Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s2):13214 Predictors of smoking cessation intentions among adolescents in Indonesia Adinda Nur Amila,1 Ferry Efendi,1,2,3 Candra Panji Asmoro,1 Rifky Octavia Pradipta,1,2 Khadizah H. Abdul-Mumin4 1Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia; 2Research Center in Advancing Community Healthcare, Surabaya, Indonesia; 3School of Nursing and Midwifery, La Trobe University, Melbourne, Australia; 4Pengiran Anak Puteri Rashidah Sa’adatul Bolkiah Institute of Health Sciences, Universiti Brunei Darussalam, Brunei Darussalam Abstract Tobacco causes more than 8 million deaths every year world- wide. In Indonesia, the prevalence of tobacco consumption remains alarmingly high among adolescents. Although many young smokers express a desire to quit, they often face significant challenges due to various influencing factors. This study aimed to analyze the predictors of smoking cessation intention among ado- lescents in Indonesia, employing a cross-sectional design and uti- lizing secondary data from the 2019 Global Youth Tobacco Survey (GYTS) conducted in Indonesia. Utilizing a purposive sampling technique, a robust dataset comprising 1,191 adolescents was meticulously curated. To analyze the data, we employed the STATA application, using inferential tests such as chi-square and logistic regression for variable identification and processing, ensuring the precision and rigor of our findings. The study find- ings revealed that most adolescents want to quit smoking (81.61%). The ability to quit smoking (adjusted odds ratio [AOR]=9.80, 95% confidence interval [CI]=6.12-15.73), percep- tion of smoking as harmful to health (AOR=2.20, CI=1.40-3.48), source of support (AOR=1.68, CI=1.02-2.50), smoking status of friends (AOR=0.48, CI=0.38-0.74), were predictors associated with adolescents’ intention to quit smoking. Data from GYTS indicated that the majority of adolescents who smoke intend to cease smoking. Based on these insights, it is recommended that the government enhance the enforcement and supervision of exist- ing tobacco control policies to effectively support youth cessation initiatives. Introduction Tobacco consumption remains a pressing global health con- cern, claiming over 8 million lives annually worldwide, with direct tobacco use accounting for more than 7 million of these deaths.1 In Indonesia, national surveys conducted in 2013 and 2018 revealed a persistent high prevalence of tobacco use among adolescents. The prevalence of smoking among individuals aged 10-19 increased from 7.2% in 2013 to 9.1% in 2018, marking a significant rise of approximately 20%.2 Additionally, a study reported a concerning trend of high levels of smoking addiction behavior among Indonesian students.3 Despite this alarming sce- nario, many adolescents express a desire to quit smoking but face considerable challenges due to a lack of strong intentions and motivation. Several previous studies have investigated smoking cessation intentions among adolescents. The survey conducted by Dadras4 focused exclusively on male adolescents aged 16 years and older. In contrast, our study targets a younger age group (13-15 years) and includes both male and female participants. Dadras4 also explored the correlation between early smoking initiation (by age) and smoking cessation among adolescents. In contrast, our study focuses on school grade levels, specifically examining students from grades 7 to 12. Meanwhile, parental involvement in influenc- ing adolescents’ cessation efforts has also been studied by Ihyauddi.5 However, the data is from the 2015 Indonesian Global School-Based Student Health Survey (GSHS). The study by Syapiila6 looked at the influence of having friends who smoke sig- nificantly in Zambia. Our study looks at the correlation between having friends who smoke and smoking cessation intentions Correspondence: Candra Panji Asmoro, Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia. E-mail: candra.panji.a@fkp.unair.ac.id Key words: adolescent; Indonesia; intention; smoking cessation; smok- ing; tobacco use. Contributions: FE, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ANA, writing – original draft; CPA, resources, supervision, and writing –review & editing; ROP, resources, investigation, and writing – review & editing; KHAM, writing –review & editing. All authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. Conflict of interest: the authors declare no conflict of interest. Ethics approval and consent to participate: the Indonesia 2019 GYTS had obtained permission from the National Institute of Health Research and Development, solidifying its credibility and legitimacy. Additionally, the questionnaires were completed by the respondents themselves and were anonymous to maintain confidentiality. All respondents provided written consent before taking the survey. Consent for publication: written informed consent was obtained for anonymized information to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Received: 8 October 2024. Accepted: 16 January 2025. Early view: 1 September 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 12(s2):13214 doi:10.4081/hls.2025.13214 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any prod- uct that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 96] [Healthcare in Low-resource Settings 2025;13(s2):13214] among adolescents in Indonesia. Notably, research examining pre- dictors of intention to quit smoking among Indonesian adolescents, utilizing data from the Global Youth Tobacco Survey (GYTS), remains conspicuously absent.7 Data from the World Health Organization (WHO) in 2019 underscore the severity of the issue, revealing that 40.6% of Indonesian students aged 13-15 years have used tobacco products, with two-thirds of boys and nearly one-fifth of girls reported as users.2 The age of initiation is particularly concerning, with the majority of adolescents starting smoking between the ages of 10 and 14, further perpetuating the cycle of addiction.8 Moreover, findings from the 2019 GYTS reveal that 18.8% of students cur- rently smoke tobacco, with a significant disparity between gen- ders, where 35.5% of boys and 2.9% of girls are active smokers. Teenagers who smoke are at a high risk of experiencing vari- ous serious health problems, both in the short term and long term.9 Firstly, smoking can damage the lungs and respiratory system, leading to issues such as shortness of breath, chronic coughing, and an increased risk of chronic lung diseases like asthma and emphysema.10 Additionally, there is a correlation between smoking and mental health problems in teenagers, as smoking can increase the risk of depression, anxiety, and stress.11 Furthermore, nicotine in cigarettes is highly addictive, and teenagers are more susceptible to addiction than adults, leading to difficulties in quitting even when they are aware of the negative consequences.12 Moreover, smoking can impact cognitive abilities and concentration, affecting academic performance and study productivity.13 Physically, smok- ing can damage the skin, teeth, and nails, as well as cause unpleas- ant mouth odor and yellowing of teeth, affecting confidence and physical appearance. Finally, smoking during teenage years can increase the risk of various serious diseases later in life, such as heart disease, stroke, cancer, and vascular disorders.14 The Ministry of Health of Indonesia, in collaboration with local governments and development partners, has implemented various measures such as banning cigarette advertising, expanding Smoking-Free Areas (SFAs), and providing education on the haz- ards of tobacco products.15 Additionally, the introduction of smok- ing cessation services through the toll-free Quit Smoking Line rep- resents a significant government initiative aimed at supporting individuals in their cessation efforts, particularly those who may face barriers to accessing traditional healthcare facilities. Research from other regions, such as China, suggests that parental disapproval, teacher intervention, and social support sig- nificantly influence adolescents’ intentions to quit smoking.16 However, similar investigations tailored to the Indonesian context are lacking. To address this gap and contribute to the design of effective smoking prevention programs in Indonesia, this study aims to analyze predictors of intention to quit smoking among Indonesian adolescents using data from the GYTS. By investigat- ing these predictors, this study seeks to inform evidence-based interventions and policies aimed at reducing tobacco consumption among Indonesian youth, ultimately mitigating the associated health risks and improving public health outcomes in the country. Materials and Methods Population, sample, and sampling This study’s population was derived from the 2019 Indonesian GYTS population. The target population consisted of students in grades 7-12, or junior and senior high school, totaling 9,992 teenagers. We used a purposive sampling technique. The inclusion criteria were adolescents who actively smoked, male or female, and smoked tobacco. The sample size was 1,191 adolescents. We conducted no intervention in the sample. Our research utilized sec- ondary data derived from the 2019 Indonesian GYTS. Variables The dependent variable, namely the desire to quit smoking, was determined based on the question: “Do you want to stop smok- ing now?”. The independent variables include age, gender, school grade, perception of smoking as harmful, belief in one’s ability to quit smoking, parental smoking status, friends’ smoking behavior, and whether the respondent had received help or advice to quit smoking. Data collection The data collection process began by downloading the GYTS dataset from the Centers for Disease Control (CDC) website (https://www.cdc.gov/tobacco/global/index.htm). Subsequently, data cleaning was performed to select relevant data and identify the variables to be utilized in the study. Analysis Data analysis was conducted using univariate and inferential statistics, including the chi-square test (p<0.05) and logistic regres- sion, with the STATA version 16 application for Windows. A chi- square analysis was conducted to determine whether a relationship existed between the independent variables and the dependent vari- able. While multivariate data analysis used logistic regression to determine the strongest factors in sequence that influence smoking cessation intentions among adolescents in Indonesia. A clear operational definition of the research was established in advance to account for various variables that could act as poten- tial confounders during regression analysis. This approach also facilitates a more focused discussion of the relevant variables in relation to the existing literature. Ethical clearance The GYTS obtained permission from the National Institute of Health Research and Development, solidifying its credibility and legitimacy. Additionally, the questionnaires were completed by the respondents themselves and were anonymous to maintain confi- dentiality. All respondents filled out written consent before taking the survey. Results The data are presented in accordance with the research objec- tives, including sample frequencies for both independent and dependent variables, chi-square test results to identify associations between variables, and logistic regression analysis to determine which independent variables are most strongly associated with and have a sequential influence on the dependent variable. A large proportion of the teenagers who smoke fall within the age range of 13 to 15 years, constituting 583 individuals (48.95%) out of a total of 1,191 teenagers. Most of these adolescents (58.27%) were enrolled in grades 7 through 9, while 497 (41.73%) were in grades 10 through 12. The majority of adolescents (87.57%) perceive smoking as detrimental to health and believe they have the ability to cease smoking if they choose to do so (87.99%). Most adolescents (54.83%) do not reside with smoking parents, and a significant portion of teenagers (53.06%) have Pathways of Change, Part II [Healthcare in Low-resource Settings 2025;13(s2):13214] [page 97] friends who smoke. Moreover, most adolescents (85.31%) have received assistance in their efforts to quit smoking. Among those who express a desire to quit, 81.61% are inclined to do so, as shown in Table 1. Table 2 illustrates that four independent variables demonstrat- ed statistically significant results concerning the desire to cease smoking (p<0.05). These variables include: perception of smoking as harmful to health (p=0.000); confidence in the ability to quit smoking if desired (p=0.000); smoking status of friends (p=0.000); and receiving assistance to quit smoking (p=0.0171). Meanwhile, the variables that showed insignificant results on the desire to quit smoking with p>0.05 were: age (p=0.0993); gender (p=0.6253); school grade level (p=0.5299); and living with parents who smoke (p=0.6116). Table 3 presents the results of the multivariate logistic regres- sion analysis, identifying four significant predictors of the inten- tion to quit smoking: perception of the harmfulness of smoking to health, self-efficacy in quitting smoking, friends’ smoking status, and receiving help to quit smoking. Adolescents who perceive themselves as capable of quitting smoking are 9.8 times more like- ly to express a desire to quit (AOR=9.81; 95% CI=6.12-15.7; p<0.001). This highlights the critical role of self-efficacy in shap- ing the intention to quit smoking. Similarly, adolescents who rec- ognize the harmful effects of smoking on health are 2.2 times more likely to express a desire to quit (AOR=2.20; 95% CI=1.40-3.48; p=0.001). This finding underscores the importance of health awareness in motivating smoking cessation. In addition, adoles- cents whose friends also smoke are 1.6 times more likely to express a desire to quit (AOR=1.60; 95% CI=1.02-2.50; p=0.040). This suggests that peer influence, while modest, has a significant impact on smoking behaviors and intentions. Lastly, adolescents who receive assistance or support to quit smoking are significantly more likely to express the desire to quit (AOR=0.48; 95% CI=3.08-7.49; p=0.002), suggesting that access to support services is crucial in reinforcing their intention to quit. Discussion The dataset from our study, involving a cohort of 1,191 adoles- cents, highlights a notable trend: a substantial 81.61% of adoles- cents express a strong desire to quit smoking. This aligns with findings from a comprehensive international study spanning 61 countries, consistently revealing that a majority of adolescent smokers aspire to overcome their smoking habit.11 Recognizing the urgency of addressing this issue, Indonesia has implemented a multifaceted approach in collaboration with the Ministry of Health, local governments, and development partners. These cross-sectoral efforts include essential measures such as bans on cigarette adver- tising, promotional campaigns, and sponsorships; the expansion of SFAs; and comprehensive education initiatives to explain the dan- gers of cigarettes and tobacco products.10 Additionally, the Ministry of Health has achieved a significant milestone by launch- ing an innovative Smoking Cessation Line. This progressive initia- tive reflects the government’s commitment to facilitating smoking cessation for individuals who may lack the time to visit healthcare facilities, acknowledging the challenge of quitting smoking. Indeed, quitting smoking remains a challenging task, mainly Pathways of Change, Part II Table 1. Univariate analysis of predictors of smoking cessation intentions among adolescents in Indonesia (n=1,191). Variable n % Age <13 175 14.69 13-15 583 48.95 >15 433 36.36 Sex Male 1122 94.21 Female 69 5.79 Grade Class 7-9 694 58.27 Class 10-12 497 41.73 Perception that smoking is harmful to health No 148 12.43 Yes 1043 87.57 Able to quit smoking if desired No 143 12.01 Yes 1048 87.99 Living with smoking parents No 653 54.83 Yes 538 45.17 Friends who smoke No 559 46.94 Yes 632 53.06 Received help to quit smoking No 175 14.49 Yes 1016 85.31 Desire to quit smoking No 219 18.39 Yes 972 81.61 [page 98] [Healthcare in Low-resource Settings 2025;13(s2):13214] because of the addictive nature of nicotine cigarettes, as supported by abundant scientific evidence highlighting the profound health risks associated with smoking. Nevertheless, the benefits of cessa- tion extend not only to one’s individual health but also to the well- being of those in proximity. In this regard, the toll-free Quit Smoking Line offered by the government serves as a vital resource for accessing critical information about the hazards of smoking and gaining invaluable motivation to embark on the journey towards quitting. The key findings in our research are that age, sex, and grade were not significant predictors. Age did not demonstrate a signifi- cant relationship, consistent with previous research indicating that the desire to quit smoking can manifest at various ages for different reasons.12 This contrasts with a study conducted in Korea, suggest- ing that the age of smoking initiation influences cessation rates.13 However, our study found consistent levels of desire to quit smok- ing across different age groups, emphasizing the need for cessation interventions tailored to adolescents regardless of age. Pathways of Change, Part II Table 2. Bivariate analysis of predictors of smoking cessation intentions among adolescents in Indonesia (n=1,191). Independent variable Dependent variable Smoking cessation intentions Yes No p X2 Correlation n % n % Age 0.0993 7.64 No correlation <13 155 88.65 20 11.35 13-15 462 79.37 121 20.63 >15 355 81.1 78 18.9 Sex 0.6253 0.37 No correlation Male 914 81.09 208 18.91 Female 58 84.15 11 15.85 Grade 0.5299 0.80 No correlation Class 7-9 570 82.01 124 17.99 Class 10-12 402 79.9 95 20.1 Perception that smoking is harmful to health 0.0000 24.32 Correlation No 103 66.64 43 33.36 Yes 869 83.38 174 16.62 Able to quit smoking if desired 0.0000 216.60 Correlation No 57 36.25 86 63.75 Yes 915 87.41 133 12.59 Living with smoking parents 0.6116 0.21 No correlation No 541 81.74 112 18.26 Yes 431 80.96 107 19.31 Friends who smoke 0.0000 31.70 Correlation No 500 87.89 59 12.11 Yes 427 75.15 160 24.85 Received help to quit smoking 0.0171 8.57 Correlation No 129 73.19 46 26.81 Yes 843 82.62 173 17.38 X2, chi-square test. Table 3. Multivariate analysis of predictors of smoking cessation intentions among adolescents in Indonesia (n=1,191). Independent variable Dependent variable Smoking cessation intentions AOR 95% CI p Able to quit smoking No (ref) Yes 9.81 6.12-15.7 0.000 Perception that smoking is harmful to health No (ref) Yes 2.20 1.40-3.48 0.001 Friends who smoke No (ref) Yes 1.60 1.02-2.50 0.040 Received help to quit smoking No (ref) Yes 0.48 3.08-7.49 0.002 CI, confidence interval; AOR, adjusted odds ratio. [Healthcare in Low-resource Settings 2025;13(s2):13214] [page 99] Similarly, sex did not emerge as a significant predictor, align- ing with previous studies in Indonesia.14 Contrastingly, studies from other regions have shown gender disparities in cessation rates.15,16 Our findings suggest a uniform desire to quit smoking among adolescent boys and girls, emphasizing the importance of gender-neutral education on smoking dangers. Grade level also did not predict intention to quit smoking, con- sistent with prior research.14 Adolescents across elementary, mid- dle, and high school demonstrated similar levels of motivation to quit smoking. This highlights the influence of environmental fac- tors on cessation intentions, such as family and peer dynamics, regardless of age or grade.12 Living with smoking parents did not predict intention to quit smoking, diverging from findings in Nigeria.17 While parental smoking influences adolescent smoking behavior, our study suggests that other factors may outweigh this influence in the intention to quit smoking among Indonesian ado- lescents. Another key finding is that having friends who smoke emerged as a significant predictor of intention to quit smoking, consistent with previous research.18 Peer influence plays a crucial role in smoking behavior, highlighting the importance of interventions targeting social networks. Adolescents with a source of support exhibited higher intention to quit smoking, consistent with the role of social support in cessation processes.19 Support from parents, friends, teachers, and professionals can significantly impact ado- lescents’ motivation to quit smoking, underscoring the importance of comprehensive support systems. Additionally, adolescents who perceive smoking as harmful to health and believe they have the ability to quit smoking are more likely to express intention to quit, aligning with previous studies.19-21 Health concerns and self-effica- cy are significant motivators for smoking cessation, emphasizing the need for educational interventions highlighting the health risks of smoking and enhancing individuals’ belief in their ability to quit. One limitation of this study stems from its reliance on sec- ondary data extracted from the 2019 GYTS in Indonesia, whereas our research was conducted in 2022. This time gap between data collection periods may introduce disparities in adolescent charac- teristics, potentially yielding variations in outcomes compared to the present context. Furthermore, our investigation was con- strained by the predetermined variables available within the results of the GYTS questionnaire, limiting the scope of factors consid- ered in our analysis. However, we consider the phenomena pre- sented in the existing data using the latest and most representative literature. We also suggest that further researchers identify adoles- cent awareness of the dangers of conventional and electronic cigarettes. Finally, the most significant findings in this study con- cluded that the various factors that most strongly influence the intention to quit smoking in adolescents in sequence include: being able to quit smoking; perception that smoking is harmful to health; friends’ smoking status; and receiving help to quit smoking. These factors are interesting to be used as reference material for adoles- cents who want to quit smoking, as well as being a consideration for policymakers in making policies to cover programs that are more targeted at active adolescent smokers. Conclusions Several factors play a significant role in the initiation of smok- ing cessation behavior, including being able to quit smoking, per- ception that smoking is harmful to health, friends’ smoking status, and receiving help to quit smoking. The findings highlight the need for empowering the interventions and policies targeted at reducing the smoking behavior of adolescents in Indonesia. Nurses and healthcare professionals can utilize these findings to develop effec- tive smoking prevention and cessation programs for adolescents, thereby improving their overall health outcomes. 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