each item were added together to
obtain the score for parental support. The Cronbachs a
was 0.91. Parental supervision was assessed by four
questions, which asked whether parents were aware of
what children did in their spare time, what they did on
their way home from school, who they spent time with,
and how they used their allowance. A 4-point scale was
used, with 1 indicating that parents did not know
anything and 4 indicating that they knew everything. Scores
for each item were summed to obtain the score for
parental supervision. Cronbachs a was 0.77. Details of the
questions can be found in Appendix 1.
Peer smoking, school attachment and neighbors were
considered as community factors. Children were asked
whether none, a few, about half, most or all of their
peers smoked. School attachment was assessed by
whether children liked their current school, teachers,
and classmates. Responses to each item had five options
ranging from 1 (do not like it/them at all) to 5 (like it/
them very much). These questions were included in the
questionnaire from 2003. The average of scores from
2003 to 2008 was used in the analysis. Eight items were
used to assess community attachment: (1) Do you or
your family visit or talk to your neighbors? (2) When
you go away, does your family ask neighbors to house
sit, including checking the mail, watering the garden,
and feeding the dog? (3) Do you think your neighbors
are trustworthy? (4) Do you think your neighbors are
kind and friendly? (5) Do you and your family
participate in community activities? (6) Do you like where you
live? (7) Do you think your living environment is safe?
(8) Are there ever strange people wandering around the
neighborhood? A 5-point scale was used for each item,
with 1 point indicating never and 5 points indicating all
the time. A score in the lowest quartile (22 points) was
considered low, and a score in the upper quartile (29
points) was considered high. Details of the questions
used in all scales are given in Appendix 1 (Additional
file 1, appendix 1).
The event time was 4th grade to the year of
experimental smoking. Because experimental smoking could
occur before the first interview, between the two
interview years, or after 2008, the data contained all types of
censoring: left censoring, interval censoring and right
censoring. The survival time was the time that students
never smoked. A parametric model is appropriate for
this type of data. A Weibull distribution consists of two
parameters describing the shape and scale of the
distribution curve . Therefore, an accelerated lifetime
model (ALT), which models the survival time assuming
Weibull distribution, was used. All analyses were
conducted using SAS version 10 (SAS Inc., Cary, USA).
Table 1 shows the characteristics of the study subjects.
There were 2071 subjects who participated in the study
in 2001. In 2002, we sent invitations to those who did
not consent in 2001, and 615 of these subjects re-joined
the study. Therefore, the total number of children at the
start of the study was 2686 4th-graders. Over two-thirds
of the participants were followed for 8 years. More boys
than girls had tried smoking at least once during the
8year follow-up. More ever-smokers lived in a rural area
Table 1 Characteristics of the study sample
Gender (n = 2686)
Boys 831 (60.13) 551 (39.87)
Girls 992 (76.07) 312 (23.93)
Residential area (n = 2686)
Taipei (urban) 1062 (73.39) 385 (26.61)
Hsinchu (rural) 761 (61.42) 478 (38.58)
Perceived school performance (n = 2341)
Poor 861 (67.21) 420 (32.79)
Fair 575 (64.90) 311 (35.10)
Good 130 (74.71) 44 (25.29)
Single-parent family (n =
No 1559 (71.03) 636 (28.97)
Yes 253 (53.49) 220 (46.51)
SES (n = 2611)
Low 341 (57.02) 257 (42.98)
Medium 1037 (69.41) 457 (30.59)
High 400 (77.07) 119 (22.93)
Parental smoking (n = 2418)
Neither 743 (78.05) 209 (21.95)
One 815 (64.43) 450 (35.57)
Both 99 (49.25) 102 (50.75)
Peer smoking (n = 2540)
None 556 (90.11) 61 (9.89)
Few 900 (71.60) 357 (28.40)
Over half 234 (35.14) 432 (64.86)
(n = 2686)
Low 591 (66.18) 302 (33.82)
Medium 893 (66.59) 448 (33.41)
High 339 (75.00) 113 (25.00)
*: p < 0.05; **: p < 0.01; ***: p < 0.001
(Hsinchu) than in an urban area (Taipei city). Children
who had poorer perceived school performance were
more likely to start smoking during the follow-up.
Children with medium to low socioeconomic status were
more likely to smoke than those with high
socioeconomic status. Children with one or both parents who
were smokers were more likely to be smokers
themselves. Socioeconomic status was inversely associated
with smoking initiation, as was community attachment.
All of these factors reached statistical significance.
Children who started smoking had significantly higher
depressive symptom scores, lower self-competence,
lower parental support, less parental supervision, and
lower school attachment scores. The smoking incidence
rate is shown graphically in Figure 1. There was a drop
in incidence in the 7th grade followed by a sharp
increase in the 8th grade. Boys were consistently more
likely to take up smoking than girls.
Table 2 shows the results of survival analysis. We used
an accelerated failure time model assuming a Weibull
distribution. The scale was 0.57, which indicated that
the hazard was increasing at a decreasing rate. A
negative value indicated an early initiation. Boys and
students who lived in a rural area, came from a
singleparent family, had parents who smoked, had peers who
smoked, had low school attachment, or had median
community attachment started smoking earlier than did
This study followed a group of 4th-graders annually and
assessed the incidence of experimental smoking and
related risk factors. The results showed that the
incidence of experimental smoking increased with age.
There was a drop in incidence in the 7th grade followed
by an increase in the 8th grade. Individual factors, such
as gender and residential area, familial factors such as a
single-parent family and parental smoking status, and
community factors, such as peer smoking status, school
attachment and community cohesion, were risk factors
for smoking initiation in school children.
The reasons for adolescent smoking are complex and
multifaceted. However, researchers have been able to
detect general trends related to the commencement of
smoking in adolescence. In Tyas and Pedersons review
, age was associated with an increase in smoking
prevalence and initiation. Chen and colleagues reported
that the mean age of initiation of use any of tobacco,
alcohol, or illicit drugs was 16 to 18 years . We
observed a similar pattern, except for the decrease in
the 7th grade, which may have been a result of the
transition involved in attending a new school. In Taiwan, six
years of education was compulsory until 1968 after
which compulsory education was extended to 9 years.
All students attend elementary school for 6 years after
which they move to junior high school for the next 3
years. During the first year in a new school, students
might go through a period of adjustment. This is also
the time when students are entering adolescence and
when they begin to explore and experiment with new
things. Once they have adjusted to the new
environment, the students may begin experimenting. This
phenomenon could be the reason for a drop in
experimental smoking incidence in the 7th grade
Girls1 1.58 3.54 2.34 4.96 3.60
Figure 1 Incidence (1/100) of smoking in school children from 2002 to 2008. 1. Incidence rate (1/100)
followed by a sharp increase in the 8th grade. One of the
advantages of our study was the examination of changes
We plotted the mean scores of depression, family
support, family supervision, self-competence, and school
attachment (Figure 2). The time effect for each of these
repeated measurements was significant. From the plots,
we see that the depression score increased over time.
Family support dropped sharply between the 7th and 8th
grades, as did family supervision. The differences
between the self-competence and school attachment
scores of 7th and 8th graders were not as significant. We
speculate that family support or supervision played an
important role in the sharp increase in experimental
smoking. This is a difficult stage for families with
adolescents. On one hand, adolescents ask for
independence; on the other hand, they may not have good
selfcontrol or make good behavioral choices.
A gender difference was observed in this study.
Gender differences in adolescent smoking have been
discussed previously. Simons-Morton et al.  proposed an
independent association between smoking and peer
influence in boys and an association between smoking
and self-control problems in girls. Societal influences
are another possible contributing factor. Chinese culture
still believes that males should be strong and
adventurous, whereas female smoking is not socially acceptable.
Our results are consistent with other observations in
Family structure and socioeconomic factors both play
pivotal roles in the smoking status of adolescents. We
found that children from single-parent families
experimented with smoking earlier than their counterparts.
Lin et al. reported that parents marital status was
significantly associated with adolescent smoking behavior
in southern Taiwan . Griesbach et al.  found
that single-parent families and stepfamilies had a
higher probability of having smokers in the household,
and Covey and Tan  confirmed that two-parent
families were protective against adolescent smoking.
Painful disruptions to normal family life, such as
parental separation, can trigger depressive symptoms in
adolescents, leading to problem behaviors, such as
Table 2 Relative risks for smoking initiation in school children
We found that parental smoking was a risk factor for
smoking initiation in adolescents. Similar results were
reported from Hong Kong . There was also a
possible gradient effect: children who had two parents who
smoked were more likely to initiate smoking than were
those with only one parent who smoked. Parental
influence may play a role in adolescents preparatory period
during which their opinions and beliefs towards
smoking are formed. This period determines their
susceptibility to smoking, with non-susceptible defined as
strong negative intentions against future smoking and
susceptible defined as one or more questions without
strong negative intentions against future smoking .
Never-smokers who believed that their parents would
disapprove of their smoking in the future were less
susceptible to initiating smoking. Distefan and colleagues
 found that maternal smoking strongly encourages
the progression of both male and female experimenters
to become established smokers. These authors also
showed that parents may serve as an impediment to
adolescents choice of friends who smoke . This
result explains our findings of the effect of parental
smoking and lack of supervision on childrens
experimental smoking. However, a comparison of the
influence of fathers and mothers was not the focus of our
The influence of peers is one of the most
determinative factors in adolescents experimental smoking. A
similar factor was reported in a cross-sectional study in
southern Taiwan . We observed a gradient effect for
peer influences. Students with a few peers who smoked
were likely to experiment with smoking early but not as
early as students who had a majority of peers who
smoked (-0.78 vs. -1.35). All of these results reached
statistical significance. However, students who smoke may
over report the number of their smoking peers. In a
study of Chinese adolescents and their perceived
smoking norms, Chen et al. found that adolescent smokers
were inclined to overestimate the number of smokers
among their peers and surrounding adults . The
results found a positive association between perceived
smoking norms and an increased risk of smoking
Figure 2 Plots of (a) mean scores of depression; (b) mean scores of family support; (c) mean scores of family supervision; (d) mean
scores of self-competence; and (e) mean scores of school attachment over time. All values reached statistical significance at the 5% level
for testing time trend.
initiation, experimentation, and establishment. In
addition to educating youth about the negative
consequences of smoking, it has been suggested that future
anti-smoking health programs should be geared toward
teaching adolescents how to overcome peer pressure to
School is part of adolescents community. We found
that as students attachment to school increased, they
were less likely to start smoking. Adolescents spend
the majority of their time at school. In addition to
taking classes, adolescents develop relationships with their
classmates and establish peer groups that greatly
impact their decisions and beliefs. Many studies have
shown that students who excel and adhere to high
academic standards are less likely to engage in smoking
behaviors [6,23]. In addition to students attitudes
toward studying, the school atmosphere can influence
adolescent smoking status. Alexander et al. found an
increase in smoking rates among popular students in
schools with a higher smoking prevalence, whereas a
decrease in smoking rates was evident among popular
students in schools with a lower smoking prevalence
. We found that students with median community
attachment experimented with smoking earlier than
those with high attachment. However, students with
low attachment did not differ from those with high
attachment. It is likely that students who do not attach
to the community are less likely to be influenced by
the community. Further investigation on the quality of
the community would provide useful information to
explain these findings.
The main limitation of this study was that students
were recruited from only two areas in Taiwan.
Therefore, the results should be generalized with caution.
Nevertheless, we obtained results similar to other
studies, suggesting that the risk factors for experimental
smoking are universal. Our findings should be taken
into account when designing anti-smoking policies for
teenagers. Another limitation of this study was the use
of self-reported status. Our study was conducted in
schools, and it is possible that students did not respond
truthfully regarding their smoking behavior for fear of
being identified or punished. Many steps were taken to
ensure the students comfort and willingness to respond
truthfully. We stressed that their answers during the
survey would not be provided to school teachers, and
we sent our own interviewers to distribute and collect
the questionnaires to ensure that teachers would not
obtain the results.
This study used a cohort to examine the incidence and
multiple influences, including individual factors,
familial factors, and community factors, on experimental
smoking in adolescents. The findings presented in this
study are consistent with those of other studies,
particularly in terms of the association between the
influences of family and friends and school and
community attachment with experimental smoking in
teenagers. We found gradient effects for the influence of
parents and friends on the decision to experiment with
smoking. We observed a sharp increase in incidence
from 7th to 8th grades. Possible reasons were curiosity
on smoking and decreasing parental support and
Additional file 1: Appendix 1. Definition of explanatory variables.
Part of the study was sponsored by the National Health Research Institutes.
HYC constructed the study idea, wrote the manuscript, and revised it. WCW
analyzed the data and contributed intensive discussion on the study. CCW
collected, edited and managed the data. JYC reviewed the literature and
drafted part of the manuscript. BSH was responsible for the fieldwork and
contributed intensive discussion on the study. LLY designed and initiated
the CABLE study and contributed intensive discussion on the manuscript. All
authors read and approved the final manuscript.
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