To smoke or not to smoke? A qualitative study among young adults

Abstract

Smoking is the major preventable cause of disease and premature death in many countries, including France, where approximately 30% of adults are daily smokers. About 60% of them want to quit, however, long-term smoking cessation rates are low, particularly among individuals with low socio-economic position. The aim of this study is to examine whether motivations for smoking cessation among young adults differ across socio-economic groups.

3 focus groups of smokers and former smokers aged 22–40 years were constituted and conducted in November 2014 in Paris. Data from the focus groups were analyzed thematically and in a cross-cutting manner. Our study shows the existence of social “communities” of smokers, in occupational and festive contexts. In addition, new forms of resistance to public health messages are observed (“neutralization”), particularly among smokers with low socioeconomic position. Finally, stress is often cited as a source of unsuccessful smoking cessation or smoking relapse. Tobacco smoking is a social behavior and is associated with symbolic as well as relational benefits, particularly among smokers who have low socioeconomic position. To be effective, interventions aiming to decrease smoking levels in the population should aim to create group dynamics encouraging smokers to quit and address the physical as well as the psychological consequences of smoking withdrawal.

Highlights

• •Young adults who smoke congregate in social “communities”, at work or at parties.
• •Persons with low socioeconomic status “neutralize” the risks related to smoking.
• •Smoking is a social behavior, associated with symbolic and relational benefits.

1. Introduction

Worldwide, tobacco use is a leading cause of preventable death (Organization WH, 2017). While in many industrialized countries, smoking levels have been decreasing, in France changes in this area have been slower. In 2010, approximately 30% of persons aged 12 to 75 were daily smokers, a figure which is stable since 2000 (Beck et al., 2011a). In particular, smoking levels remain especially high in young adults – approximately 39% of 18–25 year olds and 42% of 26–34 year olds being regular smokers (Beck et al., 2011b). In parallel, social inequalities with regard to smoking have increased over time, with relatively higher levels among individuals who have low educational attainment or are not employed, than among those who have more favorable socioeconomic characteristics (Peretti-Watel et al., 2009).

While a majority of smokers quit smoking around age 40, it has been shown that quitting before age 35 years is associated with a life expectancy comparable to that of non-smokers (Doll et al., 2004), making young adulthood a key life period for smoking cessation (Lee and Kahende, 2007). Individuals with low socioeoconomic position have higher levels of nicotine dependence and reduced levels of successful smoking cessation(Lee and Kahende, 2007; Khati et al., 2015; Legleye et al., 2011) (Pisinger et al., 2005). Additionally, levels of smoking cessation are low among smokers with high levels of depressive or anxiety symptoms (Fond et al., 2013). Women are more likely to quit smoking than men, but they also have higher relapse rates (Khati et al., 2015). So although smokers with low socioeconomic position appear as motivated to quit smoking as those from more favorable backgrounds (Pisinger et al., 2011), they encounter greater difficulties in achieving cessation.

One of the mechanisms underlying social inequalities with regard to smoking cessation may be that smokers' motivations to quit differ according to socioeconomic position. For instance, fear of smoking-related health problems and tobacco price are most frequently cited by individuals who have an unfavorable socioeconomic position (Pisinger et al., 2011). Social inequalities in smoking could also be explained by a minimisation of long-term risks on health, at the expense of the present time, among persons with unstable life situations due to low socioeconomic position (Peretti-Watel et al., 2009).

Currently, motivations to quit cited by young adults who smoke, and who would particularly benefit from cessation, are poorly understood (Peretti-Watel et al., 2007). This raises questions about the effectiveness of prevention messages regarding behavior change and their influence on individuals' motivation to be tobacco-free. Epidemiological research among young adults suggests that the birth of a child can be associated with smoking cessation - even if this behavior change is not always sustained - but also that low socioeconomic position, occupational stressors, and cannabis use are associated with a decreased propensity to quit smoking (Khati et al., 2015).

Our aim was to investigate smoking cessation motivations among young adults, using qualitative research methods. We constituted three focus groups of smokers and former smokers of similar education and income levels, under the hypothesis that education and income can be differentially related to perceptions of smoking and motivations to quit.

2. Materials and methods

2.1. Study design

To investigate the ways in which individuals react to prevention messages regarding the dangers of smoking and the way in which their reactions articulated with motivations to quit smoking, three focus groups were conducted with 6 to 10 individuals in each group. This technique, which relies upon semi-structured interviews in a setting which serves to create a group dynamic has been validated in multiple research areas (Akre et al., 2010).

A discussion guide was developed by the research team (LP, EM, ST) to enable the reformulation and clarification of questions during focus groups. Focus groups were organized according to a number of issues present in the guide and organized into different themes. The goal was to address all planned themes while giving participants the possibility to express themselves. Four major themes were examined: 1) biographical questions to assess participants' relation with regard to smoking and smoking cessation; 2) participants' reactions to public anti-smoking campaigns; 3) relationships between tobacco and a) health, b) money, c) pleasure and d) displeasure; 4) reactions of friends and family members to participants' tobacco consumption.

The focus groups were conducted in November 2014 in central Paris and moderated by an experienced sociologist (LP). Each focus group lasted about 2 h, was filmed and recorded, then transcribed into anonymous verbatim records. The study received approval from the bodies supervising ethical research conduct in France (Comité Consultatif Technique pour l'Information et les Recherches en Santé – CCTIRS, Commission Nationale Informatique et Liberté – CNIL) as all study participants signed an informed consent.

2.2. Study participants

Participants were recruited among participants of the TEMPO cohort study (www.tempo.inserm.fr)(Redonnet et al., 2012). Of the 1214 TEMPO participants, aged 22 to 40, 62 who reported being a current or former smoker and living in the Paris region were invited by mail and by email in September–October 2014 to take part in study focus groups. To contrast participants with varying socioeconomic conditions, 3 groups with varying educational and income levels were constituted (low education and low income, high education and low income, high education and high income). Because the number of positive responses from TEMPO cohort participants proved too few to create a sufficiently large sample, we used the snowball method to recruit additional participants with adequate educational and income characteristics for each group. In total, 20 individuals participated in the focus groups, which is deemed satisfactory to obtain sufficient information (Glaser and Strauss, 1967).

2.3. Data analyses

Data were analyzed using qualitative ethnographic methods (LP). Focus groups were analyzed according to conventional inductive methods of interpretive sociology that is generating general laws from particular facts. We examined the meaning given by individuals to their practice and their perceptions of it. The interviews were systematically analyzed to identify key themes spontaneously mentioned by study participants and distinguished across socioeconomic groups (Bertaux, 1980). Thematic analysis allowed participants to pinpoint tobacco-related focal points and then categorize them. This was achieved through a dynamic process going back and forth between the theoretical framework and the content of focus groups. Transcripts were carefully read and compared across different groups to identify similarities and differences in the perceptions of smoking, smoking cessation and smoking-related campaigns reported by study participants.

3. Results and data interpretation

3.1. Sample sociodemographic characteristics

As presented in Table 1, our sample consisted of 20 participants, 10 men and 10 women. Six of them were members of the TEMPO cohort and 14 were recruited via snow-ball recruitment methods. They were divided into 3 groups of varied income and education levels.

Table 1.

Characteristics of focus group participants (n = 20, Paris, November 2014).

Characteristic	Focus group 1 (high education & high income)	Focus group 2 (high education & low income)	Focus group 3 (low education & low income)
Education level	≥ Master's degree	≥ Master's degree	<Bachelor degree
Income (/month)	>4000€	<2000€	<2000€
N participants	6	8	6
Gender
Female	2	4	4
Male	4	4	2
Occupational grade	Managers, professionals	Managers, professionals	Clerks, manual workers
Age (in years, mean)	33.8	28.1	32.5
Marital status
Single	2	6	6
Living with a partner	4	2	0
Employment status
Employed	5	6	3
Unemployed	1	2	2
Student	0	0	1
Type of contract
Permanent	3	3	1
Fixed-term	2	2	3
Unemployed	1	3	1
Student	0	0	1
Smoking status
Regular smoker	4	4	3
Occasional smoker	1	0	2
Ex-smoker	1	4	1

3.2. Ephemeral communities of smokers

The first group identified includes participants with an overall positive image of themselves as smokers and a positive sense of belonging to a community (Gibbons and Gerrard, 1995). Members of this group live well their membership in what they define as the “smoking community”. This ephemeral community emerges because smoking is a collective social practice (Laurier et al., 2000; Poland et al., 2006; Haines et al., 2009). The ban on smoking in public and collective spaces has an unexpected negative result, which is the creation of informal smoking places where individuals meet to share the pleasure of a moment of tobacco consumption. Two settings appear especially important: work and parties.

“At parties, people who smoke are a community, those who do not smoke, it's another one. Smoking is something social.”1

3.2.1. Work-based communities of smokers

In France as in other countries, smoking in banned in work places, which has spawned two unexpected negative effects. First, for smokers, the pleasure of smoking is doubled with the pleasure of taking a break from work (Bevins and Palmatier, 2004):

“It's the small outlet that refreshes ideas and therefore makes us more efficient back at work.”2

Second, this work-based ephemeral community is a profitable time to reach to coworkers and managers in an informal setting that can serve work-related interests, particularly for study participants who belonged to less advantaged socioeconomic groups. Membership in a group of smokers reduces social differences and allows a form of reconciliation that can be transferred to conventional work relationships (Chapman et al., 1999):

“It is also a time of networking, when we have easier and less hierarchical access to colleagues and managers”3

“It's true that when you smoke, you are more easily accepted, it creates relations. During the cigarette break, we get to know one another.”4

3.2.2. The festive community of smokers

Parties represent another special moment where smokers tend to stick together (Shane et al., 2009). In particular, it is a setting where smokers and nonsmokers coexist and where former smokers can relapse to smoking. However, at parties there are also moments when smokers and non-smokers split. Thus smoking offers the benefits of being part of a minority that is isolated, a group within the group, where specific types of sociability - particularly emotional and romantic - can exist.

3.3. New forms of resistance to public health messages

Public health communication messages have long been top-down, that is primarily based on epidemiological data and external observations which the health authorities use to plan, decide and act on populations (Farrelly et al., 2008). These are opposite to health promotion strategies that start from the needs felt by the population.

3.3.1. Public health messages are neutralized rather than rejected

None of the participants interviewed in our study questioned the dangerousness of tobacco. All said that they are fully aware of the health consequences of smoking and claimed they agreed with public health messages that are disseminated. In addition, they were favorable to provisions that limit tobacco consumption, particularly among adolescents. Resistance to public health messages no longer seems to be expressed via a direct opposition to efforts to reduce tobacco smoking, but rather through the neutralizing of the consequences of tobacco use:

“Yes, it is dangerous [to smoke] and we accept it.”5

In the study, the discussion of the impact of public health campaigns did not focus on the veracity of the public health and medical messages which are disseminated, but rather on the ways of communicating them. Study participants found that “shock” campaigns are inadequate because they are too distant from individuals' daily experience (Farrelly et al., 2012). Study participants reported their preference for positive campaigns (Notthoff and Carstensen, 2012; Gilbert, 2005), such as those which highlight reasons to quit smoking (“for money,” “for health,” “for others,” “for taste”). Moreover, the impact of positive campaigns may increase with age (Cataldo et al., 2015). Participants found positive communications friendlier, without necessarily considering that they are effective. Messages more or less directly attacking tobacco companies did not resonate with these smokers.

3.3.2. Anti-smoking campaigns in a context of legal tobacco use

Study participants acclaimed campaigns targeting smoking cessation in particular circumstances, such as before the birth of a child. This is contradictory with evidence which showed that mass media campaigns on this topic have not proven effective (Center for Diseases Control and Prevention, 2005). The more targeted and operational the message, the more it was valued by study participants. In France, pro-tobacco advertisements have been banned since 1991, implying that study participants had no or very little direct experience of pro-tobacco advertising. This may explain why the success of prevention campaigns based on the critique of tobacco companies' advertisement has been limited. Additionally, study participants highlighted the inconsistencies of strategies used to fight tobacco:

“The state allows multinationals to sell tobacco and then they say ‘beware of them.’ It's silly. How can you trust people who act in this way?6”

3.3.3. “Immunity” for oneself, not for teenagers

Participants of our study saw themselves as immune to top-down pro or anti-smoking messages (WHO, 2001). However, they reported that these top-down public health prevention messages could be effective among teenagers around the time of initiation of smoking. According to study participants, teenagers are under-informed, influenced by others and likely to start smoking to follow a fashion or peer pressure (Simons-Morton and Farhat, 2010). It is at this stage that participants view public action as necessary.

“At my age, I can't be fooled. But I think of teenagers who are tempted by smoking, or who are starting to smoke, I reckon that they might be sensitive.”7

3.4. Events likely to generate behavior change among study participants

3.4.1. Negative effects of tobacco

Long-term health threats put forward by public health actors do not always seem to have effect on smokers, but the negative effects of smoking or the health gains related to smoking cessation can motivate individuals to quit (West et al., 2001; Underner et al., 2016).The aggravating effects of tobacco use on colds or sore throats were frequently mentioned by study participants, and they were perceived as reminding of potential gains in case of smoking cessation. Additionally, sensory disturbances such as the loss of taste and the sense of smell were also cited. Finally, shortness of breath, which can be a sign that lung cells are being destroyed and a symptom of emphysema, was also identified as a cue for smoking cessation.

“A cigarette is dry, and when you drink it humidifies your mouth, it awakens all the senses. Displeasure, it's the morning breath, coffee cigarette, you have to brush your teeth. But I don't feel enough causes of displeasure”8

3.4.2. Situations promoting smoking cessation

Life changes related to child birth, particularly the period of pregnancy, encourage women and sometimes men, to quit smoking (Khati et al., 2015). Among men, the desire to improve athletic ability is an even stronger argument (Toll et al., 2014). While participants consider that official messages regarding smoking are ineffective, the influence of relatives, and especially family members, is considered crucial. Although our study participants are between 20 and 40 years old, the influence of family seems paramount, especially the partner or the mother.

“My mother, I could never admit to her that I smoke9

• -Same for me. I could never tell my mother that I smoke10
• -I am 35 years old and I hide from my mother, I don't smoke in front of her11”

3.4.3. Situations threatening smoking cessation

When a person decides to quit smoking, she/he may feel particularly vulnerable in certain situations. As previously mentioned, this may be the case during parties, because of the proximity with smokers. Smoking relapse may also be the consequence of a romantic or work-related failure, a way to deal with a stressful situation, particularly among persons whoc have low socioeconomic position (Buczkowski et al., 2014)].

“Every time it was because of health and I relapsed, the first time, I don't know, I went to a party, I started smoking again and then I went back to smoking. The second time I relapsed because I lost my job and immediately it got to me, I went back to smoking the same day. Then, I quit for a year and a half. And then I went back to smoking, and here I am.”12

3.4.4. Tobacco price

Price increases, are viewed as inefficient by study participants, which contrasts with the findings of quantitative studies which indicate the efficacy of this type of policy (Tauras, 2004). This may be increases in tobacco price in France have been gradual; young adults see their purchasing power increase over time, therefore the impact of tobacco expenses on their budget may be limited. Nevertheless, study participants indicated changes in their smoking behavior over time, in particular frequent transitions to roll-your-own tobacco, which is cheaper than manufactured cigarettes (Levy et al., 2005). They compared the price of tobacco with other daily living expenses, such as those associated with the purchase and use of a smartphone. They also distanced themselves from risks associated with smoking, particularly participants belonging to low socioeconomic groups.

“Yes, tobacco is dangerous, but we also live with the threat of war and pollution, we spend our life with risks. So a little more a little less ...”13

4. Conclusion

Despite legal prohibitions, price increases and prevention campaigns, which have been found to effectively contribute to decreases in smoking levels (Chapman et al., 1999; Farrelly et al., 2008; Farrelly et al., 2012; WHO, 2001; Buczkowski et al., 2014), “temporary communities of smokers” remain strong, especially in work and festive settings. The conditions that make these communities possible therefore need to be addressed, to render smoking a lonely act, and deprive smokers of the symbolic and relational benefits associated with smoking. For example, at work, opportunities to take a break, socialize with colleagues and share informal moments with managers that are not related to smoking should be encouraged. Alternative non-smoking relaxation spaces, indoor and outdoor, could be devised and implemented. Similarly, another target could be places such as restaurants and bars, which have become non-smoking, and force smokers to leave their premises to smoke on heated terraces or outside. These selective gathering practices of smokers further encourage smokers to stick together and form a “community”.

Our study shows a significant lack of interest in national top-down prevention campaigns. This suggests that campaigns should be better researched, better linked to smokers' experiences, and more resonant with low-SES culture. Strategies allowing smokers to be responsible for the impact of their smoking habit on non-smokers, particularly relatives, and raising awareness about the vulnerability of persons trying to quit smoking should be encouraged. This could contribute to decreasing differences in the perception of prevention messages across various socioeconomic groups. These prevention strategies also help move the issue of risk and danger from oneself to others, thereby allowing the transformation of private places, which escape anti-smoking laws, into places where smokers and those who try to quit voluntarily reduce their space and time of connection. Creating collective movements encouraging smokers to quit via interventions such as the British Stoptober campaign (https://www.nhs.uk/oneyou/stoptober/homecould) which has been implemented in France since 2016 (https://mois-sans-tabac.tabac-info-service.fr/)could turn out more effective than encouraging smokers to stop smoking individually. For smokers who belong to socioeconomically disadvantaged groups such campaigns, combined with appropriate aid to address nicotine withdrawal as well as stress and psychological difficulties which are more frequent than in more socioeconomically favorable groups, may prove especially propitious and contribute to decreasing socioeconomic inequalities with regard to smoking.