Evidence Based Health Policy,

Cigareete smoking is a global problem. It is projected that the number of smokers increases from 1.3 billion in 2013 to 1.6 billion people in 2025 (1). Over the past decade, tobacco-related deaths around the world have tripled (2). Smoking kills more than 8 million people annually. More than 80 % of the world's 1.3 billion tobacco users live in low- and middle-income countries (3).
In the last three decades, smoking has decreased dramatically due to increased awareness regarding the health risks of cigarette smoking and effective control policy in developed countries, whereas it has increased in developing countries (4). Although health programs in developed countries have resulted in a reduction in smoking, cigarette smoking incidence is increasing among young ages in developing and low-income countries (5, 6). The existing data indicate that the first cigarette experience occurs between 11 and 15 years old and that 88 % of adult smokers start smoking before the age of 18 (7). According to the available statistics, on a daily basis, more than 3,800 younger people under the age of 18 initiate cigarette smoking (8). The younger you start smoking, the more likely you will find it hard to quit (9). Early smoking initiation brings about many problems because nicotine dependence is more severe in those who start smoking earlier compared to those who start smoking later and less possibility exists to quit smoking (5).
The use of prevention programs is regarded as the main strategy for reducing the rate of smoking among children and adolescents (10). Over the last three decades, schools have become a unique environment for implementing cigarette smoking prevention programs because most children are easily accessible and can easily apply tobacco prevention interventions and their daily activities (11, 12).
It is also worth noting that adolescents who do not acquire the necessary skills to deal with tense situations will be more prone to drug use, smoking, and antisocial behaviors (13). One of the ways to deal with tense situations is life skills training, which was developed by Botvin in 1979 (14). As an attempt to social psychology injuries prevention, the WHO developed a program entitled life skills training and suggested it to UNICEF (United Nations Children’s Fund) in 1993 (15). Since adolescents are more accessible in schools for life skills training, this course is included in developed countries' adolescent curriculum (16).
However, in developing countries, including Iran, smoking rates continue to rise, especially in adolescents (8). In Iran, tobacco use has accounted for more than 11000 annual deaths of all ages, with an upward trend in smoking prevalence over the past decades (17). In Iran, according to the WHO report, the prevalence of smoking in men, women, and the whole population is 20.4 %, 1 %, and 10.8 %, respectively (18), and the average daily cigarette consumption for smokers is 13.7 cigarettes per day (19). In a study conducted by Bidel et al. (20), the prevalence of smoking among boy students was 11.4 % in Ilam province of Iran. Given the increasing prevalence of smoking in Iran, especially in young people, and the importance of acquiring life skills to deal with risk-taking behaviors and its impact on smoking status, the objective of this study was to survey the awareness, attitude, and life skills status related to cigarette smoking among boy students in Ilam, Iran.
Materials and Methods
This was a descriptive study conducted among the first grade of high school boy students at state and non-profit schools in Ilam, in the west of Iran, in 2018.
Sample size and sampling methods
The sample size was determined based on the study of Naseri et al. (21). Given a 64 % rate of life skills in their study and a 95 % confidence interval and 0.04 effect size, the sample size was calculated according to the following formula (1):

(1):


The sample size was taken into account with the possibility of a 10 % drop out in samples. Moreover, the sampling process was conducted in two steps, i.e., firstly schools were selected by a random sampling method. Secondly, from each education grade in each school, one class was selected randomly, and that all of the students of the selected class were included using the census method.
Data collection tools
Data were collected using a questionnaire, which has already been used in the study of Neseri et al. (21) to the evaluation of students’ life skills in exposure to smoking in high school in Tabriz, Iran. The reliability of the questionnaire was determined between 0.7 and 0.75 which was variable in different parts of the questionnaire (21). Due to the minor changes in the questionnaire, the validity of the questionnaire was assessed again using the comments of 15 experts in the field of community health nursing, general health, social medicine, psychiatric nursing, psychology, and psychiatry. Additionally, the reliability of the questionnaire was evaluated using internal consistency. Cronbach’s Alpha was 0.84 which reflects the high reliability of the questionnaire.
The questionnaire included three parts:
A: The first section was related to students’ demographic characteristics.
B: The second part regarded the awareness about the harmful effects of smoking (10 items), the attitude toward smoking (10 items), and cigarette smoking-related life skills (36 items). In particular, cigarette smoking-related life skills consisted of normative expectations toward cigarette smoking (3 items), problem-solving and decision making skills (8 phrases), compatibility skills (7 items), communication skills (7 items), assertiveness skills (6 items), and finally resistance skills against smoking (5 items).
The items related to awareness comprised of two options. Responses were scored 1 for a correct answer and 0 for an incorrect answer, and higher scores indicating more awareness.
Four options were considered for attitude items. The scores 0, 1, 2, and 3 were assigned to the responses of completely disagree, disagree, agree, and completely agree, respectively. A lower score indicated a more negative attitude toward cigarette smoking.
Normative expectations questions consisted of five options. The scores 4, 3, 2, 1, and 0 were given to the responses of none of them, some of them, half of them, most of them, and all of them accordingly. The maximum score indicated the abnormality of smoking among students.
The questions related to problem-solving and decision-making skills, compatibility skills, and communication skills consisted of four options. The scores of 0, 1, 2, and 3 were allocated to the choices in the order of never, rarely, quite often, and always. Higher scores indicated higher skills.
The questions of assertiveness skills consisted of four choices. The scores 0,1,2 and 3 were given to the choices of I certainly can not, I probably can not, I probably can, and I certainly can, respectively. A higher score indicates more assertiveness skills.
The items of resistance skill comprised of three choices. The scores of 0,1 and 2 were given to the choices of not at all, maybe, and certainly, respectively. The maximum score indicates one’s high level of resistance toward smoking.
Subsequently, the score of awareness, attitude, normative expectations, and life skills was adjusted at 0-100 to more comparability of dimensions.
C: The third part was related to smoking status and evaluated via six questions.
Data analysis
Data analysis was performed using SPSS22. The normality of data was examined through the Kolmogorov-Smirnov Test. Considering the results of the K-S test, Mann-Whitney U and Kruskal-Wallis tests were used to examine the association between demographic variables and life skills. Besides, the Spearman correlation was run to examine the association between age, GPA, awareness, attitude, and life skills. Chi-Square test was applied to examine the association between demographic variables and smoking status, intention to smoke in the future. The binary logistic regression model was used to assess influencing factors on dependent variables.
The current research study was approved by the Ethics Committee of Tabriz University of Medical Sciences (IR.TBZMED.REC.1395.162) and the Department of Education in Ilam. The study participants were recruited after being informed about the purpose of the study, the voluntary nature of the study, and given the assurance of confidentiality and anonymity.
Results
Characteristics of the students included in the current analysis are summarized in Table 1. The mean age of students, the mean age
of smoking initiation, and the mean students’ GPA were 13.58, 11.26, and 17.95, respectively. 32 % of students had a smoker friend, while 17.8 % had a smoker father. The prevalence of smoking was estimated at 11.45 % among students.
It was revealed that 22.2 % of students who had smoker friends would smoke, whereas it was only 5.1 % for those who did not have any smoker friends. Out of 22.2 % of students, 5.2 % of them stated that they intend to cigarette smoking in the next year. On the contrary, only 0.8 % of students who had no smoker friend stated that they have the intention to cigarette smoking in the next year. 19.3 % of smokers and 0.2 % of non-smokers reported that they will undoubtedly smoke next year. Moreover, there was a statistically significant association between the smoking status and having a smoker friend, having a smoker family member, father’s profession, and education grade. Besides, a statistically significant association was further observed between the intention of cigarette smoking in the future, and having smoker friends, having smoker family members, cigarette smoking.
As represented in Table 2, the mean score of awareness of the harmful effects of smoking was 82.18, and the mean score of attitude toward smoking was 32.6. Additionally, the mean score of normative expectations was 68.04. The score of all items in life skills was higher than average (> 50). The total score of life skills was 57.3. The highest and the lowest score for life skills was related to problem-solving skills (56.75) and the compatibility  skills (52.21) accordingly. The results showed that the mean total score of life skills was higher among non-smokers than smokers. The non-smokers considered smoking as a deviant matter more than smokers.
The analytical statistics are presented in Table 3. The correlation between age and awareness of the harmful effects of smoking, normative expectations toward smoking, assertiveness as well as resistance skills was statistically significant. Besides, there was a statistically significant correlation between the GPA and normative expectations toward smoking and problem-solving skills. Awareness of the harmful effects of smoking had a significant negative correlation with attitude toward smoking and a significant positive correlation with normative expectations toward smoking. Moreover, a significant and negative correlation was found between attitude and normative expectations.
As shown in Table 4, awareness of the harmful effect of smoking, attitudes toward smoking, and normative expectations were significantly associated with having smoker friends. Students who had no smoker friends had more awareness of smoking and a more negative attitude towards smoking, and also considered smoking as abnormal behavior. Awareness of the harmful effects of smoking, normative expectations, assertiveness, and resistance skills was significantly associated with grade. Awareness of the harmful effects of smoking, assertiveness, and resistance skills was higher in third-grade high school students. Furthermore, first-grade high school students considered smoking as a more abnormal behavior than second and third-grade high school students. Problem-solving skills, assertiveness, resistance skills, and the total mean score of skills were significantly associated with the habitation status, and especially those living in rural areas had a higher score. Attitudes toward smoking, normative expectations, and the total mean score of life skills were significantly associated with smoking status, and non-smokers had a more negative attitude toward smoking than smokers. It was observed that non-smokers considered smoking more abnormal than smokers. The mean score of total life skills was also higher in non-smokers than in smokers.
According to the results of Binary Logistic Regression, having a smoker family member, having a smoker friend, attitude toward smoking, and normative expectations were significantly associated with smoking status. Having smoker family members and smoker friends increased the risk of smoking by 24 % and 2.28 times, respectively. A negative attitude toward smoking decreased the risk of smoking by 77 %. Besides, considering cigarette smoking as a normal action increased the risk of smoking by 2.17 times, as described in Table 5.

Variables	Modes	Frequency	Percent(%)
Grade	First grade	166	30.2
	Second grade	192	34.9
	Third grade	192	34.9
Custody status	Living with mother and father	512	93.1
	Others	38	6.9
Father’s education status	Illiterate	39	7.1
	Reading and writing	99	18
	Under diploma	97	17.6
	Diploma	175	31.8
	Academic education	140	25.5
Mother’s education status	Illiterate	59	10.7
	Reading and writing	121	22
	Under diploma	106	19.3
	Diploma	188	34.2
	Academic education	76	13.8
Family members' smoking status	Father	98	17.8
	Mother	3	0.5
	Brother	9	1.6
	Sister	7	1.3
	None	433	78.7
Friends’ smoking status	Yes	176	32
	No	374	68
Smoking initiation age	Less than ten years old	21	33.9
	More than ten years old	41	66.1
Habitation status	Urban	466	84.7
	Rural	84	15.3

 

Variables	Mean	SD
Awareness	82.18	14.19
Attitude	32.6	16.35
Normative expectations	68.04	16.65
Problem-solving skill	56.75	30.18
Compatibility skill	52.21	21.05
Communication skill	55.62	24.76
Assertiveness skill	56.28	29.89
Resistance skill	55.9	28.81
Total life skills score	57.3	13.33

 
Table 3. The Correlation Between Age, GPA, Awareness, Attitude, and Life Skills

Variables		a*	b	c	d	e	f	g	h
Age	CC**	0.093*	- 0.058	0.154**	0.061	0.019	0.034	0.134**	0.177**
	P	0.03	0.17	< 0.001	0.15	0.66	0.42	< 0.001	< 0.001
GPA	CC	0.08	- 0.04	0.14**	0.09*	0.001	0.07	0.06	0.05
	P	0.54	0.25	< 0.001	0.02	0.88	0.07	0.12	0.21
Awareness	CC		- 0.21**	0.14**	0.01	0.001	- 0.02	0.06	0.01
	P		< 0.001	< 0.001	0.82	0.86	0.59	0.11	0.7
Attitude	CC			- 0.23**	- 0.001	0.001	0.02	- 0.01	- 0.03
	P			< 0.001	0.82	0.97	0.49	0.71	0.46

*a. Awareness b. Attitude c. Normative expectations d. Problem-solving skill e. Compatibility skill f. Communication skill g. Assertiveness skill h. Resistance skill
** Correlation Coeffecience is significant at the 0.05 level.
 
 
Table 4.  Association Between Demographic Variables and Awareness, Attitude and Life Skills

Variables	a	b	c	D	e	F	g	h
Custody status	0.59	0.39	0.35	0.29	0.65	0.16	0.40	0.02*
Father’s education	0.22	0.89	0.16	0.04*	0.49	0.08	0.04*	0.001*
Mother’s education	0.23	0.87	0.14	0.13	0.30	0.2	0.01*	0.01*
Family members' smoking status	0.02*	0.58	< 0.0001*	0.84	0.57	0.84	0.53	0.69
Grade	0.005*	0.05	0.003*	0.26	0.68	0.43	0.001*	0.001*
Father’s job	0.16	0.75	0.53	0.003*	0.2	0.006	0.05	0.007*
Type of school	0.15	0.96	0.006*	0.18	0.89	0.06	0.35	0.17
Friends' smoking status	0.04*	< 0.0001*	< 0.0001*	0.72	0.95	0.8	0.62	0.18
Habitation status	0.08	< 0.0001*	0.21*	0.02	0.13	0.07	0.02	0.02
Cigarette smoking status	0.07	< 0.0001*	< 0.0001*	0.09	0.25	0.44	0.25	0.35

*P-value < 0.05 considered as significant
a. Awareness b. Attitude c. Normative expectations d. Problem-solving skill e. Compatibility skill f. Communication skill g. Assertiveness skill h. Resistance skill

Variables	Sig.	Exp (B)	95 % C.I. for EXP(B)
			Lower	Upper
Age	0.217	0.701	0.399	1.232
Custody status	0.077	1.547	0.953	2.512
Father’s education	0.583	0.893	0.594	1.340
Mother’s  education	0.426	0.850	0.571	1.267
Having a smoking family member	0.022*	1.244	1.031	1.501
Having a smoking friend	0.027*	2.281	1.097	4.743
GPA	0.136	1.161	0.954	1.412
Grade	0.341	0.714	0.357	1.427
Father’s job	0.027*	0.496	0.266	0.924
Habitation status	0.688	1.227	0.452	3.335
Awareness	0.606	0.533	0.049	5.824
Attitude	0.0001*	0.235	0.117	0.472
Normative expectations	0.006*	2.174	1.256	3.764
Problem-solving skills	0.609	1.217	0.573	2.584
Comparability skills	0.263	0.714	0.396	1.288
Communication skills	0.649	1.196	0.553	2.583
Assertiveness skills	0.728	0.900	0.499	1.625
Resistance skills	0.414	1.392	0.629	3.082