title: Tobacco Use and Influencing Factors Among Iranian Children and Adolescents at National and Subnational Levels, According to Socioeconomic Status: The Caspian-IV Study.
abstract: BACKGROUND
  Iran is facing an epidemiologic transition, with one of its features being the tendency towards smoking by adolescents. The findings of previous studies in Iran have shown that the pervasiveness of tobacco products among school students is high. No previous study has reported the prevalence and determinants of smoking in various socioeconomic statuses (SESs) and at the subnational level in Iran.
  
  
  OBJECTIVE
  To compare the prevalence of smoking and the factors that influence the initiation and continuation of tobacco use in a nationally representative sample of Iranian adolescents living in different regions with diverse socio-demographic patterns.
  
  
  METHODS
  This nationwide, cross-sectional study was conducted in 2011 - 2012 among 14,880 students, aged 6 - 18 years, selected by cluster sampling from 30 provinces. Anonymous questionnaires were completed about tobacco use and the main psychological determinants of initiation and continuation to smoke. The questionnaire was modeled on the world health organization global school-based student health survey (WHO-GSHS). The sub-national regions were defined by the criteria of geography combined with SES. According to this classification, the lowest to highest SESs were considered for the southeast, north-northeast, west, and central regions, respectively. Data were analyzed using the STATA statistical software package.
  
  
  RESULTS
  Overall, 13,486 students completed this survey (participation rate of 90.6%). They consisted of 50.8% boys, 75.6% urban residents, with a mean age of 12.47 ± 3.36 years. According to the self-report of students, 2.6 % (3.5% of boys and 1.7% of girls) were current smokers, and5.9% (7.5% of boys and 4.2% of girls) had ever been smokers. The current use of tobacco was higher in participants aged 14 - 18 years (6.11%) than in those aged 10 - 13.9 years (1.18%) and 6 - 9.9 years (0.51%). Current and past tobacco use, respectively, had the lowest prevalence in the region with the lowest SES (2.2%, 3.7%) and the greatest prevalence in the highest SES region (4.3%, 8.9%). Entertainment was the most common reason for smoking initiation (83.65% of smokers) and continuation (77.01% of smokers), followed by feelings of pleasure, and enjoying the tobacco smell. These influencing factors did not differ significantly according to SES or gender.
  
  
  CONCLUSIONS
  Smoking is a health problem for Iranian adolescents, and has a higher prevalence in areas with higher SES. Entertainment and feeling pleasure were the commonest reasons for initiation and continuation of smoking. Tobacco-control programs should begin from childhood and family-centered preventive counseling should be intensified in Iran.
authors.affiliation: Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran.
authors.forename: Roya
authors.initials: R
authors.lastname: Kelishadi
authors.affiliation: Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran; Department of Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, IR Iran.
authors.forename: Armindokht
authors.initials: A
authors.lastname: Shahsanai
authors.affiliation: Department of Community Medicine, School of Medicine, Alborz University of Medical Sciences, Karaj, IR Iran; Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran.
authors.forename: Mostafa
authors.initials: M
authors.lastname: Qorbani
authors.affiliation: Department of Pediatrics, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Esmaeil Motlagh
authors.affiliation: Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran.
authors.forename: Mohsen
authors.initials: M
authors.lastname: Jari
authors.affiliation: Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Diseases, Isfahan University of Medical Sciences, Isfahan, IR Iran.
authors.forename: Gelayol
authors.initials: G
authors.lastname: Ardalan
authors.affiliation: Health Promotion Research Center, Department of Epidemiology and Biostatistics, Zahedan University of Medical Sciences, Zahedan, IR Iran.
authors.forename: Hossein
authors.initials: H
authors.lastname: Ansari
authors.affiliation: Department of Medical Emergency, Qom University of Medical Sciences, Qom, IR Iran.
authors.forename: Hamid
authors.initials: H
authors.lastname: Asayesh
authors.affiliation: Chronic Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, IR Iran.
authors.forename: Ramin
authors.initials: R
authors.lastname: Heshmat
keywords: Adolescents; Smoking; Socioeconomic Factors