Mechanisms of adolescent smoking cessation: Roles of readiness to quit, nicotine dependence, and smoking of parents and peers
Introduction
Although primary and secondary preventions consist of approaches to reduce the prevalence of smoking, efforts related to adolescent smoking have mainly focused on preventing the initiation of smoking (e.g. Carvajal and Granillo, 2006, Vickers et al., 2002). However, there is little research on the predictors of smoking cessation among adolescents, and a sound theoretical basis for developing interventions aiming at adolescent smoking cessation is still lacking (e.g. Buttross and Kastner, 2003). To develop effective approaches to reduce juvenile smoking, more understanding of the mechanisms underlying smoking cessation in adolescents is needed. It is reported that multiple levels of influence should be considered in interventions designed to treat adolescent smokers, including addiction, psychological, peer, and parental influences (Center for Disease Control and Prevention, 1994; Fiore et al., 1996, Moolchan et al., 2000). Therefore, the present study tested a model specifying the direct and indirect relations between nicotine dependence, readiness to quit, and smoking in the social environment.
Dependence on nicotine is known to be a strong predictor of smoking cessation. Studies among adults revealed that nicotine dependence was an important impediment to cessation (e.g. Abrams et al., 2000, West et al., 2001). It is also reported that even irregular and sporadic smokers can experience symptoms of dependence (DiFranza et al., 2002a). The occurrence of dependence symptoms in adolescent smokers was found to be a precursor of daily smoking (DiFranza et al., 2002a) and a barrier to smoking cessation (Colby et al., 2000, Prokhorov et al., 2001). Adolescent smokers reported withdrawal symptoms and feelings of craving during attempts to quit or reduce smoking, and higher levels of dependence symptoms in adolescents were associated with relapse to smoking (Bagot et al., 2007, Colby et al., 2000, Horn et al., 2003).
Readiness or intention to change behavior is conceived as a proximal predictor of behavior change in several cognitive-behavioral theories, such as the theory of planned behavior (Ajzen, 1988), the theory of triadic influence (Flay and Petraitis, 1994) and the transtheoretical model (Prochaska et al., 1992). These models imply that an individual’s readiness to (try and) change is an immediate precursor of behavior change and, specifically with regard to smoking, it is thought that interventions and treatments aiming at smoking cessation will only work if smokers are ready and motivated to quit (West, 2004). However, studies on adult smokers have shown that indicators of dependence were stronger predictors of abstinence at follow-up than the smoker’s psychological readiness to quit (Farkas et al., 1996, Abrams et al., 2000). Nevertheless, there is general consensus that psychological readiness to quit plays an essential role in any theory of behavior change (Fisher, 1996, Hughes, 1996, Pierce et al., 1996, Prochaska and Velicer, 1996, Shiffman, 1996, Stockwell, 1996, Sutton, 1996, West, 2004).
West (2004) stated that the success of smoking cessation depends on the balance between an individual’s readiness to quit smoking and his/her level of dependence. Whereas a person’s readiness to quit is likely to determine whether or not a person will try to quit, dependence on nicotine will likely determine how successful actual cessation will be (Shiffman, 1996, West, 2004).
The interplay between readiness to quit and nicotine dependence in adolescent smoking cessation is not well elucidated. Among adolescents, both readiness to quit and nicotine dependence are known to be precursors of cessation (Engels et al., 1998, Kleinjan et al., 2008). Therefore, the first aim of this study is to examine the roles of readiness to quit and nicotine dependence in relation to adolescent smoking cessation, and to test whether differences in dependence influence the relationship between readiness to quit and smoking cessation.
Although individual characteristics (such as readiness to quit and nicotine dependence) are important predictors of smoking cessation, an individual rarely acts independently of their (social) environment. Consequently, smoking behavior is likely to be determined by a combination of individual characteristics interacting with environmental conditions, e.g. smoking by significant others (Van Lenthe et al., 2005). It is reported that both parental and peer smoking are consistent predictors of adolescent smoking (e.g. Conrad et al., 1992, Flay et al., 1994). Adolescents who report a greater exposure to smoking by parents and peers were less likely to quit smoking (Burt and Peterson, 1998, Ershler et al., 1989, Hansen et al., 1985, Zhu et al., 1999). However, the mechanisms by which parental and peers’ smoking affect adolescent smoking cessation are largely unknown.
Having friends and parents who smoke may hinder the process of smoking cessation in adolescent smokers in various ways. For example, smoking parents and friends may offer cigarettes thus providing easy access to cigarettes (Tucker et al., 2002), or may act as cues that may continue to trigger the craving for cigarettes (Carter and Tiffany, 2001), or may be unable to provide appropriate encouragement and support to quit smoking (Hansen et al., 1985). Moreover, it is known that, in adolescent smokers, parental and peer smoking is significantly associated with higher levels of nicotine dependence (Hu et al., 2006). Since nicotine dependence appears to be associated with adolescent smoking cessation (Kleinjan et al., 2008), parental and peer smoking may also influence adolescent smoking indirectly through nicotine dependence. Furthermore, a recent study showed that parental smoking is associated with a lower readiness to quit (Van Zundert et al., 2007), which implies that parental smoking may also influence successful smoking cessation by affecting adolescent’s readiness to quit. In an environment where parents and friends are smokers, adolescents may perceive themselves to be less ready to quit, e.g. due to dependence-enhancing factors, such as the offering of cigarettes and the presence of smoking cues. Therefore, the second aim of this study is to examine the pathways between parental and peer smoking, and both nicotine dependence and readiness to quit, in relation to smoking cessation.
To investigate the patterns of these relationships, two models are tested. In the first, the outcome variable is the number of quit attempts in the past 12 months. In the second model, the dependent variable is the actual smoking cessation for at least 1 month. In line with the idea that readiness to quit will determine whether or not a person will try to quit, and dependence on nicotine will be associated with how successful cessation will be, we expect readiness to quit to be more strongly related to the number of quit attempts, and nicotine dependence to be more strongly related to successful smoking cessation. In addition, to test whether differences in dependence may shape differences in readiness to quit, as proposed by Shiffman (1996) and West (2004), we assess whether nicotine dependence has a moderating effect on the relation between readiness to quit and both the number of quit attempts and smoking cessation. Because it is reported that, among adolescents, a lower readiness to quit coincides with substantially higher levels of nicotine dependence (Prokhorov et al., 2001), it is expected that the relation between adolescents’ readiness to quit and number of quit attempts, as well as actual smoking cessation, will be stronger for respondents reporting lower levels of dependence than for respondents reporting higher levels of dependence. With regard to smoking of parents and peers, it is expected that parental and peer smoking are related to higher levels of nicotine dependence and lower readiness to quit (Van Zundert et al., 2007), which in turn are hypothesized to be related to fewer quit attempts and a lower chance of successful smoking cessation.
Section snippets
Procedure and sample
The present study uses data from the third and fourth wave of a larger longitudinal study that started in January 2003, focusing on psychological and environmental processes in relation to tobacco use among Dutch adolescents. Following random selection from the telephone book, schools in four regions of the Netherlands were randomly selected and approached to take part. The main reason given for refusal to join this study was participation in other studies. At the time of the third wave (T1;
Smoking characteristics
At T1, respondents smoked on average 31.5 cigarettes per week (S.D. = 40.5, median = 15), and at T2 smoked 49.7 cigarettes per week (S.D. = 45.4, median = 40). Table 1 presents data on the measurements made in the present study. With respect to parents, 41% of the respondents reported to have two non-smoking parents, 33% reported having one parent who smoked, and 26% reported that both parents were smokers.
Correlations between predictor variables and number of quit attempts and smoking cessation
Of the 695 respondents who did not quit smoking at follow-up, Spearman correlations showed that
Discussion
The present study aimed to elucidate the process of adolescent smoking cessation by examining the patterns of relationships between readiness to quit, nicotine dependence, and parental and peer smoking. First, consistent with the studies of Abrams et al. (2000) and of Farkas et al. (1996) conducted among adults, we found that, compared to readiness to quit, reported symptoms of nicotine dependence in adolescents were more strongly related to actual smoking cessation. In explaining the number of
Conflict of interest
All other authors declare that they have no conflicts of interest.
Acknowledgements
Role of funding source: This study was partly financed by the Dutch Asthma Foundation and STIVORO Smoke Free. The Dutch Asthma Foundation and STIVORO Smoke Free had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors: Regina van den Eijnden and Rutger Engels designed the longitudinal study and wrote the protocol. Rinka van Zundert and Marloes Kleinjan
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