Factors associated with the intention to continue using tobacco among adolescents: A secondary analysis of the 2015 Global Youth Tobacco Survey in the Philippines

INTRODUCTION Smoking produces significant health problems affecting millions of people globally. It is the largest single cause of preventable deaths. This study aims to describe the characteristics of Filipino adolescent smokers aged 13–15 years and determine the factors associated with the intention to continue to use tobacco in the next 12 months among current smokers. METHODS This was a secondary analysis of the 2015 Global Youth Tobacco Survey (GYTS) in the Philippines to determine the association of the following factors with the intention to continue to use tobacco in the next 12 months among current smokers: 1) exposure to anti-tobacco media messages, 2) exposure to health warnings on cigarette packages, and 3) being taught about the dangers of tobacco in any class. RESULTS The adjusted odds of continuing to use of any form of tobacco in the next 12 months was higher (AOR=1.24; 95% CI: 0.62–2.49) among those who have not seen health warnings on cigarette packages and higher (AOR=1.32; 95% CI: 0.71–2.45) when not taught about tobacco in any of their classes. Finally, those who have not seen or heard antitobacco messages on television, radio, internet, billboards, posters, newspapers, magazines, or movies, were more likely (AOR=2.19; 95% CI: 1.14–4.21) to report their intention to continue to use tobacco. CONCLUSIONS Understanding the relationship of different tobacco control strategies to adolescents’ intention to continue using tobacco can contribute to the improvement of tobacco policies and programs and achieve effective tobacco control among the youth. A targeted anti-tobacco campaign in both traditional and new media should be considered an essential part of a comprehensive tobacco control program. Health warnings on cigarette packs should be supported by a policy banning the sale of single stick cigarettes. INTRODUCTION Tobacco use is one of the biggest public health threats globally and the most significant single cause of preventable deaths. Globally, it kills more than seven million a year, with more than six million of those deaths attributable to direct tobacco use. Around 80% of smokers worldwide live in lowand middle-income countries such as the Philippines1. Smoking, especially during adolescence, produces significant health problems, including respiratory illnesses, cancer, and cardiovascular disease2. To address the growing tobacco epidemic, the Philippines started implementing tobacco control measures as early as 1987. Several tobacco control policies were enacted to: 1) increase tobacco taxes, 2) ban tobacco advertising or promotion, 3) designate smoke-free places, and 4) ban the sale of tobacco products to minors3. Despite these actions, 47.5% of Filipino students aged 13–15 years were not prevented from buying cigarettes despite their age, while only 67.1% were taught in school about the dangers of tobacco use4. Moreover, there were significant decreases in the prevalence of Filipino youth who saw anti-tobacco messages in the media (from 89.4% in 2011 to 71.6% in 2015) and at sports or community events (from 88.8% in 2011 to 53.2% in 2015)4. In 2015, 14.5% of Filipino students were current tobacco smokers (smoked tobacco anytime during the past 30 Research Paper| Population Medicine Popul. Med. 2021;3(November):30 https://doi.org/10.18332/popmed/143526 2 days), while 12% were current cigarette smokers (smoked cigarettes anytime during the past 30 days)4. Current cigarette smoking among Filipino youth showed a declining trend from the year 20004. However, a 34.8% increase in current cigarette smoking was observed between 2011 and 20154. The latest Global Youth Tobacco Survey (GYTS) shows that one in ten students are current smokers and 0.7% have smoked cigarettes on 20 or more days in the past 30 days4. It is crucial to look at adolescents’ intention to continue to use tobacco, which can predict behavior. According to the Theory of Planned Behavior, a behavior is a result of the intention to do the behavior and the perceived control over it. Behavioral intentions are often influenced by the attitude towards the behavior, the subjective evaluation of the results of the behavior, and the perceived control over the behavior. While the relationship between intention and behavior is not always perfect, the intention is often used as a proxy for actual behavior. Given inadequate information, young people often underestimate the risk of becoming addicted to smoking due to nicotine, which relates to underestimating future costs and consequences5. This myopic view on the ills of tobacco use and the external costs imposed on others, which result in premature death and illness, justifies government intervention through strategies including regulation, taxation, and information dissemination. Hence, to reduce the prevalence of current tobacco use among the youth by 2% per year, the Philippines has to devise or reinvent its tobacco control and prevention strategies for the youth4. This study aims to look at three of the most common methods of message delivery and their relationship to adolescent smokers’ intention to continue using tobacco. Specifically, this study aimed to describe the characteristics of Filipino adolescent smokers aged 13–15 years and determine the association of the following factors with the intention to continue to use tobacco in the next 12 months among current smokers: 1) exposure to anti-tobacco media messages, 2) exposure to health warnings on cigarette packages, and 3) being taught about the dangers of tobacco in any class. METHODS Data source This study was a secondary dataset analysis of the 2015 Global Youth Tobacco Survey in the Philippines, which was administered from January to March 20154. The GYTS was developed by the Tobacco Free Initiative (TFI), United States Centers for Disease Control and Prevention (US CDC), and World Health Organization (WHO) in collaboration with representatives from the six WHO regions6. The GYTS is a school-based survey designed to monitor tobacco use among the youth and guide tobacco control program implementation and evaluation6. The GYTS is a school-based survey that utilized a twostage cluster sample design that produced representative samples of students in year levels that were associated with ages 13–15 years4,6. It uses a self-administered questionnaire to evaluate trends in tobacco use among adolescents and to guide the implementation and evaluation of tobacco prevention and control programs for the Filipino youth6. The Philippines has conducted five rounds of the GYTS since 2000. The Philippine version of the GYTS is a nationally representative survey of students aged 13–15 years and is regularly used to generate data that are comparable to other countries4. It utilizes a global standard to systematically monitor tobacco control indicators that include: data on the prevalence of cigarette and other tobacco use, exposure to secondhand smoke, accessibility and availability of tobacco products, the influence of media and advertising on the use of cigarettes, susceptibility, smoking cessation, and knowledge and attitudes towards tobacco use and policies4. Definition of variables Current cigarette smoking Two questions were used to define current cigarette smoking: 1) ‘Have you ever tried or experimented with cigarette smoking, even one or two puffs?’ with response ‘yes’ or ‘no’; and 2) ‘During the past 30 days (one month), on how many days did you smoke cigarettes?’ where answers were dichotomized (‘1’ for those reporting 0 days in the past 30 days, and ‘2’ for those reporting ≥1 day in the past 30 days). Participants who have answered ‘yes’ in the first question and reported at least 1 day of cigarette use in the past 30 days were considered current cigarette smokers. Intention to continue using tobacco in the next 12 months Participants were asked to indicate their future intention to continue using any form of tobacco with four response options: ‘definitely not’, ‘probably not’, ‘probably yes’, and ‘definitely yes’. For this study, the answers were dichotomized into ‘yes’ (combined ‘probably yes’ and ‘definitely yes’) and ‘no’ (combined ‘probably not’ and ‘definitely not’). Exposure to anti-tobacco media messages Participants were asked to indicate whether they have or have not seen or heard any anti-tobacco media messages on television, radio, internet, billboards, posters, newspapers, magazines, or movies during the past 30 days. Exposure to health warnings on cigarette packages Participants were asked whether they have or have not seen any health warnings on cigarette packages during the past 30 days using the following options: ‘Yes but I didn’t think much of them’, and ‘Yes, and they led me to think about quitting smoking or not starting’. The answers were dichotomized into ‘yes’ and ‘no’. Taught the dangers of tobacco use Participants were asked whether they have or have not Research Paper| Population Medicine Popul. Med. 2021;3(November):30 https://doi.org/10.18332/popmed/143526 3 been taught about the dangers of tobacco use in any of their classes in the past 12 months with the options: ‘yes’, ‘no’, and ‘do not know’. Only participants who answered ‘yes’ or ‘no’ were included in the analysis. Statistical analysis Descriptive statistics were used to identify the demographic characteristics of the participants. Crude and adjusted logistic regression analyses were performed to examine the association between independent variables and intention to continue using tobacco products among current smokers. In the logistic regression analyses, odds ratios and confidence intervals were calculated. The logistic regression models were adjusted for the effects of covariates such as age, sex, and type of school. All analyses were conducted using JASP version 0.14.1, which was released on 17 December 2020. JASP is a free and open-source program for statistical analysis. The statistical software offers standard analysis procedures in c