Original Article Journal of Addictions Nursing & Volume 25 & Number 1, 9Y15 & Copyright B 2014 International Nurses Society on Addictions
Experience of a Smoking Cessation Program Among High School Students in Taiwan Chi-Ping Chang, PhD, RN m Ting-Ting Lee, PhD, RN m Mary Etta Mills, ScD, RN
Abstract In Taiwan, the prevalence of smoking among teenagers has led to a required smoking cessation program in schools. Students caught smoking in school are required to participate in a weekly smoking cessation class. The purpose of this study was to explore the experience of high school students in a smoking cessation program. Fifteen adolescents participated in a one-on-one in-depth semistructured interview, and the content was analyzed for patterns based on the methods of Miles and Huberman. In addition, Lewin’s change theory of drive forces and restraining forces was used to describe the change in behavior as a result of the program. Five major themes were identified: the onset of smokingVchange influenced by families and friends; intention to quit smokingVdriving force; the irresistible temptation to smokeVrestraining force; limited change effectsVmore attention and assistance needed; and change in attitude rather than behaviorVsmoking remained unchanged. Changes were seen in the perceptions and attitudes of these students toward smoking at the end of the program; however, none of them were able to really quit. Most participants revealed that they used improper means to pass the carbon monoxide test requirement that was used as a measure of not smoking. Alternative future intervention strategies for further study include change in health policy to support nicotine replacement methods for heavy adolescent smoker, use of teacher support, and exercise programs to support students going through the smoking cessation period. Keywords: change theory, high school students, interviews, smoking behavior, smoking cessation, smoking interventions Chi-Ping Chang, PhD, RN, Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan. Ting-Ting Lee, PhD, RN, School of Nursing, National Taipei University of Nursing & Health Sciences, Taiwan. Mary Etta Mills, ScD, RN, School of Nursing, University of Maryland, Baltimore. The authors report no conflicts of interests. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Ting-Ting Lee, PhD, RN, School of Nursing, National Taipei University of Nursing & Health Sciences, 365 Ming Td Road, Taipei 11219, Taiwan. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000019 Journal of Addictions Nursing
INTRODUCTION Smoking is a major health risk (Robinson & Harris, 2011; U. S. Department of Health and Human Service, 2010). It is estimated that, from developed to developing countries, there are 1.3 billion people in the world currently smoking tobacco. Smoking first takes place in adolescence, with 90% of smokers reporting that they first tried smoking before the age of 18 years. Early onset is related to chronic use and nicotine dependence in adulthood. Tobacco is the most addictive recreational substance (Johnson, Rhee, Chase, & Breslau, 2004; Kandel & Chen, 2000) and is widely viewed as a major preventable cause of morbidity and mortality in young people (Thun, DeLancey, Center, Jemal, & Ward, 2010). Currently, reduction of smoking among young people is a key objective for healthcare organizations’ tobacco control (Centers for Disease Control and Prevention, 2010). Previous studies have found that teenage smoking behavior is correlated with one’s attitudes (de Leeuw, Engels, Vermulst, & Scholte, 2008), beliefs (Lipperman-Kreda & Grube, 2009), social factors, and persistent perception of academic self-rated failing or below average performance (Bergen, Martin, Roeger, & Allison, 2005). It has also been proposed that teenagers could be under social and gender role pressure to smoke and that limited interventional resources could lead to the their perception of having more health problems for their age (RavensSieberer et al., 2009). It has been estimated that treatment of 1,000 smokers could save $373,000 in healthcare costs if they successfully quit smoking (Hurley & Matthews, 2007). After not smoking for 1 week, nicotine is eliminated from the body, and the smoker stops emitting smoking-related body odor. An individual who successfully quits smoking will both reduce the risk of lung cancer by 50% and have the same chance of stroke as nonsmokers after 15 years. In Taiwan, it has been shown that reducing the number of smokers can effectively lower the consumption of medical and social resources (Bureau of Health Promotion, 2010). School-based smoking cessation interventions are popular because of easier recruitment of participants and no need for transportation. They have also been found to improve selfefficacy and increase the cessation rate (Joffe et al., 2009). Research has proposed that, although smoking cessation interventions have been perceived as an effective smoking prevention www.journalofaddictionsnursing.com
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activity, none had a plan of action on how to effectively lead to smoking cessation once the habit was formed. Some even disagreed that health professionals were the right people to give smoking cessation advice (Bull, Burke, Walsh, & Whitehead, 2008). According to Lewin’s change theory, behavior change could occur in three stages: unfreezing, moving, and refreezing. Unfreezing involves motivating individuals ready for change, moving involves encouraging individuals to adopt a new perspective that the current situation can be improved and implement a change behavior, and the refreezing stage involves reinforcing new patterns of behavior (Lee, 2006; Lewin, 1951). Previous studies have addressed the readiness or intention to change smoking behavior as conceived by the transtheoretical model (Bowden, Barr, & Rickert, 2012; Prochaska, DiClemente, & Norcross, 1993); however, adolescent smoking behavior is hard to change (Wong et al., 2011), and quitting is a very difficult step in this process. Therefore, the success of smoking cessation depends on the balance between an individual’s readiness to quit smoking and his or her level of dependence (West, 2004), which may need outside resources and assistance such as intervention-based programs or regulations (McGoldrick & Boonn, 2010). Lewin’s change theory, which included driving forces and restraining forces to compete with each other, could be applied in exploring this change process (smoking cessation) from the participant’s perspective. In Taiwan, the smoking cessation class is provided to help students quit smoking as part of a tobacco hazard prevention program. Because to quit smoking is a very difficult change process, the aim of this study was to explore students’ smoking cessation experience to improve future programs. METHOD Ethical Considerations This study was approved by the ethics committee of the local institutional review board in Taiwan. A written and verbal explanation of the study was given, and clarification concerning issues of confidentiality and disclosure of sensitive information was provided. In all cases, informed consent to record the semistructured interviews was obtained and permission was sought from all participants and their parents. Participants were informed that they could withdraw from the study at any stage and that anonymity was assured. Setting In Taiwan, smoking is prohibited in high schools, and any students caught smoking are asked to participate in a 2-hour smoking cessation class each Wednesday for 8 weeks. There were seven content areas in the program including information on tobacco, building self-respect, decision-making skills, stress management, media advertising and legal regulations, refusal skills, and a smoke-free environment. The on-campus smoking cessation program is managed by a school nurse prepared in this field. Lectures, multimedia, and films were used as teaching strategies. The school also made use of carbon 10
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monoxide (CO) monitors manufactured by Micro Medical in 2004 (Basingstoke, United Kingdom). At the end of the program, if participants showed a CO level below 7 ppm, they were viewed as having successfully quit smoking and reached the goal of smoking cessation. Participants Participants in the study were students currently registered at a high school in eastern Taiwan, who had been caught smoking on campus. Study interviews were conducted after students completed the program. The sample for the current study was recruited by announcing the need for volunteers, and 15 out of the 20 students who participated in the program were willing to be interviewed. Most participants were between the ages of 17 and 18 years old. Eleven students were in grade 11, and four were in grade 12. Most participants had older family members who were smokers. Nine participants had been smoking for fewer than 5 years, whereas six had been smoking for more than 5 years. More than half of the students smoked 5Y20 cigarettes per day. Nearly all received an allowance of less than $35.00 per week, and their academic performances were below the average. Detailed demographic information is presented in Table 1. Data Collection and Analysis Semistructured individual interviews were held in a conference room at convenient dates and times for the students. Each interview lasted between 30 minutes and 1 hour. Content was analyzed based on the qualitative data analysis method of Miles and Huberman (1994). Written notes were made following the semistructured interviews, and each interview was fully transcribed. Data collection, transcription, and analysis were done concurrently. Atlas.ti (Muhr, 1991) qualitative analytical software developed by the Technical University of Berlin was employed to code the data. At the end of each session, the content was summarized with the participating individuals and direct comments requested. Once confirmation was obtained, this summary became part of the data analysis as data validation. To ensure trustworthiness of the qualitative data, methods were applied to increase rigor by ensuring fittingness, credibility, and auditability (Sandelowski, 1986). Fittingness of the findings was addressed by purposively recruiting participants who had participated in the smoking cessation project. Credibility was enhanced by including numerous quotes from the participants’ verbal descriptions in the interviews. Demonstrated auditability was achieved by periodically discussing and comparing the content categorization and emerging themes with a nursing professor to ensure the objectivity of data analysis. FINDINGS Interviews of the students revealed that they had the intention to quit smoking. The program altered some perceptions and attitudes toward tobacco hazards but failed to enable them to quit completely when facing the temptation of cigarettes. However, for the young smokers in the current study, the smoking January/March 2014
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TABLE 1
Participants’ Demographic and Smoking Characteristics (N = 15)
Variable
n
Age, years 16
1
17
7
18
7
Grade 11th
11
12th
4
Gender Male
13
Female
2
members who smoked. If left ignored, they would likely become daily smokers when they entered high school. My classmates and my dad were all smokers and they got me curious. Everyone smoked, like it’s a natural thing to do for a guy. So I began to smoke with my friends from junior high. When I moved and started in a new school, my teacher expected a good academic performance so I had to come to school on the weekend for extra course work. I was very stressed out, so my friend suggested that I start smoking, which did help me to relax and made me feel like an adult. Also, if a new student smokes, other people would not dare to bully you. Once I became part of a group with other classmates who also smoked, my life in school got better, but then I became addicted.
Ethnicity Aboriginal
6
No aboriginal
9
Older family members smoker Yes
13
No
2
Smoking duration 3Y4 years
2
4Y5 years
7
95 years
6
Average number of cigarettes (per day) G5
2
5Y20
9
920
4
Allowance (per week) G5
7
5Y$35
6
9$35
2
Academic performance Above average
0
Average
1
Below average
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cessation interventions worked on attitude but not on behavior change. Excerpts from the participants’ descriptions illustrate each theme below. The Onset of Smoking: Change Influenced by Families and Friends Participants in the study first tried smoking when they were in grades 5 through 9 because of exposure to family Journal of Addictions Nursing
Intention to Quit Smoking: Driving Force The participants were young adolescents, but after smoking for a couple of years, they stated that they could feel the adverse effects of cigarettes on their physical fitness and health. The damage done by cigarettes was almost always unexpectedly high. My lung capacity was very low. I have a harder time catching my breath after a short run than before. Sometimes my heart hurts, too. The health and welfare tax on tobacco has risen from $0.16 to $0.50 in the past 2 years. Most high school students’ smoke imported cigarettes, which cost $2.30Y$2.60 per pack. It is a significant expenditure for students with a limited allowance. Cigarettes cost a lot of money, and it really hurts my wallet. Smoking can be detrimental to a person’s image. One of the most important things for teenagers is to establish their sexual identity, which is achieved by having romantic relationships with the opposite sex. At first, they thought smoking was a mature and ‘‘cool thing; however, they soon realized that it might actually be harmful to their interpersonal relationships, especially with girls. It’s no good if a girl sees me smoke because she won’t like a smoker. Some girls would think you are in a gang if you smoke. Most participants also stated that their family and teachers did not approve of their smoking behavior either. At home and in school where students spend most of their time, smoking was prohibited. Even families who smoke oppose the student smoking, because it is generally believed that only a teenage delinquent from a broken family smokes. My dad wants me to quit smoking. He smokes, too, but never in front of me. He told me that if I don’t stop now, I’d become addicted like him. By law, the school is a smoke-free environment, and smoking is a major violation of school regulations. If a student is caught smoking more than three times, he or she will be expelled. Smokers are at risk of losing their opportunity to get an education. www.journalofaddictionsnursing.com
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I am at strike two already. Last semester, they found that I had a lighter and cigarettes, so I have been very close to being expelled. I am worried, and my teacher is trying to help me. All the participants expressed their intention to quit because they felt that they could lose many things if they continued to smoke. They also truly hoped that they could stop smoking to meet the expectations of family, friends, and teachers. The Irresistible Temptation to Smoke: The Restraining Force Most participants expressed the belief that smoking could help calm their nerves and achieve inner peace. Several also stated that smoking can effectively soothe their negative emotions. Most teenagers felt that smoking is a method of selfhealing and that cigarettes could help them reduce anxiety, gain focus, improve the ability to communicate with others, and help ease their moods. For example, if I have an argument with a friend, then I wouldn’t stop thinking about it. It might not be a very serious problem, but I would think that maybe we won’t talk again, and then I might feel awful the whole day. However, when I smoke I won’t think about it and I relax. It works. After smoking for a while, the participants became addicted to nicotine. They knew that smoking was bad for their health, but they could not stop. During the interview, they described how they craved nicotine when they stopped smoking. It took me a little time to get used to smoking, but I could not stop after a while. I wanted to quit so I would only smoke one cigarette per day. However, I could not stop and would want to smoke again and again. From another perspective, an adolescent who smokes sees the cigarette as a catalyst for friendship with other smokers. They also felt that they could more easily gain the recognition of their peers if they smoked together. Usually a group of us would smoke together outside. Smoking can help me find more friends. I wouldn’t get to know them if I didn’t smoke. We could talk about anything when we were smoking together. All the students interviewed expressed their willingness to quit smoking, but at the same time, they felt that it would be very difficult because of both the psychological and physiological addictions. Cigarettes have become an essential part of their social life and a necessity particularly if they want recognition by their peers. Limited Change Effects: More Attention and Assistance Needed When taking the program, the students eagerly expressed their desire to get more attention and encouragement from the teachers in the school. If my teacher found a cigarette on me, then he would want to talk to me. I ignored him in the beginning. 12
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However, he said he hated to see me get expelled from school because of smoking. I used to smoke more than 10 cigarettes a day, and he told me that I did not have to quit cold turkey. Right now, I only smoke about 5 per day. It’s helpful if I get some one’s attention, because right now I feel like I’m letting him down if I smoke. Students may find lectures and films boring; however, the films about diseases and lung operations made an impression on them, and the students hoped that the school could provide more tangible assistance in terms of motivation, such as nicotine replacement therapy and physical exercise. I learned more from videos than lectures. I was a bit scared after watching the video (of lung cancer operations). Sometimes I take a cigarette and then suddenly throw it away when recalling the video. However, others did not think this kind of lecture would work on changing smoking behavior. Sports activities or the nicotine patch was thought of as being more effective. The class was in vain. There shouldn’t be so many lectures. Instead, they should have taken us to play sports and then we would experience how smoking can affect our body. Once I began to exercise a lot every day, I wouldn’t want to smoke anymore. I don’t know exactly why. But I think, doing exercises can expand my chest air volume capacity, which can help me quit smoking. The class could have been more effective if they could have given us nicotine patches or tablets. My sister used to buy me tablets when she had money. I think they are quite good. Cigarettes can be irresistible. The participants felt that they needed more attention and assistance in the process of the smoking cessation program. The class format required a major psychological shift to improve their motivation to resist the temptation of smoking. Change in Attitude Rather Than Behavior: Smoking Remained Unchanged While the students were in class, the number of cigarettes they smoked daily did not increase. However, when the classes ended, the number of cigarettes smoked did not significantly decrease either. Now I am trying to cut down in order to control my addiction but I still don’t see how I can quit completely. The students’ knowledge level of smoking and attitudes toward quitting improved as a result of the class. They also learned more about the Tobacco Hazards Prevention Act. They no longer believed that smoking is a sign of maturity and strength and now know that smoking is a public health hazard. More importantly, they started to respect other people’s rights to say no to second-hand smoke. There is a law that forbids us from smoking in public. When I need to smoke, I’ll have to go to a place where there aren’t many people around. January/March 2014
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The Tobacco Hazards Prevention Act has stated that persons under 18 years old cannot smoke and many locations completely prohibit smoking. During the class, students learned about the smoking prevention act and realized that their behaviors were inappropriate for the social norm. The laws are enforced more strictly in cities than in the country, so I have to smoke in secret. Although the participants did not smoke more than before, they were not able to quit completely either. At the end of the session, they used improper techniques to pass the CO test requirement. I was only able to pass because I cheated. I used my nose instead of my mouth to exhale so the machine can’t detect nicotineVVV! Whereas the students showed an improvement in their attitude, their behavior did not show any major changes. They had to find an alternative solution to achieve the goals set out by this program. DISCUSSION Smoking cessation classes have been supported by the health promotion programs and also have been shown to significantly improve participants’ stress management and selfefficacy for smoking cessation (Joffe et al., 2009; Kamisli & ¨ z, 2011). This study shows that smoking cessation classes O may improve students’ perceptions and attitudes toward nonsmoking, but the program had little effect on changing their behavior. Although students would not want to smoke as many cigarettes as before, their addiction to nicotine led them to inhale as much as they could with each cigarette, possibly causing more harm (Hughes & Carpenter, 2005). Thus, based on Lewin’s theory, the smoking cessation behavior remains in the unfreezing stage, and the assistance provided by the program was not strong enough to cause a behavioral change. In the unfreezing stage of change, strategies should be devised to strengthen the driving forces to quit and to weaken the restraining forces to smoke. Unfortunately, restraining forces were harder to overcome because they were often embedded in personal psychological desire or group norms within the surrounding organization or community culture (Schein, 1996). Therefore, developing and applying a program composed of individualized, tailored, and comprehensive smoking-cessation aspects might better serve the purpose to help these students. Because the behavior change of the study participants was not linear as from unfreezing and change to refreezing, this study revealed the importance of balancing the driving forces and restraining forces. The major restraining forces such as withdrawal syndromes and the temporary emotional selfhealing effect of nicotine were mentioned during the interviews as major obstacles to smoking cessation. The participants also expressed regret about how quickly they became addicted to nicotine. Some participants also wished that the classes could have provided nicotine replacement therapy. This study also reports the driving forces to quit such as physical deterioration, interpersonal relationship, tobacco tax, and legal regulation for a smoking-free environment. Policy-based interventions Journal of Addictions Nursing
such as tobacco tax and smoke-free workplace laws have been reported with excellent outcomes in quitting smoking (McGoldrick & Boonn, 2010). Although the use and efficacy of nicotine replacement treatment (NRT) in adolescent smokers is controversial (Campaign for Tobacco Free Kids, 2010), there is evidence that provides free access to NRT has significantly increased quitting rates in adolescent smokers (Bailey et al., 2013; Gray et al., 2011). Researchers have reported that therapy using a patch, tablet, inhaler, or nasal spray can be effective (Takagi, Kato, Sasamoto, & Hata, 2005). Use of NRT has a 20%Y24% chance of helping the user quit smoking (Hatsukami, Stead, & Gupta, 2008) and is more cost effective than medicines such as Bupropion or Varenicline (Geimer, Olson, Baumgarten, Kepner, & Mahoney, 2010). Because most insurance policies do not cover the cost of NRTand the therapy costs significantly more than cigarettes, people are less likely to use it. To improve the success rate, NRTshould be covered by the insurance policy for certain populations, especially for young heavy smoking people (smoking over 20 cigarettes a day; Campaign for Tobacco Free Kids, 2010). In addition, only 5% of teenage smokers think they will continue to smoke in 5 years, but it has been found that 75% of them still smoke 8 years later (Sussman, Dent, Severson, Dee, & Flay, 1998). It is obvious that teenagers have more difficulty quitting smoking than might be expected, just like adults (Corrigall, Zack, Eissenberg, Belsito, & Scher, 2001). The impact of nicotine addiction among teenagers has to be reevaluated, and health policies should put a greater emphasis on subsidizing teenagers for NRT. Smoking should also be treated as a chronic disease condition, which requires long-term treatment and a lot of patience (Hatsukami et al., 2008). Properly trained school nurses could assist in assessing the extent of the addiction and providing adequate referrals for students desiring to quit smoking. None of the participants were able to quit smoking as a result of the class; however, they did learn how to maintain a smoke-free environment and become more respectful of nonsmokers. When they wanted to smoke, they removed themselves from the presence of nonsmokers. This action itself promotes the production of smoking islands and suggests that segregation may lead to marginalization (stigma) and increased consumption (Thompson, Pearce, & Barnett, 2007). It is important that more consideration be given to any negative consequences of the denormalization of smoking (Ritchie, Amos, & Martin, 2010). Our participants indicated that they would like to receive greater personal attention from their teachers because teacher involvement and concern have a positive effect on students’ efforts to quit smoking. In the past, smoking cessation classes were the responsibility of the school health center. Because teachers are the ones who are with the students every day, they are not only transmitters of knowledge but also promote self-esteem and encourage and empower students wanting to quit smoking. The ability of teachers to provide substantial support should not be dismissed. The participants recognized the harmful effects of smoking when they played sports. Exercise has been found to correlate www.journalofaddictionsnursing.com
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significantly with motivation to quit smoking (Abrantes et al., 2009). The neurobiological reaction and the feeling of comfort experienced via exercise are similar to that created by cigarettes (Dishman et al., 2006). Studies revealed that exercise can improve the success rate of quitting smoking (Abrantes et al., 2009; Paavola, Vartiainen, & Puska, 2001). Teenagers have a lot of physical energy, but program lectures are boring to them. A 40- to 50-minute period of exercise during the smoking cessation program may enhance their motivation and bring them a feeling of relaxation. Exercise should be an element to be considered for application in future smoking cessation programs.
CONCLUSION AND RECOMMENDATION The experiences of participants during the school mandatory smoking cessation program showed that the class could change the perception and attitude of these students toward smoking from positive to negative. Teachers’ dedication to students was appreciated, yet was insufficient to reinforce the desired behavioral change. Despite the participant’s interest in quitting smoking and reinforcement of smoking cessation attitudes, the students’ behavior remained in the early stage of changeV unfreezing. Moreover, at the end of the program, most participants had to use devious methods to pass the CO test, suggesting that this element of the program might have reinforced a negative behavior. Negative consequences of the denormalization of smoking need more consideration in program design. Nicotine replacement therapy, regular exercise, and personal attention from teachers can offer verifiable help to student participants in smoking cessation classes to resist the temptation of cigarettes. Combining smoking cessation classes with an exercise program for both psychological and physical changes may prove beneficial. Implementing teacher programs, which offer greater personal attention to students, may provide more evidencebased solutions. Future studies could explore both the cost effectiveness of insurance coverage for nicotine replacement therapy in teenage populations and the impact of programmatic restructuring designed to reinforce behavioral change. Acknowledgment: This work was supported by a grant [NSC-99-2314-B-227-006-MY3] to Dr. Ting-Ting Lee from the National Science Council, Taipei, Taiwan.
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Experience of a Smoking Cessation Program Among High School Students in Taiwan Chi-Ping Chang, PhD, RN m Ting-Ting Lee, PhD, RN m Mary Etta Mills, ScD, RN
Abstract In Taiwan, the prevalence of smoking among teenagers has led to a required smoking cessation program in schools. Students caught smoking in school are required to participate in a weekly smoking cessation class. The purpose of this study was to explore the experience of high school students in a smoking cessation program. Fifteen adolescents participated in a one-on-one in-depth semistructured interview, and the content was analyzed for patterns based on the methods of Miles and Huberman. In addition, Lewin’s change theory of drive forces and restraining forces was used to describe the change in behavior as a result of the program. Five major themes were identified: the onset of smokingVchange influenced by families and friends; intention to quit smokingVdriving force; the irresistible temptation to smokeVrestraining force; limited change effectsVmore attention and assistance needed; and change in attitude rather than behaviorVsmoking remained unchanged. Changes were seen in the perceptions and attitudes of these students toward smoking at the end of the program; however, none of them were able to really quit. Most participants revealed that they used improper means to pass the carbon monoxide test requirement that was used as a measure of not smoking. Alternative future intervention strategies for further study include change in health policy to support nicotine replacement methods for heavy adolescent smoker, use of teacher support, and exercise programs to support students going through the smoking cessation period. Keywords: change theory, high school students, interviews, smoking behavior, smoking cessation, smoking interventions Chi-Ping Chang, PhD, RN, Department of Nursing, Tzu Chi College of Technology, Hualien, Taiwan. Ting-Ting Lee, PhD, RN, School of Nursing, National Taipei University of Nursing & Health Sciences, Taiwan. Mary Etta Mills, ScD, RN, School of Nursing, University of Maryland, Baltimore. The authors report no conflicts of interests. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Ting-Ting Lee, PhD, RN, School of Nursing, National Taipei University of Nursing & Health Sciences, 365 Ming Td Road, Taipei 11219, Taiwan. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000019 Journal of Addictions Nursing
INTRODUCTION Smoking is a major health risk (Robinson & Harris, 2011; U. S. Department of Health and Human Service, 2010). It is estimated that, from developed to developing countries, there are 1.3 billion people in the world currently smoking tobacco. Smoking first takes place in adolescence, with 90% of smokers reporting that they first tried smoking before the age of 18 years. Early onset is related to chronic use and nicotine dependence in adulthood. Tobacco is the most addictive recreational substance (Johnson, Rhee, Chase, & Breslau, 2004; Kandel & Chen, 2000) and is widely viewed as a major preventable cause of morbidity and mortality in young people (Thun, DeLancey, Center, Jemal, & Ward, 2010). Currently, reduction of smoking among young people is a key objective for healthcare organizations’ tobacco control (Centers for Disease Control and Prevention, 2010). Previous studies have found that teenage smoking behavior is correlated with one’s attitudes (de Leeuw, Engels, Vermulst, & Scholte, 2008), beliefs (Lipperman-Kreda & Grube, 2009), social factors, and persistent perception of academic self-rated failing or below average performance (Bergen, Martin, Roeger, & Allison, 2005). It has also been proposed that teenagers could be under social and gender role pressure to smoke and that limited interventional resources could lead to the their perception of having more health problems for their age (RavensSieberer et al., 2009). It has been estimated that treatment of 1,000 smokers could save $373,000 in healthcare costs if they successfully quit smoking (Hurley & Matthews, 2007). After not smoking for 1 week, nicotine is eliminated from the body, and the smoker stops emitting smoking-related body odor. An individual who successfully quits smoking will both reduce the risk of lung cancer by 50% and have the same chance of stroke as nonsmokers after 15 years. In Taiwan, it has been shown that reducing the number of smokers can effectively lower the consumption of medical and social resources (Bureau of Health Promotion, 2010). School-based smoking cessation interventions are popular because of easier recruitment of participants and no need for transportation. They have also been found to improve selfefficacy and increase the cessation rate (Joffe et al., 2009). Research has proposed that, although smoking cessation interventions have been perceived as an effective smoking prevention www.journalofaddictionsnursing.com
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activity, none had a plan of action on how to effectively lead to smoking cessation once the habit was formed. Some even disagreed that health professionals were the right people to give smoking cessation advice (Bull, Burke, Walsh, & Whitehead, 2008). According to Lewin’s change theory, behavior change could occur in three stages: unfreezing, moving, and refreezing. Unfreezing involves motivating individuals ready for change, moving involves encouraging individuals to adopt a new perspective that the current situation can be improved and implement a change behavior, and the refreezing stage involves reinforcing new patterns of behavior (Lee, 2006; Lewin, 1951). Previous studies have addressed the readiness or intention to change smoking behavior as conceived by the transtheoretical model (Bowden, Barr, & Rickert, 2012; Prochaska, DiClemente, & Norcross, 1993); however, adolescent smoking behavior is hard to change (Wong et al., 2011), and quitting is a very difficult step in this process. Therefore, the success of smoking cessation depends on the balance between an individual’s readiness to quit smoking and his or her level of dependence (West, 2004), which may need outside resources and assistance such as intervention-based programs or regulations (McGoldrick & Boonn, 2010). Lewin’s change theory, which included driving forces and restraining forces to compete with each other, could be applied in exploring this change process (smoking cessation) from the participant’s perspective. In Taiwan, the smoking cessation class is provided to help students quit smoking as part of a tobacco hazard prevention program. Because to quit smoking is a very difficult change process, the aim of this study was to explore students’ smoking cessation experience to improve future programs. METHOD Ethical Considerations This study was approved by the ethics committee of the local institutional review board in Taiwan. A written and verbal explanation of the study was given, and clarification concerning issues of confidentiality and disclosure of sensitive information was provided. In all cases, informed consent to record the semistructured interviews was obtained and permission was sought from all participants and their parents. Participants were informed that they could withdraw from the study at any stage and that anonymity was assured. Setting In Taiwan, smoking is prohibited in high schools, and any students caught smoking are asked to participate in a 2-hour smoking cessation class each Wednesday for 8 weeks. There were seven content areas in the program including information on tobacco, building self-respect, decision-making skills, stress management, media advertising and legal regulations, refusal skills, and a smoke-free environment. The on-campus smoking cessation program is managed by a school nurse prepared in this field. Lectures, multimedia, and films were used as teaching strategies. The school also made use of carbon 10
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monoxide (CO) monitors manufactured by Micro Medical in 2004 (Basingstoke, United Kingdom). At the end of the program, if participants showed a CO level below 7 ppm, they were viewed as having successfully quit smoking and reached the goal of smoking cessation. Participants Participants in the study were students currently registered at a high school in eastern Taiwan, who had been caught smoking on campus. Study interviews were conducted after students completed the program. The sample for the current study was recruited by announcing the need for volunteers, and 15 out of the 20 students who participated in the program were willing to be interviewed. Most participants were between the ages of 17 and 18 years old. Eleven students were in grade 11, and four were in grade 12. Most participants had older family members who were smokers. Nine participants had been smoking for fewer than 5 years, whereas six had been smoking for more than 5 years. More than half of the students smoked 5Y20 cigarettes per day. Nearly all received an allowance of less than $35.00 per week, and their academic performances were below the average. Detailed demographic information is presented in Table 1. Data Collection and Analysis Semistructured individual interviews were held in a conference room at convenient dates and times for the students. Each interview lasted between 30 minutes and 1 hour. Content was analyzed based on the qualitative data analysis method of Miles and Huberman (1994). Written notes were made following the semistructured interviews, and each interview was fully transcribed. Data collection, transcription, and analysis were done concurrently. Atlas.ti (Muhr, 1991) qualitative analytical software developed by the Technical University of Berlin was employed to code the data. At the end of each session, the content was summarized with the participating individuals and direct comments requested. Once confirmation was obtained, this summary became part of the data analysis as data validation. To ensure trustworthiness of the qualitative data, methods were applied to increase rigor by ensuring fittingness, credibility, and auditability (Sandelowski, 1986). Fittingness of the findings was addressed by purposively recruiting participants who had participated in the smoking cessation project. Credibility was enhanced by including numerous quotes from the participants’ verbal descriptions in the interviews. Demonstrated auditability was achieved by periodically discussing and comparing the content categorization and emerging themes with a nursing professor to ensure the objectivity of data analysis. FINDINGS Interviews of the students revealed that they had the intention to quit smoking. The program altered some perceptions and attitudes toward tobacco hazards but failed to enable them to quit completely when facing the temptation of cigarettes. However, for the young smokers in the current study, the smoking January/March 2014
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TABLE 1
Participants’ Demographic and Smoking Characteristics (N = 15)
Variable
n
Age, years 16
1
17
7
18
7
Grade 11th
11
12th
4
Gender Male
13
Female
2
members who smoked. If left ignored, they would likely become daily smokers when they entered high school. My classmates and my dad were all smokers and they got me curious. Everyone smoked, like it’s a natural thing to do for a guy. So I began to smoke with my friends from junior high. When I moved and started in a new school, my teacher expected a good academic performance so I had to come to school on the weekend for extra course work. I was very stressed out, so my friend suggested that I start smoking, which did help me to relax and made me feel like an adult. Also, if a new student smokes, other people would not dare to bully you. Once I became part of a group with other classmates who also smoked, my life in school got better, but then I became addicted.
Ethnicity Aboriginal
6
No aboriginal
9
Older family members smoker Yes
13
No
2
Smoking duration 3Y4 years
2
4Y5 years
7
95 years
6
Average number of cigarettes (per day) G5
2
5Y20
9
920
4
Allowance (per week) G5
7
5Y$35
6
9$35
2
Academic performance Above average
0
Average
1
Below average
14
cessation interventions worked on attitude but not on behavior change. Excerpts from the participants’ descriptions illustrate each theme below. The Onset of Smoking: Change Influenced by Families and Friends Participants in the study first tried smoking when they were in grades 5 through 9 because of exposure to family Journal of Addictions Nursing
Intention to Quit Smoking: Driving Force The participants were young adolescents, but after smoking for a couple of years, they stated that they could feel the adverse effects of cigarettes on their physical fitness and health. The damage done by cigarettes was almost always unexpectedly high. My lung capacity was very low. I have a harder time catching my breath after a short run than before. Sometimes my heart hurts, too. The health and welfare tax on tobacco has risen from $0.16 to $0.50 in the past 2 years. Most high school students’ smoke imported cigarettes, which cost $2.30Y$2.60 per pack. It is a significant expenditure for students with a limited allowance. Cigarettes cost a lot of money, and it really hurts my wallet. Smoking can be detrimental to a person’s image. One of the most important things for teenagers is to establish their sexual identity, which is achieved by having romantic relationships with the opposite sex. At first, they thought smoking was a mature and ‘‘cool thing; however, they soon realized that it might actually be harmful to their interpersonal relationships, especially with girls. It’s no good if a girl sees me smoke because she won’t like a smoker. Some girls would think you are in a gang if you smoke. Most participants also stated that their family and teachers did not approve of their smoking behavior either. At home and in school where students spend most of their time, smoking was prohibited. Even families who smoke oppose the student smoking, because it is generally believed that only a teenage delinquent from a broken family smokes. My dad wants me to quit smoking. He smokes, too, but never in front of me. He told me that if I don’t stop now, I’d become addicted like him. By law, the school is a smoke-free environment, and smoking is a major violation of school regulations. If a student is caught smoking more than three times, he or she will be expelled. Smokers are at risk of losing their opportunity to get an education. www.journalofaddictionsnursing.com
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I am at strike two already. Last semester, they found that I had a lighter and cigarettes, so I have been very close to being expelled. I am worried, and my teacher is trying to help me. All the participants expressed their intention to quit because they felt that they could lose many things if they continued to smoke. They also truly hoped that they could stop smoking to meet the expectations of family, friends, and teachers. The Irresistible Temptation to Smoke: The Restraining Force Most participants expressed the belief that smoking could help calm their nerves and achieve inner peace. Several also stated that smoking can effectively soothe their negative emotions. Most teenagers felt that smoking is a method of selfhealing and that cigarettes could help them reduce anxiety, gain focus, improve the ability to communicate with others, and help ease their moods. For example, if I have an argument with a friend, then I wouldn’t stop thinking about it. It might not be a very serious problem, but I would think that maybe we won’t talk again, and then I might feel awful the whole day. However, when I smoke I won’t think about it and I relax. It works. After smoking for a while, the participants became addicted to nicotine. They knew that smoking was bad for their health, but they could not stop. During the interview, they described how they craved nicotine when they stopped smoking. It took me a little time to get used to smoking, but I could not stop after a while. I wanted to quit so I would only smoke one cigarette per day. However, I could not stop and would want to smoke again and again. From another perspective, an adolescent who smokes sees the cigarette as a catalyst for friendship with other smokers. They also felt that they could more easily gain the recognition of their peers if they smoked together. Usually a group of us would smoke together outside. Smoking can help me find more friends. I wouldn’t get to know them if I didn’t smoke. We could talk about anything when we were smoking together. All the students interviewed expressed their willingness to quit smoking, but at the same time, they felt that it would be very difficult because of both the psychological and physiological addictions. Cigarettes have become an essential part of their social life and a necessity particularly if they want recognition by their peers. Limited Change Effects: More Attention and Assistance Needed When taking the program, the students eagerly expressed their desire to get more attention and encouragement from the teachers in the school. If my teacher found a cigarette on me, then he would want to talk to me. I ignored him in the beginning. 12
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However, he said he hated to see me get expelled from school because of smoking. I used to smoke more than 10 cigarettes a day, and he told me that I did not have to quit cold turkey. Right now, I only smoke about 5 per day. It’s helpful if I get some one’s attention, because right now I feel like I’m letting him down if I smoke. Students may find lectures and films boring; however, the films about diseases and lung operations made an impression on them, and the students hoped that the school could provide more tangible assistance in terms of motivation, such as nicotine replacement therapy and physical exercise. I learned more from videos than lectures. I was a bit scared after watching the video (of lung cancer operations). Sometimes I take a cigarette and then suddenly throw it away when recalling the video. However, others did not think this kind of lecture would work on changing smoking behavior. Sports activities or the nicotine patch was thought of as being more effective. The class was in vain. There shouldn’t be so many lectures. Instead, they should have taken us to play sports and then we would experience how smoking can affect our body. Once I began to exercise a lot every day, I wouldn’t want to smoke anymore. I don’t know exactly why. But I think, doing exercises can expand my chest air volume capacity, which can help me quit smoking. The class could have been more effective if they could have given us nicotine patches or tablets. My sister used to buy me tablets when she had money. I think they are quite good. Cigarettes can be irresistible. The participants felt that they needed more attention and assistance in the process of the smoking cessation program. The class format required a major psychological shift to improve their motivation to resist the temptation of smoking. Change in Attitude Rather Than Behavior: Smoking Remained Unchanged While the students were in class, the number of cigarettes they smoked daily did not increase. However, when the classes ended, the number of cigarettes smoked did not significantly decrease either. Now I am trying to cut down in order to control my addiction but I still don’t see how I can quit completely. The students’ knowledge level of smoking and attitudes toward quitting improved as a result of the class. They also learned more about the Tobacco Hazards Prevention Act. They no longer believed that smoking is a sign of maturity and strength and now know that smoking is a public health hazard. More importantly, they started to respect other people’s rights to say no to second-hand smoke. There is a law that forbids us from smoking in public. When I need to smoke, I’ll have to go to a place where there aren’t many people around. January/March 2014
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The Tobacco Hazards Prevention Act has stated that persons under 18 years old cannot smoke and many locations completely prohibit smoking. During the class, students learned about the smoking prevention act and realized that their behaviors were inappropriate for the social norm. The laws are enforced more strictly in cities than in the country, so I have to smoke in secret. Although the participants did not smoke more than before, they were not able to quit completely either. At the end of the session, they used improper techniques to pass the CO test requirement. I was only able to pass because I cheated. I used my nose instead of my mouth to exhale so the machine can’t detect nicotineVVV! Whereas the students showed an improvement in their attitude, their behavior did not show any major changes. They had to find an alternative solution to achieve the goals set out by this program. DISCUSSION Smoking cessation classes have been supported by the health promotion programs and also have been shown to significantly improve participants’ stress management and selfefficacy for smoking cessation (Joffe et al., 2009; Kamisli & ¨ z, 2011). This study shows that smoking cessation classes O may improve students’ perceptions and attitudes toward nonsmoking, but the program had little effect on changing their behavior. Although students would not want to smoke as many cigarettes as before, their addiction to nicotine led them to inhale as much as they could with each cigarette, possibly causing more harm (Hughes & Carpenter, 2005). Thus, based on Lewin’s theory, the smoking cessation behavior remains in the unfreezing stage, and the assistance provided by the program was not strong enough to cause a behavioral change. In the unfreezing stage of change, strategies should be devised to strengthen the driving forces to quit and to weaken the restraining forces to smoke. Unfortunately, restraining forces were harder to overcome because they were often embedded in personal psychological desire or group norms within the surrounding organization or community culture (Schein, 1996). Therefore, developing and applying a program composed of individualized, tailored, and comprehensive smoking-cessation aspects might better serve the purpose to help these students. Because the behavior change of the study participants was not linear as from unfreezing and change to refreezing, this study revealed the importance of balancing the driving forces and restraining forces. The major restraining forces such as withdrawal syndromes and the temporary emotional selfhealing effect of nicotine were mentioned during the interviews as major obstacles to smoking cessation. The participants also expressed regret about how quickly they became addicted to nicotine. Some participants also wished that the classes could have provided nicotine replacement therapy. This study also reports the driving forces to quit such as physical deterioration, interpersonal relationship, tobacco tax, and legal regulation for a smoking-free environment. Policy-based interventions Journal of Addictions Nursing
such as tobacco tax and smoke-free workplace laws have been reported with excellent outcomes in quitting smoking (McGoldrick & Boonn, 2010). Although the use and efficacy of nicotine replacement treatment (NRT) in adolescent smokers is controversial (Campaign for Tobacco Free Kids, 2010), there is evidence that provides free access to NRT has significantly increased quitting rates in adolescent smokers (Bailey et al., 2013; Gray et al., 2011). Researchers have reported that therapy using a patch, tablet, inhaler, or nasal spray can be effective (Takagi, Kato, Sasamoto, & Hata, 2005). Use of NRT has a 20%Y24% chance of helping the user quit smoking (Hatsukami, Stead, & Gupta, 2008) and is more cost effective than medicines such as Bupropion or Varenicline (Geimer, Olson, Baumgarten, Kepner, & Mahoney, 2010). Because most insurance policies do not cover the cost of NRTand the therapy costs significantly more than cigarettes, people are less likely to use it. To improve the success rate, NRTshould be covered by the insurance policy for certain populations, especially for young heavy smoking people (smoking over 20 cigarettes a day; Campaign for Tobacco Free Kids, 2010). In addition, only 5% of teenage smokers think they will continue to smoke in 5 years, but it has been found that 75% of them still smoke 8 years later (Sussman, Dent, Severson, Dee, & Flay, 1998). It is obvious that teenagers have more difficulty quitting smoking than might be expected, just like adults (Corrigall, Zack, Eissenberg, Belsito, & Scher, 2001). The impact of nicotine addiction among teenagers has to be reevaluated, and health policies should put a greater emphasis on subsidizing teenagers for NRT. Smoking should also be treated as a chronic disease condition, which requires long-term treatment and a lot of patience (Hatsukami et al., 2008). Properly trained school nurses could assist in assessing the extent of the addiction and providing adequate referrals for students desiring to quit smoking. None of the participants were able to quit smoking as a result of the class; however, they did learn how to maintain a smoke-free environment and become more respectful of nonsmokers. When they wanted to smoke, they removed themselves from the presence of nonsmokers. This action itself promotes the production of smoking islands and suggests that segregation may lead to marginalization (stigma) and increased consumption (Thompson, Pearce, & Barnett, 2007). It is important that more consideration be given to any negative consequences of the denormalization of smoking (Ritchie, Amos, & Martin, 2010). Our participants indicated that they would like to receive greater personal attention from their teachers because teacher involvement and concern have a positive effect on students’ efforts to quit smoking. In the past, smoking cessation classes were the responsibility of the school health center. Because teachers are the ones who are with the students every day, they are not only transmitters of knowledge but also promote self-esteem and encourage and empower students wanting to quit smoking. The ability of teachers to provide substantial support should not be dismissed. The participants recognized the harmful effects of smoking when they played sports. Exercise has been found to correlate www.journalofaddictionsnursing.com
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significantly with motivation to quit smoking (Abrantes et al., 2009). The neurobiological reaction and the feeling of comfort experienced via exercise are similar to that created by cigarettes (Dishman et al., 2006). Studies revealed that exercise can improve the success rate of quitting smoking (Abrantes et al., 2009; Paavola, Vartiainen, & Puska, 2001). Teenagers have a lot of physical energy, but program lectures are boring to them. A 40- to 50-minute period of exercise during the smoking cessation program may enhance their motivation and bring them a feeling of relaxation. Exercise should be an element to be considered for application in future smoking cessation programs.
CONCLUSION AND RECOMMENDATION The experiences of participants during the school mandatory smoking cessation program showed that the class could change the perception and attitude of these students toward smoking from positive to negative. Teachers’ dedication to students was appreciated, yet was insufficient to reinforce the desired behavioral change. Despite the participant’s interest in quitting smoking and reinforcement of smoking cessation attitudes, the students’ behavior remained in the early stage of changeV unfreezing. Moreover, at the end of the program, most participants had to use devious methods to pass the CO test, suggesting that this element of the program might have reinforced a negative behavior. Negative consequences of the denormalization of smoking need more consideration in program design. Nicotine replacement therapy, regular exercise, and personal attention from teachers can offer verifiable help to student participants in smoking cessation classes to resist the temptation of cigarettes. Combining smoking cessation classes with an exercise program for both psychological and physical changes may prove beneficial. Implementing teacher programs, which offer greater personal attention to students, may provide more evidencebased solutions. Future studies could explore both the cost effectiveness of insurance coverage for nicotine replacement therapy in teenage populations and the impact of programmatic restructuring designed to reinforce behavioral change. Acknowledgment: This work was supported by a grant [NSC-99-2314-B-227-006-MY3] to Dr. Ting-Ting Lee from the National Science Council, Taipei, Taiwan.
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