Learning Objective #1: understand the mediating and moderating effect of Self-efficacy on adolescent's decision making toward to start smoking.

Learning Objective #2: know the application of statistical analysis of moderator and mediator in nursing research.

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Research has shown that the concepts of self-efficacy and decisional balance are related to adolescent smoking; however, no study was found to test the mediating and moderating roles of self-efficacy on the relationship between the cognitive appraisal of smoking (decisional balance) and smoking behavior. The purpose of this cross sectional study is to examine the mediator and moderator effect of Self-efficacy on decisional balance toward smoking initiation among Taiwanese adolescents. Structured questionnaires were administered to 741 adolescents aged 11 to 17 years who were recruited from four elementary and five junior high schools in a northern city of Taiwan. A 2-step stratified random cluster sampling method was used in this study where the sampled unit was the school and class, respectively. Logistic and linear regression procedures were used to examine the mediation and moderation processes. The findings demonstrated that self-efficacy significantly interacted with decisional balance; indicating that self-efficacy moderated the strength of the association between adolescents' decision making and smoking behavior. Additionally, self-efficacy significantly mediated the relationship between adolescents' decisional balance and smoking behavior. Therefore, school nurses and health care providers may develop a smoking prevention program to increase self-efficacy to resist smoking by counteracting the effect of positive perceptions of smoking for Taiwanese adolescents.