Ambivalence and fluidity in the teenage smoking and quitting experience: Lessons from a qualitative study at an English secondary school

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published online 5 June 2012Health Education JournalMarina Buswell and Peter Duncan

Lessons from A Qualitative Study at an English Secondary SchoolAmbivalence and Fluidity in the Teenage Smoking and Quitting Experience:

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446561HEJ0010.1177/0017896912446561Buswell and DuncanHealth Education Journal

Corresponding author:Marina BuswellEmail: [email protected]

Ambivalence and Fluidity in the Teenage Smoking and Quitting Experience: Lessons from A Qualitative Study at an English Secondary School

Marina Buswella and Peter DuncanaaDepartment of Education & Professional Studies, King’s College London, UK

AbstractObjective: To evaluate a school-based stop smoking pilot project and to understand the teenage experience of smoking and quitting within that context.Design: Flexible design methods.Setting: A Kent (United Kingdom [UK]) secondary school.Methods: Semi-structured interviews analyzed following a grounded theory approach.Results: The main themes that emerged were ambivalence and fluidity. Young people can have mixed feelings towards their smoking behaviour. They experience ambivalence at the societal level in the messages they get about starting and stopping smoking and at the individual level in how they feel about other people smoking. Ambivalence in the quitting process is intensified by the phenomenon of addiction. Fluidity characterizes their way of life; things are not fixed and arrangements open to change. This was reflected in the way they approached coming to appointments.Conclusion: This research contributes a new perspective on the teenage smoking and quitting experience which others working in the field may find useful in characterizing their experience of working with young people. This ambivalence and fluidity suggests that a flexible approach in interventions with young people may be a key to success.

Keywordsexperiences of quitting, qualitative research, smoking cessation, young people

Article

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Introduction

The project was specifically designed to help school students stop or reduce smoking – in contrast to smoking education which has been shown not to affect smoking rates among young people.1 Based at a Kent (UK) secondary school, it was a collaboration between the stop smoking service and the school-based Connexions personal adviser (PA).

Project Details

• Students between the ages of 13 and 16 were offered the opportunity to cut down or quit smoking. (The option of cutting down in addition to quitting was offered as a way to give every opportunity for students to become non-smokers. Research shows this may be an appropriate approach for some smokers.)2, 3

• Text messaging was used to allow students to access the programme and remind them of appointments.

• Two initial assessment meetings were offered with four follow-up meetings (a similar model to the adult stop smoking service).

• Nicotine replacement therapy (NRT) lozenges were offered to suitable students.4

• Other treatment aids were offered: sugar free lollies and glucose tablets.

Project Outcomes

Fourteen students participated in the project. Five met together as a group and the other nine had one-to-one meetings. At the end of the project seven of the students had quit, four had cut down their smoking, two were smoking as before and one was lost to follow-up.

Rationale

In the ‘quit rate’ and targets-obsessed culture of stop smoking services it can be difficult to take time to reflect on why or why not programmes may be working. The aim of this research was to get a fuller understanding of the young people’s experience of smoking and quitting and how use-ful and appropriate the support offered was to them.

There is a need for more qualitative research in this area5 and it seems a shame that so much ‘on the ground’ experience is lost because often pilot projects are small scale and resource limited so they do not get evaluated much further than the number of quitters. However, even resource limited – and therefore flawed – investigations can offer valid and reliable results if the methods used are honestly discussed. It is our hope that we do that here. In the account that follows where use is made of the first person this refers to the corresponding author, MB.

Methods

The study was conducted, under the direction of my academic supervisor (PD) in the context of working for a stop smoking service and as a student carrying out dissertation research for a Masters in Public Health. The study design is a ‘flexible design’ approach: this does not require all research methods to be defined or a theory formulated before starting out and it recognizes that research questions may develop over the course of the study.6

We started with the following research questions:

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1. Did the pilot text-based cessation service for young smokers bring about a change in atti-tudes and behaviours in those who took part?; and

2. What were the perceptions of the project of those who took part?

We decided that using semi-structured interviews would be the best method to achieve this and would be feasible within the school context in which I was working. The interview outline was developed around the two research questions under the broad headings.

1. Change in attitudes to smoking and change in smoking behaviour2. What the project participants thought/felt about the sessions/project overall

Twelve of the 14 project participants were interviewed (one was lost to follow-up and the other unavailable for interview). The interviews were carried out over a two-month period in 2006. Each student was interviewed once. I conducted ten of the interviews in person and each interview was recorded, but no notes were taken. All these interviews were later transcribed. Two of the inter-views were conducted by telephone by the Connexions PA: these were not recorded but notes were taken. The first two interviews were treated as pilots and the interview outline altered slightly in the light of these.

Grounded theory methodology was used as a guide to analyze the interview content.7–9 Ideally data should be analyzed between visits to ‘the field’. This was not feasible; therefore this is what Robson terms a study ‘in the general style of’ a grounded theory study.6

In this case I was quite embedded ‘in the field’ as I had spent a term delivering the project in the school and interacting weekly with the students. In terms of the ‘field visits’ – that is, the interviews – there were three: two different sessions at the end of the Easter term in March and one final ses-sion in the middle of the summer term in May. These weren’t strictly follow-up visits – I inter-viewed different students on each occasion and I had only reflected on the data between visits, not done detailed analysis. In retrospect this reflection did inform the third round of interviews to some extent. The full coding and analysis of all interviews took place in July and August.

Findings

Themes from the initial analysis are given in Table 1. Open and axial coding drew out further cat-egories given in Table 2. Working on these categories we came up with a working storyline: ‘fluid-ity and ambivalence in the quitting process’. Additionally the data highlighted the importance of support from family and friends in the quitting process and the usefulness of NRT lozenges and glucose tablets in relieving cravings.

Ambivalence

Ambivalence is a concept used both in sociology and psychology with fairly technical uses and contested definitions. Traditionally it focuses at the individual level and has been defined as, ‘incompatible normative expectations of attitudes, beliefs and behaviour’ (Merton and Barber, 1963, p. 95, as cited in Connidis and McMullin, 2002).10, p. 561 More recently it has been re-concep-tualized to include societal aspects of ambivalence so that the individual is considered a social actor who experiences ‘ambivalence when social structural arrangements collide with their attempts to exercise agency when negotiating relationships’.10,p. 565

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Table 2. Categories from open and axial coding

Health concernsMoney concernsPeer pressureAddictionAmbivalenceInterpersonal supportPhysical support (treatment aids; e.g. NRT)Difficulties in quitting processSelf-esteemConfidentialityRemindingFluiditySchool discipline avoidance

These individual and societal definitions help us conceptualize the teenage smoking and quit-ting experience. Take, for example, the reasons young people start smoking: there is ambivalence not just within themselves but also in those around them. Some of the reasons they started smoking – family/friendship group norms and ‘peer pressure’ – seem at odds with the findings that other people, particularly family and friends, were key in supporting and encouraging the students in their quit attempts.

This contrast can be seen quite clearly in the responses given by interviewee 1 when asked why they started to smoke:

Because some of my friends smoked and some of my family, and I felt like really stressed and that. And then one of my friends said ‘do you want to try some’ so I did, and then I just started smoking. (I01)

Yet these family and friends were supportive through the quit attempt:

They [family] was [sic] all really happy and ‘we’re so really proud of you’ and ‘we hope you better do it’. And my aunty said she’d give me money if I did [laughs].

Table 1. Themes from the initial analysis

Reasons for starting smokingConcerns about their smoking/reasons for stoppingAttitudes to others smokingHow they found it to cut down/stopFeelings about stopping/cutting downAttitudes of others to them stopping/cutting downSupport receivedThoughts about NRTThoughts about other non-smoking aidsThoughts about the projectProject as a way of getting out of school rules/disciplinesMobile phone use – fluidity and variability

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They [friends] were really supportive and just said if you do then I’m really proud of you, but if you don’t then just keep trying. (I01)

Of course I don’t know if it is the same friends and family who are supportive but it does show that young people experience mixed messages from those closest to them.

The sense of ambivalence is also reflected in the students’ attitudes to others smoking. Almost all students talked about it being ‘their choice’ yet many of these same students expressed dislike for others smoking and a wish they (particularly family members) would quit. A number also high-lighted the way that others smoking around them made it more difficult for them to quit.

Almost all the students found some difficulty in quitting or cutting down. A number of the stu-dents did talk about experiencing cravings and addiction. Some cited it as a reason for starting in the first place:

Well ’cos my friend started and then I started and ever since then I’ve been craving I was craving for one so I got addicted. (I05)

These cravings were difficult to manage during the quitting process

I did have a few fall outs with my friends ’cos I did lash out at various people but they did understand like the nicotine cravings and that because they were all smokers themselves so in the end it did sort itself out. (I10)

Even though research has shown that young people can be just as addicted as adults,11 I know that I did not really believe this until faced with it myself. I was quite surprised at how the young people experienced strong withdrawal symptoms as adults often do, particularly the mood swings as expressed by interviewee 10.

Most of the students reported positive experiences of the quitting process such as an observed improvement in health: not coughing and feeling fitter and having more money. Some even seemed surprised with themselves, like the following student who seemed to have come along initially for ‘a laugh’ as well as wanting to quit:

I didn’t think it would actually work but it actually did . . . ’Cos I thought like everyone doing it together would make it like more of a laugh sort of thing than actually doing it but it wasn’t. (I08)

This ambivalence to joining the project need not be seen as entirely negative. Some of the students who were motivated by wanting to get out of lessons and ‘having a laugh’ did also stop smoking through the project.

Fluidity

The students’ approach to the project was very fluid. I lost contact with a number of the students during the project because, for various reasons, they were not on the same mobile phone number that they had started out on. One student had given their phone to their Mum which resulted in the mother finding out she was on the project (thankfully this was not a problem):

Ah my family I didn’t really tell ’em [that I was stopping smoking] until my mum started getting the text messages [laughs]. (I08)

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I started asking specifically during the interviews whether they had received the texts I had been sending. It appeared that the students did not really think much about changing their phones. Nor did they seem to be bothered that they had stopped receiving texts. Perhaps they extended their fluidity to my actions so they did not think it strange that I would suddenly stop texting them.

There was also a fluid attitude to the way in which the students made use of the project. They reported positive feelings about the project, they felt it was beneficial and would recommend it to friends. Yet these same students talked about needing reminding to attend sessions, or forgetting to come.

Um I missed a couple ’cos sometimes when I was away I missed some as well . . . No ’cos I forgot [laughs] . . . I totally forgot about it. (I11)

They also did not feel the need to attend if they had already quit. I had assumed that these students who had stopped attending had done so because they had relapsed and were smoking again. I was very surprised to find out this was not the case for everyone.

Well ’cos I didn’t feel the need to smoke anymore I didn’t, sometimes I didn’t feel the need to come to the interview, not the interview the appointment ’cos I thought ‘oh I don’t really need to’ but I then I thought ‘yeah I do’: it was different for different days, you know what I mean. (I10)

Whether this fluidity will have an effect on the longer-term quitters remains to be seen.

Interpersonal Support

Interpersonal support received was key, both through the project and through the encouragement of family and friends (as highlighted in earlier quotes). The students who were part of a group seemed to have particularly liked quitting together.

That was better [being in a group] ’cos then you’ve got your friends there and they’re all helping you do it and going through it with you so you’re not on your own. (I01)

They highlighted the fact that it meant they could support each other through the week between appointments.

The ‘innovative’ approach, using texts to access the project and as a reminding/support mechanism, appears to have been considered quite normal. During some interviews where I was trying to draw out their experience of using texting it all got quite stilted and it became obvious that texting was such a normal part of their lives they didn’t really understand what it was I was trying to ask them.

Treatment aids

Students also reported finding the different forms of treatment aids useful. Although some students found the NRT lozenges helpful, they didn’t always particularly like them. This put some off using them but others persevered:

Er, I think I said, like, they didn’t taste the same [as cigarettes] and at first I thought ooh they were horrible but after a while I kinda got used to it and they helped quite a lot. (I09)

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This is another area where the ‘innovative’ approach was challenged. The use of NRT is not well studied among young people, though there have been some positive preliminary results.12 The licence for NRT to include the age group 12–17 coincidentally corresponded with the start of our project. In the Stop Smoking Team we were very keen to use NRT and saw it as a major strand of the project. Whilst it was undoubtedly helpful for some of the students, it was not quite as impor-tant as originally thought. During the project it became obvious that the students really liked get-ting the sugarfree lollies and glucose tablets, as the following student explains:

They was [sic] really good because when you’ve got the lollies there’s something in your hand and that’s what I missed, having something in my hand: it was good to have something there so you could put in your mouth and with the glucose tablets they just, um, they just made you happier so you didn’t like feel you needed a fag you just felt really happy and, like, not depressed. (I01)

In addition it seemed that some of the students found that the glucose tablets took away the cravings:

The lollies helped ’cos I had something in my hand so, and the glucose thing they were just . . . [pauses] . . . they just took, like, the, um, cravings away sometimes. (I11)

This is not a new finding and glucose tablets are recommended as a means of coping with nicotine withdrawal.13

Flexibility

From a researcher/project worker perspective a third theme emerged, that of flexibility. The ambiv-alence and fluidity of the teenage smoking and quitting experience requires a flexible approach. My template for the sessions was based on the adult model of the six/seven week course; however, as I went along I realized we were not following that approach strictly. Most students did not quit at week two as is usual in the six-week programme. I found this a little difficult at first, along with some students cutting down and not quitting. I did ‘go with it’ and this seems to have been regarded well. I would in future perhaps be even more flexible, particularly with appointment times and frequency.

Synthesis and conclusions

There is a great deal of variation in the experience each person has of smoking and quitting: this is the case for adults and young people. The themes of fluidity and ambivalence seem particularly pertinent to the teenage experience and chimes with the findings in a Scottish review of stop-smoking programmes for young people which found that programmes should be flexible but struc-tured.14 These themes may be helpful in characterizing others’ experience of working with young people.

Future research should address the ambivalence in peer and family networks: having friends and family who smoke is a known risk factor and predictor of teenage smoking15, 16 and was the main reason cited among our sample. Peer and family support appears to be important, yet there has been little research into the support young people receive from peer and family networks, though it has been identified as an area worth pursuing:

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Adolescent smoking is clearly a social phenomenon that is largely tied to peer networks. Interventions that more specifically address and perhaps capitalize on beneficial peer networks may hold some promise for adolescents.17, p. i32

Key to future projects would be a means of tapping in further to support from family and friendship networks.

The analysis also draws out aspects of the intervention which should be repeated: the use of texting to make access easier and ‘normal’, the provision of NRT, glucose tablets and lollies and offering the option of group or one-to-one support. It is worth noting that the use of texting to sign up is not practicable in many schools where mobile phone use is discouraged and the option of using email as an alternative is being pursued.

Acknowledgements

Thanks to Tamsin Parker, the Connexions PA, Nicola Willis, Stop Smoking Team Manager and to Kent and Medway Public Health Network for funding the major proportion of the MPH fees.

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