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© 2007 American Public Health Association
DOI: 10.2105/AJPH.2006.100909
RESEARCH AND PRACTICE |
Pearl Bader is with Consultants in Behavior Change, Toronto, Ontario. At the time of the study, Heather E. Travis and Harvey A. Skinner were with the Department of Public Health Sciences, University of Toronto, Toronto, Ontario.
Correspondence: Requests for reprints should be sent to Pearl Bader, Consultants in Behavior Change, 250 Heath St East, Toronto, Ontario, Canada M4T 1T2 (e-mail: pearl. bader{at}utoronto.ca).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Objectives. We synthesized evidence regarding effective strategies for smoking cessation among employed or unemployed young adults aged 18 to 24 years.
Methods. For this knowledge synthesis, we used (1) a systematic review of the scientific literature, (2) a Delphi panel of experts, and (3) 6 focus groups of employed and unemployed young adult smokers.
Results. Of 51 related studies, only 4 included employed and unemployed young adults in their samples (as opposed to students), and none focused solely on them. Using the Delphi process, 27 experts reached consensus on priorities for research, practice, and policy, emphasizing population engagement, recruitment, and innovative interventions. Key themes from focus groups were that interventions should be relevant to young adults, individual choice should be respected, and the positive aspects of quitting should be stressed. Despite having negative views on traditional smoking cessation methods, participants expressed optimism about being able to quit and proposed creative recommendations.
Conclusions. Our findings set an agenda for targeting research, improving practice, and informing policy for smoking cessation among young adults. We also demonstrate the value of using 3 complementary approaches: literature review, expert opinion, and target population perspectives.
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INTRODUCTION |
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When only community members have the experience, and only academics have the theories, both forms of knowledge are weakened.—Randy Stoecker1
Although smoking rates for both adults and adolescents have decreased over the past 20 years in North America, rates for young adults aged 18 to 24 years have not changed substantially.2–4 In Canada, as in other developing countries, young adults have the highest smoking rate of all age groups, and many make numerous unsuccessful attempts at quitting.3 Yet this population has been largely overlooked in research, practice, and policy regarding effective programs for smoking cessation.
Although an extensive scientific literature that can direct interventions in smoking prevention and cessation among adults has evolved,5,6 such a body of knowledge does not exist for young adults.7 The 2 groups of young adults at particular risk for tobacco use are the employed and the unemployed (as opposed to students).8–11 Lantz noted that smoking rates were significantly higher among those not in school, making it conceivable that differential approaches and interventions are needed for specific subgroups of young adults.9 Although there are numerous studies on college students, there is a dearth of research and programs aimed at the large proportion of working and nonworking young adults. What is known about smoking cessation with this population?
We systematically reviewed and synthesized the evidence regarding effective smoking cessation strategies for adults aged 18 to 24 years who were employed or unemployed. Using a better-practices approach,12 we explored the value of 3 distinct but complementary approaches to smoking cessation among young adults: (1) a systematic review of the relevant literature, both published and unpublished; (2) a Delphi process to synthesize expert opinion; and (3) focus groups composed of young adult (aged 18–24 years) Canadian employed and unemployed smokers.
We present an overview of the main findings and key recommendations. A detailed description of the methods and findings is presented in the full background report.13
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METHODS |
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Systematic Literature Review
An extensive search was conducted to identify relevant studies on smoking cessation interventions with employed and unemployed young adults. Specific details on the search strategy are described in the full report.13 The following sources were used in the search (literature dated from 1990 to March 1, 2006): electronic bibliographic databases, key journals and reference lists from retrieved articles, electronic mailing lists, and contact with experts for unpublished research.
Because of the scarcity of studies on the topic, we chose to be inclusive rather than create a strict set of exclusion criteria. We included studies that focused primarily on young adults and studies of adult populations that had a category for "young adults." A total of 51 studies were selected, spanning the following young adult populations: (1) employed or unemployed, (2) young adults in general, (3) college students, and (4) special populations (young adults with problems besides smoking—for example, other substance abuse, depression, or anxiety).
All included studies were rated by 2 independent reviewers to assess the strength of evidence. Quality was assessed through checklists, with separate lists designed for randomized controlled trials, prospective and descriptive studies, qualitative studies, and reviews.
Delphi Panel
Examining only published research would produce limited knowledge for this synthesis. Another valuable approach is to consult experts in the field and synthesize their perspectives. We did this using a Delphi approach, which is a structured, systematic method that uses an iterative process to build consensus among a panel of experts.14
A modified Delphi method was used to identify and rank the top priorities for research, practice, and policy. The 27 members of the panel, which included researchers, practitioners (public health and tobacco treatment), and policymakers, were recruited on the basis of their expertise in the area of tobacco control; names are given in the Acknowledgments section; affiliations are given in the Full Report.13(p26) Delphi members participated voluntarily—no financial or in-kind incentives were provided. Details on recruitment of the Delphi panel are given in the Full Report.13(pp36–38,90–91)
This process (which took place through a series of e-mail communications) used sequential questionnaires over 3 rounds (Figure 1
). Round 1 asked participants to respond to open-ended questions. Responses were analyzed and organized according to common themes to generate 3 lists of priorities for (1) research, (2) practice, and (3) policy. In round 2, panelists were asked to rank the items on the 3 lists generated from round 1 and provide reasons for their choices. Their rankings were then combined to produce a total score for each priority. In addition, the reasons provided for the top choices were summarized. In round 3, consensus was consolidated as panelists were asked to either agree or rerank their choices. Successive questionnaires gave participants feedback on the collective responses of the group, providing the opportunity for individuals to modify their judgments in light of the newly shared information. Such feedback between rounds can expand knowledge, stimulate new ideas, and in itself be highly motivating for participants.
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Young Adult Focus Groups
An integral component of this knowledge synthesis was learning from the experiential wisdom of the target population. These young adults not only expressed thoughtful criticism of current smoking cessation approaches but also offered creative solutions.
Fifty-three employed and unemployed young adults participated in 6 focus groups in Toronto, Ontario. (57% women, 42% men). All groups were of mixed gender and included self-identified smokers (91%) and ex-smokers (9%). Four groups were composed mainly of employed and 2 groups of mainly unemployed young adults (77% of participants employed, 23% unemployed). A detailed profile of focus group participants is given in the full report.13(pp36–38,90–91)
Participants were asked to provide their perspectives on current best-practice smoking cessation methods, including individual and group counseling, pharmacological aids, information and communication technology, self-help materials, and quit-and-win contests. Questions related to exercise, which is a little-researched smoking intervention method, were also included. In addition, opinions were sought regarding the types of providers of smoking cessation and settings that would most appeal to young adults. Policy interventions and media campaigns also were explored.
Participants were asked to express both their own reactions and how they thought other young adults would respond. For each smoking cessation intervention, 4 main questions were posed: (1) "What is your experience with this intervention?" (2) "What do you see as the benefits of this approach?" (3) "What do you see as the concerns of this approach?" (4) "Would you (or other young adults) consider this approach if you wanted to quit smoking?"
Descriptive statistics (including sociodemographic profile, smoking status, and smoking behavior) were computed with SPSS software version 13 (SPSS Inc, Chicago, Ill). Using an inductive qualitative approach, we analyzed verbatim transcriptions of all 6 groups. The goal was to remain open to hearing what young adults were saying about how smoking cessation should be approached. Only those sections of the transcripts pertaining to interest in and perceived effectiveness of the intervention methods were coded. Key themes were identified both manually and with QSR-N6 software (QSR International, Doncaster, Victoria, Australia) and were then categorized according to the guiding questions.
The process was conducted separately within each group and then compiled across all 6 groups. Comparisons were made on the basis of frequency (how often something was said), extensiveness (how many people said it), and intensity (how strong the opinion was). To ensure trustworthiness of the analysis and interpretation, the 6 focus groups were conducted through use of a structured interview guide, and themes were cross-checked independently by the coinvestigators. In this report, we present first-order interpretations (descriptive level) rather than higher-order interpretations connecting themes to deeper theoretical constructs.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Systematic Literature Review
The impact of smoking cessation interventions on young adults is not well understood. Despite the continued high prevalence of smoking in this age group, there have been few controlled trials of efficacy. Only 4 studies in this review included employed or unemployed young adults as part of their research, 1 of which was an intervention study.15 The scientific literature on smoking cessation interventions relevant to unemployed young adults is virtually nonexistent.
Despite the paucity of direct studies, there is a body of literature that provides insight into potentially effective intervention approaches; however, there were variable, and at times contradictory, perspectives in the findings of these studies. A comprehensive description of all 51 studies is given in the full report.13(pp67–84) Highlights from the literature are described in the following sections.
Natural history.
Smoking behavior among young adults is distinct from that of both adolescents and older adults. For most young adults, the years from late adolescence through the early to mid twenties are years of profound change.16 Young adults are in the process of creating adult identities and are making corresponding lifestyle choices. Factors that predict smoking cessation are presented in Table 1. Among studies examining predictors of smoking cessation, social and environmental factors have the highest rate of agreement. These include having few friends who smoke, not being around people who smoke, and having a nonsmoking partner.
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Treatment interventions. In the few trials that have been conducted on the efficacy of smoking cessation interventions for young adults, this age group has been included as part of a general adult population.
Overall, young adults have negative attitudes toward traditional smoking cessation approaches. They typically feel that the best way to quit smoking is "on their own," even though their success rates with this option are low. Young adult smokers need smoking cessation options that are both effective and appealing. Even the most effective cessation programs will have limited or no impact if they fail to recruit and sustain participation. Only 1 study was found that addressed recruitment to smoking cessation programs.30
Policy. Several studies examined the influence of policy strategies on the smoking behavior of young adults. The general conclusion is that multiple, integrated strategies are needed for maximum effectiveness. Economists have shown that increasing the price of cigarettes produces the largest decline in smoking among adolescents and young adults.5,25,27
Delphi Panel
All 27 members of the panel completed the entire process. Confidentiality of the individual opinions of the panelists was maintained throughout the study. Findings represent the collective opinion of the panel.
After 3 Delphi rounds, the panel members reached a high level of consensus in determining the most important priorities in addressing smoking cessation for employed and unemployed young adults (Figure 1
). Specific ratings of priorities are given in the full report.13(pp 87–89) The panelists underscored the wide gap in the smoking cessation literature for young adults and offered thoughtful reflections about priorities.
Research. The top 2 priorities for future research were (1) processes of smoking and quitting and (2) recruitment, engagement, and retention. Most panelists felt that a greater understanding is needed of why young adults choose to smoke and choose to quit, rather than just whether they are successful. Little is known about how to engage young adults in smoking cessation, because they tend not to use available smoking cessation interventions. Research on effective means of recruitment and retention can help to improve success rates and reduce overall smoking prevalence.
Practice. The top 2 priorities for practice were (1) addressing tobacco in the context of other issues of young adulthood and (2) engaging young adults in smoking cessation interventions. Smoking is embedded within the context of other issues that young adults face (transition to workforce, increasing responsibilities). It is important that smoking cessation interventions be incorporated into the larger context of their everyday lives.
Policy. The top 2 priorities were (1) smoke-free indoor air restrictions and (2) integrating research into policy. The consensus was that good evidence exists on restrictions having a positive impact on cessation among adults, but that a better understanding is needed on the effect on young adults. The panel felt that integrating research with policy needs to be a guiding principle driving all areas of policy development.
It should be noted that consensus from a Delphi process does not mean that the "correct" answer was found. However, this process does attempt to "negotiate a reality that can then be useful in moving a particular field forward, planning for the future or even changing the future by forecasting its events."31
Young Adult Focus Groups
Similar to what was found in other focus group studies,32–34 participants generally held negative perceptions of traditional smoking cessation methods. Moreover, they had little interest in new approaches, either Web-based or involving cell phone text messaging. Overwhelmingly, our participants believed that the most effective method of smoking cessation was, as one put it, "If you want to quit, you should do so on your own." Although most individuals endorsed quitting on their own as their preferred method, many expressed surprise at the difficulty of quitting. In the earlier stages of smoking, they tended to overestimate their ability to quit.
The research literature and the experts agree that this population is difficult to engage in traditional smoking cessation approaches. The focus group participants shed light on the reasons underlying their resistance to quitting.
- Lack of knowledge and experience with smoking cessation interventions. Participants perceived that individual counseling meant "being told what to do," lacked information about pharmacotherapies for smoking cessation and expressed concerns about its cost, and were unaware that Web-based strategies could be individually tailored.
- Amount of effort involved. "It’s easier to smoke than not to smoke. It’s easier to just keep doing things than to change your lifestyle," said 1 participant, expressing the sentiments of many.
- The powerful grasp of smoking. As 1 participant explained, "Some people are addicted to the oral fixation, some people are addicted to nicotine, some to having it in their hand. It all depends on the person. Me, personally, I love smoking. It’s not because of the nicotine I’m addicted to, it’s because I really enjoy smoking cigarettes."
- Social connection. Participants felt, in the words of 1, that "You automatically belong to a group even if you don’t know anybody you can walk into a room with like a hundred people and 20 minutes into the party you will probably have met a good 15 of them outside, smoking. And you will know them, and you will have talked to them, and you will have this common bond."
Few participants had experience with smoking cessation interventions. Although views of individual counseling were fairly negative, their interpretation of individual counseling was of being "told what to do" by a so-called expert. They had no experience with group counseling specifically for smoking but were able to identify several potential benefits of this approach. About one quarter of participants had tried either Zyban or the nicotine patch or gum, but they felt that the cost and lack of accurate information regarding these products were huge barriers to wider usage. They were unenthusiastic about Web-based and text-messaging strategies.
Most participants felt strongly that providers of smoking cessation (such as health practitioners and counselors) should be ex-smokers, whether professional or peer, and emphatically agreed that these services should not be provided in a hospital or institution. The main criteria for settings were that they be easily accessible, be free, and not require appointments. Participants felt that neither smoke-free environments nor media campaigns were effective in encouraging smokers to quit, although they did help smokers reduce consumption. They viewed cost as a more likely incentive to quitting.
Participants proposed some creative solutions to encourage those aged 18 to 24 years to quit smoking. Interventions that involve social activities that are incompatible with smoking were seen as particularly appealing. Two recommendations focused on the role of exercise and sports: (1) intramural sports leagues (soccer, hockey, basketball, etc.) for smokers trying to quit and (2) free or low-price, government-sponsored, quit-smoking fitness facilities that would include fitness instructors to help with exercise programs and counselors to help people deal with the stress of not smoking. (Counselors, in their view, should be interactive and offer support—"people who understand you, who are going to listen, who are not pushy or forcing their ideas on you," as one participant explained.)
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONReferences |
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Despite the high prevalence of smoking in this age group, there have been few controlled trials of efficacy regarding young adult smoking cessation. The Delphi panel and the young adult focus group participants contributed significant data for this knowledge synthesis. The consensus view presented in this study offers practical and realistic guidance to researchers, practitioners, and policymakers. It reflects the best evidence to date of expert views in the tobacco control field.
Synthesis of Findings
Table 2 gives a synthesis of important findings from the systematic review of the literature and from the Delphi panel and focus group participants; greater detail is provided in the full report.13(pp51–53) The following summary highlights key areas of convergence and divergence.
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Research. The significant social component of smoking was emphasized in both the literature and focus groups. Indeed, the extent of smoking among friends was the greatest predictor of smoking cessation. All 3 sources agreed that health beliefs and risk perceptions play an integral role in smoking behavior among young adults and that young adults do not sufficiently understand the health consequences of smoking. There was consensus on critical factors for smoking cessation methods, including low or no cost, convenience and flexibility, interventions that place few demands on participants, and innovative, nontraditional interventions specific to the unique needs of young adults. Engagement and recruitment were viewed as fundamental facets of smoking cessation programs by both panelists and focus group participants. This topic was conspicuously absent in the literature.
Practice. There is a lack of intervention data on employed and unemployed young adults in the literature. The research, panelists, and focus group participants agree on the importance of new, innovative interventions for smoking cessation and the involvement of young adults in this process. More focus group participants (23%) had tried some form of pharmacological aid than any other intervention approach, yet only 2 studies in the literature focused on nicotine replacement therapy.35,36 Panelists held conflicting views on the value of pharmacotherapies with young adults. Cost was viewed as a barrier to using pharmacotherapies for smoking cessation by both panelists and focus group participants. Only 1 study assessed the effectiveness of type of provider of smoking cessation, and no studies were found on types of settings. Panelists stressed the need for research to determine which types of providers and settings are most effective. Focus group participants strongly endorsed the idea that providers of smoking cessation (whether professional or peer) be ex-smokers and preferred settings outside of hospitals or institutions.
There were few studies in the literature on information and communication technologies as a smoking cessation intervention for young adults. According to panelists, approaches using these technologies may be an effective means of engagement; however, few participants had any experience with them. Although there is a general assumption that access to the Internet is almost universal, employed and unemployed young adults have limited access to computers. According to focus group participants living on their own, buying a computer was not a priority. Most had computers when they lived at home with their parents.
Delphi panelists underscored the importance of using research information to inform the development of smoking cessation programs as well as public health policy. They also highlighted the need for existing programs and interventions to undergo systematic evaluation and quality improvement.
Policy. The research literature and panelists viewed mass media campaigns as encouraging smoking cessation and reducing levels of consumption; however, the focus group participants disagreed. Both panelists and focus group participants underscored the need for media campaigns to be specifically adapted for a young adult audience.
There is conflicting evidence in the literature regarding the effectiveness of smoking restrictions on young adult smoking behavior. Panelists believed that smoke-free indoor air restrictions reinforce the social unacceptability of smoking and that there is good evidence that these restrictions have a positive impact on smoking cessation. They did, however, acknowledge the need to better understand the effect on young adults. According to the focus groups, smoke-free environments help smokers reduce consumption but not quit. The literature and focus group participants agreed that increasing the price of cigarettes is the policy having the strongest impact on smoking cessation and level of consumption.
Recommendations
We recommend 5 strategies for facilitating smoking cessation among young adults (Table 3). These are (1) expediting research, which is the primary recommendation from our study; (2) improving practice through the development of evidence-based tools; (3) reviewing policy that affects this population; (4) giving young adults a voice by engaging them in the design and implementation of interventions; and (5) creating an agenda for action.
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Conclusions
Empirical evidence on effective smoking cessation approaches for young adults is conspicuously lacking. Moreover, our study challenges the idea that evidence-based smoking cessation guidelines for adults (e.g., see Fiore et al.37) are effective or applicable for use with young adults. What works for adults in general does not appear to work for younger adults. Research on this population is thus the primary recommendation from our study.
There is consensus among all 3 sources—research, experts, and young adults—about the need to go beyond current smoking cessation approaches and develop innovative strategies that address the unique interests, characteristics, and needs of employed and unemployed young adults. It is vital that young adults be involved in all steps of the process from conception to implementation. Albert Einstein defined insanity as "doing the same thing over and over again and expecting different results." We cannot continue to do what we have been doing and expect different results. We cannot continue to "push" traditional smoking cessation interventions that have little or no appeal to young adults.
Young adulthood is a pivotal juncture in which to target resources for smoking cessation. Smoking behavior often becomes consolidated and continues into adulthood, playing a crucial role in lifetime health and well-being. However, young adulthood is a time when traditional approaches to health education have limited effectiveness owing to perceptions of invulnerability or optimism bias—"It won’t happen to me!" The challenge is to adopt new measures that will launch young adults on a health-promoting pathway to full adulthood.
As 1 Delphi panelist said, "This is what it really is all about, isn’t it? How to engage, how to get inside their head, how to pique their interest, how to capture their imagination."
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Acknowledgments |
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This study was funded through the strategic initiative Advancing the Science to Reduce Tobacco Abuse and Nicotine Addiction, a partnership coordinated by the Canadian Tobacco Control Research Initiative.
We are grateful to the following 27 Delphi panelists, whose expertise contributed greatly to the quality and findings of this study: C. Backinger, S. Bagshaw, O. Baron-Epel, C. Breslin, T. Connolly, S. Curry, R. Dragonetti, L. Dunbar, J.F. Etter, R. Ferrence, J. Forsythe, J.Y. Frappier, G. Giovino, J. Greene, L. Hausmanis, M. Kaiserman, M. Kaufman, A. Lavack, P. McDonald, S. McIntosh, B. McKim, E. Moolchan, C. Norman, J. O’Louglin, P. Selby, S. Sussman, and K. Watts.
Note. The views expressed in this report are the authors’ and do not necessarily express those of the Canadian Tobacco Control Research Initiative.
Human Participant Protection
The ethics procedure used in this study followed a standard protocol for focus groups that was approved by the Human Subjects Ethical Review Committee of the University of Toronto.
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Footnotes |
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Peer Reviewed
Contributors
P. Bader led the study design and implementation and was responsible for writing the article. H. E. Travis helped design the study, contributed to group facilitation and to data acquisition and interpretation, and helped edit the article. H. A. Skinner contributed to study design, implementation, and article preparation.
Accepted for publication December 2, 2006.
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