Teen smoking, Smoking motivators, Smoking inhibitors, Cessation strategies



  1. Hayes, Evelyn R. PhD, APRN, BC
  2. Plowfield, Lisa A. PhD, RN


Purpose: To describe college students' decisions related to tobacco use.


Study Design and Methods: A sample of 49 smokers and 51 nonsmokers were asked about the smoking continuum of starting smoking, continuing to smoke, and tobacco cessation. An investigator-developed questionnaire was used to determine tobacco use and whether prevention and cessation messages were perceived as effective. Data were analyzed using descriptive statistics and qualitative descriptive analysis.


Results: Peer pressure was the greatest influencing factor for beginning to smoke, and health was the major reason for not beginning to smoke. Addiction and stress maintained smoking. Both smokers and nonsmokers identified cessation strategies.


Clinical Implications: Every interaction with youth is another opportunity to assess smoking status. Recommendations from teens for cessation programs identified in this study may be more attractive to teens and young adults than the current standards related to strategies for adults.


Article Content

Although Americans are continuously exposed to messages about the health risks of tobacco use, 44.5 million Americans still smoke tobacco (Centers for Disease Control and Prevention [CDC], 2006). Cigarette smoking continues to be the leading preventable cause of death in the United States, causing one of every five deaths (438,000) each year (CDC, 2005). Most adult smokers report beginning tobacco use before the age of 18 (Turner, Mermelstein, & Flay, 2004). It is estimated that 24% of teens smoke tobacco (CDC, 2005). A feeling of being invincible-a developmental characteristic of teens-may make it difficult for some teens to understand the long-term consequences of tobacco use, particularly among teens who have not developed the ability to think abstractly (Radzik, Sherer, & Neinstein, 2002). As noted by Herrman (2005), teens are sensation seekers with underdeveloped cognitive controls.


Tobacco use has been identified as 1 of the 10 leading health indicators in Healthy People 2010; two of the goals of this program are to reduce cigarette smoking by adolescents and to reduce cigarette smoking by adults (USDHHS, 2000). Nationally, 35% of adolescents smoke; the target is to reduce this percentage to 16% by 2010. In adults, 24% smoke; the target reduction is 12% by 2010. Youth are the most numerous in the "new smoker" status, with 3,000 youths becoming regular smokers every day (CDC, 2006). College students have been found to both increase their use of tobacco over their high school use and to begin smoking during their college years (Christie-Smith, 1999; Hines, Fretz, & Nollen, 1998).


Marketing tobacco to children was common in the United States until a federal ruling in 1998 that restricted such tobacco marketing. Unfortunately, the response of the tobacco companies to this ruling was to strengthen marketing to 18- to 24-year-olds (Farrell, 2005). The tobacco industry spends $26 million daily ($9.5 billion each year) on these marketing campaigns to college students (Farrell, 2005; Steffel, 2004).


Why Do Adolescents Smoke Tobacco?

Adolescents smoke because of individual variables (e.g., age, gender, and temperament), social influences (e.g., peer relationships, parental and sibling tobacco use, and family stress), and environmental/cultural influences (e.g., tobacco advertising, media messages, cost and related smoking policies; Turner et al., 2004). Mayhew, Flay, and Mott (2000) identified six stages of smoking in adolescents: (a) contemplation, (b) trying, (c) experimentation, (d) regular smoking, (e) daily smoking, and (f) nicotine addiction. Although most teens reach the stage of "trying" tobacco, a significant motivator in progressing from the "trying" stage to advanced stages is a perceived mood benefit. Teens whose smoking is related to mood enhancement are more likely to continue tobacco use (Mayhew et al., 2000).


A Web-based study of more than 4,000 university freshmen showed that tobacco use increased on Thursdays, Fridays, and Saturdays but was lower on Sundays through Wednesdays, indicating a motivating factor of social connectivity. An additional finding was that smoking is closely related to alcohol consumption (Clayton, 2004).


To help reduce tobacco use among teens, multiple antismoking messages have been developed, but teen tobacco use remains a prevalent, complex health issue. The purpose of this study was to explore the use and nonuse of tobacco by college students and to gain teen and young adult perspectives in order to increase tobacco cessation programming within an academic health environment.


Study Design and Methods


A convenience sample of 100 college students (aged 18-23 years) was used (49 smokers, 51 nonsmokers). Characteristics of the sample are presented in Table 1. Most of the subjects were freshman and sophomore students in college.

Table 1 - Click to enlarge in new windowTABLE 1. Sample Demographics


Using a survey approach, an exploratory descriptive design was used. The study reflected a social marketing framework, which requires the consumer/end-user be the central focus (Quinn, Albrecht, Marshall, & Akintobi, 2005). Teens and young adults were asked about their own tobacco use, nonuse, and cessation.



Based on review of the literature and focus group of teens and young adults, the investigators created a three-section questionnaire titled "Tobacco Use Among College Students." The self-report questionnaire addressed five major areas: (a) motivators and inhibitors of tobacco use, (b) social behavior related to tobacco use, (c) effective cessation strategies, (d) media's impact upon cessation, and (e) demographic characteristics of the respondents. Both quantitative and qualitative items were included in the questionnaire. Section 1 included 13 questions about demographic data. Section 2 contained 15 questions for smokers about attitudes and experiences related to tobacco use and included three forced-choice items and open-ended items. Nonsmokers were also asked to respond to three open-ended items about their nonsmoking decisions, maintaining their nonuse, and effects of others' smoking upon their lives. Section 3 asked participants to rate either positively or negatively tobacco cessation and prevention posters after viewing 10 posters currently in use. All participants were asked which poster was most effective in giving a nonsmoking or quitting tobacco use message. The complete questionnaire took approximately 10 to 15 minutes to finish.


The instrument was pilot-tested to determine clarity of questions, logical flow of the questions, and length of time to complete the survey. Content validity was determined by five nurse researchers and content experts by indicating the relevance/nonrelevance of each item. Revisions were made based on the pilot test and feedback from the content experts.


Data Collection and Analysis

Institutional Review Board approval was obtained. Students were invited to complete the questionnaire as they exited one of the campus dining halls. After hearing a description of the study and granting consent, participants completed the questionnaire. Both smokers and nonsmokers agreed to participate; the most common reasons given for nonparticipation were scheduled classes or required study hall attendance. Descriptive statistics and qualitative descriptive analysis were used, along with content analysis to identify common categories of responses from the open-ended items. All categories and responses were reviewed, and any differences in a participant's response from the exact wording of the category were discussed by two investigators until consensus was reached. In most cases, 100% agreement was achieved.



Results showed that students discussed three separate timeframes related to their tobacco use: beginning to smoke, continuing to smoke, and stopping smoking.


Beginning to Smoke

Nonsmokers reported the following as the top reasons for not beginning to smoke: health, "disgusting," smell, and "I don't like it." Smoker respondents indicated most frequently the following four reasons for starting to smoke: friends, peer pressure, experimenting or curiosity, and the "need to be cool." A complete list of nonsmokers' reasons for not smoking and smokers' reasons for smoking is presented in Table 2.

Table 2 - Click to enlarge in new windowTABLE 2. Reasons to Start Smoking and to Not Smoke

Smokers identified peer pressure as the most influential reason in their decision to smoke. Most smokers (55%) indicated that their boyfriend or girlfriend had asked them to stop smoking, and 33% of the sample said their parents also asked them to stop smoking. Less frequently, smokers shared that a sibling or friends had asked them to stop their tobacco use.


Continuing to Smoke

When smokers were asked the major reason they continued to smoke, their responses included addiction (38.9%), stress (20.3%), boredom (11.9%), "enjoy it" (10.2%), drinking (6.7%), and friends (5%). Less frequent responses included "to feel better,"recreation, "want to," and "don't know." The most frequently cited reasons for smokers "to light up" were stress (27.7%), alcohol (18%), meals (12.2%), and boredom (10%).


Stopping Smoking

Smokers were asked to identify incentives to stop smoking. The most frequently given incentives included money and cost (23.3%), "don't know" (18.6%), and cancer (13.9%). "Nothing would make me stop" was reported by 6.9%. When smokers were asked how-if it were available-they would spend the same amount of money that was spent on smoking each week, their most frequent response was food (28.5%), followed closely by alcohol (24.7%), clothes (15.2%), and leisure activities (11.4%).


The impact of media was another aspect of the "stopping smoking" theme. Smokers (67.3%) reported "no impact" of the media on their decision about tobacco use. The remaining 32.7% of smokers reported the impact as "makes me think I want to stop" and "makes it my decision," and stopping is portrayed as "good." The media having "no impact" was also reported by 56.9% of the nonsmokers. Of the 43.1% nonsmokers who reported that the media had an impact, their responses noted the impact as truthful advertising, telling the side effects of smoking, and giving health messages.


Smokers who shared that the media was a "turnoff" reported most frequently that the messages were either juvenile or too simplistic. The second most frequent response reflected a negative tone that included comments about preaching and condescending messages. Subjects also reported distasteful pictures as the third highest ineffective media message.


All participants were asked what types of cessation messages and programs were most attractive to teens and young adults. Forty-four percent of smokers and 47.2% of nonsmokers most frequently suggested messages that show or tell the effects of smoking.


Media Messages

In response to the display of 10 posters, more than 85% of both the nonsmokers and smokers indicated that the poster "If what happened on your inside happened on your outside, would you still smoke?" from the American Cancer Society would influence their tobacco use decision. "A loaded gun" and "Winners always quit" were the next most frequently cited posters. Each received positive responses from 18.37% of the smokers and more than 42% of the nonsmokers. In addition, 41.2% of the nonsmokers also provided support for posters "Get Your Butt" and 39.2% for "Something About Mary"; these two messages, however, were not identified as effective for smokers.


Clinical Implications

The data provide evidence that peer pressure is the greatest influencing factor in beginning smoking. This finding is consistent with other reports in the literature (Ammerman & Neinstein, 2002; Steffel, 2004; Tucker, 2002). Martinelli (1999) found that smokers had a significantly lower internal locus of control. Nurses are challenged, therefore, to devise ways to use peer pressure positively in helping adolescents to never begin smoking. For adolescents who already smoke, the finding in this study that 40% believed they were addicted is cause for concern. A recent study found that teens demonstrated addiction after fewer cigarettes over a shorter period than previously expected. Gender differences were also found; girls got hooked quicker than boys: 3 weeks and 6 months, respectively (DiFranza, 2002). Therefore, successful cessation would be enhanced by earlier intervention before physiological addiction. Significant brain development occurs throughout adolescence and is strongly influenced by interactions with the environment. Changes in the frontal lobe are pivotal in memory, decision-making, and impulse control (White, 2004). Skills for assuming responsibility and considering consequences of actions commonly develop in the twenties (Herrman, 2005).


Smokers in this study reported that stress maintained their tobacco use. These findings are consistent with research by Steptoe, Wardle, Plooard, Canaan, and Davies (1996) and Naquin and Gilbert (1996) on the influence of stress on tobacco use. This finding may indicate a need for teens and young adults to be taught more diverse and healthy coping strategies that allow immediate action to hinder reaching for and lighting up a cigarette.


Drinking alcohol was also reported by 18% of the sample as a stimulus for lighting a cigarette. The literature supports the linkage of tobacco use and alcohol associated with social and peer activities (CDC, 2006; Clayton, 2005). For some individuals the smoking habit begins and only occurs when drinking (Farrell, 2005). Because these behaviors are frequently related, early cessation of the first addictive behavior may decrease the likelihood of developing future addictions. Teen smokers are also more likely than nonsmokers to use other substances: 3 times more likely to use alcohol, 8 times more likely to use marijuana, and 22 times more likely to use cocaine (CDC, 2004; Jones, Oeltmann, Wilson, Brener, & Hill, 2001).


Both smokers and nonsmokers indicated that not smoking could best be achieved by showing the real-life effects in words and pictures. This information is helpful to nurses, because they can use posters such as the ones shown to participants in this study as a potent health education strategy.


One of the limitations of this study was that the sample was drawn predominantly from Caucasian and socioeconomically advantaged adolescents, and the results may not be generalizable to diverse populations. Despite this limitation, the unique nature of this study was that perceptions from both smokers and nonsmokers were obtained. Gaining the nonsmoking perspective is informative in maintaining and developing strategies that support continuing to promote nonsmoking messages and education. Promoting healthy teen behaviors may increase peer acceptance that surrounds nonsmoking. Nonsmoking teens may become role models for their peers and decrease the impact of strong peer pressure influencing the decision to smoke.


Nurses can play pivotal roles in working with smokers to build cessation strategies and with nonsmokers to maintain their nonsmoking status. A recent Robert Wood Johnson Foundation report indicated that most smokers (70%) see a healthcare provider annually; however, only 50% to 70% are asked about tobacco use, and less than one half (40%) are provided information on smoking cessation (Revell & Schroeder, 2005). Research has shown that asking about smoking status at every visit as part of the assessment and then advising smokers to quit influences tobacco use decisions, especially when the advice is from healthcare professionals (Revell & Schroeder, 2005; Miller, 2004). Brief interactions and counseling about cessation strategies enhance the chances that the smoker will quit. Each of us is challenged to contribute to optimizing the health of our teens and young adults and meeting the goals of Healthy People 2010.


Suggested Nursing Implications


* Take the opportunity during each interaction with youth to assess smoking status.


* Promote continued abstinence from smoking in nonsmoking adolescents.


* Use known successful smoking cessation strategies with adolescents who smoke.


* Understand the powerful role of peer pressure on adolescents and ask teens whether their friends smoke.


* Teach adolescents about the real effects of smoking on physiology.


* Help adolescents learn coping strategies that do not include smoking tobacco.




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