The World Health Organization (WHO) considers tobacco smoking a pandemic that causes about 10 million deaths per year1, and one in 10 deaths in adulthood2. In Portugal, it causes one death every 50 minutes, and in 2019 more than 13500 Portuguese died from tobacco attributable diseases3,4.

Portugal is among the European countries with the lowest prevalence of smokers5. Nonetheless, there are substantial discrepancies in the smoking prevalence among the various Portuguese regions’ populations, and the Azores have the highest prevalence of smokers4.

In Western countries, including Portugal, the first peak of tobacco initiation occurs in the beginning of adolescence (age: 11–15 years)6-8. This early initiation worsens the health impact of smoking and raises the risk of tobacco dependence and its severity9-13.

Several models are used to explain smoking behavior, including the ASE model (Attitude, Social influence, and Self-Efficacy), used in this study. The ASE model is based on the Theory of Reasoned Action14,15, and on Bandura’s selfefficacy16. This model considers that behavior is influenced by intention and that intention mediates the effects of psychosocial or motivational variables (attitude, social influence, and self-efficacy)17-19.

This study aimed to assess the prevalence of smoking behavior in Azorean adolescents and to explore the association between smoking behavior and sociodemographic and ASE variables.


Sample and procedure

Sixteen Azorean schools accepted to participate in this crosssectional study. An online questionnaire was disseminated to students from 3rd cycle and secondary school levels by the teacher responsible for the class, through an internet link. The questionnaire was available online between November 2020 and February 2021. A total of 209 students responded, most of them lived on the islands of Terceira (51.7%) and São Miguel (40.2%).

The study and the questionnaire were approved by the Ethic Committee of the University of Beira Interior and by the Regional Direction of Education (DRE) – Azores Regional Government. Participation in the study was voluntary, and the anonymity of participants and confidentiality of data collected were guaranteed.


The questionnaire was based on a review of the literature and earlier work about adolescent smoking behavior16,18,20-22. A pilot of the questionnaire with Portuguese adolescents contributed to the selection of items and item formulation in Portuguese18,23. Questions assess sociodemographic variables, beliefs about smoking (attitudes), social influence, self-efficacy, intention to smoke, and smoking behavior.

Sociodemographic variables were age, gender, year of schooling, participants’ household, the island of residence, weekly money available, and mother’s and father’s education level.

Fourteen questions measured the attitudes on smoking, answered using a Likert scale. Eight questions were about the advantages of smoking [pros of smoking, e.g. ‘If I smoke (or if I smoked), I find it pleasant’], with answers ranging: 0 = ‘I totally disagree’ to 5 = ‘I totally agree’. Six questions addressed the disadvantages of smoking [cons of smoking, e.g. ‘If I smoke (or if I smoked), I think it is bad for health’), with the possibility of answers ranging: 0 = ‘I totally agree’ to 5 = ‘I totally disagree’. Finally, the remaining two questions addressed the social advantages associated with smoking [s-pros of smoking, e.g. ‘If I smoke (or if I smoked), I think it would be easier to be part of a crowd’), with responses ranging: 0 = ‘I totally disagree’ to 5 = ‘I totally agree’. A factor analysis confirmed these three factors: pros of smoking (Cronbach α =0.85), cons of smoking (Cronbach α=0.88), and s-pros of smoking (Cronbach α=0.89). These three factors were handled in some analyses as scales (using their means).

Social influence was assessed through several questions. Some sought to assess how participants perceive relevant others’ norms on their behavior (subjective norms). Relevant others are mother, father, brother(s), sister(s), best friend, important people, people of the same age, and teachers (e.g. ‘My mother (or the woman responsible for me) thinks that I:’) was evaluated with answers ranging: 0 = ‘I smoke’ to 3 = ‘Does not apply to my case’. Others questioned whether parents or close people smoked – descriptive norms (e.g. ‘Does your father (or the man responsible for you) smoke?’), with answers ranging: 0 = ‘No’ and 3 = ‘I do not have or do not live in my home’. The remaining questions evaluated the pressure to smoke exerted by the same people mentioned above [e.g. ‘Have you ever felt pressured to smoke by your brother(s)?’], with answers ranging: 0 = ‘Often’ to 5 = ‘I do not have or do not live in my house’. A factor analysis revealed three factors, corresponding to the subjective norms (Cronbach α=0.98), the smoking influence by family members and teachers’ behavior (Cronbach α=0.92), and the smoking influence by the peer group behavior (Cronbach α=0.91). In some analyses were used as scales (considering their means).

Self-efficacy to refuse to smoke was measured using 12 questions. Some were designed to understand the individual’s ability not to smoke in certain social circumstances (e.g. ‘When you are with friends who smoke, are you able not to smoke?’), others when performing routines (e.g. ‘When you are watching TV, are you able not to smoke?’), and in situations of emotional instability (e.g. ‘When you feel down, are you able not to smoke?’). All answers to these questions were given on a Likert scale, ranging: 0 = ‘I am absolutely sure that I smoke’ to 6 = ‘I am absolutely sure that I do not smoke’. Factor analysis forced into three factors according to previous studies carried out with this questionnaire16, including in Portugal18, revealed the social self-efficacy factor (Cronbach α=0.97), routines self-efficacy factor (Cronbach α=0.99), and emotional self-efficacy factor (Cronbach α=0.98). These factors were used as scales in some analyses (considering their means).

Intention to smoke was evaluated by the question: ‘Do you intend to smoke in the next year?’, with answers on a Likert scale ranging: 0 = ‘Definitely yes’ to 6 = ‘Definitely not’.

Finally, smoking behavior was assessed using five combined questions18,21,22. In this study participants were divided into two or three groups. Two groups were never smokers (those who had never smoked not even a puff) and already smokers (those who smoke or had smoked occasionally and regularly). Three groups were the previous never smokers, occasional smokers (who smoke less than a cigarette a week or had smoked occasionally and regularly) and regular smokers (those who smoke one or more cigarettes per week).

Statistical analysis

Statistical analysis was carried out at two levels, based on the items (smoking behavior, attitudes, social influences, selfefficacy, and intention to smoke) or based on the factors of the ASE variables (pros of smoking, cons of smoking, social attitude, social influence of peers, social self-efficacy, self-efficacy emotions, and self-efficacy opportunities).

Descriptive statistics of sociodemographic variables and relevant variables were performed. Differences between never smokers and already smokers were analyzed using chi-squared test and t-test.

After, a bivariate correlation was made to explore the relationship between smoking behavior (with three groups: never smokers, occasional smokers and regular smokers) and the other variables. Finally, a logistic regression was performed using smoking behavior with two groups (never and already smokers) as dependent variable and all the other variables as independent variables. All analysis were performed using SPSS v. 26 (IBM Corp., USA).


The participants’ mean age was 15.4 ± 1.9 years, 68% were female, 88% were Catholic, and 50.7% had between €5 and €15 to spend weekly (Table 1). Most of the mothers (70.3%) and fathers (57.9%) did not smoke. Parents’ education level was low (66% of mothers and 73.7% of fathers were below secondary/high school level), and 97.4% had Portuguese nationality.

Table 1

Sample sociodemographic characteristics and comparison between never smokers and already smokers (N=209)

CharacteristicsTotal Mean ± SDNever smokers (N=144) Mean ± SDAlready smokers (N=65) Mean ± SDSatistical test (p)
Age (12–19 years) mean ± SD15.4 ± 1.914.9 ± 2.016.6 ± 1.4t(173.46)= -6.9 (p<0.05)
n (%)n (%)n (%)
SexFemale140 (67.0)95 (67.9)45 (32.1)χ2(1)=0.4 (p>0.05)
Male69 (33.0)49 (71.0)20 (29.0)
Weekly money available to spend (€)<569 (33.0)46 (31.9)23 (35.4)χ2(2)=0.4 (p>0.05)
5–15106 (50.7)75 (52.1)31 (47.7)
>1534 (16.3)23 (16.0)11 (16.9)
Mother’s education levelCycles 1–3138 (66.0)97 (67.4)41 (63.1)χ2(2)=1.2 (p>0.05)
High school39 (18.7)24 (16.7)15 (23.1)
University32 (15.3)23 (16.0)9 (13.8)
Father’s education levelCycles 1–3154 (73.7)101 (70.1)53 (81.5)χ2(2)=4.7 (p>0.1)
High school33 (15.8)28 (19.4)5 (7.7)
University22 (10.5)15 (10.4)7 (10.8)

[i] Participants are young from schools of The Azores (Portugal). Data were collected in 2020–2021.

Smoking behavior and intention to smoke

According to the data presented in Table 2, regarding the smoking behavior of the participants, 68.9% reported never had smoked, not even a puff (never smokers); all others were classified as already smokers: 16.2% had smoked occasionally, but currently do not smoke; 3.3% very rarely smoked a few puffs; 3.8% smoked a few cigarettes a year; 1.9% smoked at least once a month; and 5.7% smoked regularly (at least one cigarette a week).

Table 2

Smoking behavior, intention to smoke and perception of smokers’ percentage in the Portuguese population (N=209)

Smoking behavior
Never smoked, not even puff14468.9
Smoked occasionally but does not currently smoke3416.2
Smoke very rarely a few puffs from a cigarette73.3
Smoke a few cigarettes a year83.8
Smoke at least once a month41.9
Smoke regularly125.7
Percentage of individuals who intend to smoke next year
Maybe yes73.3
I do not know178.1
Maybe not41.9
Percentage of individuals who intend to smoke in the future
Maybe yes94.3
I do not know209.6
Maybe not94.3
Perception of smokers’ percentage in the Portuguese population

[i] Participants are young from schools of The Azores (Portugal). Data were collected in 2020–2021.

Most participants did not show an intention to smoke in the next year (82.8%) or in the future (78.0%) (Table 2).

The participants’ perception on the percentage of smokers in Portugal was illusory and inflated: 48.8% answered that 61–80% of the Portuguese are smokers (Table 2).

Comparison between never smokers and already smokers

Comparing never smokers with already smokers in the sociodemographic variables (Table 1), these two groups differed only in age: already smokers were older than never smokers (16.6 ± 1.4 vs 14.9 ± 2.0 years, p<0.05).

In the attitudes (Table 3), significant differences between never smokers and already smokers appeared in the items of beliefs that smoking is positive (0.4 ± 0.7 and 0.8 ± 1.0; p<0.05), pleasant (0.6 ± 0.9 and 1.6 ± 1.2; p<0.05), helps to be slim (2.8 ± 1.4 and 2.5 ± 1.2; p<0.05), is stupid (1.3 ± 1.6 and 1.5 ± 1.3; p<0.05), calms the nerves (0.8 ± 1.0 and 2.0 ± 1.3; p<0.05), makes one feel secure 0.7 ± 0.9 and 1.2 ± 1.2; p<0.05), makes one receive more attention (0.7 ± 1.0 and 1.1 ± 1.3; p<0.05), makes one more sociable (0.7 ± 1.0 and 1.4 ± 1.3; p<0.05), and integrate more easily (0.7 ± 1.1 and 1.5 ± 1.3; p<0.05).

Table 3

Comparison between never smokers and smokers in attitudes, social influence, self-efficacy and intention to smoke (only items with significant differences are presented) (N=209)

Never smokers (n=144) Mean ± SDAlready smokers (n=65) Mean ± SDStatistical test p*
Beliefs about smoking
Is positivea0.4 ± 0.70.8 ± 1.0t(97.2)= -3.3*
Pleasanta0.6 ± 0.91.6 ± 1.2t(96.2)= -5.7*
Helps to be slima2.8 ± 1.42.5 ± 1.2t(146.8)=1.4*
Is stupidb1.3 ± 1.61.5 ± 1.3t(151.2)= -1.0*
Calms the nervesa0.8 ± 1.02.0 ± 1.3t(99.4)= -6.4*
Makes one feel securea0.7 ± 0.91.2 ± 1.2t(95.2)= -3.3*
Makes one receive more attentionc0.7 ± 1.01.1 ± 1.3t(103.9)= -2.4*
Makes one more sociablec0.7 ± 1.01.4 ± 1.3t(100.1)= -3.9*
Integrate more easilyc0.7 ± 1.11.5 ± 1.3t(101.4)= -4.1*
When with others who smoked5.7 ± 0.94.9 ± 1.4t(85.73)=4.1*
When with friends who smoked5.7 ± 0.94.5 ± 1.6t(84.21)=5.8*
When offered a cigaretted5.7 ± 0.94.7 ± 1.4t(87.66)=5.5*
When friends offer a cigaretted5.7 ± 0.94.5 ± 1.6t(82.17)=5.8*
When feel upsete5.7 ± 0.94.8 ± 1.6t(80.81)=4.3*
When feel depressede5.7 ± 0.94.8 ± 1.7t(79.61)=4.2*
When feel nervouse5.7 ± 0.94.7 ± 1.6t(84.28)=4.5*
When feel worriede5.7 ± 0.94.8 ± 1.6t(80.51)=4.4*
When out with friendsd5.7 ± 0.94.1 ± 1.8t(77.01)=6.6*
When watching TVf5.8 ± 0.85.3 ± 1.5t(80.35)=2.7*
When doing homeworkf5.8 ± 0.85.3 ± 1.5t(85.59)=2.6*
When on way home from schoolf5.8 ± 0.85.3 ± 1.4t(82.62)=2.7*
Social influencesn (%)n (%)
Best friend smokesc
No123 (85.4)40 (61.5)χ2(3)=23.1*
Yes6 (4.2)16 (24.6)

Participants are young from schools of Azores (Portugal). Data were collected in 2020–2021.

a Pros of smoking factor.

b Cons of smoking factor.

c Social influence of the peers.

d Social self-efficacy factor.

e Emotions self-efficacy factor.

f Opportunities self-efficacy factor.

* p<0.05 for all.

In terms of social influence (Table 3), the values of both groups do not differ significantly, except in the case of a best friend who smokes, with never smokers reporting a higher percentage of best friends who never smoked. However, although differences were not significant, relevant others [e.g. mother, father, brother(s), sister(s), and best friend] for the already smokers had consistently a higher percentage of smoking behavior.

Regarding self-efficacy to refuse smoking (Table 3), the two study groups showed significant differences in all items. However, the differences were bigger in some items: ‘when you go out with friends’ (5.7 ± 0.9 and 4.1 ± 1.8; p<0.05), ‘when friends offer a cigarette’ (5.7 ± 0.9 and 4.5 ± 1.6; p<0.05), and ‘when with friends who smoke’ (5.7 ± 0.9 and 4.7 ± 1.4; p<0.05).

The results did not reveal significant differences between the two groups in the intention to smoke.

Correlations with smoking behavior

Regarding attitude scales (Table 4), the results indicated a significant correlation between smoking behavior and the pros of smoking (r=0.46). All self-efficacy to refuse smoking scales had a significant correlation with smoking behavior, especially social self-efficacy (r= -0.57) and emotional self-efficacy (r= -0.49). However, the correlations between behavior, social influence variables and intention to smoke next year were not statistically significant.

Table 4

Correlation between smoking behavior and other relevant variablesa and logistic regression results (dependent variable: smoking behavior, never smokers/already smokersa)

VariablesbrcOR (95%CI)
Age (12–19 years)0.242.14 (1.59–2.86)
Beliefs for smoking (0: I totally disagree, to 5: I totally agree)0.464.34 (2.18–8.62)
Beliefs against smoking (0: I totally agree, to 5: I totally disagree)0.13
Social self-efficacy (0: I am sure I will smoke, to 6: I am sure I won’t smoke)-0.570.30 (0.15–0.60)
Routines self-efficacy (0: I am sure I will smoke, to 6: I am sure I won’t smoke)-0.40
Emotional self-efficacy (0: I am sure I will smoke, to 6: I am sure I won’t smoke)-0.49
Cox-Snell R2=0.44

Participants are 209 adolescents from schools of The Azores (Portugal). Data were collected in 2020–2011.

a Only significant results are presented.

b Independent variables: age, sex, money available to spend, prefer to be together with non-smoking people, beliefs for smoking, beliefs against smoking, beliefs s-pros, social influence of behavior (subjective norms), social influence of family and teachers, social influence of peer group, social self-efficacy, routines self-efficacy, emotional self-efficacy, and intention to smoke.

c Correlation with smoking behavior (with three groups: never smokers, occasional smokers, and regular smokers). R significant if p<0.05.

Logistic regression

A logistic regression was performed (Table 4). Regarding sociodemographic variables, only age (OR=2.14; 95% CI: 1.59–2.86) was significantly associated with behavior. Among the ASE variables, beliefs regarding the advantages of smoking (OR=4.34; 95% CI: 2.18–8.62), and self-efficacy to refuse smoking in social situations (OR=0.30; 95% CI: 0.15–0.60) were significantly associated with behavior. This model explained 44% of the variance in smoking behavior. Social influence variables and intention to smoke did not show a significant effect on behavior.


Most participants in this sample of young Azoreans (Portugal) were never smokers (68.9%). This prevalence of never smokers was slightly higher than that reported in other studies with Portuguese adolescents of these ages4. This result is not aligned with other studies on smoking in Portugal, where Azores usually has the higher percentage of smokers among all the Portuguese regions3-5. A possible explanation for this high prevalence of never smokers could be a bias related with the participation through the internet, which may be more attractive for never smokers than for already smokers.

Despite the fact that most participants were never smokers, the considerable percentage of occasional and regular smokers indicated the need of preventing smoking behavior in this population. To improve the effectiveness of smoking prevention in young Azoreans, it is essential to have valid and evidence-based information on smoking behavior in this specific population.

The model used in this study explained 44% of the total smoking behavior variance, a result that partially validates the suitability and usefulness of this model to understand smoking behavior and to guide smoking prevention activities targeted for young Azoreans. In this study, most of this variance was explained by ASE variables, manly pros of smoking and self-efficacy to refuse smoking. Other variables that usually are important in models to explain smoking behavior, like social influence and intention to smoke, were not significant in this study10,24.

The pros of smoking relevance is an interesting result. Usually, this variable is not addressed in preventive interventions, which are often focused on the cons of smoking instead of addressing the pro-smoking beliefs that young people develop in the beginning of adolescence25. Topics like smoking is positive, pleasant, calms nerves, makes one to feel secure, makes one receive more attention, makes one more sociable and to integrate more easily, must be addressed and contradicted in smoking prevention programs.

The effect of self-efficacy to refuse smoking on smoking behavior was also highlighted in this study as in others with Portuguese adolescents10,24. All self-efficacy factors had a significant effect on smoking behavior, with emphasis on self-efficacy to refuse smoking in social situations. Emotional self-efficacy had an ambiguous result: a significant correlation with smoking behavior and a not significant effect in the regression. A possible explanation for this inconsistency may be a high relation amongst items of emotional self-efficacy and social self-efficacy.

In this study, cons of smoking had a small effect, and social influence and intention to smoke did not significantly affect smoking behavior – except having a best friend who smokes, who appeared associated with smoking behavior. These were unexpected results that need be confirmed in future studies, in particular the absence of social influence effect, considering that this variable appeared in other studies with Portuguese adolescents as very important to explaining smoking behavior10,24.

Comparing the two groups (never smokers and already smokers), the values of intention to smoke were very low and similar in both groups, suggesting that adolescents do not intend to smoke. Thus, the effect of intention on smoking behavior predicted by the ASE model and by other sociocognitive models was not confirmed in this study. Doubts about the effect of intention to smoke in smoking behavior appeared already in some studies published in recent years18,24. These low values of intention to smoke and its null effect on smoking behavior could be related with the impact of the recent smoking control policies like the tobacco control law and media campaigns.

Regarding the difference in smoking behavior by gender, published studies have shown a consistent tendency for an increase of smoking in girls, with prevalence values very similar or even higher than the boys’ values25-28. In this study, the percentage of girls who were already smokers is slightly higher than the percentage of boys, suggesting the need for gender-specific studies on smoking behavior and genderspecific interventions to prevent smoking.

The participants’ perception about the percentage of Portuguese who smoke was highly inflated, a result in line with other studies carried out in Portugal18. Almost half of participants in our study considered that more than 60% of the Portuguese are smokers, although the official prevalence of smokers in Portugal is lower than 20%4. Tobacco prevention activities should address and correct this illusory perception that tends to normalize smoking and increase the risk of smoking behavior.

Strengths and limitations

This study has several limitations. First, this is a crosssectional study, which restricts the possibility of inferring the direction of the effects. Second, data resulted from a selfreport questionnaire, and the responses were not biologically validated. Third, the questionnaire was applied online to adolescents who responded on their own initiative, which may have been more appealing to never smoking people. Finally, the sample is small, with participants from only one region, limiting the results’ robustness and generalizability.

This study also has some strengths. It was carried out with a sample of Azorean adolescents. This population is often excluded from studies carried out at the national level and even more at the international level. Online data collection can have advantages, namely, enhancing the perception of responses’ confidentiality and participants’ anonymity.

Future directions

Finally, it is essential to mention the need to carry out more studies on smoking behavior in Azorean adolescents, namely, with higher sample sizes. Future studies will confirm or not the effects on smoking behavior of the pros of smoking and of social self-efficacy to refuse smoking and the absence of effects of cons of smoking, social influence and intention to smoke. Future studies could also compare subgroups (e.g. different ages, gender and socio-economic level) to improve the knowledge of smoking behavior and increase the effectiveness of smoking prevention activities in this population.


Our study confirmed the need of smoking prevention measures targeted to young Azoreans. Results highlighted the effect on smoking behavior of the pros of smoking and of self-efficacy to refuse smoking in social situations. Having a best friend who smokes and the illusory perception of a higher percentage of smokers in the Portuguese population are also relevant to explain smoking behavior in this sample. To improve the effectiveness of smoking prevention in this population, these variables should be included in prevention activities. For example, these results suggest that smoking prevention should focus on the pros of smoking instead of on the cons of smoking, and recommend the promotion of social competencies to improve youth self-efficacy to refuse smoking in social situations and to deal with the pressure of a friend who smokes.