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Q What is the process by which adolescents who smoke come to understand that their smoking is a problem and subsequently limit tobacco use by cutting down or quitting altogether?
Qualitative study using grounded theory.
Vancouver, British Columbia, Canada
35 adolescents (mean age 16 y, 51% girls) with varied smoking experiences contributed to the initial dataset that examined youth transitions from experimental to regular smoking. The initial dataset was supplemented by follow up interviews with 12 (mean age 18 y, 75% boys) of the original 35 participants and subsequently reanalysed for this study. An additional 11 adolescents (mean age 16 y, 66% girls) participated in the validation process.
The study began as a secondary analysis of 35 interviews with adolescents with varied experiences of smoking. 1 year later, follow up interviews were done with 12 original participants. All interviews were audiotaped and transcribed verbatim. Participants’ experiences with “stopping” and “quitting” smoking were examined using grounded theory. Emerging themes were validated in 3 interviews and 2 focus groups with 11 additional adolescents.
Participants struggled to maintain a sense of control in relation to their smoking through a 4 phase process. Phase 1: determining if smoking is a problem. Each adolescent defined an acceptable pattern of tobacco use against which they could monitor their tobacco consumption to determine if their smoking was out of control. They often alluded to a “point” or “line” that should not be crossed (eg, smoking ⩽5 cigarettes per day and smoking only at a party). As long as these lines were not crossed, participants perceived that they were still experimenting and had control over the habit. Participants also monitored tobacco use and cravings as indicators of control, where excessive use of tobacco or experiencing cravings signalled loss of control. Phase 2: crossing the line. Many participants recalled times when they realised that their smoking was out of control and that they had crossed the imaginary line of acceptable smoking. Examples included being associated with smoking (eg, appearing with a cigarette in several photos) and experiencing symptoms of physical withdrawal from nicotine (eg, during hospital admission). Phase 3: implementing strategies to control tobacco. Once participants perceived that they may have crossed a line, they began to implement strategies to control their tobacco use. These strategies were designed to provide a renewed sense of control over smoking, even if it was short lived. Strategies included refraining from buying (borrowing cigarettes from friends or family while recognising the existence of limits), rationing cigarettes, limiting smoking situations (eg, “only when” at parties or on weekends), cutting out unnecessary cigarettes (eg, not smoking 2 cigarettes in a row and not smoking simply because others are smoking), “taking a puff or two” or “half butting,” and simply waiting out a craving. Some participants realised that if they could delay gratification, their craving would often fade. Besides limiting consumption, participants also looked for strategies to replace smoking. These strategies included finding substitutes (eg, chewing gum or food), getting help (eg, “co-quitting” with friends or family members), taking advantage of transitions such as New Year’s resolutions, and outright quitting. Despite their best intentions, these strategies were not followed up consistently. Circumstances such as work or school related stress and family crises prompted adolescents to abandon the process of seeking control. Phase 4: reconstructing the line. In experimenting with different strategies to gain control over their tobacco use, participants developed a sense of what did and did not work. In this process, they would often re-establish or reconstruct the line of acceptable tobacco use. Often, participants would cycle through the entire process several times. For some, the strategies were effective, and the initial line would be re-established. For others who could not regain control of their smoking, the line was reconstructed to accommodate their smoking, and “problematic smoking” was redefined as something in which they were not engaging.
To maintain a sense of control in relation to their smoking, adolescents struggled through a cycle of determining if smoking was a problem, if a “line” of acceptable tobacco use was crossed, and using creative strategies to limit or quit tobacco use.
Few studies have contributed substantially to understanding the complex process that youth experience in attempting to control their experimentation with tobacco. Johnson et al used a secondary analysis to explore fully the richness of the data. Although the study participants represent the age group that struggles with decisions about smoking, the authors did not report details about the population, such as whether they were in school or their ethnicity. Grounded theory is an appropriate methodology to explore the themes and discover the underlying theoretical tenets of the interviews. Use of a validation procedure for the emerging themes added strength to this method.
The finding that youth engage in hard work to attempt to control their smoking is relevant for advancing nursing practice in public health, health clinic, and school health settings. The study by Johnson et al supports previous research by Stein et al that described the complex processes of adolescence, which include developing identity through life choices.1 Nurses need to draw on their understanding of the developmental tasks that adolescents experience that can lead to beliefs that they are indestructible and can beat the odds of becoming addicted to cigarettes. Johnson et al found that adolescents traversed a 4 phase process of control, requiring various strategies to help renew their sense of control. Typical tobacco control interventions address prevention for people who haven’t starting smoking or cessation programmes for those who believe that they are already addicted. Few nursing programmes or clinical settings provide nurses with the knowledge they require to better understand the experience of adolescents who are in transition from being experimental to regular smokers or the interventions that are required to help stop that transition. By understanding the phases that adolescents experience in the smoking trajectory, nurses can identify interventions for tobacco control in each phase of the process.
For correspondence: Dr J L Johnson, University of British Columbia, Vancouver, British Columbia, Canada.
Sources of funding: National Cancer Institute of Canada and Canadian Cancer Society.
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