Indian Pediatr 2008;45: 963-968
Prevalence and Correlates of
Current Cigarette Smoking Among Adolescents in East Timor-Leste|
S Siziya, AS Muula and E Rudatsikira
From the Department of Community Medicine, University of
Zambia, School of Medicine, Lusaka, Zambia,
*Department of Community Health, University of Malawi, College of
Medicine, Blantyre, Malawi; and
†Departments of Epidemiology and Biostatistics and Global Health, Loma
School of Public Health, Loma Linda, California.
Correspondence to: Dr Adamson S Muula, Department of
Community Health, University of Malawi,
College of Medicine, Private Bag 360, Blantyre 3, Malawi. E-mail:
Manuscript received: March 7, 2008;
Initial review completed: March 18, 2008;
Revision accepted: April 1, 2008.
To determine the prevalence and correlates for current cigarette smoking.
Design: Secondary analysis of the East Timor-Leste Global Youth
Tobacco Survey conducted in 2006. Setting: Public and private
schools registered with the Ministry of Education. Participants: A
two-stage cluster sample of 1790 students in Grades 7 to 9. Schools were
selected with probability proportional to enrolment size, and classes were
randomly selected in each school. All students in selected classes were
eligible to participate in the survey. The school and student response
rates were 96.0% and 84.5%, respectively. Main Outcome Measure:
Prevalence of current cigarette smoking. Results: Out of 1790
adolescents, 52.1% were of ages less than 15 years, 51.8% were males,
42.8% reported having some pocket money in a month, and 72.7% had at least
a parent who was a smoker. Prevalence of current cigarette smoking was
40.3%. Current smokers also reported having bought cigarettes from
peddlers (32.4%), someone bought for them (16.7%), got from someone older
(13.7%), borrowed (13.3%), and stole (3.4%). Males were more likely to be
smokers than females (59.0% versus 19.3%). Factors positively associated
with current smoking were: parental smoking; closest friend smoking;
amount of pocket money; and exposure to anti-tobacco messages.
Conclusions: East Timor has one of the highest prevalence of cigarette
smoking among adolescents. The fact that exposure to anti-tobacco messages
was associated with being a smoker may be evidence suggesting that
anti-tobacco messages, especially from tobacco-related industry, may have
Key words: Adolescent, East Timor,
Tobacco use is the single most important preventable
cause of morbidity and mortality from non-communicable diseases(1). There
has been growing interest in adolescent tobacco smoking in the past
decade(2). Adolescent tobacco use is of public health concern because it
may lead to longterm smoking behavior into adulthood. Adolescent smokers
may also suffer from immediate or medium term effects such as incident
asthma(3). Smoking among adolescents may also be a marker of many other
lifestyle and health concerns(4,5). Francis, et al.(6) have
reported that adolescents who smoke are at higher risk of psychopathology
compared to adolescents who are non-smokers. This clustering of unhealthy
lifestyles has also been observed among adults(7).
The Global Youth Tobacco Survey (GYTS) has reported the
prevalence of cigarette smoking among 13 to 15 year old in-school
adolescents in East Timor-Leste(8). In this age group, prevalence of
current cigarette smoking was 32.4%. We are however unaware of any
published reports on social correlates of cigarette smoking among
adolescents in this setting. Therefore, using data from the Global Youth
Tobacco Survey, we conducted an analysis to identify the factors that are
associated with cigarette smoking among in-school adolescents.
Study design and participant recruitment: Our
study involved secondary analysis of data from the East Timor Global Youth
Tobacco Survey (GYTS) conducted in 2006. The survey was school based and
recruited students in Grades 7 to 9. The school population was all junior
high school (both public and private schools) that were registered with
the Ministry of Education, East Timor. Total number of schools was 127 and
total number of students was around 41,000 students.
Study administration and sampling followed the GYTS
process as described earlier(2). In brief, a two-stage cluster sample
design was used to produce representative data for all of East Timor. At
the first stage of sampling, schools were selected with probability
proportional to enrolment size. At the second stage of sampling, classes
were randomly selected and all students in selected classes were eligible
to participate. The school response rate was 96.0%, while the student
response rate was 84.5%, and the overall response rate was 81.1%. A total
of 1,790 students participated in the survey.
Study setting: East Timor shares a border with
Indonesia and lies 800 km to the northwest of Australia. East Timor is a
former Portuguese colony that was annexed by Indonesia in 1975. In 1999,
following a referendum on independence from Indonesia, violent civil
conflict led to the destruction of much of East Timor’s infrastructure.
The country has an estimated population of about 1 million.
Data collection: A self-completed questionnaire
with core and country-specific questions as outlined in the GYTS
methodology(2) was used to collect data. Completion of questionnaire
occurred within one class period and coordinators supervised the process.
Study participants were informed that they were free not to answer any of
the questions they felt uncomfortable with.
Data analysis: Data analysis was performed
using SPSS version 14.0 software (Chicago, Illinois, United States of
America). Current cigarette smoking (the main outcome) was defined as
having smoked a cigarette, even a single puff, in the last 30 days
preceding the survey. The predictor variables were obtained from the
literature as factors that have been previously reported as being
associated with adolescent smoking in other settings. These factors
include: smoking in close friends(9); gender(10); having pocket money or
allowance(11); parental smoking(12) and exposure to tobacco related
messages or advertisements(13).
A weighting factor was used in the analysis to reflect
the likelihood of sampling each student and to reduce bias by compensating
for differing patterns of non-response. We obtained frequencies as
estimates of prevalence. We conducted a backward logistic regression
analysis to estimate the association between relevant predictor variables
and current cigarette smoking.
Study participants’ characteristics: A total
of 1790 in-school adolescents participated in the East Timor Global Youth
Tobacco Survey in 2006. Overall, 52.1% of the participants were of ages
less than 15 years, 51.8% were males, 42.8% reported having some pocket
money in a month, and 72.7% had at least a parent who was a smoker.
Prevalence of current cigarette smoking was 35.7%. Males were more likely
to be smokers than females (59.0% versus 19.3%). Further description of
the sample is presented in Table I.
Characteristics of Study Participants in the East Timor Global Youth Tobacco Survey 2006
|Pocket money received (US$)
| Father only
| Mother only
|Close friends smoked
| None of them
| Some of them
| Most of them
| All of them
|Frequency of media messages seen on
| A lot
| A few
|Frequency of cigarette brand names seen
when watched sports events or other programs on television (TV)
| Never watched TV
| A lot
|Frequency of cigarette advertisements
seen on billboard
| A lot
| A few
|Frequency of cigarette advertisements
or promotion seen in magazines
| A lot
| A few
*unweighted frequency; † weighted percent
Sources of cigarettes in the past 30 days:
Of the current smokers, 24.1% reported that they usually bought their
cigarettes in a store, and 41.2% who bought cigarettes in a store had
never been refused purchase because of their age. Altogether, 21.9% of the
smokers had ever been offered ‘free’ cigarettes by cigarette company
representatives. Current smokers also reported having bought cigarettes
from peddlers (32.4%), someone bought for them (16.7%), got from someone
older (13.7%), borrowed (13.3%), and stole (3.4%).
Factors associated with current cigarette smoking:
We also assessed whether the selected predictor variables were
associated with self-reported history of cigarette smoking. In a
multivariate analysis, we found that parental smoking, peer smoking,
increasing age, male gender, exposure to cigarette promotion media in
magazines, and exposure to anti-smoking media messages were independently
associated with being a current cigarette smoker (Table II).
Factors Associated with Current Smoking Among in-school Adolescents in East Timor, 2006
|Age <15 years
||0.70 (0.68, 0.72)
||2.52 (2.45, 2.60)
|Pocket money received
||1.79 (1.67, 1.93)
||0.73 (0.67, 0.79)
||1.51 (1.43, 1.60)
||0.56 (0.53, 0.60)
||1.00 (0.93, 1.07)
||0.85 (0.81, 0.89)
|Close friends smoked
|None of them
||0.43 (0.41, 0.46)
| Some of them
||1.04 (0.99, 1.10)
|Most of them
||1.02 (0.97, 1.08)
|Frequency of media
messages seen on anti-smoking program
| A lot
||1.16 (1.11, 1.20)
||1.17 (1.12, 1.23)
|Frequency of cigarette
brand names seen when watched sports events or other programs on
|Never watched TV
||0.64 (0.60, 0.67)
| A lot
||0.87 (0.83, 0.91)
||1.74 (1.64, 1.84)
|Frequency of cigarette
advertisements seen on billboard
||0.73 (0.70, 0.77)
||1.38 (1.31, 1.44)
|Frequency of cigarette
advertisements or promotion seen in magazines
||1.10 (1.05, 1.15)
||1.06 (1.01, 1.11)
OR (95%CI) * adjusted estimates for all the factors in the table in a backward logistic regression analysis
We have reported an overall prevalence of current
cigarette smoking of 40.3% among in-school adolescents in East Timor in
2006. The prevalence of smoking among adolescents in East Timor is
probably among the highest in the world. Rudatsikira, et al.(10)
have reported prevalence of cigarette smoking of 4.5% and 1% among male
and female adolescents, respectively in Ethiopia. Kyrlesi, et al.(14)
reported a prevalence of current cigarette smoking of 16.2% among Greek
in-school adolescents. Singh and Gupta(15) have reported current cigarette
smoking of 2.1% and 1.7% among 13 to 18 year old males and females
respectively in Jaipur, India. Among 7 to 9 graders in Thailand,
Assanangkornchai, et al.(16) have reported prevalence of
current cigarette smoking of between 8.8% and 14.6%.
There are at least two possible reasons for the high
prevalence of smoking among adolescents in East Timor. Firstly, the
proximity and free flow of persons between East Timor and Indonesia, where
smoking is prevalent. Male smoking in Indonesia ranges from 50% to about
83%(17). As the Indonesian government has been developing policy aimed to
prevent smoking in the last few years, the tobacco companies in Indonesia
have started to pay more attention to East Timor for targeting customers.
This will make it a more challenging situation if East Timor does not have
strong policy and political will to tobacco control. Secondly prolonged
periods of liberation fighting had compromised the public health
infrastructure to enable concerted public health effort to prevent
We found that boys were more likely to have been
smokers than girls. Another study in another setting has reported this
observation(10). We believe the gender disparity could result from
societal tolerant attitudes towards male smoking compared to female
smoking. We also observed that having parents who smoked or having close
friends who were smokers were independently associated with smoking in the
adolescents. The association between having a close friend who smoke and
adolescent’s own smoking may suggest that an adolescent who is a smoker
may be more likely to choose other smokers as friends. Alternatively,
having a friend who smokes may be an influence in initiating smoking.
Livaudais, et al.(18) have reported that having friends who were
smokers at baseline was associated with eventually becoming a smoker among
Latino adolescents in the United States. Simmons-Norton(19) has reported
on the socialization selection effects among adolescents regarding peer
The association between having a parent who is a smoker
and adolescent’s own smoking may be an indication of parental tolerance to
smoking or easy availability and accessibility of cigarettes within the
home. Adolescents who have parents who smoke may also have higher
acceptability of smoking.
We also found that if the adolescent reported having
been exposed to cigarette advertisements or promotion in magazines, he or
she was more likely to be a current smoker than if the adolescent was not
exposed. However we also found that exposure to anti-smoking
advertisements was associated with being a smoker, while more exposure to
cigarette brand names and promotional billboard were associated with lower
likelihood of being a smoker. That exposure to pro-tobacco advertisements
is associated with adolescent smoking has been reported elsewhere(20).
The apparent paradoxical finding where exposure to
anti-smoking campaign was associated with increased likelihood of being a
smoker is not a new finding. Henriksen, et al.(21) have reported
that tobacco-industry supported anti-tobacco messages may have the
opposite effect on adolescent smoking. Weiss, et al.(20) and
Straub, et al.(22) have also reported that anti-smoking or
anti-tobacco messages may not be adequate to prevent smoking among
adolescents. It would appear that in our study, exposure to anti-tobacco
messages in fact had the opposite effect on adolescents. This calls for
evaluation of tobacco messages targeted towards adolescents.
We also found that adolescents who received more than
US$ 5 as pocketmoney in a month and those who got less that US$ 1 were
more likely to be smokers. Unger, et al.(23) have suggested that
limiting the amount of pocket money among adolescents who receive more
money may be a reasonable intervention. We do not know why even those who
received less than a dollar had higher likelihood of smoking than those in
the middle-income group. This could be a spurious finding. In an
environment where smoking is prevalent, adolescents may also access
cigarettes from friends, borrow from someone, having their cigarettes
bought by someone (without them having to pay for them) and stealing from
their own parents. It may also be an indication that there may have been
another confounder that was not measured.
Our study has a number of important limitations.
Firstly data were obtained only from in-school adolescents. To the extent
that out of school adolescents are different from in-school adolescents in
their smoking habits, our results may not be extrapolated to the entire
adolescent population in East Timor. Data were also collected from those
adolescents who were present on the day of the survey. Those students who
were absent were never followed up. We do however believe that any biases
that may have been introduced as a result of non availability of study
participants was likely to be minimal as the response rate was high
i.e. 81.1%. Furthermore our analysis took into consideration the
non-response rate by weighting the analysis. Thirdly, data were
self-reported. Like in all surveys that rely on self-reported data, there
is always a possibility of both inadvertent and deliberate mis-reporting.
An evaluation of a similar methodology to the GYTS in the United States
however has reported high reliability of adolescents reports(24).
The prevalence of smoking appears to be among the
highest in the world. Exposure to anti-smoking messages did not appear to
be associated with lower likelihood of being a smoker. Our findings
suggest that health education or improving knowledge will be less
effective to prevent smoking behavior without significant involvement or
support from other aspects such as supportive environment, strong policy
support, and community participation. There will be need for involvement
and partnership from different stakeholders and community.
We are grateful to the Centers for Disease Control
(CDC), Atlanta, Georgia, United States of America for making the data set
available for our analysis. We are also thankful to all the students who
participated in the East Timor-Leste Global Youth Tobacco Survey 2006.
Contributors: SS conducted data analysis,
participated in the interpretation of the data and drafting of manuscript.
ASM participated in the data analysis, interpretation of the findings and
drafting of manuscript. ER participated in the interpretation of results
and drafting of manuscript.
Funding: Adamson S Muula, is funded by the
University of Malawi, Junior Faculty Training Funding.
Competing interests: None stated.
What is Already known?
• Tobacco is a leading cause of death and
disability in the developed world and an emerging epidemic in
What This Study Adds?
• Prevalence of cigarette smoking in East
Timor-Leste appears to be among the highest in the world and
exposure to anti-smoking messages did not appear to be associated
with lower likelihood of being a smoker.
1. Mathers CD, Loncar D. Projections of global
mortality and burden of disease from 2002 to 2030. PLoS Med 2006; 3:
2. Warren CW, Riley L, Asma S, Eriksen MP, Green L,
Blanton C, et al. Tobacco use by youth: a surveillance report
from the Global Youth Tobacco Survey project. Bull World Health Organ
2000; 78: 868-876.
3. Gilliland FD, Islam T, Berhane K, Gauderman WJ,
McConnell R, Avol E, et al. Regular smoking and asthma incidence
in adolescents. Am J Respir Crit Care Med 2006, 174: 1094-1100.
4. Rudatsikira E, Siziya S, Kazembe LN, Muula AS.
Prevalence and associated factors of physical fighting among
school-going adolescents in Namibia. Ann Gen Psychiatry 2007; 6: 18.
5. Dierker LC, Sledjeski EM, Botello-Harbaum M,
Ramirez RR, Chavez LM, Canino G. Association between psychiatric
disorders and smoking stages within a representative clinic sample of
Puerto Rican adolescents. Compr Psychiatry 2007; 48: 237-244.
6. Francis K, Katsani G, Sotiropoulou X, Roussos A,
Roussos C. Cigarette smoking among Greek adolescents: behavior,
attitudes, risk, and preventive factors. Subst Use Misuse 2007; 42:
7. Poortinga W. The prevalence and clustering of four
major lifestyle risk factors in an English adult population. Prev Med
2007; 44: 124-128.
8. Global Youth Tobacco Survey. (Available from URL:
factsheet%202006.pdf. Accessed August 20, 2007.
9. Chalela P, Velez LF, Ramirez AG. Social
influences, and attitudes and beliefs associated with smoking among
border Latino youth. J Sch Health 2007; 77: 187-195.
10. Rudatsikira E, Abdo A, Muula AS. Prevalence and
determinants of adolescent tobacco smoking in Addis Ababa, Ethiopia. BMC
Public Health 2007; 7: 176.
11. Unger JB, Sun P, Johnson CA. Socioeconomic
correlates of smoking among an ethnically diverse sample of 8th grade
adolescents in Southern California. Prev Med 2007; 44: 323-327.
12. Otten R, Engels RC, van de Ven MO, Bricker JB.
Parental smoking and adolescent smoking stages: the role of parents’
current and former smoking, and family structure. J Behav Med 2007; 30:
13. Andreeva TI, Krasovsky KS, Semenova DS.
Correlates of smoking initiation among young adults in Ukraine: a
cross-sectional study. BMC Public Health 2007; 7: 106.
14. Kyrlesi A, Soteriades ES, Warren CW, Kremastinou
J, Papastergiou P, Jones NR, et al. Tobacco use among students
aged 13-15 years in Greece: the GYTS project. BMC Public Health 2007; 7:
15. Singh V, Gupta R. Prevalence of tobacco use and
awareness of risks among school children in Jaipur. J Assoc Physicians
India 2006; 54: 609-612.
16. Assanangkornchai S, Pattanasattayawong U,
Samangsri N, Mukthong A. Substance use among high-school students in
Southern Thailand: trends over 3 years (2002-2004). Drug Alcohol Depend
2007; 86: 167-174.
17. Reynolds C. The fourth largest market in the
world. Tob Control 1999; 8: 89-91.
18. Livaudais JC, Napoles-Springer A, Stewart S,
Kaplan CP.Understanding Latino adolescent risk behaviors: parental and
peer influences. Ethn Dis 2007; 17: 298-304.
19. Simons-Morton B. Social influences on adolescent
substance use. Am J Health Behav 2007; 31: 672-684.
20. Weiss JW, Cen S, Schuster DV, Unger JB, Johnson
CA, Mouttapa M, et al. Longitudinal effects of pro-tobacco and
anti-tobacco messages on adolescent smoking susceptibility. Nicotine Tob
Res 2006; 8: 455-465.
21. Henriksen L, Dauphinee AL, Wang Y, Fortmann SP.
Industry sponsored anti-smoking ads and adolescent reactance: test of a
boomerang effect. Tob Control 2006; 15: 13-18.
22. Straub DM, Hills NK, Thompson PJ, Moscicki AB.
Effects of pro- and anti-tobacco advertising on nonsmoking adolescents’
intentions to smoke. J Adolesc Health 2003; 32: 36-43.
23. Unger JB, Sun P, Johnston CA. Socioeconomic
correlates of smoking among ethnically diverse sample of 8th
grade adolescents in Southern California. Prev Med 2007; 44: 323-327.
24. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG.
Reliability of the 1999 youth risk behavior survey questionnaire. J
Adolesc Health 2002; 31: 336-342.