INTRODUCTION:

Smoking is the act of inhaling and exhaling the smoke of burning tobacco products, usually in the form of cigarettes, cigars or pipes [1]. Tobacco smoke contains more than 4000 chemicals, of which not less than 250 are hazardous to health and more than 50 are identified causes of various cancers. Tobacco smoking is the leading preventable cause of death and it kills up to half of its lifetime users. Tobacco causes nearly 7 million deaths each year because of direct tobacco use as well as

exposure to second-hand smoke [2]. Currently, there are approximately 1.3 billion smokers globally, which are expected to rise to 1.6 billion by 2025 [3]. Out of all those smokers, around 80% live in low- and middle-income countries where there will be more adverse impacts of the burden of tobacco-related diseases [2]. Malaysia is one of the middle-income countries with a high prevalence of smokers especially among the males and adolescents [4]. There are an estimated 5 million smokers in Malaysia, 20% of whom are 18 years old and below [5].

A national survey conducted in 2016 among Malaysian adolescents aged 10-19 years old (Tobacco and Electronic Cigarette Survey among Malaysian Adolescent – TECMA) found that an alarming 78.7% of ever smokers had their first cigarette before the age of 14 years old. The same study also showed that 28.5% of the current adolescent smokers have already developed low nicotine dependence [6]. Nicotine dependency not only causes physical withdrawal, but it also causes lifelong addiction. Nicotine addiction is one of the hardest addictions to break. To reduce the tobacco consumption and to promote smoking cessation, the Malaysian government have launched anti-smoking measures by intensifying the health promotion activities, banning all advertisements of tobacco products, increasing the taxes on cigarettes, introducing smoke-free areas, instituting the anti-smoking campaigns (“Tak Nak”) and increasing the number of smoking cessation clinics in primary health care centers in Malaysia [7].

Despite instituting anti-smoking measures, the smoking prevalence is still high and estimated 20,000 deaths in Malaysia are attributed to smoking annually [8]. Many factors contribute to the prevalence of tobacco smoking. To consolidate the actions towards evidence-based interventions for smoking cessation, there is a need to evaluate community understanding and behaviour with regards to smoking. Thus, we conducted a cross-sectional survey exploring the smoking prevalence and its associated factors including socio-demographic characteristics, their knowledge, and attitude towards smoking among residents in Kampung Gong Penaga, Kuala Terengganu, Malaysia.

METHODS AND MATERIALS:

A cross-sectional study was conducted in Kampung Gong Penaga located in the district of Kuala Terengganu. The standardized pre-test, self-administered questionnaire was used to collect the data from all eligible residents of 15 years and above from each house. Those who had communication difficulties, those who were terminally ill or had mental problem were excluded from this study. Prior to the data collection by trained year 3 medical students from UniSZA, the important research information including confidentiality of respondent’s identity were explained and informed consent were obtained from each respondent.

The questionnaire included 4 domains (A, B, C and D) with 90 questions altogether. Section A consisted of 10 questions exploring the socio-demographic profile of the respondents. Section B was comprised of 29 questions assessing respondents’ knowledge about contents of tobacco products (5 questions), addiction (1 question), smoking related health issues (8 questions), smoking effects to secondary and tertiary smokers (8 questions), law and legislation about smoking in Malaysia (6 questions) and anti-smoking activities done in Malaysia (1 question). Every single item in section B provides three answer choices: “Yes”, “No”, “Don’t know”. Two marks were given to a correct answer, zero to wrong answer and one mark to don’t know option. In section B, there were another 9 questions probing the source of anti-smoking information.

Section C entailed 27 questions evaluating the attitude towards the concepts of smoking (8 questions), social learning behaviour (2 questions), environmental tobacco smoking (3 questions), government laws and legislation against smoking (12 questions) and tobacco availability and accessibility (2 questions). The answers to all questions in Section C were based on the level of agreement ranging from “strongly agree” to “strongly disagree” with five-point Likert scale: 5- scores was given for “strongly agree” and 1 score was given for “strongly disagree” in each positive statement whereas the reverse scoring was applied in each negative statement. Section D had 9 questions focusing on respondents’ smoking status and pattern of their smoking. In this study, those who smoked at least one tobacco product during the previous 30 days were defined as current smokers. Respondents who smoked daily during the previous 30 days were considered as current daily smokers while the persons who smoked less than daily during the previous 30 days were considered as current occasional smokers. In the analysis, ex-smokers who did not smoke during the previous 30 days and never smokers were considered as non-current smokers.

Statistical Package for Social Sciences Version 22.0 was used to analyse the data. Data distributions and frequencies (%) were examined. Then, all continuous variables were expressed as mean and standard deviation (SD) or as median and interquartile range (IQR), while categorical variables as frequency and percentage. Inferential statistics was applied to present the prevalence of smokers, and multiple logistics regression with forward likelihood ratio method was applied to explore the factors associated with prevalence of smoking among the respondents. The variables chosen for multivariable analysis were decided not only based on statistical significance in univariable analysis (p <0.250) but also on clinically importance and principle of parsimony. The level of significance was set at p value of 0.050. Results are presented as adjusted odds ratio (Adjusted OR), 95% confidence interval (CI), Wald statistic with degree of freedom (df) and p value.

RESULTS:

Socio-demographic characteristics among residents of Kg. Gong Penaga

A total of 349 Malay respondents including 176 males (50.4%) and 173 females (49.6%) participated in this study. The participants ranged in age from 15 and 90 years old, having mean age of 39.21 years (16.12). Most of the subjects were married (68.2%), employed (53.0%), and had higher level of education attainment (86.5%) and income of RM 1000 and above (57.9%). More than half of the respondents (53.9%) had smokers in their family. Among them, smokers are mostly brothers followed by father, spouse, children, mother and sisters. Moreover, 66.5% of them have smokers in either friends or colleagues (Table 1).

Knowledge regarding tobacco smoking and its effect on health issues

Most respondents known about tobacco products are present in manufactured cigarettes (91.1%), hand-rolled cigarettes (84.8%) and cigars (68.8%). However, only some respondents knew that shisha smoking (22.3%) and electronic cigarettes (17.8%) contain tobacco products. Nevertheless, almost all of the respondents (97.4%) had knowledge that smoking can lead to addiction. Regarding the smoking related health issues, nearly 90% of the respondents knew that cigarette contains carcinogenic compounds and smoking tobacco is hazardous to health. Out of many smoking-related diseases, majority recognized that tobacco smoking causes lung cancer, heart attack and chronic bronchitis. However, 47 respondents (13.5%) did not know smoking causes impotency in males while 144 (41.3%) respondents were unsure whether tobacco smoking causes cervical cancer in females.

The tobacco smoking harms not only smokers themselves but also non-smokers because of being exposed to second-hand smoke. The harmful effects of second-hand smoke were recognized by majority (92.8%) of the respondents. They knew that the smoking during pregnancy increases still birth (70.8%), low birth weight (73.6) and congenital anomalies (77.9%). As for children and babies, the participants well recognized that second-hand smoke causes cough (92.3%), wheezing (84.0) % and asthma (90.8%) except ear infections (44.7%). Concerning the law for tobacco products in Malaysia, 60 (17.2%) respondents have not heard about it. However, most participants heard about the “smoke-free zone” (94.0%) and could give the correct answer about legal age for smoking in Malaysia which is 18 years old (65.3%). Furthermore, nearly all respondents (97.1%) also noticed health warnings on cigarette packages while 59.9% of respondents knew that cigarettes cannot be sold in loose forms such as individual sticks. In this study, 90.5% of all respondents heard about the anti-smoking activities and information available in Malaysia. They got that information from all sources including television, newspaper, poster, radio, etc.

Attitude towards smoking among residents in Kampung Gong Penaga

Regarding the concept of smoking, majority of respondents disagreed that smoking helps reduce stress (49.3%), gives satisfaction (46.4%), makes weight loss (41.0%), increases work performance (51.6%) and is a symbol of attraction to women (67.6%). Moreover, 217 (62.2%) respondents also disagreed the statement that smoking is not as harmful as it’s claimed on the cigarette pack. However, surprisingly, more than half of the respondents agreed that smoking is bad for smoker only if he/she smokes a lot every day (65.6%) or for many years (66.5%).

Concerning the family and peer influence, about 62.1% and 79.4% of the respondents believed that smoking status of individual is influenced by their family members or by their friends who are smokers. With regards to environmental tobacco smoking, almost all of the respondents (92.2%) agreed that parents or adults should not smoke near children. In addition, more than 70% responded that they become uncomfortable when someone smokes near them whereas only 71 (20.3%) out of 349 of the respondents agreed that they will let visitors smoke in their house.

About Malaysian government’s law and legislation against smoking, the majority of respondents (75.6%) agreed that the Ministry of Health is active in fighting against smoking. Likewise, most of them agreed that smoking should be banned in the hospital (95.1%), workplaces (86.6%), restaurants (85.9%), bars (59.9%), public transport vehicles (90%), schools (94%), universities (93.4%) and places of worship (93.5%). The opinion that the taxes for tobacco products should be increased and all cigarette advertising should be completely banned was supported by 71% and 71.4% of respondents respectively. Slightly more than half of the respondents (54.7%) agreed that the warning labels on cigarette packages led the smokers to think about quitting. With regard to the respondents' views on tobacco sales, 88.3% of them believed that tobacco sales to children and adolescents should be strictly restricted. Other than that, only 34.9% of the respondents thought that selling of cigarettes in loose form or individual sticks should not be prohibited while 49.3% disagree to this statement.

Total knowledge and attitude scores towards smoking among residents in Kampung Gong Penaga

According to the scoring system mentioned in the methodology, the respondents’ knowledge score was ranged from 14 to 57 with mean score of 47.15 (6.89). As for the attitude score, it was ranged from 50 to 133 with mean score of 102.13 (11.93) (Table 2).

Prevalence of smoking and patterns of smoking among residents in Kampung Gong Penaga

Based on the study result, there were 95 out of 349 respondents (27.2%) categorised as current smokers. Out of all those smokers, 74.7 % of them smoke every day during the previous 30 days and the rest smokes occasionally. Most of them have already established the habit of smoking at the age of 15 years old. The minimum age of the smokers started smoking was 11 years old while the oldest was 30 years old. The sources of their first cigarettes were mainly from friends (49.5%), shops (48.4%), siblings and others (1.1%) and none from their parents (0.0%). Surprisingly, as for the place of first trying smoking, school has the highest votes (31.6%) and restaurant is the lowest (2.1%).

They smoked mostly cigarettes (88.4%) and pipes were the least used (8.4%). Among all smokers, 38.9% smokes about 6-10 sticks or session per day, and most of them stated that craving for cigarettes (29.5%) and getting pleasurable feeling from smoking (27.4%) as their reasons why they keep smoking. With regards to quitting smoking, 60.0% of the smoker respondents had tried to quit smoking in the past 12 months.

Table 1: Socio-demographic characteristics of respondents (n =349)

Variables	Frequency (%)	Mean (SD)	Mini	Max
Age		39.21 (16.12)	15	90
Gender Female Male	173 (49.6) 176 (50.4)
Marital status Single Married/Widow/Divorced	111 (31.8) 238 (68.2)
Level of education Up to primary school Secondary school and above	47 (13.5) 302 (86.5)
Occupation Unemployed or student Employed	164 (47.0) 185 (53.0)
Monthly income <RM 1000 RM 1000 and above	147 (42.1) 202 (57.9)
Smokers in the family No Yes	161 (46.1) 188 (53.9)
Spouse smoking status No Yes	285 (81.7) 64 (18.3)
Father smoking status No Yes	281 (80.5) 68 (19.5)
Mother smoking status No Yes	346 (99.1) 3 (0.9)
Brother smoking status No Yes	278 (79.7) 71 (20.3)
Sister smoking status No Yes	348 (99.7) 1 (0.3)
Children smoking status No Yes	308 (88.3) 41 (11.7)
Smokers in Friends/Colleagues No Yes	117 (33.5) 232 (66.5

Table 2: Summary of total knowledge and attitude scores towards smoking among respondents (n =349)

Variables	Mean (SD)	Minimum	Maximum
Knowledge score	47.15 (6.89)	14	57
Attitude score	102.13(11.93)	50	133

Factors associated with smoking among residents in Kampung Gong Penaga

After adjusting the confounding variables using multiple logistic regression analysis revealed that being male (p <0.001), being employed (p =0.025), having smokers in the family (p =0.002), having colleague or friend smokers (p <0.001) and total attitude score were found to be significantly associated with prevalence of smoking among the respondents (Table 3).

DISCUSSION:

The Ministry of Health in Malaysia has initiated and implemented several anti-smoking policies and measures to reduce the prevalence of smoking among the Malaysian population via legislation, health promotional activities, and community intervention programs in 2005 with the ultimate aim to reduce public health problems related to smoking. In addition to active anti-smoking measures, regular monitoring of smoking prevalence to evaluate the effectiveness of anti-smoking measures is also crucial to combat smoking [4]. On the other hand, according to Theory of Planned Behaviour (TPB) and the Theory of Reasoned Action (TRA) [9], there are fundamental factors that influence the intra-personal factors including attitude, subjective norm, perceived personal control, and intently related to the behaviour. Theoretically, a person is most likely to imitate a behaviour as normal that acted by their admired people [10]. These issues called for up-to-date evidence-based findings are an important input for proper and specially tailored anti-smoking policies and programmes.

Prevalence and pattern of smoking

The prevalence of current smoking among adult Malaysians in this study (27.2%) is a little bit high compared to the findings by Rampal et al. (2003), (2006) and the National Health and Morbidity Survey (NHMS) in 2015, which found smoking rates of 25.9 %, 23.6% and 22.8 %, respectively [11,13]. However, it is higher than rates from the Global Adult Tobacco Survey (GATS) in 2011 which reported that 23.1 % of all adults were current smokers [5]. The National Health and Morbidity Survey, however, included both urban and rural populations and did not report the prevalence separately for the Malays in rural areas. [13] The prevalence of smoking among Malaysians aged 15 years and over, remains high despite the implementation of several anti-smoking measures over the past decades. In California, the smoking rate declined by (51.9%) between 1988 and 2016, from (23.7 % to 11.4 %) (14). In Thailand Overall, (24.0%) of adults (13.0 million) currently smoked tobacco in 2011[15]. This could be due to the fact that other countries with more successful reduction in smoking prevalence quickly adopted the World Health Organization’s Framework Convention on Tobacco Control, while Malaysia has a shorter history of implementing tobacco control measures and these variations may be due to differences in the tobacco control programs and legislation implemented in these countries.

Regarding the smoking pattern in this study, there were 95 out of 349 respondents (27.2%) are current smokers. Out of all those smokers, (74.7 %) of them smoke every day and the rest smokes occasionally during the previous 30 days. Similar to other research findings, most of them have already established the habit of smoking at the age of 15 years old. The minimum age of the smokers started smoking was 11 years old while the oldest was 30 years old [10]. Also consistent with other research the sources of their first cigarettes were mainly from friends, shops, siblings and others. Surprisingly, as for the place of first trying smoking at school with the highest votes and a restaurant is the lowest. They smoked mostly cigarettes and least pipes. Majority of smokers smokes about 6-10 sticks or session per day, and most of them eager for cigarettes and getting pleasurable feeling from smoking was the reason why they reluctant to quit smoking that was lower than the previous study revealed the proportion of Malaysian adults who smoke more than 21 sticks per day had increased by (18%) from 2006-2012 [13].

Socio-demographic Characteristics

Regarding the respondents’ age factor, there was no significant association between respondents age and smoking status (p=0.833). Unfortunately, our result was opposed by previous studies, their results showed a significant association between ages and smoking status. Study conducted by (16) showed the prevalence of smoking decreased with advancing age; (59.3%) among 21–30 years old to (56.8%) among 31–40 years old to (48.5%) among 41–50 years old and further decrease to (35.0%) among those aged 61 and above. In addition, a study by the Global Adult Tobacco Survey (GATS) showed a similar prevalence of current smokers in Malaysia was higher among the 25–44 years old age group (54.9%), decreased to (43.8%) for 45–64 years old age group and decreased further to (25.3%) for respondents 65 years old and above [17]

In this study, there is an association between gender and the smoking prevalence among the residents in Kampung Gong Penaga (p <0.001). Females who were currently smoking within one month was low (1.2%) compared with males (52.8%). It is slightly different with the prevalence on national level conducted in the year 2015, where the prevalence of current tobacco smokers among men was (43.0%), compared with just (1.4%) among women [13]. In the national level, the prevalence for women is slightly higher compared to this study prevalence. Possible reasons might be, the respondents were all Malay in ethnicity. In Malay ethnic, smoking among females is considered as less socially acceptable behaviour.

Based on occupational results, (53.0 %) were employed while the rest are unemployed or students. Being employed were found to be significantly associated with the prevalence of smoking among the respondents (p<0.001). Our results are opposed by a study in which there was significantly associated with the type of occupation with current smoking status [16]. Previous literature studies reveal the elementary workers and agricultural workers had a higher tendency to smoke than those in management and other professional occupations. This finding is consistent with what has been reported from previous studies in Europe, Asia and Finland were postulated that lower- level occupational groups face more physical and psychosocial stressors compared to the managerial and professional classes and therefore, are more likely to engage in high-risk health behaviours such as smoking. Moreover, in Finland, smoking prevalence was also found to be high in people with low socioeconomic levels and still working that may be due to psychological stress in which they still need to work, and their daily life is a factor they still smoke to reduce psychological stress especially older ages. In addition, smoking practices may be a habit practiced by colleagues [17, 18].

Knowledge regarding tobacco smoking

In order to achieve successful tobacco control measures, smoking-related community understanding and behaviour are needed to be evaluated. In this sense, the study assessed the respondents’ knowledge regarding tobacco smoking and its effect on health issues and their attitude towards smoking. In this study, the respondents’ knowledge score was ranged from 14 to 57 with a mean score of 47.15 (6.89) and the attitude score ranged from 50 to 133 with mean score of 102.13 (11.93) regarding tobacco smoking and its effect on health issues while Ukraine recorded the highest mean summary knowledge score (3.84), 95% CI (3.75; 3.92)(19).Fortunately, majority knew that the tobacco products are present in manufactured cigarettes (91.1%), hand-rolled cigarettes (84.8%) and cigars (68.8%) while only some respondents knew that shisha smoking (22.3%) and electronic cigarettes (17.8%) contain tobacco products. However, almost all of the respondents (97.4%) knew that smoking can lead to addiction. Quite similar findings of other studies in California, Malaysia, Pakistan, Saudi Arabia, and China respectively have been evidenced [10, 20, 24].

Among the respondents of this study ninety present (90%) of them were aware of that cigarette contains carcinogenic compounds and smoking tobacco is hazardous to health. Most people from the village recognized that tobacco smoking causes lung cancer, heart attack, and chronic bronchitis. However, 47 respondents (13.5%) were not aware of smoking causes impotency in males and 144 (41.3%) respondents were unsure about tobacco smoking causing cervical cancer in females. Studies regarding health and awareness evidenced Indians (31.8%), Nepalese (0.2%) and Sri Lankans( 20.8%) were aware of smoking causing cervical cancer [25]. The higher percentage among Malaysians may be due to a better spread of awareness by anti-smoking campaigns conducted by the government compared to the other countries. Recent decades researches have compiled evidences on relationship between cigarette smoking and erectile dysfunction. This factual knowledge is a part of public education in the western countries. In Malaysia, sexual impotency in male due to smoking was unlikely to be mentioned in the anti-smoking campaign or public education; therefore, within the community regarding erectile dysfunction in males and its association with smoking has been overlooked.

Exploring previous literature concerning knowledge of smoking effect on health issues especially smoking causes lung cancer is proved to be lower; the percentages depicted are Iraq (30.1%), China (53.7%) in female smokers (84.7%) in male who are non-smokers, Nigeria (58.3%) and Ukraine (89%) respectively [19,26, 28]. However their respondents knew smoking can cause impotence in male smokers (52.6%), premature aging (64%) and stroke (66.3%). Iranian were confirmed to have knowledge that smoking can cause heart disease (69%), and cause bronchitis (58%), cause stroke (38%) and Ukraine’s respondents had knowledge that smoking can cause impotence, caries, and infertility in [19]. One Chinese study revealed less than half of the respondents had knowledge that smoking causes heart attack and stroke were evidenced in percentages 48.0% and 21.4% respectively, these respondents were smokers had either stroke or heart attack in the past [27]. Reviewed literature on cross-sectional survey of smoking among Vietnamese adults showed that general knowledge score on specific diseases related to tobacco smoking such as stroke, heart attack, and lung cancer was lower in percentage i.e. 51.5% than that of current study results [29].

In this study, concerning smoking effect on pregnancy, most of the respondents i.e. 70.8% knew that pregnant women smokers can increase the risk of stillbirth; higher percentage i.e. 73.6% of respondent’s revealed having knowledge regarding low birth weight found with. These results were compatible with another literature study conducted on American women of child bearing age who were smokers, result of this study revealed 96.0% of them aware that smoking can cause low birth weight and only 57.0% of them knew smoking can cause stillbirth [30]. Nearly 80% of our respondents knew that smoking can cause congenital abnormalities that were comparable to the previous study conducted in a southern Brazilian city that was 88.1% [31]. Effectiveness of health warning and pictures of babies with congenital abnormalities and others which displayed on cigarettes packaging might be one of the reasons for a good level of knowledge among the respondents.

Second-hand smoke is a real and significant threat to public health. Both smokers and non-smokers can acquire adverse health effects from the smoke of burning cigarettes. For smokers, via inhaling mainstream (MS) smoke, for non-smokers inhale mostly side stream (SS) smoke, which is produced into the surrounding air between puffs from the end of the smouldering cigarette. Therefore, side stream smoke is a major source of environmental tobacco smoke (ETS) [32]. In this study, the harmful effects of second-hand smoke were also recognized among 92.8% of the respondents. The current study documented the children and babies effected by the second-hand smoke cause health issues were noticed such as cough (92.3%), wheezing (84.0) % and asthma (90.8%) except ear infections (44.7%). The results found to be higher in their percentage in comparison to the previous study that was (83%) in Vietnam [29].

Concerning the law for tobacco products in Malaysia, more than half, 60 (17.2%) respondents were not aware. The majority of respondents were aware of “smoke-free zone” (94.0%). The legal age for smoking in Malaysia which is 18-year-old was known correctly by 65.3% of the respondents. This study also evidenced almost all respondents i.e. 97.1% also noticed health warnings on cigarette packages, the respondents (59.9%) were known that cigarettes cannot be sold in loose forms such as individual sticks. This study, also evinced all respondents i.e. 90.5% were aware of anti-smoking activities, the information which they attained through television, newspaper, poster, and radio.

Attitude towards smoking

In this study the concept of smoking evidenced in respondent’s attitude towards smoking; here the respondents disagree with smoking helps to reduce stress (49.3%), gives satisfaction (46.4%), makes weight loss (41.0%), increases work performance (51.6%) and is a symbol of attraction to women (67.6%). This concept was supported by the previous study at IUMK in Kuantan revealed that the highest percentage of respondents disagreeing to smoking was giving the satisfaction, releasing stress and controlling body weight [22] Moreover, 217 (62.2%) respondents also disagree the statement that smoking is not as harmful as it’s claimed on the cigarette pack.

The similar results showed in the previous literature, the respondents (20% to 25%) thought the effect of smoking is not harmful as it was depicted on the pack [33]. However, surprisingly, more than half of the majority of respondents (65.6%), these respondents (66.5%) also agreed that smoking is bad for smoker’s health if they are excessive smokers or smoking since many years these results comparable with the previous study findings of Riyadh, Saudi Arabia [33].

Influences on Smoking behaviour

Concerning the family and peer influence, about (62.1%) and (79.4%) of the respondents believed that smoking status of individual highly influenced by their family and friends who are smokers. One previous study in this area depicted only 12% which was much lower in its percentage [34]. With regards to environmental tobacco smoking, almost all the respondents (92.2%) agreed that parents or adults should not smoke children around. In addition, more than (70%) responded revealed their discomfort when someone smokes in their proximity, whereas 71 (20.3%) out of 349 of the respondents were comfortable and let visitors smoke in their house. This result was supported by the previous study, with respect to the health effects on the passive smokers, most of the health professionals agreed that smokers should be given the advice to avoid smoking around children [35].

About the Malaysian government’s law and legislation against smoking, the majority of respondents (75.6%) agreed that the Ministry of Health is active to fight against smoking. Likewise, most of them agreed that smoking should be banned in the hospital (95.1%), workplaces (86.6%), restaurants (85.9%), bars (59.9%), public transport vehicles (90%), schools (94%), universities (93.4%) and places of worship (93.5%). The opinion that the taxes for tobacco products should be increased and all cigarette advertising should be completely banned was supported by (71%) and (71.4%) of respondents respectively. That was supported by the previous studies done among different countries [24, 36, 37]. More than half of the respondents (54.7%) agreed that the warning labels on cigarette packages led the smokers to think about quitting. However in the previous study, less than half, only (42.9%) of respondents agree that pictorial health warnings on cigarette packs are very successful in influencing the smokers to cease smoking [38].

With regard to the respondents' views on tobacco sales, (88.3%) of them believed that tobacco sales to children and adolescents should be strictly restricted. This finding was supported to the previous study showed that tobacco sales should be prohibited to children as well as a youth has been agreed by most of the health professionals (35). Other than that, only (34.9%) of the respondents thought that selling of cigarettes in loose form or individual sticks should not be prohibited while 49.3% disagree with this statement. According to the previous study, a high percentage (94.6%) of respondents agreed that selling cigarettes in sticks or loose packets should be banned (37). In this study, after adjusting the confounding variables using multiple logistic regression analysis revealed that being male, being employed, having smokers in the family, having colleague or friend smokers and total attitude score was found to be significantly associated with the prevalence of smoking among the respondents. This finding was similar to the findings of a previous study in IUMK in Kuantan [22].

The known fact is that no research studies are free from limitations. Indeed, the observed limitations of the current study are firstly, the study being cross-sectional allows the investigation of the relationship only between socio-demographic variables and smoking. Secondly, smoking status was determined via self-response of tobacco smoke by using simple written question without objective biochemical verification. This could include second-hand smoke and environmental smoke questionnaires. Thirdly, smoking behaviour, such as knowledge, attitude and tried to quit smoking among adult female smokers who have been identified as determinants of smoking were not assessed in this study. Lastly, the representativeness and adequacy of sample size, as well as the high response rate cannot be generalized to other states.

SUMMARY AND CONCLUSION:

The current study concludes with signifying the importance of understanding various factors associated such as socio-demographic characteristics among residents, knowledge regarding tobacco smoking and its effect on health issues and various demographic aspects of smokers influencing their attitudinal changes regarding smoking. The findings of the current study reveals the smoking prevalence among Malaysian males, being employed, having smokers in the family, having colleague or friend who are smokers, and smokers rated poor attitude scores towards tobacco smoking. Thus the study findings call upon the immediate actions for planning, implementation, and bringing improvement of existing anti-smoking policies. The study signifies the need for targeting these sub-populations to reduce the morbidity, mortality and economic burden of the country. The current study opens a door to future researches which addresses validity and reliability of intra-personal behaviour exploration questionnaires, large-scale surveys observing at other tobacco use behaviours. Specifically smoking behaviour can include, use of smokeless tobacco, pipes, and cigars, studies can further explore by making comparisons. The current study, further recommends research studies on Malaysian states with and without state-wide smoking bans, and longitudinal studies of young adults by gender, their successes and challenges in tobacco use cessations. The implication of this study can aid the community health workers to curb this social malaise and promote health.

DISCLOSURE:

The authors report no conflicts of interest in this work.

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