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• Volume 9, Issue 7
• Barriers to smoking cessation: a qualitative study from the perspective of primary care in Malaysia
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• http://orcid.org/0000-0001-7225-2133 Kooi-Yau Chean 1 ,
• Lee Gan Goh 2 ,
• Kah-Weng Liew 1 ,
• Chia-Chia Tan 1 ,
• Xin-Ling Choi 1 ,
• Kean-Chye Tan 1 ,
• Siew-Ting Ooi 3
• 1 Department of Family Medicine , RCSI & UCD Malaysia Campus , Penang , Malaysia
• 2 Department of Family Medicine , National University Health System , Singapore , Singapore
• 3 University of Dublin Trinity College , Dublin , Ireland
• Correspondence to Dr Kooi-Yau Chean; kychean{at}rcsiucd.edu.my , kychean{at}hotmail.com

Objectives This qualitative study aims to construct a model of the barriers to smoking cessation in the primary care setting.

Design Individual in-depth, semistructured interviews were audio-taped, then verbatim transcribed and translated when necessary. The data were first independently coded and then collectively discussed for emergent themes using the Straussian grounded theory method.

Participants and setting Fifty-seven current smokers were recruited from a previous smoking related study carried out in a primary care setting in Malaysia. Current smokers with at least one failed quit attempts were included.

Results A five-theme model emerged from this grounded theory method. (1) Personal and lifestyle factors: participants were unable to resist the temptation to smoke; (2) Nicotine addiction: withdrawal symptoms could not be overcome; (3) Social cultural norms: participants identified accepting cigarettes from friends as a token of friendship to be problematic; (4) Misconception: perception among smokers that ability to quit was solely based on one’s ability to achieve mind control, and perception that stopping smoking will harm the body and (5) Failed assisted smoking cessation: smoking cessation services were not felt to be user-friendly and were poorly understood. The themes were organised into five concentric circles based on time frame: those actionable in the short term (themes 1 and 2) and the long term (themes 3, 4, 5).

Conclusions Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these barriers, which can be guided by the recommended time frames to help patients to succeed in smoking cessation.

• qualitative study
• primary care
• smoking cessation strategies
• grounded theory

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjopen-2018-025491

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Strengths and limitations of this study

As a qualitative study from the primary care perspective, this paper contributes to the limited literature available on smokers’ lived experiences of their attempts to quit smoking.

A diversity of participants from different races and from both high and low nicotine dependence were recruited.

The use of in-depth qualitative methods allowed detailed account of smokers’ experience in smoking cessation.

Focus group interview was not performed in this study because of participant reluctance and hence the opportunity to observe the interaction among participants was unavailable.

Introduction

Cigarette smoking harms almost every organ of the body resulting in premature death in half of all smokers, 1 and unfortunately there are over one billion smokers in the world. 2 The prevalence of ever having tried to quit smoking varies in different countries, for example, less than 20% of smokers in China and Malaysia reported recent attempts to quit. 3 Additionally, the estimated number of attempts before quitting successfully varied widely, ranging from 6.1 to 142. 4 In those who tried to quit smoking, the abstinence rate at 6 months is only 3%–5% among those who self-quit 5 and 19%–33% among those who opt for pharmacotherapy. 6 We must therefore take an in-depth look from a variety of perspectives to understand the reasons contributing to failures in smoking cessation.

Eighty per cent of smokers in the world live in developing countries. 2 Hence, studies related to quit smoking behaviours conducted in the relevant cultural and socioeconomic settings of developing countries are needed.

Malaysia is a developing country with a complex society—ethnically, linguistically, culturally and religious faiths. It has three major races of Malays, Chinese and Indians, with numerous indigenous ethnic groups. Such ethnic and cultural diversity may make smoking cessation a more complicated task for medical practitioners.

Approximately 22.8% of Malaysians smoke. 7 The smoking rate for adult males is 43% 7 and for adult females is 1.4%. 7 The high prevalence of current smokers is associated with males, Malays, the rural population, government servant and those with low educational background. 7 By ethnic distribution, the prevalence of smokers was the highest among the Malays, followed by Indians, then Chinese. 7 There are no statistics available for indigenous groups. Over the past 12 months, 52.3% of current smokers in Malaysia made an attempt to quit smoking. 7 Overall, less than 10% of current smokers visited a healthcare provider with 75.4% of them having been advised to quit smoking. 7

This study was triggered by the results of one of our smoking related study, ‘Assessing Airflow limitation Among Smokers in a Primary Care Setting’ ( https://doi.org/10.21315/mjms2018.25.3.8 ). In that study, the authors found a high prevalence of airflow limitation among smokers and from it implied urgency in helping smokers to quit smoking. So the triggered research question is what barriers prevented smoking cessation from take place.

This study aims to explore barriers to quitting smoking from the perspective of primary care. We chose a qualitative study because ‘this will be able to capture expressive information about beliefs, values, feelings, and motivations that underlie the behaviour’ 8 of participants. The process of comparing and exploring smokers’ answers to our open questions can also potentially lead us to ‘discover’ new patterns of information regarding barriers to quitting smoking in this unique society. Primary care providers with ‘whole person medical practice’ 9 have the most opportunities to help smokers to quit smoking. Identifying barriers to quitting is an important step in both the 5As approach (Ask, Advise, Assess, Assist and Arrange) and the 5Rs approach (Relevance, Risks, Rewards, Roadblocks and Repetition) 10 in brief intervention. Our study will help primary care practitioners in smoking cessation counselling.

Study design

A grounded theory study method was chosen as this will allow a new understanding of the barriers to smoking cessation from the primary care perspective. This study method may be defined as a ‘general method of comparative analysis’ 11 without pre-existing conceptualisation to uncover social processes. A theory is then constructed through the data analysis, 12 which is presented.

Setting and sample

This study was conducted in Penang, Malaysia during January and February 2017. We recruited participants using purposive sampling, which is a ‘non-probability’ and a criterion based sampling technique. 13 Subjects were selected based on certain characteristics, which will enable a holistic and in-depth exploration of the research topic. From a previous smoking related study in 2016–2017, the authors had a ready list of 191 participants with at least one failed quit attempts. Their demographic profile, smoking history and Fagestrom test for nicotine dependence level were also available. We contacted the eligible participants by telephone to explain the purpose and the nature of the study. Participants had the option to meet with investigators at RCSI & UCD Malaysia Campus or an alternative preferred location (including their homes) for an interview. Sample size was determined on the basis of theoretical saturation. Subjects from both high nicotine dependence (Fagerstrom score 6–10) 14 and low nicotine dependence (Fagestrom score 1–5) 14 were included. Twelve invited smokers refused to participate in the study. Eight of them did not give any reason and four stated that they were too busy. We did not manage to organise any focus group discussion as intended because our participants felt that they were too shy to speak in such a group format. In the smoking cessation barriers model presented in this paper, we defined short-term potential modifiable strategies as less than 3 months of smoking abstinence 15 16 and potential long term strategies as 12 months or longer of smoking abstinence 17 18 based on study designs reported in the current literature (2015 to 2019) obtained from PubMed searches.

Data collection

Interview guide.

Opening question:

Please share with us your experience in quitting smoking in the past.

How many times have you tried/did you try (before you succeeded)? When was it?

How long did you stop for?

How did you stop smoking?

What caused you to resume smoking after stopping?

What makes the process difficult?

What is your reflection on this experience? What did you learn from this experience?

Would you like to say something we haven’t talked about and that is important for you?

The interviews were conducted in participants’ preferred language which included English, Malay, Mandarin and Hokkien dialect. The duration of interviews took between 20 and 60 min. The interviews were audio-recorded and transcribed verbatim. Non-English interviews were translated to English by the respective interviewers.

The interviewers met up with the participants within 2 weeks of the interviews to verify the accuracy and to correct any transcription errors. At the second encounter, participants were encouraged to provide additional information if they wished.

Data analysis

Data was anonymised and transcribed. All six researchers started line-by-line open coding independently to ensure that the analysis was holistic and inductive. The researchers then met for axial coding and clustering to develop master headings and subsequently higher categories. Fragmented codes were linked by using the techniques of constant comparison, continual checking and clustering of emerging themes to formulate a theoretical model. 19 QDA Miner Lite software 20 was used to assist with code frequency analysis, coding retrieval and Boolean text search.

Patient and public involvement

No patient or public were involved in the design, recruitment and conduct of the study.

We interviewed 57 participants. Table 1 shows the participants’ demographic characteristics in detail.

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Demographic characteristics of participants (n=57)

Themes generated from grounded theory

Theme 1: personal and lifestyle factors.

A majority of abstinent participants were unable to resist temptation cues when challenged. Their smoking relapses were attributed to the influence of friends who smoked in social activities or work places.

I felt it was because I mingled with friends who are all smokers. So, if I am the only person who has the plan to stop smoking and mix with friends who are still smoking, that is why… because the cigarette is exposed. I don’t have any choice. (Participant 17)

Participants conceded that relapses in smoking cessation were often related to impaired capacity for self-control and lack of intrinsic motivation.

‘Control… no power of control. Self-control is weak, rather weak. (Participant 13)

Some participants related that the decision to resume smoking was rather impulsive.

Yes, it is a mistake. Because I was already not looking for (cigarette) that time, I already was not craving, but just ‘try, try’. After then, it was like learning again, learning again the taste slowly, it was like normal… tried to discipline ah, err. After 1 week, it was very hard, definitely very hard, (I) want to find a cigarette, then (I) must resist, resist the temptation until 2 weeks then it went. By week 3, I feel that even the smells smoke from other smokers make me not comfortable; not because I was craving for a cigarette, but it was because it was like ‘stinky’. After then, gradually 1 month, 2 months, it is ok lah. It is stable. By third month and fourth month like that, definitely I was not looking (for a cigarette). After then, I started to have the urge for a cigarette, so I want to try again, so it was my fault. It was like ‘play… play’ smoke, smoke again, not because of addiction oh. (Participant 17)

In addition, the withdrawal of extrinsic factors that motivated our participants to stop smoking was felt to be the reason for the resumption of smoking. For example, recovering after sickness, release from prison, no longer in a smoking free zone, no longer taking care of a sick relative or no longer being nagged.

I was admitted to ICU (intensive care unit) for five times in IJN (National Heart Institute). So I smoked again after my bypass, I resumed smoking. (Participant 28)

Theme 2: Nicotine addiction

Cigarettes contain highly addictive nicotine, and participants did report overpowering withdrawal symptoms on quitting.

…Stopped 1–2 months, I felt more tired…If I didn’t smoke, I was not able to open my bowel, I became constipated……If I smoked at night, I slept better.(Participant 26)

I was feeling difficult, breathless at times. I also noticed that I had chest discomfort which was more when I work. I had no choice but to smoke again.(Participant 51)

Psychological dependence was clearly highlighted by the pleasure they experienced from smoking. Participants described experiences which were strongly suggestive of psychological addiction to cigarette smoking, regardless if they realised it or not.

That actual problem is our mind, the brain… because why, you know? When we are not smoking, the brain will tell you: ‘There are other smokers there, could you ask him for one cigarette? (Participant 37)

…because for smoker, you feel that something is missing. So, you tend to ask for a stick. Ask for a stick, you know. Then from then starts again. Two sticks…(Participant 41)

Theme 3: Sociocultural norms

Some participants expressed that the offering of cigarettes from friends and relatives was the main reason for their failure to quit. It was normal for smokers to offer their friends and relatives cigarettes as a sign of goodwill and a close relationship.

My friends… They offer and we don’t refuse it. We take it as a token of friendship. (Participant 43)

In some participants, despite having informed their peers that they had quit smoking, they were still coerced into smoking. The peers gave them the impression that smoking a small amount of cigarettes would not affect their ability to quit smoking.

I actually managed to quit—roughly 3 months. After that, I went for a course in Bangi for a week. There, I had colleagues who smoke, they offered me. I said I didn’t want (to smoke) because I’ve quitted. And they said, ‘Never mind, only one… So he gave me, and I smoked. After that, after lunch, he offered me again. (Participant 9)

For Muslim participants, the withdrawal of social and religious motivation after Ramadan (Fasting month) also increased the tendency to relapse.

The month of ‘puasa’ (the fasting month), I was free for the 1 month. Don’t want lah, I don’t want to smoke in front of my family. Then, when it is during ‘iftar’, smoking will waste a lot of time. So, I let myself relax for 1 month. I wanted to rest during fasting month. For my lungs to cleanse it…After the fasting month, I started back but less (cigarette). Sometimes 3–4 sticks, 5–6 sticks. (Participant 23)

Theme 4: Misconception

Smoking cessation is a complex and dynamic process and most smokers make multiple attempts of reduction and abstinence. 21 Some participants perceived smoking cessation as just a game of the mind.

…to quit smoking depends on will power. For me, this is a game of the mind. We set our mind, err, tomorrow, I don’t want to smoke tomorrow, then I will not smoke tomorrow. (Participant 23)

I smoke for ‘saja’ (just for fun), not because of addiction. But, if it is due to emotional problems, up to here (point to his head); there are a lot of problems not solved, and the feeling is up to here (point to head), this is another experience, then there will be just cigarette only. When the mind is not calm, err, finish one stick then another, again and again. (Participant 17)

Patients usually trust their doctors and therefore take their doctors’ recommendation seriously. Ideally, this advice would include cessation tips and the correction of false beliefs and misconceptions.

I stopped abruptly, so I felt breathless. Then my family brought me to the hospital …Then the doctor scolded me, ‘Did you want to die?’ You cannot stop (smoking) completely all of a sudden. If you want to stop, you need to come to the hospital and meet with the MO (medical officer), the doctor, to get their advice… At least you have to smoke one a day. (Participant 9)

Some participants exaggerated or misinterpreted the effects of smoking cessation as harmful to health.

I stopped for a few months then I became frightened. My friends said once stopped, disease will come. Also, I saw my friend (who) died after stopping (smoking). (Participant 11)

There are side effects when stop smoking, after I stopped smoking, I was diagnosed with high blood pressure and had a heart attack as well. (Participant 28)

One participant who believed that secondhand smoke was more harmful than smoking itself.

If I breathe in secondhand smoke, it is more poisonous than if I smoke myself. (Participant 1)

It was interesting to also highlight the belief that smoking might in fact, be therapeutic.

I had that disease (Idiopathic thrombocytopenic purpura) for a long period, I did not know… I suffered from bleeding gum when I brushed my teeth, sometimes it happened spontaneously. So I resumed smoking. Once I started (smoking)… the gum bleed stopped…smoking is good. (Participant 33)

One participant commented that hand-rolled tobacco leaves were less hazardous than commercial cigarettes.

People said ‘rokok daun’ (tobacco leaves) is better when compare to a cigarette. I cannot ‘tahan’ (stand) without smoking…, so, after discharged from the hospital, my friend recommended ‘rokok daun’(tobacco leaves) to me. The smell is there…I tried it and I continue to smoke…At least, this ‘rokok daun’ is better, and I managed to stop the cigarettes. (Participant 49)

Interestingly, there were participants who developed defense mechanisms themselves to ward off the concept that smoking is dangerous/unacceptable. This was particularly true when the participants felt obliged to refrain from smoking in the presence of young children or other family members.

…Sometimes I smoke alone in my own room. But, I, err, I open the windows. My room has air-conditioner but I don’t even turn it on… ‘I turn on the fan to blow away all the smoke. (Participant 6)

Theme 5: Failed assisted smoking cessation

Some participants tried conventional methods (smoking cessation clinics, nicotine replacement therapy) as well as alternative methods such as electronic cigarettes in their attempts to quit smoking. Most participants expressed that pharmacotherapy was ineffective. This perhaps resulted in a negative impression towards the effectiveness of assisted smoking cessation.

Smoking cessation clinic does not work. I tried chewing the gum, no use. Not working at all. Whatever medications they gave to stop smoking did not work. (Participant 16)

I already bought the type of cigarettes, that ‘blocked’, I am not sure if you have heard that before. The one with three cigarettes that is like when you smoke, it has no taste. May be you can quit, but I cannot. I brought from the pharmacy. (Participant 18)

Non-pharmacological factors also contributed to the dropout from smoking cessation clinics. These included the accessibility of the clinic and the language spoken. Language barriers were highlighted because of multiple languages spoken in Malaysia.

I have been to smoking cessation clinic two times. It is just too troublesome to keep going there. (Participant 27)

But I have gone there (stop smoking clinic). They were all Malay and my Malay is not very (good)… I did not really understand. (Participant 1)

Some participants also noted that they did not know the methods available to quit smoking even though they were willing to try them. Participants implied that their medical practitioners did not convey nor educate them in the methods available to help them to quit smoking.

Doctors don’t teach how to stop. And also nobody help you to stop. Do you think so? So, you don’t know the way to stop. (Participant 24)

A descriptive model from grounded theory

Figure 1 presents a descriptive model showing the relationship among the five grounded theory themes of participants’ perceived reasons for failed quit smoking attempts. Notes accompanying the diagram in figure 1 provided examples of each grounded theory theme.

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A grounded theory of barriers to smoking cessation.

The five themes are displayed as five concentric circles to show the relationship of the themes to one another. Theme 1 (Lifestyle & Social Factors) describes the participants perceived the need to ‘avoid presence of smokers, easy access to cigarettes, impaired self-control, and boredom’ in order to avoid nicotine addiction (theme 2). Theme 3 (Social & Cultural Norms) which includes ‘offering and accepting cigarettes as token of friendship’ have had great relapse consequences on abstinent smokers. Theme 4 (Misconception) relates smokers’ lived experiences on why they continue to smoke. Some smokers perceive smoking as a ‘game of the mind’ and they can quit anytime they wish to do so; others continue to smoke because of the misconception that stopping smoking will be harmful to health. Theme 5 (Failed Assisted Smoking Method) describes failures in the healthcare delivery system as perceived by smokers. Participants interviewed in this study had negative experiences of the smoking cessation services received, such as ‘limited accessibility’, ‘language barrier’ and ‘Do not know how the methods work’.

Time frames for overcoming barriers to smoking cessation

In this grounded theory study, we created a model of five themes of smoking abstinence barriers. Two were potentially surmountable in the short term (less than 3 months) and three were potentially surmountable in the long term (12 months or longer) time frames ( figure 1 ).

Smoking cessation is a challenging human process for both patients and doctor alike. Despite many decades of trying, we are struggling to make a significant improvement in cessation rates. A 2014 systematic review of qualitative and quantitative literature by Twyman et al 22 on six vulnerable groups (low socioeconomic; indigenous; mental illness; homeless; prisoners and at risk youths) described three common cessation barriers. These were: smoking for stress management, lack of social support from health and other service providers and a high prevalence and acceptance of smoking in vulnerable communities.

Our study adds to what is known from Twyman et al ’s 22 review. New areas are covered namely; our participants were community based. Demographically, the mean age group (SD) was 58 (10.8); our participants comprise the three major races in Malaysia, with diverse cultural backgrounds. In addition, the uniqueness of the grounded theory method used in this study was that it produced the results on the lived experience of barriers to smoking cessation, which then formed the theory that explained the barriers to smoking cessation.

In Twyman et al ’s study, the duration of ‘short term’ and ‘medium and long term’ in the smoking cessation strategies was not defined. We have defined the time frames based on current literature namely, for short term as less than 3 months 15 ,  16 and long term as 12 months or longer in smoking cessation strategies. 17 18 The two studies agree on lifestyle and individual factors as short-term abstinence strategies, and similarly on cultural factors as long-term abstinence strategies. Misconception as a theme was not identified in Twyman et al ’s paper. We have classified this newly discovered theme as one that requires long-term strategy because the patients who made the remarks were in the precontemplative stage of change namely, smoking cessation ‘as a game of the mind’ and stopping smoking as harmful to health.

There are several conclusions to be taken from this study:

(1) Theme 3: Offering cigarettes to one another is perceived as a sign of friendship and this cigarette culture serves as an impediment to smoking cessation in this society. In China, offering cigarettes is a sign of mutual respect during social events. 23 24 It is customary for a subordinate to light a cigarette for his seniors. 24 Smokers in our community will need to be taught methods of rejecting the offer of cigarettes and reassurance that declining an offer of a cigarette is not seen to be rude.

(2) Theme 3: Smokers find it easier to stop smoking during Ramadan due to the religion, cultural and environmental influences. 25 Although many Muslim smokers (97.7%) 26 in Malaysia smoke fewer cigarettes during Ramadan, only 15% perceive Ramadan as a strong motivator to quit smoking 27 and therefore most relapse after Ramadan. It is also known that such smoking behaviour changes during Ramadan are associated with those of higher incomes, high nicotine dependence and those who are not aware that smoking is ‘haram’ (forbidden). 25 Ramadan should be seen as an excellent opportunity for the implementation of a religious-competent intervention to improve cessation rates.

(3) Theme 4: Our participants revealed a number of misconceptions which were considered to be different from those listed in the literature. 28 For example, misinformation and misconceptions led them to believe that reduction in tobacco consumption is acceptable, but if they were to quit smoking entirely, it will cause disease. Secondhand smoking is perceived to be more harmful than active smoking and therefore they believe that in a smoking environment, active smoking is encouraged. In addition, false beliefs that smoking may be therapeutic or smoking with the fan on or hand-rolled cigarettes are less hazardous is present in this community. Therefore, clinicians should first assess and dispel the relevant false beliefs during counselling sessions.

(4) Theme 1 and Theme 2 interactively: To healthcare practitioners, tobacco smoking is regarded as an addiction. However, to patients, it is regarded as self-determined lifestyle choice. 29 Such discrepancy was observed in this study. It has long been established that nicotine addiction is the biggest cause of failure in smoking cessation. Nicotine can be as addictive as heroin, cocaine or alcohol 30 31 and as a result, attempts to quit smoking are often unsuccessful because of withdrawal symptoms including stress and weight gain. 32 Nevertheless, our participants did not perceive addiction as the major factor of failure, instead they expressed overwhelmingly that quitting smoking is a ‘game of the mind’. Smokers blamed themselves as having poor determination in that stopping smoking is a matter of how they control their mind. This finding is consistent with that of a recent quantitative study 33 which showed that most smokers believe willpower is necessary or sufficient for quitting. Such belief in mind control as the tool to quit smoking undermines the use of formal cessation assistance. The failure to recognise symptoms of addiction of smoking renders smokers to ‘not believe’ in the usefulness of pharmacotherapy. 34 The use of smoking cessation strategies in our setting has been low 35 and we believe such misconceptions contribute greatly to the failure of smoking cessation. Participants were reluctant to receive professional help and preferred to ‘quit’ by themselves. A national survey in 2016 in Malaysia revealed that nearly 80% of former smokers quit without any professional intervention. 35 More work is needed to help smokers to accept that cigarette smoking is highly addictive and that nicotine addiction is very powerful. In addition, healthcare practitioners need to ensure sufficient patient knowledge to improve their confidence to acknowledge withdrawal symptoms and to focus more on the end result during the cessation process.

Limitations

The main limitation of this study is that only in-depth interviews and no focus group interviews were conducted. We did not organise any focus group interviews because the participants were too shy to speak in a group. While the opportunity to observe the interaction among the participants was lost, we managed to gain a more in-depth, detailed account of smokers’ experience without them feeling inhibited to speak in a group.

Another possible limitation is selection bias. The highest education grade completed by the majority (70.1%) of the participants was either primary school or lower secondary education and this could have resulted a ‘less-educated-population’. Nonetheless, we think the data obtained in our study are sufficiently robust to describe reasons contributing to failures in smoking cessation in this community.

Implications and recommendations

We have provided suggestions for applications based on the grounded theory findings in the discussion above. We can use similar grounded theory design to explore theme 2 and theme 5 with the view of defining the extent of ignorance in the symptoms of nicotine addiction; misconceptions and patient concerns on service provision deficiencies and lack of user-friendliness.

In addition, the themes of this model serve as a checklist for clinicians when exploring barriers to smoking cessation. In particular, in step 4 of both the 5A 10 (assist) techniques and 5R 10 (Roadblock) technique of brief intervention for smoking cessation so that appropriate action plan can be tailored accordingly. With all these efforts, hopefully, we could reach better smoking cessation rates.

Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these identified categories to help patients overcome barriers to smoking cessation guided by the time frames recommended by the authors. This study highlighted the importance of sociocultural environment and misconception as factors contributing to the failure to quit smoking in this community. Educating smokers to dispel their misbeliefs is crucial. Development of religiously and culturally competent interventions should be considered to reduce relapse rate.

Acknowledgments

We thank all the participants in this study. We are grateful for their involvement and effort.

We also thank Professor Paul Fogarty for his diligent copyediting of this article.

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Contributors K-YC conceived the idea. K-YC and LGG contributed to the design of the study. K-YC, K-WL, C-CT, X-LC, K-CT and S-TO conducted the individual focus interview, translated and transcribed independently. K-YC, K-WL, C-CT, X-LC, K-YC and S-TO carried out thematic analysis as a group and drafted the original manuscript. K-YC and LGG critically revised the manuscript. All authors provided approval of the final manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The data that support the findings of this study areavailable from the corresponding author, Chean K-Y upon reasonable request.

Patient consent for publication Not required.

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Article Contents

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A Systematic Review of Qualitative Studies on Factors Associated With Smoking Cessation Among Adolescents and Young Adults

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Sarah Bitar, Magali Collonnaz, Jennifer O’Loughlin, Yan Kestens, Laetitia Ricci, Hervé Martini, Nelly Agrinier, Laetitia Minary, A Systematic Review of Qualitative Studies on Factors Associated With Smoking Cessation Among Adolescents and Young Adults, Nicotine & Tobacco Research , Volume 26, Issue 1, January 2024, Pages 2–11, https://doi.org/10.1093/ntr/ntad167

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To summarize findings from qualitative studies on factors associated with smoking cessation among adolescents and young adults.

We searched Pubmed, Psychinfo, CINAHL, Embase, Web of Science, and SCOPUS databases, as well as reference lists, for peer-reviewed articles published in English or French between January 1, 2000, and November 18, 2020. We used keywords such as adolescents, determinants, cessation, smoking, and qualitative methods.

Of 1724 records identified, we included 39 articles that used qualitative or mixed methods, targeted adolescents and young adults aged 10–24, and aimed to identify factors associated with smoking cessation or smoking reduction.

Two authors independently extracted the data using a standardized form. We assessed study quality using the National Institute for Health and Care Excellence checklist for qualitative studies.

We used an aggregative meta-synthesis approach and identified 39 conceptually distinct factors associated with smoking cessation. We grouped them into two categories: (1) environmental factors [tobacco control policies, pro-smoking norms, smoking cessation services and interventions, influence of friends and family], and (2) individual attributes (psychological characteristics, attitudes, pre-quitting smoking behavior, nicotine dependence symptoms, and other substances use). We developed a synthetic framework that captured the factors identified, the links that connect them, and their associations with smoking cessation.

This qualitative synthesis offers new insights on factors related to smoking cessation services, interventions, and attitudes about cessation (embarrassment when using cessation services) not reported in quantitative reviews, supplementing limited evidence for developing cessation programs for young persons who smoke.

Using an aggregative meta-synthesis approach, this study identified 39 conceptually distinct factors grouped into two categories: Environmental factors and individual attributes. These findings highlight the importance of considering both environmental and individual factors when developing smoking cessation programs for young persons who smoke. The study also sheds light on self-conscious emotions towards cessation, such as embarrassment when using cessation services, which are often overlooked in quantitative reviews. Overall, this study has important implications for developing effective smoking cessation interventions and policies that address the complex factors influencing smoking behavior among young persons.

• nicotine dependence
• smoking cessation
• environmental factors
• young adult
• qualitative research
• tobacco control

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A Qualitative Study of Smoking Behaviors among Newly Released Justice-Involved Men and Women in New York City

• PMID: 27263202
• PMCID: PMC4888099
• DOI: 10.1093/hsw/hlw014

Long-term effects of cigarette smoking result in an estimated 443,000 deaths each year, including approximately 49,400 deaths due to exposure to secondhand smoke. Tobacco is a major risk factor for a variety of chronic health problems, including certain cancers and heart disease. In this article, authors present qualitative findings derived from individual interviews with men and women who were incarcerated in New York state and New York City. Participants were 60 racially and ethnically diverse men and women ages 21 through 60 (M = 46.42, SD = 6.88). Of the participants interviewed, 91.7 percent released from a smoke-free correctional facility resumed cigarette smoking and 8.3 percent remained abstinent. Daily consumption ranged from smoking four cigarettes to 60 cigarettes. The four themes that emerged from the study were (1) lifetime exposure to cigarette smoking influences smoking behavior; (2) cigarettes help relieve stress and are pleasurable; (3) there is a relationship between access, availability, and relapse; and (4) smoking cessation strategies are available. Negative influences from participants' families and peers, stressful housing situations, and mandated programs emerged from this study as key challenges to abstaining from smoking cigarettes. Involving family members and partners in smoking cessation interventions could influence newly released justice-involved men and women not to resume cigarette smoking and possibly maintain long-term abstinence.

• Interviews as Topic
• Middle Aged
• New York City / epidemiology
• Qualitative Research
• Risk Factors
• Smoking / epidemiology*
• Tobacco Use Cessation

The Impact of Active and Passive Smoking Upon Health and Neurocognitive Function.

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Opinion 24 March 2016 The Cognitive Deficits Associated with Second-Hand Smoking Jonathan Ling  and  Thomas Heffernan 5,894 views 23 citations

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Original Research 13 January 2016 In vivo Cigarette Smoke Exposure Decreases CCL20, SLPI, and BD-1 Secretion by Human Primary Nasal Epithelial Cells James Jukosky ,  4 more  and  Mardi A. Crane-Godreau 2,770 views 7 citations

Opinion 23 September 2015 Regulatory Issues Surrounding Audit of Electronic Cigarette Charge Composition Mirjana Jovanovic  and  Mihajlo Jakovljevic 2,329 views 6 citations

General Commentary 01 September 2015 The Psychobiological Problems of Continued Nicotine Dependency in E-Cigarette ‘Vapers’. Commentary: “Electronic Cigarettes” Andrew C. Parrott 6,886 views 13 citations

• Open access
• Published: 19 January 2019

Effectiveness of stop smoking interventions among adults: protocol for an overview of systematic reviews and an updated systematic review

• Mona Hersi   ORCID: orcid.org/0000-0003-1784-1167 1   na1 ,
• Gregory Traversy 2   na1 ,
• Brett D. Thombs 3 , 4 ,
• Andrew Beck 1 ,
• Becky Skidmore 1 ,
• Stéphane Groulx 5 , 6 ,
• Eddy Lang 7 , 8 ,
• Donna L. Reynolds 9 , 10 ,
• Brenda Wilson 11 ,
• Steven L. Bernstein 12 ,
• Peter Selby 10 , 13 ,
• Stephanie Johnson-Obaseki 14 , 15 ,
• Douglas Manuel 15 , 16 , 17 , 18 , 19 ,
• Smita Pakhale 15 , 17 , 18 ,
• Justin Presseau 17 , 18 , 20 ,
• Susan Courage 2 ,
• Brian Hutton 1 , 18 ,
• Beverley J. Shea 1 , 18 ,
• Vivian Welch 17 , 18 , 19 ,
• Matt Morrow 21 ,
• Julian Little 18 &
• Adrienne Stevens 1  

Systematic Reviews volume  8 , Article number:  28 ( 2019 ) Cite this article

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Tobacco smoking is the leading cause of cancer, preventable death, and disability. Smoking cessation can increase life expectancy by nearly a decade if achieved in the third or fourth decades of life. Various stop smoking interventions are available including pharmacotherapies, electronic cigarettes, behavioural support, and alternative therapies. This protocol outlines an evidence review which will evaluate the benefits and harms of stop smoking interventions in adults.

The evidence review will consist of two stages. First, an overview of systematic reviews evaluating the benefits and harms of various stop smoking interventions delivered in or referred from the primary care setting will be conducted. The second stage will involve updating a systematic review on electronic cigarettes identified in the overview; randomized controlled trials will be considered for outcomes relating to benefits while randomized controlled trials, non-randomized controlled trials, and comparative observational studies will be considered for evaluating harms. Search strategies will be developed and peer-reviewed by medical information specialists. The search strategy for the updated review on e-cigarettes will be developed using that of the candidate systematic review. The MEDLINE®, PsycINFO, Embase, and the Cochrane Library electronic databases will be searched as of 2008 for the overview of reviews and from the last search date of the selected review for the updated review. Organizational websites and trial registries will be searched for unpublished or ongoing reviews/studies. Two reviewers will independently screen the title and abstracts of citations using the liberal accelerated method. Full-text screening will be performed independently by two reviewers. Extracted data will be verified by a second reviewer. Disagreements regarding full-text screening and data extraction will be resolved by consensus or third-party adjudication. The methodological quality of systematic reviews, risk of bias of randomized and non-randomized trials, and methodological quality of cohort studies will be evaluated using AMSTAR 2, the Cochrane risk of bias tool, and a modified version of the Scottish Intercollegiate Guidelines Network critical appraisal tool, respectively. The GRADE framework will be used to assess the quality of the evidence for outcomes.

The evidence review will evaluate the benefits and harms of various stop smoking interventions for adults. Findings will be used to inform a national tobacco cessation guideline by the Canadian Task Force on Preventive Health Care.

Systematic review registration

PROSPERO (CRD42018099691, CRD42018099692)

Peer Review reports

Prevalence and burden of tobacco smoking

In 2012, approximately 45,500 deaths (18% of all deaths in Canada) were attributed to tobacco smoking [ 1 ]. Smoking continues to be a leading cause of preventable death and disability [ 2 , 3 ]. Among smoking-related deaths, most were attributable to cancers, cardiovascular disease, and respiratory diseases [ 1 , 4 ].

Worldwide, it is estimated that nearly one in seven adults smoke tobacco daily [ 5 ]. According to the Canadian Community Health Survey (CCHS), five million (16%) Canadians over the age of 12 years in 2017 smoked tobacco [ 6 ]. In Canada, daily or occasional smoking is higher in males (19% versus 13%), particularly among those 20 to 34 years of age (24%) [ 6 ]. Among females, smoking is most prevalent in those 50 to 64 years of age (17%) [ 6 ]. Higher rates of smoking have been shown in people with lower education (<secondary education: 20%; completion of university: 10%) and lower income (lowest household income: 23%; highest household income: 12%) [ 7 , 8 ]. The rate of smoking in Indigenous populations is two to three times the national average, ranging from 34 to 53% across First Nations, Métis, and Inuit populations [ 9 ]. Studies suggest that smoking rates are also higher in people with substance use disorders and mental health issues [ 10 , 11 , 12 ]. Although smoking prevalence has declined overall across Canada, smoking rates vary across the country, with Prince Edward Island reporting the lowest (12%) and Newfoundland and Labrador reporting the highest (20%) rates [ 13 ].

Smoking is the leading cause of cancer with evidence linking it to increased risk of several types of cancers including lung, mouth, upper aerodigestive tract, bladder, cervix, colon, and rectum [ 14 ]. Smoking also increases the risk of non-malignant respiratory diseases (e.g. chronic obstructive pulmonary disease, tuberculosis), cardiovascular disease (e.g. coronary heart disease, stroke, artherosclerosis, aortic aneurysm, peripheral vascular disease), reproductive issues (e.g. infertility, spontaneous abortion, premature birth, low birth weight), neonatal death, sudden infant death syndrome, early menopause, osteoporosis, and many other chronic health conditions [ 15 , 16 , 17 , 18 , 19 ]. Tobacco smoking using a water pipe or hookah is associated with lung and esophageal cancer as well as infectious diseases due to sharing of the pipe [ 20 , 21 , 22 ]. Exposure to second- and third-hand smoke also increases the risk of many diseases including stroke, lung cancer, cervical cancer, respiratory diseases, infections, perinatal and neonatal death, and sudden infant death syndrome [ 16 , 23 , 24 , 25 , 26 ].

Smoking is associated with lower health-related quality of life. Longitudinal data from the Canadian National Population Health Survey found that individuals who smoke tobacco had a lower health-related quality of life compared to those who had never smoked. Smoking cessation was associated with improvement in health-related quality of life. In women, health-related quality of life was similar to those who had never smoked tobacco after 10 years of cessation. In men, it took 20 years of cessation to achieve a health-related quality of life equivalent to those who had never smoked tobacco [ 27 ].

In 2012, the total cost of tobacco use in Canada was estimated at $16 billion CDN [ 1 ]. This estimate includes both direct (i.e. hospital expenditure, physician care, medications) and indirect (i.e. economic loss associated with premature death and disability) costs which were approximately $6.5 billion and $9.5 billion, respectively [ 1 ].

Smoking cessation, defined as quitting or the discontinuation of tobacco smoking, reduces the risk of smoking-related diseases and premature death [ 3 , 28 , 29 ]. Quitting at 30 years of age increases life expectancy by a decade while quitting at 40 and 50 years of age increases expectancy by 9 and 6 years, respectively [ 30 ]. For every two individuals who quit smoking tobacco, one will avoid a tobacco-related death [ 31 ]. According to the 2017 Canadian Tobacco, Alcohol and Drugs Survey, about 63% of Canadians who reported smoking at some point in their life have successfully quit smoking [ 13 ]. Among the 44% of respondents who made an attempt to quit in the past year, 16% made a single attempt while 12% attempted four or more times [ 13 ]. In 2017, reducing smoking consumption was the most common cessation method (approximately 63%) among survey respondents, followed by the use of pharmacotherapies (approximately 55%) [ 13 ]. Approximately 32% of those who attempted to quit tobacco smoking in 2017 used electronic cigarettes (e-cigarette) as a cessation method [ 13 ].

Stop smoking interventions

Approved pharmacotherapies.

Nicotine replacement therapy (NRT) and cytisine are available over-the-counter while varenicline and bupropion are available by prescription [ 32 ]. NRT is the most widely used pharmacotherapy for smoking cessation available over the counter. NRT products administer nicotine thereby reducing withdrawal symptoms and cigarette cravings [ 33 ]. It is available in various forms (e.g. patches, chewing gum, lozenges, tablets, buccal spray, and inhalers) and nicotine dosages [ 34 ]. Cytisine is a naturally occurring nicotine partial agonist found in the laburnum plant and is pharmacologically similar to varenicline [ 35 ]. It is approved as a natural remedy for smoking cessation in Canada [ 36 ].

Varenicline and bupropion do not contain nicotine. Varenicline is a nicotine receptor partial agonist that triggers the release of dopamine thereby reducing nicotine withdrawal symptoms and relieving cravings [ 37 ]. Varenicline also prevents the stimulating effects of nicotine [ 38 ]. Bupropion, the only antidepressant medication approved for smoking cessation [ 39 ], is a non-competitive antagonist of nicotinic acetylcholine receptors [ 40 ] and also inhibits uptake of dopamine, serotonin, and noradrenaline [ 41 ]. Although the mechanism of action is unclear, bupropion may promote cessation by reducing nicotine withdrawal symptoms via inhibition of dopamine and noradrenaline reuptake [ 42 ].

Electronic cigarettes

Electronic cigarettes, also known as e-cigarettes, electronic nicotine (or non-nicotine) delivery systems, or vaporizers, represent another potential intervention strategy by which individuals employ behaviour substitution in their efforts to quit smoking. Most e-cigarettes are battery-operated and are used to inhale a vapour that can contain nicotine and other chemicals such as flavourings, propylene glycol, and/or vegetable glycerin [ 43 , 44 ]. A heating element within the device releases liquid that is vaporized into a fog or smoke-like cloud [ 43 ]. These devices can provide similar behavioural and sensory cues of smoking with no or lower levels of nicotine [ 44 ]. There is some evidence to suggest that e-cigarettes significantly reduce exposure to other toxic compounds found in combusted cigarette smoke such as carbon monoxide, acrolein, acetaldehyde, and formaldehyde [ 45 , 46 ]. However, other studies have found that some e-cigarette brands contain high levels of toxic metals including nickel, cadmium, chromium, lead, and manganese [ 47 ]. The recently passed Canadian Tobacco and Vaping Products Act (Bill S-5) now allows adults to legally purchase e-cigarettes containing nicotine in Canada. However, it bans the sale of e-cigarettes to individuals under 18 years of age, specific flavours that are appealing to youth (e.g. confectionary, soft drink), ingredients that suggest health benefits (e.g. vitamin, caffeine), and certain types of advertising and promotion (e.g. health benefits, products using tobacco brands) [ 48 ].

Behavioural therapies

There are various behavioural interventions used for tobacco cessation. Broadly, behavioural interventions may promote smoking cessation directly, be directed to improve adherence to smoking cessation pharmacotherapies, or promote other health behaviour change along with the stopping smoking behaviour (e.g. healthy eating, alcohol reduction).

Behavioural interventions can be classified by intensity (very brief, brief, intensive), frequency of contact, modality of contact, type of provider, and content. These factors can influence the effectiveness of the intervention. Details on the specific behavioural change technique(s) (i.e. the content or “the smallest active ingredients of interventions capable of inducing change in behaviour” [ 49 ]) that are being targeted are essential in determining not only what components of behaviour support systems are effective, but how they can be replicated in practice [ 49 ]. A taxonomy of behavioural change techniques used in individual behavioural support for smoking cessation has been developed to support such evaluations [ 50 ]. Examples of behavioural change techniques include goal setting (e.g. setting a quit date), advice on altering routines to avoid exposure to smoking cues, and providing information regarding withdrawal symptoms [ 50 ].

Another aspect of behavioural change interventions is understanding the psychological theory underpinning the design of the intervention. For example, the Transtheoretical Model of Change, also known as the ‘Stages of Change’ model, is highly used in the smoking cessation literature, but not supported empirically in systematic review evaluations [ 51 , 52 ]. Although these theories may have face validity, evaluating them is important not only to understand effectiveness but also to avoid harms. Evidence suggests that stage-based approaches for smoking cessation are not more effective than non-stage interventions indicating that readiness or motivation to stop smoking may not be integral for quitting [ 51 , 52 ]. Further, stage-based interventions might prevent providers from offering effective treatment to those deemed unmotivated to stop smoking thereby prolonging their exposure to the toxic constituents of smoke.

Brief advice interventions consist of healthcare professionals providing verbal instructions with a “stop smoking message” [ 53 ]. These interventions may vary in intensity, frequency, and duration but generally only last a few minutes. Individual or group therapies are led by counsellors such as physicians, nurses, clinical psychologists, and counsellors. The objective of such interventions is to provide an opportunity for people who smoke to share cessation experiences; derive support; learn coping skills to manage cravings, lapses, and relapses; and promote self-control [ 54 ]. More intensive face-to-face interventions require greater effort and resources and may only reach a small segment of the smoking population [ 55 ]. Telephone counselling can supplement or replace these therapies as a way of providing services to a larger number of people [ 56 ]. These can take the form of proactive (i.e. counsellor-initiated) or reactive counselling (i.e. tobacco smoker-initiated) [ 57 ].

Self-help interventions are information aids, such as manuals or programmes, used by individuals without the direct support of healthcare professionals [ 55 ]. The goal is to provide some of the benefits of brief advice and counselling but without the necessary attendance. Traditional self-help materials, such as print, audio, and video recordings, can be more widely accessible and are increasing their reach via newer technology (e.g. web-based, mobile applications and games, streaming content) [ 58 ]. However, increased reach may not necessarily be more effective if the content of the instruction is not effective.

Some therapies, such as exercise-based interventions, have been used alone or as adjuncts to other interventions. Exercise alleviates withdrawal symptoms and relieves cravings [ 59 ]. Although the mechanism of action is unclear, several hypotheses have been proposed [ 59 , 60 ]. The biological hypothesis suggests that exercise and nicotine have similar impacts on beta-endorphins, cortisol, noradrenaline, and adrenaline [ 59 , 60 ]. For example, like nicotine, exercise stimulates the release of adrenaline and noradrenaline thereby relieving cravings [ 59 ]. Although the evidence is inconsistent, the beneficial effect of exercise on cessation may also be attributed to increases in positive affect or distraction from withdrawal symptoms and cravings [ 59 , 60 ].

Alternative therapies

Alternative therapies for smoking cessation include hypnosis, acupuncture (including acupressure and electrostimulation), and laser therapy [ 59 , 61 ]. It is hypothesized that acupuncture, acupressure, and laser therapy alleviate withdrawal symptoms by stimulating peripheral nerves which triggers release of opioid peptides, dopamine, enkephalin, and serotonin [ 62 ]. The mechanism of action underpinning the effect of hypnotherapy on smoking cessation is related to strengthening impulse control [ 63 ]. St. John’s Wort is a herbal product commonly used by patients as an alternative to standard antidepressant medications [ 64 ]. St. John’s Wort may promote smoking cessation by alleviating tobacco withdrawal symptoms and decreasing negative affect through various mechanisms including inhibition of monoamine oxidase A and B and dopamine and noradrenaline reuptake [ 39 , 65 ]. S-Adenosylmethionine (SAMe), a natural health product, promotes the production of dopamine and norepinephrine and may therefore alleviate tobacco withdrawal symptoms [ 66 ].

Current clinical practice and recommendations

Canadian guidelines.

In 2011, the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT) published recommendations for adults and specific populations (e.g. Indigenous, hospital-based, mental health, substance use disorders, pregnant and breastfeeding women, and youth) that were informed by six guidelines [ 67 ]. CAN-ADAPTT recommends that healthcare providers routinely ask patients about their tobacco use and advise those who smoke tobacco to quit. Those willing to begin treatment should be offered assistance such as brief advice, individual and group counselling (focused on problem-solving skills or skills training and providing support), self-help materials, motivational interviewing, or pharmacotherapies. Where possible, CAN-ADAPTT recommends combining counselling and pharmacotherapies as the preferred approach. Providers are encouraged to follow-up regularly and modify treatment as needed.

The Registered Nurses’ Association of Ontario (2017) released recommendations based on previous guidelines and a systematic review [ 68 ]. They recommend using brief interventions to screen individuals for tobacco use, developing person-centered tobacco intervention plans, referring tobacco users to intensive interventions and counselling on the use of pharmacotherapies (i.e. NRT, varenicline, bupropion), and evaluating the effectiveness of these interventions and adjusting as needed. They conclude that there is insufficient evidence regarding e-cigarettes, hypnotherapy, laser therapy, electrostimulation, acupressure, and acupuncture as cessation tools. For pregnant or postpartum women, they recommended intensive behavioural counselling, in conjunction with NRT.

Guidelines from international organizations

Guidelines from international organizations are consistent in recommending behavioural interventions and/or pharmacotherapies (i.e. NRT, bupropion, and varenicline) for smoking cessation. The UK National Institute for Health and Care Excellence (NICE, 2018) recommends individual or group behavioural support, very brief advice, bupropion, combination of short- and long-acting NRT, or varenicline in conjunction with behavioural support [ 69 ]. New Zealand’s Ministry of Health (2014) recommends brief advice (approximately 30 s), behavioural support, NRT, buproprion, varenicline, and nortriptyline. They consider a combination of behavioural and pharmacotherapy to be the most effective [ 70 ]. As part of their “Risk estimation and the prevention of cardiovascular disease” guideline, the Scottish Intercollegiate Guidelines Network (2017) recommends (1) varenicline or combination NRT (i.e. “interventions involving more than one type of nicotine replacement delivery”) alone or as part of a smoking cessation programme, and (2) bupropion and single NRT [ 71 ]. The US Preventive Services Task Force is currently updating their 2015 guideline [ 17 ]. The 2015 guideline, based on an overview of reviews [ 72 ], recommends behavioural interventions and approved pharmacotherapies (i.e. bupropion, varenicline, NRT). Only behavioural interventions are recommended for pregnant women as the evidence regarding pharmacotherapies was insufficient for this subgroup.

We did not identify any guideline that recommends the use of e-cigarettes for smoking cessation. However, NICE recommends that, when advising those interested in using e-cigarettes containing nicotine, primary health care providers should communicate that “many people have found them helpful to quit smoking cigarettes” and that e-cigarettes, while not without risk, are less harmful than tobacco smoking [ 69 ]. Similarly, Public Health England’s recently developed guidance for clinicians includes e-cigarettes as a smoking cessation option to discuss with patients. The guidance indicates that e-cigarettes present less risk than smoking and that they may be as or more effective than nicotine replacement therapy [ 73 ]. Other organizations state that there is currently insufficient evidence regarding the beneficial effects of e-cigarettes to make recommendations [ 17 , 71 ].

A majority of the available guidelines are out of date (i.e. last database search range: 2008 to 2015). Although recent, the NICE guideline excludes several smoking cessation interventions including varenicline, exercise, and alternative therapies (e.g. acupuncture, hypnotherapy) [ 69 ]. Limitations in existing clinical practice guidelines necessitate the development of a Canadian guideline on tobacco cessation strategies for adults.

Objective and key questions

The goal of this evidence review is to determine the effectiveness of stop smoking strategies for adults. Pharmacotherapy, behaviour change interventions, electronic cigarettes, exercise interventions, and complementary and alternative medicine interventions will be considered. Adult populations will include subgroups of interest such as those with co-morbid conditions, pregnant women, various demographic factors, and the distinction of opportunistic and treatment-seeking individuals. This synthesis will be used by the Canadian Task Force on Preventive Health Care (Task Force) to inform their development of a clinical practice guideline on stop smoking interventions.

The evidence review will consist of two stages. First, the overview of stop smoking interventions will be conducted. An overview of systematic reviews approach was selected to compile the evidence base in light of the large volume of primary and synthesized evidence that exists. The second stage will involve updating the most recent, comprehensive, and high-quality systematic review on e-cigarettes identified in the overview of reviews. Only the e-cigarettes strategy will be updated because of the increasing use of this strategy and its quickly evolving evidence base. This protocol document serves to outline the methodology for both review types.

For the purpose of the evidence review, tobacco smoking will refer to any form of smoked tobacco (e.g. cigarettes, pipes, cigars, cigarillos, via water pipe or hookah). This will not include tobacco use for traditional or ceremonial purposes such as that used by Indigenous people in sacred rituals and prayers for healing and purification [ 74 , 75 ].

Stage 1: Overview of systematic reviews of stop smoking interventions

The overview will evaluate the benefits and harms of stop smoking interventions among adults. If feasible, the overview will also evaluate the benefits and harms of behavioural change techniques (i.e. “the smallest active ingredients of interventions capable of inducing change in behaviour” [ 49 ]). Figure  1 illustrates the framework of the overview of systematic reviews. The overview will address the following key questions:

Key question 1a ( KQ1a ). What are the benefits and harms of interventions to promote cessation of tobacco smoking among adults?

Key question 1b ( KQ1b ). What is the comparative effectiveness (benefits and harms) of interventions to promote cessation of tobacco smoking among adults?

Key question 1c ( KQ1c ). What are the benefits and harms of behavioural change techniques or clusters of techniques to promote cessation of tobacco smoking among adults?

Stage 2: Updated systematic review on e-cigarette use for smoking cessation

This update will evaluate the benefit and harms of e-cigarettes to promote cessation of tobacco smoking among adults. This protocol outlines key questions and eligibility criteria for the updated review. However, should the candidate review from which to update have slightly different parameters, we will transparently declare any necessary changes from the protocol in the final report.

Key question 2a ( KQ2a ). What are the benefits and harms of electronic cigarettes for tobacco smoking cessation in adults?

Key question 2b ( KQ2b ). What is the comparative effectiveness (benefits and harms) of electronic cigarettes for tobacco smoking cessation in adults?

Analytic framework for the overview of reviews. *Practitioner advice (of varying length/intensity, and by various provider types); Intensive individual counselling (of varying length, of varying number of sessions, and by various provider types); Intensive group counselling (of varying length, of varying number of sessions, and by various provider types); Self-help interventions (print-based or web-/computer-based); Internet or computer-based interventions with counselling/support; Telephone-based interventions (e.g., mobile phone-based, quit lines/help lines) with counselling/support; Nicotine receptor partial agonists (varenicline and cytisine); Bupropion; Nicotine replacement therapy (e.g., patch, gum, lozenge, mist, inhaler); Ecigarettes; Exercise interventions; ‘Alternative’ therapies (e.g., acupuncture, acupressure, electrostimulation, hypnosis, St. John’s Wort, S-adenosylmethionine); Combinations of interventions. **Practitioner advice (of varying length/intensity, and by various provider types); Intensive individual counselling (of varying length, of varying number of sessions, and by various provider types); Intensive group counselling (of varying length, of varying number of sessions, and by various provider types); Self-help interventions (print-based or web-/computer-based); Internet or computer-based interventions with counselling/support; Telephone-based interventions (e.g., mobile phone-based, quit lines/help lines) with counselling/support; Other behaviour change interventions evaluated on a case-by-case basis with the Working Group

The evidence review will be completed by the Evidence Review and Synthesis Centre (ERSC) at the Ottawa Hospital Research Institute. A working group (WG) of Task Force members and external content experts was formed for development of the topic, refinement of the key questions and scope, and rating of outcomes. Outcomes were rated on a scale of 1 to 9 according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology; those rated as critical (mean score 7 to 9) and important (mean score 4 to 6) for decision-making were selected. Patients identified through patient engagement activities conducted by the St. Michael’s Hospital Knowledge Translation Program have also rated the outcomes. The process of incorporating patient priorities is described in the CTFPHC’s Patient Engagement Protocol ( https://canadiantaskforce.ca/methods/patient-preferences-protocol/ ).

Reporting of this protocol was guided by the PRISMA Statement for Protocols (PRISMA-P) to the extent possible and where appropriate [ 76 ] (Additional file  1 ). The protocol is registered in PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/ ) (CRD42018099691, CRD42018099692). The final overview will be reported using the Preferred Reporting Items for Overviews of systematic reviews including harms pilot checklist (PRIO-harms) [ 77 ], and the updated systematic review will be reported using PRISMA [ 78 ].

A team of clinical and content experts will be consulted at key points during the conduct of the evidence review. Amendments to this protocol will be noted in the final report.

Guidelines for the conduct of overviews of reviews are currently lacking [ 79 ]. Given this current gap, the methodology for this overview will be guided by the Cochrane Handbook of Systematic Reviews of Interventions ( Chapter 22 ) [ 80 ] as well as other available reports on overview methodology [ 79 , 81 , 82 , 83 , 84 , 85 ].

Literature search

The search strategy will be developed and tested through an iterative process by an experienced medical information specialist in consultation with the review team. We will search Ovid MEDLINE®, Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, PsycINFO, Embase Classic + Embase, and the Cochrane Library on Wiley. Databases will be searched from 2008 to the current date. The draft search strategy can be found in Additional file  2 . The search strategy will be peer-reviewed using the PRESS 2015 guideline [ 86 ]. Results of the PRESS reviews will be provided in an appendix in the final report.

We will search for unpublished literature and reports of ongoing and completed reports using the Canadian Agency for Drugs and Technologies in Health (CADTH) Grey Matters checklist [ 87 ] and through searches of the following websites: CADTH, Ontario Tobacco Research Unit, The Canadian Partnership Against Cancer (cancerview.ca), SurgeonGeneral.gov , Philip Morris, Foundation for a Smoke-free World, Public Health England, Tobacco.org , Truth Initiative, Physicians for a Smoke-Free Canada, Centers for Disease Control and Prevention Smoking and Health Resource Library, Canadian Cancer Society, American Cancer Society, American Thoracic Society, US National Cancer Institute, US National Comprehensive Cancer Network, National Institute for Health and Care Excellence, World Health Organization Framework Convention on Tobacco Control, World Health Organization’s International Clinical Trials Registry Platform, OpenTrials.net , International Prevention Research Institute, North American Quitline Consortium website, and the Ottawa Heart Institute’s Ottawa Model for Smoking Cessation. We will also scan the bibliographies of relevant reviews and other identified overviews for grey literature and references not identified in our database search. Grey literature searching will be restricted to English and French language documents and will be limited to what can be completed within 1 week by one reviewer.

Eligibility criteria

KQ1a and KQ1b will examine interventions that can be delivered or referred to in the primary care setting. This includes certain behavioural change interventions, pharmacotherapies, e-cigarettes, exercise interventions, and alternative therapies (Table  1 ). Interventions that cannot be delivered or referred to by a wide variety of primary care practitioners (e.g. quit-to-win contests, biomedical risk assessment, aversive smoking, incentivized cessation) as well as specific behavioural counselling techniques (e.g. motivational interviewing, stage of change-based counselling) which require specialized training that has been shown to vary [ 88 ] and may not be readily available to all primary care practitioners will be excluded. We will also exclude reviews on broader public health interventions (e.g. mass media, taxation, packaging restrictions) as well as those on broad lifestyle interventions not specific to tobacco smoking behaviour and that do not attempt to isolate for the effect of our included interventions (i.e. when delivered as part of a multifaceted lifestyle intervention). Generally, pharmacotherapies that are not approved by Health Canada as smoking cessation aids (e.g. clonidine, lobeline, anxiolytics, nortriptyline, opioid antagonists, silver acetate, rimonabant) or not available in Canada (e.g. Nicobrevin, Nicobloc, nicotine vaccines, mecamylamine) will be excluded. However, due to their ease of access, an exception will be made for St. John’s Wort (sold in various forms in pharmacies and health stores across Canada), cytisine, and S-adenosylmethionine (SAMe) (licensed natural health products).

Systematic reviews for KQ1a and KQ1b will be selected for inclusion according to the eligibility criteria outlined in Table  1 [ 89 , 90 ].

In addition to the other interventions listed in Table  1 , the intent of KQ1a/b is to capture reviews which examine behavioural change interventions (e.g. practitioner advice, counselling, self-help interventions). These reviews may provide information on the active components of these interventions, referred to as behavioural change techniques . Examples of such techniques include providing information on consequences of smoking, explaining the importance of abrupt cessation, strengthening ex-smoker identity, and receiving prompt commitment from the patient [ 50 ]. If there is sufficient data, subgroup analysis by behavioural change technique or clusters of techniques will be performed for KQ1a/b (see the “ Subgroup analysis ” section).

While the intent of KQ1a/b is to synthesize reviews of behavioural change intervention s (these reviews may or may not report the behavioural change techniques used as part of these interventions), the intent of KQ1c is to capture reviews which specifically examine the effectiveness of behavioural change techniques or cluster of techniques. A taxonomy of behavioural change techniques used in smoking cessation interventions will guide the coding of techniques encountered in the literature [ 50 ].

Eligibility of reviews for KQ1c will be evaluated in consultation with the WG on a case-by-case basis with selection for inclusion dependent on applicability to the primary care setting. For example, the WG may decide to include behavioural change interventions outside of those listed in Table  2 or may decide to include reviews in specialty settings if the review examines behavioural change techniques that can reasonably be applied in primary care. Selection of reviews for KQ1c will be guided by the eligibility criteria outlined in Table  2 . All decisions regarding the selection of reviews will be reported in the completed review.

Study selection

Duplicates will be identified and removed using Reference Manager [ 91 ]. Title and abstract and full-text screening will be conducted using an online systematic review managing software, Distiller Systematic Review (DistillerSR) Software© [ 92 ]. Two reviewers will independently screen the title and abstracts of citations using the liberal accelerated method (i.e. a second reviewer verifies records excluded by a first reviewer). References will be randomized, and screening will be done concurrently to ensure that each reviewer cannot determine whether a given reference was excluded by another reviewer. The full text of potentially relevant citations will be retrieved, and two reviewers will independently assess the article for relevancy. If unclear whether a review is eligible after duplicate review, a third person will be consulted before excluding the review. Conflicts will be resolved by consensus or by consulting with a third team member. The reasons for exclusion at full-text screening will be documented.

Both screening forms will be piloted by reviewers prior to commencement of screening, with adjustments made, as needed, to maximize efficiency. If necessary, articles will be ordered via interlibrary loan. Only those received within 30 days will be included. Exclusions due to unavailability of articles will be noted.

A list of potentially relevant reviews available only in abstract form will be made available, but these studies will not be included in the overview.

Data mapping and overlap detection

Given the proliferation of systematic reviews [ 81 ], we anticipate that we will encounter multiple systematic reviews covering the same research question (i.e. population, intervention, comparison, outcomes, time points, and settings). Such reviews are expected to rely on the same evidence base (i.e. same studies and data); therefore, inclusion of these overlapping systematic reviews may potentially bias the overview findings as the same primary studies are counted more than once [ 93 ].

While there is currently no optimal approach for addressing the issue of overlapping reviews [ 79 ], existing options include the following: (1) limiting inclusion to a single systematic review using a priori established criteria or (2) including all available reviews and computing the degree of overlap [ 79 , 81 , 93 ]. Limiting inclusion to a single systematic review for a given research question may result in missing data, and while inclusion of all available reviews may improve comprehensiveness, it also increases workload and complexity [ 81 ].

To detect and address overlapping systematic reviews, we will first map the research questions (i.e. population, intervention, comparator, outcomes, time points, setting) and characteristics (i.e. date of last search, comprehensiveness, and quality) of all eligible systematic reviews. Where there are multiple reviews addressing the same research question, we will compare the review characteristics and exclude those which are “superseded by a later review, or (contain) no additional (studies) compared with a review of similar, or higher, methodological quality” [ 79 , 94 ]. For example, an up-to-date, high-quality systematic review may report on a single intervention (e.g. acupuncture) while another review, of lower methodological quality and with an older search date, may report on a number of alternative therapies including acupuncture. Although superseded by the former in terms of quality and recency, the latter review captures evidence on additional interventions. Inclusion of both reviews would be necessary to capture all available information on alternative therapies for smoking cessation. In this particular example, we would rely on the former review for data on acupuncture and on the latter for all other interventions (i.e. excluding acupuncture). As described by Pollock et al., the decision to exclude reviews based on these criteria can be a complex process often due to slight differences in research questions [ 94 ]. The criteria above will be used as a guide; with the pool of candidate reviews in hand, information will be mapped to facilitate decisions about potential exclusion. Decisions to exclude reviews due to redundancy will be tracked and documented in a table of characteristics of excluded reviews.

In cases where overlapping data cannot be avoided (i.e. overlapping reviews with similar search dates, quality, and comprehensiveness), we will include overlapping reviews and calculate the degree of overlap using the corrected covered area (CCA) [ 83 , 93 ]. Although reporting the degree of overlap is recommended, it does not minimize or omit potential bias caused by inclusion of overlapping reviews [ 83 , 93 ]. The CCA is calculated using the formula below, where N is the total number of studies across reviews (including multiple occurrences of the same study), r is the number of unique (first occurrence) studies, and c is the number of reviews.

The benefit of the correction for primary studies is that it diminishes the impact of large reviews that may add area but not necessarily overlap. Hence, the CCA corrects for the first time that studies are counted. The higher the CCA value, the greater the overlap among reviews: CCA value 0–5 would represent slight overlap, 6–10 of moderate overlap, 11–15 of high overlap, and > 15 of very high overlap.

Mapping of review characteristics will be conducted by a single reviewer. The decision to exclude a review, using the criteria described above, will be made by two reviewers via discussion, with review by the guideline WG. Where overlapping reviews are included, concordance of results/conclusions will be explored (see the “ Discordance ” section of the manuscript).

Quality assessment of systematic reviews

The methodological quality of reviews will be evaluated according to the AMSTAR 2 instrument (Additional file  3 ). This updated version of the original AMSTAR tool allows for the appraisal of systematic reviews of randomized and non-randomized studies of interventions [ 95 ]. We will evaluate each review against the 16-item instrument. An overall rating of quality will be assigned according to the algorithm suggested by Shea et al. [ 95 ]. Reviews failing to meet any of the seven critical AMSTAR 2 items will be deemed to have a “critical flaw” while non-fulfillment of the remaining items will be deemed a “non-critical weakness” of the review (Additional file  4 ). Reviews with one or more critical flaws will receive a low or critically low rating, respectively. Reviews with no critical flaws will be considered either high or moderate quality depending on the number of non-critical weaknesses (i.e. high-quality reviews have a maximum of one non-critical weaknesses and moderate-quality reviews have more than one weakness). Aside from decisions on inclusion related to assessing duplicate or overlapping reviews, reviews will not need to meet a particular threshold for methodological quality to be included.

The quality of systematic reviews will be evaluated by one reviewer and verified by another. Disagreements regarding by-item and overall rating of quality will be resolved by consensus or third-party adjudication if consensus cannot be reached.

Data extraction and management

Data extraction forms will be developed a priori in DistillerSR and pilot tested on a sample of studies to adjust forms, where needed, to maximize efficiency. Full data abstraction will be completed by one reviewer and verified by a second reviewer. Disagreements will be resolved by consensus or third party adjudication if consensus cannot be reached.

Additional file  5 lists draft items to be collected from reviews during data extraction. We will extract data as synthesized and/or reported in the reviews. We will not consult primary studies for the purpose of data extraction, risk of bias assessment, or for verifying the accuracy of the data reported in the systematic reviews.

We will collect data regarding outcomes of interest as reported by review authors. For reviews reporting a meta-analysis, we will collect the pooled effect estimates, corresponding confidence intervals, and results of statistical tests for heterogeneity (e.g. number of studies, number of participants, chi-square, Cochrane Q, corresponding p values, I 2 ).

For network meta-analyses, ideally sufficient evidence from direct comparisons will be available, and treatment effect estimates along with measures of uncertainty from those analyses will be extracted. However, where little to no evidence from direct comparisons is available and indirect comparison data exist, we will extract both analyses and determine extent of consistency of results and make appropriate interpretations. For indirect comparison analyses, effect estimates and corresponding credible intervals will be collected from indirect comparisons. We will extract and transparently describe if and how authors’ ranking of treatments was used, ensuring appropriateness; ranking may take the form of rank probabilities, mean/median rank, surface under the cumulative ranking (SUCRA) curve, or a P-score [ 96 , 97 , 98 ].

For outcomes where a pooled analysis was not performed, how data are extracted will be informed by authors’ reporting. For example, if effect estimates from primary studies are reported, then a range of those effects could be extracted. In the absence of optimal quantitative data, a narrative summary of findings will be extracted from the reviews. Data will be collected for all reported and relevant (see Table  1 ) time points of follow-up.

Where reviews partially overlap with the scope of interest, such that a subset of studies may be conducted in a different population (e.g. adolescents), setting (not relevant to primary care), or other relevant parameter, we will attempt to determine whether the analyses undertaken are sufficiently direct to the overview question by considering the relative contribution of those studies to the analysis, subject to adequate reporting of this information. How these analyses are handled (inclusion versus exclusion) will be reviewed with the WG for their input; those decisions and any accompanying uncertainty in the applicability of the included results will be detailed in the report.

Subgroup analysis

The overview will seek information on various factors that would typically be considered variables for effect modification. In the case of an overview, we expect to encounter reviews that have undertaken subgroup or meta-regression analyses. There may also be reviews through the process of defining scope that would have focused their interest according to a particular factor, such as evaluating the effects of an intervention in a particular setting. Reviews addressing both of these approaches will be included. Variables of interest listed below are those that we have considered as being potentially important effect modifiers that would influence the development of guideline recommendations or implementation considerations. According to guidance, we have restricted subgroup analysis to characteristics that are measured at baseline rather than after randomization [ 99 ].

Populations

Fewer versus more quit attempts (specific groupings will depend on what is found in the literature)

Opportunistic versus individuals seeking treatment

Baseline level of nicotine dependence (e.g. using a validated scale or cigarettes per day as a proxy)

By demographic factors (age, SES, sex, ethnicity, LGBTQ+)

By comorbid conditions (e.g. mental illness, HIV infection, cardiovascular disease, COPD, obesity, substance use disorder)

By pregnancy status

Intervention-related variables

Dose, type, duration, number of sessions

Specific forms of an intervention (e.g. yoga as a form of exercise)

KQ1a/b: behavioural change technique (e.g. providing information on consequences of smoking, explaining the importance of abrupt cessation, receiving prompt commitment from the patient)

Family medicine clinics

Walk-in clinics

Smoking cessation clinics

Urgent care facilities

Emergency departments

Public health units

Dental offices

Behavioural health/substance use treatment facilities (ambulatory or outpatient)

Academic research settings

Other variables

By industry funding status (subgroup and/or sensitivity analyses performed in eligible reviews will be sought)

Evidence synthesis

While there are both simple (e.g. comparing 95% confidence intervals, statistical test of summary estimates) and complex (e.g. Bucher method, network meta-analysis) methods available for indirect comparisons of treatments across reviews, all approaches are based on the assumption that the primary studies are similar [ 85 , 100 ]. This would require overview authors to be familiar with the primary study literature and not to rely solely on review authors’ reporting of the primary studies [ 85 ]. Given that we will not have opportunity to read and become familiar with the primary study reports themselves, conducting network meta-analyses or informal indirect comparisons of interventions will not be performed. As noted above, any existing network meta-analyses located in the literature will be included and commented on.

Similarly, subgroup analyses within reviews will provide evidence for effect modification. For factors that comprise the focused scope of a given review, as described in the previous section, we will provide the appropriate statements relating to interpretation but be unable to perform comparisons across reviews in the absence of the direct familiarity with the primary studies. Where possible, we will evaluate the credibility of subgroup analyses [ 99 , 101 , 102 ].

Although a narrative synthesis of available evidence to ensure appropriate interpretation will be provided for readers, the use of GRADE tables will facilitate appropriate presentation of this information in tabular form to avoid juxtaposition that may lend to inappropriate comparisons on the part of the reader [ 83 , 85 , 103 ]. Comparisons across reviews with similar scope will be limited to an assessment of the extent of concordance or discordance of the review results and, for discordance, an exploration of a potential explanation.

Discordance

Reviews that overlap in terms of scope may present discordant results and/or conclusions due to variation in eligibility criteria, data extraction, risk of bias assessment, data synthesis approach, or interpretation of the results [ 104 ]. In those instances, we will investigate the source(s) of discordance using the algorithm developed by Jadad et al. as a guide [ 104 , 105 ].

Where overlapping reviews of similar quality rely on the exact same studies, we will investigate whether discordance was due to differences in data extraction (e.g. reviews may have extracted data at different time points of follow-up or reviews may vary regarding definitions of outcomes or outcome measurement methods), heterogeneity testing (e.g. reviews differ in their investigation of clinical and methodological heterogeneity and the decision in which to conduct a meta-analysis), or the synthesis approach (e.g. quantitative versus qualitative synthesis or in the statistical methods used).

If overlapping reviews do not rely on the exact same studies, we will investigate differences in the eligibility criteria. If similar, we will evaluate whether discordance is attributable to differences in the search strategies (e.g. number and type of databases searched, whether grey literature was searched) or in the application of the eligibility criteria. If reviews use different eligibility criteria, Jadad et al. [ 105 ] recommend comparing the publication status of primary studies (e.g. whether there are differences in the inclusion of unpublished reports), evaluation of the methodological quality of primary studies (e.g. differences across reviews regarding the assessment of quality of primary studies and how quality was used in interpreting the results of the review), language restrictions, and quantitative synthesis [ 105 ].

In addition to exploring sources of discordance, we will categorize discordance as follows: (1) direction of effect (i.e. reviews report results in opposite directions), (2) magnitude of effect (i.e. reviews report results in the same direction but differ in the size of the effect estimate), and (3) statistical significance (i.e. statistical significance reached in one review but not others) [ 105 ].

Quality of the body of evidence

The Task Force endorses the use of GRADE methodology for assessing the quality of the body of evidence for critical and important outcomes [ 106 ]. Currently, there are no methods to evaluate the strength of evidence across systematic reviews [ 83 ]. For each outcome of interest reported in each individual review, we will provide GRADE assessments by intervention/comparison [ 107 ]. We will not evaluate the strength of the evidence across reviews.

For reviews that have used GRADE methods, we will provide results for the overall quality of evidence, including reasons for downgrading. If available, we will also report the ratings for each of the five domains of GRADE (i.e. risk of bias, imprecision, indirectness, inconsistency, publication bias). We will not consult primary studies as a quality control measure.

If GRADE methods were not used in a given review, we will attempt to conduct GRADE assessments using information available in the review (e.g. risk of bias assessments). This will likely be challenging due to reporting issues; therefore, we will provide our best interpretation based on the available information and note any limitations. For systematic reviews that include a network meta-analysis, using information reported in the review, we will evaluate the quality of evidence using the GRADE extension for network meta-analysis [ 108 ]. As above, we will not consult primary studies for the purpose of conducting GRADE assessments. We will make note if it is not possible to conduct GRADE for a given review or outcome.

Stage 2: Updated systematic review on electronic cigarettes for smoking cessation

The search strategy for this update will be developed using the search strategy of the candidate systematic review, once identified. The search strategy of the candidate review will be evaluated and modified as necessary. Databases will be searched from the last search date of the review. Using the OVID platform, we will search Ovid MEDLINE®, Ovid MEDLINE® Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase Classic + Embase, and PsycINFO. We will also search the Cochrane Library on Wiley. The final search will be peer-reviewed using the PRESS 2015 guideline [ 86 ]. Results of the PRESS reviews will be provided in an appendix in the final report. The grey literature will be searched using the same approach outlined for the overview of reviews.

Studies will be selected for inclusion using the criteria outlined in Table  3 .

Study selection and data extraction

Study selection and data extraction will follow the same process described for the overview of reviews. Where study eligibility is unclear, authors will be contacted by email twice over 2 weeks for additional information.

We will collect both self-report and biochemically validated tobacco abstinence and relapse. Data will be collected for all reported and relevant (see Table  3 ) time points of follow-up. Where needed, we will convert data (e.g. standard error to standard deviation) to facilitate consistent presentation of results across studies. Authors will be contacted by email twice over 2 weeks if any information is missing or unclear. Refer to Additional file 6 for a list of draft items to be collected during data extraction

We will consult studies included in the original review to ensure that all outcomes of interest (Table  3 ) have been captured.

Risk of bias assessment

For consistency, risk of bias assessments/quality appraisal will be performed for all available studies (i.e. studies included in the original review and newly identified studies). The risk of bias of randomized and non-randomized controlled trials will be assessed by one reviewer using the Cochrane risk of bias (ROB) tool [ 109 ] (Additional file  7 ). We will consider industry funding under the “other sources of bias” domain of the tool. A modified version of the Scottish Intercollegiate Guidelines Network critical appraisal tool [ 110 ] (Additional file  8 ), which accounts for potential sources of bias including that arising from industry funding, will be used to evaluate the quality of prospective cohort studies. Verification will be done by a second reviewer. Disagreements will be resolved by consensus or third-party adjudication.

Some domains are outcome-specific and will be assessed at the outcome level. Overall risk of bias for the body of evidence will be evaluated according to the importance of domains, the likely direction of bias, and the likely magnitude of bias [ 109 ]. The Agency for Healthcare Research and Quality guidance will be followed for evaluating risk of bias for outcome and analysis reporting bias [ 111 ].

Study characteristics will be summarized narratively and presented in summary tables. Where possible, relative and absolute effects with 95% confidence intervals will be calculated for the GRADE summary of findings and evidence profile tables. Risk ratios and risk differences will be used to report effects for dichotomous data. For calculating the risk difference from meta-analyzed data, we will use the median baseline risk for the control group in the included studies, although we may perform sensitivity analysis using differing baseline risks if thought to be suitable. For continuous outcomes, mean difference (i.e. difference in means) effect measures will be used for outcomes using the same measure and standardized mean differences for outcomes using different measures, consistent with GRADE guidance [ 112 ].

Meta-analysis

We will examine the extent of clinical and methodological heterogeneity to determine appropriateness of performing meta-analysis. The Cochrane’s Q (considered statistically significant at p  < 0.10) and I 2 statistic will be used to assess the statistical heterogeneity across included studies [ 113 , 114 ]. If appropriate, data from the original systematic review will be meta-analyzed with data from newly identified studies, using random effects models. For time-to-event data, the hazard ratio will be pooled using the generic inverse variance method. Analyses will be stratified by study design. For observational studies, we will use adjusted risk estimates in the meta-analysis.

Should meta-analysis not be appropriate due to considerable heterogeneity, the range of effects will be presented and results will be discussed narratively. Studies will also be presented in a forest plot without a pooled risk estimate. Clinical and methodological sources of heterogeneity will also be explored using subgroup, sensitivity, and/or meta-regression analyses, depending on how data are reported in studies. We will follow previously published guidance for meta-regression [ 115 ].

Sparse binary data and studies with zero events

Results will be synthesized narratively if studies report rare events. The risk difference will be used for outcomes (e.g. serious adverse events) where at least one intervention group contains zero events.

If there are sufficient data, the following subgroup analyses will be conducted:

By use of other substances (alcohol, cannabis, opioids)

By setting (e.g. family medicine clinics, walk-in clinics, urgent care facilities)

Nicotine content (groupings will depend on what is found in the literature)

Intensity of behavioural therapy (groupings will depend on what is found in the literature)

Duration of e-cigarette usage as part of the intervention (groupings will depend on what is found in the literature)

By type or generation of e-cigarette device

By industry funding

Sensitivity analysis

Sensitivity analyses restricted to low risk of bias studies may be performed. Sensitivity analyses may also be performed to explore statistical heterogeneity or to evaluate the impact of various decisions made during the conduct of the review.

Small study effects

To evaluate small study effects, a combination of graphical aids and/or statistical tests will be performed if there are at least 10 studies in the analysis.

The Cochrane Review Manager software version 5.3 [ 116 ] will be used to conduct analyses. Where needed, Comprehensive Meta-Analysis (CMA) or Stata may be used.

Grading the quality of evidence and interpretation

For critical and important outcomes, the GRADE framework [ 106 , 117 ] will be used to assess the quality of the evidence.

Smoking is a leading cause of preventable death and disability, accounting for nearly 20% of all deaths in Canada. It is estimated that the cost of tobacco use in Canada is around $16 billion CDN, when considering factors such as hospital expenditure, physician care, and economic losses associated with premature death and disability. In response to this important public health care issue, the Canadian Task Force on Preventive Health Care will be developing a national tobacco smoking cessation guideline informed by an overview of systematic reviews of the benefits and harms of various stop smoking interventions for adults and relevant subpopulations, where available. This document has outlined the methods for undertaking the overview and an update of e-cigarette evidence for that overview.

Abbreviations

Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment

Chronic obstructive pulmonary disorder

Electronic cigarette

Human immunodeficiency virus

Key question

National Institute for Health and Care Excellence

Nicotine replacement therapy

Randomized controlled trial

Socioeconomic status

Working group

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Acknowledgements

Other members of the Canadian Task Force on Preventive Health Care who provided additional comments: John Leblanc, Guylène Thériault, John Riva. Detailed descriptions of each member are available at https://canadiantaskforce.ca . The authors also acknowledge Marion Doull and Rachel Rodin from the Public Health Agency of Canada for their input and direction during project scoping and refinement.

Funding for this protocol and subsequent evidence review is provided by the Public Health Agency of Canada. This funding will support all phases of conduct of the evidence review, including the search and selection of the evidence, collection of the data, data management, analyses, and writing. The funder was involved in the development of the protocol and will give approval to the final version. For the conduct of the review, the funder will also be given opportunity to comment, but final decisions will be made by the review team. In addition, the funder will not be involved in study selection, data extraction, or analysis.

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Not applicable.

Author information

Mona Hersi and Gregory Traversy contributed equally to this work.

Authors and Affiliations

Knowledge Synthesis Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Centre for Practice-Changing Research, 501 Smyth Road, Box 201, Ottawa, Ontario, K1H 8L6, Canada

Mona Hersi, Andrew Beck, Becky Skidmore, Brian Hutton, Beverley J. Shea & Adrienne Stevens

Public Health Agency of Canada, Ottawa, Ontario, Canada

Gregory Traversy & Susan Courage

Lady Davis Institute of the Jewish General Hospital, Montreal, Quebec, Canada

Brett D. Thombs

Department of Psychiatry, McGill University, Montreal, Quebec, Canada

Department of Community Health Sciences, University of Sherbrooke, Sherbrooke, Quebec, Canada

Stéphane Groulx

Centre de recherche Charles-Le Moyne – Saguenay–Lac-Saint-Jean sur les innovations en santé (CR-CSIS), Université de Sherbrooke, Quebec, Quebec, Canada

University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada

Alberta Health Services, Calgary, Alberta, Canada

Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada

Donna L. Reynolds

Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Donna L. Reynolds & Peter Selby

Division of Community Health and Humanities, Memorial University of Newfoundland, St. John’s, Newfoundland, Canada

Brenda Wilson

Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA

Steven L. Bernstein

Addictions Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada

Peter Selby

Department of Otolaryngology, University of Ottawa, Ottawa, Ontario, Canada

Stephanie Johnson-Obaseki

The Ottawa Hospital, Ottawa, Ontario, Canada

Stephanie Johnson-Obaseki, Douglas Manuel & Smita Pakhale

Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada

Douglas Manuel

Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Douglas Manuel, Smita Pakhale, Justin Presseau & Vivian Welch

School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada

Douglas Manuel, Smita Pakhale, Justin Presseau, Brian Hutton, Beverley J. Shea, Vivian Welch & Julian Little

Bruyere Research Institute, Ottawa, Ontario, Canada

Douglas Manuel & Vivian Welch

School of Psychology, University of Ottawa, Ottawa, Ontario, Canada

Justin Presseau

Patient representative, Vancouver, British Columbia, Canada

Matt Morrow

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Contributions

MH, GT, AB, and AS drafted the protocol. BS developed the search strategy and provided text for the protocol. JL, BJS, BH, and VW critically reviewed the protocol and provided methodological expertise. SLB, PS, SJO, DM, SP, and JP reviewed the protocol and provided clinical expertise for the review. MM provided a patient perspective for the protocol. Members of the Tobacco Working Group for the Canadian Task Force on Preventive Health Care (BT, SG, EL, DLR, BW) critically reviewed and provided feedback on the protocol. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Mona Hersi .

Ethics declarations

Ethics approval and consent to participate, consent for publication.

Written informed consent to publish was obtained from the stakeholders who provided feedback on the protocol. A copy of the written consent is available for review by the Editors-in-Chief of this journal. The stakeholder feedback has been anonymized and included as Additional file  9 .

Competing interests

BH has received consultancy fees from Cornerstone Research Group for methodologic advice related to systematic reviews and meta-analysis and is a member of the Editorial team for Systematic Reviews . PS reports grants and research support from Pfizer Inc., Bhasin Consulting Fund, and Patient Centered Outcomes Research Institute; consulting fees from Pfizer Canada Inc., Evidera Inc., Johnson & Johnson Group of Companies, Medcan Clinic, NVision Insight Group, and Myelin & Associates; receival of drugs free of charge or at a discounted rate for study through open tender process from Johnson & Johnson, Novartis, and Pfizer Inc.; assisted in organizing the Pfizer Canada Inc. Advisory Board events; and speaking engagements (content not subject to sponsor approval)/honoraria from Pfizer Inc. The remaining authors declare that they have no competing interests.

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Additional files

Additional file 1:.

PRISMA Statement for Protocols (PRISMA-P) checklist. (DOCX 18 kb)

Additional file 2:

Search strategy for the overview of reviews. (DOCX 16 kb)

Additional file 3:

AMSTAR 2 Critical Appraisal Tool. (DOCX 77 kb)

Additional file 4:

AMSTAR 2 critical domains for assessing overall rating of quality. (DOCX 14 kb)

Additional file 5:

Draft data extraction items for the overview of reviews. (DOCX 13 kb)

Additional file 6:

Draft data extraction items for the updated review of e-cigarettes for smoking cessation. (DOCX 12 kb)

Additional file 7:

Cochrane risk of bias tool. (DOCX 29 kb)

Additional file 8:

Modified SIGN methodology checklist for cohort studies. (DOCX 26 kb)

Additional file 9:

Stakeholder feedback. (DOCX 34 kb)

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Hersi, M., Traversy, G., Thombs, B.D. et al. Effectiveness of stop smoking interventions among adults: protocol for an overview of systematic reviews and an updated systematic review. Syst Rev 8 , 28 (2019). https://doi.org/10.1186/s13643-018-0928-x

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• 15 April 2024

Revealed: the ten research papers that policy documents cite most

• Dalmeet Singh Chawla 0

Dalmeet Singh Chawla is a freelance science journalist based in London.

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Policymakers often work behind closed doors — but the documents they produce offer clues about the research that influences them. Credit: Stefan Rousseau/Getty

When David Autor co-wrote a paper on how computerization affects job skill demands more than 20 years ago, a journal took 18 months to consider it — only to reject it after review. He went on to submit it to The Quarterly Journal of Economics , which eventually published the work 1 in November 2003.

Autor’s paper is now the third most cited in policy documents worldwide, according to an analysis of data provided exclusively to Nature . It has accumulated around 1,100 citations in policy documents, show figures from the London-based firm Overton (see ‘The most-cited papers in policy’), which maintains a database of more than 12 million policy documents, think-tank papers, white papers and guidelines.

“I thought it was destined to be quite an obscure paper,” recalls Autor, a public-policy scholar and economist at the Massachusetts Institute of Technology in Cambridge. “I’m excited that a lot of people are citing it.”

The most-cited papers in policy

Economics papers dominate the top ten papers that policy documents reference most.

Data from Sage Policy Profiles as of 15 April 2024

The top ten most cited papers in policy documents are dominated by economics research; the number one most referenced study has around 1,300 citations. When economics studies are excluded, a 1997 Nature paper 2 about Earth’s ecosystem services and natural capital is second on the list, with more than 900 policy citations. The paper has also garnered more than 32,000 references from other studies, according to Google Scholar. Other highly cited non-economics studies include works on planetary boundaries, sustainable foods and the future of employment (see ‘Most-cited papers — excluding economics research’).

These lists provide insight into the types of research that politicians pay attention to, but policy citations don’t necessarily imply impact or influence, and Overton’s database has a bias towards documents published in English.

Interdisciplinary impact

Overton usually charges a licence fee to access its citation data. But last year, the firm worked with the London-based publisher Sage to release a free web-based tool that allows any researcher to find out how many times policy documents have cited their papers or mention their names. Overton and Sage said they created the tool, called Sage Policy Profiles, to help researchers to demonstrate the impact or influence their work might be having on policy. This can be useful for researchers during promotion or tenure interviews and in grant applications.

Autor thinks his study stands out because his paper was different from what other economists were writing at the time. It suggested that ‘middle-skill’ work, typically done in offices or factories by people who haven’t attended university, was going to be largely automated, leaving workers with either highly skilled jobs or manual work. “It has stood the test of time,” he says, “and it got people to focus on what I think is the right problem.” That topic is just as relevant today, Autor says, especially with the rise of artificial intelligence.

Most-cited papers — excluding economics research

When economics studies are excluded, the research papers that policy documents most commonly reference cover topics including climate change and nutrition.

Walter Willett, an epidemiologist and food scientist at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, thinks that interdisciplinary teams are most likely to gain a lot of policy citations. He co-authored a paper on the list of most cited non-economics studies: a 2019 work 3 that was part of a Lancet commission to investigate how to feed the global population a healthy and environmentally sustainable diet by 2050 and has accumulated more than 600 policy citations.

“I think it had an impact because it was clearly a multidisciplinary effort,” says Willett. The work was co-authored by 37 scientists from 17 countries. The team included researchers from disciplines including food science, health metrics, climate change, ecology and evolution and bioethics. “None of us could have done this on our own. It really did require working with people outside our fields.”

Sverker Sörlin, an environmental historian at the KTH Royal Institute of Technology in Stockholm, agrees that papers with a diverse set of authors often attract more policy citations. “It’s the combined effect that is often the key to getting more influence,” he says.

Has your research influenced policy? Use this free tool to check

Sörlin co-authored two papers in the list of top ten non-economics papers. One of those is a 2015 Science paper 4 on planetary boundaries — a concept defining the environmental limits in which humanity can develop and thrive — which has attracted more than 750 policy citations. Sörlin thinks one reason it has been popular is that it’s a sequel to a 2009 Nature paper 5 he co-authored on the same topic, which has been cited by policy documents 575 times.

Although policy citations don’t necessarily imply influence, Willett has seen evidence that his paper is prompting changes in policy. He points to Denmark as an example, noting that the nation is reformatting its dietary guidelines in line with the study’s recommendations. “I certainly can’t say that this document is the only thing that’s changing their guidelines,” he says. But “this gave it the support and credibility that allowed them to go forward”.

Broad brush

Peter Gluckman, who was the chief science adviser to the prime minister of New Zealand between 2009 and 2018, is not surprised by the lists. He expects policymakers to refer to broad-brush papers rather than those reporting on incremental advances in a field.

Gluckman, a paediatrician and biomedical scientist at the University of Auckland in New Zealand, notes that it’s important to consider the context in which papers are being cited, because studies reporting controversial findings sometimes attract many citations. He also warns that the list is probably not comprehensive: many policy papers are not easily accessible to tools such as Overton, which uses text mining to compile data, and so will not be included in the database.

The top 100 papers

“The thing that worries me most is the age of the papers that are involved,” Gluckman says. “Does that tell us something about just the way the analysis is done or that relatively few papers get heavily used in policymaking?”

Gluckman says it’s strange that some recent work on climate change, food security, social cohesion and similar areas hasn’t made it to the non-economics list. “Maybe it’s just because they’re not being referred to,” he says, or perhaps that work is cited, in turn, in the broad-scope papers that are most heavily referenced in policy documents.

As for Sage Policy Profiles, Gluckman says it’s always useful to get an idea of which studies are attracting attention from policymakers, but he notes that studies often take years to influence policy. “Yet the average academic is trying to make a claim here and now that their current work is having an impact,” he adds. “So there’s a disconnect there.”

Willett thinks policy citations are probably more important than scholarly citations in other papers. “In the end, we don’t want this to just sit on an academic shelf.”

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• Published: 10 November 2012

Starting to smoke: a qualitative study of the experiences of Australian indigenous youth

• Vanessa Johnston 1 ,
• Darren W Westphal 1 ,
• Cyan Earnshaw 1 &
• David P Thomas 1 , 2  

BMC Public Health volume  12 , Article number:  963 ( 2012 ) Cite this article

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Adult smoking has its roots in adolescence. If individuals do not initiate smoking during this period it is unlikely they ever will. In high income countries, smoking rates among Indigenous youth are disproportionately high. However, despite a wealth of literature in other populations, there is less evidence on the determinants of smoking initiation among Indigenous youth. The aim of this study was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group.

This project was undertaken in northern Australia. We undertook group interviews with 65 participants and individual in-depth interviews with 11 youth aged 13–20 years led by trained youth ‘peer researchers.’ We also used visual methods (photo-elicitation) with individual interviewees to investigate the social context in which young people do or do not smoke. Included in the sample were a smaller number of non-Indigenous youth to explore any significant differences between ethnic groups in determinants of early smoking experiences. The theory of triadic influence, an ecological model of health behaviour, was used as an organising theory for analysis.

Family and peer influences play a central role in smoking uptake among Indigenous youth. Social influences to smoke are similar between Indigenous and non-Indigenous youth but are more pervasive (especially in the family domain) among Indigenous youth. While Indigenous youth report high levels of exposure to smoking role models and smoking socialisation practices among their family and social networks, this study provides some indication of a progressive denormalisation of smoking among some Indigenous youth.

Conclusions

Future initiatives aimed at preventing smoking uptake in this population need to focus on changing social normative beliefs around smoking, both at a population level and within young peoples’ immediate social environment. Such interventions could be effectively delivered in both the school and family environments. Specifically, health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.

Peer Review reports

There are significant disparities in tobacco use among young people worldwide. In the United States, American Indian and Alaskan Native young adults have the highest prevalence of current cigarette smoking of all ethnic subgroups in the country [ 1 ]. In Australia, 42% of Indigenous Australians are current smokers by early adulthood (15–24 years) [ 2 ]. Many Indigenous smokers begin their habit at a young age. In 2004–05, 10% of Australian Indigenous current and ex-smokers reported they began smoking regularly before the age of 13 years and over two-thirds before the age of 18 years [ 3 ].

Adult smoking usually has its roots in adolescence. If individuals do not take up smoking during this period it is unlikely that they ever will [ 4 ]. Moreover, once smoking becomes established, cessation is challenging; the probability of subsequently quitting being inversely proportional to the age of initiation [ 5 ]. Consequently, the prevention of the onset of adolescent smoking is a key component of efforts to reduce the overall prevalence of smoking and smoking-related morbidity and mortality. This is particularly true for Indigenous Australians for whom tobacco use is responsible for 20% of deaths [ 6 ].

Research reviews and longitudinal studies have revealed an array of often inter-related factors that are associated with smoking initiation and progression [ 7 – 10 ]. These include personal (e.g. age, ethnicity, substance abuse, emotional disorders, risk perceptions), family (e.g. parental smoking, parenting styles, parental attitudes towards smoking, socioeconomic status), social (e.g. peer smoking), and environmental factors (e.g. tobacco advertising, cigarette pricing). The most consistent findings in the literature relate to the influencing role of peers and family on youth smoking behaviour [ 11 – 13 ], while there is emerging evidence on the impact of environmental determinants such as indoor smoking bans [ 14 , 15 ] and social marketing campaigns [ 16 ].

Despite this wealth of literature, there is a paucity of published research that focuses on young Indigenous Australians and tobacco [ 17 ]. One qualitative study in Western Australia investigated smoking experimentation and notions of addiction among youth using focus group methods. The study included a subgroup of Australian Indigenous youth (n = 37) and found they were more likely than non-Indigenous youth to cite stress, boredom and overt encouragement from friends as reasons for smoking [ 18 ]. Overall, this study found that although adolescents had a reasonably good understanding of the concept of addiction, they did not generally regard smoking as particularly addictive at their age. An exploratory study of rural adult Aboriginal women’s experiences of smoking initiation in south-east Australia identified peer and family influences as factors contributing to smoking initiation; participants reported that smoking was normalised within extended family networks and that young women often smoked in order to be accepted among their social networks [ 19 ]. While these recently published studies have shed some light on smoking among Indigenous youth, one was retrospective and limited in its scope by gender and geographical location [ 19 ] and the other did not explore in-depth the broader social and cultural determinants of initiation and smoking [ 18 ]. There are still significant gaps in our knowledge. While there is more research in the international literature that reports on smoking uptake in other Indigenous and minority groups [ 20 – 22 ], they remain a relatively small proportion of the evidence base considering the burden of smoking in these specific populations. Further research is required to understand young Indigenous people’s experiences, behaviours, interactions and social contexts as they relate to smoking, especially in Australia.

The aim of this research project was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group. Specifically, we sought to understand the factors that predispose Indigenous youth to start smoking, or protect them from taking up this behaviour.

Research design

This project was undertaken in northern Australia between June and December 2011. It involved one urban (Darwin) and one remote site (a small mainland community of approximately 1000 residents 580 km east of Darwin). This project took a participatory approach to give young Indigenous people, an often marginalised group, both agency and a voice in research which has direct relevance for them and which may ultimately impact upon them [ 23 ].

We collaborated with a team of four trained Aboriginal ‘peer researchers’ (a male and a female in each site). An opportunity arose early in the research to involve two non-Indigenous peer researchers and recruit a smaller non-Indigenous sample. We included this sample to explore any significant differences in determinants of early smoking experiences and to elicit more data about the wider social and environmental context in which young Indigenous people start smoking. The focus on Indigenous smoking remained unchanged.

We undertook focus group discussions (FGDs) and semi-structured individual interviews. In the focus group discussions we aimed to generate a range and diversity of views on smoking initiation and to explore differing perspectives [ 24 ]. In the interviews we explored individual experiences in more depth to understand the smoking or non-smoking trajectory of individual participants [ 25 ]. Alongside these traditional qualitative methods, we also used visual methods (photography) to explore the social context and social influences of youth smoking.

In recent years, the use of visual methodologies has gained increasing prominence in social research, especially with marginalised communities. The most well known of these methodologies is ‘photovoice’ [ 26 , 27 ], a methodology that uses photography to promote community engagement on health and social issues. The use of photography in this project, while informed by the principles of photovoice, was employed as an individual exercise to promote reflection about the social context and social impact of smoking, as seen through the eyes of young people [ 28 ]. The photos acted as prompts for discussion about smoking and as such the method is more in line with the technique of photo-elicitation, where the emphasis is on the images as a means to unearth rich verbal data in individual interviews, rather than focusing on the visual content of the photos themselves [ 29 ].

We gave disposable cameras to 11 young people (both smokers and non-smokers) and asked them to take photos of how they experienced smoking in their everyday lives. The team then asked participants to talk about the content of their photos and their interpretations of the visual data they had created [ 30 ].

Data collection and analysis

The young peer researchers contributed to defining the final research questions and research methods, recruited participants, undertook the data collection with the support of the research team, and assisted in interpreting the data. All peer researchers attended a two-day training workshop.

We utilised a mix of network and purposive sampling to recruit youth (13–20 years) across key sociodemographic factors: age, gender, and geographical location (urban/remote). We aimed for a mix of never smokers, experimental smokers and regular smokers in the final sample. Our primary points of recruitment were three participating schools (two in Darwin and one in the remote community). However, to include young people who might not be attending school, we recruited through the local social networks of the peer researchers and through a not-for-profit local youth centre in Darwin that caters to at-risk, mostly Indigenous youth. Youth were recruited to take part in focus group discussions initially and from this group a subset were selected for in-depth interviews based on their interest and enthusiasm for the project and ensuring a mix of ages, gender and smoking status.

While we intended to divide FGDs by gender, in most instances this was not possible because of the challenges of getting young people to commit to set times when they had many competing priorities. We ran 15 group interviews; seven of these were run as FGDs. The remaining 8 included only 2 or 3 participants owing to unforeseen circumstances for young participants at the time. In these 8 we loosely followed the focus group interview guide but commonly deviated to a deeper exploration of the personal experiences of one or more participants. We also conducted 11 photo-interviews with individual participants (in one session three Indigenous participants felt more comfortable meeting together). Towards the end of data collection, our sample included a diverse range of participants and no new themes were emerging. While we would have liked to interview more non-Indigenous smokers to compare to our Indigenous cohort, time and resources for the project did not allow this.

We pilot tested the focus group and individual interview guide with our youth researchers. Because they were all members of the eligible target group for this project, we included their interviews as key informant data. Group and individual interviews ranged in duration from 30 to 90 minutes and were held at schools, a youth centre and our research institution. Participants were reimbursed with a AUD$30 gift voucher in recognition for their time and effort. The interviews were audio-recorded and transcribed verbatim for analysis.

We used the theory of triadic influence (TTI) [ 31 ], an ecological model of health behaviour, as an organising theory for data collection and analysis. The TTI asserts that all behaviours are influenced by an interaction of genetic (nature) and environmental (nurture) factors. It divides these factors into three streams of influence on behaviour: environmental (community characteristics, media influences, legislation and policy), social (including parent and peer influences and their attitudes, use of tobacco and characteristics of relationships) and personal (genetic, biological, personality variables, gender, ethnicity and age) [ 8 ]. All three streams flow from causes more distant from the behaviour, over which individuals may not have much control, through to predictors closest (proximal) to the behaviour, providing a cascade of multiple and interacting influences. Proximal predictors are conceptualised as those that predict behaviour, while distal influences help explain it [ 32 ]. We structured the questions relating to why youth smoke in our interview guides around this framework and predictors of youth smoking found in the literature. The topics covered in our semi-structured group and individual interview guides were: age of initiation, where youth smoke and with whom, where they access tobacco at different ages and stages of smoking, why they start smoking and for regular smokers, why they continue to smoke. The individual interviews probed more deeply into individuals’ smoking or non-smoking ‘careers’ to date.

Our first level of analysis organised ‘chunks’ of textual data into open codes that arose inductively from the data. Two authors (VJ and DW) each independently coded a sub-set of the group and individual interviews and then compared coding. Code terms were discussed and refined and after a second level of analysis of the same sub-set of data, codes were grouped into categories and a category codebook was constructed. Consensus was reached through discussion and iterative review of codes and categories. This involved a process of constant comparison between and within categories as we proceeded to work through the data. A third author was available to consult if a consensus could not be reached about the categories; however, this was not needed. The first author completed the remainder of the data analysis using the codebook. The final level of analysis involved elucidating the key themes arising from the data as they corresponded to the theory of triadic influence. After this the first author discussed the findings and her interpretations with the research team, including one Indigenous peer researcher, which elicited further discussion and refinement. The content of photos was not specifically analysed in this study; instead the dialogue generated by the photos were analysed thematically as described above. Data were organised and managed using NVivo 9.

Ethical approval was given by the Human Research Ethics Committee at Menzies School of Health Research, including its Aboriginal sub-committee.

In total we interviewed 65 young people aged 13–20 years in this project. The majority (71%) were Indigenous (see Table  1 for participant demographics). Twenty-six (40%) were female. Of the Indigenous participants, 21 (46%) were smokers (inclusive of occasional and regular smokers). Of the 19 non-Indigenous participants, 3 were smokers. The majority of Indigenous and non-Indigenous participants had experimented with smoking to varying degrees. We were only able to recruit nine participants living in the remote community due to a change in staff roles at the remote community school and the involvement of peer researchers in cultural ceremony business, which meant they were unavailable for long stretches of time. However, we did recruit 22 youth who attended boarding school in Darwin but who resided in a remote community. Approximately 50% of the final sample nominated a remote community as their home. All participants attended school or were employed at the time of the study.

Because our primary aim was to explore the determinants of smoking initiation among Indigenous young people we focus our findings on the prominent themes that emerged from the Indigenous data and draw attention to where there are significant differences with non-Indigenous youth within these themes. Unless indicated, all quotations used to support the emergent themes came from Indigenous participants. In this study, we use the terms youth, young people and adolescents interchangeably to describe our study group (aged 13–20 years).

The findings highlight the particular role of young people’s immediate social context on smoking uptake. While there were other factors that were perceived to influence youth initiation and/or smoking progression, such as personality, stress and nicotine dependence, these were lesser themes and are not detailed in this paper.

Starting to smoke

Participants identified different stages of smoking from first puff and experimentation, through to social or ‘casual’ smoking, and established smoking. These classifications implicitly acknowledge that starting to smoke is not a ‘one off’ event. Instead, it is a dynamic process with several stages between pre-contemplation to established (daily) smoking [ 4 ]. In this study, themes that emerged relating to smoking initiation (i.e. first few cigarettes) highlight the particular role of family influences. Facilitating access to tobacco, role modelling and smoking socialisation were all factors that contributed to early smoking experiences.

‘Trying it out’

Acquiring tobacco from family members was a common route of access for early smoking experimentation, and particularly common for the first puff, which was usually opportunistic and facilitated by the availability of tobacco in the home. Some participants were supplied tobacco directly by family members, usually older cousins or siblings. Young people also took tobacco from ashtrays, cigarette packets, or discarded cigarette butts.

In this study, participants reported that experimenting with smoking commenced usually between the ages of 10 and 13, but it was not unusual to take a first puff before this; as early as seven or eight years. Those who revealed that they initiated smoking earlier generally lived with other smokers and had greater exposure to the behaviour and more ready access to tobacco. A key motivation for experimenting with smoking was curiosity, particularly if there was high exposure among young peoples’ family and/or social networks.

Many Indigenous participants had their first smoking experience and experimented with relatives around their age or older, usually siblings or cousins. Overt pressure from older relatives to try smoking was reportedly not uncommon. Further, family members sometimes played a key role in providing instruction on smoking technique, as well as methods by which to mitigate the taste or physiological effects of tobacco smoke:

Q. Have you tried smoking before?

When I was ten. My sister was a smoker; I used to hang around her a lot. And one night she told me to put some smoke in my lung. So I did…I stole them when mum and dad were asleep. And she told me to have a puff, so I did, but then I started coughing and I said “Yuck, how do you do that?” and she said “If you keep doing it, you get used to it.” And yeah I tried, and she told me “If you swallow it and have a feed, it’s better” and yeah, so I did that…

(Female, smoker, 15 years)

The first puff was universally characterised as a ‘bad’ experience, described as “disgusting” and “yuck.” For some it was such a negative experience that they delayed trying again for a significant period of time. However, if subsequent “tries” were supported by family or peers, the negative physiological effects could be overshadowed by positive reinforcement [ 22 ]. For a few participants, the first puff was instrumental in establishing themselves as non-smokers. Generally, those for whom the physiological effects contributed to their decision not to smoke also received reinforcing messages from their family and/or friends not to smoke.

Family as ‘teachers’

Smoking in the household and among extended family networks was prevalent for youth smokers in this study and a key theme was that of learning to be a smoker through family exposure. “Teaching [smoking] from parents” took various forms. These included being exposed to tobacco and smoking paraphernalia from an early age when asked to roll cigarettes or light a ‘smoke’ for older family members. Direct mimicry and copying adult smoking behaviour using rolled up paper or twigs was also learned through observation. There was the implicit assumption that if parents smoked, it must be sanctioned:

Oh well, as a little kid, like mucking around you know, you copy your parents, you don’t know what they’re doing, you think it’s cool, and then you’re probably like six years old and you just think how cool, I’m going to try it too.

Because you learn a lot when you’re growing up through visual and seeing how everything works really. So it’s accepted and the fact that your family is doing it, so yeah, must be okay if mum’s doing it.

(Male, smoker, 19 years)

This echoes previous qualitative research with Native American youth, who perceived that because smoking was so prevalent among families; it was regarded as ‘normal’ and acceptable behaviour [ 22 ] Further, a permissive or ambivalent attitude by parents of their smoking, lack of or ineffective consequences for youth smoking, and a general lack of monitoring were themes reported by smokers:

Q. Are there rules around where you smoke at home?

Yeah, just not inside, that’s basically it. And I think my brother, because he’s under 18, Mum’s doing the same thing that she did with me. [She says] “If you want to smoke, smoke outside the gate.” So yeah, I think he smokes outside the gate usually when she’s at home, but when she’s not there, he’ll go out the back with everyone else.

Young people reported that parents did not generally give their children tobacco or actively support their smoking behaviour. However, it was perceived that by the time young people reached their mid-late teenage years, parents often thought their children were ‘old enough’ to make their own decisions or that they were beyond parental control to influence their lifestyle choices. This scenario was more commonly described among Indigenous compared with non-Indigenous participants:

Q. Does your father know that you smoke?

I’m pretty sure he’s aware that I smoke; like my step mum does know. Every now and then when I’m stressed out because of him, I will like have one out the back or whatever. And she doesn’t care like, because my older sister does it, and she’s whatever, like she can’t stop us, we’re like older, we’re ourselves now, we’re not little kids.

(Female smoker, 15 years)

Another way in which family facilitated youth smoking behaviour was through smoking together. Sharing of cigarettes or sharing in the act of smoking has previously been found to nurture a sense of belonging and social cohesiveness among Aboriginal families and communities [ 33 ]. Similarly, in this study, some young people reported that sharing a smoke with relatives provided opportunities for socialising, ‘hanging out’ and gaining support, which also reinforced the behaviour:

So it was always good to go talk to my Aunty, because I know that she’s been through a lot through her life, so it was good to talk to her about the issues that I had in my life at the time. And yeah, it was just good to sit down and have a smoke.

While numbers in our sample living in a remote community at the time of the study were small, data from this group and from boarding students suggest that in the remote setting, smoking within families is normative and exposure frequent. High prevalence of smoking in remote Australia and frequent overcrowding support this [ 2 ]. Data elicited from photos taken by three remote interviewees focused on the litter from used butts and discarded cigarette packets in homes and generally around the community (see Figure  1 ). Smoking was also associated with other social activities in remote communities, such as gambling, where young people were provided the opportunity to win disposable income that could be used to purchase tobacco.

Cigarette butts. Three young people in the remote community site discussed this photo during a group interview. It is a photo of a window sill in a home where residents discard their cigarette butts among other rubbish. The participants reported that smoking is common in this remote community; very few households have no smokers living in them. While some households are smoke free inside, many are not.

Findings for the non-Indigenous participants suggested that youth were similarly influenced to smoke by watching family, and frequently accessed tobacco covertly from household supplies. However, there was less indication that they regularly experimented with family members (they smoked mainly with peers) or were actively given tobacco by family members. While experimenting with family was commonplace among Indigenous participants, as described above, some did report that they smoked exclusively with friends and avoided smoking around family, because they were afraid that relatives would disclose their behaviour to parents.

Indigenous and non-Indigenous participants who smoked at the time of interview and who indicated that they had been exposed to family influences to smoke as children reported a progression in their smoking later in high school.

A contrast: the influence of anti-smoking socialisation

While the data mostly focused on determinants of smoking, lack of access to tobacco and role modelling in the home, as well as anti-smoking socialisation from family appeared to be protective against starting to smoke. Explicit parental anti-smoking socialisation was a more significant theme for non-Indigenous, compared with Indigenous participants (although the majority of non-Indigenous participants were non-smokers). Nevertheless, the protective effect of anti-smoking socialisation, when it did occur, appeared to be the same across ethnic groups.

Both Indigenous and non-Indigenous non-smokers generally reported no or less exposure to smoking in their households. A lack of access and direct role modelling was, they perceived, a key determinant of their not becoming smokers, even though most did experiment to varying degrees.

My parents never smoked, so you’re just never really around it… So, none of us smoke… none of my brothers or sisters smoke.

(Female, non-smoker, 18 years)

Additionally, strong anti-smoking socialisation in the home was a central theme among non-smokers. Anti-smoking socialisation by parents included instituting smoke free indoor spaces, not smoking around children, strong anti-smoking messages, and clear and communicated consequences to smoking. This was true even when parents were smokers themselves and appeared to be moderated by whether youth and their parents had a positive relationship characterised by respect and trust. This theme is well illustrated by data elicited by a photo taken by Sandy (a pseudonym), one young woman in this project (see Figure  2 ).

Little brother. My brother came along at an age where I was probably the most likely to make my mind up about smoking. I was around 11 or 12 years old and I had a lot more exposure from my friends.. but then once he came along and my mum stopped, there was just none around the house. It helped reinforce the decision not to smoke. ( Female, non-smoker, 17 years ).

Sandy is a 17 year old Indigenous young woman from a close-knit family living in Darwin. Sandy was exposed to smoking among her immediate and extended family from an early age but despite this, she was brought up not to smoke. While her mum smoked, she never did so around the children. She banned smoking inside the house and provided strong anti-smoking messages, telling them it “was a disgusting habit”. When her two younger brothers were born Sandy’s mum quit for good and this appeared to be a defining moment for Sandy. While she experimented on a few occasions, her dislike of the experience and positive family influences were reportedly central to her decision not to smoke. While many of Sandy’s aunties and uncles smoke, she reported that none of her cousins did; highlighting a generational shift among her family towards not smoking.

Smoking as a social activity

It was during high school (approximately 13–18 years) that progression of smoking from initiation to more frequent experimentation and in some cases regular smoking was perceived to generally occur. Additionally, during this period, the influence of friends and broader social networks on smoking behaviour reportedly increased, as exposure to smoking among peers escalated and smoking assumed a fundamentally social function.

Smoking alone at this developmental stage was not perceived as commonplace. Instead, teenagers smoked where “everyone else smokes;” often in groups in public but out of the view of parents and teachers. In remote communities, adolescents went to secluded water holes and places in the bush to smoke. In the city they smoked at the bus stop (see Figure  3 ), outside the mall and the skate park - common ‘hang out’ or ‘meet up’ spots where smoking was embraced as a social activity. They also smoked at school despite universal ‘No Smoking’ policies. Participants across different schools shared stories of known secluded smoking sites behind the toilets, on the oval, in bushes on the school perimeter where smoking was commonplace.

Bus stop. I see lots of people just having a quick smoke before they go on a bus or kids just sitting around, I don’t know, copying each other, having a smoke before and after they go to school. ( Female, smoker, 15 years ).

Young people acknowledged there were greater restrictions on smokers with smoke free laws. However, the over-riding perception was that such laws did not necessarily impact on smoking initiation, especially as the smoke free regulations young people are most in contact with (at school, bus depot, outside the mall) were commonly flouted by smokers, with perceived negligible consequence. Compliance with smoke free laws in the remote context was perceived as particularly poor. Despite this, a few urban Indigenous participants did reflect on the impact of smoke free areas in denormalising smoking and impacting on behaviour. Those who perceived smoke free laws as effective in preventing youth smoking also generally reported being influenced by other anti-smoking messaging from family and/or media:

But smoking is just becoming you know, more and more banned everywhere and you just - I don’t see it that much anymore, I mean I guess that is a pretty important thing - the lack of smoking in my life is pretty significant.

(Female, non-smoker, 20 years)

As youth progressed from trying smoking for the first time to more regular smoking often during high school, avenues for acquiring tobacco broadened, as has been described elsewhere [ 34 ]. Peers became a more common means to access tobacco, although Indigenous participants in particular cited family members as a continued source of tobacco during adolescence. Friends shared smokes, went halves, and ‘bummed smokes’ off one and other; behaviour that reinforced social bonding through shared experience and consequently reinforced smoking.

Other sources of tobacco included older friends or sometimes strangers who were approached to purchase tobacco. Youth also reported the ability to access a black market where cigarettes were purchased as single sticks at an inflated price. While this practice has been previously identified in remote settings, [ 33 ] this was also reportedly a means to access tobacco for both Indigenous and non-Indigenous youth across schools in the urban setting. Additionally, it was reportedly not uncommon for under-aged youth to purchase tobacco directly at outlets; usually ‘known’ small corner shops where identification of age is rarely required: the larger retail outlets were avoided. This emphasises findings from previous research that has reported that youth are adept at finding outlets that are prepared to sell tobacco to minors [ 35 ] and the difficulties with enforcing bans on sales to underage purchasers [ 36 ].

Starting to smoke to ‘fit in’

Participants noted that during high school years, social pressure to smoke was an increasingly influential determinant of experimentation and progression of smoking. The process of peer socialisation, whereby adolescents take on the values and behaviours of the ‘group’ in order to be accepted [ 37 ], was a theme that cut across Indigenous and non-Indigenous participants, but was a more central theme for female participants generally.

There were differing perceptions as to the prevalence of overt pressure to smoke. Nevertheless, a range of participants did report feeling ‘forced’ into smoking on one occasion or more; the consequences for not smoking included ridicule and humiliation. However, a more consistent theme was that peer socialisation worked more through indirect pressure to conform to social norms, rather than peers providing direct encouragement to smoke. Some young people smoked so as to ‘fit in’ with friends, to avoid being the ‘odd one out’ or an ‘outcast’ among peers:

“They want to be the same as the other ones who smoke…Because if you are a non-smoker and you see them over there, and they are your friends, it doesn’t suit you if you are not smoking. But if you start smoking, it’s like you are a member of that group.”

(Male, non-smoker, 20 years)

Others started to smoke to project or maintain a certain image, again generally to be accepted by a specific group or crowd, or to attract the opposite sex. Smoking in this context played a functional role in assisting young people to reflect an image that was “rebellious,” “cool”, or “grown up”:

Oh well, I grew up running around and yelling out gang names… Yeah so for me it was something to fit in with the group. Now I’m addicted and can’t get off it. So now I’m swearing because it costs me $20.00 a day.

(Female, smoker, 17 years)

“They’re growing up, they think they getting smarter and smarter, like an adult, becoming a woman and not a girl anymore.”

(Female, smoker, 20 years)

Conversely, non-smokers commonly described smoking in pejorative terms, describing it as “gross,” and “disgusting,” and this negative imagery was a key reason given for not starting to smoke. This characterisation of smoking was more dominant among non-Indigenous than Indigenous participants, perhaps reflecting the difference in the degree to which smoking is denormalised in the majority population. Nevertheless, some Indigenous participants reported similar views, especially if they had also received strong anti-smoking messages from their families:

It’s sort of switched from cigarettes being cool to cigarettes being just disgusting and really not, yeah, not cool at all…That’s how I see it.

(Female, non-smoker, 17 years)

Participants perceived that a negative image of smoking had progressively developed as a consequence of the behaviour being less common in the community than it once was. A perceived drop in prevalence, increasing restrictions on smokers as a consequence of smoke free areas, and graphic pack warnings have all assisted in denormalising and to an extent stigmatising smoking, in some instances stigmatising the smokers themselves. This had implications for not only how non-smokers perceived smoking but also how non-smokers related to smokers themselves:

My brother’s like that. If a girl smokes, he doesn’t want a bar of it. It’s just a really big turn off.

Participants also highlighted the particular role of alcohol, usually in the context of social gatherings, in facilitating smoking. Smoking in combination with marijuana was also reported, highlighting the common co-occurrence of tobacco, alcohol and cannabis use in adolescence [ 38 ]. Alcohol use promoted participation in social gatherings in which access and availability of tobacco was increased and social inhibitions and control reduced. Youth who smoked infrequently in the context of social gatherings, and often in association with alcohol were commonly defined as ‘social’ smokers, regardless of the regularity of their smoking behaviour.

The reinforcement of social networks

Related to the theme of peer influence on smoking initiation, is the role that peer behaviour played in maintaining smoking (or non-smoking) behaviour. In the previous section, we described how adolescents reported being socialised to smoke by the influencing norms and behaviours of their social group (peer socialisation). Another avenue through which peer influence led to group homogeneity in smoking and other behaviours is ‘peer selection.’ This describes the process whereby young people gravitate towards or select social networks with similar norms and behaviour to their own [ 39 ]. This is exemplified in the following quote, where a young male smoker described how he was ‘encouraged’ to seek out other smokers, as a consequence of feeling marginalised by the wider school community. In this instance the ‘smokers’ group’ was described as a separate entity with inclusion predicated on smoking status and members exhibiting strong social bonding by virtue of being excluded from the mainstream:

In school, I mean, smoking was something that was frowned upon by most people, so I did feel singled out at that point as well as a smoker, which encouraged me more to hang around with more smokers and begin the cycle of more and more cigarettes going in to my body too …Like the whole smoking group socialised together and we all mixed in after a while because there was no point in being separated because we were all singled out anyway…

This participant’s social context, while providing him with a supportive environment, also contributed to a progression in smoking intensity. This is a reminder of how universal efforts to denormalise smoking may potentially cement smoking in the lives of some youth who find themselves excluded by social practices that are progressively viewed as ‘deviant’ and unacceptable [ 40 ].

Socialising processes that may encourage adolescent smoking also operated to protect young people from smoking [ 41 ], as highlighted by data elicited from a photo taken by one young non-Indigenous woman interviewed for this project (see Figure  4 ). Talking about the image, she explained that her group of non-smoking friends entertained themselves with other activities during school breaks when smokers commonly go for a smoke. As a collective, they found no “need for cigarettes” in their lives and these distinguishing values and behaviours consistently reinforced the group as non-smoking.

Friends. So this is two of my best friends. And so this is at lunch time when a lot of smokers do go for smokes as well. We find other ways to entertain ourselves. So they have their phones out, food, just talking. No need for cigarettes. And sometimes we study during lunch as well. Yeah. My friends don’t smoke, I don’t smoke. These are the people that I’m like really closely knit with. ( Female, non-smoker, non-Indigenous, 15 years ).

Indeed, peers in non-smoking peer groups were often cited as a source of sometimes vehement anti-smoking messages and demonstrated the power of indirect pressure to conform to actual or perceived social norms, particularly in this age group. This was a lesser theme among Indigenous participants but was nevertheless present, as exemplified in the following excerpt, where a young Indigenous woman recalled the negative reaction of her friends on the few occasions she experimented with smoking at parties:

My close friends disapproved highly…they sort of thought that I got what I deserved the next day, from being sick, they weren’t really that sympathetic they were like well, “that’s what you get.” So I guess, like, I think that helped in me not smoking as well; my close friends didn’t approve of smoking at all, they thought it was trashy and they really talked it down a lot.

The findings of this study revealed that for Indigenous (and non-Indigenous) young people, their immediate social environment, that is, family and peer networks, played a central role in smoking initiation and progression. This highlights the social stream of influence within the TTI framework on youth smoking behaviour in this context.

Flay, Snyder and Petraitis [ 32 ] identify that within the social stream, the ‘ultimate cause’ of youth smoking is the social context in which an individual lives. Context determines the breadth, extent and nature of interpersonal interaction [ 42 ]. This flows through to and interacts with the next level of influence at the social-personal nexus, where smoking behaviour is influenced by social bonding to significant others and observed (modelled) behaviours. Family and peer groups have a key role at this level of influence, as this study’s findings demonstrate. The experiences and the information youth gain within these social networks inform and shape their understanding of what is normative and acceptable behaviour [ 40 ]; social normative beliefs about smoking subsequently contribute to young people’s decisions or intentions to smoke [ 32 ].

Our study did not yield detailed information about the broader social context in which youth start to smoke. However, our findings that high exposure to smoking role models as well as to activities that may facilitate tobacco use (e.g. gambling), coupled with perceived poor compliance of smoke free areas in the remote Indigenous context, may shape the interpretation of social norms related to smoking in different ways to urban youth. At the next level of influence, both general parenting practices and smoking-specific practices influenced the development of young peoples’ social normative beliefs around smoking and subsequent smoking behaviour. Lack of, or inconsistent consequences for smoking, was reported by smokers in this study. Similarly, previous research has found that children of parents who have an ‘unengaged’ or more permissive parenting style are more likely to smoke, compared with children whose parents have a more ‘authoritative’ style of parenting (i.e. set clear limits for behaviour, as well as monitor compliance) [ 43 , 44 ]. In this study, low levels of parental efficacy in reducing teen tobacco use and lenient household rules about smoking in the home was also reported, despite parents often providing contradictory anti-smoking verbal messages. Focus group and cross-sectional research with a Native American population in the US suggest that these Indigenous parents may also have more lenient anti-smoking socialisation beliefs compared with other ethnic groups [ 45 , 46 ]. However, this was found to vary more by education level of the parent than by ethnicity [ 46 ], suggesting that socioeconomic and not ethnic status is the more influential determinant of such beliefs.

Related to the theme of parenting, smoking-specific practices within families, including role modelling smoking, facilitating access to tobacco and socialisation into smoking were also influential in smoking uptake among youth. Modelling smoking behaviour was central to how young people ‘learnt’ to smoke, consistent with the well established research finding that parent and sibling smoking is a strong and significant predictor of the risk of smoking uptake by children and young people [ 47 ]. Family as both a direct and indirect source of tobacco was also a significant finding in our study, as has previously been reported among minority and Indigenous ethnic groups in the US [ 20 ]. Socialisation of youth to smoking by other family members included the active initiation of young people to smoking and sharing in the act of smoking. In the Indigenous context particularly, the role of older siblings and cousins in this socialisation process cannot be overlooked. They were frequently the source of tobacco and the instigator of smoking experimentation for young people in the family environment; this has also been reported in other minority and Indigenous ethnic groups [ 22 , 48 ]. While role modelling and access to tobacco were also influential for non-Indigenous youth, they did not report the same degree of active socialisation to smoking as did Indigenous participants.

In contrast to the above, families who engaged in anti-smoking socialisation were reportedly successful in establishing norms around non-smoking and subsequently protecting youth against smoking uptake. Henriksen and Jackson , p.87 [ 49 ] define anti -smoking socialisation as “the transmission of knowledge, attitudes and skills that prepare children to resist smoking”. This can take several forms: establishing household smoking bans, monitoring children’s behaviour and establishing clear expectations of negative consequences for smoking, as well as expressing anti-smoking messages [ 50 ]. In this study, young children who were raised in households with fewer smokers and/or whose family members provided strong anti-smoking socialisation generally reported less inclination to try smoking and if they did try, to progress beyond experimentation. This was particularly the case if parents were non-smokers but appeared to hold, even if parents smoked. Several robust epidemiological studies have upheld the hypothesis that anti-smoking socialisation is protective against youth smoking [ 50 – 52 ]. Further, in this study the effect of these parenting practices appeared to be influenced by the strength of family ties, suggesting an interaction between general and smoking-specific parenting practices, and highlighting the role of social bonding in influencing normative beliefs about smoking.

The other significant influence on social norms around smoking in this study was the peer group. There is no clear consensus in the literature as to the relative importance of family and peer influence on adolescent smoking at different stages of smoking. Some reports suggest that the effect of family smoking is particularly relevant for younger children [ 53 , 54 ], whereas peer group behaviours are more important in influencing smoking during teenage years [ 55 , 56 ]. More recent longitudinal research suggests parental influences are important for initiation and escalation of smoking [ 57 , 58 ]. Peer behaviour too, has been found to affect initiation, progression and trajectories [ 42 ].

Our qualitative design was not able to ‘unpack’ the relative contribution of family and peers on smoking at different stages in this context. However, the data suggest that family influences were particularly salient for smoking initiation and experimentation but also appeared to set the foundation for some youth to progress to more regular smoking during their teenage years, or conversely not to continue beyond experimentation. Peers appeared more influential during adolescence, a critical time of transition to physical and emotional maturity and to a coherent sense of self [ 59 ].

We found evidence for both peer socialisation and peer selection and both significantly influenced social norms around smoking. These processes not only affected smoking initiation but also continued to reinforce smoking beyond initiation. Similar to the two earlier qualitative studies that included Australian Indigenous youth [ 18 , 19 ], we found that peer socialisation is more a normative process and less one of overt pressure to smoke [ 42 ]. Smoking to ‘fit in’ with peers highlights that group membership in adolescence confers significant benefits of acceptance and friendship, but can also require conformity in both attitudes and behaviours, which may be detrimental to health [ 60 ]. A related theme is the role that smoking plays in the creation or experimentation of different social identities [ 61 , 62 ] during this developmental stage. In this study, smoking was used by Indigenous and non-Indigenous participants to reflect a range of social identities from rebelliousness to ‘grown up’; identities that conferred symbolic capital within their various social contexts [ 40 ]. While smoking was used as a ‘style tool’ by some youth to communicate identity and status, it was regarded by others as a “stigmatising liability”, p.77 [ 40 ], influencing normative beliefs against smoking. This finding was more pronounced among non-Indigenous participants.

Our study also found that there is substantial peer group homogeneity in respect to adolescent smoking [ 63 ] with smokers and non-smokers separately ‘clustering’ [ 42 ] in close friendship networks. Peer group membership reinforced social norms around smoking behaviour, acting to reinforce or protect against smoking depending on the composition of the group. This further emphasises that smoking, contrary to being an ‘individual’ lifestyle choice, is instead enmeshed in collective patterns of consumption, and selected from among what is “socially feasible” so as to construct and maintain a social identify that expresses difference both among and between social groups, p.61 [ 64 ]. What this study also highlights is that in a context of falling smoking prevalence, peer influence can also be protective [ 65 ]. This was particularly the case for non-Indigenous participants who were non-smokers but there is evidence of changing social norms among Indigenous youth as well.

There are limitations to this study. We only included a relatively small sample of non-Indigenous participants, and within this sub-group we were only able to recruit a small number of smokers. This means that we were not able to provide a more nuanced comparison across ethnic groups but instead have focused our analysis on the major themes arising for Indigenous youth and the significant similarities and differences between the two ethnic groups. We found few marked differences in the perceptions and reported experiences of smoking by gender, although female participants appeared to be more strongly influenced by peer smoking than boys [ 42 ]. However, if we had conducted separate group interviews for females and males as planned, we may have uncovered more subtle gender differences in smoking behaviours, as has been reported elsewhere in the literature [ 66 ]. Additionally, our findings are more representative of the perspectives of youth in school or employment, which restricted our ability to explore in-depth differences across socioeconomic status, and therefore limit the generalisability of the findings. Finally, the qualitative nature of the study means we must caution against inferring causality between suggested determinants and smoking behaviour of participating youth. Social desirability may have biased participants’ responses and led them to self-censor their actual views. In addition, participants were volunteers who may have different smoking-related attitudes and experiences than Indigenous and non-Indigenous youth in the community.

Despite the limitations, this study is one of the first in Australia to provide in-depth data on the qualitative determinants of smoking among contemporary Indigenous young people. We found that family and peer social influences are particularly salient in smoking uptake among Indigenous youth, emphasising the importance of the social stream of influence within the TTI in this context. Our findings also suggest that the types of social influences to smoke were similar between Indigenous and non-Indigenous youth but that these influences were more pervasive (especially in the family domain) among Indigenous youth. This reflects the fact that Indigenous smoking prevalence is double non-Indigenous prevalence and smoking in many Indigenous families and communities remains a normative social practice [ 19 , 33 ]. The conclusion we draw is that higher rates of smoking uptake among Indigenous Australians are likely attributable to known causes of smoking initiation [ 67 ].

Our findings have implications for both future research and practice. One important avenue for research is to explore the range of responses and beliefs regarding youth smoking from the perspective of Indigenous parents of children and adolescents, as they were excluded from our recent study and we relied solely on young peoples’ reporting of these. This is important given the role of general parenting and smoking-specific practices on youth smoking uptake. Longitudinal research with Indigenous youth to explore both the generalisability of these findings and the differential contribution of family and peer influences on smoking at different stages would be valuable; this may have implications for preventative interventions at different stages of smoking.

Future smoking prevention activities need to focus on changing social normative beliefs around smoking, both at a population level (through smoke free policies and laws and social marketing campaigns) and within young peoples’ immediate social environment. Such activities would complement other effective initiatives to prevent youth smoking, such as increasing the price of cigarettes [ 68 ]. Currently, all Australian states and territories have banned smoking in enclosed public places, particularly workplaces and restaurants [ 69 ]. The Northern Territory has traditionally lagged behind other jurisdictions in implementing smoke free areas. For example, if a majority of staff at a NT school campus agree, the school can designate a discrete outdoor area for smoking if it is not in the line of sight of children. This is in contrast to all other states and territories in Australia that ban smoking on all government school grounds by Education Department policy. The NT Department of Education and Children's Services should consider following other jurisdictions in making the whole of school campuses smoke free. The NT Tobacco Control Regulations should also be amended to remove this exemption relating to NT schools. Importantly, schools should not only implement but enforce smoke free policies, as enforcement of policy (not its existence) is necessary for it to be effective in reducing smoking prevalence among youth [ 1 ].

Another avenue through which schools might intervene to reduce youth smoking is to further explore interventions designed to alter social norms within established peer groups and harness the power of positive peer influences to reduce youth smoking. This has been successfully trialled in the United Kingdom. Drawing on ‘diffusion of innovation’ theory, the Stop Smoking in Schools Trial (ASSIST) utilised trained influential school students to act as positive peer supporters during informal (out of classroom) interactions to encourage young people not to smoke [ 70 ]. The study found a 22% reduction in the odds of being a regular smoker in intervention, compared to control schools for two years after its delivery [ 71 ].

Another obvious area for attention is the family unit, where interventions could be targeted to encourage positive parenting practices, both generally, as well as smoking-specific practices [ 42 ]. A Cochrane review of the effectiveness of interventions to help family members strengthen non-smoking attitudes and promote non-smoking by children or adolescents, found that while the evidence base is limited, some well-executed RCTs show family interventions may prevent adolescent smoking [ 72 ]. Health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.

In conclusion, it is encouraging that this study provides some evidence for changing social norms relating to smoking among young Indigenous Australians. Measures to continue to denormalise smoking and to support families to socialise their children against smoking youth should contribute to reducing smoking uptake in this population and make significant inroads into reducing the disease and death caused by smoking in Indigenous communities.

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Acknowledgements

The team gratefully acknowledges the enormous contribution of the peer researchers who worked on this project: Cyan Earnshaw, Derek Mayo-Spry, Tiffany Wanybarrnga, Alvin Gaykamangu, Jasmine Christie and Renae Williams. We would also like to thank the schools and the Darwin not-for-profit youth centre who participated in the project for their advice and assistance with engaging young people. Lastly, we thank all of the young participants who donated their time and energy to this project and to The Lowitja Institute for funding it.

Vanessa Johnston is supported by a National Health and Medical Research Council (NHMRC) Postdoctoral Training Fellowship for Aboriginal and Torres Strait Islander health research (545241). David Thomas is supported by a National Heart Foundation Research Fellowship (CR 09D 4712). The views expressed in this publication are those of the authors and do not reflect the views of NHMRC or the National Heart Foundation.

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Vanessa Johnston, Darren W Westphal, Cyan Earnshaw & David P Thomas

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All of the authors made contributions to the conception and design of the ‘Starting to Smoke’ study. VJ, DW and CE were responsible for data collection and analysis and all authors contributed to the interpretation of the findings. VJ drafted the manuscript; the remaining authors critically reviewed it and made revisions. All authors have approved the final manuscript.

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Johnston, V., Westphal, D.W., Earnshaw, C. et al. Starting to smoke: a qualitative study of the experiences of Australian indigenous youth. BMC Public Health 12 , 963 (2012). https://doi.org/10.1186/1471-2458-12-963

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Vaping Expectancies: A Qualitative Study among Young Adult Nonusers , Smokers, Vapers , and Dual Users

Paul t harrell.

1 Division of Community Health & Research, Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA, USA

2 Department of Psychiatry & Behavioral Sciences, Eastern Virginia Medical School, Norfolk, VA, USA

Thomas H Brandon

3 Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA

Kelli J England

Tracey e barnett.

4 School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, USA

Laurel O Brockenberry

Vani n simmons, gwendolyn p quinn.

5 Department of Population Health, New York University, New York, NY, USA

Background:

“Expectancies,” or beliefs about outcomes, robustly correlate with and predict several behaviors including electronic nicotine delivery system (“e-cigarette”) use. However, there is limited qualitative research available regarding relevant e-cigarette vaping expectancies.

Objectives:

The present study used a qualitative approach to derive and refine e-cigarette expectancy themes among young adults.

We conducted 12 focus groups and two individual interviews with young adult nonusers , e-cigarette vapers , cigarette smokers, and dual users to assess beliefs about the effects of e-cigarettes. After a series of open-ended questions, follow-up questions assessed reactions to domains previously examined in expectancy measures for cigarette smoking and e-cigarette vaping. The constant comparative method was used to derive themes from transcripts.

Four main themes ( Positive Reinforcement, Social Benefits, Negative Affect Reduction, Negative Consequences ) emerged from the results. Each theme contained three associated subthemes ( Positive Reinforcement : Sensorimotor Experiences, Taste, Stimulation; Social Benefits : Social Facilitation, Influence on Others, Convenience; Negative Affect Reduction : Stress Reduction, Appetite Reduction, Boredom Reduction; and Negative Consequences : Health Risks, Addiction, Secondhand Effects).

Conclusions/importance:

Previously identified smoking expectancies appear relevant for young adult vaping, with some notable refinements. Positive reinforcement aspects encompassed aerosol clouds, vaping tricks, and unique flavors. Social benefits included influencing others via social media and competitive activity, as well as the convenience of use in a variety of places. Negative affect reduction was controversial among user groups, but vaping was seen as more interesting than smoking and thus more effective at boredom reduction. Young adults were uncertain regarding negative consequences, but appreciated a potential for secondhand effects. Measure refinement via qualitative research and future field testing can enhance our understanding of this relatively new behavior, supporting tobacco control surveillance, marketing/labeling regulations, and counter-advertising development/evaluation.

Introduction

The impact of electronic nicotine delivery systems (“e-cigarettes”) on population health continues to be controversial. The extent to which e-cigarettes are helpful or harmful to public health will depend on the differential impact concerning two key groups: (1) cigarette smokers seeking to quit; and (2) youth susceptible to smoking. 1 – 3 For cigarette smokers seeking to quit, switching from cigarette smoking to e-cigarette “vaping” may be an effective harm reduction technique, given the substantially lower levels of harm found with e-cigarette use to date. 1 , 4 , 5 However, e-cigarettes are not harmless 6 , 7 and the evidence regarding the effectiveness of e-cigarettes for quitting cigarette smoking, although supportive, also suggests that long-term use is common. 8 , 9 Thus, current evidence allows for the possibility that e-cigarettes may improve the health of cigarette smokers, provided they are motivated to completely quit smoking. However, long-term use remains a concern.

For youth nonsmokers, there is considerably more concern regarding the rapid levels of growth. 10 , 11 There is widespread agreement that e-cigarette initiation among nonsmokers, particularly youth, should be avoided. The only debate, if any, is regarding whether or not the rates of youth usage constitute an epidemic. 12 , 13 Given that data showing e-cigarette use among youth and young adults is associated with the initiation, persistence, and escalation of cigarette smoking, 7 , 14 e-cigarettes potentially could slow or even reverse reductions in cigarette smoking.

Understanding e-cigarette attitudes and use patterns among young adults may be particularly important. Young adults are more likely than older adults to experiment with e-cigarettes, whether or not they have ever smoked cigarettes. 15 This age range, sometimes referred to as “emerging adulthood” represents a time when youth transition into social contexts (eg, college, workplaces) with tolerance or even promotion of risky behaviors, often resulting in an increased prevalence of substance use and the development of addictive patterns. 16 , 17 Almost all (99%) of those with a history of daily cigarette smoking report trying their first cigarette before the age of 26 years. 18 Although adolescent smoking in the United States has decreased dramatically since 2011, the likelihood of young adult smoking initiation has increased. 19 Indeed, since approximately 2004, nicotine initiation in young adulthood is now more likely than adolescence. 20 , 21 As such, young adults are an ideal population for helping to understand the potential long-term impact of e-cigarettes on public health.

One prominent theoretical construct in predicting behavior, based on social cognitive theory, is referred to as “outcome expectancy,” that is, belief about the result of a behavior. 22 Drug outcome expectancies refer to beliefs about the results of drug use and are a key tool in predicting substance use initiation and continued use. 23 Before use of a substance, drug expectancies are believed to develop from observation via the media, peers, and family members. 24 After use initiation and during continued use, expectancies tend to become stronger, more specific, and more positive (eg, “smoking will help me relax around friends”). 25 E-cigarette expectancies are associated with e-cigarette initiation, 26 – 28 switching from combustible cigarettes to e-cigarettes, 29 vaping frequency and dependence, 30 and intention to quit e-cigarettes. 29

Prior e-cigarette expectancy research primarily used adaptations of existing smoking expectancy measures (eg, “smoking calms me down when I feel nervous” altered to “vaping calms me down when I feel nervous”). 26 , 27 , 29 – 32 For example, 28 of 40 items initially used by Pokhrel and colleagues 26 and 9 of 14 items used by Harrell and colleagues 31 were directly derived from prior smoking expectancy measures. Other research by Hershberger and colleagues 28 used items from a broad variety of sources, including items previously found to be predictive of use or intent to use e-cigarettes and beliefs previously found to be targeted in e-cigarette advertisements, 26 , 27 , 33 – 35 to create a Comparing E-cigarettes and Cigarettes questionnaire. 28 Implicit in much of this research is the assumption that e-cigarette use may be driven by motives similar to cigarette smoking. However, there is little research examining this issue directly.

Qualitative research conducted so far suggests young adult perceptions regarding e-cigarettes may be unique from cigarette smoking. E-cigarette users in Hawaii reported distinctive beliefs related to social, recreational, and sensory outcomes. These included positive beliefs, such as sensory satisfaction, social enhancement, and control over intake, as well as negative beliefs, such as addiction, health consequences, and high expenditures. 36 Focus groups in Connecticut found adolescents and young adults reporting benefits of e-cigarettes including usefulness in quitting cigarette smoking, but also concerns regarding lack of satisfaction, nicotine addiction maintenance, and health impact. 37 , 38 In North Carolina, youth reported appreciating the flavor variety and reduced harm, as well as the ability to modify nicotine content and perform tricks (e.g. French inhale), but disliked the uncertainty regarding content, the addictive potential, and the lack of a cue to stop use. 39

The present study adds to the literature by using qualitative methods to probe for e-cigarette expectancies among young adults. We aspired to understand both why some young adults use e-cigarettes (ie, risk factors for use), and why some do not use e-cigarettes (ie, protective factors against use). Further, beliefs among cigarette smokers are important to understand, as there are considerable concerns regarding prolonged dual use of both substances or transition from e-cigarettes to cigarettes. 7 To investigate these issues, we assembled groups of young adults stratified by their use of cigarettes and e-cigarettes.

Young adults (aged 18–29 years) were recruited from a large metropolitan city in southeastern United States from November 2015 through May 2016. Advertisements publicized a paid opportunity for young adults to provide opinions about e-cigarettes and vaping. Interested participants were screened over the phone to assess if they met inclusion and exclusion criteria for one of the groups for which we were recruiting. Stratification of cigarette use and e-cigarette use yielded four group categories: nonusers; cigarette smokers; e-cigarette vapers ; and dual users . Screening questions asked about prior and current use of cigarettes and e-cigarettes. Based on prior research regarding “established” e-cigarette use, as well as the use of a young adult sample, criteria for substance use included 50 or more lifetime use occasions. 40 As shown on Table 1 , nonusers reported no use of either product in the past month and no more than 50 lifetime use occasions; cigarette smokers reported smoking at least 50 times, current daily smoking, and no e-cigarette use in the past month; e-cigarette vapers reported using e-cigarettes at least 50 times, current daily e-cigarette use, and no smoking in the past month; and dual users reported using e-cigarettes at least 50 times, current daily use of either substance, and past-week use of both substances. We focused on daily, rather than nondaily use, in an attempt to get opinions from consistent, informed users. We screened 209 individuals. Of these, 42 were ineligible due to past-month nondaily use, 29 were ineligible due to age, 9 met criteria for a group for which we were not currently recruiting, and 3 were ineligible due to recent experimental e-cigarette use (<50 lifetime occasions). The remaining 121 met qualification criteria for one of the groups. However, most of these participants were unable to meet during a planned time and did not respond to attempts to follow-up. We enrolled 49 participants in total.

Focus group inclusion criteria: stratification by cigarette and e-cigarette use.

We conducted a total of 14 sessions. These included four focus groups involving young adult nonusers (n = 3, 5, 8, 5), three exclusive cigarette smoker groups (n = 2, 3, 2), three exclusive e-cigarette vaper groups (n = 8, 2, 2), two dual user groups (n = 2, 4), and two individual interviews with dual users . These additional individual interviews were conducted due to both difficulty in recruiting dual users and perceived importance of their perspective, as arguably the most risky group. 41 , 42 Sessions were either conducted at a local community college or at a medical school located near both a community college and a 4-year university. Two research team members, a moderator and a note-taker, facilitated each meeting. Sessions were digitally recorded and lasted approximately 1 hour. To verify smoking status, a Vitalograph BreathCO monitor was obtained to provide expired air carbon monoxide (CO) concentration readings.

After informed consent, the moderator began the session with the aid of a semi-structured interview guide. The session began with a brief summary of the expectancy concept and the research goal of examining expectancies for e-cigarette use. Participants were initially encouraged to respond broadly regarding what they would expect to happen if they were to use an e-cigarette. Follow-up questions were then asked to ensure that all beliefs regarding short-term, long-term, positive, negative, personal, and social effects were addressed. Next, if not previously mentioned, themes from cigarette smoking expectancy questionnaires, 32 , 43 – 45 and the limited research on e-cigarette expectancies available, 26 , 27 , 31 were probed. These included assessment of four domains previously found to be important for college students and adults: Health Risks, Stimulation/State Enhancement, Negative Affect Reduction, and Weight Control; 43 , 44 three domains found to be relevant for adolescents, college students, and adults: Social Impression, Social Facilitation, and Boredom Reduction; 26 , 44 and a domain that was cited as an important factor for e-cigarette initiation: Sensory Experience. 26 Lastly, participants were asked if there were any areas not discussed and if there was anything they wished to add. Participants received $25 for participation. The study protocol was approved by a medical school Institutional Review Board.

Audio recordings were transcribed into verbatim transcripts. Interim analysis was conducted after each set of focus groups to examine if saturation had occurred, that is, themes were being repeated by multiple participants and no new information was emerging. 46 Based on quality standards for qualitative research, 47 , 48 transcripts were coded using inductive content analysis and the constant comparative method. 49 Specifically, the initial code book included the eight a priori themes (domains from the literature) from the interview guide. This allowed for an initial framework upon which subsequent coding could expand on or refute. Transcripts were coded independently by at least two coders, including the lead author and research assistants trained in qualitative coding. If ideal levels of reliability (κ ⩾ 0.8) were not achieved, a third team member was asked to code the transcript. Codes were refined via comparison and discussion, and reorganized into key themes and subthemes until consensus was reached. This analysis phase was repeated until all coding discrepancies were resolved and novel codes no longer emerged (ie, saturation). Novel code emergence and eventual saturation is described below for each theme. Summaries of each code and representative quotes are provided below.

Participant characteristics

The sample was young (M = 20.78 years, SD = 2.36) and majority male (n = 34, 69.4%). As shown in Table 2 , 22 identified as non-Hispanic white, 15 non-Hispanic African American, 4 non-Hispanic Asian, and 2 non-Hispanic multiracial; 6 identified as Hispanic. Approximately half of the participants (n  =  25, 51.0%) were students at a 4-year university. Others were community college students (n  =  9, 18.4%), graduate students (n  =  3, 6.1%), a high school student (n  =  1, 2.0%), and nonstudents (n  =  11, 22.5%).

Sample characteristics (n = 49).

Mean carbon monoxide readings were consistent with self-report of cigarette smoking status ( nonusers M = 0 ppm; vapers M = 1.5 ppm, SD = 1.9; cigarette smokers M  = 17.5 ppm, SD = 6.6; dual users M = 11.2 ppm, SD = 14.1). The majority of nonusers reported never using cigarettes/cigars (n = 17, 77.3%) or e-cigarettes (n = 16, 72.3%), with three nonusers reporting smoking once or twice (13.6%) and two reporting smoking 10 times (9.1%). Two nonusers (9.1%) reported vaping once or twice, one (4.5%) reported vaping 4 times, one (4.5%) reported vaping 20 times, and one (4.5%) reported vaping 30 times. The majority (n = 10, 83.3%) of the vapers reported vaping over 100 times, all (n = 7, 100.0%) of the smokers reported smoking over 100 times, and majorities of the dual users reported both vaping (n = 6, 75.0%) and smoking (n = 6, 75.0%) over 100 times. The majority (n = 7, 58.3%) of the vapers were ex-smokers (over 50 lifetime cigarettes), but the remainder (n = 5, 41.7%) had smoked fewer than 50 lifetime cigarettes. All exclusive vapers reported the use of advanced e-cigarette devices (eg, “rebuildable atomizer,” “tank”), rather than first generation “cig-a-likes.” Most cigarette smokers (n = 5, 71.4%) had never established a pattern of e-cigarette use, with estimates of lifetime use ranging from 0 to 30 times. However, the remaining two were “ex-vapers,” having established a pattern of e-cigarette use previously, but without any current use. All dual users used e-cigarettes in the week prior to screening and most (n = 7, 87.5%) were daily e-cigarette users. A minority (n = 3, 37.5%) used first generation “cig-a-likes,” while most (n = 5, 62.5%) reported use of more advanced devices (eg, mechanical mod, box mod, tank). Additionally, all dual users smoked cigarettes in the past week and three-quarters (n = 6, 75.0%) were daily cigarette smokers.

Content analysis

Positive Reinforcement: Participants noted various positive effects they felt could arise immediately from e-cigarette use. Initially, we coded only for Sensory Experience and Stimulation / State Enhancement. However, reports of the importance of hand movements (described below) resulted in changing this theme to describe Sensorimotor Experiences. In addition, reports of taste appeared frequently enough to merit its own theme. Thus, Positive Reinforcement effects included Sensorimotor Experience, Taste, and Stimulation.

Numerous sensorimotor experiences were described. See Table 3 for full quotes by group. Nonusers noted that “on social media, there are people that like doing like weird tricks” that are “fun to watch.” Vapers reported that they liked “seeing the cloud” and that it was “visually satisfying.” Dual users noted that some people refer to themselves as “cloud chasers” who “have competitions.”

Example quotations within the main theme of Positive Reinforcement.

“I do know a couple of people who do vape who have never smoked a cigarette in their life. Only because you can do tricks and stuff with it. You can have fun with it. The vapor, it is a rather thick vapor – that is the vegetable glycerin doing that – and you can do different things with it. You can blow O’s, you can make tornados.” (Dual user)

We used the term “sensorimotor experience,” rather than simply “sensory experience” to include hand movements. Nonusers observed that “everyone today is on their phone” and “when they are not on their phone, [e-cigarette users] have a vape,” so they always have “something to do with their hands.” Indeed, users reported they valued being able to do “something with my hands” and “craved the inhaling” experience that was similar to smoking.

“I’m a twitchy person. I play drums when I was little all the way up, and I have to be doing something with my hands ‘cause I can’t smoke so that really does [help]. . . keeping your hands busy and always constantly doing something.” (E-cigarette vaper)

Taste was added as its own category due to repeated mentions, both positive and negative. A nonuser reported curiosity about the flavors.

“He [my friend] has a bubble gum flavor and I like the bubble gum smell. And I’m like, ‘That smells really really good. I bet it tastes just like bubble gum.’ But then, I’m like, ‘I probably shouldn’t do it.’” (Nonuser)

A vaper emphasized that you are doing it for “the flavor,” but cigarette smokers felt it would not be “strong enough” and would be “watery” or “just nothingness.” An ex-vaping smoker also noted issues with “burnt out” coils in the e-cigarette that taste “horrible.” Dual users enjoyed the “variety” and “choice,” but also noted that sometimes you needed the “original taste” and “hit” from cigarettes. There was some disagreement, however, about whether the flavor or the nicotine were more important.

“With me, it is more of a flavor thing ‘cause I’ve always smoked Marlboro Reds and I’ve never had a juice that could replicate that flavor. . . It is kind of an acquired taste after a while. It is just something that a vape can’t really achieve. Maybe it’ll be easier to replicate as time progresses. . . It’s not so much the nicotine thing for me. Just the flavor.” (Dual user)

Participants also commented on the Stimulation effects of e-cigarettes, with all groups repeatedly using the term “buzz” to describe the experience, although some cigarette smokers felt the stimulation would be “weaker.” Users also commented on the ability to modify nicotine dosage.

“I started with a higher level because the average cigarette is somewhere around 32 mg nicotine. You get a really strong buzz. So I went to 12 mg so I would get a little bit of the same feeling but not intense and crazy like it would be.” (Dual user)

Social Benefits: Several positive potential interpersonal benefits were noted by the participants. Initially, these were coded solely as Social Impression and Social Facilitation, but additional themes of Influence on Others and Convenience emerged. Relatively low codes of Social Impression resulted in the abandonment of this theme. Thus, Social Benefits codes included Social Facilitation, Influence on Others, and Convenience. As shown in Table 4 , participants noted Social Facilitation as a potential advantage of e-cigarettes, as use had “all the social aspects of smoking,” so that participants could hang “out with friends” who smoke cigarettes and still feel “like you maybe belong.” In addition, users were able to participate in social events related to e-cigarettes. Indeed, some felt vaping was more social than traditional smoking.

Example quotations within the main theme of Social Benefits.

“I would say [with vaping] it’s even a bigger social aspect [than smoking] because you have – you don’t have cigarette conventions, you don’t have shops where you go sit down, relax, and smoke. There’s a large social aspect to [vaping] and I think it’s a great thing.” (E-cigarette vaper)

Another social benefit noted was Influence on Others. Nonusers reported concerns that e-cigarette use was becoming a trend among youth.

“It’s a danger with the art part of it. You make these rings and they look cool and the kids be like, ‘I want to do that’ but then do it later with a real cigarette maybe.” (Nonuser)

In contrast, vapers appeared to enjoy getting others to try the devices, particularly if it could help others quit cigarette smoking. Both vapers and dual users reported that others will “try out” their devices “to see what the craze is all about.”

“I’ve had people walk up to me and ask, ‘What this is?’ And I’ve talked to them about it because a lot of people smoke and are trying to get out of it. So I talk to a lot of people who smoke about vaping and they usually walk away pretty satisfied with the conversation.” (E-cigarette vaper)

Convenience also came up as a notable aspect of e-cigarettes. Nonusers were concerned e-cigarettes are used more than traditional cigarettes “because it is easier and more convenient.” E-cigarette vapers agreed.

“It’s not like a cigarette where you are restricted to certain areas. It’s a lot more accessible and you can use them in a lot more places.” (E-cigarette vaper)

In addition, users appreciated that they can “decide how long you want to do it for instead of the cigarette telling you.”

“So, just to have that convenience of – pull it out, take a puff, and put it back wherever it was – allows you to do whatever you were doing and go about your day and doesn’t really restrict your life.” (Dual user)

On the other hand, cigarette smokers felt that e-cigarette use gets “kind of technical” in terms of maintenance and other issues.

“I think I broke 1 or 2 vape pens and I kept buying them every time. Then the coil went out maybe one time and I just went and bought another $15 pen and just didn’t want to change it out anymore.” (Cigarette smoker)

Negative Affect Reduction: Initial codes included Negative Affect Reduction, Weight Control (Appetite Reduction), and Boredom Reduction. However, Stress Reduction emerged as the most important aspect of negative affect mentioned in the groups. As shown in Table 5 , participants from all groups felt that Stress Reduction was a reason for using e-cigarettes. Nonusers reported observing people vape “as a stress reliever” and that users “can’t function properly” without it. Some smokers were skeptical that e-cigarettes could provide adequate relief, but some dual users specifically noted that e-cigarettes could be helpful as an alternative to smoking.

Example quotations within the main theme of Negative Affect Reduction.

“I had to smoke a cigarette after my exam too. Smoking e-cigarette, I’m not quite sure. I don’t think it would help.” (Cigarette smoker) “[It] like takes the edge off. In a situation I would smoke a cigarette I would just hit the vape instead. Stressful situations, school which is stress, everything that is stress, I would drive to smoke a cigarette, now I try to lean towards the vape instead.” (Dual user)

The pattern was repeated in relation to Appetite Reduction. Nonusers felt that starting one “unhealthy habit” might lead one to start other unhealthy habits. In contrast, a smoker wondered if e-cigarettes would be as effective as tobacco cigarettes.

“It satisfies my hunger, so I’m not really hungry for food because I already chain smoked some cigarettes. But I think if I was to try an e-cigarette my appetite would probably be normal.” (Cigarette smoker)

Dual users disagreed on the effectiveness of vaping for appetite reduction compared to smoking. One reported that either activity “pretty much destroys your appetite.” However, another dual user disagreed.

“Partially. Yes. But then there is another part. I don’t know. It doesn’t do the same thing. For some reason if I smoke a cigarette I feel like I don’t need to eat. I smoke an e-cigarette I feel like, I still am going to go to the kitchen and get that extra slice of pizza. Let’s be real.” (Dual user)

Boredom Reduction responses were similar. Nonusers felt this could be a risky way to deal with boredom, indicating that is how “addictions form,” but vapers felt it would be effective.

“It really does work to cure boredom though. . . I can’t smoke so that really does relieve the boredom factor.” (E-cigarette vaper)

Cigarette smokers felt vaping would be ineffective to reduce boredom for more than “5–10 minutes,” while some dual users felt it may be even more effective than smoking.

“When I am bored yes, e-cigarettes. I don’t normally smoke when I am bored but I might have an e-cigarette or a vape, stuff like that.” (Dual user)

Negative Consequences : Initial coding included Health Risks. As shown in Table 6 , participants noted additional potential negative consequences that could detract from the appeal of e-cigarette use, specifically Addiction and Secondhand Effects. Health Risks were brought up as a concern, although participants expressed uncertainty regarding these risks. Nonusers indicated that “inhaling anything” besides “oxygen is not good for you.” Similarly, cigarette smokers indicated that “putting chemicals in your body” can never be “that good” and that they “had heard [of] a couple of people getting pneumonia.” In contrast, vapers reported general uncertainty, but overall felt it would not be problematic if you “know what you are doing” and proper precautions were taken.

Example quotations within the main theme of Negative Consequences.

“Compared to someone who doesn’t use e-cigs and doesn’t use any tobacco products at all, you’re obviously not going to be as healthy if you do this because you are still inhaling something that you shouldn’t be, right? Like it’s not air, its high density water vapor, so I mean you are still doing something that is ultimately bad for your body even if it’s not as bad or barely bad at all.” (E-cigarette vaper)

Dual users generally reported that e-cigarettes were much safer than traditional, combustible cigarettes.

“For the 2 years I’ve been doing it, I’ve seen a big difference in my own health in a way. When I started vaping, it was just a thing that I did and I still smoked a pack a day at that point. . . After I finally took the initiative to make it my go-to instead of a go-to cigarette – sometimes it is this [vaping device] and cigarettes sometimes – I’ve seen a difference in my health in a different way where lung function and everything about that [had an] effect. Positive effect.” (Dual user)

Another concern reported was the possibility of Addiction. Nonusers indicated concerns that use could lead to neglecting responsibilities and worried about “the addictive effects and the withdrawals when you stop using it.”

“You [are] probably spending more money on doing these things and taking time away. And if you are our age, it’s taking time away – you guys know – it’s taking time away from homework, your social life, things like that.” (Nonuser)

Some vapers and dual users also reported addiction concerns.

“It is also kind of a dependence thing. Like once you start it you aren’t going to want to stop it because you are going to feel awful. And it is a lot based off of the individual. Some people are more addictive than others.” (Dual user)

However, many denied they were addicted to vaping. Some users regarded vaping as a “hobby,” rather than attributing use to nicotine addiction.

“I definitely do it every day but I feel like I could stop if I really wanted to, you know.” (E-cigarette vaper)

Dual users reported beliefs that e-cigarettes can help them quit their combustible cigarette addiction with some reporting wanting to quit nicotine entirely.

“My long term effect is hopefully going to be quitting cigarettes and it has been working so far and I hope to be done by the time I’m out of school.” (Dual user) “When you have that craving – now I’m craving my vape – I just want a little bit of nicotine. I don’t want all that nicotine that a cigarette is going to give me all the time now. So stepping down to 0 is going to be [my goal].” (Dual user)

Secondhand Effects came up as a novel concern. Nonusers indicated annoyance and concern regarding secondhand effects of e-cigarette aerosol, although some reported that e-cigarette aerosol “smells better” than cigarette smoke.

“But now like because the e-cigarettes are flavored, I don’t mind breathing walking by breathing it in though. But now I kind of want to research it, ‘cause can it cause something in the long term?” (Nonuser)

Vapers and dual users generally reported beliefs of no or minimal secondhand effects from vaping.

“There aren’t any chemicals to be thrown back at anybody. It is just – the only harmful thing that is in it is nicotine if you choose to use it. And you take that up when you inhale it.” (E-cigarette vaper)

Studies examining e-cigarette expectancies over the past few years have used measures modified from existing cigarette smoking expectancy questionnaires. 26 – 31 The extent to which items from these measures are relevant to e-cigarette use, particularly among young adults, was uncertain. To address this concern, we conducted focus groups and individual interviews with groups of young adults stratified by e-cigarette use and cigarette smoking. Consistent with theory and survey-based research, 23 , 26 , 28 , 31 vapers and dual users reported many benefits of e-cigarette use, whereas nonusers and exclusive cigarette smokers indicated overall skepticism. Some domains previously found to be relevant for cigarette smoking were again mentioned here as relevant for vaping, including the overall themes of Positive Reinforcement, Social Benefits, Negative Affect Reduction, and Negative Consequences. 23 , 43 , 44 Important potential refinements and novel subthemes were identified for future research.

Positive Reinforcement refers to the various rewarding effects associated with acute drug use. 43 Participants indicated the importance of some of these immediate outcomes, including clouds, hand movements similar to smoking, the tastes of different flavors, and stimulation (“buzz”). There was particular emphasis placed on some experiences novel to e-cigarettes, such as vaping tricks, unique flavors, and various levels of nicotine. Vaping tricks appear particularly influential, given their ability to be posted on social media and be a source of competitive activity.

Social benefits were also noted as important, particularly being able to spend time with friends who smoke cigarettes, as well as visit vape shops and go to e-cigarette conventions. Participants noted “influence on others,” that is, a belief that others who see one vaping might be intrigued by it, as a potential benefit/concern. The importance of this issue may be related to the rapid growth of e-cigarette use over the past decade and the increased value of social connection among this cohort. As noted by other researchers, perception of increased social standing is an important component of e-cigarette use, both among young adults 28 , 36 and among adults in general. 28 “Convenience” was noted as another important construct. This is consistent with positive e-cigarette expectancies identified via concept mapping. 50 Although convenience is not an outcome expectancy per se (because it is not a belief regarding the consequences of vaping), beliefs about issues such as convenience and cost may nevertheless be important drivers of substance use behavior. For example, prior research examining a convenience belief measure among e-cigarette users with a history of cigarette smoking found that, unlike other positive beliefs, convenience was not associated with decreased rates of cigarette smoking. 29 Instead, that study found a trend towards higher rates of continued smoking, perhaps suggesting e-cigarette use allows the “convenient” maintenance of nicotine addiction in locations where cigarette smoking is prohibited. On the other hand, participants also noted that e-cigarette use can be more complicated than cigarette smoking and this may discourage individuals from initiating or continuing e-cigarette use.

Negative affect reduction was noted in relation to stress and other unpleasant emotions, unwanted food cravings, and boredom reduction. Notably, these patterns differed by user group. Nonusers generally expressed concern about vaping as a coping strategy. Exclusive vapers tended to be most positive in their endorsement of e-cigarettes to fill these needs, while cigarette smokers tended to be skeptical. Dual users reported viewing vaping as a tool to avoid smoking, albeit one that was typically inferior to smoking. An exception to this was boredom reduction, where vaping was seen as a more interesting activity than cigarette smoking.

Finally, a number of negative consequences were brought up, including health risks, addiction, and the novel concern of secondhand effects. There was general uncertainty noted regarding potential health risks, although nonusers and cigarette smokers seemed to agree there must be some negative health effects. One cigarette smoker mentioned the potential for pneumonia, an unproven consequence unique to e-cigarettes. 51 , 52 Vapers and dual users tended to be more positive, believing health risks to be minimal if handled properly and certainly much less than smoking. Secondhand effects were also reported as a concern. Most smoking expectancy measures were created before the Surgeon General’s report on secondhand effects of smoking. 53 Dangers associated with secondhand effects of either smoke or aerosol are now much more widely appreciated, which may explain why this issue emerged as a new concern. Again, these young adults were uncertain about possible effects from e-cigarette aerosol, but generally thought it was much less risky, and better smelling, than cigarette smoke.

Overall, the findings indicated some overlap between e-cigarette vaping and cigarette smoking expectancies, but also revealed some areas that may be missing and should be studied further. Cigarette smoking expectancy measures have a long history in research related to understanding initiation, dependence, and treatment of cigarette smoking. 54 Research on e-cigarette vaping expectancy measures to date suggest they can similarly be helpful. 28 , 29 , 55 The present findings support the relevance of prior literature and add to our understanding of similarities and differences between smoking and vaping expectancy measures, particularly the differences by user group among a young adult population.

Limitations

There are some limitations to this study that should be noted. An important limitation is the difference in the sizes of each group, which may have biased the results and categories that were coded. Future studies may consider different inclusion criteria. Data collection involved two interviews in addition to the focus groups. This allowed for more of a perspective from the relatively rare and likely more risky group of dual users. 41 , 42 However, interviews may yield different content than focus groups. Focus groups allow for interaction data resulting from participants questioning one another and commenting on each other’s experiences, but also creates social contexts that may result in concealment of certain information. Interviews, on the other hand, avoid both the advantages and disadvantages of focus groups. Combining these two types can allow for confirmation across data collection techniques and enhancement of the richness of the data, but the potentially divergent epistemological assumptions inherent to the two methods need to be considered. 56 Future research may consider including larger numbers of both interviews and focus groups to help address how information obtained varies by type in relation to this issue.

Our relatively small sample is unlikely to be representative of the population as a whole. However, the purpose of this study was the identification of themes for further field testing. Tests with larger groups will help assess generalizability. Further, although a strength of this study is the inclusion of young adults from diverse racial, ethnic, and education backgrounds with a variety of different patterns of cigarette smoking and e-cigarette use, there were some limitations in participant diversity. First, the sample was majority male. Although this is similar to e-cigarette users in the general population, 15 , 57 it should be noted that female e-cigarette users and smokers may have different attitudes. 58 , 59 Our inclusion criteria defined dual users as past-week use of both substances, unlike other studies that defined dual use based on past-month usage. 41 , 42 For this qualitative study, we preferred past-week use so that participants could easily recall their experiences and provide a detailed and accurate responses to the prompts. In addition, nondaily users were excluded. These decisions may have resulted in a relatively smaller, more experienced groups due to their more recent use of both substances and daily use of at least one substance. On the other hand, use and nonuse were defined in part using the demarcation of 50 lifetime use occasions, rather than the 100 cigarettes criteria sometimes used. 60 , 61 Few participants in this study used between 50 and 100 times, but they nonetheless may differ from other classifications. These may be worthwhile subpopulations to evaluate in future research. Finally, data collection was conducted before the advent of widespread “pod mod” and Juul use, 62 which should be investigated in subsequent studies.

Implications

A variety of interventions to discourage uptake of e-cigarettes among nonsmoking youth, and perhaps, if justified, to encourage smokers to switch to e-cigarettes, are possible. These could include marketing regulations, labeling requirements, and counter-messaging development. Success of these techniques will be enhanced by a clear and compelling research base involving relevant constructs, such as expectancies. Field testing and further refinement of these e-cigarette expectancy themes and associated items will provide critical data on young adults’ likelihood to engage in this rapidly increasing behavior, as well as a tool to enhance research, clinical, and public health efforts. Examining expectancies and other constructs in more detail can aid in providing a fuller picture of e-cigarette beliefs and, thus, more informed targets for intervention.

Acknowledgments

We thank Jean Forster and Thomas Eissenberg for input and advice regarding focus group interpretation. We further thank Bryanna Vesely for help in recruitment, scheduling, and conduct of focus groups, as well as Research Assistants Lauren Marshall, Jillian Phillips, Leigh Sitler, Thomas Small, and Jacob Smith for assistance in coding and formatting. We thank all study participants for their participation.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by grant number R03CA195124 from the National Cancer Institute at the National Institutes of Health (NIH) and Food and Drug Administration (FDA) Center for Tobacco Products. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH or the FDA.

Declaration of conflicting interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Author THB receives research support from Pfizer, Inc. No other conflicts of interest are declared.

Author contributions: PTH led the manuscript writing and revision process and the interpretation and synthesis of transcripts, with input from THB, KJE, TEB, LOB, VNS, and GPQ. THB provided project mentorship. GPQ provided qualitative expertise consultation. LOB assisted with revisions. All authors read and approved the final manuscript.”

Human Subjects Statement: This study was approved by the Eastern Virginia Medical School IRB.