INTRODUCTION

Tobacco use is the most preventable cause of morbidity and mortality in Malaysia. About 20000 deaths are reported annually¹ and smoking-related diseases have been identified as major contributors to disability-adjusted life years (DALYs) among the Malaysian population². The Malaysian government has enacted comprehensive measures involving various agencies and non-governmental organizations (NGOs) to address health issues related to smoking, by promoting healthy lifestyle campaigns, engaging in advocacy, introducing smoke-free areas, raising the prices of tobacco products by changing the tax structure of cigarettes from kilograms to sticks, and implementing community intervention programs such as KOSPEN (Komuniti Sihat, Pembina Negara — Healthy community, developed the nation)³. Such initiatives⁴ are intended to decrease the prevalence of smoking among Malaysian adults to 15% by the year 2025.

Various studies have shown that smoking behavior is learned and begins during adolescence^5,6. A similar phenomenon has been reported in Malaysia, where over 80% of adult smokers began smoking before the age of 21 years¹. According to the theory of human development, most adolescents start smoking during adolescence because of abstract thinking, common during that phase, which contributes to the occurrence of ‘Formal Operations’ and ‘Personal Fable’⁷, when adolescents feel that they are unique and omnipotent. In addition, they might also feel that people around them are eagerly watching or listening to them; the feeling of the presence of an imaginary audience and a sense of invincibility⁸ might drive adolescents (younger than 18 years old) to engage in risky health behaviors, such as smoking, to attract the attention of their peers. Furthermore, the earlier a young person begins smoking, the more likely he or she will continue to do so because of the addictive effects of tobacco products⁹. This pattern decreases a person’s likelihood to quit smoking¹⁰ and increases the risk of smoking-related illness, such as cancer¹¹. Therefore, reducing smoking initiation among adolescents aims at lowering the prevalence of smoking among Malaysian adults that will ultimately reduce smoking-related morbidity and mortality among Malaysians.

Measures to prevent adolescents from accessing tobacco products have included educational efforts imploring them to choose wisely, and make rational, mature decisions regarding their behaviour, including smoking¹². In addition, making cigarettes less available to youth has indirectly encouraged them to smoke less frequently and less willing to share their cigarettes¹³. These measures have been identified as some of the best strategies to reduce smoking initiation, as shown by various studies, including those related to reducing smoking initiation among adolescents¹⁴, along with decreasing the progression of experimental smokers to frequent smokers¹⁵.

The World Health Organization (WHO) developed the Framework Convention on Tobacco Control, which urged all member countries to take pro-active measures to reduce the supply of tobacco to adolescent smokers to discourage them from smoking¹⁶. Through the Ministry of Health, the Malaysian government has implemented similar measures, including prohibitions on the ownership, use, and purchase of tobacco products by individuals under 18 years, as well as a ban on the sale of tobacco products to adolescents through tobacco control regulations enacted in 2004. Additionally, the country has banned retail sales (i.e. selling tobacco sticks) and set a minimum price for cigarettes¹⁷.

Research has revealed that adolescents generally obtain tobacco products from social sources¹⁸. In addition, epidemiology studies^18,19 have shown that older teenagers, males and heavy smokers^18,19 are more likely to buy cigarettes from a commercial store. The opposite is true for young female smokers. Similarly, infrequent smokers of both genders are more likely to obtain tobacco from peers and other adults²⁰.

In Malaysia, limited research has explored the procurement of tobacco products among adolescent smokers; most studies have focused on the prevalence of and factors related to smoking among adolescents. Only three small-scale studies have investigated tobacco procurement by adolescents over the last two decades^21-23. Those studies pertained to specific localities among upper Secondary school students only^21-23; thus, their findings cannot be generalized outside these regions and groups. Furthermore, the sociodemographics of respondents in those localities (i.e. Kota Tinggi, and Petaling) were different to those of Malaysian adolescents, in term of age, and ethnicity.

The adaptation of findings from Western countries concerning the procurement of tobacco products may not be applicable to Malaysia, due to social and cultural differences, the dynamics of smoking among adolescents, and the level of enforcement against cigarette procurement. Therefore, current information on how Malaysian adolescent smokers obtain cigarettes is of paramount importance, given the paucity of data available. Such findings will assist in discovering loopholes in the existing law and enforcement activities in order to curb adolescent access to cigarettes. The present study illustrates the sources of cigarettes, and the associated factors, for school adolescent smokers in Malaysia.

METHODS

We conducted a nationwide study entitled ‘Tobacco and E-Cigarette survey among Malaysian Adolescents’ (TECMA), in 2016, to obtain the latest data on tobacco and e-cigarette use among Malaysian school adolescents. A cross-sectional study design with multiple-stage stratified cluster sampling was used to select a representative sample size of Malaysian school adolescents, 10–19 years old, based on the latest sampling frame of upper Primary and Secondary school enrolment provided by the Ministry of Education (DOE) of Malaysia. The first strata consisted of 15 States in Malaysia, and the second included their subdivision into urban and rural areas. The primary sampling unit was either the Secondary or Primary schools available in each State, selected based on proportion to size sampling approach, followed by class selection (i.e. secondary sampling unit) from each chosen school. All students from the selected classes were invited to participate in the study. In total, 138 schools were selected (82 urban and 56 rural). The sample size was determined using an estimated prevalence of 3% e-cigarette users among adolescents in Korea²⁴ at a 95% confidence interval (CI) with a design effect to account for any cluster effects among students in the classes. We also set a tolerable error of 1.5% and expected a non-response rate of 20%. Based on these parameters, 13980 respondents were required for the study. A total of 13162 adolescents participated in the study, yielding a response rate of 88.7% (13162/14832).

RESULTS

Overall, 13.5% of school adolescents were current smokers, with a significantly higher proportion among Bumiputra Sabah adolescents (16.1%) followed by Malay (13.8%). The study showed that the ratio of male to female current smokers was more than 10:1, and the prevalence of smoking among school adolescents in rural areas was almost twice as high as their urban counterparts (7.8%, 95% CI: 7.0–8.7 for urban; 14.9%, 95% CI: 13.5–16.4 for rural). Approximately 21.7% of current smokers reported smoking frequently (Table 1).

Table 2 shows that over half (54.3%) of current smokers obtained cigarettes from a store; the proportion was significantly higher among young males (56.5%, 95% CI: 51.7–61.1) than young females (32.0%, 95% CI: 17.5–50.9), and for current smokers from upper Secondary school (59.6%, 95% CI: 52.4–66.4) compared to those from upper Primary school (32.7%, 95% CI: 24.3–42.3). In addition, the proportion of frequent smokers who bought cigarettes from a shop was nearly twice as high compared to infrequent smokers (84.2%, 95% CI: 77.0–89.4; and 43.7%, 95% CI 38.3–49.3, respectively; p<0.001). Multivariate analysis (Table 3) by locality revealed that, in urban settings, female current smokers (AOR=12.5, 95% CI: 1.38–99.8), those from lower Secondary school (AOR=3.76, 95% CI: 1.41–10.02) and upper Secondary school (AOR=4.41, 95 % CI: 1.72–13.06), with upper Primary school as reference, and frequent smokers (AOR=4.41, 95% CI: 2.25–9.46), were more likely to buy cigarettes from shops compared with young males, upper Primary school students, and infrequent smokers. However, no similar trend was observed among smokers from rural settings; only frequent smokers were more likely to buy cigarettes from a shop (AOR=6.19, 95% CI: 2.41–15.88). No significant association was found between ethnicity and knowledge of smoking regulations with buying cigarettes in either urban or rural areas.

DISCUSSION

Our study found that over half of current smokers (54.3%) obtained cigarettes from commercial sources, contradicting studies in developed countries reporting that adolescent smokers obtain cigarettes from social sources^18,25. The proportion of adolescents who obtained cigarettes from commercial sources was 3.5- to 5.5-fold higher compared with youth in Minnesota, in 2003 and 2011 (16.3% and 9.7%, respectively). Findings from a longitudinal study by Robinson et al.²⁶ revealed that 16% of 4416 youth smokers obtained their cigarettes from a commercial source. The prevalence of cigarettes obtained from commercial sources in the present study was much lower than that reported by Lim et al.^22,23 among Secondary school students in Kota Tinggi, Johor²², and Petaling Jaya, Selangor²³, as it was by Zulkifli and Rogayah²¹ among youth smokers in Kelantan. However, the prevalence is worrisome given that legislation prohibiting the sale of tobacco products to individuals under 18 years old has been enforced for over a decade. We postulated that the higher proportion in our study might be due to the wide availability of cigarettes in Malaysia, where such products can be sold by any business, such as sundry shops, restaurants, and service stations without restrictions. No licensing mechanisms are in place to control cigarette sales, and a lack of manpower to uphold such policies may also be problematic.

Currently, the power to enforce tobacco product sales is only granted to the Medical Officer of Health, through the environmental officers/assistants EHOs (EHOs/AEHOs) in the district health department, who are heavily involved in prevention and control activities of communicable and non-communicable diseases in their respective districts; therefore, they cannot focus fully on enforcing tobacco control activities. Detailed studies should be carried out in this aspect to identify the actual factors contributing to our findings.

Male school adolescents from urban areas were significantly less likely to purchase cigarettes compared with female smokers. This finding was quite surprising given the higher prevalence of smoking among young men in Malaysia, and our finding is not congruent with that of Kaestle et al.¹⁸, Lim et al.^22,23 and Minaker et al.²⁷, all of whom reported that men were more likely to obtain cigarettes from commercial sources. This finding of the present study could be due to several factors, such as the tendency of adolescent male smokers to befriend male peers who smoke, thus promoting social connectivity and togetherness²⁸. In this case, young men habitually obtain cigarettes and smoke together with groups of friends on their way to and from school, at the train or bus station, or when socializing; as such, smoking becomes a social signifier within peer groups where they consume and exchange cigarettes together for group inclusion³. By comparison, female smokers, who constitute a small proportion of smokers and are therefore less likely to have social support to obtain cigarettes, access cigarettes independently and over the counter. Girls of similar age may appear physically older due to developmental differences; thus, sales people may be more mistrustful of boys and subsequently attribute negative motives to boys but not to girls of an equivalent age²⁹. Consistent findings from other studies suggest that underage girls may have less trouble purchasing cigarettes than boys³⁰. Additionally, social bonding among urban communities might not be as strong as in rural regions due to the environment and longer working hours, resulting in less time to mingle in neighborhoods. Urban residents are also more self-centered; such communities typically disregard or are oblivious to underage girls buying cigarettes from a store³¹.

Together with previous studies^18,25, our study demonstrated that age is significantly associated with increased use of tobacco and commercial access but decreased social access. As the age of youth increases, physical and psychological development is not advanced; hence, adolescents struggle against dependency. This phenomenon is well described in the adolescent development literature^7,8. Upper Secondary students appear to be more mature physically and are more fearless, courageous, heroic, and apt to explore risky situations. This age group may begin to admire adult smokers; according to social cognitive theory, humans learn behaviors by observing others³². Imitation is more likely when observers admire those they are observing. The developmental perspective posits that adolescent behaviors are motivated by the desire to assume adult characteristics⁸. Therefore, higher-grade students may be more confident when making over-the-counter cigarette purchases. This trend aligns with our findings that upper Secondary students are more likely to obtain cigarettes from commercial sources, followed by lower Secondary and upper Primary students. Furthermore, older youth may be better able to afford cigarettes via commercial routes, as teenagers from upper Secondary school may earn money through a part-time job and thus be able to afford over-the-counter purchases. Tyas and Pederson³³ indeed reported that a higher number of adolescent smokers bought their own cigarettes, had a part-time job, and earned personal income. However, similar patterns were not observed in rural areas; no significant association emerged between gender, level of schooling and ethnicity, with obtaining cigarettes via commercial sources. We postulated that social bonding among residents in rural areas could explain this finding, with traditional values (e.g. positive attitudes and values of friendliness, helpfulness, hospitality, and neighborly behavior) prevalent among rural residents. Families are closely bonded to one another and are aware of and have acknowledge on the issues happening around them. The value of community or society precedes that of an individual. Some adolescent smokers may perceive society and their parents/guardians as being against smoking^5,23; therefore, adolescents may be less likely to become involved in activities (e.g. direct cigarette purchases) that could tarnish their image with authority figures.

Frequent smokers in our study were more likely to purchase their own cigarettes in rural and urban localities after adjusting for the effects of confounding factors. Similar findings have been reported in other research^25,27. Regular smokers typically identify common stores that offer easy access to cigarettes, such as grocery stores and convenience stores. As frequent buyers, they may be familiar with certain premises where they can procure cigarettes illegally. Forster et al.²⁰ and Minaker et al.²⁷ similarly discovered that daily smokers make most tobacco purchases to win friends by offering cigarettes to peers. Frequent smokers may also be more likely to buy cigarettes in stores due to tobacco addiction. Addiction is a dynamic process that typically begins with occasional smoking and later progresses to frequent. Frequent smokers find quitting difficult when they are already addicted to smoking. More advanced stages of smoking are greatly associated with purchasing their last cigarette^25,27. Most youth began to purchase their own cigarettes once dependence sets in from increased levels of cigarette consumption²⁷. The frequent smokers might also patronize the same premises to buy cigarettes, thus cultivating a close relationship with the shop owner and purchasing cigarettes more easily from that store.

This study also revealed that knowledge of smoking regulations was not associated with buying cigarettes in rural or urban settings. With the proliferation of laws prohibiting underage tobacco sales, we expected that access to cigarettes among underage youth would be stricter. We hypothesize that inadequate regulation enforcement could contribute to this finding. The EHOs/AEHOs enforce Control of Tobacco Product Regulation (CTPR) in Malaysia¹⁷. Nevertheless, manpower is extremely limited in conducting compliance checks at all tobacco retailers. These public health inspectors can barely oversee all premises. Moreover, charges and penalties only apply when shop owners or salespeople are directly caught selling tobacco products to minors¹⁴. Lack of enforcement and burden of proof may cause adolescent smokers to believe that the probability of being caught purchasing tobacco is low; thus, they may not worry about breaking a law that prohibits them from buying cigarettes. However, more studies should be carried out to verify the absence of a significant association between knowledge of relevant tobacco laws and cigarette sources.

This research has several limitations. First, we did not include an appraisal of knowledge and attitudes of retailers regarding legislation prohibiting tobacco sales to persons under 18 years of age. Second, cigarette sources were self-reported; respondents may have under- or over-reported this information.

CONCLUSIONS

This study showed that adolescents can easily access commercial sources of cigarettes in Malaysia. Current selling mechanisms in the country allow any store to sell tobacco; therefore, store owners can participate freely in the tobacco products business without restrictions. Laws concerning the sale and distribution of cigarettes could potentially affect adolescent tobacco use and decrease youth access to tobacco. To accomplish this, licensing of tobacco outlets may prove helpful; specifically, establishing a licensing system for cigarette sales could be an effective regulatory tool. Under this system, all stores that sell tobacco would be required to obtain a special license to do so. This measure would allow the government to better monitor youth access to tobacco, marketing exposure, retailer density, and retailer location. Under such a licensing system, licensees would be required to verify a cigarette buyer’s age through proof of identity and age, to avoid violating regulations. In addition, health promotion activities should be intensified to raise retailer awareness about existing laws prohibiting cigarette sales to adolescents.