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Susceptibility to smoking among South East Asian youth: a multilevel analysis
  1. G E Guindon1,2,
  2. K Georgiades3,4,
  3. M H Boyle3,4
  1. 1
    Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
  2. 2
    Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
  3. 3
    Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada
  4. 4
    Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
  1. G Emmanuel Guindon, Centre for Health Economics and Policy Analysis, Health Sciences Centre 3H1, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada L8N 3Z5; guindoge{at}


Objective: To estimate the extent to which susceptibility to smoking is associated with between-context differences (schools and classes) and to identify factors at school, class and individual levels that influence individual susceptibility to smoking among young never-smokers in South East Asia.

Methods: Cross-sectional data from the Global Youth Tobacco Survey conducted in Cambodia (2002), Laos (2003) and Vietnam (2003) are used to conduct multilevel analyses that account for the nesting of students in classes and classes in schools. The outcome variable is smoking susceptibility, defined as the absence of a firm decision not to smoke. Explanatory variables include school-level (current tobacco use prevalence in school, exposure to anti-smoking media messages and exposure to tobacco billboard advertising), class-level (classroom prevention) and individual-level influences (parents’ and friends’ smoking behaviour, knowledge of the harmful effects of and exposure to secondhand smoke at home, age, sex and pocket income).

Results: Multilevel analyses indicate that 4.5 and 4.2 of the variation in smoking susceptibility is associated with school and class differences, respectively. Students who have parents or friends who smoke, who are exposed to secondhand smoke at home and those who have access to pocket income are found to be more susceptible while greater knowledge of the harmful effects of secondhand smoke appears to diminish susceptibility to smoking. For girls only, billboard tobacco advertising increases the risk of susceptibility and classroom prevention decreases risk while for boys only, attendance at schools with higher prevalence of tobacco use increases risk of susceptibility and anti-smoking media messages decreases risk.

Conclusions: This study highlights a number of modifiable factors associated with smoking susceptibility and identifies interactions between teen sex and several factors associated with the susceptibility to smoking. This finding provides support for the call to move beyond gender-blind tobacco control policies.

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  • Funding: GEG is supported by a Social Sciences and Humanities Research Council of Canada (SSHRC) Canada Graduate Scholarship (CGS). During this study, GEG was supported by an Ashley Studentships for Research in Tobacco Control, Ontario Tobacco Research Unit and KG was supported by a SSHRC post-doctoral fellowship award. MHB is supported by a Canada Research Chair in the Social Determinants of Child Health.

  • Competing interests: GEG is a former employee of the World Health Organization—Tobacco Free Initiative whose objective is to reduce the global burden of disease and death caused by tobacco.

  • i Note that the survey conducted in Cambodia uses a different methodology (for example, definition of smokers) from that of Laos and Vietnam. Such differences undermine the comparability of the studies.

  • ii The smoking continuum was defined as: never smoker; puffer; non-recent experimenter; recent experimenter; former established; current established.

  • iii The question reads: During the past 30 days (one month), how many advertisements for cigarettes have you seen on billboards? [A lot; A few; None.]

  • iv The question reads: During this school year, were you taught in any of your classes about the dangers of smoking? [Yes; No; Not sure.]

  • v Note that the category 11 years includes people under the age of 11 and the category 17 years includes people older than 17 years. Given that so few observations fall into these categories, we are confident the outcome will not be affected in a meaningful way.

  • vi Formula and Formula where ϕ02   school-level intercept variance and τ02   class-level intercept variance.

  • vii “High” and “low” refer to values occurring in schools with, respectively, the top 15, and the bottom 15, of the school-dependent effect.

  • viii This finding is only true when the relation between susceptibility and anti-smoking messages is not allowed to vary across sex (that is, no contextual interaction between sex and anti-smoking messages).