Journal of Health Promotion and Behavior (2021), 06(01): 9-20 Research

Masters Program in Public Health, Universitas Sebelas Maret

Multilevel Analysis of the Biopsychosocial Determinants

and Contextual Peer Groups on Smoking Habit in High School
Students in East Lampung, Lampung, Indonesia
Retno Sulistyani1), Setyo Sri Rahardjo2), Pawito3)

1)Masters Program in Public Health, Universitas Sebelas Maret

2)Faculty of Medicine, Universitas Sebelas Maret
3)Faculty of Social and Political Sciences, Universitas Sebelas Maret

ABSTRACT

Background: Smoking is still one of the great- sure (b= 3.04; 95% CI= 0.78 to 3.62; p=
est public health threats faced by citizens of the 0.002), money pocket (b= 3.22; 95% CI= 0.87
world. Data from the Central Statistics Agency to 3.59; p= 0.001), cigarette price (b= 2.73;
in 2018 shows that smoking behavior in 95% CI= 0.54 to 3.28; p= 0.006), intention to
Lampung Province has a prevalence of 35.95%. smoke (b= 2.80; 95% CI= 0.69 to 3.95; p=
The World Health Organization (WHO) states 0.005), attitude toward smoking (b=3.83; 95%
that smoking kills more than 8 million people CI= 1.80 to 5.58; p<0.001) increased the likeli-
per year worldwide. This study aimed to ana- hood to smoke in male adolescents. School had
lyze the determinants of adolescent smoking strong contextual effect on smoking in adoles-
behavior at the individual level and at the cents with ICC= 21.83%.
school level. Conclusion: The influence of family, peers,
Subjects and Method: This was a cross sec- media exposure, money pocket, cigarette price,
tional study conducted in East Lampung Re- intention to smoke, attitude toward smoking
gency, Indonesia, from October to November increase the likelihood to smoke in male
2020. A number of 200 male adolescents were adolescents. School has strong contextual effect
selected by random sampling. The dependent on smoking in adolescents
variable was smoking behavior. The indepen-
dent variables were the influence of parents, Keywords: smoking behavior, adolescents,
peers, media exposure, pocket money, cigarette contextual effect of school
price, intention, attitude, and contextual effect
of school. The data were collected by question- Correspondence:
naire and analyzed using a multiple multilevel Retno Sulistiani. Masters Program in Public
logistic regression with Stata 13. Health, Universitas Sebelas Maret. Jl. Ir.
Results: The influence of family (b=2.88; 95% Sutami 36A, Surakarta 57126, Central Java.
CI= 0.73 to 3.85; p= 0.004), peers (b= 2.85; Email: retnosulistiani91@gmail.com. Mobile:
95% CI= 0.65 to 3.52; p= 0.004), media expo- +6285867006699.

Cite this as:

Sulistyani R, Rahardjo SS, Pawito (2021). Multilevel Analysis of the Biopsychosocial Determinants and
Contextual Peer Groups on Smoking Habit in High School Students in East Lampung, Lampung, Indonesia.
J Health Promote Behav. 06(01): 9-20. https://doi.org/10.26911/thejhpb.2021.06.01.02.
Journal of Health Promotion and Behavioris licensed under a Creative Commons
Attribution-NonCommercial-ShareAlike 4.0 International License.

BACKGROUND estimated that there are more than one

Smoking is still one of the biggest public billion people smoking. About 80% of the
health threats faced. The World Health world's smokers live in developing
Organization (WHO) states that smoking countries, namely low-income and middle-
kills more than 8 million people per year income countries (Alsubaie, 2018).
worldwide (WHO, 2015). In 2015, it is

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The results of Riskesdas 2018 show sion and mass media, they begin to recog-
that the prevalence of smoking at the age of nize and try to smoke (Ariani, 2011).
10-18 years shows an increase in 2016 as Smoking is one of the main risk fac-
much as 8.8% and in 2018 as much as 9.1%. tors for non-communicable diseases such
In the age group over 15 years, the number as cardiovascular disease, stroke, chronic
of smokers was 33.8%. Of these, 62.9% obstructive pulmonary disease, lung cancer,
were male smokers and 4.8% were female oral cancer, and abnormalities in pregnan-
smokers. This increase in the number of cy. These diseases are the main causes of
smokers is accompanied by an increase in death in the world (Kusumasari, 2017).
the proportion of diseases caused by ciga- Nearly 80% of smokers start smoking when
rette consumption such as hypertension, they are not yet 19 years old. Generally,
stroke, diabetes, heart disease, cancer people start smoking at a young age and do
(Ministry of Health, 2018). The results of not know the dangers of smoking addiction.
data from the Central Statistics Agency in The consumer's decision to buy cigarettes is
2018 smoking behavior in Lampung Pro- not based on sufficient information about
vince has a prevalence of 35.95% (BPS, the risks of the purchased product, the
2018). effects of addiction and the impact of the
Adolescents are very vulnerable to purchase that is imposed on other people
smoking behavior because it is considered (Kemenkes RI, 2015).
as a means to help with physical, cognitive, This study aimed to analyze the deter-
and emotional changes that occur during minants of adolescent smoking behavior at
this phase of life (Duncan et al, 2017). the individual level and at the school level.
According to them, smoking among adoles-
cents is a symbol of association, because if a SUBJECTS AND METHOD
group of adolescents has smoked then the 1. Study Design
individual adolescents in that group feel This was a cross sectional study conducted
they must smoke because they do not want at 25 schools in East Lampung Regency,
to be considered a stranger, not because the Indonesia, from October to November
individual likes cigarettes (Isa et al, 2017) . 2020.
One of the factors influencing 2. Population and Sample
smoking behavior in adolescents is family The population studied was all male ado-
and peers. Family is the primary unit which lescents in East Lampung Regency, from
functions to transfer social and cultural fac- October to November 2020. Sampling was
tors, while friends are the source of identity carried out using random sampling tech-
formation in adolescents. The first expe- nique to select adolescents and schools in
rience of smoking in adolescents occurs the East Lampung Regency. The subjects
when there are two social sub-agents at used were 200 subjects from 8 subjects in
play, namely family and friends. Parents each level 2 (school).
who smoke are not only role models but 3. Study Variables
also increase adolescent access to cigarettes The dependent variable was smoking beha-
(Liem, 2014). Media exposure factors also vior in adolescents. Independent variables
affect smoking behavior in adolescents. The were the influence of parents, peers, media
influence of media exposure is very influ- exposure, pocket money, cigarette prices,
ential on the lives of adolescents. When intention, and attitude and level 2 is school.
adolescents see advertisements on televi-

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4. Operational Definition of Variables obtained using a questionnaire filled out by

Smoking behavior is an activity or acti- research subjects. Secondary data were
vity of smoking teenagers. The influence of obtained from the East Lampung District
parents is the attitude of adolescents Health Office in the form of adolescent data
towards the behavior of parents who in East Lampung Regency. The instrument
smoke/ don't smoke at home. used was a questionnaire.
Peers are peers as individual interactions 6. Data Analysis
in adolescents with the same age level and Univariate analysis was carried out to see
involve relative intimacy. the frequency distribution and characteris-
Media exposure is the exposure of ado- tics of the research subjects, while bivariate
lescents through various kinds of mass analysis was performed using the chi-
media and electronic media related to ciga- square test and the calculation of the odds
rette advertisements/promotions both ratio (OR) with a 95% confidence level (CI)
read, heard and seen by respondents. to study the relationship between smoking
Pocket money is money that comes from behavior in adolescents and the indepen-
giving from parents or other family dent variable. Multivariate analysis was
members to meet the needs of teenagers in carried out using logistic regression
school. through a multilevel approach indicated by
The price of cigarettes is the price that the Intra Class Correlation (ICC) value.
must be paid to obtain cigarettes. 7. Research Ethics
Intention is the desire made by adoles- Research ethics includes informed consent,
cents to choose to participate or not in anonymity, confidentiality and ethical
smoking behavior. clearance. The ethical clearance in this
Attitudes are adolescent responses in the study was conducted at Dr. Moewardi Hos-
form of positive or negative assessments pital, Surakarta and was declared ethical
related to things that affect adolescents in based on decree number: 1.188/X/HREC/
smoking behavior. The scale of measure- 2020.
ment in the independent variable is a conti-
nous scale, because for the needs of data RESULTS
analysis, it is converted into a dichotomous 1. Univariate Analysis
scale. The univariate analysis included smoking
5. Instruments behavior, family influence, peer influence,
The data is in the form of primary data and media exposure, pocket money, cigarette
secondary data. Primary data were price, intention, and attitude.
Table 1. Univariate analysis (continuous data) influence of family, peer influence,
media exposure, pocket money, cigarette price, intention, and attitude towards
smoking behavior in adolescents.
Independent Variable N Mean SD Min. Max.
Family influence 200 5.40 1.07 2 7
Peer influence 200 5.40 1.17 1 7
Media exposure 200 3.76 0.87 0 5
Pocket money 200 411,250 95,952.97 150,000 800,000
Price of cigarettes 200 11,762.50 2,780.91 8,000 20,000
Intention 200 2.83 0.88 0 4
Attitude 200 11.61 2.11 4 17

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Table 1 shows mean of family influ- 95,952.97 with the lowest allowance= Rp.
ence was 5.40 (Mean= 5.40; SD= 1.07). 150,000 and the highest is Rp. 800,000.
The mean of peer influence was 5.40 The mean of cigarette price was Rp 11,762
(Mean= 5.4; SD= 1.17). The mean of (Mean= 11,762.50; SD= 2,780.91). The
media exposure was 3.76 (Mean= 3.76; mean of intention was 2.83 (Mean= 2.83;
SD= 0.87). The allowance variable has a SD= 0.88). The mean of attitude was
mean= Rp 411,250 and SD= Rp. 11.61 (Mean= 11.61; SD= 2.11).
Table 2. Univariate analysis (dichotomous data) of family influence, peer influ-
ence, media exposure, pocket money, cigarette price, intention, and attitude
towards smoking behavior in adolescents.
Variable N %
Smoking Behavior
Smoke 42 21.0
Do not smoke 158 79.0
Family Influence
Weak 156 78.0
Strong 44 22.0
Peer Influence
Weak 156 78.0
Strong 44 22.0
Media Exposure
Low 147 73.5
High 53 26.5
Pocket money
<450,000.00 149 74.5
≥450,000.00 51 25.5
Cigarette prices
Cheap 54 27.0
Expensive 146 73.0
Intention
Low 143 71.5
High 57 28.5
Attitude
Negative 169 84.5
Positive 31 15.5

Table 2 shows that most of the study 143 (71.5%) low intention, and 169 (84.5%)
subjects who did not smoke were 158 had positive attitude.
(79.0%), the influence of weak families was 2. Bivariate Analysis
157 study subjects (78.0%), the influence of The statistical analysis used to see the effect
weak peers was 156 study subjects (78.0%), of a dependent variable (smoking behavior)
low media exposure was 147 (73.5%), on the independent variable (family influ-
pocket money <Rp 450,000 as many as 149 ence, peer influence, media exposure,
(74.5%), 146 (73.0%) expensive cigarettes, pocket money, cigarette prices, intention,
and attitude) is in table 5.

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Table 3. Bivariate analysis of family influence, peer influence, media exposure,

pocket money, cigarette prices, intention, and attitude towards smoking behavior
in adolescents.
Smoking Behaviour
Variable Group Yes No OR p
n % n %
Family Influence 3.80 <0.001
Weak 24 46.1 132 83.5
Strong 28 53.9 26 16.5
Peer Influence 4.39 <0.001
Weak 23 54.7 133 84.1
Strong 19 45.3 25 15.9
Media Exposure 4.50 <0.001
Low 20 47.6 127 80.3
High 22 52.4 31 19.7
Pocket money 4.26 <0.001
<450,000.00 21 50.0 128 81.0
≥450,000.00 21 50.0 30 19.0
Cigarette prices 5.68 <0.001
Cheap 24 57.1 30 19.0
Expensive 18 42.9 128 81.0
Intention 3.86 <0.001
Low 20 47.6 123 77.8
High 22 52.4 35 22.2
Attitude 6.99 <0.001
Negative 25 59.5 144 91.1
Positive 17 40.5 14 8.9

Table 3 shows the results of the chi- adolescents with strong peer influence
square test of the influence of family, peer (OR= 4.39, p<0.001).
influence, media exposure, pocket money, c. The effect of media exposure on
cigarette prices, intention, and attitudes smoking behavior in adolescents
towards smoking behavior in adolescents as Low media exposure decreases the likeli-
follows: hood of smoking behavior in adolescents.
a. The effect of family on smoking Adolescents with low media exposure
behavior in adolescents decreased the likelihood of smoking 4.50
Weak family influence reduces the likeli- times than adolescents with high media
hood of smoking behavior in adolescents. exposure (OR = 4.50, p <0.001).
Adolescents with weak family influence d. The effect of pocket money on
decreased the likelihood of smoking 3.80 smoking behavior in adolescents
times than adolescents with strong family Adolescents with an allowance of <Rp
influence (OR = 3.80, p <0.001). 450,000 reduce the likelihood of smoking
b. The effect of peers on smoking behavior in adolescents. Adolescents with
behavior in adolescents an allowance of <Rp 450,000 reduce the
Weak peer influence reduces the likelihood likelihood of smoking 4.26 times than ado-
of smoking behavior in adolescents. Adoles- lescents with an allowance of ≥Rp 450,000
cents with weak peer influence decreased (OR = 4.26, p <0.001).
the likelihood of smoking 4.39 times than

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e. The effect of cigarette price on g. The effect of attitude on smoking

smoking behavior in adolescents behavior in adolescents
The high price of cigarettes reduces the Teens with a positive attitude reduce the
likelihood of smoking behavior among ado- likelihood of smoking behavior in adoles-
lescents. Adolescents who thought the price cents. Adolescents with positive attitude
of cigarettes was expensive decreased the decreased the likelihood of smoking 6.99
likelihood of smoking 5.68 times (OR= times (OR= 6.99, p <0.001).
5.68, p <0.001). 3. Multivariate Analysis
f. The effect of intention on smoking Multilevel multiple logistic regression ana-
behavior in adolescents lysis explains the effect of more than one
Adolescents with weak intention reduce the independent variable and variable at level
likelihood of smoking behavior in adoles- 2, namely school. The results of the analysis
cents. Adolescents with weak intention can be seen in Table 4.
decreased the likelihood of smoking 3.86
times (OR= 3.86, p <0.001).
Table 4. The results of multilevel multiple logistic regression analysis of the effect
of family, peer, media exposure, pocket money, cigarette price, intention, and
attitude on smoking behavior in adolescents
95% CI
Independent Variable b p
Lower Limit Upper Limit
Fixed Effect
Family influence (strong) 2.88 0.73 3.85 0.004
Peer influence (strong) 2.85 0.65 3.52 0.004
Media exposure (high) 3.04 0.78 3.62 0.002
Allowance (≥Rp.450,000.00) 3.22 0.87 3.59 0.001
Price of cigarettes (cheap) 2.73 0.54 3.28 0.006
Intention (high) 2.80 0.69 3.95 0.005
Attitude (positive) 3.83 1.80 5.58 0.000
Random effect
Schools 0.91
N observation= 200
N group= 25
Average of group= 8, min=8, max=8
Log likelihood= -49.05
p= 0.003
p LR test vs logistic regression= 0.132
ICC= 21.83%

Table 4 shows the results of a multi- adolescents. Adolescents with strong family
level analysis of smoking behavior in ado- influence had a risk (logodd) for smoking
lescents using a multiple multilevel logistic 2.88 units higher than adolescents with
regression. The results of the analysis can weak family influence (b= 2.88; 95% CI=
be described as follows: 0.73 to 3.85; p= 0.004).
a. The effect of family on smoking b. The effect of peers on smoking
behavior in adolescents behavior in adolescents
There is a positive influence between the There is a positive influence between peer
influence of family on smoking behavior in influence on smoking behavior in adoles-

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cents. Adolescents with strong peer influ- Adolescents who had a positive attitude
ence had a risk (logodd) of smoking 2.85 towards smoking had a risk (logodd) for
units higher than adolescents with weak smoking 3.83 units higher than adolescents
peer influence (b= 2.85; 95% CI= 0.65 to who had negative attitudes towards
3.52; p= 0.004). smoking (b= 3.83; 95% CI= 1.80 to 5.58;
c. The effect of media exposure on p<0.001).
smoking behavior in adolescents h. The effect of school on smoking
There is a positive influence between media behavior in adolescents
exposure on smoking behavior in adoles- The school level shows that there is a con-
cents. Adolescents who had high media textual influence on smoking behavior in
exposure had a risk (logodd) of smoking adolescents (ICC= 21.83%). The variation
3.04 units higher than adolescents who had of smoking behavior among adolescents
low media exposure (b= 3.04; 95% CI= was 21.83% influenced by school. Table 4.4
0.78 to 3.62; p = 0.002). shows that the ICC score in this study is
d. The effect of pocket money on greater than the 8-10% rule of thumb, so
smoking behavior in adolescents the contextual influence in this study is that
There is a positive influence between pocket school is very important to note.
money on smoking behavior in adolescents.
Adolescents with an allowance of ≥Rp DISCUSSION
450,000 have a risk (logodd) of smoking 1. The influence of family on smoking
3.22 units higher than adolescents who behavior in adolescents
have an allowance of <Rp 450,000 (b= Family has an important influence on the
3.22; 95% CI= 0.87 to 3.59; p= 0.001). behavior that occurs in adolescents. One of
e. The effect of cigarette prices on them is smoking behavior. In a family, if
smoking behavior in adolescents one member of the family smokes, it is
There is a positive influence between the likely that it will influence them or other
price of cigarettes on smoking behavior in family members to smoke, especially
adolescents. Adolescents who thought the children, they smoke to show their identity
price of cigarettes was cheap had a risk so that they can look more mature like their
(logodd) to smoke 2.73 units higher than father or siblings who others (Roupa et al.,
adolescents who thought the price of ciga- 2016; Mcgee et al., 2015).
rettes was expensive (b= 2.73; 95% CI= The family environment has an
0.54 to 3.28; p = 0.006). important role in preventing or promoting
f. The effect of intention on smoking smoking, especially parents have a very
behavior in adolescents important role in the process of developing
There is a positive influence between inten- children's behavior. Children will imitate
tion on smoking behavior in adolescents. good behavior from their parents. In the
Adolescents who had high intention had a form of good behavior and bad behavior.
risk (logodd) to smoke 2.80 units higher Like the smoking habit of parents and other
than adolescents who had low intention (b= family members (Mulvhill, 2014; Soesyas-
2.80; 95% CI= 0.69 to 3.95; p= 0.005). moro et al., 2016; Alves et al., 2016).
g. The effect of attitudes on smoking 2. The influence of peers on smoking
behavior in adolescents behavior in adolescents
There is a positive influence between atti- Peers can also positively influence smoking
tude on smoking behavior in adolescents. behavior through the same mechanisms of

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peer influence and selection. Peers give ments or micro-influencers to imitate their
influence to continue smoking. This is behavior (Thomas, 2016).
because gathering with peers is a habit and Media exposure has a positive correla-
has become a lifestyle for adolescents so tion with the perception of smoking preva-
that adolescents want to share in the taste lence, which in turn has a positive correla-
of cigarettes or because they have bad tion with smoking intention. This overview
feelings for friends who smoke (Mulvhill, of smoking increases adolescent percep-
2014; Pandayu et al., 2017; Arifiyanti et al., tions of smoking prevalence. If adolescents
2019). perceive smoking as normative behavior,
Atmojo et al. (2017) show that peers they may consider the behavior permissible
have an influence on smoking behavior in and intend to adopt the behavior. However,
adolescents. Adolescents have a perspective if the image of the smoker is not good in the
on smoking behavior that is greatly influ- media, it can reduce the effect of the per-
enced by their peers. Perspectives will ception of smoking behavior. Social media
determine the decision taken in the end serves as an effective communication
whether a teenager will smoke or not. The channel to generate, share, receive, and
behavior of popular friends is stronger than comment on content about smoking (Yang
the influence of unpopular friends. The et al., 2013; Yoo et al., 2016).
smoking tendency of 80% of their most 4. The effect of pocket money on
popular friends has a negative long-term smoking behavior in adolescents
effect on individual smokers. The popula- This is in line with Arifiyanti et al. (2019)
rity of a friend influences the influence of which states that adolescents with an allow-
friends on various risky behaviors, such as ance of >Rp 300,000 per month increase
smoking behavior, binge drinking, drug smoking behavior by 2.89 units compared
abuse, and sexual behavior (Robalino and to adolescents with an allowance of ≤Rp
Macy, 2018; Amorha et al., 2017; Pandu- 300,000 per month. Tobacco use was
winata et al., 2018; Atmojo et al. , 2017). found more in adolescents who earned high
3. The influence of media exposure allowances. This is also in accordance with
on smoking behavior in adoles- the results of research which shows the
cents same relationship, namely adolescents who
This is in line with the research of Mangun- have a high amount of pocket money tend
song et al., (2016) which states that ciga- to support the behavior of using their
rette advertisements that describe the pocket money to buy cigarettes, the higher
dangers of smoking can explain smoking the allowance owned by adolescents, the
behavior by 16.2%. The existence of modern more likely the teenager to buy cigarettes
media has created an establishment that (Anggarwal and Kumar, 2014).
can lead to a causal relationship between Purnaningrum et al., (2017) also
media and smoking. The cigarette industry shows a significant relationship between
is rapidly adopting television as its main pocket money and smoking behavior in
advertising medium, and consumers are adolescents. The availability of high pocket
well aware of the cigarette brands being money will affect the increase in smoking
promoted on television. Cigarette com- behavior among adolescents. Allowance
panies have hired micro-influencers to pro- should be given on a policy basis and not
mote them and they smoke in general. This excessive. Allowance given unwise will
can influence someone who sees advertise- cause problems, namely adolescents

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Sulistyani et al./ Biopsychosocial Determinants and Contextual Peer Groups on Smoking Habit

become extravagant, adolescents do not behavior (Pandayu et al., 2017; Ganley and
value money and teenagers are lazy to Rosario 2013).
learn, so that teenagers tend to be tempted 7. The influence of attitudes on
and feel addicted to spending pocket money smoking behavior in adolescents
by buying cigarettes because the price of This study is in line with Riyadi et al.,
cigarettes is not expensive and they can buy (2019) which states that attitudes have a
sticks Pandayu et al., 2017). direct relationship with smoking behavior
5. The effect of cigarette prices on with p= 0.004. Attitude is a person's ten-
smoking behavior in adolescents dency to respond, assess or express both
Arifiyanti et al., (2019) shows that adoles- beliefs, feelings or behavior towards an
cents with perceptions of cheap cigarette idea, event or situation that is socially
prices are likely to increase smoking beha- important. Attitudes include situations in
vior by 2.84 units compared to adolescents which individuals have ambivalent (ambi-
with perceptions of expensive cigarette valent) assessments of an object, namely
prices. Smoking behavior usually occurs having positive or negative attitudes
during adolescence. The link between price towards the same object (Murti, 2018).
cigarettes and tobacco use is very strong The results of the study by Pandu-
among young people. Smokers are more winata et al., (2018) support the theory that
sensitive to price. Efforts to reduce cigarette attitude is a predictor of smoking behavior.
purchases by increasing cigarette prices by Adolescents in general have a high curiosity
10% reduce a person to smoke by 11.3% attitude, because they are driven by high
(Cui et al., 2019). curiosity, adolescents tend to want to be
6. The effect of intention on smoking adventurous to explore everything and try
behavior in adolescents everything they have never experienced and
Smoking behavior is positively related to are also driven by desire like adults causing
smoking intention. If adolescents perceive teenagers to want to try to do what they
smoking as normative behavior, they may often do. done by adults. As a result, it is
consider the behavior permissible and not uncommon for boys to secretly try to
intend to adopt the smoking behavior. smoke because they often see adults doing
Someone who has a high intention to it (Ganley and Rosario 2013; Delpia et al.,
smoke, smoking behavior can occur (Yang 2016; Pandayu et al., 2017)
et al., 2013; Riyadi et al., 2019). 8. The influence of schools on
The results of study by Delpia et al., smoking behavior in adolescents
(2016) show that subjective norms have an School is a place of education that can be
indirect positive effect through intention. said to be successful if it is able to change
Subjective norms contain beliefs about the children's behavior for the better. At school
social pressure that individuals get and feel it can also lead to behavior changes in ado-
from the expectations of people who have a lescents, both positive behavior and nega-
high enough influence on their lives. The tive behavior. One of the negative behaviors
higher the expectations of other people who that can occur in school is smoking beha-
are considered important for their lives to vior in adolescents. Although in fact at
prevent smoking behavior, the higher a school itself there are rules that prohibit
person's intention to carry out preventive smoking. But sometimes students smoke in
behavior.The higher a person's intention, school secretly. It is because at school they
the higher the likelihood of smoking also meet their peers (Roupa et al., 2016).

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Sulistyani et al./ Biopsychosocial Determinants and Contextual Peer Groups on Smoking Habit

This is in line with Robalino and Macy https://doi.org/10.7860/jcdr/2014/9

(2018) which states that 20% of adolescents 758.4613.
smoke at school. Schools with no education Alsubaie ASR (2018). Prevalence and deter-
about smoking are more likely to be adoles- minants of smoking behavior among
cents who smoke because of their lack of male school adolescents in Saudi
knowledge. School really determines ado- Arabia. Int J Adolesc Med Health.
lescents to have more opportunities to 32(4). https://doi:10.1515/ijamh-201-
interact with people of the opposite gender, 7-0180.
teenagers in this school can use cigarettes Alves J, Perelman J, Soto-Rojas V, Richter
to project an image of maturity. Teens tend M, Rimpela A, Loureiro I, Federico B,
to perceive smoking as a symbol of maturity et al. (2016). The role of parental
or attractiveness (Heo et al., 2014). smoking on adolescent smoking and
its social patterning: A cross-sectional
AUTHOR CONTRIBUTION survey in six European cities. Journal
Retno Sulistiani acted as the main of Public Health. 39(2): 339–346.
researcher who coordinated the research, https://doi.org/10.1093/pubmed/fdw
carried out all stages of the research, and 040.
completed the research paper. Setyo Sri Amorha KC, Jiburu EM, Nduka SO, Okonta
Rahardjo played a role in compiling the MJ (2017). Cigarette smoking preva-
research framework, processing research lence and awareness amongst under-
data, presenting the results of research graduate students of the University of
analysis, and preparing research papers. Nigeria, Nsukka. J Basic Clin Pharm.
Pawito plays a role in developing ideas, 8: 239-244. https://www.jbclinphar-
research designs, and research hypotheses. m.org/articles/cigarette-smoking-pre-
valence-and-awareness-amongst-un-
CONFLICT OF INTEREST dergraduate-students-of-the-universi-
There is no conflict of interest in this study. ty-of-nigeria-nsukka-3934.html.
Ariani RD. 2011. Hubungan antara iklan
FUNDING AND SPONSORSHIP rokok dengan sikap dan perilaku
This study is self-funded. merokok pada remaja (Studi kasus di
SMAN Semarang). The relationship
ACKNOWLEDGEMENT between cigarette advertising and
Our gratitude goes to all school principals smoking attitudes and behaviors in
and high school teachers in the district of adolescents (Case Study at SMAN
East Lampung who has helped research and Semarang). Artikel ilmiah Semarang:
students who have been willing to become Progam Studi Sarjana Kedokteran
research subjects. Fakultas Kedokteran Universitas
Diponegoro.
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