In Malaysia, smoking is more prevalent among males. This trend is in agreement with other studies on various populations worldwide [23
]. Furthermore, ethnic variation in the prevalence of this behaviour was observed which is also seen in other populations [25
]. Apart from smoking, other risk habits for oral mucosal lesions such as alcohol consumption and betel quid chewing is also prevalent. The practice of multiple habits simultaneously in this study which is more commonly found among males is in line with other studies [26
Data on smoking behaviour from other studies are mainly on only one ethnic group for the country, for example data on Indians from India, and on the Chinese from China and Taiwan. However, there is a need to understand the smoking behaviours among the different ethnic groups. As Malaysia is one of the few countries in Asia that has various races living in the same environment, this study provided a good platform for comparing smoking behaviour among different ethnicity. The Malays were found to be significantly more likely to start smoking, while smoking cessation was least likely among the Indians. It was also observed that the proportion of quitting smoking was highest among the Chinese, however multivariate analysis did not find any statistical significance. The ethnic variation seen could be attributed to their attitude towards health. In a national study on 16,127 Malaysians, the Malays and Indians were found to have the highest prevalence of obesity while it was lowest among the Chinese [27
], which probably reflects their level of awareness, knowledge and interest on health and nutrition issues. It was also reported that the Chinese scored the highest for general knowledge on breast cancer, followed by the Malays and Indians [28
]. Furthermore, Malay and Indian women were also reported to be the more likely to present with late stage breast cancer as compared to the Chinese [29
], which indicates that generally, the Chinese are more concerned of their health status.
History of betel quid chewing has been significantly found to increase the likelihood of smoking commencement. This could be explained by the fact that tobacco included in the quid would probably already promote nicotine dependency, thus leading to the initiation of smoking. Concurrently, this study also found that those currently practicing the habit of betel quid chewing are less likely to stop smoking. An interesting observation is that among males, univariate analysis found that those who quit smoking were more likely to be regular alcohol consumers, which is not in agreement with other studies [26
]. This higher rate of smoking cessation among alcohol consumers in this population could be due to the fact that the practice of another habit that promotes addiction such as consuming alcohol eases and lessen the withdrawal symptoms in the process of removing the addiction and dependency to nicotine that is found in cigarettes. Among the different type of tobacco use, kretek users were found to be the least likely individuals to stop smoking. This could be attributed to the higher nicotine content in kretek as compared to cigarettes [31
], which promotes greater dependency among its users.
Interestingly, in this study, univariate analysis found no dose-response relationship as found by other researchers [32
], where in this present study, no difference was seen in the quit rate across the years of smoking and number of cigarettes smoked previously. This finding could be explained by the fact that most of those quitting smoking are of the Chinese ethnicity, which has been shown to be more health conscious compared to the other ethnic groups. Researchers have suggested that the main reason for quitting smoking is health concerns [19
]. Thus, awareness and willingness to quit smoking based on health reasons supersede the number of years and sticks smoked previously. On the other hand, as there is currently a declining trend of social acceptability of tobacco use, there is also the risk of underreporting by the respondents on their smoking status [34
In line with findings by other researchers, males were found to be more likely to start smoking earlier. This could be largely attributed to the sociocultural environment of the population. Males are more likely to initiate the behaviour due to peer pressure and as a sign of masculinity and machoism [17
], while females are less likely to start smoking as it is always associated with social stigma. In Asian countries such as Malaysia, it is perceived to be alright if males smoke. However, it is considered to be culturally inappropriate if a female smokes indicating that they are perceived as ill-mannered and 'bad' [35
]. Other reasons cited by females for not smoking are health concerns, family values and spouse influence [38
]. Although smoking is generally more prevalent among males, literature has showed that in recent years, there is a trend of an increasing prevalence among females [39
]. Of interest to note, this study found that the female smokers are less likely to quit smoking as compared to males which is in concordance with other studies [40
]. A plausible explanation relates to the main concern that women have when thinking to quit which is weight gain. It was reported that the barriers in smoking cessation among fifty percent of female smokers are concerns about weight gain [42
]. Their fears are not unfounded as studies have shown that females gain more weight than males after quitting smoking [43
]. This concern may be reflected in our study population where none of the female smokers in the 20-25 age group were found to quit smoking.
Although cigarette smoking has been accepted worldwide as a risk factor for an array of chronic, potentially fatal diseases such as cancer, there are still pockets of society that could not see the link between tobacco and disease [21
]. This present study found that smoking is still very prevalent, especially among the males in Malaysia. This scenario could be due to the lack of emphasis on consequences of practicing this behaviour over an extended period of time prior to the conduct of the study. Presently, the government has introduced various campaigns and health policies targeted at reinforcing the adverse effect of this behaviour, not just on health, but also the social and economic impact on the individual and society such as the nationwide 'Say No' campaign. Policies targeting smokers were introduced where graphic warnings on the effect of smoking on lungs, oral cavity and babies were displayed on cigarette boxes. Strategies to reduce the prevalence of smoking were also carried out through the annual increase in the tax on cigarettes.
In relation to the ethnic variation in the smoking behaviour observed in this population, efforts on future policies and strategies by health personnel needs to be targeted and tailored towards the high risk groups as identified in this study. The reasons that influence the initiation and cessation of smoking should also be further investigated so that health authorities are better equipped to formulate future cessation programs more efficiently. Furthermore, future efforts need to also target and emphasize the hazards of other high risk behaviours, such as concurrently smoking, chewing betel quid and drinking which is currently seen in this population.