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Introduction
According to reports from the World Health Organization (WHO), tobacco consumption is a world-class problem. The mortality associated with this product’s use is seven million people per year, of whom 86 % are direct consumers, and about 13 % are passive smokers. Although until a few years ago tobacco was only regularly consumed by adults, most consumers currently start smoking during their teenage years. Today, more than 150 million adolescents worldwide consume tobacco, and surprisingly, this number seems to be increasing in some countries despite countless public health interventions 1.
In fact, different authors have discussed this issue that does not distinguish between developed and developing countries 2-3.
Sinha et al. 4, through a study conducted in a group of people in the Southeast Asian region, reported that the prevalence of tobacco consumption in students aged 13-15 years ranges from 5.9 to 56.5 %. It is important to emphasize that the reported prevalence was higher in men than in women, and several other smoking products reported higher consumption than cigarrettes.
In the United States, the prevalence of tobacco consumption in adolescents ranges from 9 to 25 %. According to different reports, the most frequently used products are e-cigarettes (13.4 %), hookah (9.4 %), and cigarretes (9.2 %), with 40 % using more than one product 5-6.
In Colombia, a study conducted by Pardo et al. estimated the prevalence of smoking in adolescents in five major cities of the country (Bogotá, Bucaramanga, Cali, Manizales, and Valledupar). According to the results, the frequency of cigarette consumption ranged from 7.4 to 34.1 %, the risk of non-smokers starting smoking was between 12.3 and 32%, and the cities with greater smoking frequency were Manizales (68.8 %), Bogotá (57.1 %), and Cali (55 %) 7. Currently, according to data from the Colombian Ministry of Health and Social Protection, the prevalence of smoking is 26.8 % 8.
Regarding the starting age of consumption and the associated factors, several studies denote that adolescents begin experimenting with cigarettes and other tobacco products between the ages of 10 and 14. The usual risk factors are: being at least 13 years old, the academic level of the parents, having parents who are smokers and being exposed to advertising related to these products in different scenarios 9-13.
This research aimed to estimate the prevalence of smoking and the potential factors associated in teenage students in the city of Palmira in 2018. The need for this research arose from factors such as new social dynamics, the entry of new tobacco products into the Colombian market and the fact that teenage smoking is of public health interest, in addition to other contextual elements that were considered.
Methods
Design and Participants
A cross-sectional study was conducted with an analytical component, which included adolescents between the ages of 11 and 19, studying at six different schools in the city of Palmira, Colombia. The total student population for this age range at these six schools was 3566, from the sixth to the eleventh grade. To calculate our sample size, we considered how representative the results were, using a formula to estimate ratios with a correction factor, based on the following assumptions: a 95 % confidence level, 5 % permissible standard error, and a expected ratio of 17 %, with a n of 205 students. A stratified probabilistic sampling was conducted to select participants.
To collect the information, four previously trained people attended educational institutions for a month in the first semester of 2018. Then, they implemented the Global Youth Tobacco Survey, whose original questions were drafted as per the WHO and Unicef’s “Tobacco-Free” initiative, revised and adapted in Colombia in 2001 by the National Institute of Cancer Research 14. Before implementing the survey, the project was socialized and research was conducted regarding the willingness of each student to participate, which was expressed by both the students and their legal guardians.
This study considered sociodemographic variables, such as age, gender, academic degree, religion, and socioeconomic status and level, as well as the academic level of their parents. Variables related to tobacco consumption (cigarette, hookah, and e-cigarette), such as starting age of consumption, number of cigarettes smoked, place where products are obtained, and usual place of consumption. Social factors such as being in a relationship, possibility of accessing tobacco products, and having smoking parents or friends. Preventive and perception measures for the risk of consumption, such as the opinion expressed by their parents about the consumption of tobacco, perception of the difficulty of quitting, belief that smoking increases the circle of friends, exposure to tobacco advertising, and perception of its influence on the decision to smoke.
Statistical analysis
The data analysis was performed using the statistical package SPSS, version 24. Initially, an exploratory study of the variables was made to identify omitted and extreme values. The Kolmogorov Smirnov test, with Lilliefors correction, was used for standardizing the variables and determining the use of parametric or non-parametric tests. Quantitative variables were expressed through measures of central tendency with their corresponding measures of dispersion. Additionally, qualitative variables were described in frequency or percentages. To establish the raw association between independent variables and tobacco consumption, odd ratios were estimated with their corresponding 95 % confidence intervals (CI). Finally, a binary logistic regression was conducted with the “Wald Test,” using the variables that presented a statistical significance < 0.20 in the bivariate analysis.
Ethical aspects
The research followed the ethical guidelines of Resolution 8430 from the Ministry of Health of Colombia and the Declaration of Helsinki. The protocol had the ethical endorsement of the Santiago de Cali University, the authorization by the Ministry of Education of the city of Palmira, and the approval of the institutions involved. All participants filled out the informed consent or approval and their data was treated confidentially.
Results
In total, 205 teenage school students were assessed, of which 58 % were female, with an average age of 15 years (SD: +/− 1.8). The majority (60 %), at the time of the study, were between ninth and eleventh grades and their socioeconomic status was Level 2 (48 %). From a spiritual perspective, 34 % practiced a religion. As for the educational level of their parents, the most frequent was elementary school (46 % of mothers and 32 % of fathers) (Table 1).
Table 1 Sociodemographic characteristics of school adolescents in the city of Palmira in 2018
| No | % | ||
|---|---|---|---|
| Gender | |||
| Male | 118 | 58 | |
| Female | 87 | 42 | |
| Socioeconomic Level | |||
| 1 | 54 | 26 | |
| 2 | 99 | 48 | |
| 3 | 49 | 24 | |
| 4 | 3 | 2 | |
| Religious | |||
| Yes | 70 | 34 | |
| No | 135 | 66 | |
| School Grade | |||
| Sixth | 33 | 16 | |
| Seventh | 28 | 14 | |
| Eight | 22 | 10 | |
| Ninth | 34 | 17 | |
| Tenth | 45 | 22 | |
| Eleventh | 43 | 21 | |
| Mother’s Academic Level | |||
| None | 1 | 1 | |
| Does not answer | 23 | 11 | |
| Elementary school | 95 | 46 | |
| Secondary school | 53 | 26 | |
| Technical education | 15 | 7 | |
| Undergraduate | 17 | 8 | |
| Graduate | 1 | 1 | |
| Father’s Academic Level | |||
| None | 24 | 12 | |
| Does not answer | 50 | 24 | |
| Elementary school | 40 | 20 | |
| Secondary school | 65 | 32 | |
| Technical education | 11 | 5 | |
| Undergraduate | 15 | 7 | |
| Graduate | 0 | 0 | |
Source: Own elaboration.
Regarding the smoking habit, it was found that the total prevalence of smoking was 38.5 %. The most used product was the e-cigarette (20 %), followed by conventional cigarettes (18.5 %) and hookahs (17.1 %) (Figure 1). After analyzing tobacco consumption by gender, it was observed that this is higher in women (47 %) than in men (32 %).
Source: Own elaboration.
Figure 1 Prevalence of tobacco product consumption in schooled adolescents in the city of Palmira in 2018
When considering the consumption characteristics of each smoking product, it was observed that the average starting age for cigarette consumption was 13 years (SD: +/− 5.5). Majrity of the smoking adolescents (55 %) smoke an average of nine cigarettes (SD: +/6), to a greater extent, 1-3 days a month. Regarding e-cigarettes, women consume it more frequently (80 %), and the starting trend for consumption is 15 years, similar to what happens with the hookah. Generally, the use of tobacco products in this age range occurs in public places or where they normally meet with their closest circle of friends (37 and 23 %, respectively).
After estimating the raw odd ratio of the sociodemographic, family, and social variables, it was found that those associated with smoking were female (0R = 1.88 95 % CI: 1.06-3.32 P = 0.03), from low socioeconomic level (0R = 2.72 95 % CI: 1.32-5.6 P = 0.008), with a partner who consumes tobacco (0R = 2.51 95 % CI: 1.36-4.63 P = 0.003), with the possibility of buying individual cigarettes (0R = 2.86 95 % CI: 1.58-5.1 P = 0.000), with smoking friends (0R = 6.96 95 % CI: 3.69-13.12 P = 0.00), and with a belief that it is difficult to quit once you start (0R = 2.36 IC 95 %: 1.30-4.28 P = 0.006). Conversely, the protective factors identified were being a man, belonging to a high socioeconomic level, and believing that tobacco-related advertising may affect their decision to smoke (Table 2).
Table 2 Smoking and sociodemographic, family, and risk perception variables in schooled adolescents in the city of Palmira in 2018
| OR | 95 % CI | P | |||
|---|---|---|---|---|---|
| LCL | UCL | ||||
| Gender | |||||
| Female | 1.88 | 1.06 | 3.32 | 0.03 | |
| Age | |||||
| 11-15 Years | 1.18 | 0.60 | 2.05 | 0.06 | |
| School Grade | |||||
| 9-11 | 1.19 | 0.67 | 2.11 | 0.66 | |
| Religious | |||||
| No | 1.75 | 0.95 | 3.2 | 0.07 | |
| Socioeconomic Level | |||||
| 1-2 | 2.72 | 1.32 | 5.6 | 0.008 | |
| Education Level | |||||
| Mother | 1.62 | 0.73 | 3.60 | 0.23 | |
| Father | 0.54 | 0.21 | 1.36 | 0.19 | |
| Social, Family Factors, and Risk Perception | |||||
| Boyfriend or girlfriend smokes | 2.51 | 1.36 | 4.63 | 0.003 | |
| Possibility of buying individual cigarettes | 2.86 | 1.58 | 5.1 | 0.007 | |
| Friends that smoke | 6.96 | 3.69 | 13.12 | 0.000 | |
| Friends offering cigarette | 7.1 | 2.27 | 22.4 | 0.000 | |
| Family perception of consuming tobacco | 0.44 | 0.19 | 1.01 | 0.08 | |
| Believing that it is difficult to quit once you start | 2.36 | 1.30 | 4.28 | 0.006 | |
| Believe that women who smoke have more friends | 0.23 | 0.10 | 0.53 | 0.001 | |
| Believe that men who smoke have more friends | 1.02 | 0.57 | 1.83 | 0.95 | |
| He/she believes that tobacco advertising can influence his/her decision to consume it | 0.52 | 0.29 | 0.93 | 0.02 | |
UCL: upper confidence limit; LCL: lower confidence limit.
Source: Own elaboration.
Finally, the logistic regression model that best fits X2 is presented as follows: 58.57 P = 0.000. The variables independently associated with smoking are age (between 11 and 15 years. OR: 3.17 95 % CI: 1.48-6.79 P = 0.003), being in a relationship with someone who smokes (OR: 3.09 95 % CI: 1.48-6.4 P = 0.003), the possibility of buying individual cigarettes (OR: 2.60 95 % CI: 1.26-5.3 P = 0.01), and being surrounded by smoking friends (OR: 7.0 95 % CI: 3.4-14.5 P = 0.000) (Table 3).
Table 3 Regression model of the variables associated with tobacco consumption in schooled adolescents from official institutions in Palmira, Valle, in 2018
| P | OR | 95 % CI | ||
|---|---|---|---|---|
| LCL | UCL | |||
| Age | 0.003 | 3.1 | 1.48 | 6.79 |
| Boyfriend or girlfriend smokes | 0.003 | 3.0 | 1.48 | 6.46 |
| Possibility of buying individual cigarettes | 0.010 | 2.6 | 1.26 | 5.39 |
| Friends smoke | 0.000 | 7.0 | 3.44 | 14.55 |
Source: Own elaboration.
Discussion
The consumption of smoking products continues being a public health issue from which adolescents are not exempt. In this study, a global prevalence of tobacco consumption of 38.5 %, 95 % CI (31.6-45.4 %) was found; the most commonly used products are e-cigarettes (20 %, 95 % CI; 14.2-25.7 %) andconventional cigarettes (18.5 %, 95 % CI (14.2-25.7 %). The aforementioned information is interesting considering that the common use of these products is associated with the onset of chronic diseases and constitutes a main cause of premature death 15.
The behavior found is closely related to what was reported in the study by Mohammed et al., wherein a group of 695 Saudi adolescents between 11 and 16 years reported a prevalence of 39.6 %, but it is far from the consumption frequency of smoking products reported in Latin American countries and cities such as Mexico that identified a prevalence of 24 %; Brazil (20.9 %); Argentina (22 %); Paraguay (12.9 %); and Venezuela (9.4 %) in teens 3,16-18.
In Colombia, according to the data from the Ministry of Health and Social Protection gathered in main cities, the frequency of tobacco consumption is 28.6 %, with a higher prevalence in men (28.8 %) than in women (24.6 %), and a greater frequency in students from public educational institutions than private (27.8 and 20.4 %, respectively). When performing the analysis by city, Barranquilla (20.8 %) showed the lowest prevalence, while Medellín reported the highest (28.3 %). Both results are far from the numbers reported in this research 8.
The frequency of e-cigarette consumption reported in this study proves an increased tendency in the use of these devices. This behavior happens because the product has been presented as a less harmful alternative than the conventional cigarette and, in some cases, harmless 19-20. In accordance with the above, a study conducted in Canada with 1188 subjects between 16 and 30 years revealed that 16.1 % had tried the e-cigarette 21. In contrast, in countries such as the United States, in recent years, the consumption of e-cigarettes has increased from 2 % in 2011 to 11 % in 2015, even more frequently than conventional cigarettes in adolescents 22.
E-cigarette is the most common of the electronic nicotine release system devices; it produces aerosols and its use is called “vaping.” The expelled vapor is not harmless to health because it uses high amounts of propylene glycol or glycerol, heats a solution at 250 degrees Celsius in refillable cartridges, and contains varying concentrations of nicotine between 0 and 24 milligrams. Besides, the actual nicotine contents of the cartridges do not usually match with those presented in the containers 23.
The nicotine levels that these cigarettes release can be higher than therapeutic nicotine, so they can generate addiction and withdrawal symptoms by reducing their use, in addition to high levels of cotinine (nicotine metabolite) similar to cigarrette smoking (60.6 + or − 34.3 versus 61.3 + or − 36.6 mg/ml) 24. Additionally, these devices have various flavors to attract the general population: sweet flavors contain diacetyl (flavor authorized for intake, not for inhalation), a substance that when inhaled becomes a risk factor of getting bronchitis obliterans 25.
E-cigarette is offered as a less harmful product than the conventional cigarette, which helps delay the decision to smoke 26; however, the aerosol it produces comes with potentially harmful components, which contain toxic, carcinogenic compounds, and heavy metals such as chromium, lead, and nickel (the latter, higher than in conventional cigarettes) 27. Among the health effects linked to e-cigarettes, the following stand out: explosion and burns, mainly in hands and face; an 18 % increase in airway resistance and a significant decrease in the nitric oxide exhaled fraction, which is observed in diseases such as inflammation of the airways, infectious and lipoid pneumonia, irritation of the pharynx and mouth, dry cough, disorientation, and heart failure. Vaping has the potential to modify the genetic expression of cells of the bronchial epithelium, which represents a risk of malignant transformation 28-31.
Regarding the starting age of cigarette consumption, the data show that this is decreasing. In this research, an average of 13 years was found, which matches the average age reported for Colombia by the Ministry of Health and Social Protection, through the Overview of school health in Colombia report 8. These results are also similar to those reported by Cisneros et al. 32, which identify 14 as the starting age for Mexican teens.
Regarding gender, women presented a higher incidence than men, a different result from those presented in other studies as the habit has been traditionally associated with men 33-34. Changes in social dynamics can explain this result, because women have had the opportunity to adopt behaviors and practices that were previously exclusive to men.
Tobacco consumption is associated with various family and social factors, and this study highlights independent factors, such as having a partner with a smoking habit, possibility of buying individual cigarettes, and being surrounded by friends that smoke. The factors described here have been reported by studies such as that of Morello et al., which found that using tobacco is associated with having friends who regularly consume these products (OR 12.6 95 % CI 7.8-20, 5) 35. By contrast, a study conducted in Cuba showed that having family members who are consumers (72 %), teachers who smoke (44 %), and having a partner who smokes (38 %) are among the most usual motivations for consuming tobacco 36.
From the independent factors related to tobacco consumption in this research, it is important to emphasize the ability of buying individual cigarettes-an aspect that, combined with the usual place of consumption (public places), is quite surprising owing to the multiple efforts made by Colombian government entities to restrict the sale of these products to minors and discourage their consumption. A clear example of this are the regulations that widely forbid the sale of tobacco products to minors, the tobacco consumption ban in public places, the rise in prices of these products, and the regulation of the sale per unit 37.
Protective factors were identified such as being of a high socioeconomic level and the perception that tobacco-related advertising may have an influence on their decisions to use it.
Regarding the study limitations, it is important to mention that only adolescents enrolled in official schools were included in the research, which may limit the ability to extrapolate the data to their peers with different characteristics.
The findings of this research are extremely important, given that they report an increase in the smoking habit frequency in adolescents and the new contribution of e-cigarettes in normal consumption. Moreover, they reflect clear changes in the consumption pattern described recently, such as a higher consumption frequency in women, which require strengthening prevention strategies and regulations regarding the sale of devices such as e-cigarettes.
The data found not only invite educational and government institutions to strengthen strategies aimed at reducing tobacco consumption in adolescents but also invite parents to inform their children about the effects of tobacco consumption, because this event is socially transmitted.
Conclusions
Tobacco consumption is a recurring problem in teenage school students. The overall prevalence found is higher than previously reported, and the most frequently used product is the e-cigarette. It was observed that women had a higher consumption prevalence, a fact that shows that consumption patterns of these products have changed along with role women play in society.
