WILLINGNESS TO SMOKING AMONG COLLEGE STUDENTS: A MODIFICATION OF THEORY OF PLANNED BEHAVIOR

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1 Original Article 297 WILLINGNESS TO SMOKING AMONG COLLEGE STUDENTS: A MODIFICATION OF THEORY OF PLANNED BEHAVIOR Monthira B. Thaveesri 1, Rungpetch C. Sakulbamrungsil 2, Nopdol Thongnopnua 3, Anuchai Theeraroungchaisri 2, Cha-Oncin Sooksriwong 4, Wirat Tongrod 1 1 Faculty of Pharmaceutical Sciences, Huachiew Chalermprakiet University, Samuth Prakarn 10540, Thailand 2 Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok 10330, Thailand 3 Faculty of Pharmaceutical Sciences, Srinakharinwirot University, Nakornayok 26120, Thailand 4 Faculty of Pharmaceutical Sciences, Mahidol University, Bangkok 10400, Thailand ABSTRACT: The study enhanced understanding of factors that determine smoking behavior of college student by including willingness to smoke variable into the theory of planned behavior model (TPB). It was expected that the modified model incorporating willingness and its antecedent constructs i.e., prototypes or social images would provide more predictive validity to intention and smoking behavior. College students (N=769) completed questionnaires measuring sociodemographic information, affective attitudes, instrumental attitudes, descriptive norms, injunctive norms, PBC, intention, willingness, prototypes, perceived risks, and smoking behavior. Structural equation models revealed that in the modified model, variance of willingness to smoke was explained by 18%, intention to smoke 40.6%, and smoking behavior 17.6% whereas TPB constructs under the nest of the modified model, i.e., affective attitudes, instrumental attitudes, descriptive norms, injunctive norms, and PBC could explain 33.8% of variance of intention to smoke and 12.0% of smoking behavior. As expected, including the willingness and prototypes increased predictive validity of intention by 6.8%, and smoking behavior by 5.6%. However, the TPB model solely explained 47% of intention variance and 39.7% of smoking behavior. Keywords: Theory of planned behavior, prototype/willingness, college students, smoking, structure equation model INTRODUCTION Smoking is one of risk behavior problems worldwide, including Thailand [1]. More than 10 million (21.2%) of Thai people addict to cigarettes smoking [2]. Amongst regular smokers to begin smoking, a group of years was the highest at 84% and its average age was 18.4 years old [3]. Therefore, the identification of significant determinants lead to smoking in college group who are at this age range is very important. Metaanalysis revealed that the theory of planned behavior (TPB) model could explain on average 27% of the variances of studied behaviors [4]. The TPB [5, 6] states that, attitudes toward behavior, norms, and perceived behavior control, have causal impacts on the behavior through the mediation of behavioral intention. Smoking behavior was statistically significant with attitudes towards smoking [7]. The rational process of TPB is based on assumption that the decision making, i.e., behavioral intention to perform behavior of interest is deliberative and logical sequences [5, 6]. * Correspondence to: Monthira B. Thaveesri Monthira@Hcu.ac.th Gibbons & Gerrard studies [8,9] argued that risktaking, such as smoking in young adolescents, was not intended or planned. They have developed the prototype/willingness (P/W) model, which proposed a second path behavioral willingness, to health risk behaviors other than behavioral intentions. The model suggested that adolescents often brought themselves into the risk taking behavior situations, e.g. drinking, smoking, and unprotected sex. Once in the situation, for many young people, it is their desires or willingness to join or engage in the behavior with no planned intention prior to the situation. There has been no study employing the willingness construct in explaining smoking behavior of college students in Thailand. The current study thus aims to understanding the factors involved smoking behavior of college students by including willingness in the TPB model. MATERIALS AND METHODS Participants One private college was purposively selected as the studied site. Anonymous questionnaires were distributed to 769 undergraduate students in several

2 298 Original Article classrooms. The study was approved by the HCU Ethic Committee, Huachiew ChalermPrakiet Unversity, Thailand. Measures Attitudes toward smoking were measured on 7- point bipolar scales. Two aspects of attitudes included: Affective attitudes which were defined as the extent of the feeling experienced or expected from smoking whether it was Relaxed-Stressed, Excited- Bored, and Unpleasant-Pleasant [10, 11]. The Cronbach alpha of affective attitudes scale was Instrumental attitudes which were defined as the extent of the feeling toward smoking behavior whether it was Admirable-Offensive, Foolish-Wise, Not appropriate-appropriate, Right-Wrong, and Bad-Good. The Cronbach alpha of instrumental attitudes was Norms including injunctive and descriptive norms were measured by rating on 7-points scale ranged from 1 disagree to 7 agree. Injunctive norms was defined as the extent of belief on smoking behavior acceptance by significant others, including father, mother, important person, and people who love them [10, 11]. The Cronbach alpha of the injunctive norms showed Descriptive norms was defined as how much they believed their important person, people at their age, and their close friend smoked [10, 11]. The Cronbach alpha of this scale was Perceived behavior control (PBC) [11]: Perceived control of ability to refrain from smoking was assessed on 7-point scale of disagree-agree to 3 statements: I can control myself quite well for not smoking even I feel like to., I have self confident that I can control myself for not smoking., and If I make my decision for not smoking, I am sure that I can do. The Cronbach alpha of the scale was Perceived risks: Conditional perceived risk [8] was assessed by 2 statements If I regularly smoke the same amount of cigarettes smoked by people at my age, I will have high chance to get laryngeal cancer., and People at my age who smoke have high chance to get laryngeal cancer. The 7-point scale of disagree-agree was used and the Cronbach alpha was Prototypes/typical images: Prototypes or typical images were common characteristics of smokers that they pictured in mind, with no specific to anyone in particular [8, 9]. In our study, typical images of smokers emerged from an interview with a small group of college students. Factor analysis revealed two factors: positive prototypes, and negative prototypes. Response on 7-point scale ranged from 1 disagree to 7 agree. Positive prototypes included attractive, smart, charming. The Cronbach alpha was Negative prototypes included confused, cough, and uncontrolled. The Cronbach alpha was Behavioral willingness referred to willingness to smoke in a specific circumstance [8, 9]. Willingness to smoke was measured respondents smoking decision under 3 different scenarios respondents were prone to join. The decision choices were no smoke, try to smoke, and smoke as desire. Three scenarios included Scenario at party: Cigarettes are provided enough for everybody, my willingness to smoke would be Scenario with friends: Cigarettes are provided enough for everybody, my willingness to smoke would be Scenario in room accommodation: Cigarettes are provided, my willingness to smoke would be Behavioral intention was assessed by 3 items: I believe in myself that I will not smoke., I won t smoke even my close friend ask me to do., and I never think of self smoking. using 7-point scale ranged from 1 disagree to 7 agree. The Cronbach alpha was Smoking behavior was measured on current and past smoking behaviors. Current smoking status: Participants were asked to categorized themselves as one of the 4 groups: No smoking, Trial, Occasionally smoke, Daily smoke, and Quit smoking. Last time smoke: Participants classified themselves about their past smoking behaviors as one of these: Never smoke, Had tried, Last smoke occurred within 1 month, Last smoke occurred within 6 months, and Last smoke occurred within one year or more than one year. Data analysis Measurement model comprising the hypothetical constructs of the TPB, and the modified TPB model were developed. Confirmatory factor analysis (CFA) was conducted to test the preconceived theory. The sample was randomized into two subsample groups approximately 50% of cases. The first subsample (N=382) was used for model development and the other subsample (N=387) was used for model validation, providing a second confirmation of the measurement theory that survived initial testing. Structural equation model (SEM) The relationships amongst constructs were J Health Res vol.26 no.6 December

3 Original Article 299 conceptualized in a structural model. LISREL 8.8 for Windows with Maximum Likelihood (ML) method [12] was used for SEM analysis. The firstorder models were tested and the extent of covariance matrices accounted by the observed data was reported. Determination of model fit was based on model characteristics and combinatorial fit indices [13]. TPB and the modified Models: The TPB model consisted of the components of TPB, i.e., affective attitudes, instrumental attitudes, descriptive norms, injunctive norms, perceived behavior control, intention to smoke, and smoking behavior. The modified TPB model comprised the TPB with addition of willingness construct, positive prototypes, negative prototypes, and perceived risks construct. RESULTS Of this sample, 609 (79.2%) were female, and 160 (20.8%) were male. The age of the participants ranged from 17 to 25 years (Mean = 20.6 years, SD = 1.5). A confirmatory factor analysis was conducted to verify the latent variables of each item. All factor loadings were significant (Table 1). Cross validation of subsample 2 also had a good fit. Table 2 displayed the correlations among the latent variables obtained from SEM. The path diagram of TPB model in Figure 1 demonstrated that all of the determinant variables had direct effects on the intention to smoke with 47% predictive value and 39.7% on smoking behavior. Of the modified model, all factor loadings of CFA were significant (Table 3). Correlations among construct variables were illustrated in Table 4. Cross validation of subsample 2 displayed a good fit. Path analysis of the modified TPB model was demonstrated in Figure 2. The modified model exhibited effects of variables with 18% predictive value on the willingness to smoke, and 40.6% on the intention to smoke. Overall, the model could predict 17.6% of smoking behavior variance. Under the nest of the modified model, when only the hypothethical constructs of TPB were free to intention to smoke and smoking behavior, the model explained 33.8% of intention to smoke, and explained 12.0% of smoking behavior. Including the willingness factor increased the predictive validity of intention to smoke and smoking behavior by 6.8%, and 5.6% respectively. Table 1 Factor loadings of CFA (TPB model) Construct and indicator Factor loadings Descriptive Norms People of same age smoke.45 Important person smoke.41 Close friend smoke.76 Injunctive Norms Mother disapproved smoking.70 Father disapproved smoking.79 Important person disapproved smoking.71 People who love me disapproved smoking.66 Affective Attitudes Relaxed-stressed.72 Excitedbored.71 Unpleasant-pleasant.80 Instrumental Attitudes Admirable-offensive.71 Foolish- wise.74 Not appropriate-appropriate.79 Right-wrong.69 Bad-Good.76 Perceived Behavior Control (PBC) when feel like to smoke.65 Confidently.77 If decision is confirmed.71 Intention to smoke Intention not to smoke.74 Not smoke even close friend ask to.80 Never think of self smoking.70 Smoking Behavior Smoke status (Smoke).87 Last time of smoking (Pbeha).76 All loadings significant P<0.001; 2 (209, n = 382) = , P =.00; CFI =.98; RMSEA =.05; SRMR =.05 Table 2 Correlations among constructs of TPB Intention to smoke - 2. Smoking behavior Descriptive norms Injunctive norms Affective attitudes Instrumental attitudes Perceived behavior control

4 300 Original Article 2 (4, n = 382) = , P = 1.00, CFI = 1.00; RMSEA = 0.0; SRMR = ; R 2 intention to smoke = 47.0%, and R 2 smoking behavior = 39.7% Figure 1 Path analysis of TPB model Table 3 Factor loadings of CFA (the modified TPB model) Construct and indicator Factor loadings Construct and indicator Factor loadings Descriptive Norms Positive Prototypes People of same age smoke.45 Attractive.60 Important person smoke.44 Smart.76 Close friend smoke.74 Charming.81 Injunctive Norms Negative Prototypes Mother disapproved smoking.69 Confused.63 Father disapproved smoking.78 Cough.73 Important person disapproved smoking.71 Uncontrolled.71 People who love me disapproved smoking.69 Willingness to smoke Affective Attitudes At party.93 Relaxed-stressed.71 With friends.95 Excited- bored.72 Room accommodation.87 Unpleasant-pleasant.80 Intention to smoke Instrumental Attitudes Intention not to smoke.75 Admirable- offensive.72 Not smoke even close friend ask to.81 Foolish-wise.74 Never think of self smoking.69 Not appropriate-appropriate.79 Perceived Risks Right- wrong.69 Laryngeal cancer occurs to me.82 Bad-Good.76 Laryngeal cancer occurs to others.84 Perceived Behavior Control (PBC) Smoking Behavior When feel like to smoke.64 Smoke status (Smoke).91 Confidently.78 Last time of smoking (Pbeha).73 If decision is confirmed.72 All loadings significant P<0.001; 2 (472, n = 382) = , P = 0.0 CFI =.98; RMSEA =.05; SRMR =.04. Table 4 Correlations among constructs of the modified TPB model Willingness to smoke - Intention to smoke.51 - Smoking behavior Descriptive Norms Injunctive Norms Perceived Risks Positive Prototypes Negative Prototypes Affective Attitudes Instrumental Attitudes Perceived Behavior Control J Health Res vol.26 no.6 December

5 Original Article 301 Note: * Non significant, 2 (6, n = 382) = 5.95, P = 0.43, CFI = 1.00; RMSEA = 0.0; SRMR = ; R 2 willingness to smoke 18.0%, R 2 intention to smoke = 40.6%, and R 2 smoking behavior = 17.6% Figure 2 Path analysis of the modified model DISCUSSION All three main factors, i.e., attitudes, norms, and perceive behavior control, explained the intention to smoking and smoking behavior quite well under the TPB model [14]. Affective attitudes and instrumental attitudes had been included into the modified model to provide a more contribution of unique variance [11, 15]. Affective attitudes and instrumental attitudes had direct effects to intention to smoke 0.59, and 1.00 respectively. These factors could be interpreted as participants with more positive attitudes toward smoking increased their intentions to smoke. Consistent to the previous study in Thai adolescents [16]. The effect of attitudes was strong and directly to intention to smoke. Additionally, negative affective attitudes was associated with the intention to quit smoking [17]. Descriptive norms seemed to be a better predictor of intention than injunctive norms. The direct effects of the PBC on the intention to smoke and the smoking behavior were 1.13, and respectively. Since smoking is not a goal-oriented behavior, perceived behavioral control over no smoking should lead to negative behavioral intention and smoking behavior. However, the behavioral intention showed the opposite result. On the other way, the perceived control over no smoking caused less of smoking behavior because it exerted its direct effect by taking into account available information, opportunities, skills, and other resources required to perform the behavior as well as possible obstacles that might have to be overcome. Under the frame of the modified model, willingness construct contributed additional variance on intention by 6.8% and smoking behavior by 5.6% when comparing variance explanation of TPB in the nest model. Both constructs of norms, and positive prototypes had direct impacts on the willingness to smoke significantly but not attitudes or negative prototypes. Consistent to P/W model: the more concern to positive images increased the more willingness to smoke, willingness that was not apparently intended but rose up according to the opportunity of engaging in the risk behavior in riskconductive situations. Whereas not explicitly demonstrated, the present results support the idea of dual process models. Psychological and neuropsychological evidences had supported the structure of dual process models posit that humans possessed two memory systems [18]. Basically one system was based on fast, effortless, and automatic retrieving process and the other was based on slow, effortful, and logical thinking process. If the intention was on the side of logical system, perhaps the willingness could be on the other side as the reaction process. Fishbein and Ajzen [19] argued that asking people under certain circumstances whether they would or would not perform the behavior might simply measure a more specific intention than a plain intention in general situations. Dual-mode processing models of human judgment implied that the TPB was consistent with this approach [20]. Specifically, at one end of the information processing continuum, the unfamiliar situations were assumed to bring careful

6 302 Original Article deliberation to mind and evoked the production of beliefs, attitudes, and intention that subsequently directed to behavior. At the other extreme, routine behaviors were supposed to be performed spontaneously and to be guided by automatically activated attitudes and intentions. However, as of the test results from this study, it was evidenced that the willingness and the intention were distinct constructs and had some correlations as there were not spurious effects arising from the same common causes of attitudes and norms. Besides, path analysis revealed that the effects of norms, attitudes, perceived risks of smoking, and typical images of smoking to the willingness and to the intention were differently in both directions and scales. CONCLUSION The current findings provided support for direct effects of prototype images influence on the willingness to smoke. The social images could extend more understanding in smoking behavior among college students. The more concern of the social images affected the willingness to engage in the behavior and eventually to engage in smoking behavior. Under the modified model, willingness construct added the unique variance on the intention to smoke and smoking behavior, however the TPB model itself, with only attitudes, norms, and PBC could provide more explanation of the intention to smoke and smoking behavior above the modified model. LIMITATION First, the actual behaviors of participants were obtained at the same time as the measures of behavioral willingness and behavioral intention. Therefore, the temporal sequence of cognitive determinants and the actual smoking behavior could not be observed directly. However, the study was based on the most commonly used theoretical model (TPB) and used the structure equation modeling as an analysis could provide some confidence when results revealed the model fit. For this reason, a longitudinal extended temporal sequence measurement was not likely to generate a largely different relationship between behavioral determinants and smoking behavior. Second, the sampled population was college students. The effects of components might behave differently with the other populations. ACKNOWLEDGEMENTS We are thankful to Prof. Tsuneji NAGAI, the expresident of FAPA-CP for granting some funds and Assoc. Prof. Dr. Pornpen PAMYOTHIN, the president of FAPA-CP for her kindly support about the study. REFERENCES 1. World Health Organization. WHO report on the global tobacco epidemic, The MPOWER package [cited 2011 March 25]. Available from: tobacco/mpower/mpower_report_full_2008.pdf/2 2. National Statistical Office. Summary results of smoking and drinking alcohol consumption among Thais; 2007 [in Thai]. [cited 2011 March 25]. Available from: um_alco-ciga50.pdf 3. Hamann S, Charoenca N, Kungsakulniti N, Sirichotiratana N, Pawaputanont na Mahasarakham C, Jiratananont S. Revision of knowledge about tobacco consumption control. Bangkok: Kaenjan Press; 2005 [in Thai]. 4. Armitage CJ, Conner M. Efficacy of the theory of planned behavior: a meta-analytic review. Br J Soc Psychol. 2001; 40: Fishbein M, Ajzen I. Belief, attitude, intention and behavior : an introduction to theory and research. Reading, Mass : Addison-Wesley; Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall; Ko Ko AM, Hongsranagon P, Havanond P. Knowledge, attitude and practices (KAP) on cigarette smoking among adult Myanmar migrant workers: a case study in Ratchaburi province, Thailand. J Health Res Oct- Dec; 26(4): Gibbons FX, Gerrard M, Blanton H, Russell DW. Reasoned action and social reaction: willingness and intention as independent predictors of health risk. J Pers Soc Psychol. 1998; 74: Gerrard M, Gibbons FX, Stock ML, Van de Lune LS, Cleveland MJ. Images of smokers and willingness to smoke among African American pre-adolescents: an application of the prototype/willingness model of adolescent health risk behavior to smoking initiation. J Pediatr Psychol. 2005; 30: Hagger MS, Chatzisarantis NLD. First- and higherorder models of attitudes, normative influence, and perceived behavioral control in the theory of planned behaviour. British J Soc Psycho. 2005; 44: Kraft P, Rise J, Sutton S, Roysamb E. Perceive difficulty in the theory of planned behavioural control or affective attitude? Br J Clin Psychol. 2005; 44: LISREL for Windows [computer software]. Version 8.8. Lincolnwood (IL): Scientific Software International; Hair JF, Black WC, Babin BJ, Anderson RE, Tatham RL. Structural Equation Modeling: an Introduction. In: Stevens K, editor. Multivariate data analysis. 6th Edition. New Jersey: Pearson Prentice Hall; p Ajzen, I. The theory of planned behavior. Organ Behav Hum Decis Process. 1991; 50: J Health Res vol.26 no.6 December

7 Original Article Ohtomo S, Hirose Y. The dual process of reactive and intentional decision-making involved in eco-friendly behavior. J Environ Psychol. 2007; 27: Ua-Kit N, Phuphaibul R, Panitrat R, Carol JL, Vorapongsathorn T. Cigarette smoking behavior among Thai adolescents in Metropolitan Bangkok. Thai Journal of Nursing Research. 2004; 8: [in Thai] 17. Hosking W, Borland R, Yong H, Fong G, Zanna M, Laux F, Thrasher J, Lee WB, Sirirassamee B, Omar M. The effects of smoking norms and attitudes on quitting intentions in Malaysia,Thailand and four Western nations: a cross-cultural comparison. Psychology & Health. 2009; 24: Smith ER, DeCoster J. Dual-process models in social and cognitive psychology: conceptual integration and links to underlying memory systems. Pers Soc Psychol Rev. 2000; 4: Fishbein M, Ajzen I. Predicting and changing behavior: the reasoned action approach. New York: Psychology Press; Ajzen I, Sexton J. Depth of processing, belief congruence, and attitude-behavior correspondence. In: Chaiken S, Trope Y, editors. Dual process theories in social psychology. New York: Guilford; p