Abstract
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.
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
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.
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.
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.
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.
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.
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
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
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.
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.
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.
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
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.)
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.
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.
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.
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.
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.
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.
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.”
aIt is likely that a combination of policies, rather than any single policy, most significantly influences smoking behavior of young adults. create strategic research grant opportunities aimed at this target population, require funded investigators in tobacco control (whenever appropriate) to differentiate young adults from other age groups in data collection and analyses and to routinely report results broken down by age cohorts and employment status, and require research grant proposals and study reports on tobacco control interventions (including policy analysis) to address issues of plausibility and practicality. an action plan on specific initiatives for advancing research, practice, and policy regarding smoking cessation for young adults, media events promoting and advocating research and services on smoking cessation, and a virtual knowledge network enabling participants to continue involvement and collaboration supported, in part, by information and communication technology. FIGURE 1— Summary of priorities for research, practice, and policy from modified Delphi process, 2006 Note. ICT = information and communication technology. A modified Delphi method was used to identify and rank the top priorities for research, practice, and policy. The 27 members of the panel were recruited on the basis of their expertise in the area of tobacco control. This process used sequential questionnaires over 3 rounds. 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. For more information on this method, see the Methods section.
Predicts Smoking Cessation Predictor Yes No or Mixed Smoking behavior Level/intensity of smoking Ellickson et al. (2001),17 Paavola et al. (2001),10 Rose et al. (1996)11 Chen et al. (2001)18 Age of onset Gilpin et al. (2005)6 Chen et al. (2001)18 Intention to quit Ellickson et al. (2001),17 Rose et al. (1996),11 Tucker et al. (2005),19 Tucker et al. (2000)20 Nicotine addiction Breslau and Peterson (1996)3 Association with drinking behavior Gilpin et al. (2005),6 Paavola et al. (2001),10 Winefield et al. (1992)21 Social influences Friends who smoke Chassin et al. (2000),22 Chen et al. (2001),18 Ellickson et al. (2001),17 Ho (1998),23 Paavola et al. (2001),10 Rose et al. (1996),11 Tucker et al. (2005),19 Tucker et al. (2000)20 Nonsmoking parents Chassin et al. (1996),24 Gilpin et al. (2005),6 Paavola et al. (2001)10 Ellickson et al. (2001),17 Rose et al. (1996)11 Nonsmoking partner Chen et al. (2001),18 Tucker et al. (2005)19 Children Having children Chen et al. (2001)18 Living with children Rose et al. (1996),11 Tucker et al. (2005)19 Environmental influences Access to cigarettes Tucker et al. (2000)20 Price of cigarettes Chaloupka and Wechsler (1997),25 Czart et al. (2001),26 Farrelly et al. (1999),5 Tauras (2004)27 Sheu et al. (2004),28 Gilpin et al. (2005)6 (latter reported mixed results) Smoke-free indoor air restrictions Czart et al. (2001)26 (predicts not cessation but level of smoking) Chaloupka and Wechsler (1997)25 (in restaurants and schools but not public places and workplaces), Tauras (2004)27 (perhaps in public places and workplaces but not restaurants) Mass media (cigarette ads and sales bans) Ho (1998)23 Czart et al. (2001)26 Occupational status Student Employed vs unemployed Paavola et al. (2001),10 Rose et al. (1996)11 Chen et al. (2001)18 Employed: white-collar vs blue-collar and service workers Paavola et al. (2001)10 Educational status Education level Breslau and Peterson (1996),3 Chassin et al. (1996)24 Chen et al. (2001)18 Grades Ellickson et al. (2001)17 Health beliefs Perceived health status (physical and mental) Rose et al. (1996),11 Tucker et al. (2005)19 Tucker et al. (2000)20 Attitudes regarding harmful effects of smoking Tucker et al. (2000)20 Misperceptions regarding health risks Murphy-Hoefer et al. (2004)29 Activities Involved in physical activities (sports, exercise) Paavola et al. (2001)10 Attends bars or clubs Gilpin et al. (2005)6 Other Assuming adult social roles Chassin et al. (1996)24 Able to resist peer pressure and other prosmoking influences Ellickson et al. (2001),17 Tucker et al. (2000)20 Psychological characteristics Chen et al. (2001),18 Winefield et al. (1992)21 Adolescent rebelliousness and problem behavior Tucker et al. (2000)20 Literature Experts Young Adults Research Natural history Prevalence Young adults comprise largest proportion of smokers in Canada (27%) Patterns Smoking behavior is relatively persistent from adolescence to adulthood; young adults are more likely to engage in occasional smoking; young adults have a lower daily consumption than older adults; smoking rates vary according to employment status (student, employed, or unemployed Most felt little is known about processes of smoking and quitting; research exploring factors that influence initiation and maintenance of smoking is needed Most (74%) participants were medium to heavy smokers, 17% light smokers, 9% ex-smokers; average age at first cigarette was 13 (range = 6–20); mean no. cigarettes smoked per week was 90; almost half reported planning to quit smoking in next 6 months Predictors of smoking cessation Little is known about factors that affect smoking cessation among young adults; predictor variables with highest agreement among reviewed studies included extent of smoking among friends (8 studies), increased price of cigarettes (5 studies), and intent to quit (4 studies); inconsistent findings regarding education and employment Need research to understand determinants of both contemplation of quitting and actual quitting and to understand meaning and functions of both smoking and quitting for young adults; need clearer understanding of needs of different subpopulations of young adults A principal benefit of smoking is its significant social component; participants say they would have the most difficulty in resisting smoking when partying with friends or when stressed; all but 1 participant reported having friends who also smoke Psychological characteristics No differences found in smokers vs nonsmokers (but few studies exist) Attitudes Health beliefs, risk perceptions These play an important role in smoking by young adults; smokers engage in risk minimization, believe they are at less risk than others, undervalue health consequences of smoking, and do not fully understand short-term effects of smoking; strategies for smoking cessation need to be tailored to fit young adults’ health beliefs Important to increase awareness of the consequences of smoking and of quitting Contrasting views on perceived health risks: some participants thought consequences are in the future and others were already seeing effects of smoking on their appearance and easily became tired or out of breath Smoking cessation methods Important factors in selecting a smoking cessation method include likelihood of its success; its cost, convenience, and flexibility; pain of quitting; low-demand interventions; social support; settings in naturally occurring social groups (such as community groups and fitness groups); participating in activities incompatible with smoking Programs need to be easily accessible and comprehensive; important factors in selecting a smoking cessation method include acceptability of program, cost and convenience, and confidentiality Participants held negative views toward traditional smoking cessation approaches; a prevailing theme was that individuals should quit smoking on their own; they had little interest in relatively new approaches, such as Web-based or cell phone text-messaging interventions; they had negative views on smoking cessation methods based in part on lack of knowledge and experience with smoking cessation interventions; important factors in selecting smoking cessation method include need of accurate information, cost, convenience, easy accessibility, location outside of hospitals or institutions, emphasis on benefits of quitting; they wanted interventions that were innovative and not conventional Engagement and recruitment Received little attention in literature; social marketing principles could be beneficial in designing and promoting smoking cessation programs Young adults tend not to access available smoking cessation programs; little is known about how to engage young adults in smoking cessation; research into recruiting and retaining young adults in smoking cessation is needed; important to involve young adults in smoking cessation program and policy decisions Participants believed accurate information on types of interventions and programs available would help recruitment; innovative interventions that recognize specific needs of young adults would encourage recruitment and engagement; wanted to be involved in designing and developing smoking cessation interventions Interventions Significant lack of intervention data on young adults in general, less for employed young adults, none for unemployed Should be addressed in context of other issues of young adulthood (i.e., in larger context of their everyday lives); current interventions not always appropriate for all population groups; recruiting and engaging young adults for cessation programs requires creation of innovative interventions Participants lacked experience with smoking cessation interventions; had minimal information regarding various types of interventions and were misinformed about most; although the preferred smoking cessation method is quitting on their own, were surprised at how difficult it was and were often unwilling to exert necessary effort; wanted to be involved in designing and developing smoking cessation interventions Individual counseling (face to face, telephone quitlines) No studies of face-to-face counseling; quitlines have shown some effectiveness with adults, but few studies with young adults Little is known about effective approaches of individual counseling for young adults; research to determine which types of interventions most effective is needed Had little experience with individual counseling; some had seen telephone number for a quitline but did not use it; had the perception that individual counseling involves professionals telling them what to do, and they would rather talk to friend about smoking concerns, although some see benefit (i.e., good to know that someone available if one wants to quit) Group counseling Few studies; groups led by peer leaders showed some value (1 study) Little known about effective approaches of group counseling for young adults; research to determine which types of interventions are most effective is needed Had no experience; saw numerous potential benefits such as opportunity to share ideas and experience andlearn from others; several would consider but prefer nontraditional methods (i.e., with focus on activities rather than just talking about quitting smoking) Pharmacological aids (including nicotine replacement therapy) Few studies; 2 on nicotine replacement therapy found neither nicotine lozenges nor nicotine gum were effective in reducing cravings among young adults (although they did reduce cravings among older adults) May be effective as smoking intervention for young adults, but this topic had most conflicting views of panel members (i.e., some thought because of success with adults, should be encouraged for young adults, and others thought there is no evidence supporting use of pharmacotherapies with young adults and it needs more research); cost seen as barrier to use by young adults 23% had tried some form of pharmacological aid; some knew of others who had quit smoking using nicotine patch; had misperceptions regarding nicotine replacement therapy; some would consider using nicotine replacement therapy if it were free and others if they had more accurate information Information and communication technology Few studies; some effectiveness for Web-based smoking cessation found; some promise shown for cell phone text messaging Important innovative channel for young adults; may be an effective way to engage them Only 8% had checked Internet for smoking cessation Web site; general lack of enthusiasm for this approach; lack of access a major barrier (no longer living at home or in school); misperceptions about smoking cessation Web sites; thought too much effort involved; several would consider if they provided with individual feedback, knew it had high success rate, was not boring, and was targeted specifically to young adults Self-help materials No intervention studies Very few with experience or interest; thought reading materials would be too time-consuming and boring; would consider if more relevant to young adults; they endorsed a 1-pager with simple bits of advice that could be carried in wallet or purse Quit-and-win contests No intervention studies No experience; thought cessation would only be temporary with this approach Exercise Few studies on exercise-based interventions, none for young adults Elicits most lively and enthusiastic discussion of any smoking cessation method (in all groups); several involved in some form of exercise; perceive many benefits (e.g., helps deal with stress, self-esteem, cravings, weight control, replaces time spent smoking with positive activities); several thought exercise and smoking not incompatible; most thought exercise would be a useful method to help smoking cessation Providers Few studies on effectiveness of type of provider; groups led by peer leaders showed some value (1 study) Research needed to determine which types of providers are most effective with young adults Strongly endorsed providers being ex-smokers, whether professional or peers Settings No studies on effectiveness of different types of settings Research needed to determine which settings are most effective with young adults Settings should not be hospitals or institutions; some endorse idea of separate smoking rehabilitation centers; main criteria: easy access, free, and no appointments required Policya Mass media Purposeful messages that decrease social acceptability of smoking are most effective; type of campaign significantly related to age; TV is an effective medium for young adults; integrating promotions with young adult activities is a promising strategy to encourage cessation; “borrow” marketing strategies from tobacco industry Mass media and social marketing campaigns encourage smoking cessation and reduce smoking prevalence; help to create or change social climate; to date, there is no mass media campaign on smoking cessation targeting young adults; this strategy needs to be implemented and adapted for young adults Most believed media campaigns not effective in encouraging young adults to quit; had not seen young adults featured in any media campaigns; believed young adults need to appear in media campaigns if they are to be effective; ads should be straightforward and focus on short-term effects of smoking that are most relevant for young adults Smoke-free indoor air restrictions Lack of agreement on effectiveness of smoking restrictions for young adults; less impact on young adults than on older adults; agreement that smoking restrictions in workplace not very effective for smoking cessation among young adults but does tend to decrease consumption of cigarettes Reinforces the social unacceptability of smoking; good evidence that these restrictions have a positive impact on both initiation and cessation, but better understanding of effect on young adults needed Most did not believe smoke-free environments help smokers quit, but do feel that it helps cut down consumption Increased prices (taxes) Strongest impact on smoking cessation and level of consumption; increasing prices produce largest decline in young adults smoking Most believed increasing cost would be a motivator to quit smoking Sales and distribution Differing opinions on impact of sales and distribution of cigarettes; most felt there is clear evidence of connection between availability and use of tobacco and that reducing access can be effective policy measure for young adults, although some thought these measures only marginally successful Believed there should be less prominent placement of cigarettes in stores (e.g., under the counter); should have designated stores (such as Liquor Control Board of Ontario) for selling cigarettes to decrease current easy availability Recommendation Description Expedite research There is an urgent need to initiate and support major programs of research on smoking cessation for employed and unemployed young adults (aged 18–24 years). Specific recommendations for research funding agencies include the following: • • • Improve practice Develop and disseminate evidence-based practice guidelines and toolkits for effective smoking cessation approaches and strategies with young adults; guide would include approaches at multiple levels in various settings, with both context-based and individual strategies for engaging and delivering smoking cessation interventions. Review policy Conduct tobacco control policy reviews at national and state levels that analyze the effectiveness of tobacco control policies and accountability frameworks for smoking prevention and cessation with young adults. Results would inform both the research and practice agendas in advancing effective programs. Give young adults a voice Concerted efforts are needed to ensure that young adults (smokers and nonsmokers) are involved in formulating research needs and questions, helping with the design and implementation of programs, and creating policy targeted at young adult smoking prevention and cessation. Comments from our focus groups underscore the value of directly involving young adults in knowledge generation and transfer. Create an agenda for action Convene a think tank on smoking cessation for young adults; this would bring together national and international experts from the research, practice, and policy fields and provide a forum for the involvement of young adult smokers. The think tank would focus on the needs and recommendations reported in this and other knowledge synthesis reports, and build momentum for coordinated and sustained action. Outcomes from the think tank would include the following: • • • 
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.
