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Smoking Decisions from a Teen Perspective: A Narrative Study

Lynne Baillie, PhD; Chris Y. Lovato, PhD; Joy L. Johnson, PhD; Cecilia Kalaw, MA Objective: To explore the transitional phase between experimental and regular smoking from the perspective of teens. Method: Narrative analysis of semistructured, individual interviews. Results: The need to belong and immediate social gain are major themes influencing teen smoking decisions. Conclusions: Our findings have significance for public health workers planning and implementing tobacco-use prevention programs aimed at teens whose smoking behaviors are not yet determined by nicotine addiction. How such programs have been traditionally framed and the ways in which peer influence and risk behaviors have been addressed may be largely irrelevant to the rationale of the adolescents themselves. Key words: teens, smoking, narrative inquiry, tobacco control
Am J Health Behav. 2005;29(2):99-106 tive approaches to preventing adolescent tobacco-use. The pressure to smoke exerted upon adolescents by the peer group and the adolescent tendency towards high-risk health behaviors traditionally are cited as being major influences on smoking activity during this time.^'^ Adolescence is often described as a phase in which individuals gradually acquire autonomy, expand social skills, and develop stable identities.'' Successfully accomplishing these developmental tasks requires group membership, which "provides the security of a provisional identity."* Consequently, the progression from child to adult is seen as being a socially determined process, one in which the acceptance and tolerance of the group become the guiding factors in decision making. Even with the emergence of a broadened awareness of complex adolescent smoking patterns, the social influence of peers remains one of the primary factors associated with tobacco use in adolescence.''" However, other recent research into negative behaviors, such as drug abuse and delinquency, indicates that peer influence is overestimated.'' Indeed, Unger'2 suggests, "It may be the adults.

lthough there appears to be a decline in the prevalence of cigarette use by teens, smoking prevention remains an important public health goal in North America. For example, in Canada, 23% of adolescents between the ages of 15 and 19 reported they were current smokers.' Prevalence in the United States is similar, vwth 30% of 12'*'graders reporting they are current smokers, 21% of 10*-graders, and 12% of S"^graders.^ Outcome studies regarding the effectiveness of school-based prevention programs report mixed results,^" and there remains a pressing need to identify effecLynne Baillie, Prevention Coordinator, British Columbia Cancer Agency, Centre for the Southern Interior, Kelowna, BC, Canada. Chris Y. Lovato, Associate Professor, Department of Health Care and Epidemiology; Joy L. Johnson, Professor and CIHR/NHRDP Health Research Scholar, School of Nursing; Cecilia Kalaw, Project Director, Nursing and Health Behaviour Research Unit, School of Nursing, University of British Columbia, Kelowna, BC, Canada. Address correspondence to Dr Baillie, British Columbia Cancer Agency, Centre for the Southern Interior, 399 Royal Avenue, Kelowna, BC, Canada VIY 5L3. E-mail: lbaillie@bccancer.bc.ca Am J Health Behav. 2005;29(2):99-106

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not teens, whose description of events is reflected in the term "peer pressure" (p 168). Although there appears to be a strong relationship between having friends who smoke and cigarette use, the genesis of that connection remains uncertain. The ways in which it features in terms of the attitudes and behaviors regarding the decisions made around smoking are also less than clear.'^.i" Within a youth development approach, adolescence is also seen as being a time in which risk-taking behaviors are purposefully adopted in order to gain group acceptance.* However, Wyn and White'^ take issue with this approach and challenge its suitability as a vehicle for the adult interpretation of adolescent actions and beliefs, claiming "it is far too simplistic to characterize risky behavior as an inevitable part of growing up" (p 70). They offer an alternative understanding by suggesting that what adults categorize as risks are, for the young people themselves, "simply a conventional response to a complex situation" (p 70). If, as Wyn and White suggest, the adult concepts of risk and risk taking do not match those of the adolescent, then prevention programs guided by such an adult framework reduce the likelihood of successful intervention in risk-taking behaviors, such as smoking. To maximize the impact of prevention and intervention, the programs offered must be immediately relevant to the adolescents for whom they are intended. At this point in the history of tobacco control, the argument cannot be made that adolescents are unaware of the health costs of lighting up. Today's teens are arguably the most well-informed generation regarding the health risks associated with tobacco use. Finding, then, how adolescents interpret and apply (or ignore) that information should be central to how we talk to them about the health risks of smoking. In this qualitative study, we focus on the concepts of peer influence and risk taking as presented to us by adolescents themselves. We examine how these concepts occur within their own accounts of smoking experiences. By remaining within the configurations of meaning provided by the narratives of our respondents, we attempt to locate the defining characteristics of' peer influence and risk

taking as they occur within adolescent experience. In our discussion, we question whether the traditional representations of health risk and peer influence as found in prevention programs might not be reinterpreted to become more congruent with the ways in which adolescents themselves approach and define smoking in their own lives. The research presented in this paper is part of a larger 4-year study into the transitions from experimentation to regular smoking among adolescents. METHODS We used narrative inquiry to glean insight into the interplay between meaning and interpretation of cigarette use as created by adolescents living within their personal context. It has long been accepted that we live storied lives and that narrative is the thread that we use to understand our experiences, as well as to share those experiences with others.'^"^ Further, not only do our narratives serve to interpret our past and articulate our present but they also guide the unfolding reality of what is to come. Narrative is the way we make sense of our surroundings and our actions, to ourselves and to others, and the narrative framework that we use is the lens through which we approach the world.'^ The adolescents who participated in this study relayed information not only about specific incidents in their smoking history, but also about how they themselves made and continue to makethese incidents meaningful. Participants We recruited 35 participants (17 female and 18 males), between 14 and 18 years of age, through community centers, schools, and youth workers. Mean age of the participants was 16 years (range 14-18 years of age). The ethnic breakdown was 26 white, 7 Aboriginal, and 2 "other." Data collection took place in urban and rural settings in British Columbia, Canada. We used a purposeful sampling strategy to identify a range of adolescent accounts regarding their tobacco-use experiences. The study included 11 former experimenters (had smoked more than one but fewer than 100 cigarettes in lifetime, but had not smoked in past 30 days), 14 daily smokers (had smoked more

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than 100 cigarettes in lifetime and smoked every day over the past 30 days), 6 occasional smokers (had smoked more than 100 cigarettes in lifetime, but had not smoked every day in the past 30 days), and 2 former smokers (had smoked more than 100 cigarettes in lifetime, but had not smoked any cigarettes in the past 30 days). Te ens, rather than younger children still at the experimental phase, were selected as we required a retrospective smoking narrative. Flyers and posters describing the study were distributed in community centers, youth organizations, and schools in different neighborhoods. Adolescents who expressed interest were screened for eligibility through a brief telephone interview. Participants were remunerated ($25) for their contribution to this research in order to attract a wider range of respondents. Following a brief description of the purpose of the study, participants were asked to sign a consent form in accordance with University of British Columbia Human Subjects Committee Guidelines. In order to insure confidentiality, parents were informed only that the study focused on attitudes towards tobacco use, and teens were assured that their parents would not receive information about their smoking. Interviews, which were conducted one-to-one, lasted 45-60 minutes and were audio-recorded. Participants were then invited to talk about their smoking history and encouraged to refiect upon the factors that may have contributed to their becoming smokers or nonsmokers. In order to allow narrative responses to emerge, interviews were semistructured, using prompts. Data Analysis In keeping with the purpose of a narrative approach, we analyzed participants' interviews for not only the responses they gave in relation to their cigarette use, but also the wider personal context of what they said. All members of the research team analyzed d a t a independently. Themes were then identified and developed collaboratively at team meetings. Analysis of the narratives adhered to the 4 steps outlined by Muller.'^ After entering the text and becoming completely familiar with the narrative in its entirety, we identified the categories most relevant to our guiding research
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question, by compiling the reasons and contexts provided by participants to account for smoking occurrence. Next, through successive readings and critical reflection, connections and relationships within the data were identified and themes and patterns established. That is, we examined these relevant categories for similar narrative structures across participants - were they telling us similar stories? In the third step, we sought to achieve internal consistency of interpretation by verifying emerging themes and patterns and by confirming the absence of negative cases and the inadequacy of alternative constructions. We did this by continually returning to our larger research group for critical examination of our interpretations. Each of these 3 steps is part of an iterative process. We continuEilly considered new information or insight as it became available to the research process, trying "to keep intact, as much as possible, the context of each story, its sequential and structural features, and the consequences of events for each individual."'* The final step, representing an account, namely bringing together participants' stories and researchers' understandings, constitutes this paper. RESULTS Among these stories of smoking experience there appears the notion of smoking as a deliberate social tool used to personal advantage. Many of the young smokers to whom we talked were similarly utilizing the activities surrounding smoking to satisfy personal social needs, and although some young smokers mentioned peer pressure, this expressed satisfaction far superceded any considerations of physical harm. Their decisions to smoke did not appear predominantly to be driven either by the coercion of peer influence or by the ignoreince of the serious health risks involved. That is not say that these elements were not present in some of their stories. However, even when specifically mentioned, these elements did not play the leading roles as portrayed in the interventions presented to young people. Instead, adolescents talked about the ways in which they themselves used smoking and, in doing so, provided reasons that went beyond the understanding contained in the conventional conceptions of peer influence and risk taking. In

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the following sections, we discuss these findings and place them against the conventional concepts surrounding adolescent tobacco use. Quotes contain the verbatim responses of participants and are followed by the pseudonyms (chosen by each participant) and their age in years. One Little Common Thread: Peer Pressure vs Need to Belong In these narratives, the relationship between smoking behaviors and having peers who smoked did not appear to equate with "pressure" as it is conventionally portrayed in prevention programs. In fact, although there were exceptions, it was more usually the case that these others either did whatever they could to dissuade participants from taking up smoking or were completely apathetic towards it. That is, rarely did they report that others actively engaged them in the act of smoking or exerted any expectation of smoking behaviors. Many participants also commented that peers were not seen as influencing the decision to smoke; in fact, some told us that friends were more likely to accept their decision not to smoke. Yeah, no one pushes them on you. Then it's like, "Oh, come on, just keep me company" and I'd be like, "No, I really don't think I should," and they'd belike, "Okay." So most of my friends are really understanding about that. (Sandy: 17yrs) They [friends] all smoked at the time [of her quitting] ... There wasn't a big reaction,... and I never really bothered them about smoking, and they never bothered me about not smoking. (Cindy: 17yrs) It's not like, "Come on try this. It's good." It's not like that anymore. It's just, you know, whatyou choose is fine with everyone. (Shannon: 18yrs) Within many of these narratives, smoking is described functionally as a tool with which to negotiate the social world: It provides these young people with a script with which to enter into social situations and to begin the process of communication. Not only do adolescents view cigarette use as a means to meet and interact

with others, but they are also quite sophisticated in their awareness of this. The following quote provides an example of the deliberate and selective nature of cigarette use among adolescents: I'm thinking (of smoking) as more as an accessory to me having Jun ... It's just sort of there inside my closet that I take out once in a while to wear out when I'm going out somewhere ... (Sandy: 17yrs) The metaphor of cigarettes as an elective fashion accessory reveals that, for this young woman, smoking is something having a distinct social function and quite deliberately used to that end; she does not "wear" cigarettes to school. This kind of conscious application of smoking moves cigarette use far beyond the definitions of peer pressure and risk behavior as currently represented in prevention initiatives. Using the already available social protocols offered by a common and identifiable activity provides adolescents with a map to group membership and relating to others that they may not otherwise be able to achieve: I probably wouldn't know the people I know ... 'cause you know you kind of, everyone crowds outside in a ball when it's cold out and, "Oh, can I bum a smoke, can I borrow a lighter?" and you just kind of meet people and start talking with people. So, I met people that way. (Yvette: 16yrs) / think nonsmokers don't always have a group ... It's always like one little common thread between every smoker is the fact that they're smoking ... you always have the common way to start conversations ... it's almost like a comfort knowing that you have those few people that are gonna be there. (Shannon: 18yrs) These narratives contain a personal social purpose beyond appearing "cool" or following the herd. It must be included in the considerations about adolescent smoking, that, for these young people, the contexts of smoking carry a definite social benefit. When peer influence is considered as

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being a central factor in the smoking equation, then the core of prevention is avoidance and management strategies, resulting, for example, in the resistance approaches favored by many interventions. If, however, external pressure is reconceived as purposeful decision carrying a definite benefit, then such strategies become completely inappropriate. Indeed, it would appear that health educators and adolescents are working from totally different scripts. If cigarettes are seen advantageously as a social lubricant, why would teens then want to say, "No" to smoking? They Haven't Collapsed and Died, You Know: Future Health Risk vs Immediate Social Gains Without exception, the adolescents who shared their stories were aware of the dangers of smoking. However, although they easily could recite all the harmful effects cind dangers inherent in tobacco use, most of them did not relate these to their own smoking and provided us with several reasons why such factors would not apply to them, the most common being that they would be able to stop long before their health was in any danger. / have friends who have been smoking for 4 years, 5 years, and they're still smoking - nothing's happened to them. They haven't collapsed and died, you know? So, I still think I have some years to go before I stop. (Sandy: 17yrs) My dad, he's been smoking since he was like about 14, and he's 38 now, and he doesn't have no cancer or anything. (Nathan: 16yrs) Yeah, there's pretty gross stuff (in antitobacco video), and it tells you all about emphysema ...but all the people they show are like 40 and 50. I won't die from smoking for a while. (Greg: 16yrs) Although these teens could lessen the immediacy and relevance of their knowledge of tobacco-related health risks by erecting the barrier of time, they did not do so when considering the risks involved for others. Distancing and diminishing health risks appear to be relevant only to
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the teen smokers themselves. It was not uncommon for teen smokers to express deep concern for others who might become smokers due to their own inadvertent influence. I'm not allowed to smoke in front of my sisters, and even if I was, I wouldn't, just 'cause it's being that much more closer to a smoker, right? (John: 16yrs) / hate smoking when little kids are around. I can't stand it 'cause I don't want them to see it ... I cringe when I see like the little grade 7's smoking. I just want to tell them, rip it out of their mouths and be like, "Don't do that. It's stupid!" (Cheryl: 16yrs) One teen who had spoken at length of the social benefits he enjoyed from smoking in terms of "bonding with friends" and smoking being "like a secret club" also told us that he would definitely stop smoking when he had his own children. Why would I stop if I have a kid? Just for health reasons, I wouldn't want to like, force any secondhand smoke on my child. (Richard: 18yrs) The antitobacco messages designed to impact upon young smokers are further diluted by this attitude that they, somehow, are not the ones at risk; therefore, they are not part of the intended target audience. / always read thepackage, and it says like, "Smoking can kill you," "Smoking can damage your unborn baby." But, I mean, I wasn't pregnant and I was young and healthy, so I thought like, it's not going to bother me. (Cindy: 17yrs) Rather than citing themselves as smokers, adolescents talk of using cigarettes as a social lubricant, much as adults will use alcohol; and, just as adults rationalize their alcohol consumption ("I'm only a social drinker"), so, too, do adolescents justify their smoking by classification. Accordingly, adolescents typically described themselves to us as being "recreational," "occasional," "social,"and "experi-

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mental" in their use of cigarettes; Rarely did they refer to themselves simply as being "smokers." / don't consider myself a smoker, just a once in awhile kind of thing. (Karen: 15yrs) / ain't saying that I'm a smoker, right? Because you can't say you're a smoker if you smoke like once a week... I'd say I'm a nonsmoker except when I drink. (Donna: 18yrs) The methods used by teens to distance themselves from the prevention and cessation messages that they see all around them every day are both effective and resistant. Minimizing the amount of smoking they do and emphasizing the social benefits not only distance adolescents from the negative aspects of smoking, but also remove them from the impact of the health risk messages to which they are exposed. This makes it possible to acknowledge the veracity of antitobacco information while continuing to use cigarettes. By placing the gulf of time between their present smoking and the probable health consequences, by not finding any personal relevance in prevention/cessation messages, and by not casting themselves as outright "smokers" per se, then clearly such messages are not really intended for them. It then becomes easier to ignore these interventions than it is to reassess their smoking behavior, which is currently providing them with desirable advantages. DISCUSSION In electing to join smokers, adolescents are using the act of smoking to satisfy personal social needs versus submitting to peer pressure in order to fit the desired group's requirements for acceptance. Our results suggest that most adolescents did not identify peer pressure as being the primary influence in their decisions to smoke or not to smoke. Rather, they tend toward other reasons for their decision to smoke. In many cases, adolescents told us that choices regarding tobacco use are freely made. Further, adolescents do not appear to consider their own tobacco use as being a serious health-risk behavior. In fact, the perceived psychosocial advantages of smoking more than outweigh any consid-

ered physiological danger. For the adolescents in our study, it appears that the act of smoking has much less relevance than the psychosocial benefits imparted by cigarette use. Consequently, the dissonance between "smoking" (as defined by prevention and intervention initiatives) and "cigarette use" (as interpreted by adolescents) can emerge. This may be another reason why the adolescents we listened to had such difficulty defining themselves as outright "smokers." To be a smoker and to be seen as such do not appear to be the prime purpose behind their cigarette use. If we take the stories that were told to us by the adolescents in this study and maintain these as our frame of reference, then many of the observations held by adults concerning adolescent peer pressure and risk behaviors become open to reinterpretation. For example, the youth development model operates within a discourse that focuses upon adolescence as a time of risk-taking behaviors and vulnerability, and has been instrumental in guiding research and program development in the field of adolescent tobacco control.'''^o This approach creates the possibility for simply categorizing adolescent behavior as being "risky," irrational, and in some way markedly different from "normal" adult responses. If, however, this view is challenged, then it becomes possible to reinterpret "adolescent risk behaviors" as a social process.'^ Further, if identity is about forging social connections - belonging or not belonging - then adolescents are faced with the tasks of negotiating an identity and choosing how they belong in a variety of settings. It may be, therefore, that adolescents use smoking to accomplish these adolescent tasks. That is, they may be using cigarettes in shaping, defining, and characterizing who they are and what their personal relationships will look like - both through the social acts clustered around smoking (accessing, buying, sharing, lighting up, finding places to smoke, etc) and in creating and sharing narratives about smoking. What are these adolescents telling us? In creating their "smoking narratives," what is it that they both want to believe and want us to know? From these narratives, it can be surmised that the responses would include the following: That nonaddicted smoking is not al-

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ways a spontaneous act - in many instances, it is quite deliberate; Tbat adolescent smoking behaviors occur within a complex matrix of socially defined meanings that cannot be readily isolated; That the consideration of health risk inherent in smoking is not usually a determining factor. This may not sound like a revelation. However, when tbe term cigarette use is substituted for smoking, the shift in interpretation makes possible a much wider range of understanding having immediate implications for the design and implementation of interventions. It is hard to imagine that there could be a young person who is not aware that a link exists between tobacco and disease; they have been exposed to this message since infancy. Why, then, do adolescents initiate and continue a behavior that they clearly know to be harmful? On the basis of the narratives we heard in this study, there are several possible answers to this question. The predominant possibility to consider is that, from an adolescent perspective, there is little or no connection between their using cigarettes as a social mediator and their consideration of smoking as a healthrisk behavior. It would appear that adolescents are not so much smoking as they are using cigarettes as a sociad accessory, and to them, the contextual activities surrounding cigarette use are far removed from the acts of smoking as portrayed in prevention and cessation initiatives and consequently rendered harmless. Wyn and White'^ make the point that "the very idea of risk implies a rational assessment of the chances of 'getting away with it'" (p 68, original quotation marks). In other words, a behavior can be perceived as being "risky" only if the full implications of the potential consequences have been considered. Most of the adolescents in our research did not appear to approach smoking in this way. Although they did not deny the rationality of smoking as a high health risk, they refuted that their own behaviors fell under that same rubric. Quite simply, these young people do not consider the way that they use cigarettes constitutes a personal health-risk behavior. Another consideration is that, to the adolescent mind, cigarette use offers definite and immediate benefits that outAm J Health Behav. 2005;29(2):99-106

weigh any potential and distant harm, in that it facilitates "the identity project" in that it can provide a sense of belonging.* There are several important implications to be considered from this study: The underlying assumption that teens are pressured into smoking by peers continues to pervade cessation/prevention initiatives and fails to take into account the possibility that decisions made by adolescents regarding smoking are both freely made and have - for the adolescents themselves - positive psychosocial results. Thus, the relevance to youth of existing intervention models requires further investigation. Further, it would appear from our findings that youth typically feel in control of their smoking behaviors and that some preaddicted youth go to great lengths to monitor their cigarette use carefully. However, both influence and risk models imply a loss of control, and many prevention programs center upon developing and practicing skills to overcome external persuasion and operating within a discourse that focuses on the interpretation of cigarette use as an isolated health risk quite apart from the psychosocial needs of the adolescent. How valuable can resistance initiatives be if these aspects are not even a factor in adolescent considerations? The primary focus of many adolescent prevention interventions has been guided by the health profession's concept of peer influence and health risk. Yet we loiow little about how adolescents themselves experience the influence of peers or how they determine risk and the ways in which their perceptions of these behaviors differ during the initial sampling and early experimentation phases of cigarette smoking. A consequence of this is that the dialogue around the development and evaluation of adolescent tobacco-prevention initiatives tends to be a very one-sided conversation with the voice of the adult researcher, teacher, or parent encouraging a shift in individual attitudes and behaviors.^' How youth smoking comes to be conceptualized in prevention programs primarily involves t;he processes derived from adult observation and interpretation of adolescent behaviors. Although youth may be recruited in the design and implementation of such initiatives, they tend to be guided by received wisdom rather than their own lived experience.'"

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We propose that the ensuing mismatch between the theoretical assumptions guiding adolescent tobacco control design and the practical reality of teen life raises serious questions about the efficacy or relevance of these messages. Acknowledging this distinction may allow public health workers to continue fuelling the momentum that has been gained in tobacco control over the last several decades. Indeed, we would argue that the tobacco industry is already not only aware of this distinction, but has been making use if it for some time. We fail adolescents by clinging tenaciously to an intervention paradigm that typically represents teen smoking as a foolhardy activity brought about through pressure exacted by equally foolhardy peers and cured by isolation and education, a paradigm that interprets adolescents as readily accepting but deliberately defying this rationale. The information obtained from these adolescent narratives of smoking emphasizes the urgent need to shift intervention research and development to a social perspective that gives adolescent needs and interests central focus, one that can accommodate the subtle and complex ecology that continues to allow our youth to consider cigarette use as an answer for their needs. Acknowledgment This research was supported by a grant from the National Cancer Institute of Canada.
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