Indonesian adolescents’ perspectives on smoking habits as a reference for a prevention program: a qualitative study

Three focus group discussions involving 24 junior high school students (mean age=13.75 years) were the main source of data for this phenomenological qualitative study. The discussion guide was developed by the researchers based on the reviewed literature and validated by experts. The research findings were analyzed using an inductive content method with systematic steps based on the stages of qualitative data analysis.

also found that teenagers are vulnerable to negative social influences from commercial groups that promote cigarettes, and therefore building their self-confidence is crucial to reduce vulnerability [4].
Another smoking vulnerability for children comes from their siblings and friends [16]. In some communities, the smoker usually has emotional and communication connections with their groups and becomes a socio-cultural identity; the smoking habit is accepted as a normative practice. Similar perceptions and behaviors will be adopted by the youth who are part of this community and interact with those groups [17]. An earlier report also found that youth smokers were usually in low socioeconomic circles, from broken families with addicted parents [5] and household conflict [18].
In addition to these factors, religion also influences smoking habits. In the United States, increased doctrinism was associated with reduced risks [19]. In a Turkish study, fewer religious employees smoked compared with general staff [20]. A study conducted in China also reported that pious Muslim men were mostly non-smokers [21]. Therefore, religious approaches can be effective in programs for cigarette and drug addicts, and Islamic teachings have been reported to be effective in preventing children from starting this behavior [22]. However, this view is probably different in Indonesia, which consists of two major groups of Islamic scholars: Nahdatul Ulama (NU) and Muhammadiyah. The sources and references of these groups have similarities, but they maintain different ideologies and understandings about Islamic thoughts on smoking. Muhammadiyah issued a fatwa (Islamic scholars' decision) that smoking is forbidden or haram, and NU tends to reject this fatwa [23]. This leads to different perceptions among the Islamic community, including the adolescents.
Aceh Province Indonesia, the only province that has implemented Islamic laws since 2000, has both NU and Muhammadyiah followers. Although the NU religious model predominates, neither model is followed consistently with regard to smoking. Therefore, it is still interesting to study the smoking habits in this community. Regarding the Islamic view on smoking, Aceh Islamic Scholars (Majelis Permusyawaratan Ulama) support smoking prevention by publishing a fatwa forbidding smoking (registration number 18 in 2014).
This qualitative research provides a specific description of the phenomenon of smoking among Indonesian Muslim adolescents, which focuses on adolescents' perspective as a whole, including the Islamic viewpoint and other related factors. The research findings will be a crucial reference for the development of effective smoking prevention intervention programs.

Methods Study design and participants
This is a phenomenological study, which used focus group discussions (FGDs) to explore the perspectives of Muslim adolescents on smoking, relevant to the qualitative concept [24]. Students from three junior high schools representing three sub-districts in Aceh Besar were chosen as the participants to represent a moderate life condition (between city and village life). These schools are suburban, with good public transportation and located less than 20 km from the capital of Aceh Province. Based on the district statistics in 2017, the total population in the district was 409,109 inhabitants (around 2000 people/km 2 ), with an average household size of 4, a poverty level of 15.41%, labor force participation rate of 59.17%, and open unemployment rate of 8.49%; service, trading, and agriculture are the main sources of income [25]. The three schools were chosen based on the following inclusion criteria: located in Aceh Besar district, with the same accreditation level (B), and in a community with moderate life conditions. Participants were chosen by purposeful selection according to the following inclusion criteria: male students, aged 12 to 18 years, living with parents, and able to communicate in the Indonesian language. The exclusion criteria were students less than 12 years old or more than 18 years old and unable to communicate well in the Indonesian language. The researchers asked permission from the school management before approaching the students. Then, the students were informed about the aim of the study and the study procedure. The researcher approached the participants and their parents by phone before collecting data. The written consent form was sent to parents via the school management except for the 18-year-old participant; he signed the form himself. Twenty-four participants, eight students from each school, were eligible to take part in the research. All communications with the students and their parents were conducted via their school management.
Data collection and procedure Data collection was conducted in January 2019 in the three junior high schools. FGDs were conducted in these three locations (FGD A, B, and C) and each FGD involved eight students. Each FGD was conducted in the school and lasted for 60-90 minutes. Three cycles of FGD is considered adequate to obtain data saturation. The justification for this was also based on previous research in which FGDs were used as the data collection method. The interviews were run by the principal researcher, a senior lecturer from the Faculty of Nursing, Universitas Syiah Kuala. She has good knowledge about qualitative studies and is also experienced in running FGDs in the community. The discussion protocol was developed by the researchers, based on the reviewed literature, and was discussed in a group meeting with several experts in qualitative research before the FGDs. The FGD process was guided by the researchers with an expert-validated protocol. The interviews were audio-recorded and the transcribed verbatim by two research assistants with a master's degree and good knowledge about FGDs and qualitative studies. The FGDs were formulated to obtain detailed information about adolescents' perceptions, opinions, and feelings about smoking. The FGD began by asking questions about perceptions on smoking: "What do you think about smoking?" Followed by "Why do adolescents smoke a cigarette?" and they were further asked to describe the factors that predisposed the behavior. The moderator (principal researcher) delivered the questions to all participants. Then, each student was given enough time to explore their opinions and perceptions.

Data analysis
The data were analyzed manually using inductive content analysis, with the steps carried out systematically, based on the stages of qualitative data analysis and the various parties involved [24].
The information from all FGDs was combined and considered as the unit of analysis and transcribed verbatim. The transcripts were read repeatedly by three experts in qualitative research and the researchers to obtain an overall understanding. Then, the data were broken into units of meaning and labeled with codes. The codes were compared sequentially based on similarities and differences and further formulated into sub-themes and themes, before being translated into English. Back translation was done, and two language experts assisted the researchers to ensure the best semantic equivalent and accuracy between Bahasa Indonesia and English.

Ethical considerations
This study obtained ethical approval from the Research Ethics Committee of the Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia. Participants had the right to refuse to be involved, they knew the research objective and their personal identity was guaranteed confidentiality. Written consent to participate in this study was obtained from participants' parents, except one participant who was 18 years old gave his consent. In Indonesia, 18 year olds can make decisions about her/himself and can have an identity card.
The researchers attempted to build relationships with the participants before the FGDs to establish trust. Direct communication with all participants and their parents was conducted by phone and at an informal meeting. The study objective was explained, all information about the study was given, and the students were assured that their personal identity was confidential from the public, other students, and teachers. The teachers were excluded from the FGD, and the participants had the opportunity to explore their perceptions freely. Before the FGD, we informed all participants that they had equal opportunity to express their opinions. We also emphasized that every comment was useful and appreciated in developing a smoking prevention program.

Characteristics of the participants
Most of the participants in this study were 13 years old; the minimum age was 12 years and the maximum age was 18 years. Most of the participants and their parents were smokers (Table 1).

Perception of smoking
The perception of smoking was the main theme when participants discussed smoking behavior. This theme was divided into three sub-themes: smoking is a social habit, contradictive feelings, and Islamic perspective.

Smoking is a social habit
Smoking is perceived as a social habit in the Acehnese community, as seen from the following statement: Other participants also confirmed that smoking is a social habit and usual behavior in the community: … it is normal to see someone smoking cigarettes in the community. [FGD A, P2, P5, P7] Therefore, the results illustrate that participants perceive smoking behavior as a societal practice.
Hence, it was not considered a violation of any the rules and customs in the local community.

Contradictive feelings about smoking
Contradictive feelings are a discrepancy between behavior and perception. Therefore, the desire to stay away from cigarettes is evident from one participant's statement. They did know about the negative effects of smoking but they were unable to say no to a cigarette from a friend. The phenomenon is known as a contradictive feeling among adolescents, where in the one hand, they want to reject cigarettes, but on the other hand, they face a situation that makes them unable to do.
This was interpreted from the participant's statement:

Smoking-related factors
This study indicated that factors related to smoking for adolescents included peer pressure, parents' smoking status, curiosity, and masculinity.

Smoking because of peer pressure
Peer pressure is defined as a condition whereby friends persuade or influence an adolescent into partaking in a habit. However, due to the strong ties and the tendency to behave in a similar manner as their acquaintances, adolescents obtain recognition and are thus considered a part of the group.
This sub-theme was reinforced by the perception that avoiding smoking makes them a ridicule to their peers as illustrated by the following statement: Therefore, smoking was perceived to be a way for the adolescent to be recognized by their peers as having masculine characteristics.

Smoking out of curiosity
Adolescence is a transition period, characterized by strong curiosity about everything, including trying cigarettes, as found in the teenagers in Aceh. The phenomenon was confirmed from the following statement: The first time I smoked was because I was curious about the taste of the cigarette. I tried it, which got This result reflects a connection between curiosity and the smoking habit among adolescents in Indonesia.

Discussion
In this qualitative research, teenagers expressed their perceptions of smoking, based on social contexts and Islamic perspectives. The results are important for educators and health practitioners, especially those involved in smoking prevention efforts and health promotion, to assist in the development of effective intervention programs appropriate for participants' religion. The following discussion is presented according to the sub-themes.
The outcomes of this research indicate that smoking is perceived as a social habit that exists in the local community. Adolescents consider it to be acceptable and not contrary to the norms of society.
These results verify previous studies, carried out in Mexico, where smoking was generally described as socially acceptable for men but not for women [5]. Such perceptions also promote smoking among teenagers. This finding is consistent with previous studies. When smoking has been accepted in social networks, especially among family members and friends, and is strongly associated with cessation and relapse, prevention is likely ineffective [26].
Muslim teenagers in Indonesia apparently have a similar perception about smoking as adolescents in other countries. They tend to smoke because it is considered an acceptable habit in their social environment. This is in line with previous research showing that teenagers were sensitive to friends who smoked, and also within a wider network of friends [27]. Furthermore, other investigations reported that young adults have a special relationship with smoking. It is capable of perpetuating social inequality, based on their socio-economic status in the environment, which is worrisome, during this early stage of life because of the bad impact through the life journey [28].
The results also showed that teenagers experience contradictive feelings in relation to smoking, which are linked to the information they have about its consequences. However, warning labels that are contrary to expectations of positive effects of smoking can reduce the expectation that the explicit outcome is slightly positive, subsequently reducing the behavior in the short term. Hence, it is important to disseminate information to the public about the effects of smoking on health [29], although teenagers are a vulnerable age group, easily influenced by various positive and negative issues; some partake in this habit because there is no direct immediate impact on health [29].
Furthermore, warnings about the dangers attributed to smoking cause contradictive feelings, as they incite fear. Therefore, contradictory warning labels are more meaningful if targeted at current smokers, and can also prevent youth from starting the behavior [29]. However, this is an important issue to consider when initiating a program. A previous study illustrated the importance of negative affect indirectly motivating the desire to stop smoking, hence, serving as a source of information to influence adult smokers and non-smoking adolescents to accept the health risks [30].
Contradictive feelings also arise because of the inability of adolescents to control behavior according to their desire. Smoking is a voluntary response to unintentional desires, which in some cases, involves neglecting the use of voluntary efforts to resist impulsive actions. However, the case of adolescents tends to resemble other human behaviors [31]. The results of this study indicate the experience of contradictive feelings related to smoking; even though the decision has been made, they remain sensitive. This theme also relates to differences in views about the laws governing the behavior among scholars.
Related to the Islamic perspective, there are two groups of Islamic scholar in Indonesia, NU and Muhammadiyah, which have different opinions on the law about smoking, Muhammadiyah scholars issue fatwa that forbids smoking, whereas NU tends to not support this standpoint [23]. However, teenagers who do not smoke cigarettes say that religion is the reason they do not participate.
Furthermore, this agrees with previous research in Jordan, which showed a close relationship between religious obedience and smoking, indicating the importance of culturally appropriate programs to help health workers [32]. Moreover, one of the most significant factors associated with the habit is a decrease in religiosity [33], because Muslim smokers in Malaysia refer to their religion as a guide to stop it or not [34]. The Quran and the hadith are the primary references for the law and living principles for the faithful [35], although the law on smoking is not directly stated in either. Hence, it is still debated in Indonesia, especially in Aceh; therefore, scholars have issued fatwa about the topic by also considering the contents of these sources. For a Muslim, a fatwa includes religious rules that are not specified in the Quran and Hadits but are considered by Islamic scholars.
The results of this study on teenagers in Aceh showed that some perceive this habit, according to Islam as haram, because it is seen as unhealthy due to its adverse effects and can eventually lead to death. Therefore, Islam forbids any behavior that has a negative effect on the human body as stated by the implicit law on smoking, supported by Quran Al-Baqarah: 195, which means "And do not drop yourself into destruction". Furthermore, it is also illegal because it is identified with a slow suicide, which is supported by the Quran, stating "And do not kill yourself; indeed, Allah is the Most Merciful to you. (Quran An Nisaa: 29). However, prohibition is also about the danger imposed on others, reinforced by the words of the Prophet Muhammad: "It should not start giving bad effects to other people, as well as repaying it." Moreover, this embargo was also in accordance with the fatwa of the Aceh Islamic Scholar (14, in 2014), according to the Islamic view that stressed its prohibition by medical experts. A person who allows children to participate in this habit is a sinner. Hence, it is concluded that cigarettes must be avoided by Muslims.
In addition, the Muslim perspective is emphasized by prominent scholars that urge abstinence and announce fatwas against tobacco on the grounds of their potential to cause poor health and further offend the commands of the Quran, therefore ensuring personal health and that of others [36].
However, some teenagers in this study viewed smoking as makruh, which means it is allowed, although it is better to not smoke. Furthermore, this result agrees with a previous study, which stated its permissibility, whereby Muslim smokers perceive the behavior as acceptable in Islam -hence, Makruh -although, if it is too much, it could be haram [37]. This awareness fuels the desire to smoke and the desire to continue to do so among teenagers, eventually creating dependence.
Adolescents tend to observe the short-term impact of smoking and therefore adopt the behavior because there is no immediate effect on health, indicating the inadequacy of the information available to them about the dangers. Furthermore, this study is in line with previous studies, which reported that a number of secondary school students in urban areas lack specific knowledge about smoking-related diseases [37], and also other studies that showed the main motivation is to be social.
The dangers of tobacco are seen to be low, and an independent risk factor is a perception that friends and other students take substances and drink alcohol [38]. Based on the results, Muslim adolescents who consider this habit as makruh and not forbidden are more at risk of participating. Hence, preventive efforts are urgently needed to preventing inception, which promotes dependence.
This investigation also showed the similarity between factors related to smoking, as in previous studies, where the influence of friends was observed as an important factor. It was also stated that the main related factors include having friends who are addicted, being offered cigarettes, and ease of access [39]. However, relatives and accomplices who smoke played an important role in influencing these practices [16], consistent with a study that reported a significant association between the status of family and friends and adolescent behavior [40]. Therefore, teenagers in Aceh and the world at large are highly influenced by their associates, and hence, they tend to adopt common behaviors [41]. Furthermore, this is in agreement with other research that reported that habit was driven by peer pressure and fashion [42].
Adolescents feel more comfortable sharing similarity with their friends, including smoking behavior; those who have such friends tend to behave likewise [43]. This agrees with previous studies, where the importance of peer pressure on this habit among students was shown [44]. Furthermore, this investigation indicated that this factor remains a focus in prevention intervention programs, involving practices to increase self-efficacy in an attempt to anticipate peer pressure and prevent the habit becoming a culture. Predictors include regular physical activity and low rejection of self-efficacy among men [45].
Parenting seems to be an important stimulus for adolescents in the period of conduct development [43]. As seen generally, Muslim teenagers in Indonesia are strongly influenced by guardians, because they serve as role models as shown in the analysis carried out in Aceh. This agrees with previous studies, where families play a strong role and therefore affect adolescent smoking behavior [46].
However, other papers have reported the close relationship between tobacco use and exposure to second-hand smoke and low socio-economic status in non-intact households where parents also smoke [5]. The continuity of this practice by guardians enhances dependence in the teenager, which is consistent with studies that show a strong positive relationship between parents and the behavior of adolescents, most significantly the father [47], because this is a strong risk factor for habit initiation between the ages of 12 and 17 years [48].
This research further illustrates the importance of exemplary behaviors in adolescents as role models in a community (at home with parents and siblings), at school and university (teacher/lecturer), and at work (director/head) [44]. However, the presence of family members who are addicts also reduces the desire to quit [49], and within the school environment, role models play an important part [50], because the behavior is significantly associated with intention factors, rejection skills, self-efficacy, friends and parents, and an anti-smoking environment [51]. Based on this discussion, the importance of character is known, although past research has differed on the influence of parents with a history of smoking and those currently addicted. Hence, an adolescent who has parents with a history of smoking in the past are at lower risk than children with current habitual guardians [52].
Adolescents were determined to smoke because it made them appear strong and mature, in agreement with earlier research, which associated initiation with the desire to be a real man. Having a positive subjective health status, promoting self-perception of being thin or of average body weight, portrays average happiness; stress, consuming alcohol, suicidal ideation, having sexual relations are associated with low or average academic achievement, as well as having parents with a middle school education or less, skipping travel trips with family within the previous 12 months, and having relations who allow smoking at home [53]However, the results do not support previous studies in Canada, which perceived smoking as unhealthy and uncool [17]. Misunderstandings about the topic still occur in Aceh, due to the perception that it indicates a person's maturity. This illustrates the problem of the self-concept experienced by teenage smokers as being against the goals of increasing selfconfidence, in agreement with previous studies that showed men with lower self-esteem exhibited more positive beliefs and behaviors than women [54]. However, others found that of the 13 risk factors investigated, eight (including smoking status of parents and friends, the absence of a ban at home, exposure to cigarettes in cars, vulnerability, increased symptoms of depression, and selfesteem) were statistically significant in relation to the initiation of the habit in teenagers, after adjusting for age and the education level of the parents [54]. Previous research also found that another influence was the stigma of not smoking (and reducing smoking) as well as guilt, loss of selfesteem, self-defense, and determination to continue [55].
Based on the theory of development, adolescence is characterized by an increase in curiosity about various objects, because it is a stage of cognitive development, enhancing the need to explore new activities, including smoking. Furthermore, curiosity is identified as a person's internal motivational system, activated by specific stimuli or activities, which involve uncertainty and novelty and further motivate exploratory behavior [56]. This study showed inquisitiveness to be a major factor contributing to the risk of smoking among adolescents in Aceh, supporting previous studies that reported a close relationship between seeking a sensation and cigarette use. Conversely, the search for an increased thrill was significantly associated with e-cigarette experience among Texas teens [57], driven by curiosity, peer pressure, and fashion [42].
Being inquisitive is also attributed to other factors; pro-smoking attitudes and perceived social norms support smoking and low self-efficacy is against this habit in a cross-sectional manner [55]. The consequences of interest tend to expose adolescents to the behavior, which is difficult to terminate [42]. Hence, the issue of curiosity is essential when developing prevention programs for adolescents.
Furthermore, rejection of self-worth is an important predictor of smoking incidence, which does not depend on specific communication about the topic among parents, siblings, and friends [58].
However, this result complements various previous findings, which serve as a guideline for the development of effective smoking prevention interventions. This study may have a limitation; there is possibility that opinions from the smokers dominated the discussions because most of the participants were smokers.

Conclusion
The results of this study illustrated that adolescents consider smoking as a social habit, a contradictive feeling, and from the Islamic perspective, it is deliberated by most teenagers to be makruh. The initiators were peer pressure, parents' smoking status, curiosity, and masculinity. We recommend that health professionals who are interested in developing smoking prevention programs should consider religious factors as a significant issue that could increase the effectiveness of the program.

Ethics approval and consent to participate
This study obtained ethical approval from the Research Ethics Committee of the Faculty of Nursing, Universitas Syiah Kuala, Banda Aceh, Indonesia. Participants had the right to refuse to be involved.
They were given detailed information about the research and confidentiality was guaranteed. Written consent to participate in this study was obtained from participants' parents.

Consent for publication
All data about the respondents in this article were approved by the participants for publication.

Availability of data and material
The datasets used in the current study are available from the corresponding author on reasonable request.

Competing interest
There was no conflict of interest among the authors.

Funding
Some of the funds for collecting the research data were provided by Universitas Syiah Kuala. Funding for preparing the proposal, the analysis, interpretation of the data, and writing the manuscript was provided by the researcher.

Authors' contributions
FF was involved in all aspects of the research, including research design, data collection, and analysis.
MA and SRJ were involved in research design, interpretation of the data, and editorial review and revision. TT participated in research planning, data analysis and interpretation, and review of published articles. All authors agreed to the final article for publication.