Health Education Research Advance Access originally published online on June 15, 2004
Health Education Research 2004 19(6):626-634; doi:10.1093/her/cyg087
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Health Education Research Vol.19 no.6, © Oxford University Press 2004; All rights reserved
Exploring children's conceptions of smoking addiction
1 School of Marketing, Tourism and Leisure, Edith Cowan University, Perth, WA 6027 and 2 Centre for Behavioural Research in Cancer Control, Division of Health Sciences, Curtin University, Perth, WA 6102, Australia
3 Correspondence to: C. Wang; E-mail: c.wang{at}ecu.edu.au
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Abstract |
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Tobacco addiction is a major health problem for both adults and young people—between 20 and 60% of adolescents are dependent on nicotine and more than two-thirds who attempt to quit experience withdrawal symptoms. Yet, anti-smoking efforts targeted at children emphasize primary prevention and ignore addiction education, which is generally considered relevant only to adult smoking and cessation efforts. This study reports children's concepts of smoking and addiction from interviews with 32 Western Australian boys and girls, aged 9–10 years, all non-smokers. Results suggest children's concepts of smoking addiction may influence attitudes toward smoking trials. Children who thought addiction happened immediately were committed to never smoke at all. Others who thought addiction happened after several cigarettes expressed intentions to experiment. These children believed they could avoid addiction by smoking less than the number of cigarettes that caused addiction. Children who defined addiction as ‘liking’ or ‘enjoying the taste of cigarettes’ believed they could avoid being ‘hooked’ as long as they managed to avoid enjoying the experience. Recent findings that children can get ‘hooked’ within a few days of smoking highlight the importance of addiction strategies targeted at children, particularly in relation to influencing intentions to experiment with smoking.
Tobacco addiction is a major health problem for both adults and young people—between 20 and 60% of adolescents are dependent on nicotine and more than two-thirds who attempt to quit experience withdrawal symptoms. Yet, anti-smoking efforts targeted at children emphasize primary prevention and ignore addiction education, which is generally considered relevant only to adult smoking and cessation efforts. This study reports children's concepts of smoking and addiction from interviews with 32 Western Australian boys and girls, aged 9–10 years, all non-smokers. Results suggest children's concepts of smoking addiction may influence attitudes toward smoking trials. Children who thought addiction happened immediately were committed to never smoke at all. Others who thought addiction happened after several cigarettes expressed intentions to experiment. These children believed they could avoid addiction by smoking less than the number of cigarettes that caused addiction. Children who defined addiction as ‘liking’ or ‘enjoying the taste of cigarettes’ believed they could avoid being ‘hooked’ as long as they managed to avoid enjoying the experience. Recent findings that children can get ‘hooked’ within a few days of smoking highlight the importance of addiction strategies targeted at children, particularly in relation to influencing intentions to experiment with smoking.
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Introduction |
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The issue of cigarette addiction has important long-term ramifications for health practitioners' endeavors to reduce the prevalence of smoking. In Australia, approximately half of all adult smokers take up the ‘Quit’ challenge annually, but only around 5% manage to achieve any long-term success (Quit Victoria, 1995
). In the US, 40% of smokers try each year to stop smoking with a 3% success rate (Smokefree, 2002) and, in the UK, only 2% are successful from the 33% who decide to quit (Moxham, 2000).
Such low success rates point to the addictive nature of cigarette smoking and generally support claims that ‘the marketplace for tobacco products is sustained by this addiction’ [(Kessler, 1995), p. 187]. In part as a result of the difficulty faced by smokers in giving up cigarettes, 19 000 adult smokers in Australia and 3 million around the world die every year from smoking-related diseases such as heart disease and lung cancer (Petersen and Pearlman, 2002).
The tobacco industry must target young people as the primary source of new customers to counteract the number of smokers leaving the market either through quitting or death (Kessler, 1995). In Australia, school children under the age of 18 (the legal age at which cigarettes can be purchased) smoke more than AUS$100 million worth of tobacco products each year (ASH Australia, 1999). While there are some signs that smoking rates in Australian school children may be falling (e.g. from 16 to 14% in the 12–15 years age range), decreases achieved in this younger segment appear to be lost in the 16–17 years age group where about one-third are current smokers (Hill et al., 2002).
Such trends in youth prevalence and the very real difficulty in giving up smoking once the habit is established highlight the long-term importance of keeping young people cigarette-free. Statistics show that 89% of all adult smokers in Australia start smoking before 21 years of age (Health Department of Western Australia, 1998). In the UK, 91% of adult smokers start as adolescents (Rugkasa et al., 2001) and, in the US a similar majority of habitual adult smokers are ‘hooked’ by age 18 (Institute of Medicine, 1994). Once past this period of ‘maximum vulnerability’, a person who has not become a smoker is unlikely to ever be one [(de Meyrick, 2001), p. 100].
As part of the urgent need to address the issue of smoking uptake in young people, our study explored the thinking processes that precede the decision to start smoking. Specifically, we interviewed West Australian 9- to 10-year-old children who were non-smokers, and asked them to articulate their thoughts about smoking, how easy it is to stop and whether they intended to experiment with cigarette smoking in the future.
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The problem of addiction |
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Primary health promotion efforts aimed at educating young people about cigarette smoking concentrate predominantly on prevention, and smoking cessation and cigarette addiction concepts are not often addressed. The significance of this neglect is highlighted by Rugkasa et al.'s (Rugkasa et al., 2001
) study of 10- to 11-year-old children. They found that, although familiar with the concept of adult addiction, few children actually mentioned addiction as a danger or consequence of children smoking. Similarly, an in-depth study of young female smokers (14–17 years) showed that addiction to smoking was an unanticipated consequence (Moffat and Johnson, 2001). The girls ‘never expected to become addicted’ and, when it happened, it came as a surprise [(Moffat and Johnson, 2001), p. 674]. Moffat and Johnson (Moffat and Johnson, 2001) argued the need to better understand what smoking addiction meant to young people and to explore how decisions to smoke are influenced by this.
However, a search of the literature revealed little systematic work on children's conceptions of addiction other than Rugkasa et al.'s (Rugkasa et al., 2001) study. Since the US Surgeon General's warning that cigarette smoking is as addictive as cocaine and heroin (US Department of Health and Human Services, 1988), many tobacco addiction studies have focused largely on the pharmacology of nicotine (a naturally occurring substance in tobacco that causes dependence) and its psychoactive effects, and the processes leading up to addiction [see, e.g. (Royal College of Physicians, 2000)].
Additionally, tobacco addiction is often considered in tandem with quitting (smoking cessation), which is regarded primarily as an adult issue (Wood, 1999). There is also a danger that discussions of cigarette addiction may provide young smokers with the excuse: ‘I can't quit because I'm addicted’ and thus perpetuate smoking behaviors (Wood, 1999).
While young people (12–17 years) are generally knowledgeable about smoking and health issues (Health Department of Western Australia, 1998), Rugkasa et al. (Rugkasa et al., 2001) found that many children (10–11 years) still hold misconceptions and unrealistic ideas about smoking addiction. For example, young people who smoke may refer to themselves as ‘addicted’ even though they may not be physically dependent on nicotine (National Drug Strategy, 1994). Eiser (Eiser, 1985) described this as social conditioning whereby teenage experimental smokers ‘experience’ addiction because that is what they have been taught or conditioned to expect. On the other hand, just under 60% of young smokers (11–15 years) still believed that it would be easy (almost half believing that it would be very easy) for them to quit smoking altogether if/when they chose to (Goddard, 1990). Only 18% felt they would be unlikely to succeed if they had to quit (Goddard, 1990).
Wood [(Wood, 1999), p. 105] described this ‘quitting is easy’ perception as ‘adolescent mythology’. Rugkasa et al. (Rugkasa et al., 2001, p. 595) showed that ‘addiction, as defined in the literature, seems to be largely irrelevant to children's ideas and experiences’ and suggested that some misconceptions may result from children's confusion over health promotion messages. In their study of 10- to 11-year-old children, Rugkasa et al. (Rugkasa et al., 2001) found that anti-smoking messages were not always understood. Similarly, Wang and Henley (Wang and Henley, 2001) found that anti-smoking health messages were often not internalized by young people (10–15 years) in the way health promoters intended.
Most adolescents who smoke daily have no intention of being lifetime smokers and believe they will stop the habit in the next 5 years. However, the reality is that more than three-quarters will still be smoking 5–7 years later (National Center for Chronic Disease Prevention and Health Promotion, 2001; Siqueira et al., 2001). Young smokers do become addicted to the nicotine in cigarettes and other tobacco products just like adults, although the proportion of physically addicted young people is probably only around half the rate of adult smokers (Colby et al., 2000). Young people experience the same physiological and psychological symptoms such as hunger, dizziness, difficulty in concentrating, irritability and cravings for cigarettes that characterize adult ‘withdrawal’ (Institute of Medicine, 1994).
Similar to adult smokers, three-quarters of young smokers have tried to give up smoking and have failed, and at least seven in 10 wish they had never started (Kessler, 1995). In many adolescent smokers, there is a ‘sense of regret and helplessness’ [(Kessler, 1995), p. 187] because they no longer feel able to stop smoking whenever they want to (WHO, 1998).
Empirical studies on adolescent cigarette addiction generally conclude that a substantial proportion of young smokers (between 20 and 60%) can be appropriately classified as dependent on nicotine (Colby et al., 2000).
Clearly, addiction has central relevance to young people and smoking. Our study explored children's concepts of smoking addiction and investigated the significance of this conceptualization in determining smoking intentions.
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Method |
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Two Western Australian government schools and two independent primary/junior schools in the Perth metropolitan area were randomly selected from the Western Australian telephone directory, and asked to participate in a study on children's health in which cigarette smoking was one of the topics of interest. From these schools, clusters of students in the targeted age groups and class level were sampled after obtaining active consent from principals, teachers, parents and children.
A total of 46 children (14 boys, 32 girls) were interviewed. Nineteen children were from independent schools while 27 were from government schools. Three of the schools were co-ed schools and one was an all-girls institution. All the children were from Year/Primary 5 and were aged 9–10 years. (In Australia, Year/Primary 5 is 2 years away from the start of high school/secondary school, i.e. Year 8). The children were non-smokers, although they did have indirect experiences with cigarette smoking as a result of parents, siblings, relatives, friends and/or neighbors who were current or ex-smokers. Only two (4%) of the children (one boy and one girl) admitted to ever having a puff once.
From general discussions on cigarette smoking, addiction was a salient issue for 32 (70%) of the 46 children, i.e. the children spoke about addiction without being prompted. There were nine boys (64%) and 23 girls (72%) in this group, with 21 from government schools and 11 from independent schools. This paper reports the concepts of addiction expressed in those 32 interviews.
Socioeconomic status (SES) information was not collected in this study, although this could be inferred from the type of school that children attended, i.e. government schools would generally be lower SES than independent (private) schools. An analysis of the postcodes of the schools confirmed this assumption. However, determining a child's SES solely from the type of school he/she attends has inherent limitations. In any case, there were no apparent content differences between government and independent school children's responses, although proportionately more children in the former group raised the issue of addiction during discussions on cigarette smoking. No content differences were obvious with respect to the gender imbalance, nor in the two children who had tried cigarettes.
The children were individually interviewed in their schools in sessions lasting between 20 and 30 min. Assurances of confidentiality were given. Children were advised that they could refuse any of the questions and that sessions could be terminated at their request at any time. These conditions satisfied ethics procedures, but were also intended to increase the openness and honesty of the responses children would give.
The interview process was semi-structured around the main themes of ‘Why do people smoke?’, ‘How easy/difficult is it to stop smoking?’ and ‘Would you smoke and why/why not?’. These questions were developed around cigarette smoking in general and children were not specifically asked what they thought about addiction. Any discussions on addiction were raised by the children on their own without explicit direction or suggestion from the interviewer. In this way, we hoped to minimize any likely influence on what the children had to say and how they actually said it. Although a consistent questioning procedure (i.e. method/order of questions) and line of questioning (i.e. subject matter) were maintained in all sessions for analysis and comparison purposes, children were generally allowed to pursue and articulate any thoughts they had on cigarette smoking and related concepts. This method of inquiry is modeled after Laurendeau and Pinard's (Laurendeau and Pinard, 1962) pre-planned or directed conversations/interviews and Piaget's (Piaget, 1930) clinical method. The objective was to tap children's conceptual understanding of a particular subject area by asking ‘how’ and ‘why’ questions, and allowing children to clarify vague or incomplete responses.
Each interview session was audio-taped, transcribed and analyzed using QSR NUD*ST5, a qualitative analysis software program. Consistent with the methods outlined above, a content analysis was performed to identify, group and compare themes in the data that provided insights into children's understanding of smoking addiction. Rather than an investigation into the extent and accuracy of children's knowledge of smoking and addiction, the analysis performed sought to uncover, at a deeper level, the interpretation, meaning and significance that children attach to that knowledge. In this respect, we took a primarily emic, or insider's, idiosyncratic perspective rather than an etic, or external, more objective perspective.
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Results |
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Verbatims are given as quotations with age in years and gender following.
Smoking and addiction
Some children stated addiction as a consequence of smoking: ‘smoking makes you addicted’ [9, male], ‘when people start smoking they get addicted to it’ [10, male]. The children explained being ‘addicted’ to smoking as ‘you just can't stop doing it’ [9, male]. Some children thought in terms of developing a ‘big habit’ [9, female] that was similar in concept to addiction because ‘when you take it [cigarettes] and have it once, it becomes a habit for you...then you just can't stop’ [9, female]. Other children did not use the words ‘addiction’ or ‘habit’ but nevertheless conveyed the concept of addiction: ‘you just don't want to stop and you just want to keep going and going’ [9, male]. Generally, the children associated smoking with regularity and persistence of behavior. Some conveyed their belief that this behavior was not normal using emphasis (e.g. ‘big’ habit) and repetition (e.g. keep ‘going and going’). None of the children expressed the belief that giving up smoking was easy.
Nature of addiction
Addictive behavior was seen as developing for a variety of reasons. One child explained that cigarettes contain ‘this thing called nicotine and that makes you addicted...and it makes you can't stop smoking’ [9, male]. Another identified that cigarettes have ‘a drug in it that makes you get addicted to it...and you keep smoking all the time’ [9, female]. This was because ‘every time you take one [cigarette] another drug comes in [to your body] and it keeps coming in...so if you've got a lot in there...in your lungs...like if you've got a tonne in there then it would be really really hard [to stop]’ [9, female]. A more insidious explanation was that ‘the devil at your side says take it, take it, take it [so] you'll keep taking it’ [9, female].
For other children, the nature of ‘addiction’, ‘habit’ and ‘don't want to stop’ were less distinct or ominous, and ‘just happened’ because smokers ‘like the taste’: ‘you've tasted it [cigarettes] before and you just want to keep doing it’ [9, male]. As a result, cigarettes per se were seen as making smokers lose control: ‘once you see a cigarette packet, you can't avoid it, you have to buy it’ [9, female], ‘people can't stop [smoking] because when they see other people smoking, they just want to smoke too’ [10, male]. This irresistible quality was likened to ‘when you eat chocolate, it's got a nice taste and then you just can't stop’ [9, male] and ‘it's like us quitting on soft drinks...it's really hard’ [9, male].
Addiction onset
The onset of addiction was conceptualized in two ways. Children spoke of being ‘hooked’ as either a function of quantity (the number of cigarettes smoked) or duration (the number of days or weeks of continuing to smoke).
Some children believed that smoking as few as one or two cigarettes would cause addiction: ‘just one smoke...and then you get addicted to them straight away’ [10, female], ‘after you've had a couple of cigarettes you get really addicted to it’ [9, male]. Others thought they could safely smoke up to five cigarettes: ‘you can smoke five and then it would become a habit’ [9, female]. One child thought the maximum number of cigarettes that could be smoked was 20 before addiction set in. For these children, addiction onset was thought of in terms of the quantity or number of cigarettes smoked.
Other children thought of addiction onset in terms of duration, ranging from ‘1–2 days’ of smoking, to ‘a few days’, ‘2 weeks’, ‘2 years’ and even ‘a long time’.
Because many children conceptualized the nature of addiction as ‘liking the taste’ of cigarettes/smoking, perseverance was seen as a factor in addiction onset: ‘sometimes [the] first time they [smokers] try it they don't like it, second time they try it they think it's a little bit good, then third time they try it they think it's really good so then they keep on doing it’ [9, male]. Perseverance was an important issue because even though the children had never smoked, most believed that cigarettes tasted ‘yucky’ or ‘gross’ and that liking cigarettes was an acquired taste.
Intention to smoke and addiction
The children in this study viewed smoking (and smokers) very negatively: ‘they [smokers] were just being stupid the first time they did it’ [9, male], ‘they're dopey’ [10, female], ‘if [smokers] take one smoking cigarette, if they're a stupid person, they get addicted to it’ [9, male]. In keeping with this view, none of the children said they intended to become a smoker.
However, some children said they would like to experiment: ‘I don't really like smoking [but] I just want to experience it’ [9, female].
Significantly, children who said they would like to try smoking held a common belief that addiction onset required more than one cigarette or more than 1 day of smoking. These children believed that cigarette trials were not dangerous if these experiments fell within the perceived ‘safe’ range: ‘I might try it but I won't do it for like 2 weeks ‘cause then I'll get the habit’ [9, male], ‘you can smoke about five and then it could become a habit’ [9, female], ‘one might be OK but if you have five in a week it won't be OK’ [9, female].
In contrast, children who believed that one cigarette or smoking for 1 day would produce almost immediate addiction consequences were strongly committed to never smoking at all.
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Discussion |
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Addiction—also called ‘habit’ or ‘don't want to stop’ by children in this study—was a salient issue in children's discussion of cigarette smoking. Importantly, children identified addiction as a negative consequence of smoking behavior and were generally fearful of being addicted.
In our sample, children's addiction fears were related to the smoker's general inability to resist cigarette smoking (‘you just can't stop doing it’). Children in this study also expressed strong beliefs that smoking harms your health. However, health and cigarette addiction were not described as inter-related concerns. Rather, in this sample of children, the fear of being ‘hooked’ on cigarettes—of having no control—seemed to be the more dominant reason for children to say they would never smoke.
While children described smoking as addictive, the actual nature of this addiction was not properly understood. Only one child identified that nicotine in cigarettes caused addiction. Another child had some notion that a drug (hidden in cigarettes and deposited in the smoker's lungs when smoked) caused people to have cigarette cravings. Outside of these ‘facts’, children thought of addiction as resulting from liking the taste of cigarettes—which was comparable to the personal ‘addiction experiences’ that they were familiar with, e.g. their own enjoyment of candy, soft drinks, fast food, TV programs and video games. The significance of this concept of addiction was that these children believed experimenting or trying cigarettes was safe and acceptable as long as they made sure they did not enjoy the experience or like how cigarettes tasted.
Beliefs regarding how easily addiction ensued were closely linked to children's intentions to experiment with cigarettes. Children who perceived addiction onset to be immediate were uncompromising in their beliefs against cigarette trial. Conversely, children who believed they had a window of opportunity to smoke ‘safely’—either in terms of number of cigarettes or number of days/weeks—were tempted to ‘see what smoking is like’ despite stating strong intentions to ‘never’ smoke.
In a practical health promotion context, children's decisions regarding both experimenting with and taking up cigarette smoking may be based at least in part on their understanding—or misunderstanding—of cigarette addiction. This contrasts with Rugkasa et al.'s (Rugkasa et al., 2001) UK findings that the issue of tobacco addiction was perceived by children to be primarily an adult phenomenon that had little relevance to childhood smoking.
A recent opinion piece in the European press asserted that ‘lack of awareness about addiction and dependency is one of the reasons why children are so susceptible’ (Cyprus Mail International Daily, 2002). However, there is evidence that some young people are aware of the negative consequences of addiction. A letter in the New Scientist from a 17-year-old youth presents this view explicitly: ‘Teenagers start smoking for many reasons—some as an act of rebellion, some as a response to peer pressure—but the main reason that non-smoking teenagers do not smoke is out of fear of addiction’ (Davidson, 2002). Similarly, a Health Canada qualitative study on young women and smoking concluded that fear of addiction acted as a ‘substantial deterrent for the non-smokers’ whose wish to be seen as independent young women conflicted strongly with the notion of being dependent on a substance [(Health Canada, 2000), p. 4]. In this Canadian study, young women smokers described the process of addiction as an ‘insidious’ progression from experimenting, to believing themselves to be in control, to finding they were unable to stop smoking [(Health Canada, 2000), p. 6]. Moffat and Johnson (Moffat and Johnson, 2001) suggested that this occurred because young smokers tended to downplay and disbelieve that they could become addicted. Manfredi et al.'s (Manfredi et al., 1998) study of young, low-SES women found that ‘wanting to show not being addicted to cigarettes’ was one of the major motivating factors for quitting [(Manfredi et al., 1998), p. 316]. However, they also found that perceptions of being addicted delayed planning to quit, perhaps because withdrawal symptoms were being anticipated (Manfredi et al., 1998).
Children in our study clearly delineated between smoking ‘experimentation’ and ‘regular’ smoking. Whilst remaining fearful of addiction and at the same time, maintaining highly negative views of smoking and smokers, some of the children did not see any apparent contradiction in wanting to try cigarettes. Their willingness to experiment appeared to be facilitated by a belief in their ability to devise strategies to escape or avoid becoming addicted, such as not letting themselves ‘like the taste’.
Such perceptions are worrying because Russell (Russell, 1990) suggested that as few as four cigarettes could be enough to get ‘hooked’. More recently, DiFranza et al. (DiFranza et al., 2000) found that for some children, nicotine addiction could develop within a few days of smoking or just smoking one cigarette every other day. These findings indicate that children who believe they can be addicted almost immediately may not have unrealistic perceptions and provide some validity to an education strategy aimed at highlighting the risks of addiction.
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Conclusion |
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These findings have important implications for primary prevention interventions targeted at young smokers. The fear of addiction could be a protective factor in prevention efforts since this may be more salient for young people than health threats such as lung cancer. Addiction is a short-term consequence with high probability, whereas lung cancer is a long-term consequence, probably perceived as having a lower probability. de Meyrick [(de Meyrick, 2001
), p. 106] articulated emphatically that ‘[addiction] is not a remote "statistical probability", it is an immediate promise’ easily verified by the smokers who display cravings for cigarettes and the large numbers who unsuccessfully attempt to quit. It may be useful therefore to use the possibility of ‘rapid onset’ of addiction as a way of persuading young people to choose not to experiment with smoking especially given the corroborative evidence from addicted smokers everywhere. However, more investigation, especially longitudinal, is required to determine the extent that fear of smoking addiction—based on realistic and unrealistic beliefs—will actually protect children through adolescence against cigarette trials and smoking uptake. Additionally, we need to understand how children's smoking intentions change as their perceptions of smoking addiction mature.
Fear of addiction could also be used in early cessation efforts with young people in an attempt to interrupt the progression from experimentation to addiction onset. Some researchers have argued that targeting young people with smoking prevention efforts will never be 100% effective because of the association of smoking with adulthood for adolescents in the transitional phase. Instead, they suggest that targeting young people with early cessation efforts would be more realistic (Lynch, 1995). This view is supported by Sargent et al. (Sargent et al., 1998) who recommended that cessation interventions are necessary to forestall the transition from occasional, opportunistic smoking to daily, addicted smoking. Targeting young people with early cessation messages could be seen as part of a long-term strategy to prevent adult smoking. The difficulty here is that highlighting the dangers of addiction could reduce perceived self-efficacy and lead to maladaptive coping strategies.
In conclusion, this study built on previous research into children's concepts of addiction [i.e. (Rugkasa et al., 2001)] and contributes insight on several important issues. First, the findings suggest that addiction is a salient issue for children as young as 9–10 years. Second, the study contributes an important finding relating to children's intentions to smoke: those who perceived a ‘safe window’ before addiction set in were likely to say they would try smoking. This window could be expressed in terms of duration of smoking or quantity of cigarettes smoked. Third, children expressed the belief they could adopt strategies to avoid addiction such as not liking the taste. However, it is important to note the limitations to our study. The sample was small (only 32 children in the 9–10 years age group), predominantly female and restricted to four urban schools located in Western Australia. Nevertheless, these in-depth data provide a starting point for further research in this area and particularly on whether an increased focus on addiction could serve to delay if not prevent trial altogether. Future research in this area should contribute to developing practical health promotion strategies involving addiction education for children.
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Acknowledgments |
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We wish to thank the referees who reviewed this paper and provided some very helpful comments and suggestions. The Centre for Behavioural Research in Cancer Control is part funded by the Cancer Foundation WA.
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Received on December 12, 2002; accepted on March 1, 2004
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