Cigarette and hookah smoking and their relationship with self-esteem and communication skills among high school students

Introduction

Adolescents smoking is associated with significant health problems and it may increase the risk factors of health problems during adulthood.¹In order to reduce the health threat caused by tobacco, the World Health Organization (WHO) has targeted 30% decline in the prevalence of tobacco usage among people older than 15 years until 2025 (the base year was 2010).²

According to the WHO, the prevalence of tobacco smoking among Iranian adolescents was 5.9%, which is 7.5% among males and 4.2% among females in 2017.³Furthermore, the WHO has reported that the prevalence of tobacco smoking among American adolescents was 13.4% (14.6% males and 12.2% females).³In England, 7% of adolescents (6% males and 8% females) are smoking.³

There is an increasing trend of smoking prevalence among Iranian adolescents.⁴ For instance, studies have demonstrated that high school students become smoker faster than other groups.^5-7Another study in Iran showed that 14.3% and 2.8% of the never smokers became experimenters and regular smokers respectively and 16.5% of the experimenters became regular smokers.⁶These findings support preventive measures during and before adolescence. Moreover, other studies have reported the prevalence of hookah smoking among adolescents in different cities. For example, according to the result of research was conducted in Tabriz, 44.9% of the high school students had experienced smoking hookah and 6% of them have continued smoking.⁸ Also, another study reported that 21.6% of the students had smoked hookah at least one time during their lifetime, and 9.7% were hookah smoker during study time.⁹ Furthermore, the results of a meta-analysis of articles published between 2000 to 2014 showed that 23% of the high school students in Iran had experienced hookah smoking.¹⁰

Numerous studies have determined the low self-esteem and deficiency in life skills, especially skills of resistance against smoking as the predictors of smoking.^11,12 These factors are very important and there is a strong association between them and tobacco smoking among adolescents.^13,14 In addition, low self-esteem in adolescents increases their smoking tendency during adulthood as well.¹⁵ Moreover, there is a positive relationship between low self-esteem at school and drug abuse,¹⁶ which might be provoked by poor performance at school and low approval of the peers.¹⁷ Nazarzadeh et al found a significant and negative relationship between self-esteem and smoking stages.¹⁸ Likewise, Khosravi et al indicated that low self-esteem is associated with progress at smoking stages.¹⁹ On the other hand, Mohammadpoorasl et al found no significant relationship between self-esteem and progress at smoking stages²⁰ and between low self-esteem of adolescence and smoking during adulthood.¹⁵

Considering the inconsistency and ambiguity in the literature of the relationship between self-esteem and communication skills with cigarette and hookah smoking and, particularly, due to limited studies available in Iran, this study aimed to investigate the relationship between self-esteem and communication skills with stages of cigarette smoking and hookah use among a representative sample of adolescents.

Materials and Methods

Results

Out of all participants, 1038 students (81.5%) were never smoked, 190 (14.9%) experimenter and 45 (3.5%) of them were regular smokers. In terms of hookah smoking, 756 (61.8%), 429 (35.1%) and 38 (3.1%) of students were never smoker, experimenter and regular smoker, respectively.

Table 1 shows the distribution of cigarette smoking by demographic, socioeconomic and behavioral characteristics. As seen in the table, gender, general risk taking behaviors, having self-injury experience, having smoker friend(s), having smoker in the family member(s), hookah smoking status, self-esteem, attitude towards smoking and average grades of previous year were statistically associated with cigarette smoking.

Table 2 shows the distribution of hookah smoking by demographic, socioeconomic, and behavioral characteristics. As shown in this table, gender, general risk taking behaviors, having self-injury experience, having smoker friend(s), having smoker in the family member(s), cigarette smoking status, self-esteem, attitude towards smoking and average grades of previous year were statistically associated with cigarette smoking.

Four ordinal logistic models were used to analysis the relationships between self-esteem and communication skills and cigarette smoking stages and hookah smoking status with and without controlling for potential confounders (Table 3). After controlling for gender, general risk taking behaviors, self-injury experience, substance abuse, smoker friend(s), smoker in the family, hookah smoking status, living with parents, communication skills, attitude towards smoking and average grades of previous year, the results indicated that the higher score of self-esteem protects the students form progressing to advanced stages of cigarette smoking (odds ratio [OR] = 0.95, 95% CI: 0.92-0.99, P = 0.012). In fact, for one unit increase in self-esteem score, the odds of higher cigarette smoking stages versus the odds of lower cigarette smoking stages is .95 times smaller, given the other variables are held constant in the model. After controlling for potential confounders, there was no significant association between self-esteem score and hookah smoking status. Also, after controlling for potential confounders, the results did not show any significant association between communication skills score and cigarette smoking stages and hookah smoking status.

Discussion

The present study is aimed to investigate the relationships between self-esteem and communication skills with stages of cigarette and hookah smoking among adolescents in high schools of Tabriz. The results showed that self-esteem had significant relationship with smoking stages in the sense that each unit of increase in self-esteem score reduces the chance of progressing to the higher stages of smoking by 5%. A study in Shiraz reported an insignificant impact of self-esteem on progressing in smoking stages.²⁵ Results of numerous studies have supported the relationship between self-esteem and smoking, or the stages of smoking among adolescents.^18,19,24 Therefore, it has been suggested that the smoking prevention programs consistently cover the comprehensive health education or health promotion programs such as self-esteem improvement training.²⁶ In contrast, another study has shown that self-esteem is a determinant of smoking behavior among female adolescents, but not males, probably because women are exposed to various stimulants for beginning and maintaining the smoking behavior.²⁷ However, this study found no significant association between gender and smoking. Based on the results of this study and the literature as well, it seems it is necessary to conduct more studies in this area, especially longitudinal and interventional studies to practically determine the effect of self-esteem improvement programs on smoking prevention.

Regarding to the relationship between self-esteem and stages of hookah smoking, the univariate analysis of variance showed a significant relationship between self-esteem and stages of hookah smoking. In fact, students with monthly smoking of hookah had less self-esteem score than those with experience of hookah smoking; also students with experience of hookah smoking had less self-esteem score than those without experiencing of hookah smoking. However, in the multivariate analysis and by controlling for aforementioned confounders, the relationship was disappeared. Karimy et al have showed that self-esteem is a significant predictor of hookah smoking.¹¹This finding is consistent with the results of univariate analysis in our study. Fakhari et al did not find any significant relationship between self-esteem and hookah smoking.⁸In spite of the preventive role of family in cigarette smoking families encourage or at least they are neutral about adolescents’ hookah smoking behavior. This can be due to the wrong attitudes about the effect of hookah on health.²⁸Moreover, according to the results of a cross-sectional study conducted in Tabriz on the prevalence of hookah smoking among high school students, 95.3% of regular hookah smokers said that their age is not an impediment for hookah smoking in the coffee shops.⁹ Therefore, it is expectable that due to the accessibility of hookah as well as the lack of legal and social constraints, the smoking of hookah is not considered to be harmful by adolescents. Regarding the role of family, the accessibility of hookah for adolescents in family, as well as considering it as an entertainment in parties, obscenity of hookah smoking seems to be significantly diminished. Therefore, regardless of the status of self-esteem and communication skills, adolescents tend to smoke hookah‏.

There was no significant relationship between communication skills and stages of cigarette smoking. However, Botvin et al found that training the life skills with focusing on increasing the students’ ability to come up with direct pressure of smoking, reducing their sensitivity to indirect social effects of smoking, and improving their ability to reduce anxiety had created a significant difference between intervention and control groups in terms of ratio of the individuals who had experienced tobacco smoking. They concluded that such types of trainings reduce the probability of initiation of smoking behavior in the intervention group.²⁹ Consistently, another study confirmed that similar training programs decreased the smoking rate among the trained adolescents compared to control group.³⁰ In the other interventional study in 4 states of Germany, the researchers taught students subjects like problem solving, critical thinking, effective communication skills, decision making. The follow-up results in six months after the training showed 16% of the smoker students in the intervention group and 20% in the control group. The difference between two groups was statistically significant.³¹ Results of another interventional study, in which the parents and adults were trained on communication skills, showed that the adolescents of the trained parents began smoking significantly less than others. Therefore, it is suggested that training of the communication skills to adults might affect smoking and other suspicious behaviors of adolescents.³²It seems that, finding more reliable and strong results requires conducting further studies, especially longitudinal interventional studies to determine the effect of communication skills training programs on smoking prevention.

The study conducted by Guo et al on the use of training programs including life skills to control and prevent the illegal drug abuse among students showed that the students in intervention group consume significantly less illegal drug than the control group. Also, students in intervention group had more tendency toward avoiding the illegal drugs consumption.³³ Relying on these findings, it may be assumed that training of communication skills would be effective in preventing hookah smoking. However, this proposition needs to be tested by designing longitudinal interventional study.

Limitations

This study has several limitations. The main limitation is that the sample size only included tenth grade students. This may reduce the generalizability of the findings. Another limitation was cross-sectional nature of the study that makes it difficult to investigate the causal relationship between independent and dependent variables. Finally, the study relied on self-reported data.

Conclusion

The findings showed that self-esteem is associated with the stages of cigarette smoking. However, the relationship between self-esteem and hookah smoking was disappeared after controlling for demographic, socioeconomic and behavioral variables. Furthermore, after controlling for potential confounders, the communication skills score showed no statistically significant relationship with both cigarette and hookah smoking. Investigating these relationships requires further studies, especially longitudinal and interventional once to determine the effect of self-esteem improvement programs and communication skills training on the prevention of cigarette and hookah smoking.

Ethical approval

The research protocol was approved at the organizational committee of ethics in Tabriz University of Medical Sciences (Ethics code: IR.TBZMED.REC.1396.216).

Competing interests

The authors declare that there is no conflict of interests.

Authors’ contributions

The first, second and seventh authors contributed to the design of the work. The first and fifth authors conducted the data collection. The first, second and fifth authors conducted the data analyses. The second, third, sixth and seventh authors contributed to the interpretation of the results. The first, fourth, fifth and sixth authors contributed to drafting the manuscript. The sixth and seventh authors supervised the development of work and helped in manuscript evaluation. The fourth author helped to evaluate and edit the manuscript.

Acknowledgments

The authors would like to greatly acknowledge financial support for this study from Tabriz University of Medical Sciences. They also wish to thank all the participants of this study for their valuable cooperation and participation.

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