“Isn’t there a bunch of side effects?”: a focus group study on the beliefs about cessation treatments of non-college educated young adult smokers

Abstract

Smoking remains more prevalent among non-college educated and racial/ethnic minority young adults in the U.S. These smokers are less likely than their college educated/non-Hispanic white counterparts to use cessation treatments approved by the U.S. Food and Drug Administration (FDA). Alternative cessation methods (e.g., e-cigarettes) have also grown in popularity among smokers. Therefore, we conducted a focus group study to explore perceptions and beliefs about various cessation treatments among, racially/ethnically diverse, non-college educated young adult smokers. Seventy-five 18–29-year-old current smokers without a 4-year college education were recruited from the U.S. Washington, D.C. metropolitan area and attended one of twelve focus groups to discuss their awareness, beliefs, experiences, and intention for future use of cessation treatments. Focus groups were stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic) and educational attainment (≤ high school vs. some college without obtaining a bachelor’s degree). We used a thematic approach to analyze the discussions. We found that few participants were aware of cessation counseling or cessation related programs. Many participants reported previously using nicotine replacement therapies and e-cigarettes to quit smoking. Participants had little intention to use prescription medications due to perceived side effects. Participants’ awareness, beliefs, and intentions of using other cessation treatments varied by race/ethnicity and educational attainment. In conclusion, our findings, if confirmed by subsequent quantitative studies, suggest that targeted media campaigns may be needed to explain the contents and benefits of behavioral cessation programs to non-college educated young adult smokers. Targeted media messages aim to overcome negative perceptions related to nicotine replacement therapy and prescription medications among non-college educated young adult smokers, especially those from racial/ethnic minority populations, may promote successful smoking cessation in this population.

1. INTRODUCTION

Smoking cessation rates among U.S. adult smokers have remained low over the years. In 2017, 55.4% of U.S. adult smokers attempted to quit smoking, while only 7.4% succeeded (Babb, Malarcher, Schauer, Asman, & Jamal, 2017). Although evidence-based cessation treatments are available, in 2015, only 31.2% of U.S. adult smokers used cessation counseling and/or medication when trying to quit (Babb et al., 2017). Willingness to quit smoking varies by race/ethnicity. For example, non-Hispanic black smokers were more likely than non-Hispanic white and Hispanic smokers to report wanting to quit smoking (72.8%, 67.5%, and 67.4% respectively) (Babb et al., 2017). Additionally, non-Hispanic black smokers were more likely than non-Hispanic white and Hispanic smokers to make a quit attempt in the past year (63.4%, 53.3%, and 56.2%, respectively) (Babb et al., 2017). However, only 4.9% of non-Hispanic black smokers succeeded in quitting smoking over a 12-month period, while 7.1% of non-Hispanic white and 8.2% of Hispanic smokers succeeded in quitting smoking over the same period of time (Babb et al., 2017). Educational attainment is inversely associated with cigarette smoking, i.e., those with less education are more likely than those with more education to be smokers (Jamal et al., 2017). This is because compared to those with more education, individuals with less education were more likely to start smoking, less likely to make quit attempts, and less likely to succeed in quitting smoking (Maralani, 2013; Zhuang, Gamst, Cummins, Wolfson, & Zhu, 2015).

Smoking cessation during young adulthood is associated with improved health outcomes later in life. For example, individuals who quit smoking before 30 years old have a similar mortality rate than those who have never smoked cigarettes (Doll, Peto, Boreham, & Sutherland, 2004; Taylor, Hasselblad, Henley, Thun, & Sloan, 2002). Despite this finding young adult smokers are less likely than older smokers to be interested in quitting smoking (62.3% of 18–24 year-old smokers vs. 72.4% of 25–44 year-old smokers) (Babb et al., 2017). Likewise, young adults were less likely to report using evidence-based cessation treatments (e.g., counseling or medications) which increased the likelihood of successful cessation (Babb et al., 2017). Given a recent meta-analysis showed that these evidence-based cessation treatments are efficacious in promoting smoking cessation among young adult smokers (Suls et al., 2012), promoting the use of evidence-based smoking cessation treatments, especially among non-college educated young adult smokers from racial/ethnic minority populations, should be an important public health goal.

Health behavioral theories posit that perceptions and beliefs about a health behavior predict intention to engage and subsequently engaging with the health behavior (Ferrer & Klein, 2015). Specific to smoking cessation, previous studies found that smokers displayed negative perceptions about pharmacological-assisted cessation and expressed concerns about side effects and low efficacy (Ferguson et al., 2011; Morphett, Partridge, Gartner, Carter, & Hall, 2015; Smith, Carter, Chapman, Dunlop, & Freeman, 2015), and these negative perceptions in turn, were associated with low intention to use and poor adherence to pharmacotherapies (Fucito, Toll, Salovey, & O’malley, 2009; Shiffman, Ferguson, Rohay, & Gitchell, 2008).

Most previous studies did not focus on young adults. For example, an extensive study that explored perceived barriers of utilizing telephone smoking cessation counseling program adopted a predominately middle-aged, white sample (mean age=49 years, 67% self-identified as white) (Solomon et al., 2009). Notably, this study found that compared to older participants (ages ≥30 years), young adult participants (18–29 years old) perceived higher levels of stigma if they use telephone smoking cessation counseling. Available research, although limited also suggests that perceptions related to cessation treatments varied by race/ethnicity. Solomon and colleagues (2009) found that compared to black participants, white participants were more concerned about privacy if they use telephone smoking cessation counseling and less confident about the efficacy of the service in assisting smoking cessation. Another study found that Latino participants (compared to non-Latino participants) reported being less likely to use telephone smoking cessation counseling because “they see no need for assistance with smoking cessation” (Burns, Deaton, & Levinson, 2011). Together, these studies suggested that perceptions about smoking cessation counseling differed by age and race/ethnicity. Additionally, when studies were conducted with young adult smokers, they often included college students (e.g., Kishchuk, Tremblay, Lapierre, Heneman, and O’Loughlin (2004)), but not those without a college education. Furthermore, little is known about young adult smokers’ perceptions and beliefs of various smoking cessation methods approved by the U.S. Food and Drug Administration (FDA), especially among non-college educated, racial/ethnic minority young adult smokers.

To inform future quantitative studies about young adult smokers’ perceptions and beliefs of various smoking cessation methods, we conducted a focus group study among racially/ethnically diverse young adult smokers without a 4-year college education (hereafter as “non-college-educated young adult smokers”) to explore their awareness, beliefs, past usage, and future intentions of using various smoking cessation treatments. The specific smoking cessation treatments examined in this study included FDA-approved (nicotine replacement therapy, prescription medications, and behavioral programs/counseling) as well as alternative cessation methods volunteered by the participants. We further examined whether these perceptions and beliefs differed by race/ethnicity and educational attainment.

2. MATERIALS AND METHODS

2.1. Participant Eligibility and Recruitment

We recruited young adult smokers in the U.S. Washington, D.C. metropolitan area. The inclusion criteria were: (1) between 18 and 29 years old, (2) resided in the Washington, D.C. metropolitan area (including Washington, D.C., Maryland, and Virginia), (3) self-identified as non-Hispanic white, non-Hispanic black, or Hispanic, (4) attained less than a 4-year-college education (i.e., did not obtain a bachelor’s degree and were not currently enrolled in a bachelor’s degree program), (5) earned less than the median household income of the Washington, D.C. metropolitan area (US$90,000), and (6) reported smoking ≥100 cigarettes in their lifetime and currently smoking every day or some days. Shugoll Research, a consumer research firm, recruited the participants through an existing volunteer database, Craigslist, and Facebook listings. A project coordinator screened these individuals for eligibility and obtained informed consent from the eligible participants. The study was determined by the National Institutes of Health Office of Human Subjects Research Protection to be exempted from a review by the Institutional Review Board.

2.2. Data Collection

Participants were invited to complete an anonymous online survey which collected information on demographics, tobacco use behaviors, past cessation treatment use, and tobacco-related attitudes and beliefs. Participants reported their age, gender, race/ethnicity, educational attainment, and annual household income. They also reported if they used the following products every day, some days, or not at all at the time of survey: cigarettes, e-cigarettes, cigars (including cigarillos and filtered cigars), hookah, roll-your-own cigarettes, and smokeless tobacco. Regarding past smoking cessation behaviors, participants were asked if they had stopped smoking for one day or longer in the past 12 months because they were trying to quit smoking. Those who answered “yes” were then asked about the smoking cessation methods they used in the past 12 months (e.g., nicotine replacement therapy, prescription medications, behavioral counseling programs, cold turkey).

Participants who completed the survey were then scheduled to participate in focus group discussions. Our focus group discussions were designed to explore the breadth of perceptions and beliefs related to smoking cessation methods through generating the consensuses or disagreements from participants of diverse backgrounds. We aimed to explore the breadth of perceptions and beliefs related to smoking cessation methods, through understanding the consensuses or disagreements regarding these perceptions and beliefs. Therefore, we used focus group discussions instead of individual interviews as focus groups can better serve these purposes (Stokes and Bergin 2006). Focus groups were stratified by educational attainment (≤high school vs. some college without obtaining a bachelor’s degree) and race/ethnicity (Hispanic vs. non-Hispanic black vs. non-Hispanic white), resulting in a total of 12 focus groups (six strata with two groups in each stratum). Focus group discussions were held at the Shugoll Research’s focus group facility located in Bethesda, Maryland. Focus group discussions were held between January 25 and March 20, 2018. The research team developed a discussion guide to explore perceptions, beliefs, and experiences with different smoking cessation methods. Focus groups were audio-recorded and led by a Professional Moderator provided by Shogull Research who was experienced in conducting focus group discussions with racially and ethnically diverse participants. Each focus group lasted approximately 90 minutes. Participants were provided with a gift card (US$125) as an incentive for completing the online survey and participating in a focus group discussion. Participants were also compensated for parking (US$8).

The moderator began by asking participants if they were aware of different cessation treatments. The treatments included the following: behavioral counseling programs (e.g., phone coaching, one-on-one counseling, and group counseling with a health professional), prescription medication (e.g., Wellbutrin, Zyban, Bupropion, Chantix, or Varenicline), and over-the-counter nicotine replacement therapy (e.g., nicotine patches, gum, lozenges, nasal spray or a nicotine inhaler). The follow-up questions included the following: where they learned about each treatment, perceived benefits/disadvantages of each treatment, whether they had used each treatment, and whether they intended to use each treatment in the future. Participants were also asked to suggest other smoking cessation methods and discussed their perceived benefits and disadvantages as well as their intentions to use these methods in the future.

2.3. Data Analysis

Audio recordings of the focus group discussions were transcribed verbatim and analyzed using a thematic approach (Boyatzis, 1998). Two members of the team (JCC and KC) examined all transcripts to draft a coding scheme. Two members (BJ and KC) reviewed all transcripts and edited the draft coding scheme. Three coders (DAD, KD, LO) then underwent transcript coding training through watching video tutorials and participating in a didactic workshop about coding qualitative transcripts. The coders then test-coded two transcripts to gain familiarity with the coding scheme and to establish coding consistency. The entire team then thoroughly discussed the coding of the two test transcripts and resolved any discrepancies. Subsequently, the coding scheme was applied to all transcripts using an online qualitative data analysis platform, Dedoose®. Each transcript was coded by two coders independently. The research team reviewed and resolved differences in coding to gain a final consensus on the coding. After, the team analyzed the transcripts by closely examining the coded text and identifying emergent themes, subthemes, and patterns. After major themes and subthemes were identified, representative quotes were selected from the transcripts. All authors reviewed the themes and subthemes and verified the results of the analysis.

3. RESULTS

3.1. Participant Characteristics

Data from the online survey showed that, of 75 young adult smokers who participated in the study, 63% were male, and 48% had a high school education or less (43% with some college education without a degree, 2% with an occupational/vocational associate’s degree, and 7% with an academic associate’s degree). All participants had less than the median household income (US$90,000) of the Washington, D.C. metropolitan area: 29% reported very low income (US$10,000-$24,999), 47% reported low income (US$25,000-$49,999), and 24% reported lower than median income (US$50,000 and $89,999). Among the participants, 63% reported smoking every day, 36% reported smoking some days, and 1% reported not currently smoking despite reported current smoking during eligibility screening. We did not collect information on the duration of smoking. Regarding current non-cigarette tobacco product use, 48% reported using e-cigarettes, 47% reported using cigars, 37% reported using hookah, 23% reported using roll-your-own cigarettes, and 3% reported using smokeless tobacco. Regarding smoking cessation behaviors, 65% of participants reported trying to stop smoking for one day or longer because they were trying to quit in the past 12 months, 12% used nicotine replacement therapy, 6% used prescription medications, and 10% used behavioral counseling programs during their quit attempts. Participants also reported using other methods to quit smoking such as cold turkey (78%) and e-cigarettes (41%).

3.2. Perceptions of FDA-approved Cessation Treatments

3.2.1. Nicotine Replacement Therapy (NRT)

All participants were aware of NRT as a smoking cessation method; however, most participants had negative perceptions towards these therapies. Some participants mentioned that nicotine gum tastes “disgusting” and “awful.” NRT was viewed as expensive, having similar or higher prices than cigarettes. Some participants described these high prices deterred them from initiating and continuing to use NRT for cessation. Many participants also mentioned that they perceived NRT as ineffective for successful cessation, because it did not reduce “cravings” for cigarettes. Some participants reported they, their friends, or their family had to simultaneously use NRT and cigarettes to satisfy their cravings for nicotine. Some participants said they would use NRT as a cessation treatment in the future, while others said they would not use NRT.

Participants with some college education were more likely than those with high school education or less to report using NRT and discussed the benefits of the treatment. The main perceived benefit of NRT mentioned by participants with some college education was its “convenience” because they could “wear [the patches] on the go.” Participants with some college education perceived NRT as not as “intrusive” as smoking because they could use them in public places where smoking is prohibited (e.g., restaurants). Another benefit was stimulation from nicotine (especially from nicotine gums), which helped them feel more “alert and awake” and gave them a “light buzz.”

3.2.2. Prescription Medication

When the moderators read aloud the list of prescription medications for smoking cessation, many participants recognized Chantix and a small number recognized Wellbutrin. A few participants used Chantix before (e.g., “I took Chantix, I want to say five, six years ago…”), and a couple of them have used Wellbutrin. Additionally, several participants have heard about experiences with Chantix from their family and/or friends (e.g., “My aunt tried it”, “His brother used Chantix”) or through television commercials. Participants who used Chantix and Wellbutrin reported first-hand experiences of their side effects. For example, one participant said, “The dreams [after using Chantix] were insane… I stopped taking them because of the dreams.” Another participant reported a drug interaction with Wellbutrin (“Taking the Wellbutrin combined with the other [medication], it was a bad effect. So I just didn’t take that [Wellbutrin]”). Participants who have used Chantix and Wellbutrin also reported that these medications were not effective for them (e.g., “the Wellbutrin, I don’t think it did anything for me. And plus it just - it tripped me out because it was, you know, all the side effects.”) Among those who have not used these medications, they reported anecdotes from their family and/or friends about various side effects such as personality changes (e.g., “he didn’t seem like his usual self for a pretty long time after [using Chantix]”), as well as having “nightmares, depression,” and suicidal thoughts (“Somebody tried it and it made them want to kill themselves.”) Additionally, many participants expressed reservation about taking medications for smoking cessation in general (e.g., “I wouldn’t want to take – put other toxins or drugs in my body to [quit smoking] – especially that have side effects… it scares you.”). In terms of differences by educational attainment, participants with some college education tended to hear about prescription medications from anecdotes from a third party, i.e. friends and family. Many participants with some college education have heard successful stories that prescription medications helped smoking cessation (i.e. “I knew a couple people that were like in their 30s and 40s whom didn’t have crazy dreams and took Chantix and just immediately wanted to stop smoking.”, “My sister actually has taken Wellbutrin before and stopped [smoking].”). Participants with high school education or less primarily heard of prescription medication from television commercials, and most of them did not report hearing success stories with these medications from their social network. Despite that few participants expressed an intention to use prescription medications for smoking cessation in general, a few participants with some college education expressed interest in using Chantix only for a short period of time (e.g., “I’d consider the Chantix only if I was confident that would work quickly”) or then these medications were paired with other treatments (e.g., “addiction is like an imbalance in your mind, in your body… [medications to treat addition] would need to be paired with something else, almost like an antidepressant.”) In contrast, participants with high school education or less did not report intention to use prescription medications for smoking cessation, in part due to the financial cost of those medications (“I’ve never tried it because I can’t afford it.”).

3.2.3. Behavioral Counseling Programs

When asked about awareness of any behavioral counseling programs available for smoking cessation, two participants named the “1–800 Quitline” (which is actually 1–800-QUIT-NOW) and reported seeing commercials about the service on television. One participant reported using the service, “I called before, and they sent free patches, and gum and stuff like that.” A few participants heard of group cessation counseling programs (e.g., “Cigarette Anonymous [referring to Smokers Anonymous]”, “In my building, they had something every week. Somebody come[s] in and it’s a cessation program.”), but have not tried them. However, many participants expressed little understanding about the contents and processes of behavioral counseling programs. For example, one participant stated, “I just don’t know what I would expect from [phone counseling].” Another participant thought that cessation counselors would just repeat what was already known: “well, I know what’s wrong with the situation. Why are you going to tell me what I already know a thousand times?”

The moderator explained to the participants that in behavioral cessation programs, trained counselors would help them figure out how to work through emotional triggers for smoking e.g., anxiety and stress. Many participants then expressed interests in these programs and perceived them to be potentially helpful for smoking cessation. For example, one participant welcomed emotional support that could be provided by these programs, “Because most of my reasons for smoking is I need someone to talk to, and I don’t have someone to talk to.” Another participant believed one-on-one counseling would be more personal by stating, it “can…tailor it to why you smoke, and what can help you stop versus just – you have the biological part, but everything else is in your head… Maybe somebody could help you figure it out.” One participant stated, “[behavioral programs] would be my first route [to] get counseling on how to deal with the cravings” before using NRT or prescription medications. However, several participants perceived that behavioral cessation programs would not work for them. The following reasons were given: having certain personality types (e.g., “I’m extremely hard headed”), not knowing people who used these programs (e.g., “you don’t really run into so many people that say they’re trying [these programs]”), perceiving these programs to be time consuming (e.g., “I don’t have time to go out and just sit for an hour and talk to somebody or sit in a group.”) and were only for those addicted to cigarettes (e.g., “I wouldn’t go because I don’t think I’m addicted to cigarettes.”).

A few participants used cessation smartphone applications (e.g., “Yes. [I’ve used these apps] couple times.”) or heard of them from family members (e.g., “my cousin used an app [to quit smoking]”). One participant who used these applications said that some applications showed the immediate health benefits of smoking cessation (e.g., improved heart rate and blood pressure), which were “huge motivator[s] to quit smoking.” However, another participant believed that these applications “would make it worse,” because “I’m more of an out of sight out of mind kind of person (i.e., do not crave for cigarettes when they aren’t exposed to possible triggers)” and these applications would remind them of smoking.

Regarding differences by educational attainment, while telephone counseling and group counseling were mentioned by participants of different educational attainment; smartphone applications were only mentioned by those with some college education. More participants with some college education expressed willingness to use the behavioral counseling programs than those with high school education or less.

3.3. Perceptions of alternative cessation methods

3.3.1. Cold Turkey

Cold turkey, commonly defined as to abruptly stop smoking altogether, was frequently used by many participants (e.g., “Every time I’ve quit – I’ve quit probably four or five times – it’s been cold turkey.”). Many participants believed that quitting smoking was a matter of mental determination. For example, one participant stated, “You have to put it in your mind and then you set that a goal… you got to be willing to stop on your own.” Another participant also claimed, “It’s mind – it’s a mental decision [to quit smoking]” and NRT and prescription medications were “just another ploy to keep you in [the addiction]”, which was echoed by other participants that NRT and prescription medications were a “crutch” or “latch on” during the cessation process. A couple of participants reported their attempts to quit smoking were successful for a short period of time while only using the cold turkey method, (e.g., “I stopped, like cold turkey stop, for two to three months...”. Several recalled their family and/or friends using the cold turkey method to quit smoking (e.g., “only people I know [that] successfully quit smoking cigarettes is cold turkey”, “[my best friend] eventually [quit smoking] cold turkey.”) Several participants acknowledged that quitting cold turkey was difficult (e.g., “You gotta tell yourself no, but like it’s hard to tell yourself no sometimes”, “You’re probably not going to stop cold turkey because it’s hard for a smoker to stop cold turkey”). However, instead of cold turkey, these participants would gradually cut back or wean themselves off cigarettes (e.g., “So I’m slowing down. I went from smoking a pack in a week. Now it’ll take me two weeks to smoke a whole pack.”). While all participants who tried to quit cold turkey relapsed back to smoking, they still believed that they would be able to quit smoking cold turkey in the future (e.g., “I would just say, you’ve got to go cold turkey. If you would say to yourself that you don’t want to smoke. Have a legitimate reason that you want to stop smoking for, and stick to it.”) They were more willing to use this method than cessation aids for future quit attempts (e.g., “You know why everybody don’t want to go and [use different cessation treatments]? You just got to quit. As you know, you got to stick to it and quit.”)

3.3.2. Electronic cigarettes (E-cigarettes)

E-cigarettes was the most commonly mentioned alternative cessation method. It was used primarily by non-Hispanic white participants and those with some college education to quit smoking. Most of the participants who never used e-cigarettes heard of e-cigarettes from friends and family. Perceived benefits of using e-cigarettes to quit smoking included mimicking the action of smoking (e.g., “it filled the same hole”) and consuming nicotine to assuage cravings (e.g., “it gives the nicotine sensation.”). Several participants described how e-cigarettes were convenient to use due to it they being non-combustible (e.g., “I’m still getting that same nicotine but without having to go outside in 20-degree weather.”). They could use the product in locations like bathrooms, cars, or general work areas without worrying about “[setting] off fireworks” (referring to a smoke alarm) or bothering other people with the smell compared to cigarettes. Several participants also described that some brands of e-cigarettes were “tiny” enough “to fit in [their] pocket” so they were able to take it anywhere. Some participants thought that e-cigarettes had a “good flavor” compared to cigarettes. However, participants who used e-cigarettes reported that using the product did not result in long-term cessation (e.g., “it doesn’t take away the [nicotine] cravings or the actual craving of the cigarette. You’re just like, ‘I want a cigarette after this.’”, “I’ve jumped back from vaporizing [to smoking].” Several participants reported that using e-cigarettes for smoking cessation led to dual use (i.e. “I’m smoking both now”) or increased nicotine addiction (e.g., “I tried vaping, but then, it made me smoke [cigarettes] more”.)

3.3.3. Other Cessation Methods

Hypnosis was also discussed as an alternative cessation treatment. Some participants believed that hypnosis was “appealing” for smoking cessation. They reported secondhand success stories with hypnosis (“My aunt had hypnosis, and it worked really well for her”). Many participants with some college education expressed intention to use hypnosis. However, some disapproved hypnosis, stating they didn’t “want people in [their] personal business.” Non-Hispanic white participants also suggested several other smoking cessation methods. Substitutions with marijuana were mentioned by several participants, stating that they preferred marijuana over cigarettes and using marijuana to reduce cigarette consumption (i.e. “I smoke a lot of weed [to quit smoking cigarettes].”, “I don’t know if it’s just the act of smoking or what, but when I’m smoking a ton of weed, I don’t really care about cigarettes…”). Hispanic participants tended to mention that they substituted cigarettes with marijuana for cessation. One participant also reported blunt use (“I do with the cigarillos the blunt that has a little tobacco leaf on it.”). Several participants with some college education also reported using other oral fixations (e.g., food) or physical activity as a replacement for cigarette smoking.

4. DISCUSSION

Young adult smokers are a priority population for smoking cessation given the tremendous individual and public health benefits (Doll et al., 2004; Taylor et al., 2002). However, little is documented in the literature about young adult smokers’ perceptions and beliefs related to various smoking cessation methods, and how these perceptions and beliefs vary by race/ethnicity and educational attainment. Through conducting a focus group study with non-college-educated Hispanic, non-Hispanic white, and non-Hispanic black young adult smokers, we found that our participants held more negative than positive perceptions and beliefs about NRT and prescription medications for smoking cessation.

Similar to the findings on former smokers in Australia by Smith, Carter et al. (2015), young adult smokers in our sample also based their perceptions and beliefs about smoking cessation treatments on firsthand or secondhand experiences. These perceptions and beliefs ranged from distasteful, expensive, ineffective, to the side effects being too severe. Similar to the previous research findings on Australian adult current and former smokers (Morphett, Partridge et al. 2015; Smith, Carter et al. 2015), young adult smokers in our sample also believed quitting smoking was a personal responsibility, cold turkey was the preferred way to quit smoking, and using NRT and prescription medications for smoking cessation was a sign of mental weakness and lack of commitment to smoking cessation. Our results supported findings from a previous study showing an association of perceived deficits in using pharmacotherapy, including efficacy and “harmfulness,” with a low prevalence of ever pharmacotherapy use (Ryan, Garrett-Mayer, Alberg, Cartmell, & Carpenter, 2011). Our results may also explain the low prevalence of using FDA-approved smoking cessation treatments among young adult smokers, especially among those with lower educational attainment (Curry, Sporer, Pugach, Campbell, & Emery, 2007).

Many non-college-educated young adult smokers in our sample were unaware of behavioral counseling programs for smoking cessation. Even among those who were aware of these programs, few articulated how these programs could help them quit smoking. Smoking cessation media campaigns often include information to access behavioral counseling programs. For example, the campaign Tips From Former Smokers® by the US Centers for Disease Control and Prevention (CDC) features the 1–800-QUIT-NOW phone number in their advertisements (Rigotti & Wakefield, 2012). However, these campaign messages did not explicitly state what smokers should expect when calling the phone number. Therefore, it is possible that despite the reach of the Tips From Former Smokers® campaign (72% of U.S. smokers recall seeing Tips From Former Smokers® advertisements) (Huang et al., 2015), our study participants remained unclear about how calling the phone number could help them quit smoking. It is important to note that some participants expressed interest in using behavioral counseling programs after they had a better understanding of these programs during the discussions.

We also observed racial/ethnic differences in perceptions and beliefs related to the FDA-approved cessation treatments. Specifically, discussions related to prior use of FDA-approved cessation treatments were more prevalent in non-Hispanic white young adult smokers compared to non-Hispanic black and Hispanic young adult smokers in our study. A previous study has shown that blacks were less likely to report ever use of pharmacotherapy and had significantly negative attitudes toward pharmacotherapy, including doubts of efficacy and harmfulness (Ryan et al., 2011). Additionally, discussions related to prior use of FDA-approved cessation treatments varied by educational attainment even among non-college educated young adult smokers. For example, participants with some college education tended to have more knowledge about FDA-approved cessation treatments than those with high school education or less. This could be due to higher prevalence of pharmacotherapy use among more educated than less educated young adult smokers in general (Curry et al., 2007).

Our studies also found many alternative smoking cessation methods reported or used by non-college-educated young adult smokers. E-cigarettes were a common method for smoking cessation used by our participants. However, participants who used e-cigarettes did not successfully quit smoking, and many ended up using both products. This may be, in part, due to the low prevalence of daily e-cigarette use in our sample (8%), a behavior that has been associated with smoking cessation (Coleman et al., 2018).

Other methods, such as substitution with an oral fixation, were also frequently discussed by the participants. In particular, marijuana was reportedly used as a substitute to reduce cigarette consumption. However, participants did not report completely replacing cigarettes with marijuana. Previous studies have suggested that individuals who dual-use marijuana and tobacco were less likely than those who only use tobacco to abstain from tobacco use (Peters, Budney, & Carroll, 2012). Therefore, non-college educated young adult smokers who also use marijuana may need additional support to quit smoking. Unfortunately, how to effectively assist dual-users to quit tobacco remains unclear (Agrawal, Budney, & Lynskey, 2012).

Our findings, if confirmed by subsequent quantitative studies with nationally representative samples, have several implications for promoting FDA-approved cessation treatment use among non-college-educated young adult smokers. First, addressing the negative perceptions of NRT and prescription medication for smoking cessation would be warranted. Strategies include lowering the costs of NRT/prescription medications and communicating the effectiveness of these treatments to this population. Second, making smoking cessation media campaigns intended to motivate smokers to access behavioral counseling programs for smoking cessation. Third, developing and disseminating health communication interventions to help non-college-educated young adult smokers gain a better understanding of the contents and processes of these programs may promote utilization by this population. Fourth, these health communication interventions should be tailored to address specific negative perceptions of FDA-approved cessation treatments held by groups of specific race/ethnicity and/or educational attainment. For example, our participants claimed that NRT and prescription medications are ineffective in assisting smoking cessation based on personal or indirect experiences. Since a previous study suggested that 69% of adult smokers who used NRT, bupropion, and varenicline prematurely discontinued these medications (Balmford, Borland, Hammond, & Cummings, 2011), to overcome the perceived ineffectiveness, media messages may need to emphasize the importance of treatment adherence to maximize treatment benefits.

4.1. Limitations

Our study has several limitations. First, since this is a formative research study with a small sample stratified by race/ethnicity and educational attainment, our findings, especially those related to comparing racial/ethnic groups and educational attainment, should be considered as preliminary. Given the qualitative nature of our study, these findings need to be confirmed with quantitative studies using representative samples. Second, as in all focus group discussions, opinions may be influenced by other participants attending the same session. Third, our data were collected from a purposeful sample of non-college-educated young adult smokers residing in the Washington, D.C. metropolitan area. Therefore, this study’s results may not be representative of all young adult smokers of similar characteristics from other geographic areas. Fourth, our sample had fewer participants of Hispanic-descent than non-Hispanic-descent. We also had fewer female than male participants.

5. CONCLUSION

Smoking cessation during young adulthood offers tremendous public health benefits. Use of evidence-based smoking cessation treatments can increase the success rate among young adult smokers. Given the general low prevalence of cessation treatment use among non-college-educated and racial/ethnic minority young adult smokers, we conducted a focus group study with a sample of this population. We explored awareness, beliefs/perceptions, past use, and intention for future use of different cessation programs in this focus group study. We found that non-college-educated young adult smokers generally held more negative than positive perceptions and beliefs about NRT and prescription medications. They also lacked knowledge about how behavioral cessation program could help them quit smoking. There were suggestive differences in awareness, perceptions, past use, and intention for future use of evidence-based cessation treatments by race/ethnicity and educational attainment. Health communication interventions are needed that target racial/ethnicity minorities and those with less than college education with a specific focus of addressing negative perceptions of NRT and prescription medications and brining awareness of behavioral cessation programs.