Social Contingencies and College Quit and Win Contest: A Qualitative Inquiry

Abstract

Objectives

To investigate the social contingencies associated with participation in a college Quit and Win contest to promote smoking cessation.

Methods

Six focus groups (N = 27)were conducted with college students who participated in a Quit and Win research trial.

Results

Themes included: 1) participants reluctant to disclose quit decision; 2) perception of little support in their quit attempt, and 3) the social environment as a trigger for relapse.

Conclusion

Although Quit and Win contests appear to motivate an initial quit attempt, the reluctance of smokers to disclose their quit attempt limits the potential positive impact of social support when utilizing this public service campaign.

The most preventable cause of morbidity and mortality in the United States is tobacco use.¹ According to the Center for Disease Control, an estimated 480,000 people die prematurely from smoking or exposure to secondhand smoke each year. ¹ Smoking initiation occurs primarily in adolescence and young adulthood, with nearly 90% of smokers starting by age 18 and 99% having started by age 26. Nationally, the prevalence of smoking among 18 to 25 year olds is 31.8%.² If smoking continues at current levels, 5.6 million of today’s youth may die prematurely from a smoking-related illness, making cessation among young adults a national health priority.¹ Fortunately, smokers who quit smoking before age 34 have a mortality rate similar to those who have never smoked.³ Therefore, helping smokers quit early in their smoking trajectory is crucial to prevent lifelong morbidity and mortality.

Nearly one-third of U.S. young adults between the ages of 18 and 25 attend college, ⁴ making the college campus a potential venue to reach young adults smokers. According to the findings of the 2013 College Student Health Survey, approximately 23.1% of students reported having smoked on at least one occasion in the previous month and 10.4% were daily smokers.⁵

Many college students who smoke are not interested in quitting and do not seek out cessation services.⁶ Although college health care providers are in an ideal position to provide smoking cessation interventions, between 25% – 33% of students report that they were not asked about smoking behaviors at their medical visits.⁷ Further, colleges and universities report little demand for cessation programs, with 88% of schools who offer cessation programs reporting they had no waiting list for the programs offered and 6.2% of schools discontinuing services because of lack of interest.⁶

National data indicate that most smokers who try to quit, do so on their own and most do not succeed.⁸ Abstinence rates among those who attempt to quit smoking without any cessation assistance average only 5% at 6 months.⁹ This compares to 29.7% using varenicline,¹⁰ 20.2% using buproprion SR,¹⁰ 22% using the Nicotine Patch ¹¹ and 9.8% utilizing counseling services.¹² In a survey of almost 14,000 students, of those who considered themselves smokers, over half (54.7%) made at least one quit attempt over the past 12 months, with an average of 4.3 quit attempts during the year.⁵ It is apparent that colleges and universities need more appealing interventions to help their students quit smoking.

One potentially promising way to help college smokers quit is through Quit and Win contests, where smokers pledge to quit smoking for a period of time in exchange for the chance to win a substantial prize. Several aspects of Quit and Win contests appear well-suited for dissemination on college campuses. These include the opportunity for targeted promotion in the campus setting, the ease of contest implementation, and the apparent attractiveness of the contest format to younger smokers.¹³

The primary theoretical assumption underlying the success of Quit and Win Contests is that extrinsic incentives and community support surrounding the contest will motivate a quit attempt and the 30-day duration of the contest period will contribute to sustained cessation after the end of the incentivized contest period. In a study by Thomas and colleagues,¹⁴ Quit and Win contests were conducted and evaluated at 4 colleges and university campuses (n=588). Results indicated that 72.1% of survey responders reported continuous 30-day abstinence during the contest period. Of those, 44.7% remained abstinent 2 weeks post-contest(cotinine confirmed). Rooney and colleagues¹³ also evaluated the efficacy of a Quit & Win contest among a college-aged population (n=152). Abstinence rates at the end of the 7 week contest were 30% (CO validation). Abstinence rates at 6-month follow-up were 12% (self-report). Although abstinence rates decrease over time, Quit and Win contests remain an effective intervention for young adults compared with other cessation methods.^15,16

Quit and Win contests have the potential to create a supportive environment in which college smokers may be motivated to quit. Support during a quit attempt is an important component to cessation success. Lawhon and colleagues¹⁷ found a higher level of positive support early in the quit attempt was predictive of treatment success. Similarly, Mermelstein and colleagues¹⁸ investigated the role of social support in cessation and maintenance and found that partner support for quitting and the perceived availability of general support were associated with initial cessation and short-term abstinence. Quit and Win contests could be an important avenue to capitalize on social support and leverage long-term cessation success. However, little is known about the social contingencies of quitting during a Quit and Win Contest.

From 2010 through 2013, a study examining the efficacy of Quit and Win Contests among college smokers was implemented on campuses across the Midwest. In order to understand their experiences, attitudes and beliefs about the social contingencies of quitting during the contest period, we invited students who participated in the 2011–2012 academic year to attend qualitative focus groups after completion of their follow-up visits.

METHODS

Overview of Parent Trial (Quit and Win Contests)

Participants

The parent trial, Enhancing Quit and Win Contests to Improve Cessation among College Smokers, is a National Institute of Health (NIH) funded randomized clinical trial designed to test the efficacy of single (i.e., one 30-day contest) and multiple(three, successive, 30-day contests)quit and win contests, with and without counseling. Eligible students were at least 18 years of age, enrolled full-or part-time in one of the participating institutions for the entire academic year, and smoked at least 10 days per month. Students were excluded from participating if they were pregnant or planning to become pregnant, had used a smoking cessation aid in the 7 days prior to enrollment or screened positive for pathological gambling.

Procedures

Interested students were instructed to complete a short electronic survey to determine eligibility; provide an electronically signed informed consent; and complete a baseline questionnaire composed of demographic, tobacco-related, and psychosocial variables. The final step to enrollment, providing a urine sample to document positive smoking status, occurred in person at pre-specified times and campus locations. A total of 1217 participants were enrolled in the Quit and Win Study. Enrolled participants were asked to quit smoking and to maintain abstinence from all tobacco products for at least 30-days for the chance to win a trip for two to the Caribbean worth $3,000 or the equivalent in retail gift cards. All participants were offered a 2-week supply of Nicotine Replacement Therapy in the form of the patch. Half of all participants were randomized to receive counseling to accompany contest enrollment. Counseling was administered over the phone by trained professional counselors employed by a provider of QuitLine services for various state sponsored programs and health plans. The sessions were designed using Motivational and Problem Solving (MAPS) counseling. MAPS is a unique approach, derived from a Motivational Interviewing framework, which utilizes motivationally based techniques to enhance commitment and intrinsic motivation for change in combination with cognitive-behavioral techniques to target self-efficacy, coping, stress, and negative affect. A small subset of counselors were provided specialized training in MAPS and ongoing supervision and fidelity monitoring in order to provide the counseling specific to this trial.

Overview of Focus Groups

Enrollment

In the spring of 2013, participants enrolled in one of two Midwestern colleges who participated in the 2011–2012 Quit and Win research study were invited to attend a focus group. Approximately 13% of the total Quit and Win Study sample were invited to participate in the focus groups (n=156).

Interested individuals were asked to complete an online informed consent and a short survey. Of the 156 email invitations sent, 17% (N=27) participated in the focus groups.

Procedure

A total of six focus groups were conducted at two Midwestern universities, 3 groups for each school. Focus groups were stratified by school and were held at each respective institution. Each group was attended by 4 or 5 participants and lasted one hour. All subject identifiers were excluded from transcription to protect the anonymity of the participants. Participants were provided with a meal and a gift card for their time. A moderator led the discussion groups and followed a semi-structured interview guide. The moderator was trained by Kruger and Casey and has over a decade of experience moderating focus groups (JT). The moderator’s guide was developed through a collaboration of the research team and was designed to address the overarching issue of the importance of social contingencies in a smoking cessation trial utilizing financial incentives. Questions were selected after reviewing the literature on social influences, support and social implications of quitting.

Discussions included the following major topics: participant’s motives to join the parent Quit and Win Study, reasons to quit smoking, disclosure of decision to quit (who they told and why), the reaction of others on their decision to quit smoking, their opinion on our intra-treatment support provided and social triggers for relapse. In order to elicit answers to the questions, the moderator used probes such as “please tell me more”, “please give me an example”, and “please help me understand”. Please see Table I for an outline of focus group topics and questions.

Table 1.

Outline of Focus Group Topics and Questions

Topic	Questions
Social Support	Tell us about your experience with Quit and Win. What motivated you to join? Did you tell others that you have joined the Quit and Win Contest? Why or why not? How did they respond? Tell us about the support you were offered.
Social Influence	How did your relationship with other smokers in your life change when you were trying to quit? How did your smoking and non-smoking friends react to your quit attempts? If you relapsed, what were the triggers/
Social Network	Discuss what influenced you the most to quit smoking? Tell us how smoking is perceived in your social network?
Reactions to Quit	What kinds of feedback did you receive from your family and friends when you were trying to quit. What impact did it have in your quit attempts?
Intra-treatment Support	If you were in the counseling group, tell us about the support you received from your counselor. How helpful where the support e-mails from the Quit and Win team with your quit attempts?
Support Sources	What are your thoughts about having a “buddy” assigned to you to help you with the quitting process?

Measures

Baseline demographic and psychosocial characteristics included: gender, age, ethnicity, marital status, employment status and school attended. Tobacco-related variables included number of cigarettes smoked per day, number of 24-hour quit attempts in past year, and other tobacco use. Nicotine dependence was measured using “time to first cigarette” from the Fagerstrom Test for Nicotine Dependence.¹⁹ Participants were classified as nicotine dependent if they smoked cigarettes within 30 minutes of waking. Investigator initiated questions were used to assess motivation to join the Quit and Win Study and influences to quit smoking including : health concerns, wanting to break the habit, people important to me wanting me to quit, cost of cigarettes and smoking restrictions. Binge drinking was examined using questions from the AUDIT ²⁰ ( i.e., # of days drank 5 or more drinks). Support from others was measured using the Important Others Climate Questionnaire.²¹ Social influence was assessed by asking how many of participant’s five closest friends smoked cigarettes. Additional variables collected at time of focus groups included current smoking status (yes or no), the relationship of support person during quit and whether support person was a smoker.

Data Analysis

Survey Data

Baseline demographic and psychosocial descriptive statistics collected at enrollment into the parent trial were computed using SAS version 9.3.²² In addition, current tobacco-specific and social support variables were captured at the time of enrollment to the focus groups.

Focus Group Themes

All sessions were audiotaped and transcribed verbatim. A psychologist with 10 years’ experience using qualitative methodology led the analysis and trained the three coders. The independent coders first deductively sorted verbatim transcripts by hand into themes emerging across the SIX major topic areas developed by the research team and detailed in the moderators guide. Coders then inductively open-coded by hand within each major topic area.²³ A fourth, independent researcher, an epidemiologist with focus group experience cross-checked inductive codes and identified any minor discrepancies in the coding or when different terminology was used to describe the same content.²⁴ Overall, the fourth independent researcher found high intercoder reliability. The research team then met as a group to discuss the themes and to reach a consensus when more than one theme emerged or when terminology differed across coders. Specifically, the fourth investigator presented her interpretation of each coder’s inductive work and the coder clarified as necessary and final themes were discussed.

RESULTS

Participants

The demographics, tobacco-specific characteristics and support variables are presented in Table 2. The average age of participants was 27.4 (±7.2) years, 63% were women and 92.6% identified as White. Over half (55.6%) were married or living with a partner and 22.2% were working full-time. Participants smoked 8.4 (±5.4) cigarettes per day (cpd) on 26.8±6.0 days/month; 40.7% were nicotine dependent; and 2.7(±1.7)of their five closest friends smoked. 52% were quit at the time of the focus group. The average number of quit attempts was 4.1 (±6.5).

Table 2.

Baseline Demographic and Tobacco-Related Variables

Variable	Total (N=27)
Female, n (%)	17 (63.0%)
Age, mean (SD)	27.4 (7.2)
Race, n (%)
White	25 (92.6%)
Native Hawaiian or Other Pacific Islander	1 (3.7%)
More than one race	1 (3.7%)
School attended, n (%)
Midwestern University 1	13 (48%)
Midwestern University 2	14 (52%)
Married or living with partner, n (%)	15 (55.6%)
Employment, n (%)
Full-time	6 (22.2%)
Part-time	13 (48.1%)
Not employed	6 (22.2%)
Other	2 (7.4%)
Currently smoking, n (%)	13 (48%)
Time to first cigarette, ≤30 minutes, n (%)	11 (40.7%)
CPD on days smoked, mean (SD)	8.4 (5.4)
Days smoked, past 30	26.8 (6.0)
Quit attempts/past year, mean (SD)	4.1 (6.5)
Binge drinking, > 0 days, n (%)	18 (66.7%)
Other tobacco use (i.e. smokeless, pipe, cigar, hookah), yes, n (%)	5 (22.7%)
Motivation for joining Quit and Win, strongly agree and agree, n (%)
I’d try to quit even if there was not a contest	10 (37.0%)
Joined for the chance to win a trip	18 (66.7%)
Joined for the chance to win a shopping spree	18 (66.7%)
Joined for chance to complete surveys to receive gift cards	19 (70.4%)
Joined to get free nicotine patches	11 (40.7%)
Joined to get free coaching on how to quit	15 (55.6%)
Joined because a nonsmoking friend encouraged me	8 (29.6%)
Influence to quit and stay quit, n (%)
People important to me wanted me to quit	15 (55.6%)
Concern about health problems	20 (74.1%)
Smoking restrictions at home or school	1 (3.7%)
Wanted to break the habit	18 (66.7%)
Cost of cigarettes	9 (33.3%)
Five closest friends smoke, mean (SD)	2.7 (1.7)
Important Others Climate Questionnaire, mean (SD)	5.1 (1.0)
a Relationship of support person, n (%)
Spouse/Partner/Boyfriend/Girlfriend	16 (59.2%)
Friend	5 (18.5%)
Relative	4 (14.8%)
Roommate/Housemate	2 (7.4%)
a Support person is non-smoker, yes, n (%)	16 (59.3%)

^aVariables assessed at time of focus group enrollment.

Focus Group Themes

The seven major topics with relevant themes are presented in Table 3 and are discussed in detail below.

Table 3.

Focus Group Topics and Themes

Topic	Theme
1) Motivation to Join Quit and Win	Gift cards for completing surveys and submitting urine samples Chance to win a trip to the Caribbean Extra push to quit
2) Reasons to Quit Smoking	Family, kids and significant others Saving money Health reasons
3) Disclosing Decision to Quit	Reluctant to tell others about quit attempt because of disappointing others if fail Told others because of situation Told others for accountability and support
4) Reactions from Others about Quit	Reactions from non-smokers: supportive but did not understand the difficulty of quitting Reactions from smokers: unsupportive and tried to undermine quit attempt Both smokers and non-smokers doubted their ability to quit
5) Intra Treatment Support	Cessation counseling was not helpful because participants were too busy and didn’t feel accountable to counselor Support emails were not read, too many
6) Other Sources of Support	“Buddy Program” is generally a good idea to promote support and accountability Prefer a former smoker as a buddy Potential for interpersonal issues
7) Triggers for Relapse	Stress (work, school, social relationships) Being around smokers Previous behaviors linked with smoking (eating, alcohol, driving, locations like smoking spot)

Motivation to Join Quit and Win

Surprisingly, the opportunity to win the lottery-based prize for winning the contest was not the primary motive for joining the Quit and Win Study. Participants had the prevailing attitude that the likelihood of their winning the $3,000 contest prize was small and unlikely. A few participants questioned whether there really was a prize at all. Most participants cited the opportunity to receive automatic gift cards for their survey completion and as compensation for providing a urine sample as the primary reason they joined and maintained their participation in the Quit and Win contest. These participants reported that receiving the smaller gift cards kept them engaged throughout the 6-month program. One participant said,

“I really did not care about the contest; I mean it was like buying a lottery ticket. It is ok to dream and that is why you do it but the gift cards are like a paycheck, you know like ‘I am doing my quit and win job’ you know…getting that compensation. The gift cards were far more tangible in my hands and my pocket.”

Many participants felt that the Quit and Win study gave them the increased motivation they needed to quit.

“I wouldn’t have quit at that time if there wasn’t a contest. And I’d probably still be smoking.”

Although not the primary reason, there were a number of participants who were drawn into the program because they were attracted to the idea of winning a trip.

“I saw the sign and I said ‘oh that looks like fun’, so the whole Caribbean trip kind of drew me in when I first looked at it.”

Reasons to Quit Smoking

Participants primarily quit for family, children and significant others. Individuals voiced a number of reasons why quitting for loved ones was important to them. These examples ranged from quitting simply because others around them did not like the habit, concern about the influence their smoking had on their children, and concern regarding the possibility of negative health outcomes from smoking on their loved ones.

“I would say what encouraged me to quit the most was my family because they are very clear about the fact that it’s obnoxiously disgusting”.

“My main motivator was my kids, I did not want them to have to see me die of lung cancer like my friend who watched a friend die”.

Participants also reported that they wanted to quit in order to save money on cigarettes.

“For me it was saving money. Over the past few years, cigarettes have doubled in price, it is crazy. I see people that pay like $7.50 and I would never. Now that it is supposed to go higher, it is another motivation for me to quit.”

Quitting for health reasons was the last major theme to arise when asked about reasons to quit.

“For me it was just for health reasons, knowing that it is not healthy to do the habit, knowing that I was getting in to the age where I had no excuse to continue doing it, I was old enough, smart enough to know better and I was at a point where I started to do damage to my body.”

Disclosing Decision to Quit

The majority of participants did not tell many others about their participation in the study or their decision to quit to others. They described concern that they may not be able to quit and thus, made them hesitant to tell others because of the accountability that might have been associated with disclosure of their intention to quit.

“I was selective as to who I told, I have been trying to quit for a while and I hate turning in those broken records, that look of defeat or disappointment in the family.”

“I didn’t want to tell anybody. Not that they would not be supportive…but to talk about it to me is a commitment, a failure when you don’t succeed”.

In some cases, they told others simply because of the situation. For example, when someone offered them a cigarette or when hanging out with their friends they used to smoke around, they found they needed to explain why they weren’t smoking.

“When it did come up, it came up just as a casual situation where people were noticing that I was not smoking so I told them that I was not smoking. I tried not to frame it like I was quitting but I would just say “I am not a smoker anymore.”

Participants expressed differing views on who they felt they wanted to tell about their efforts to quit smoking. The main reasons for telling people of their quit efforts was for accountability and also for support. For one participant, who was successful in her quit attempt, telling others was key in achieving her goal of being tobacco-free.

“I thought the most important thing about the whole thing was, for me that I told a lot of people that I was going to quit smoking, which I have never done before and I think that was helpful. I told people that “this is it” usually I would not commit that I would quit smoking and I would not tell anybody.”

In some cases they told individuals who they felt would be supportive:

“My main support, I think always is my mom, who was a smoker many years ago and who has quit for long time. I am just open with her about my struggle in trying to quit.”

Reactions from Others about Quitting

Participants tended to divide their responses into two groups; reactions from non-smokers and reactions from smokers. By and large, reactions from the non-smokers whom they confided in were positive. However, this was tempered by the fact that participants did not feel that non-smokers really understood the struggle to quit. A common belief was that non-smokers do not and cannot understand the addictive quality of nicotine, and therefore, cannot understand the difficulty of quitting, whereas a current or former smoke can.

“ She doesn’t understand it because she’s never been a smoker. So if you’re not a smoker you don’t really get it at all.”

“ I am one of the few smokers in my circles and so having them to understand the struggle…I mean if I told another smoker that I have smoked two cigarettes in two days that is a big deal, but to a non-smoker it might have been 2 cartons a day.”

Although participants felt that smokers could understand the difficulty of quitting, they did not find current smokers supportive of their quit attempt and felt that they undermined their attempts to quit.

“My best friend, when I was trying to quit everyday she would say ‘are you really quitting? You’re really quitting? You don’t want a cigarette?’ I think there’s a guilt thing about being a smoker that you want other people to join in with you. I’m not the only one being a little naughty.”

Participants felt that often the people they told about their decision to quit smoking did not believe they could do it. This pertained to both smokers and non-smokers. The perceived lack of faith in their ability to quit, sometimes translated into negative outcomes. For example, one participant didn’t even try to quit after her friends doubted her.

“… My friends were like you can’t do it. Not that they ever said that but it was like kind of the impression that they gave off. So then I was like alright, whatever, then I won’t do it.”

Intra-treatment of Social support

Intra-treatment of support conveys support mechanisms built into the study, as opposed to support found outside of the study, such as via their family or friends. As noted previously, half of all participants in the study received smoking cessation counseling over the phone as an additional way to receive support. Of those who attended the focus groups, eight were assigned to the study groups receiving counseling. We asked those who received the counseling to share their thoughts and opinions about their experience with the counseling.

Few believed that the counseling was helpful to them and they did not see their counselor as a source of support. Most participants reported that they were too busy for the counseling sessions and that the sessions became a hassle, another thing to do in their already hectic schedule. A few even commented that it added more stress to their lives. A number of participants expressed a desire for face-to-face counseling or group counseling instead, citing the phone as too impersonal. Interest in group support was particularly strong, although participants admitted that scheduling and attending sessions would be difficult in their busy lives.

“I didn’t get much from the counseling, she was a very pleasant woman that I spoke to for a while and that was fine, I don’t know if it helped at all or something I just did.”

When asked about the weekly support emails, many participants did not remember receiving them or admitted that they did not read them. Most of the participants who did read the emails found them entertaining, but not particularly helpful. A common complaint was that there was just too many of them.

“It’s kind of like work spam emails where a couple people in the office will send like a plethora of emails all the time, you read them but you don’t really internalize them because there’s so many of them.”

Opinions about Potential Support Sources

In an effort to inform future intervention designs, we asked participants to comment on their opinions about a possible alternate design to a Quit and Win trial in which we assigned a “buddy” as a source of support. Although most expressed a desire to choose their own buddy, many described concern that they would not be able to identify an appropriate person from their current network or would not be able to engage someone to join with them and therefore, would not be able to join the contest. Further, a number of participants agreed that creating a potential competition for quitting may damage their relationship and they may be compelled to lie if they fail to remain abstinent.

“I like the idea of being paired up, my concern personally would be it could turn in to a competition, and even if that goal is good, it takes away from the actual focus of the goal, which is being healthy.”

When asked about whether they would prefer that their support person be a non-smoker, current smoker or former smoker, they overwhelmingly expressed the belief that the ideal person would be a former smoker.

“I am about sharing struggle, if you can’t share my experience, I don’t know why you would waste my time on trying to convince me of something you can’t understand. Don’t get me wrong, I would take the support from anyone but if I am going to have someone there as a partner or a pillar to lean on I definitely would take those words from someone who is successful in the other side and who is successfully navigating it than someone who doesn’t know what you are talking about.”

Some participants described having a positive experience when a current smoker friend joined at the same time, citing a feeling of increased accountability.

“So I actually did have a friend who was in the program with me and it was extremely helpful. We both held each other accountable almost every day. It definitely helped.”

Participants overwhelmingly agreed that the choice of a buddy should entirely depend on the smoker’s preferences and the decision of whether to have a buddy should be left to the participant to decide. Further, they expressed the opinion that the program will only work if the participant is ready to quit smoking, regardless of the amount of support received from another.

“You know what I think the bottom line is you have to want to quit, and you do it on your own terms and it does not matter if you have a buddy. You either have to be ready or you are not.”

Triggers for Relapse

Stress often emerged when discussing smoking relapse. Not knowing or being able to find effective alternative solutions to manage stress was a common reason given for relapse. Stress related to school, work, and social relationships tended to be the most talked about; often overlapping one another.

“It’s always been about managing stress. I can go for days or even a week or more without a cigarette and not have a problem but then something happens and that’s the only option I have to relieve my stress.”

The difficulty of resisting the temptation to smoke when around other smokers or in certain social situations was often elicited relapse. Whether it was starting a new relationship with a smoker, being out with smoking friends, or having smoking roommates, these environments made it difficult to stay quit. One participant talked about her struggles to stay quit while living with a smoker.

“It is living with a smoker and that is hard, especially you can’t get them to go outside to smoke. When they smoke and blow it right at you, it just makes you want one, sometimes it makes you want to throw up but sometimes you would want one.”

Participants reported that it was challenging to refrain from smoking when confronted with a smoking trigger.

“I had a real hard time driving on a freeway. I mean driving is one of my smoking times. Because I get anxious, one day I was just…I pulled over and bought a pack of cigarettes.”

Many mentioned that drinking alcohol was also a strong trigger for them. As one participant explained:

“If I ever quit drinking alcohol, then I would definitely be able to stop smoking. It’s like a synergistic effect.”

DISCUSSION

Our findings suggest that the primary reason college smokers joined the Quit and Win Study was for the gift cards they received for taking surveys and providing samples and not for the chance to win the trip, as had been the initial assumption. Another reason college students joined the study was because it gave them the extra motivation they needed to quit. Consistent with prior research, young adults do not always seek smoking cessation support from others. In a study of cessation treatment and aids, less than a quarter of participants received social support.²⁵ Whether this was because participants did not seek it out or because it was not offered is not known. In our sample, participants were reluctant to pursue support from others, mainly for fear of failure. However, when they disclose their quit attempts to others, it is to receive support and accountability. Reactions from others about their quit attempts were mixed; non-smoking friends and family were mostly supportive, however, participants did not feel that they understood the difficulty of quitting. Participants thought current smokers to be unsupportive in that they attempted to sabotage their quit attempts. .

Steps taken to enhance support during the study, such as cessation counseling and supportive emails were not perceived as helpful. Previous research has shown no significant differences found for 30-day cessation between students who received Motivational Interviewing counseling and those who did not.¹² Social environment, including being around other smokers, emerged as a major trigger for relapse. Associating with other smokers may create pressure to smoke and serve as a way to maintain affinity with others in the group.²⁶

Because social support is correlated with positive short-term cessation outcomes^17,18 it will be important in future cessation efforts to increase support. Focusing on building a sense of community among participants in a Quit and Win contest is one way to increase support for student smokers trying to quit. Organizers of Quit and Win contests could achieve this through a variety of ways, including a “kick-off” party on the first day of the quit and a celebration on the final day of the contest, which could include a public drawing of the winner. However, participants in this focus group were resistant toward telling others about their quit attempt. Reasons for their reluctance included fear of failing and disappointing others, as well as the social stigma attached to smoking. A private, anonymous support group through social media, such as Facebook or Twitter could be one potential source of support among participants. In a recent study evaluating interest in using Facebook as a tool in smoking cessation among young adults, about one-third of respondents indicated that they would utilize this resource. Social support and convenience were cited as strengths of a Facebook intervention.²⁷ Creating a blog, where participants could write about their own experiences, challenges and feelings surrounding smoking and quitting, is another potential source of support. In a recent study investigating themes discussed on a blog in an internet smoking cessation program, it was determined that the messages were found capable of supplying social support to members of the blog.²⁸ Participants of this focus group also discussed the idea of a “buddy program”, where a friend would be assigned as a designated support person. There was general favorability of this idea and should be considered as another method to increase social support. The majority of participants favored having a former smoker as their designated support person. A former smoker has overcome the challenges to quitting and has developed effective coping strategies. Further, they understand and can empathize with the emotional and physical challenges of becoming a non-smoker.

One study examining the efficacy of a smoking-cessation website for college students that used peer-email support found that greater peer engagement via email was associated with increased smoking abstinence at 30 days.²⁹

This study has a few potential limitations, including a small sample size. Only 2.2% (n=27) of the Quit and Win Study sample participated in the focus groups and were recruited from 2 universities out of the 19 two-year colleges and four-year universities that participated in the program. It would be unwise to generalize our findings to all college students, as these 27 participants may not be representative of the opinions of the total sample. For example, our participants were slightly older than the average college students and may not represent the “typical” four-year university student. Research has shown that 4-year college smokers were more likely to smoke for social reasons, such as fitting in with other people.³⁰ Also, participants from 2-year colleges were not recruited to be a part of the focus groups. The 2-year college participants may represent a different type of smoker, with different social support networks and different experiences. However, the demographics at one of the schools we chose are very similar to that of other 2-year colleges in that it is mainly a commuter school with an older population. Moreover, because of the lack of racial and ethnic representation in the focus groups, these results may not apply to all racial or ethnic groups. In addition, participants attended the focus group about a year after their participation in the Quit and Win contest and their retrospective recall may be biased. Finally, information depicting the gender and school attended was not gathered when transcribing the focus groups. Therefore, this information is not available.

Despite these limitations, several strengths of this qualitative research deserve mention. The results of this study add to the knowledge of the reasons college students participate in Quit and Win Contests and their motivations to quit. It also adds to the understanding of who college students look toward for support in their quit, the reactions of their family and friends and their opinions on other avenues of support, such as counseling and supportive emails.

This is an initial step toward a deepened understanding of social support among college students in their quit attempts and should be used to inform future smoking interventions. Building social support resources for college students participating in a smoking intervention program is a promising way to increase success.