Health Education Research Advance Access originally published online on August 17, 2005
Health Education Research 2006 21(2):181-191; doi:10.1093/her/cyh054
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Ambivalence and uncertainty: experiences of and attitudes towards addiction and smoking cessation in the mid-to-late teens
1 Division of Community Health Sciences, Public Health Sciences, Medical School, Edinburgh University, Teviot Place, Edinburgh EH8 9AG, UK
2 NHS Health Scotland, Rosebery House, 9 Haymarket Terrace, Edinburgh EH12 5EZ, UK
3 Department of Epidemiology and Public Health, Brook House, 21-6 Torrington Place, London WC1E 6BT, UK
*Correspondence to: A. Amos. E-mail: amanda.amos{at}ed.ac.uk
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Abstract |
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The late teens is an important transitional period as adolescents move into new social worlds which support or challenge their smoking. This paper draws on research with 99 Scottish 16- to 19-year olds which explored their understanding of their smoking and attitudes towards quitting and cessation support. The study involved qualitative interviews mostly with friendship pairs. Interviewees also completed a brief smoking questionnaire. Most regarded themselves as smokers but few thought they were addicted. Many were interested in quitting but this was not a priority. Perceived barriers to quitting related primarily to habitual and social aspects of dependence including friends' smoking, the smoking culture at work or college, stress and boredom. Few were interested in nicotine replacement therapy or cessation services, which they felt belonged to the world of older addicted smokers. The most effective quitting strategy was thought to be will-power. Traditional cessation services are therefore in their current form unlikely to appeal to older adolescents. Services aimed at this age group need to be grounded in their understandings of smoking and the social factors which support smoking. Young smokers should also be helped to understand how support may increase quitting success and how encourage quitting before smoking becomes entrenched in their daily routines.
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Introduction |
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Reducing smoking among young people is a key objective of the British government's tobacco control strategy [1]. As part of this strategy, resources have been provided for health services to run local smoking cessation services. One of the key target groups for these services is young people. The focus on reducing smoking among young people reflects concerns about the lack of decline in their smoking compared with adults. Smoking rates in British adults declined from 32% in 1988 to 27% in 2001 [2]. In contrast, smoking rates among 16- to 19-year olds at 28% were the same in 2001 as in 1988. Similar concerns have been raised in other countries with long histories of smoking, with calls for a higher priority to be given to promoting smoking cessation among young people [3, 4].
There is a wealth of research on smoking among younger adolescents. However, the development and evaluation of smoking cessation programmes for older adolescents has been hampered by the lack of research on smoking, including attitudes towards and experiences of quitting, in the mid-to-late teens [5]. This may be due to the difficulties of researching adolescents once they have left school, but it may also reflect an assumption that they are not interested in quitting and/or would not use cessation services. Some recent research has started to challenge this view.
Particularly striking has been the experience of ‘Smokeline’, the Scottish telephone helpline. Set up to help adult smokers who wanted to quit, in its first years of operation half the calls were from teenagers, mostly about their own smoking [6]. National surveys have found that nearly half of the young smokers wanted to quit and almost three-quarters had tried to quit [7]. A study of Scottish 11- to 18-year olds [8] also found that many were worried about their smoking but their quitting intentions were inconsistent and varied from day to day. Similarly, a study of US high school smokers found that while most had thought about quitting, and some had tried to quit, they did not intend to quit in the foreseeable future [9].
Recent qualitative studies with older teenagers have indicated that the meanings they attach to their smoking, and their understanding of their behaviour (including whether they are addicted), may affect motivations to quit and the likely effectiveness of such attempts. For example, a Scottish study of 17- to 18-year old students [10] identified three types of smokers: ‘social’ smokers who smoked intermittently with friends, did not classify themselves as smokers and were not interested in quitting; ‘confirmed’ daily smokers who felt somewhat addicted and had some interest in quitting but were content to be smokers and ‘unhappy’ daily smokers who had tried or wanted to quit but felt too dependent on nicotine. A US study found that adolescents similarly distinguished between social and ‘real’ smokers, with social smokers perceiving themselves to be in control of their smoking and therefore rejecting cessation messages as personally irrelevant [11]. A recent Canadian study also highlighted how participants felt that quitting was especially difficult for young people because of the complex, multidimensional and developmental nature of tobacco dependence [12]. These dimensions related to the social, pleasurable, empowering and emotional functions of smoking which could ultimately lead to ‘full-fledged’ dependence, which encompassed physical as well as socio-psychological needs.
There is also evidence that factors associated with smoking uptake and maintenance in younger adolescents, such as friendship groups, friends' smoking and alcohol consumption [13, 14], remain important in the mid-to-late teens, regardless of gender and occupational status [15–17]. For example, on transition to new educational and occupational spheres, changes in friends and peer groups may affect patterns and levels of smoking [13, 18], as may changes in income and leisure activities, particularly increased drinking [19]. Furthermore, other research has stressed the importance for young smokers of the enhancement of social identity through smoking with others [12, 20–22]. In peer groups where smoking status is central to the group's social identity, peers are likely to share similar smoking behaviours [23]. One study found that smokers were less likely to have quit 5 years after leaving school if their friends smoked, approved of smoking and offered them cigarettes [17]. However, our understanding of how peers influence smoking behaviour remains limited [23] and there is a need for more ethnographic studies that provide insight into how social meanings and processes impact smoking and cessation [24].
In a previous paper [25], we drew on qualitative interviews with 16 to 19-year olds to discuss how social factors, particularly friends and social location, promote or challenge smoking in this transitional period of their lives. This paper draws on these interviews to explore how issues around quitting are linked with the social context of young people's smoking and how they understand their own smoking, especially perceptions of habit and addiction. Interviewee accounts are used to illustrate how becoming a non-smoker in environments where smoking is normative and supported by structures such as friendship groups poses particular challenges for young people who are still in the process of identity formation. We consider how they inform their intentions to quit and their views on cessation support including nicotine replacement therapy (NRT).
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Methods |
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Sample
The study involved 48 mainly paired interviews with 99 16- to 19-year old smokers. To optimize diversity, interviewees were purposively recruited from various educational and occupational backgrounds from Lothian, Scotland (Table I). A total of 75 were daily smokers and 24 non-daily smokers (Table II). Potential recruitment settings were notified about the project and their support obtained. These included a youth café, further and higher education institutions and workplaces. Those in charge spoke to interviewees about the study before the researcher approached them. Interviewees were invited to bring a friend along to the interview. The research complied with the British Sociological Association guidelines on ethical practice and the principles of informed consent. Confidentiality and anonymity were assured.
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Interviews
Data were collected using a brief structured questionnaire on smoking behaviour, dependence and motivation to quit, and a longer semi-structured interview. This paper draws in part on responses to quitting questions in the questionnaire [26, 27], but mainly from the qualitative interview data.
The interviews were conducted in 2002 and carried out by one of the authors. They lasted about an hour and mostly involved friendship pairs (42). Four interviews involved three friends and three were single interviews. Paired interviews were chosen as they generate rich data about adolescents' smoking attitudes and behaviour and the ways smoking is located within social relationships. Interviews with friends can also facilitate more natural conversation than individual interviews and allow greater insights into group norms and social meanings [28]. A topic guide was used to generate discussion around several themes, including the role and meaning of smoking in their lives, smoking history, current smoking patterns, perceptions of habit and addiction, motivation to quit and different types of cessation support. The topic guide was used flexibly in that issues were discussed as interviewees raised them rather than in a rigid sequence. Interviewees were encouraged to discuss in more depth topics that were particularly meaningful or salient to them.
Analysis
The tape-recorded interviews were transcribed into NVivo. The transcripts were analysed thematically moving from descriptive to analytical coding, with particular attention being paid to experiences and attitudes to quitting, quit attempts and future intentions to quit. All the authors were involved in the analysis, with at least two reading each transcript and agreeing on coding categories and emergent themes. A modified grounded theory approach was taken whereby emergent themes were revised iteratively as the fieldwork and analysis progressed. Responses to questions on quitting from the structured questionnaire were analysed in SPSS and contrasted with what was said in the interviews. In the Results, interviewees are identified by sex, number, occupational/educational category (school, college, university, unemployed, employed) and smoking status according to questionnaire response (daily, non-daily).
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Results |
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Habit and addiction
All interviewees regarded their smoking as a habit but varied as to whether they thought that it was also an addiction. There were three distinct groups: those who said that they were not addicted, those who were ambivalent and those who were emphatic that they were addicted.
Not addicted
Around a fifth described their smoking as due to habit not addiction and did not define themselves as smokers. This included mostly non-daily smokers, like F7, a student, who said ‘if I was addicted to smoking then I'd be smoking every day’, and those who were primarily cannabis smokers like M17 (college) who said ‘I'm a half and half smoker. I don't really buy fags, if I want a fag I just have one when someone is having one’. Several daily smokers also claimed that they were not addicted because they could control their smoking. F12 (university) said she could ‘stop and like prove it to yourself’. M66 (school) explained that he was not addicted because he ‘never felt like I really need one’. Similarly, M42 (employed) refuted feelings of need as ‘I'm not sweating at the bit for a fag’. Others reasoned that they were not addicted as they only smoked with or smoked less than their friends. F77 (not daily, employed) said that she was not addicted but her ‘pal is addicted. I don't think I really need one’. Similarly, F70 (not daily, school) said that her ‘friend is a heavy smoker, she smokes like forty a day!’ For some, addiction evoked images of desperation and cravings, which they sought to disassociate themselves from. M41 (daily, college) explained that addiction was a term associated with ‘a heroin addict’ and that he did not see his smoking in this way.
Ambivalent
Most interviewees were initially unsure about whether they were addicted. This was not something they had thought about and found it difficult to articulate their views. For instance, two employed daily smokers gave ambivalent responses:
F84: [It's] an addiction.While most considered themselves to be smokers, on reflection they did not feel totally addicted, thinking rather that the habitual aspect of smoking was as important a factor in determining their smoking patterns. Some cigarettes were smoked in response to perceived need, like ‘first thing in the morning’ (F29: daily, college), but this was not perceived as problematic.F85: A habit, I don't really know.
F84: It's an addiction that's a habit.
F85: I think it's a habit, it's not really an addiction [because] you would be wanting a fag every minute.
For some, smoking was not considered an overwhelming addiction because of its predominantly social nature. F99 (not daily, unemployed), who had hesitantly described herself as a smoker, said:
I'd say it's a bit of both really 'cos I can do without, I do have a craving like other people, but it's more a social thing really.For others, the notion of control was crucial. F18 (daily, school) said that her smoking was ‘a bit of both’, but reckoned she could ‘go for a day or something and not need one’. Some felt that they could quit smoking if they chose to. F40 (daily, college), who did not consider herself ‘a full time smoker’ and had never tried to quit, explained that she ‘could stop just like that. I don't smoke a lot so I would find it easy to quit’.
Some spoke reluctantly of their sense of progressing towards addiction, using terms such as ‘probably’, ‘verging on’ and ‘leading into’. F22 (daily, unemployed) described her addiction as recent. She had started ‘wanting it more and more two months ago or something’. While M19 (daily, employed) conveyed a sense of powerlessness as ‘It's kind of leading into an addiction now, I'm falling into that’, F51 (daily, employed) said that her smoking was ‘probably an addiction now. It used to be a habit, but now it's not’.
Addicted
Around a fifth were emphatic that they were addicted to smoking. They were least likely to imagine being non-smokers in the future, having tried to quit previously. Accounts of addiction centred on feelings of need. For example, M60 (daily, employed) claimed that he was addicted because:
I need it. I don't think I could go for a day without a fag. I went like a couple of days without a fag and just had maybe 1 or 2 fags and that, but ended up going to buy them. Kept on getting cravings.Some interviewees had realized that they were addicted when they experienced withdrawal symptoms, like M53 (daily, college):
I didn't really think of myself as being addicted to smoking before I tried to quit. I could feel the sort of withdrawal symptoms.Similarly, M63 (daily, unemployed) had been a ‘nervous wreck’ when he tried to quit:
The nicotine, the body is missing it, you've not got it, the body is missing the nicotine.In contrast to those who saw smoking as social and within their control, these interviewees referred to how their smoking was no longer confined to particular contexts and friendship groups. Smoking had become something ‘more than just sitting with friends’ (F81: daily, college).
Quitting
Responses to the structured questionnaire suggested considerable interest in quitting, similar to that in older smokers [26, 27]. Three-quarters indicated that they had tried to quit, with a similar proportion interested in quitting in the future. Indeed, 63 said that they wanted to quit in the next 6 months. However, when this was explored in the interviews, it became clear that few actually intended to quit in the next 6 months. Nearly half (45) saw quitting as something that would happen in the distant future. The rest were divided between those who would like to quit in the next year (26) and those who were undecided or had accepted that they would always smoke (28). In the rest of this section we consider experiences and attitudes to quitting, perceived barriers and future intentions.
Quit attempts and barriers
Most described how they had attempted to quit in the past, though few had lasted longer than several days. Barriers to quitting were mentioned frequently, in particular, concerns about social and physical image. Smoking was viewed predominantly as a social behaviour and an important mechanism for sustaining and reinforcing social bonds. Being with smoking friends reinforced smoking, and the negative impact this had on quitting attempts was often mentioned. F79 (daily, employed) said that she had resumed smoking after ‘my friends daring me to do it’. Many expressed concerns about social image, fearing they would no longer ‘fit in’ with friends and peers if they quit. F98 (daily, unemployed) said her friends would not be pleased if she gave up because:
Nearly all of them smoke [They'd be] teasing me and not wanting to see me 'cause they'd all be smoking.Similarly, F8 (not daily, university) said that among her friends ‘if we don't smoke, you are like left out’, and F75 (daily, college) felt that she would:
Probably lose out on talking to people 'cos I talk to a lot of smokers so I wouldn't be around them and I'd lose a lot of conversation with them.F98 (daily, unemployed) explained that smoking has been a large part of her life and quitting would mean:
A big chunk of my life away and I might not want to go about with the same pals and not being able to do that would be horrible.Drinking alcohol with friends was also felt to increase both smoking and the likelihood of relapse following a quit attempt. Interviewees explained that when they drank, they smoked more and had little control over their smoking. F15 (daily, university) said that she smoked ‘twice as much when I'm drinking’, while M41 (daily, college) explained that ‘I just want to stop completely but when I'm drunk, it just becomes compulsive’. M17 (daily, college) had managed to last for a few days without smoking but ‘one night when I was out drinking I ended up smoking’. F78 (daily, employed) had ‘Tried to quit a few times but it's been stupid wee things like I'll have been drunk and have one again’. Smoking when drinking was taken as the cultural norm, and was thus a significant barrier to successful quitting. Most interviewees also smoked cannabis and, as discussed elsewhere [29], this posed further problems for quitting. Compared with smoking tobacco, smoking cannabis had positive functionality. It enhanced socializing and provided relaxation, stress relief and enjoyment. Regular users did not want to give up cannabis but recognized that tobacco in the ‘joint’ and the ritual around its preparation reinforced cigarette smoking.
Some interviewees described how their transition into new social worlds had militated against quitting. M59 (daily, employed) said he smoked more now because of increased social activity since leaving school, like ‘getting into pubs [and] socialising with friends’. By contrast, the social worlds inhabited by the unemployed like M25 (daily) were impoverished. M25 did not want to give up because his life was ‘boring. There's nothing else to do’. Others spoke of how smoking helped them deal with stresses in their lives and how stressful events could trigger relapse. F12 (daily), a student, explained that smoking helped her cope with university life:
It's really difficult. I thought that may be I'd quit after 1st year but the way things are going I doubt it.M96 (daily, unemployed) said it was:
Stress, just a relationship, a family relationship. I started thinking about things and I started smoking again.Interviewees also spoke of quit attempts failing once they returned to their daily routines and pro-smoking cultures, like M3 (daily, college training) who said he did fine until ‘I go back to my work’. M53 (daily, college) expressed similar sentiments about risky contexts while trying to quit. The only time that he was likely to succeed was ‘over the holidays when I am away from college. It's like habit at breaktime’.
A theme that emerged for some women, but not men, was concerns about weight gain. F81 (daily, college) had noticed that ‘you eat less when you smoke’ and F75 (daily, college) said she smoked because she had heard ‘somebody say that smoking increases your metabolism and stuff’.
Some cessation attempts were not intentional but rather pauses, for example, during periods of illness. However, as has been found in other studies [9], most interviewees constructed these as quit attempts. Staying with parents for a few days also meant that some abstained from smoking because of parental disapproval.
Future intentions
While most interviewees did not wish to smoke when older, they thought that they would continue smoking for now, eventually quitting at some unspecified time in the future. Anticipated reasons for quitting included getting pregnant, ill-health, being told to give up by their doctor or simply getting older ‘one day I'll probably just [stop] and that will be it, enough’ (F79: daily, employed). In contrast, a minority accepted that being a smoker was part of their adult identity, like M4 (daily, college) who said he ‘could give up if I wanted to but I don't want to give up’. F76 and F77 (both not daily employed) reckoned that they would always be smokers:
F76: I think I'll always have an occasional fag.In conclusion, despite the questionnaire responses, quitting was not considered an especially salient issue or immediate priority for young smokers:F77: Probably all my life.
F76: I think that I'll probably do that too.
My friends talk about it, but its not a big thing, it's not in the same way you see a lot of older adults really seriously talking, like trying to quit in massive ways and trying new methods and stuff. (M1: not daily, college).
Cessation support
Most were aware of a range of cessation support including telephone helplines, pharmaceutical aids such as NRT and cessation services. Although, many knew about Smokeline, few were persuaded of its merits for young people. F7 (not daily, student) said ‘I think people would be embarrassed to phone a service that is associated with having a problem, especially people of our age’. This contrasts with the large number of calls from smokers in their mid-teens. Few had used NRT and their understanding of how it worked was poor. For example, M61 (daily, unemployed) had heard that NRT ‘can also make you want more’ nicotine, while M24 (daily, school) said:
If you want to stop smoking, you don't want more of that nicotine. The nicotine patches are still giving you the nicotine so it defeats the purpose.Fear about becoming addicted to NRT products themselves was also common. Many knew someone who had tried NRT, but they tended to be older family members or friends, rather than peers. Most had heard of disappointing results with few relating success stories. M90 (daily, unemployed) said that nicotine gum had helped his parents, and F81 (daily, college) talked about the inhalator, though with reservations, for her own use:
My Mum had one in the house, [But] I couldn't imagine myself sitting in a café or something with one of them, I would feel stupid.Interviewees also complained about the price of products since few knew that NRT was available on prescription. Some such as F64 (daily, unemployed) believed that addiction only affected older adults and therefore NRT was for older, more established smokers with less control who:
Don't have it in themselves to do it, they have patches, their mind starts thinking ‘oh it is helping’, but it is themselves that is doing it.Cessation services were also viewed largely negatively, especially potential services for young people. F30 (daily, college) said that drop-in centres and counselling services were ‘dorky’ and ‘(young) people would not use them’. Counselling services were also considered ‘not the thing to do’ (M9: daily, college) because ‘it sounds bad, it's like sad, not [for] youngsters anyway’ (F94: daily, employed). Moreover, social smokers and those like F40 (daily, college) who did not feel addicted would not use either cessation services or NRT:
I personally wouldn't use patches and stuff'cos I think I am not addicted and I could stop if I wanted to, I could stop just like that.Health Board for Scotland TV advertisements which addressed smoking and younger teenagers were thought to be relevant but most found it difficult to imagine anything that would help young people quit. With probing, some suggested that for those who did want to stop smoking, a local amenity at school or a drop-in centre with advice and an opportunity to talk to someone in distinction to counselling might help. Others suggested trying to ‘wean [themselves] off it’ (M53: daily, college), felt they could quit with family support or like F62 (daily, unemployed) have more structure to their days:
More things to do, something to pass the time, something for us to do. We are unemployed, we are out looking for work, we do try, but there is nothing for us to do in the meantime.Most thought that the key to quitting was ‘willpower within yourself’ (F98: daily, unemployed). They believed that if a person wanted to give up smoking strongly enough, they would succeed and cited examples of people who had quit smoking with no support:
I think my dad just like went cold turkey and just stopped completely and did it purely through willpower. (F2: not daily, university)However, they thought that socializing with friends who smoked, drinking alcohol and life stresses made quitting difficult at this stage in their lives.
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Discussion |
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Smokers in their mid-to-late teens have diverse patterns and levels of smoking. While many have smoked regularly for years, others have only recently started [25]. This study found that there was also considerable variation in their definitions of smoking status and their understandings of their own smoking behaviour and level and nature of dependence, and these informed their intentions to quit and interest in cessation support.
The subjective smoker categories that emerged in this study were similar to the typology of student smokers developed by MacFadyen et al. [10], which distinguished between social, confirmed and unhappy smokers. However, in contrast to some qualitative studies in North America where adolescent smokers readily admitted to feeling addicted [9, 30], most participants in this study were ambivalent or unsure about whether they were addicted. Rather, most felt that they smoked particular cigarettes in response to habit, but others in response to ‘need’, for example the first cigarette of the day. Only a minority felt that they were completely addicted. These different findings might reflect methodological (focus groups versus paired interviews) and/or cultural differences (North America versus Scotland). However, a qualitative study of US 16- to 17-year old girls reported a similar reluctance to admit to being addicted, which hinged on the theme of being in control, with smokers feeling that they ‘could control their cigarettes rather than have their cigarettes control them’ [31]. Nichter et al. argued that such accounts reflected a key developmental imperative of adolescence, the establishment of an autonomous self. Similar concerns emerged in our study notably when many participants, when discussing the need for cessation services, distanced their own ‘youthful’ smoking from that of adult smokers who had smoked for much longer and were therefore perceived as addicted and more in need of NRT and other support (it was more that they were not ‘for them’, i.e. not aimed at them).
Running through many of these accounts was a common understanding that becoming addicted was a process in which smokers progressed from being an ‘in control’ social smoker, through to a more regular ‘habitual’ smoker to a full-fledged smoker addicted to nicotine. While social smokers felt that they could resist becoming addicted, others recognized that the nature of their dependence had changed or was changing. Indeed, most recognized their dependence as being multifaceted but primarily related to what they characterized as the habitual nature of their smoking. These habitual aspects bore striking similarities to the multiple dimensions of smoking dependence described by adolescents in two recent qualitative studies [12, 30]. O'Loughlin et al. described dependence as adolescents' feelings of need driven by their environments and peer interactions. Similarly, older adolescents in our study talked about the social (e.g. with friends) and emotional (e.g. stress reduction, coping) roles of their habitual smoking, and their importance in smoothing transitions to new social and occupational worlds. In this sense, while many appeared to resist admitting to loss of control and autonomy in relation to being addicted to nicotine, it seemed to be more acceptable for older adolescents to locate dependence within functional roles and the social context of smoking. Given that research with younger adolescents has found that nicotine addiction can develop rapidly even without daily smoking [32], our findings raise important questions about the ability of older adolescents to fully appreciate the role that nicotine plays in their smoking. It is therefore not surprising that this predominantly psychosocial interpretation of their own dependence informed their views on quitting and need for support.
Most were interested in quitting, had tried to quit in the past and felt that they would quit at some point. While the questionnaire responses indicated that most wanted to quit in the next 6 months, it was clear from the interviews, as found with younger adolescents [9], that most were much more ambivalent about quitting in the near future. In addition, some previous quit attempts had not been intentional but rather had been driven by ‘external’ constraints. This raises questions about the validity of using measures of intentions to quit, which were developed with adult smokers, such as the widely used stages of change instrument, with adolescents when their smoking patterns, levels and intentions are labile and can vary from day to day [8, 9].
Most knew from experience or anticipated that quitting would be difficult, but again this was related more to the habitual aspects of smoking and the social contexts they inhabited, rather than cravings resulting from nicotine withdrawal. Smoking was taken for granted as a central aspect of youth culture, enmeshed in the lives of daily smokers or related to particular contexts for non-daily smokers. Friends' smoking habits, the smoking culture at work or college, stress and boredom were all regarded as barriers to quitting [30]. Drinking alcohol with friends posed particular problems as this often led to binge smoking and relapse after trying to quit.
Since smoking was perceived as enhancing sociability, its role in maintaining a particular social image was highlighted, particularly for the young women. Research has suggested that smoking can function as a symbol of shared identity and belonging for girls, who compared with boys have few alternatives for the construction of non-submissive identities [21, 33, 34]. Indeed, interviewees noted that quitting might exclude them from friendship groups where smoking was the norm [31]. This was especially salient for young women who valued the expressive quality of smoking, since it facilitated conversation among friends, and saw smoking as predominantly a social activity. Thus, smoking in older adolescents appears to facilitate peer bonding in the same way as among younger adolescents, which remains important as older adolescents move into new social worlds and with the need to form new friendships. A further gender dimension was some young women's concern that quitting would cause weight gain and for some it was part of a strategy to maintain a desired weight [30].
Given the emphasis on the habitual, social aspects of dependence, it is not surprising that attitudes towards NRT and smoking cessation services with their perceived focus on dealing with nicotine addiction were largely negative. There was little interest in using NRT. Indeed, many felt that it would reinforce rather than help break nicotine addiction, reflecting a widespread misunderstanding of how NRT works. NRT and cessation services were not familiar aspects of young people's lives [9], but belonged to the world of older adults who had been smoking longer and were addicted. Cessation services were mostly thought not appropriate for younger people because their image was incompatible with the self-image that they wished to project. The most effective strategy for quitting was perceived to be internal—individual responsibility and will-power [8, 9, 20]. This echoes the perceptions of many adult smokers, particularly those on low incomes [35], despite clear evidence that supported quit attempts in adults have higher success rates [36]. There was generally little interest in using cessation services at this stage of their lives. Rather, cessation was something to aspire to when they were older, stimulated by increasing responsibilities like pregnancy or ill health.
Meeting the needs of this diverse group of smokers poses many challenges for tobacco control and smoking cessation services. These include:
- Service development—This study supports and extends the conclusion of Balch's [9] study with school pupils that cessation services are currently unlikely to appeal to older adolescents. Services need to be made more attractive to young smokers, so that they can better understand the importance of quitting early, nicotine addiction and how support may increase quitting success. They also require services that relate to their perceptions of smoking, dependence and the social factors which support and maintain their smoking.
- Service delivery—NRT does not appear attractive or relevant to young smokers because many do not perceive themselves to be addicted and are not motivated to quit in the short term. Further research is needed to assess whether NRT could be effective with this age group if they were motivated to quit and chose to use it. This study also indicates that current methods of assessing dependence and motivation may need adapting to make them more valid for older adolescents. Attention also needs to be focused on how to support young smokers who want to quit smoking but who also use cannabis [29].
- Service evaluation—Given the lack of research with this age group, there is a need to evaluate the effectiveness of new services as they develop as well as better quality trials of theoretically informed interventions [37]. For example, few studies have evaluated the effectiveness of NRT with young people [38]. Tobacco consumption among young smokers is variable and, therefore, dependence needs to be carefully assessed, as this will influence both the type of cessation support that it is appropriate to offer and the likely success rate.
- Smoke-free policies—It is important to implement changes in young people's social environment that support prevention and cessation. Given the powerful social influences on young people's smoking, it is likely that smoke-free policies in schools, colleges, universities, workplaces, pubs and bars will be important in reducing smoking in this age group [39–41]. Indeed, since the announcement of plans to introduce comprehensive legislation for smoke-free public places in Scotland, there has been a 50% increase in calls to the Smokeline [42]. Given the strong association between smoking and drinking, and drinking as a cause for relapse, smoke-free bars, pubs and clubs may particularly impact older adolescents, not only reducing their smoking levels but also reducing the progression from social to regular smoking and increasing the success of quit attempts.
- Service delivery—NRT does not appear attractive or relevant to young smokers because many do not perceive themselves to be addicted and are not motivated to quit in the short term. Further research is needed to assess whether NRT could be effective with this age group if they were motivated to quit and chose to use it. This study also indicates that current methods of assessing dependence and motivation may need adapting to make them more valid for older adolescents. Attention also needs to be focused on how to support young smokers who want to quit smoking but who also use cannabis [29].
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Acknowledgements |
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We would like to thank those who participated in this study. Gratitude is also expressed to Hannah Whiteman and Ann Stronach for their secretarial support. The research was funded by the Chief Scientist Office, Scottish Executive Health Department. The views expressed in this paper are those of the authors and do not necessarily reflect the views of the funding body.n
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References |
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Received on September 3, 2004; accepted on July 4, 2005
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