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Asia-Pacific Journal of Public HealthXX(X) 1 –15

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430341 APHXXX10.1177/1010539511430341Turkson et al.Asia-Pacific Journal of Public Health

1Huazhong University of Science and Technology, Wuhan, China2Tongji Medical College, Wuhan, China

Corresponding Author:Anthony J. Turkson, PhD, School of Mathematics and Statistics, Huazhong University of Science and Technology, 430074 Wuhan, China Email: [email protected]

Salient Latent Constructs Underlying Smoking Initiation and Continuous Use by Student-Smokers of Huazhong University of Science and Technology, China

Anthony J. Turkson, PhD1, Xiang J. Wang, PhD1, and Freeman F. K. Gobah, MSc2

Abstract

The factor analysis model was used to parsimoniously reduce the number of variables that influence smoking among students to salient factors that cut across continents, race, and socio-cultural settings among university students in China. Stratified random sampling and snowball techniques were employed to obtain the sample. A Likert-type questionnaire was used to col-lect data. The results revealed that of the 39 variables identified to influence smoking, 34 were retained and regrouped in terms of common features they share into 13 salient factors that accounted for 58% of variances in the original variables. The predominant hidden construct was influence by association. The other 12 factors were labeled and ordered as follows: emotional needs, family history, addiction, peer pressure, lack of full realization of the consequences of their action as regards the expense of smoking, social needs, advertisement, psychologi-cal needs, self-image, environmental factors, ineffective policies, and underestimation of health risks. Irrespective of regional demarcations, factors that influence smoking initiation and con-tinuous use are same.

Keywords

smoking, cigarette, youth, factor analysis

IntroductionCigarette smoking causes 87% of lung cancer deaths.1 The consumption of tobacco has reached the proportion of a global epidemic and will keep increasing due to the expansion of the world’s

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2 Asia-Pacific Journal of Public Health XX(X)

population.2 For centuries the act of smoking has become the object of extensive research,3 and the vast expanse of knowledge on smoking necessitates the use of innovative frameworks and models to achieve a very comprehensive and coherent perspective about the smoking lifestyles of students from all over the world and at all levels of education. Human beings have a long period of infant and child development that allows them to adapt and acquire coping skills that help them survive in their environment; due to the increasingly complex nature of society, the early socialization process needs to build capacities for communication, learning, and making decisions for healthy behaviors.3

The underlying causes of smoking are complex and deep rooted; therefore, research on it must expand beyond the boundaries of theoretical concepts to include methods that could unearth the latent constructs associated with each observed variable perceived to influence smoking. Recent literature on smoking usually identifies important factors that either promote or reduce the prevalence of smoking among the youth; we do not intend to do the same. We purport to subject the many identified variables to factor analysis with the view of reducing the many variables to a significant few that have the property of accounting for almost all the variances in the original variables. We note that some of the identified variables pertain to one set of youth located in one region whereas other set of variables pertain to another category of youth located in another region. Applying the principles of factor analysis unearths the hidden constructs that cut across continents, religion, culture, social status, and age, thus making it possible for researchers and health policy makers to base their decisions on the parsimonious results that have the tendency to affect all people irrespective of race or sociocultural settings. In the study, we sought answers to 2 main research questions: first, how many factors could explain the interrelationships among the 39 latent constructs that are perceived to influence smoking initiation and continuous use; second, how could these few factors be interpreted in a subject matter terms to give meaning and direction to the aim of the study?

Recent Literature on SmokingTwo requirements are necessary for someone to smoke: being able to acquire cigarettes and hav-ing a setting suitable to lighting up. Peer groups create an important source and setting for the uptake and maintenance of smoking—friends and relatives supply cigarettes to begin smoking; commercial outlets then become the main source to continuing smoking. It has been noted that irrespective of recent legislations in Norway and Taiwan to prevent the sale of tobacco to minors, young people do not have difficulty obtaining tobacco4,5; moreover, increased media exposure on cigarettes is associated with increased risk of smoking.6 Studies have also shown that tobacco companies promote physical availability of tobacco products to geographic areas with disadvan-tageous socioeconomic status; low-income and lower-middle-income countries are acutely vul-nerable to exploitation by the tobacco industry as they often lack the resources and capacity to implement protective tobacco control policies.7,8 Notwithstanding the ratification of the World Health Organization (WHO) framework convention on tobacco control, the percentage of stu-dents in Columbia who reported seeing pro-cigarette advertisements on billboards and newspa-pers or magazines increased significantly between 2001 and 2007.9 The acceptability of smoking by young people is further enhanced by role models in the movie industry and celebrities who are seen smoking.3 In another study, it was revealed that young people who reported home environ-ments that were characterized by difficulty communicating with parents, lack of parental care, low levels of trust, and an unhappy home life resorted to lifestyles that included smoking.

In another study conducted in 3 large areas among Pacific youths (N = 5659) living in Tonga, Vanuatu, and Pohnpei in the Federated States of Micronesia, the investigators examined the



Turkson et al. 3

association between nonsmoking and positive emotions; across all these areas, it was found that being confident and being happy were significantly associated with nonsmoking.3,10 In the National Health Statistics report in the United States, factors that contributed to the risk of youth smoking were identified, which included low prices of cigarette, peer pressure, easy access to tobacco products, and tobacco industry advertisement and promotion; it was also revealed that retail cigarette marketing increases the likelihood that the youth would start smoking. The report concluded that cigarette pricing strategies contributed to increases all along the smoking con-tinuum, from initiation to experimentation to regular smoking, and that the promotion of ciga-rettes increased the likelihood that the youth will move from experimentation to regular daily smoking.11

Other risk factors associated with youth smoking have also been identified: having lower self-image than peers, perception that tobacco smoking was normal or acceptable, and parental smok-ing4,12; other predictors of young people’s current and established smoking habits include exposure to environmental tobacco smoke at home or in cars, exposure to pro-tobacco messages, perceived benefits of smoking, and perceived peer acceptance of smoking.13 In addition to the aforementioned factors, opportunity to smoke, emotional stress, and influence from friends were also identified as factors contributing toward youth’s engagement in smoking.14 In a related study, 40% of young people in Fiji, Ghana, Malawi, Nigeria, South Africa, Sri Lanka, and Zimbabwe have the notion that males who smoke have more friends than those who do not smoke2; it has been revealed that students attending schools at mountainous areas have a greater likelihood of smoking than students attending city schools.15 Other related studies revealed the following: more males than females smoke, those whose mothers are smokers smoke more than those whose mothers are nonsmokers, those whose friends are smokers smoke more than those whose friends are nonsmokers, poor achievers in schools smoke more than high achievers, and students who were trying to lose weight have higher odds of current cigarette use than students who are not trying to lose weight.16,17

It was established through an empirical study that well-controlled evidence-based school interventions have failed to show positive long-term effects on cessation of smoking by students; moreover, school-based education programs alone have been shown to be ineffective in promot-ing smoking cessation.18,19 It has also been established that dramatic events such as the diagnosis of serious smoke-related diseases in close relatives could act as a catalyst to behavior change leading to an increased willingness of current smokers to participate in smoking cessation programs.20

China committed itself to implementing a thorough smoke-free environment within 5 years when it signed on the WHO framework convention on tobacco in 2006; the 5 years is up and the pledge is still hanging on the balance. It was noted by a social commentator that “in China, plans turn to reality in a short time only if the government is determined to do it, but now the problem is we are not sure whether the government has decided.”21 It has been noted that funding of school tobacco programs has a positive influence on tobacco instructional activities that are aimed at encouraging smoking cessation; according to the study, this feat could be achieved through teacher training, student cessation support, interest in tobacco use prevention education, involvement of school staff, family involvement, and use of evidenced-based programs.22

It is a long-standing assertion that tobacco use is a health hazard on the part of the users and nonusers alike; research has shown that its continued use is attributed to lack of knowledge.23 An empirical study on 356 freshmen categorized as ever-smokers and nonsmokers of Tokyo Metropolitan University to determine their knowledge, attitude, and practice of smoking ciga-rette revealed that there were significant differences between the 2 categories in terms of health and smoking, smoking perception, and knowledge on the economic impact of tobacco.24




Smoking and chewing of tobacco cause serious diseases such as cancer of the lungs, pharynx, and esophagus. Additionally, smoking causes coronary diseases, high blood pressure, stroke, and ulcer of the stomach. A woman who uses tobacco frequently may become sterile.25 The nicotine present in tobacco products give a temporary feeling of well-being and facilitates memory reten-tion; therefore, users readily get addicted to it.

Research has shown that the joint probability of trying smoking, becoming addicted, and dying prematurely was higher than that of any other addiction26; moreover, young people who smoke have reduced capacity to implement practices that promote advancement at home and school.3 It has further been noted that tobacco kills more than AIDS, legal drugs, illegal drugs, road accidents, murder, and suicide combined.2

MethodsThe target population was all university students who smoke, both foreigners and Chinese nationals, in Huazhong University of Science and Technology (HUST), China. The minimum age of respondents in the study was 18years, whereas the maximum age was 39 years. The approximate number of students within the university was 50 000, with 1272 foreign students. The university is situated near the West Lake and covers an area of more than 1152 acres; because of its green surroundings, the university has been referred to as the “university in the forest.”

Altogether there are 56 apartments on the main campus of the university for student accom-modation; 4 of these apartments house mainly Chinese postgraduate students, while 4 apart-ments house all foreign nationals. These apartments are located in 5 districts within the main campus, north, south, east, west, and central. A combination of methods was used to select the required sample size. Two apartments were selected where foreign students reside, 2 apartments where Chinese postgraduate students reside, and 25 apartments where undergraduate students reside; a random sampling technique was used to select the apartments. After selecting the 29 apartments randomly, we adopted the technique of snowballing to get the required sample size, which we pegged at 1200 students. Due to the nature of the data we collected and the method we adopted, a period of nearly 2 months was used to get all the sampling units; once a sampling unit had been included in the sample, their particulars were noted to avoid double sampling.

To obtain the subjects of interest, that is, students who smoke, we used the snowballing method; we first moved to the selected apartments, one apartment at a time and looked for our initial contacts that fell within the interest group. The initial contacts were asked to refer to us more students who fit into the study selection criteria; once this was done and their contact infor-mation provided, they were also contacted. In some cases, we were physically led to their rooms. The same cycle was repeated with the new contacts, and we continued from one apartment to another until the targeted sample size of 1200 was obtained. To each student we administered a structured questionnaire. The questionnaire had both the Chinese and English versions to facili-tate understanding for those whose official language was either, respectively, Chinese or English. The questionnaire contained 39-variable closed-type declarative statements that was designed using the 5-point Likert-type scale.27 The students were asked to indicate to what extent they agree or disagree with each statement; 5-point options were provided, “Strongly agree,” “Agree,” “Undecided,” “Disagree,” and “Strongly disagree.”

The Likert-type questionnaire was used because it is an uncomplicated technique for measur-ing attitudes for persuasive research. For the positive statements, a score of 5 was given to the students who strongly agreed to the statements, a score of 4 to those who agreed, 3 to those who were undecided, 2 to students who disagreed, and 1 to those who strongly disagreed; for the nega-tive statements, the scoring was done in the reverse order—strongly agree was scored as 1 while



Turkson et al. 5

strongly disagree was scored as 5. The questionnaire sought information from the subjects from 2 basic areas: personal information and hidden constructs that were perceived to have influence on student smoking initiation and continuous use. In determining whether the factor analysis model was appropriate to carry out this study, we considered correlation matrix, Bartlett’s test of sphericity, and the Kaiser–Mayer–Oklin (KMO) value of sampling adequacy.

Personal Information• Age• Gender• Number of years student has been smoking• Main reason for smoking initiation• Continent from which student comes from

Perceived Hidden Constructs Influencing Smoking Initiation and Current UseVariable set 1—Social influences

• Time with friends outside school hours• Social groups• Perceived peer acceptance of smoking• Influence by peers to start smoking• Smoking as means of socialization in cultural settings

Variable set 2—Self-image

• Redeem low self-image• Promote belongingness• Help concentrate on studies• To feel secure

Variable set 3—Psychological needs

• To overcome boredom• To overcome loneliness• To overcome stress• To overcome shyness• For fun• Good for relaxation• Makes me feel comfortable• Gives me appetite for food• Taste is good

Variable set 4—Home environment

• Lack of parental care• Unhappy home life• Financial status of parent• Broken home




• Parent involved in smoking• Neighbors involved in smoking• Religious policy• School policy effectiveness• School location

Variable set 5—Perception

• Price of cigarette inexpensive• Widespread visibility of smoking• Overestimation of prevalence of smoking• Underestimation of health hazards• Availability of cigarette in community• Smoking by role models in movies• Promotion of cigarette by industries

Variable set 6—Addiction

• Difficult to stop• Addicted to it• Several attempts yielded no results• Smoking has become part of me• Lack of knowledge on how to stop

In line with the purpose of the study, the coded variables (see Supplementary Table) were keyed into SPSS release 17 and analyzed using the factor analysis model. The reliability test in SPSS was also invoked.

Review of Statistical MethodsPrinciples underlying factor analysis models. Let be a p-variable random

vector. Then the model for the variables is formulated as follows:

where pij ( ) are the factor loading, (m < p) are the factors,

and are the error or uniqueness factors.Factor analysis is a multivariate technique that attempts to account for the correlation pattern

present in the distribution of an observable random vector in terms of a minimal number of unob-servable random variables, called factors. The aim of factor analysis is the orderly simplification of a large number of intercorrelated measures to a few representative constructs or factors.28 The size of the factor loadings helps us in the interpretation of the factors; variables with large load-ings indicate that they are representative of the factors, whereas small loadings mean they are not. The larger the absolute size of the loading, the more significant the loading is in interpreting the principal component structure.29 These guidelines are considered useful when the sample size is greater than or equal to 50. Loadings of at least .45 as a cutoff point are appropriate.30 It will

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Turkson et al. 7

be ideal to have at least 100 cases for factor analysis.29 It is not the overall sample size that is important but the ratio of sampling units to variables. A ratio of 10:1 and a ratio of 4:1 are recom-mended. Two tests can be performed to check multivariate normality and sampling adequacy: the KMO test and the Bartlett test of sphericity.29,30 The KMO test looks at the degree of overlap among the variables. For the variables to have appreciable degree of overlap, KMO ≥ .6. The Bartlett test, on the other hand, is a measure of the multivariate normality of the set of distribu-tions. It also tests the linearity in the data set by checking whether the correlation matrix is an identity matrix or not. A significance value less than .05 indicates that the data set fails to pro-duce an identity matrix and therefore acceptable for carrying out factor analysis.

ResultsThe minimum age of the participants in this study was 18 years, 23.3% of the students were within the age range 15 to 19 years, and 50.7% were in the age range 20 to 24 years; altogether 74% of the students were between the ages of 15 to 24 years (see Table 1). Physical observation of the correlation matrix revealed that there were some appreciable degree of correlation between the 39 variables and that the matrix was not an identity matrix. Bartlett’s test of spheric-ity, which tested the hypothesis that the correlation matrix was an identity matrix, yielded a value of 8261.234 and an associated level of significance of P < .050; thus, the hypothesis that the correlation matrix is an identity matrix is rejected. The KMO value was .669, and according to Kaiser, this value is meritorious; therefore, there is enough evidence that the factor analysis model could be used in the study. The ratio of the subjects to the number of variables we used was close to 30:1, which far exceeds the recommended ratios of 4:1 and 10:1.

The eigenvalue greater than 1 criteria was invoked to select only variables whose variances were at least 1.00; we also retained factors whose observed variable loadings were at least .45. The retained variables were interpreted in terms of common features that they share with each other; moreover, to enhance the interpretation of the variables, we subjected the initial loadings to varimax rotation. We note from Table 2 that out of the 39 original variables used in the study, 34 were retained and regrouped under 13 main factors according to characteristics that they share with each other. These 13 factors, herein called latent constructs, could account for 58% of the total variance among all 39 variables. The first factor, titled “Influence by Association,” accounted for 6.14% of the variance. The second factor, “Emotional Needs,” accounted for 6.12% of the variance; the third factor, “Family Smoking History,” accounted for 5.85% of the variance, and the fourth factor, “Addiction,” accounted for 5.67% of the variance. The fifth

Table 1. Demographic and Social Characteristics

Count Percentage Count Percentage

Age (Years) (Years) 15-19 280 23.3 0-4 809 67.4 20-24 608 50.7 5-9 335 27.9 25-29 226 18.8 10-14 35 2.9 30-34 77 6.4 15-19 21 1.8 35-39 9 0.8 Gender Region Male 1032 86 Africa 320 26.7 Female 168 14 Asia 725 60.4 Others 155 12.9




Table 2. Results of Factor Analysis Using the Principal Component Extraction Methoda

Factor 1: Influence by association (6.14) Factor 5: Influence from peers (5.18) Just for fun 0.709 Spending time with friends 0.619 Mates smoke 0.698 Influenced by friends 0.860 Sense of belongingness 0.734 Peers accept smoking as cool 0.843Factor 2: Emotional needs (6.12) Factor 6: Lack of full realization (5.14) Overcome loneliness 0.555 Price inexpensive 0.593 Overcome shyness 0.651 Increase appetite for food 0.574 Overcome boredom 0.749 Lack of health education 0.586 Enhance relaxation 0.675 Underestimates health hazard 0.666Factor 3: Family history (5.85) Several attempts failed 0.627 Go out with friends 0.759 Factor 7: Social needs (4.20) Addicted to it 0.525 Socially deprived 0.806 Family member smokes 0.608 Broken home 0.754 Means of socializing 0.764 Factor 8: Advertisement (3.68)Factor 4: Addiction (5.67) Advertisement 0.718 Become part of me 0.745 Availability of cigarette 0.707 Unhappy home life 0.670 Factor 9: Psychological needs (3.42) Difficult to stop 0.702 Concentrate on studies 0.767Factor 10: Self image (3.27) Comfortable 0.528 Enjoy the taste 0.579 Factor 12: Ineffective policies (3.02) Redeem self-image 0.610 School policy not effective 0.735Factor 11: Environmental factor (3.22) Role models influence 0.476 Location of school 0.719 Factor 13: Underestimates risk (3.02) Not dangerous to health 0.812

aBold phrases represent labeled factors; under each factor are the variables sharing similar latent characteristics. Enclosed in parentheses of the labeled factors is the percentage of variance explained. Placed before each variable is the factor loading, the higher the loading the better.

factor, “Influence From Peers,” accounted for 5.18% of the variance; the sixth factor, “Lack of Full Realization of the Consequences of Their Action as Regards the Expense of Smoking,” accounted for 5.14%; the seventh factor, “Social Needs,” accounted for 4.20%; the eighth factor, “Advertisement,” accounted for 3.68%; the ninth factor, “Psychological Needs,” accounted for 3.42%; the 10th factor, “Self-Image,” accounted for 3.27%; the 11th factor, “Environmental Factors,” accounted for 3.22%; the 12th factor, “Ineffective Policies,” accounted for 3.02%; and the 13th factor, “Underrating of Health Risks,” accounted for 3.02% of the variance in the 39 variables.

From Figures 1 and 2, the 3 topmost reasons toward smoking initiation, distributed across the regions, are as follows: Africa—peer pressure (count = 81; 25.5%), curiosity (45; 4.2%), and to overcome stress (33; 10.4%); Asia—peer (171; 24.3%), curiosity (95; 13.5%), and fun (69; 9.8%); other region—peer (33; 18.5%), curiosity (20; 11.2%), everyone does and to overcome stress (18, 10.1%). Overall reasons: peer (285; 23.8%), curiosity (160; 13.3%), and fun (111; 9.3%). From Figure 3, we note that the majority of the students from Africa (236; 74.2%), Asia (487; 69.2%), and other regions (86; 48.3%) have smoked for between 0 and 4 years. Altogether, 809 (67.4%) have smoked for between 0 and 4 years, 335 (27.9%) have smoked for between 5 and 9 years, and 56 (4.7%) have smoked for at least 10 years. From Table 1, we note that from Africa, the number of students who smoke in the age bracket 15 to 19 years is in the majority (139; 43.7%), followed by those aged 29 to 24 years (125; 39.5%). In Asia, the number in the age



Turkson et al. 9

Figure 1. Pie chart displaying main reasons toward smoking initiation of university students of HUST, China “Other reasons” included its attractiveness, to ward off people, to feel high, and to maintain a slim posture.

Figure 2. Comparative bar chart showing reasons for smoking initiation among university students of HUST, China, distributed by the region from which students come from “Other countries” include Mexico, Ecuador, Turkey, the United States, Bolivia, Brazil, Canada, Russia, Merida-Venezuela, and Albania.




bracket 20 to 24 years (433; 60.1%) is in the majority, followed by those aged 20 to 29 years (154; 21.9%). In the “Other region,” the number of student smokers in each of the respective age brackets, 20 to 24, 25 to 29, and 15 to 19 years, are 60 (33.7%), 44 (24.7%), and 54 (30.3%), respectively. Altogether (when all the regions are put together), the age distributions are as fol-lows: 15 to 19 years (280; 23.3%), 20 to 24years (608; 50.75%), and 25 to 29 years (226; 18.8%). The study captured 1032 (86%) male students and 168 (14%) female students who smoke.

Internal ConsistencyA reliability test was conducted to access the internal consistency among the 39 variables. Cronbach’s α was .67, which indicates that there was a high degree of internal consistency in the data used for the analysis.

LimitationsThe snowball method we used to collect the sample was nonrandom; we were introduced to only students who were known by their colleagues as smokers, and those who were not part of this clique were possibly left out, which may have introduced into the study some errors associated with nonrandom sampling. Moreover, the results would have been further enhanced if the sample size was increased. Needless to say, the internal consistency of the data overrides the identified limitations.

DiscussionThe minimum age for the student-smoker in this study was 18 years, 23.3% of the students were within the age bracket 15 to 19 years, and 50.7% were within the age bracket 20 to 24 years;

Figure 3. Comparative bar chart of length of time university student-smoker has continued smoking by region



Turkson et al. 11

altogether, 74% of the student-smokers were between the ages of 15 to 24 years. The majority (95.3%) had smoked for between 0 and 9 years. By the principle of location, most of the students started smoking at the age of 15 years

the figure confirming earlier statistics that 90% of the youth start smoking before they turn 18 years; it also confirms that most of the students experienced their first taste of cigarette while at the high school. The result also showed that majority the (86%) of the students captured in the study were males, whereas 14% were females. This figure confirms the findings of Seo et al13 that more males than females smoke. There is a call for concern for this revelation: what is the driving force behind many males resorting to smoking than their female counterparts. Could it be attributed to the aggressiveness and assertiveness of males; one school of thought has it that females are more concerned with human health and safety than their male counterparts, and other schools of thought say that males are likely to use smoking as a way to get along in life, while females smoke for purely social reasons.

We turn our attention to the 13 salient latent factors underlying smoking initiation and con-tinuous use among the students of HUST.

The first factor is influence by association. Most of the students indicated that they started smoking when they saw their mates smoking. They also smoked for the mere reason that they wanted to belong to a clique, and some students saw smoking as fun. The implication is that influence by association has a significant impact on smoking initiation and continuous use.

The second factor is emotional needs. Some of the students mentioned that they took to smok-ing to overcome loneliness, stress, and boredom and to enhance relaxation. The Current literature on smoking reveals that many youth were attracted to smoking cigarette for the same reasons. The question that immediately arises is, “Have there been any empirical studies to prove to this claim?” We think that even if those claims are anything to go by, they are perceptions and not facts.

The third factor is family smoking history. It was revealed that some of the students resorted to smoking because it was a means of socialization in their cultural setup; additionally, their immediate family members and friends smoke. It was also mentioned that within their family setup smoking appears to be an addiction, because it runs through the family line, and this find-ing is revealing in 2 dimensions: (a) that a child learns easily what the parent does, and parents therefore provide models of behavior for their children; once a parent smokes, the child sees it as acceptable and does not see anything wrong with it; (b) if parents smoke, children of such parents have easy access to cigarettes. If parents stop smoking, their children will be less likely to start smoking.

The fourth factor is addiction. Some of the students indicated that they have been addicted to cigarettes; it was also mentioned that smoking had become part of them and that it was difficult to stop, and they attributed their addiction to smoking cigarettes to unhappy home life. This rev-elation is worrisome, and the whole of civil society is called on to sympathize with them; family members, friends, and colleagues must be supportive and encourage smoking cessation pro-grams in schools, colleges, and the community.

The fifth factor is influence from peers. Some students were initiated into smoking by spend-ing time with friends who were current smokers; they also perceived that smoking was accepted by all peers. In Figure 1, the most significant cause of smoking initiation was peer pressure. Most of the literature on smoking initiation revealed that peer groups create important source and set-ting for the uptake and maintenance of smoking4,5; it will take the collective efforts of all well-meaning people to help in overcoming this peer pressure menace. If parents take an active role in the social life of their children, and be interested in the friends of their children, inviting them

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for dinner and other social activities, will such love and care for their children not help? If educa-tors of these youth are well trained in health hazards associated with smoking and the need for smoking cessation, could they not in turn educate their students on human traits, such as respon-sible decision making, consequences of choices, goal setting, coping with stress and anxiety, self-esteem and assertiveness?

The sixth factor is lack of full realization of the consequences of their action as regards the expense of smoking. Some students perceived that the price of cigarettes was not expensive, and they also thought that smoking gave them appetite for food; moreover, they perceived that there was lack of education on smoking, and they agreed in principle that they had underestimated the health hazards associated with smoking and claimed that they had made several attempts to stop smoking but to no avail. These variables were labeled “lack of full realization of the conse-quences of their action as regards the expense of smoking” for the following reasons: first, sta-tistics have shown that smoking shortens one’s life span by 10 years; second, it costs a smoker hundreds of dollars per year to smoke, and this amount of money could be invested into a profit-able venture; third, the health risk associated with smoking is alarming—risk of heart diseases and lung cancer, and in the case of females, menstrual disorders, early menopause, breast cancer, and cancer of the cervix.

The seventh factor is social needs. This factor was informed by the following variables: bro-ken home and deprived social lives. In the reviewed literature, mention was made of the fact that tobacco companies promoted physical availability of tobacco products in geographical areas that are disadvantaged socioeconomically.7 Statistics on parental separation and smoking initiation showed that parental separation increases the likelihood that their children will start smoking and that the way it comes about is partially due to depressive symptoms and rebellious attitudes indi-rectly created by the separation.

The eighth factor is advertisement. It was revealed that smoking initiation and continuous use was to some extent influenced by advertisement and availability of cigarettes in the market, which is similar to findings in earlier studies,6,7,9 which says that increased media exposure on cigarettes is associated with increased risk of smoking; moreover, tobacco companies promote physical availability of tobacco products in geographic areas with disadvantageous socioeconomic status. Again it has been observed that notwithstanding the ratification of the WHO framework conven-tion on tobacco control, the percentage of students in Columbia who reported seeing pro-cigarette advertisements on billboards and newspapers or magazines increased significantly between 2001 and 2007. It is imperative to note that tobacco companies have adopted new and innovative schemes of marketing their products, and their target groups are mainly children, teenagers, and females; in some cases cigarettes are portrayed as weight and shape controls, and in other instances they are portrayed as modules for attractive and athletic models.

The ninth factor is psychological needs. To some students smoking cigarettes gave them com-fort, while at the same time served as learning stimulants. There was an argument in the literature to the effect that the nicotine present in tobacco products gave temporary feeling of well-being and facilitates memory retention.2,3 This temporary feeling of well-being is been perceived by students as comforting enough for which reason they had overlooked all odds against smoking and continue to smoke.

The 10th factor is self-image. Some students believed that smokers belong to an esteemed class of people in the society; they also believed that smoking was enjoyable and elevates one person above the others. Companies of tobacco products usually use role models and celebrities to portray positive images of smokers; some of these models for all intents and purposes do not really smoke but do so solely for advertisements. Adolescents, as vulnerable as they are, in their attempt to improve their self-image are easily enticed as they see these role models smoking.



Turkson et al. 13

The 11th factor is environment. Some of the students believed that the location of the school played an important role in smoking initiation and continuous use; there is empirical evidence in the literature to this assertion: “students attending schools at mountainous areas had a greater likelihood of smoking than students attending city schools.”13

The 12th factor is social needs. The claim of the students was that school policies banning smoking on campuses were ineffective and that government policies banning advertisement of cigarette smoking had achieved no result. This finding confirms earlier findings, which state that well-controlled school interventions have failed to show positive long-term effects on cessation of smoking by students.16,17

The 13th factor is the underrating of health risks associated with smoking. The students asserted that smoking was not dangerous to their health; they perceived smoking as normal and acceptable and refused to reason with statistical results, which showed the awesome danger associated with smoking. To such groups of students there is a call to intensify the education on the health risk of smoking cigarettes.

ConclusionsFrom the onset, we sought to use the factor analysis model to reduce the many—variables that influence smoking among the youth to a few salient latent factors that cut across continents, culture, and age. We noted in the study that the majority (67.4%) of the students had smoked for about 4 years. We also noted that a greater proportion (58.7%) of the students in the study were from the continent of Asia, followed by Africa (26.5%). The study unearthed 13 salient latent factors that had influence on the smoking initiation and continuous use of cigarettes among the youth. It is significant to note that many of the students yielded to smoking because of societal influence. Other factors worth considering were the influence from peers, psycho-logical needs of the students, emotional needs, social needs, family smoking behavior, adver-tisements, low self-image, ineffective policies, and underestimation of the health risk associated with smoking. Faced with emotional and social needs, they perceived that they could derive the needed satisfaction by taking to smoking. Their continuous smoking and addiction have been influenced by availability of cigarettes on the market. The findings of this study is revealing; we therefore call on all stakeholders of education, public health institu-tions, and civil society to come up with and implement effective health education policies meant to curb the peer pressure menace and the influence by association syndrome. Parents are also called on to take special interest in the social lives of their children: educating them on the consequences of wrong associations and the health hazards associated with smoking cigarettes.

Authors’ Note

The consents of the students were sought, and the purpose for which the data were collected was made clear to them.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.




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