Health Promotion Model Not Smoking among Adolescents: A Path Analysis Evidence from Indonesia

Smoking behavior is a threat to public health. This study identified factors that influence non-smoking behavior among adolescents. The aim is to determine the effect of media exposure, knowledge of the dangers of smoking, social capital, access to cigarettes among adolescents by using Theory of Planned Behavior (TPB).This cross-sectional study was conducted in Kulon Progo Regency, Yogyakarta Province, Indonesia, in April - May 2018. The dependent variable is non-smoking behavior. Independent variables were intention to not smoke, attitude to smoking, knowledge of tobacco use, subjective norms of not smoking, control of perceived behaviors for not smoking, media exposure to cigarette advertising, access to cigarettes and social capital among teenagers. Data were collected by questionnaire and analyzed by path analysis carried out in Stata 13.This study resulted in an attitude towards not smoking (b = 1,15; 95% CI = 0,55 to 1,75; p< 0,001), subjective norm for not smoking (b = 1,56; 95% CI = 0,96 to 2,16; p <0,001), and perceived behavioral control for not smoking (b = 1,99; 95% CI = 1,39 to 2,60; p <0,001), which affects the intention of not smoking, and finally on non-smoking behavior. Exposure to tobacco advertising has an indirect impact on non-smoking behavior through attitudes toward non-smoking (b = -0,82; 95% CI = -1,28 to -0,37; p< 0,001) and the intention not to smoke. This exposure to cigarette advertising also has an indirect impact on non-smoking behavior through low knowledge about smoking (b = -0,45; 95% CI = -0,47 to -0,03; p = 0,037). Weak social capital has an indirect impact on non-smoking behavior through subjective norms of smoking (b = 0,64; 95% CI = 0,25 to 1,05; p = 0,001) and the intention not to smoke. Knowledge about tobacco smoking (poor) impact on perceived behavior control not to smoke (b = 1,59; 95% CI = 1,15 to 2,03; p <0,001) and influential to attitude positive toward no smoking (b = 1,60; 95% CI = 1,16 to 2,05; p <0,001).Health promotion model with Theory of Planned Behavior (TPB) can be used to explain not smoking behavior among adolescents.  


INTRODUCTION
The active smokers of the Indonesian population aged 10 years and over the prevalence There were 64.9% of male sex and 2.1% of female sex Indonesian residents who still smoked cigarettes in 2013 (1). Teenage smoking behavior is caused by a high curiosity for all things (2). A study in Malaysia stated that the minimum age for smoking is 10 years while the maximum age is 40 years. Most participants start smoking at the age of <20 years with a higher frequency of 18 years. More than half of the participants 58.5% stated that peer influence to use smoking ( 3).
Smoking can provide pleasure to the smoker himself, but on the other hand it can also have a negative impact on the smoker himself and for those around him. Someone who is exposed to cigarette smoke for eight hours is comparable to direct smoking as many as 20 cigarettes a day. A study says that heavy smokers are more susceptible to autonomic dysfunction and can cause the development of cardiovascular disease in smokers (4) Questioner. Data was analyzed using Chi-Square and the result was junk food consumption leading to 4 times risk for hypertension (OR, 4,083, lung cancer and adenocarcinoma (6). The efforts of the central and regional governments by making regulations on smoke-free areas.
The Kulon Progo regent has even made regulations regarding the prohibition of cigarette advertisements in the form of billboards on the street protocol.
The teenagers hope that who are already smoking can gradually reduce the frequency of smoking and even stop smoking after knowing a lot of the harmful ingredients in cigarettes.
Research conducted in India regarding nicotine content in cigarettes caused a person to become addicted by doing in-vitro development and evaluation of nicotine troches for smoking cessation (7). The purpose of this study was to identify the factors that influence nonsmoking behavior in adolescents in Kulon Progo Yogyakarta.  (8).   Table 3 shows the results of the final path   model analysis, the path analysis table is     On the indirect effects, Table 3 also shows that perceived behavioral control for not smoking

Discussion
Adolescence is a transition period between childhood and adulthood. Social life at the level of adolescence is characterized by prominent intellectual and emotional functions. This situation, according to Erickson, is referred to as a period of identity crisis, which is a very complex process of forming self-identity and selfconcept of adolescents (10). This study aims to test the hypothesis of using Theory of Planned Behavior (TPB) that the stronger the intention not to smoke, the more likely someone is not to smoke. In addition to the intention, there are also other factors that will be discussed in this study.

Non-Smoking behavior and intention
The results of path analysis show that there is a direct influence between adolescent's intention not to smoke on non-smoking behavior with a positive correlation coefficient. This study provides empirical evidence that supports TPB.
This finding is consistent with previous research which said that 78% of students in Iran in 2014 who did not smoke were controlled by the intention not to smoke, while 22% were again influenced by behavioral control factors (11).
Someone who has a strong intention to stop smoking, then the smoking behavior gradually will also decrease (12).

Non-Smoking behavior and attitude
There is an indirect relationship between

Non-Smoking behavior and perceived behavior control (PBC)
According to TPB, the effect of PBC on behavior can be direct or indirect. This is consistent with research that states that there are 22% perceived behavioral control that can affect someone to behave smoking (11).
Another study said that there was a perceived behavioral control on the intention of adolescents to smoke (15). Encouragement for strong individuals not to smoke should be actualized immediately, because if it is postponed, it is possible for someone to change their mind to change their behavior, this is possible because of environmental factors, family, community friends are also very influential. Smoking initiation in adolescents is caused by factors of parents whose education is low, the influence of relatives and close friends who behave smoking (16).

Non-Smoking behavior and subjective norm
The results of this analysis show that there is a positive influence on subjective norms nonsmoking against the intention not to smoke.
Subjective norms are a person's belief in the demands of others who are considered important to him so that individuals are willing to display or not display a certain behavior in accordance with the demands that exist in the social community.
Similar studies report that there is no direct effect of subjective norms on cigarette use behavior, but report that subjective norms have a statistically significant indirect effect on intention through perceived attitudes and control of behavior (17).

Non-Smoking behavior and knowledge
The results of path analysis show that there knowledge and smoking behavior as in this study (13). Similar studies also reported that subjects with greater knowledge of smoking had a lower risk of smoking (OR = 0.88; 95% CI = 0.86-0.91), but this characteristic is reduced after adjusting for potential confounders (18).

No-Smoking behavior and media exposure
The  (19).

Non-Smoking behavior and social capital
The results of path analysis show that there is a positive influence between social capital and subjective norms of non-smoking. Smoking is the door to the beginning of adolescents to carry out other negative activities, such as drinking, drugs and so on (20). This finding is consistent with the results of other studies that active social participation is positively related to smoking cessation (OR = 1,39; 95% CI = 1,07 to 1,82) (21).

Non-Smoking behavior and access to cigarette
The results of path analysis show that there is a negative influence between access to cigarette on non-smoking behavior. The Government of the Republic of Indonesia conducts campaigns and enhances regional advocacy and guidance in implementing regional policies without smoking. Smoking causes carcinogens (20) , in Scotland, the prevalence of adolescent smoking is caused by cultural factors, access and availability of cigarettes which are very easily achieved by teenagers (23)with rural areas having a higher prevalence than urban areas in some countries, and a lower prevalence in others. These differences are most likely due to substantive differences in rurality between countries in terms of their type, family affluence, area level deprivation and rurality. We imputed missing rurality and deprivation data using multivariate imputation by chained equations, and re-analysed the data (N=3577. The results of other studies on the impact of tobacco on health, taken a policy to ban cigarette advertising in various mass media both print and electronic so that people are not easy to access cigarettes (24).

CONCLUSION AND RECOMMENDATION
The construction of TPB includes attitudes towards non-smoking, subjective norms on not smoking, and perceived behavioral control for not smoking, impacts on the intention not to smoke, and finally on non-smoking behavior. These findings can be used to design health promotion program to prevent and reduce smoking behavior among adolescents.