Community Experience In Protecting Early-Teenagers From Initiation Of Smoking : An Indonesian Perspective


 
 Initiation of smoking habit often occurs in early teens due to the interaction of teenagers with the social environment. The community has an important role in protecting teenagers from the habit of smoking.
 
 
 
 The research was aimed to explore the experience of the community in protecting the early-teenagers from smoking habit from the perspective of Indonesian people.
 
 
 
 The qualitative study used the descriptive phenomenology approach on 100 participants (early-teenagers, parents, teachers, and school nurses) who were selected through snowball sampling method. Data collection was carried out through in-depth interviews using open-ended questions. The data were analysed manually using the data source triangulation method.
 
 
 
 Six research topics were concluded: 1) screening of habits related to health, 2) smoking bans, 3) punishment for smoking habit, 4) smoke-free counseling, 5) evaluation of efforts done, and 6) follow-up of smoking-free programs.
 
 
 
 The results of the study indicated the importance of consistent efforts to prevent the initiation of smoking habit in early-teenagers both at school and at home. The communities around them at school and home need to have people with healthy non-smoking habit as good role models for the teens.



INTRODUCTION
Smoking is the main cause of death in the world that can actually be prevented.In the US, around 443,000 deaths annually are caused by smoking [1].Meanwhile, in Indonesia, smoking causes 427,948 deaths annually [2].According to the World Health Organization (WHO), Indonesia is the third largest country, after China and India, in terms of number of smokers [3].Regardless of the massive spread of information on the dangers of smoking and the rules that regulate free-smoking area, the number of smokers in Indonesia has not reduced; in fact, it keeps increasing.The national survey in 2007 showed that the proportion of smokers in Indonesia was 23.7% and it increased to 24.3% in 2013 [4].Not only that the total number of smokers keeps increasing, the smoking habit also starts earlier.The age group with the highest smoking initiation was the 15-19 years old and followed by the 10-14 years old [5].
Smoking habit in teenagers is a serious health problem, since it increases the risks of various diseases when they get older.Early start of smoking habit causes stronger nicotine addiction, thus quitting smoking will be more difficult.Moreover, early start of smoking habit increases the risk of drug abuse later.Smoking habit among teenagers is highly affected by the social environment [6].In order to prevent the teenagers from starting smoking, it needs collaborative effort from all parts of the community.This research was aimed to explore efforts taken by the community to prevent smoking in teenagers.

MATERIALS AND METHODS
The research was designed as qualitative research using the descriptive phenomenology approach.This approach was used to explore the experience of the community in preventing their teenagers from initiation of smoking habit as seen through the perspective of Indonesian people.The study was approved by the ethical committee of the Faculty of Nursing, University of Indonesia (No. 0528/UN2.F12.D/HKP.02.04/2016).
The research was performed with 100 participants, consisting of early-teenagers, parents, teachers of junior high schools, and school nurses, with 25 participants in each category, in Malang, Indonesia.The participants were selected based on the following criteria: teenagers from 12-13 years old who have tried smoking and their parents, as well as their school teachers and school nurses.Characteristics of early-teenagers are 10 persons aged 12 years old and 15 people aged 13 years old; They consist of 18 males and 7 females.The parents consist of 13 fathers and 12 mothers.Teacher consist of 9 men and 16 women.School Nurses consist of 11 men and 14 women.
The importance of the study was increasing community awareness on the importance of preventing early-teenagers from initiation of smoking.Participants were selected based on the achievement of data saturation.The participants signed a consent form prior to being involved in the study.
The instrument used to collect data was in-depth interviews using open-ended questions.The research was carried out by the research team, led by a nurse specializing in community health from the Faculty of Nursing, Brawijaya University, and supervised by lecturers from the Faculty of Nursing, the University of Indonesia.Before data collection was started, the participants were informed of the objectives, the importance, and the procedure of the study.
Qualitative data analysis was started with arrangement of the interview transcripts and research notes.Manual data analysis was performed based on the Colaizzi method.The data analysis was performed manually since the data contained confidential information on beliefs, values, personal feelings, and attitudes of the participants, which could not be interpreted by analytical software.The data analysis procedures were performed following these steps: (1) Reading of all the interview transcripts from every participant to get the general picture on the community experience; (2) Reviewing every transcript and extracting significant statements from them; (3) Explaining the meaning of every significant statement found; (4) Organizing the theme of the experience into clusters; (5) Integrating the complete picture of the study; (6) Concluding the unequivocal statements in the results and discussion; and (7) Requesting participants to read their own transcript questionnaire as the final step of validation process.
The research results were presented as keywords, sub-themes, and themes of the experience.This study collected six meaningful themes from the community experience in protecting their early-teenagers from smoking habit.

RESULTS
The participants had various experiences in handling smoking habit among teenagers.Efforts such as health screening, smoking bans, punishment for smoking habit, counseling, evaluation, and follow-ups .

Health Screening
Health screening is performed by school nurses in order to identify common health problems among earlyteenagers.This activity is carried out routinely every year in schools.
The question was: "What are you doing to know a teenager was smoking or not?"…included in the health screening is diseases and their risks among the students" (Nurse_10).
"Every year we have health screening program in our school to identify health problems commonly suffered by the students" (Teacher_22).
The participants claimed that they immediately prohibit the students from smoking if such habit was detected.

Smoking Restriction
The participants informed the reasons for banning smoking among early-teenagers, such as effects on physical health and financial issues.Teens is part of the growing period, therefore it needs to be well taken care of to secure the teenagers' health later as they grow older.
The question was: "What is the reason that you tell teenagers so that they should not continue to smoke?" "Smoking is not good for your health, stop it" (Nurse_14).
"You are so young, do not smoke, keep yourself healthy" (Parent_25).
Another reason stated by the parents to prohibit their children from smoking was the financial issue.Teenagers are not independent yet in terms of financial situation, thus smoking, especially if they choose the more expensive brands of cigarettes, was considered as an extra burden for the family's financial management.
"Yes, Father.I will smoke later when I am an adult and I can earn my own income" (Teenager_4).
"At the moment, because all of his financial needs are under my responsibility, I ban him from smoking" (Parent_4)."Please do not smoke, Son.It is expensive.Be considerate to your father" (Parent_15).
"My parents told me not to start smoking now.They said I can smoke later when I have my own job" (Teenager_5).
The participants described their contribution in stopping the smoking habit among teenagers by prohibiting them from smoking.There were two methods mentioned: total ban on smoking and gradual quitting of smoking.Total ban of smoking implied that smoking teenagers have to quit smoking immediately and they were not allowed to smoke at all."Stop!Please, stop smoking" (Parent_25)."If possible, never smoke" (Parent_16).
On the other hand, several participants opted for gradual withdrawal of smoking, considering that the addictive effect of smoking cannot be ceased immediately, thus it is better to stop the habit gradually.
"My son was smoking several times a day, so I asked him to reduce it gradually."To quit smoking immediately is difficult" (Parent_6).Furthermore, other than giving verbal smoking bans, the participants also gave punishments when they found the teenagers under their care initiated smoking.

Penalty or Punishment for Smoking Habit
Penalty or punishment given to teenagers who were caught smoking was performed in the form of financial, physical, and psychological penalties.Financial penalty was performed by confiscating the cigarettes as a proof of the smoking habit.
The question was: "What are you doing when looking at teens continue to smoke?" "The teacher took away my cigarettes" (Teenager_5).
"We took the cigarettes away as a proof of their smoking habit" (Teacher_7).
After confiscating the cigarettes, the teachers usually add physical penalties too by asking the teen smokers to do pushups.
"…the teacher punished me and asked me to do several pushups" (Teenager_5).
Lastly, the students was also given psychological punishment in the form of warning letters and their parents were also informed and asked to see the teachers at school."So, do I need to call your parents here?"(Teacher_6).
"I was given punishment for smoking and also a warning letter" (Teenager_6).
Other than penalties, the teachers also provided counseling for the teen smokers.

Smoke-Free Counseling
The counseling given by the teachers was aimed to get the students to be aware of the dangers of smoking, thus it was expected that they would quit gradually.
The question was: "What are you doing to open the awareness of teenagers about the dangers of smoking?" "My experience was when I was involved in counseling the students on the dangers of smoking" (Teacher_1).
"I called them and I lectured them on the dangers of smoking" (Teacher_14).
"We have to help them to gradually quit smoking" (Teacher-11).
"Those who used to smoke several times a day, they have to try to reduce it.Immediate cessation of smoking is impossible" (Teacher_15).
After the participants put efforts to conduct programs to overcome the problem of smoking among teenagers, they performed evaluation on the programs.

Evaluation of Effectiveness of the Programs
Evaluation of the effectiveness of the programs was carried out by the teachers through interviews, direct observation, and the use of assisting tools.The teachers directly asked and required the students to report back in order to monitor their smoking habit.
The question was: "What are you doing to evaluate the success of the smoke-free program?"When we evaluated, we asked them questions; thus it means that we did not simply ignore them after we gave them counseling.Instead, we interviewed them again later" (Teacher-14).
"The student had to report back to me" (Teacher_15).
Other than interviews, the teachers also observed to identify if there were students who smoke at school.Observation was performed directly on teenagers, simply to see their lip color and whether they smelled like the smoke of cigarettes."I observed the student's behavior.Every time, after the break and everyone entered the class back, one of them always asked for an excuse to go to the restroom....So I took the initiative to go there after him too.There I found the restroom to smell like cigarette and smoke still lingered in it; thus, I continued my observation on his behavior" (Teacher_7)."I could detect the students who smoke; their lips were dark blue" (Teacher_18).
"The smell of the smoke of cigarettes could be detected in the class.Even if there was only one student who smoked, I knew it" (Teacher-23).
Indirect observation was also performed using Closed Circuit Television (CCTV) by the teachers to detect smoking habit at school.Installation of CCTV was aimed to monitor remote parts of the school.
"We installed CCTV in this school; however, the students were smart and they found places undetected by the CCTV in order to smoke" (Teacher_19).
"Now, we have installed CCTV at parts of the school that are remote and quiet, which are often chosen by the students to hang out" (Teacher_12).
The teachers followed up the results of the evaluation of the trend of cigarette smoking at school.

Follow-Ups on Smoking-Free Programs
The follow-ups of evaluation results performed by the teachers on smoking habit among teenagers were carried out in the form of random checking and invitation to teacher-parent meeting.Random checking was performed routinely as well as incidentally, by checking the students' bags.
The question was: "What are you doing to follow-up after evaluating smoke-free program?" "We routinely perform random checking.The students have to open their bags and we check it" (Parent_24).
"I checked his bag randomly and I found that he still had cigarettes in his bag" (Teacher_17).
"My son was caught by the teacher bringing cigarettes in his schoolbag" (Parent_22).
The teachers would follow-up the results of the random checking by inviting the parents for a discussion session at school.The parents are invited when the students kept the smoking habit, even though he had been given health counseling and warning.
"Yes, when we find a student continues to smoke, we call his parents, and we discuss the problem" (Nurse_13).
"The teacher contacted us in order to discuss the situation" (Parent_8).

Parents' Initiatives to Overcome the Smoking Habit Among Teenagers
Smoking habit has bad effects health-wise and financially.Smoking increases the risks to get various diseases in the future such as cardiovascular diseases, diabetes, respiratory problems, and cancer [7,8].The addictive effect of smoking would increase the financial expenditure of the smoker, thus it may potentially create financial problem when the income allocated to purchase cigarettes comes from cutting other allocated budget.Therefore, smoking bans applied by the parents is a good method to maintain the teenagers' health and prevent them from having financial problems.
The results showed that smoking bans were applied by the parents either totally or gradually.Selection of the best method has to be based on how strong the teenager is addictive to nicotine.When he is a heavy smoker, thus the best method is gradual quitting [9,10].The decision should be taken to avoid discomfort caused by nicotine addiction if it is stopped abruptly.
The parents allowed the teen children to smoke when they themselves were smokers and when their prohibition against smoking was not obeyed by the children.Several parents also allowed their teen sons to smoke due to the thought that it was normal for men to smoke.Such attitude and behavior taken by the parents were not supportive on the effort to prevent early initiation of smoking.Smoking bans are ineffective when the parents themselves smoke [11].When the parents have smoking habit, it increases the risk of their children to follow their footsteps [12,13].Therefore, in order for smoking bans to be effective, parents need to be good role models for the teenagers by not smoking.Thus, the teenagers would think that smoking is highly disapproved by their non-smoking parents [14].

The Teachers' Contribution in Handling Teen Smokers
Schools are the ideal place to implement programs to prevent smoking since it has teen students coming from various age groups, including the age where initiation to smoking usually takes place.The research results showed many efforts taken by the schoolteachers to overcome the problem of teen smokers in their schools, such as smoking bans and punishment or penalty for students who were caught smoking, counseling and evaluation followed by random checking and report to parents.Unfortunately, when all those efforts have been taken and the effect was not as expected, some teachers finally gave up and let their students smoke.
The first action taken by the teachers to overcome the problem of teen smokers was by implementing smoking bans and penalty/punishment for smokers.When a school does not have clear regulations on smoking, it increases the risk of its students to be smokers.Botello-harbaum et al. (2009) reported that students living in an environment with relatively loose regulations in terms of smoking had greater possibility to be active smokers [15].The students would think that the lack of smoking bans as a sign that smoking is a habit that is well accepted, thus it increases their risk to be active smokers.As explained by Lipperman-kreda, Paschall and Grube (2009), strict regulations regarding smoking in schools could help to prevent or reduce smoking habit among teenagers within and out of the school area [16].When the teachers could create a smoke-free area, it helps to reduce the smoking habit among the students in other places.Thus, smoking bans at school is highly important to prevent the teenagers from smoking instead of giving them the freedom to choose.
Counseling and health education followed by evaluation and follow-ups were the next step taken by the schools to prevent smoking habit among teenagers.Counseling could bring positive effect in increasing the students' knowledge on the dangers of smoking, however it was not effective in changing their behavior [17,18].Even when counseling was followed by follow-up actions, it still could not reduce the prevalence of teen smokers.Counseling, evaluation, and follow-ups could not stand alone to prevent smoking among teenagers [19,20].In order to prevent and reduce the smoking habit, counseling needs to be supported by the family as well [21], considering the large influence coming from the social environment of the teenagers such as peer pressure that caused smoking habit to spread wide among them [22 -24].Family support could be in the form of supporting the teenagers to avoid smoking or to quit smoking if they were already smokers and to create better environment for the teenagers including monitoring the teenagers' activities to reduce possibility of smoking [21].

The Role of School Nurses in Handling Smoking Habit Among Teenagers
The research results showed that the school nurses have put efforts to stop teen smoking habit by providing health screening.The activity was aimed to increase the students' health by detecting risk factors that had potentials to cause the students to get diseases and other health problems.When the nurses detected signs that the students smoked, they immediately talked to the students to make them quit smoking by considering the many health risks associated with smoking.
Smoking habit among teenagers could possibly lead to drug abuse and bring risks of other health problems including decreased fitness, respiratory infections, underdeveloped lungs, reduced lung maximum capacity, and lung cancer [25].Those problems were also added with the negative correlation between smoking and personal health attitude.Smoking habit in teenagers was found to negatively correlate with consumption of breakfast,, fruits and vegetables, and milk, as well as with physical activity.However, it was positively correlated with consumption of soft drinks, fast foods, and alcoholic drinks, as well as with sedentary lifestyle [26].
As has been reported [27], health screening brings positive effect on healthy habits.When one gets results of a screening test that explains the risk of getting a disease, then he/she would work hard to avoid the risks.Therefore, health screening performed by the school nurses to detect smoking habit in teenagers is important.Through screening, the nurses could detect smoking habit, provide health service for smoking-related health problems, and advise the teenagers to quit smoking.

CONCLUSION
The research results showed variety of efforts that have been taken by the community to overcome the problem of teen smokers.Before finally giving up, many parents have tried to prevent their teen children from smoking by banning it, while school teachers contributed by prohibiting smoking in the school area and giving punishment or penalty for smokers, followed by counseling, evaluation, and follow-ups.Meanwhile, school nurses played their roles by performing regular health screening.
Teen smoking was an issue that has to be handled by all parts of the community.The research results showed the importance of collaboration among various elements in the society to prevent early initiation of smokers, especially parents, schoolteachers, and school nurses.They should not give the teenagers freedom of choice in terms of smoking, since it directly increases the risk of smoking.For optimal results, consistent efforts are needed both at school and at home.When the teachers put prohibition on smoking, then the parents should have similar rules at home.The parents and the teachers should be good role models for healthy lifestyle for the teenagers.

ETHICAL APPROVAL AND CONSENT TO PARTICIPATE
The study was approved by the ethical committee of the Faculty of Nursing, University of Indonesia (No. 0528/UN2.F12.D/HKP.02.04/2016).

HUMAN AND ANIMAL RIGHTS
No animals/ humans were used for the studies that are bases of this research.

CONSENT FOR PUBLICATION
Informed written consent was obtained from all the participants.