Background Tobacco marketing is a contributing factor to adolescent smoking, and now targeting adolescents in low- and middle-income countries. Especially, promotional items with tobacco brand logos have a great impact on adolescent smoking.
Objective The authors evaluated whether receptivity to tobacco marketing is associated with susceptibility to smoking among non-smoking male students in Lao PDR.
Methods The authors conducted a cross-sectional study with self-administered questionnaires among 526 non-smoking male students in grades 8th and 11th (aged 12–19 years) in Vientiane Capital, Lao PDR. The authors investigated receptivity to tobacco marketing by three measurements: awareness of tobacco marketing, recognition of tobacco marketing messages and owning/being willing to use promotional items. The authors then conducted multiple logistic regression analysis to determine whether marketing receptivity had an independent association with smoking susceptibility, which is defined as the absence of a firm decision not to smoke.
Results About 20% of the participants were susceptible to smoking. Recognition of marketing messages was significantly associated with susceptibility to smoking (OR=1.76, 95% CI 1.01 to 3.08), as was any owning/being willing to use promotional items with recognition of marketing messages (OR=2.39, 95% CI 1.34 to 4.24). In contrast, any owning/being willing to use promotional items without any recognition of marketing messages was not significantly associated with susceptibility.
Conclusions A significant association was detected between smoking susceptibility and marketing receptivity, which has been little explored in previous research in low-income countries. Owning/being willing to use promotional items was associated with smoking susceptibility only when there is also recognition of marketing messages.
- Advertising and promotion
- low-/middle-income countries
- social marketing
- public policy
- global health
- harm reduction
- primary healthcare
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- Advertising and promotion
- low-/middle-income countries
- social marketing
- public policy
- global health
- harm reduction
- primary healthcare
Since the 1990s, the criticism of tobacco marketing as a contributing factor to adolescent smoking has been intense.1 Adolescence is the time of smoking onset and the beginning of regular use2; the adolescent period is the most crucial time for implementing effective strategies to prevent adult smoking. Adolescents' future smoking behaviour has been predicted by their exposure to tobacco marketing, which includes advertising, promotion and sponsorships.3
In particular, adolescents in low- and middle-income countries are aggressively targeted by tobacco marketing; four of five teenagers living in these countries report that they have recently seen pro-tobacco advertising.4 This suggests that evidence from low- and middle-income countries is required to understand the impact of tobacco marketing on adolescent smoking and to combat the global tobacco epidemic in those settings, perhaps especially in Asia, which the tobacco industry regards as an important market.5
Lao People's Democratic Republic (Lao PDR), a lower-middle-income economy in Southeast Asia, has one of the highest prevalence of tobacco use in the region. The prevalence of current smoking among adults in 2003 was 40.3% (67.7% among men and 16.0% among women) (Lao Health Survey).6 As for adolescents, the prevalence of current smoking in four major provinces in 2007 was 5.0% among boys and 1.1% among girls (Global Youth Tobacco Survey, GYTS).7 Although the smoking prevalence among Lao adolescents is lower than that in neighbouring countries,8 19.6% of boys and 5.8% of girls reported being susceptible to smoking (GYTS),9 which predicts future smoking among adolescents.10 Existing data therefore suggest the probability that a certain number of Lao adolescents, especially boys, will start to smoke in the near future. Moreover, providing functional items embellished with the company logo is an alternative means of tobacco marketing at retail shops in many low- and middle-income countries, including Lao PDR, where direct advertising is prohibited.11 In Lao PDR, an official Notice from the Prime Minister's Office has banned all direct tobacco advertising such as billboards since 1994. However, various forms of tobacco marketing still exist especially at point-of-sale (POS), such as the display of tobacco products, posting calendars with the photographs of beauty contest winners and providing gifts with purchase of cigarettes.11 ,12 However, little is known about how adolescents recognise and respond to tobacco marketing in these countries.
In this study, we aimed at examining the relationship between receptivity to tobacco marketing in Lao PDR and smoking susceptibility among male students. Among several exposure measurements such as awareness of tobacco marketing, receptivity to tobacco marketing and frequency of visiting retail shops,13 ,14 we used the receptivity measurement which shows a robust effect on adolescent smoking.15 It was developed based on the theoretical framework of persuasive communication, which has three components: exposure to the message, attention to the message and cognitive responses to the message.16 Adolescents who own or are willing to use tobacco promotional items are defined as the highest level of receptivity to tobacco marketing and are more likely to transit towards smoking and even to be established smokers.17 ,18 The objective of this study was to examine an association between receptivity to tobacco marketing and susceptibility to smoking among male students who had never previously tried smoking in Vientiane Capital, Lao PDR.
Study site and participants
We conducted a cross-sectional study in Vientiane Capital, a city with a population of approximately 700 000, in May 2010. The sampling procedure described below is summarised in figure 1. First, four of nine districts were randomly selected. Second, three lower (6th–9th grade) out of seven on average and three upper (10th–12th grade) out of four on average public secondary schools were randomly selected in each district. Then, two classes out of three on average for each 8th grade and two classes out of five on average for each 11th grade were randomly selected. Finally, all the male students in selected 48 classes were recruited. We excluded female students because of the relatively low prevalence of smoking among them.7 In total, 902 male students in public secondary schools were selected. Of the 902 male students selected, 42 were absent on the day of data collection and two did not bring informed consent forms signed by a parent (858, 95.1%). Then, eight students were excluded because they were older than 19 years, and 102 students because they did not answer one or more questions measuring variables to be included in the multiple logistic regression analysis (748, 82.9%). Finally, the analysis sample excluded 222 students who had smoked at least a few puffs. In total, we included 526 (58.3%) non-smoking male students in the analysis.
This study was approved by the ethical committee of the University of Tokyo, Japan, and by the National Ethics Committee for Health Research, Ministry of Health, Lao PDR. Based on two discussion groups to understand the students' receptivity to tobacco marketing, we initially developed the self-administered survey questionnaire in English and translated it into Laotian. We modified it based on back translation and comments from public health and education experts in Lao PDR. Finally, we conducted a pilot study and revised it accordingly. The parents of the recruited students had the opportunity to refuse their child's participation; if they agreed, they returned a signed informed consent form by the day of data collection. Students also had the opportunity to refuse or to discontinue participation at any time. To ensure confidentiality, the questionnaire was completed anonymously.
We measured smoking status with the following two questions: (1) ‘Have you ever tried cigarette smoking, even a few puffs?’ and (2) ‘During the past 30 days, on how many days did you smoke cigarettes?’ Students who answered ‘yes’ to the first question were regarded as ever smoked and excluded from the analysis. Among these students, those who answered anything other than ‘0 days’ were considered current smokers for the purpose of calculating school-level peer smoking. We assessed susceptibility to smoking by asking students the following three questions: (1) ‘Do you think you will be smoking cigarettes soon?’ (2) ‘If one of your best friends offered you a cigarette, would you smoke it?’ and (3) ‘At any time in the next 12 months, do you think you will smoke a cigarette?’10 Each of the three questions was rated on a 4-point scale ranging from ‘yes, definitely’ to ‘definitely no.’ Students who answered ‘definitely no’ to all three questions were considered non-susceptible; all other students were considered susceptible. Susceptibility to smoking was defined as the absence of a firm decision not to smoke, and this measurement has been validated in previous longitudinal study.10
We modified the measurement of receptivity to tobacco marketing from that used in a previous study,13 a four-category measure comprised of three components: owning or being willing to use promotional items, having a favourite advertisement and naming an advertised cigarette brand. The latter two components were asked by open-ended questions. In our pretest using their measurement, however, we found that it is difficult to get the answer for open-ended questions among Lao male students. Therefore, we modified it following the three components based on persuasive communication theory: awareness of tobacco marketing, recognition of pro-tobacco messages and cognitive responses to tobacco marketing. Cognitive response was measured as owning or being willing to use promotional items. The composition of the three components described below is summarised in table 1.
First, we measured the awareness of tobacco marketing in three dimensions: advertisements, promotions and sponsorships. For this, we asked 12 questions regarding the frequency with which students had seen or heard tobacco marketing in various types of media and locations. For awareness of advertisements, we asked six questions regarding whether they had seen or heard advertisements in the following six media: television, radio, billboards, newspapers or magazines, the internet and advertisements at POS. For awareness of promotions, we asked three questions regarding whether they had seen any of the following: a smoking scene on TV/videos/movies, promotional items and tobacco pack displays at POS. We also asked two questions regarding the frequency of visits to retail shops and minimarts, as these shops are often replete with pro-smoking messages in Lao PDR.11 For awareness of sponsorships, we asked one question regarding whether they had seen tobacco advertisements at sports events/fairs/concerts/community events sponsored by tobacco companies. Any positive response to the above 12 questions was taken as a positive indication of awareness of tobacco marketing.
Second, to measure recognition, which refers to understanding the messages communicated by tobacco marketing, we asked participants whether they had seen any of a list of nine messages such as ‘smoking is enjoyable’ (‘yes’ or ‘no’). One message in this list from a previous study19 was modified to alternative message ‘smoking make people more powerful’ based on the discussion groups we conducted prior to the main survey. Any affirmative response was taken as a positive indication of recognition of pro-tobacco messages.
Finally, to measure cognitive response, we asked two questions to assess students' owning or being willing to use promotional items: how many items they own that have a tobacco company name or logo on it and whether they would ever use or wear something that has a tobacco company name or logo on it, such as a lighter, T-shirt or hat. Any positive response to the above two questions was taken as a positive indication of owning or being willing to use promotional items.
We combined all three components into a single variable, receptivity to tobacco marketing, with five categories (levels): No awareness = no positive response to awareness of tobacco marketing (minimum level); Awareness = positive response only to awareness of tobacco marketing without the other two components (low level); Recognition = positive response to recognition of pro-tobacco messages without owning/being willing to use promotional items (middle level); Owning/being willing without recognition = positive response to owning or being willing to use promotional items without recognition of pro-tobacco messages (same as low level); Owning/being willing with recognition = positive responses to both recognition of pro-tobacco messages and owning or being willing to use promotional items (high level). Because only eight participants (1.5% of the final sample) indicated No awareness, we excluded the category of No awareness from the subsequent analyses and results.
For owning or being willing to use promotional items to be viewed as a high level receptivity, it should be developed after recognising the pro-tobacco messages communicated by tobacco marketing (middle level receptivity). Therefore, we divided the Owning/being willing variable in two, depending on the recognition of pro-tobacco messages.
We assessed perceived parental disapproval of smoking, and the smoking of close friends, parents and older siblings. School-level peer smoking was assessed by calculating the proportion of current smokers at a given school by using the two smoking status questions among the 748 eligible students. A current smoker was defined as a student who had smoked at least one cigarette during the past 30 days prior to the survey.20 We divided the school-level proportion of current smokers into three equal ranges: low, middle and high level of peer smoking.
To determine the relationship between receptivity to tobacco marketing and susceptibility to smoking, bivariate regression analyses were conducted to assess unadjusted associations. After controlling for confounding factors (age, ethnicity, perceived academic performance, parental education level, perceived parental disapproval of smoking, the smoking of close friends, the smoking of parents, the smoking of older siblings and school-level peer smoking), we conducted multiple logistic regression analysis with awareness as the reference category to determine whether receptivity to tobacco marketing was independently associated with susceptibility to smoking. We tested our data for multicollinearity and found no evidence of it (variance inflation factor=1.10). All the statistical analyses were conducted using Stata /SE V.11 (StataCorp LP).
As for socio-demographic characteristics and social influences regarding smoking (table 2), the mean age of the participants was 15.3 (SD 1.64) years (data omitted from table 2), and 96.2% were members of the lowland Lao ethnic group. The school-level proportion of current smokers among the 748 eligible students ranged from 0.0% to 41.9% and was categorised into three levels with three equal ranges: low level (0%–14.9%), middle level (15%–29.9%) and high level (30%–45.0%). About 20% (109) of the participants were susceptible to smoking.
As for the distribution of the three components of receptivity to tobacco marketing (table 1), almost all (98.5%) of the 526 participants were aware of any tobacco marketing. One-third (34.2%) of the participants had perceived at least one tobacco marketing message, and over one-third (41.1%) indicated that they had received or would ever use promotional items.
As for the distribution of the four categories of receptivity to tobacco marketing (table 1), the proportion of those reporting awareness of tobacco marketing without any recognition of pro-tobacco messages nor owning or being willing to use promotional items (Awareness) was highest (40.5%) and that of owning or being willing to use promotional items without any recognition of pro-tobacco messages (Owning/being willing without recognition) was second highest (24.9%).
Association between predictors and susceptibility to smoking
We observed a significant relationship between receptivity to tobacco marketing and susceptibility to smoking even after controlling for possible confounders: socio-demographic characteristics and social influences (table 3). Participants who recognised pro-tobacco messages were 1.76 (95% CI 1.01 to 3.08) times as likely to be susceptible to smoke compared with those who were only aware of tobacco marketing. Moreover, participants who owned or were willing to use promotional items with recognition of pro-tobacco messages were 2.39 (95% CI 1.34 to 4.24) times as likely to be susceptible to smoke compared with those who were only aware of tobacco marketing. In contrast, owning or being willing to use promotional items without recognition of pro-tobacco messages was not significantly associated with susceptibility to smoking. Participants with strong perceived parental disapproval of their smoking were more likely to be susceptible to smoking compared with those who expected more adverse reactions from their parents (OR=1.88, 95% CI 1.19 to 2.95).
Our results provide evidence for an association between receptivity to tobacco marketing and higher risk for future smoking initiation among non-smoking male students in Lao PDR. Previous researches have already reported a significant association between receptivity to tobacco marketing with owning or being willing to use promotional items as the highest level in the receptivity index and future progression to smoking.13 ,18 Our findings suggest that focusing only on the restriction of promotional items is neither sufficient nor efficient, and the comprehensive ban of tobacco marketing to discourage recognition of pro-tobacco messages is strongly needed to reducing susceptibility to smoking among male students.
While students who owned or were willing to use promotional items with recognition of pro-tobacco messages were more than twice as likely to be susceptible to future smoking initiation, those who did not recognise any pro-tobacco messages were not likely to be susceptible to smoke even if they owned or were willing to use promotional items. One possible explanation for is that they might readily use a product provided free of charge regardless of which company's logo adorns it. Students who reported that they owned or were willing to use promotional items without any recognition of marketing messages might not have developed any cognitive responses to tobacco marketing. They were not paying attention to tobacco marketing or cigarette behaviour, even if they were attracted to the promotional items themselves.
Our findings also suggest that owning or being willing to use promotional items might enhance the association between recognition of marketing messages and susceptibility to smoking. As promotional items allow adolescents to ‘try on’ the smoker identity, these items might lead them to be more susceptible to subsequent smoking behaviours.21
In addition to the significant association of receptivity to tobacco marketing with susceptibility, our study indicates the importance of smoking prevention among Lao male students. One-fifth of non-smoking male students in this study reported susceptibility to smoking, a prevalence consistent with previous research in Lao PDR.9 As susceptibility to smoking is the first step in the process of smoking uptake, preventing non-susceptible adolescents from becoming susceptible is essential to reducing smoking prevalence. Moreover, nearly all the participants were aware of some form of tobacco marketing, which implies that tobacco marketing are widely recognised by male students in Lao PDR despite of an official Notice from the Prime Minister's Office, which bans all direct tobacco-related advertising since 1994.11
The results of multiple logistic regression analysis showed that perceived strong parental disapproval of smoking was significantly associated with reduced smoking susceptibility, whereas parental smoking was not associated with it. Previous studies have consistently shown that the effect of parental disapproval of smoking is stronger and more robust than the effect of parental smoking.22
Surprisingly, friends' smoking was not related to susceptibility in our study, despite its identification as one of the strongest predictors of adolescent smoking susceptibility and initiation in many countries, including in Asia.9 One possible explanation for this finding is the difference in the measurements of friends' smoking. In this study, we asked smoking behaviour of their close friends, whereas other study has defined friends broadly without limiting the frame of reference to close friends.17 Exploring smoking behaviour among broader peer networks might uncover a different finding.
The study has several limitations. First, as this is a cross-sectional study, a causal relationship cannot be demonstrated, and the possibility of the reverse association, with more susceptible students being more aware of and more easily involved in tobacco marketing, cannot be excluded. Second, the association between receptivity to tobacco marketing and susceptibility to smoking could have been underestimated as the study participants were non-smoking students and susceptibility measures lack of a firm commitment not to smoke. Finally, the generalisability of our findings is restricted because our sample included only urban male students who are attending public schools. As the gross enrolment rate among male adolescents is 82.5% in Vientiane lower secondary schools and 52.7% in upper secondary schools,23 our participants, especially the 11th graders, might not be representative of urban male adolescents.
Despite these limitations, our findings are unique and important for the following two reasons. First, they show a significant association between smoking susceptibility and marketing receptivity, which has been little explored in previous research in low-income countries. Second, they demonstrate that owning/being willing to use promotional items is associated with smoking susceptibility only when there is also recognition. Preventing exposure by banning all formed of tobacco marketing in order to discourage message recognition might be a key to preventing the onset of adolescent smoking in Lao PDR. In 2009, Lao PDR has enacted a Tobacco Control Law that includes comprehensive tobacco marketing bans. Our findings strongly support the Lao government's actions to prohibit tobacco marketing in the interests of the prevention of student smoking. In addition, training and practice of resistance skills to media influences as one component of comprehensive tobacco use prevention programme would also be effective to preventing the adolescents smoking.
What this study adds
This study found an association between receptivity to tobacco marketing and susceptibility to smoking among male students in Lao PDR where such evidence is quite limited.
Focusing only on the restriction of promotional items is neither sufficient nor efficient, and the comprehensive ban of tobacco marketing to discourage recognition of pro-tobacco messages is strongly needed to reducing susceptibility to smoking among male students.
The authors thank school directors, teachers, students who voluntarily participated in this study and their parents for their contributions. Without support from Ministry of Education, Lao PDR, and the Vientiane Provincial Department of Education, the study might not have been possible.
Funding This study was funded by the Ministry of Health, Labor and Welfare of Japan (Kosei Kagaku Research Grant, International Cooperation Research Grant 21S3). The study sponsor did not have any specific role in any procedure of this study.
Competing interests None.
Patient consent We obtained consent forms with signatures from all the participants' guardians. The consent form was developed based on the format of the ethical committee in the University of Tokyo, Japan.
Ethics approval This study was approved by the ethical committee of the University of Tokyo, Japan and by the National Ethics Committee for Health Research, Ministry of Health, Lao PDR.
Provenance and peer review Not commissioned; externally peer reviewed.
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