Utility of the theory of reasoned action and theory of planned behavior for predicting Chinese adolescent smoking
Introduction
China is the largest cigarette manufacturer in the world, producing approximately 35 million cartons of cigarettes annually (Zhang & Cai, 2003). In 2003, 4.07 million households in 23 provinces engaged in tobacco planting, 0.2 million Chinese people worked for tobacco industry, and 3 million tobacco retailers sold cigarettes. Overall, the tobacco industry accounted for 7.38% of the Chinese national revenue in 2003 (Liu & Xiong, 2004).
Cigarette consumption has been tremendous as well in China. A population survey conducted in 30 provinces of China in 1996 among urban and rural residents aged 15–69 years old revealed that 63% of Chinese males and 3.8% of Chinese females were current smokers, accounting for one third of smokers worldwide (Yang et al., 1999). The prevalence rate of smoking increased 3.4 percentage points from 1984 to 1996 (Yang et al., 1999). The number of smokers increased 30 million from 320 million in 1996 to 350 million in 2002 (Yang, Ma, Liu, & Zhou, 2005). Chinese smokers consumed an average of 14.8 cigarettes per day in 2002(Yang et al., 2005), a substantial increase from 10 cigarettes per day in 1990 and only one cigarette per day in 1952 (Zhang & Cai, 2003). The high smoking rates have caused about 51.9% of Chinese non-smokers to be exposed to secondhand smoke at least 1 day per week and about 15 min per day at home, public places, workplaces, and other settings (Yang et al., 2005).
It is well known that smoking can give rise to adverse health consequences. Over 1 million Chinese people die each year from various smoking related disorders (Zhang & Cai, 2003). Diseases attributed to smoking include chronic obstructive pulmonary disease, lung cancer, esophageal cancer, stomach cancer, liver cancer, tuberculosis, stroke, and ischemic heart disease, which caused 0.6 million deaths in 1990 (Liu et al., 1998). If the current smoking trends continue, it is estimated that 3 million Chinese will die from smoking related diseases in 2050 (Zhang & Cai, 2003).
Smoking prevalence among adolescents is also increasing in China. About 9 million Chinese adolescents aged 15–19 years old were ever smokers in 1996, accounting for 18% of all males and 0.28% of all females (Zhang & Cai, 2003). National surveys conducted in 1984, 1996, and 2002 indicate that smoking prevalence among adolescents in China has increased substantially in recent years (Yang et al., 1999, Yang et al., 2005). If current trends continue, it is estimated that 100 million men now less than 30 years old will die from smoking related diseases (Zhang & Cai, 2003).
Smoking prevention and cessation programs have been implemented by the Chinese government and public health agencies from central to local levels (Jiang, 2005). Achievements were significant and the increase in smoking prevalence rates appeared to be slowing among both men and women (Yang et al., 2005). However, the number of smokers was still increasing. 74% of the current smokers did not plan to quit (Yang et al., 2005). More unfortunate is that, while the overall prevalence rate of smoking has declined slightly from 1996 to 2002, the prevalence of smoking among both male and female adolescents continues to increase (Yang et al., 2005). Therefore, it is important to develop and implement cost-effective smoking prevention programs for adolescents in China. To achieve this goal, it is necessary to identify the most significant determinants that lead to adolescent smoking.
Numerous risk and protective factors influence adolescent smoking, including intrapersonal, interpersonal, social, cultural, and environmental characteristics (Tyas & Pederson, 1998). In China, rapid changes have occurred in the social and built environment with the development of economy and policy, which might have impacted people's lifestyle including smoking behaviors. Whether or not and to what extent and in which pathway cognitive factors attribute to the initiation of adolescent smoking are not well known. It is necessary to investigate this to develop more effective smoking prevention programs. The Theory of Reasoned Action and the Theory of Planned Behavior are useful for this purpose.
The Theory of Reasoned Action (TRA), developed by Fishbein and Ajzen (Ajzen and Fishbein, 1980, Fishbein and Ajzen, 1975), addresses the impacts of cognitive components, such as attitudes, social norms, and intentions, on behaviors. According to this theory, individuals' attitudes toward a certain behavior and norms representing their perception of other people's view of such behavior will determine their behavioral intentions, which may further lead to performance of the behavior.
Since behaviors that are not fully volitional are also influenced by the individual's perception of his or her ability to perform the behavior, Ajzen (1985) extended TRA by adding perceived behavioral control as an additional predictor of behavioral intentions. A new theory named the Theory of Planned Behavior (TPB) was thus developed (Ajzen, 1985).
The TRA and TPB have been applied to numerous behaviors including diet (Arvola, Lahteenmaki, & Tuorila, 1999), physical activity (Blue, Wilbur, & Marston-Scott, 2001), safer sex (Bowen, Williams, McCoy, & McCoy, 2001), smoking (Bursey & Craig, 2000), and other behaviors (Hillhouse et al., 2000, McKinlay et al., 2001, Millstein, 1996, Syrjala et al., 2002). These theories have been used to investigate, explain, or predict behaviors in various age groups, including adolescents (Berg, Jonsson, & Conner, 2000), college students (Garcia and Mann, 2003, Rise et al., 2003), and adults (Bogers, Brug, Van Assema, & Dagnelie, 2004). Several studies have used the TRA and TPB to predict smoking behaviors among adolescents. For example, Harakeh used TPB to investigate whether parenting factors and parental smoking could predict the onset of smoking (Harakeh, Scholte, Vermulst, de Vries, & Engels, 2004); Hanson (1999) used TPB to identify beliefs related to smoking behaviors among African American, Puerto Rican, and non-Hispanic White female adolescents; O'Callaghan tested the effectiveness of various theories including TRA and TPB on predicting smoking among high school students (O'Callaghan, Callan, & Baglioni, 1999); and Maassen used TPB to examine the determinants of smoking among Gambian youths aged 14–18 years (Maassen, Kremers, Mudde, & Joof, 2004). Although the TRA and TPB have been used to predict adolescent smoking in the United States and other Western cultures, their applicability to Chinese adolescents who live in a different cultural and economic environment is unknown. Hu used TPB to predict the intentions to quit smoking across workplaces in southern Taiwan (Hu & Lanese, 1998). However, this study did not include adolescents. The present study was conducted to determine whether TRA and TPB could be used to predict smoking among adolescents in the Mainland of China, the country with the largest number of smokers worldwide.
Other than its main effect in TPB, perceived behavioral control's moderation effect was also tested in TRA. Overall, three models were tested and compared in this study: model 1 (TRA), model 2 (TPB, in which perceived behavioral control was a predictor of smoking intention), and model 3 (extended TRA, in which perceived behavioral control was a moderator in TRA). These models are presented in Fig. 1. We hypothesized that TRA and TPB were applicable to predict smoking among Chinese adolescents, and that one model might be superior to the others.
Section snippets
Methods
These data are part of the China Seven Cities Study (CSCS), a larger project in China to assess the effects of changing economic and social factors on health behaviors including tobacco use. The information will be used to develop community based smoking and other drug abuse prevention programs. The CSCS includes seven cities in four regions of China: Northeastern (Harbin, Shenyang), central (Wuhan), southwestern (Chengdu, Kunming), and coastal (Hangzhou, Qingdao).
Demographic characteristics and smoking variables
The demographic characteristics and smoking variables of the sample were reported in Table 1. The sample contained slightly more girls than boys (51.37% versus 48.63%). An overwhelming majority was Han nationality, accounting for 95.73% of the entire sample, with no gender differences (95.92% of females versus 95.54% of males, p = 0.27). The mean age was 14.96 years old (SD = 1.68), but the age distributions were different among girls and boys (p < 0.0001) with more girls at the ages of 12 or
Discussion
Cognitive factors have been associated with smoking in both developed and developing countries. A cross-sectional pilot study conducted in the same China seven cities has found that psychological intent to exhibit autonomy, to regulate mood, to control weight, and to make friends have been reasons for adolescents to smoke(Weiss, Spruijt-Metz, Palmer, Chou, & Johnson, 2006). This ongoing longitudinal study provides more opportunities to investigate whether and how and to what extent more
Acknowledgments
This research was supported by the University of Southern California Transdisciplinary Tobacco Use Research Center (TTURC), funded by the National Institutes of Health (grant #1 P50 CA84735-01), and the Sidney R. Garfield Endowment. The authors thank the China Seven Cities Study (CSCS) directors and project staff at the Centers for Disease Control and Prevention in the cities of Chengdu, Hangzhou, Harbin, Qingdao, Shenyang, and Wuhan and the Institute for Health Education in Kunming, People's
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