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Beliefs and Social Norms About Smoking Onsetand Addictions Among Urban Adolescent CigaretteSmokersRonald J. Peters a , Steven H. Kelder a , Alexander V. Prokhorov b , Angela Meshack a ,Carolyn Agurcia b , George Yacoubian c & Jennifer Griffith aa University of Texas Health Science Center at Houston, School of Public Health,Center for Health Promotion, Research and Development , Houston, Texasb University of Texas MD Anderson Cancer Center, Department of Behavioral Science ,Houston, Texasc McFarland and Associates , Silver Spring, MDPublished online: 08 Sep 2011.

To cite this article: Ronald J. Peters , Steven H. Kelder , Alexander V. Prokhorov , Angela Meshack , CarolynAgurcia , George Yacoubian & Jennifer Griffith (2005) Beliefs and Social Norms About Smoking Onset andAddictions Among Urban Adolescent Cigarette Smokers, Journal of Psychoactive Drugs, 37:4, 449-453, DOI:10.1080/02791072.2005.10399819

To link to this article: http://dx.doi.org/10.1080/02791072.2005.10399819

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Short Communication

BELIEFS AND SOCIAL NORMS ABOUT

SMOKING ONSET AND ADDICTIONS

AMONG URBAN ADOLESCENT

CIGARETTE SMOKERS

Ronald J. Peters, Jr. Dr.P.H., M.S.*

Steven H. Kelder, M.P.H., Ph.D.**

Alexander V. Prokhorov, M.D., Ph.D.***

Angela Meshack, Dr.P.H., M.P.H.****

Carolyn Agurcia, M.A.*****

George Yacoubian Ph.D., M.S.******

Jennifer Griffith, B.S.*******

Abstract-Cigarette smoking is a behavior which i s most often developed during adolescence. The association between smoking onset and nicotine addiction has not been clearly established among ethic minorities. To better understand this relationship, this study used a qualitative approach to investi­gate relevant beliefs and norms associated with cigarette smok­ing initiation and development of nicotine addiction among 52 high school students who identified themselves as current smokers. In general, it was found that both boys and girls believed nicotine addiction starts during an individual's ini­tial cigarette smoking event. The majority of both groups re­ported that their second smoking event was initiated during the same or next day after their first event. In addition, this research confirmed that friends and siblings who use tobacco are strong reinforcers in youth smoking initiation.

Keywords-beliefs, initiation, onset, smoking, social norms

Despite most teenagers being well informed about the carcinogenic effects of nicotine, national data show that close to 35% of high school students are current cigarette smokers (CDC 2000) Data from the 2000 Monitoring the Future survey showed that 7%, 1 4%, and 2 1 % of eighth,

*Assistant Professor of Behavioral Sciences, University of Texas Health Science Center at Houston, School of Public Health, Center for Health Promotion, Research and Development, Houston, Texas.

* * Associate Professor of Epidemiology and Behavioral Science, University of Texas Health Science Center at Houston, School of Public Health, Center for Health Promotion, Research and Development, Houston, Texas.

***Associate Professor of Behavioral Science, the University ofTexas MD Anderson Cancer Center, Department of Behavioral Science, Houston, Texas.

* * * *Faculty Associate, University of Texas Health Science Center at Houston, School of Public Health, Center for Health Promotion, Research and Development, Houston, Texas.

Journal of Psychoactive Drugs 449

I Oth, and 1 2th graders, respectively were daily cigarette smokers (Johnston, O'Malley & Bachman 1 998). Modest declines in tobacco-use prevalence have occurred over the last few years, yet smoking remains a significant public health problem. Additionally, smoking rates as high as 75% are reported among absentees, school dropouts, and other high-risk youths (Karle et al. 1 994; Grunbaum & Hasen­Engquist 1 993; Glynn, Anderson & Schwartz 1 99 1 ; Pirie, Muray & Luepker 1 988) .

Although it is evident that adolescent cigarette addic­tion is a behavior which is developed during adolescence that endures throughout adulthood, the association between smoking onset and nicotine addiction has not been clearly established (Russell 1 990). Adolescent nicotine addiction has been demonstrated in several studies that included un­successful qui t attempts and wi thdrawal symptoms (Prokhorov et al . 200 I , 1996; Dozois, Famow & Miser 1 995; Henningfiled, Clayton & Pollin 1 990). However, there remains a gap in the research on smoking uptake and the addiction to cigarette smoking among ethnic minority adolescents (Colby et al. 2000a).

The primary purpose of this qualitative study was to obtain relevant onset trends in a multi ethic sample of high school students who were current smokers. According to the theory of planned behavior, beliefs and norms are im­portant constructs in understanding behavior (Ajzen 1 99 1 ). Consequently, a qualitative approach was selected to cap­ture the language, perceptions, beliefs, and norms of the adolescents in this sample.

METHODS

The parent study for this project is Project Aspire, a four-year study funded by the National Cancer Institute that examined a CD-ROM based cigarette smoking prevention and cessation program for high school students (Alex Prokhorov, M.D., Ph.D., principal investigator). The basis for this article is a substudy of Project Aspire entitled "Safer

*****Research Coordinator, the University of Texas MD Anderson Cancer Center, Department of Behavioral Science, Houston, Texas.

* * * * * * Director of Research, McFarland and Associates, Silver Spring, MD.

* ******Research Associate, University of Texas Health Science Center at Houston, School of Public Health, Center for Health Promotion, Research and Development, Houston, Texas.

Please address correspondence and reprint requests to Ron Peters, Dr.P.H., University of Texas-Houston, School of Public Health, Center for Health Promotion Research and Development, 7000 Fannin, Houston, TX, 77030; email: rpeters@sph.uth.tmc.edu.

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Decisions." Safer Decisions was designed to primarily in­vestigate cigarette smoking onset and nicotine addiction patterns among teenagers who were current cigarette smok­ers . The substudy was undertaken to assess the norms and beliefs about onset patterns among a multicultural population of teens to inform the intervention in the par­ent study.

Recruitment

The project team met with school district personnel from a large and diverse high school in the southwestern region of the United States to secure approval to conduct the study on their campus. After receiving the approval, three teachers volunteered to help faci litate recruitment.

In each of their six classes, the volunteering teachers along with project coordinators explained the participation requirements, the procedures, and the incentives. Students were invited to participate in focus groups to find out what adolescents feel about cigarette smoking. Written informed consent from parents and students was required for study participation. After returning consent forms, smoking sta­tuses of students were verified using criteria based on the Youth Risk Behavior Survey definition of current smoker as one who has smoked on one of the last 30 days (CDC 2000). After identifying current smokers and to protect their identities, those students met the research team two to three days later at another location in the school independent of any school personnel or other students.

Characteristics of Sample Two hundred-fifty students were invited to participate

in this study. Of the 1 80 students who returned consent forms, 52 (38 males and 14 females) were identified as cur­rent smokers and thus eligible for the study. The ethnic distribution of the sample was 52% Hispanic American, 17% African American, and 3 1 % Anglo American, and the gen­der distribution was 27% female and 73% male. The ethnic distribution of the entire school enrollment was 22% His­panic American, 34% African American, and 34% Anglo American, and 53% female and 47% male. The difference in distribution for gender and ethnicity were due to smok­ing difference between these groups. The focus group conduction methodology suggested by Krueger ( 1 994) was followed. All of the interviews were tape-recorded. All fo­cus groups were conducted by graduate school level facilitators who were well trained on qualitative research methods. Student participants were provided with one school dance ticket for their involvement in this study. All research procedures received institutional review board approval.

The qualitative research session began with a general introduction and an overview of the confidential nature of the focus group. This was followed by demographic ques­tions on age and race and an "icebreaker" question "What do you like to do when you are not at school?" The focus

Journal of Psychoactive Drugs 450

Urban Adolescent Cigarette Smokers

groups ended with a typical closing and appreciation of the student participant.

The authors developed seven open-ended questions based on the Theory of Planned Behavior to identify youth participants' subjective norms and salient beliefs about their initial experiences with cigarette smoking and addiction (Glanz, Lewis & Rimer 1 997). The seven questions were as follows: ( 1 ) Who was with you the first time you smoked a cigarette? (2) Why do you believe that you smoked your first time? (3) How long was it before the second time you smoked? (4) Who was with you the second time you smoked a cigarette? (5) Why did you do it your second time? (5) How long does someone have to smoke ciga­rettes before they are hooked? (6) When do you know somebody is addicted to cigarettes? (7) How many ciga­rettes does it take for someone to be addicted?

All focus group interviews were transcribed verbatim and transcripts were coded and consequently abstracted. Open-ended questions were used to elicit students' beliefs and to develop personal themes. Neutral probes were used by the interviewers a minimum of two times to elicit full responses to each question.

RESULTS

Table l provides illustrative quotations portraying the domains for each theme. Comparisons of themes by gen­der are shown in Table 2 .

Who Was with You the First Time You Smoked?

Themes analyzed by gender to determine the salient people who were present when students initiated smoking cited boys and girls with similar responses (see Table 2). Students cited friend as most frequently present during smoking uptake, followed by cousin for both genders. Other salient people at hand during smoking initiation differed by gender. For girls, their sisters were present while boys reported their brothers present; only girls reported being alone during smoking initiation.

Why Do You Believe that You Smoked Your First Time?

B oth genders named "peer pressure" and "curiosity" as the chief reasons for smoking when asked "Why do you believe you smoked your first time?'' (Table 2). Unlike girls, boys indicated "Cool/Image" as an additional reason for smoking initiation.

How Long Was It Before the Second Time You Smoked?

In response to the query "How long was it before the second time you smoked?" the next day ranked highest among males (Table 2). The majority of the sample who responded to this question smoked within 30 days or less of smoking initiation. However, the percentage of girls stat­ing that they smoked for a second time during the same day of their first smoking experience was higher than for boys.

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TABLE 1 Examples of Norms and Beliefs from Major Themes

Self-Medication/Coping CooVImage Boredom "My parents were arguing so I went

in her car and saw her cigarettes there, I wanted it to calm me down"

"I thought is was kind of cool" "I wanted to act cool"

"I was bored" "I was with my cousins and kind of

bored" Craving/Withdrawal "Because I was having problems at

my house and my friend told me if you want to feel better you should start doing it"

"I was craving it and I wanted to be with my friends"

Self Purchase "When they start buying them"

"I had to have another cigarette" "When they are shaking" Money Inquiry

Peer Pressure

Challenge

"When they come up to you talking about can I borrow three dollars" "Because someone asked me if I had

ever done it" "Because he (boyfriend) kept telling

me try it, try it"

"My homeboys gave me 10 dollars to do it" Aesthetics

"My cousin and friend offered it to me" "Because everybody was smoking

"Because my brother and sister dared me to do it"

"When they have that nasty cough" "When they smell like smoke"

one at the bus stop" Other Modeling Recurrence

Older Family Modeling "Because I saw my friends doing it" "Because everybody else was doing it,

"When they do i t every day" "When they start smoking one after

"Because my mother does it" "Because I wanted to try it, I saw my

Grandmom doing it"

so I wanted one" another"

Accessibility "Because my dad and my grandpa does it" "Because I saw my family"

"You could buy cigarettes from the store and not be carded"

Curiosity "We were just curious" "Something to try" "I was curious to see if it was an effect"

Who Was with You the Second Time You Smoked? The most salient people who were present the second

time students smoked cigarettes did not differ much from their first initiation (Table 2). For both boys and girls, friends were the people around most frequently during their sec­ond time smoking. Boys were more likely to report that they were alone during the second time they smoked. Un­l ike boys, some girls reported they were with their boyfriends the second time they smoked.

How Long Does Someone Have to Smoke Cigarettes

Before They Are Hooked? In response to the question "How long does someone

have to smoke cigarettes before they are hooked", the first time emerged as the most frequent answer among both gen­ders (Table 2). The third time was the next most frequent response for boys and the second time the next most fre­quent response for girls.

When Do You Know Somebody Is Addicted to Cigarettes?

"Self purchase" and "craving/withdrawal" emerged as the most frequent responses for both genders when they

were asked "When do you know somebody is addicted to cigarettes"? (Table 2). For girls, the theme of recurrence

Journal of Psychoactive Drugs 451

also was found to be a strong indicator of addictive be­havior.

How Many Cigarettes Does It Take for Someone

to Be Addicted?

When asked "How many cigarettes does it take for someone to be addicted" there were differences among gen­ders (Table 2). Boys ranked "one pack" very highly more frequently than girls. However, girls reported "one" and "two" cigarettes more frequently than boys.

DISCUSSION

This study used a qualitative approach to investigate the beliefs and norms associated with cigarette smoking initiation and development of nicotine addiction among adolescent current smokers. The most frequently given re­sponse for both boys and girls was that nicotine addiction starts during an individual's initial cigarette smoking event. The most frequent response for both groups was that their second smoking event was initiated during the same or next day. In addition, the most frequent response among ado­lescents in the study was that their n icotine addiction was established by the time they smoked a whole pack

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TABLE 2 Gender Comparisons

Who was with you the

first time you smoked? Boys Friend (22) Cousin (4) Brother (4) My uncle (3) Sister (2)

Girls Friend Cousin Alone Sister

(6) (2) (2) (2)

How long was it before the second time you smoked?

Boys Girls The next day ( I 0) The next day (2) I year (5) I year (2) 6 months (4) Same Day (2) 7 days or less (3) 7 days or less ( I ) 7 to 1 4 days (3) 7 to l 4 days ( I )

1 4 to 3 0 days ( I ) 1 4 to 3 0 days ( I ) 2 years (3) 3 months ( I ) Same day ( I ) 4 months ( I )

3 years ( I )

4 years ( I )

How long does someone have to smoke

cigarettes before they are hooked? Boys Girls First time (8) First time Third time (6) Second time Second time (5) Depends on Depends on person

person (5) Don' t know Fi fth time (4)

How many cigarettes does it take for

someone to be addicted? Boys Girls

(5) (4)

(2) (2)

I Pack ( I 0) I cigarette (3) 1 -7 2 cigarettes (3)

cigarettes (3) One Pack ( I ) 3 Packs (2) 3 Packs ( I )

Note: Frequencies are shown in parentheses.

of cigarettes. These findings are important in determining that early extent to which addiction is identified.

It is well documented that adolescents are more vul­nerable to nicotine addiction than adults (Colby et al. 2000b; Prokhorov et al. 1 996). According to clinical studies, nico­tine stimulates receptors in the brain that are involved in reward pathways in both humans and animals. Among hu­mans the start-up time of the course of these receptors is not definitive (Ksir et al. 1 985). Several students reported that addiction occurred during their first smoking event and it only takes an individual one cigarette to become addicted. The results of these data show that adolescents believe that it takes very little time for youth to develop an addiction.

Journal of Psychoactive Drugs 452

Why do you believe that you

smoked? (First Initiation) Boys Girls Peer pressure ( 1 0) Peer pressure Curiosity (8) Curiosity Cool/image (5) Older family Older family modeling

(5) (3)

( I ) modeling (5) Self-medication/

Boredom (2) coping Challenge (2) Other modeling (2) Accessibility ( I )

Who was with you the second

time you smoked a cigarette? Boys Girls

Friend (20) Friend Alone (5) Boyfriend Cousin (2) Cousin Uncle ( I ) Sister Sister ( I )

When do you know somebody is

addicted to cigarettes? Boys Girls Craving/ Self purchase

withdrawal (7) Recurrence Self purchase (7) Craving/ Aesthetics (2) withdrawal Recurrence ( I ) Money inquiry Money inquiry ( I ) Aesthetics

( I )

(6) (2) ( I )

( I )

(3) (3)

(2) ( I ) ( I )

In addition, this qualitative research supports previ­ous research that revealed that friends and siblings are strong reinforcers in youth smoking initiation (Flay et al . 1 994; Eckhardt, Woodruff & Elder 1 994; Chassin et al. 1 986; Croft et al . 1 985; Alexander et al. 1 983) . The present analysis revealed that peer and family supportiveness were important in smoking initiation. However, more boys were alone during their second smoking event than girls. This finding furthers the evidence that males may be more apt to view smoking as a less social event (Clayton, 1 99 1 ) .

Qualitative research is an opportunity to explore sub­ject ive aspects of human behavior and to ident ify comprehensive personal beliefs . The present findings are

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l imited by the number and types of questions as well as number of participating students. The generalizability of the findings to different adolescent groups is limited. How­ever, the data uncovered in this research open interesting possibilities to be elucidated, confirmed, and replicated by quantitative research.

The sample size was limited and did not have balanced gender representation. However, a wealth of information was received from each of the 52 student participants. Future

Urban Adolescent Cigarette Smokers

studies, both qualitative and quantitative, from a sound theo­retical background, can address gender as well as ethnic comparisons in adolescent smoking beliefs to replicate and confirm the present findings. This research will help to fur­ther understanding about adolescents' social norms and beliefs regarding nicotine dependence and may lead to the prevention of initial smoking events, which all too often lead to increased risk for smoking-related mortality and morbidity throughout a youth's lifetime (Russell 1 990).

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