Disadvantaged youth and smoking in mature tobacco control contexts: a systematic review and synthesis of qualitative research

Factors sustaining legitimacy of smoking in Vocational Education and Training (VET) schools: a qualitative needs assessment

BACKGROUND

Most adult smokers started smoking in their teenage years, which increases the risk of nicotine dependence. In Denmark, there is a high prevalence of youth smoking among students in Vocational Education and Training (VET). However, reducing and preventing smoking in this group is a major challenge. This article presents a needs assessment aimed to explore factors sustaining legitimacy of smoking in VET schools and consider the measures needed to prepare VET schools' implementation of smoking reduction and prevention interventions.

METHODS

Participant observations were conducted in four VET classes representing three VET schools in Denmark with a duration of four days each. Individual, semi-structured interviews were conducted with teachers, managers, and a student advisor, as well as four focus groups with a total of 20 students. Interviews were audio-taped, transcribed, and the data material was analyzed following Malterud's systematic text condensation.

FINDINGS

Factors that helped sustain legitimacy of smoking in VET schools included a positive and normalized attitude towards smoking at home and among friends, an understanding of smoking as an integral and expected practice in VET professions and schools, a perceived reliance on smoking as an icebreaker in new social relations and as a pedagogical tool, and smoking as a habit and a means to deal with boredom and stress relief.

CONCLUSIONS

The factors sustaining legitimacy of smoking in VET schools are reciprocal and call for smoking reduction and prevention intervention efforts which consider and address social influence, habitual behavior, and psychological needs, as well as changes at the policy level.

Addressing Intergenerational Inequity in Tobacco-Harm: What Helps Children of Smokers to Remain Nonsmokers?

INTRODUCTION

Children of people who smoke are more likely to take up smoking themselves. In Aotearoa New Zealand (NZ), adolescent smoking declined dramatically between 2000 and 2016 despite limited change in parental smoking, demonstrating that the cycle can be broken.

AIMS AND METHODS

This study aimed to identify modifiable factors associated with never smoking in Year 10 students (14-15 years) who had at least one caregiver who smoked. We used data from the Youth Insights Survey (2016 and 2018, pooled, N = 5,422) and identified students with at least one caregiver (mother, father, grandparent, other caregiver) who smoked (N = 2,205). To investigate modifiable factors potentially associated with nonsmoking we used logistic regression with marginally adjusted prevalence estimates.

RESULTS

Overall, 41% of students had at least one caregiver who smoked. In this group, the majority (65%) had never smoked themselves. After adjustment, never-smoking was more prevalent among students attending low-deprivation (more affluent) schools (73% had never smoked) compared to high-deprivation schools (44%); students not exposed to others' smoking inside the home (72%) or in cars (70%) in the past week compared to those exposed (59% and 51%, respectively); and students whose parents would be upset if they were caught smoking (68% vs 49% for those whose parents would not be upset), or who had high self-esteem (69% vs 55% for those with low self-esteem).

CONCLUSIONS

Modifiable factors independently associated with non-smoking in adolescents with caregiver(s) who smoked were: nonexposure to smoking inside the home and in cars, parental expectations of nonsmoking, and high self-esteem.

IMPLICATIONS

Even in countries like NZ with relatively low adult smoking rates, children's exposure to caregiver smoking may be prevalent, particularly in structurally disadvantaged populations. This study suggests that action to promote smokefree homes and cars, build high self-esteem in young people, and communicate expectations of non-smoking are likely to help children of people who smoke to remain nonsmokers. A comprehensive approach that also addresses "upstream" factors (eg, socioeconomic deprivation) and underlying causes of structural inequity (eg, institutional racism) is needed. Such policy and community action may help to break intergenerational cycles of tobacco use and health inequity.

Hidradenitis suppurativa and social disadvantage: A nationwide administrative data study of the French hospitalized population

BACKGROUND

A lower socioeconomical status (SES) has been reported in patients suffering from hidradenitis suppurative (HS). However, limitations in the available studies prevent drawing definitive conclusions.

OBJECTIVES

The objective of this study was to assess the SES of HS patients using a specific SES indicator, the French DEPrivation index (FDep), specifically designed and validated for the French population.

METHODS

This cross-sectional cohort study compared the HS hospitalized population with the general hospitalized population without HS. Data were extracted from the French national hospital discharge database, an exhaustive database on all reimbursed hospital stay in the country with a rolling 10-year history (2012-2021). We included all patients aged 7-75 years with at least one stay in a French hospital. A 1:40 propensity score matching, adjusted for age, sex, smoking status and obesity, was performed to create 2 groups of comparable patients. Subgroup analysis was done in the minor (7-17 years) and major (25-75 years) populations independently.

RESULTS

In the overall population, we identified 33,880 patients with HS and 24,445,337 patients without HS. After propensity score matching, logistic regression showed a significant association between HS and social disadvantage. There is a 22.5% increased risk of developing HS for individuals being in quintile 5 (the most disadvantaged quintile) versus quintile 1 (the least disadvantaged quintile) (p < 0.0001). After propensity score matching, the logistic regression showed no association between HS and social disadvantage in the 7-17 subgroup. In this minor population, an association between HS and social disadvantage was observed when propensity score matching was performed on age and sex only.

CONCLUSIONS

We demonstrate a significant association between HS and low SES in the adult population. In children between 7 and 17, low SES was associated with obesity and tobacco consumption, but not with HS when the populations were matched on these confounding factors.

Prevalence and Correlates of Tobacco Use in Young People Presenting to Australian Primary Mental Health Services

INTRODUCTION

In Australian youth primary mental health settings it is unclear as to the rates and correlates of tobacco use at service entry.

AIMS AND METHODS

We aimed to delineate the prevalence and correlates of recent tobacco use (eg, cigarettes, chewing tobacco, cigars, etc) in the past 3 months in young people at their first presentation to primary mental health services as a function of age. Cross-sectional self-report measures were collected using a tablet device from young people presenting to one of five Australian primary mental health (headspace) services. Logistic regression assessed correlates of past 3-month tobacco use in adolescents (12-17 years) and young adults (18-25 years).

RESULTS

Regular (at least monthly) tobacco use in the past 3 months was found in 23.4% (n = 247, N = 1055) of the sample. Increasing age (odds ratio [OR] =1.47 per year; 95% confidence interval [CI]: 1.15 to 1.89), male sex (OR = 1.98; 95% CI: 1.02 to 3.83), being in a relationship (OR = 1.96; 95% CI: 1.01 to 3.82), and poorer functioning (OR = 0.95 per unit Social and Occupational Functioning Assessment Scale increase; 95% CI: 0.91 to 0.99) predicted regular tobacco use in adolescents, but not in young adults. Living in a regional location (OR = 2.10; 95% CI: 1.40 to 3.13) and not studying (OR = 0.47; 95% CI: 0.31 to 0.73) predicted tobacco use in young adults. Having a diagnosed mental illness other than depression and/or anxiety predicted tobacco use in both groups (adolescents OR = 2.49; 95% CI: 1.26 to 4.94; young adults OR = 1.80; 95% CI: 1.13 to 2.89).

CONCLUSIONS

Nearly a quarter of young people with mental illness are using tobacco, supporting the need for early intervention approaches. Adapting treatment targets by age could improve the impact of interventions in adolescents versus young adults. Poor functioning and lack of engagement in education were associated with tobacco use in both age groups, respectively; however, more research is needed to determine the direction of these relationships.

IMPLICATIONS

Young people with mental illness have a high prevalence of recent tobacco use and this is evident when they first present to youth primary mental health services. Youth-oriented mental health settings may provide a unique window for tobacco use prevention and early intervention to reduce smoking in people with mental illness, a priority population. Age-specific targeted approaches might be needed in adolescents and young adults.

Reducing lifestyle risk behaviours in disadvantaged groups in high-income countries: A scoping review of systematic reviews

High prevalence of risk behaviours may exacerbate existing poor health in disadvantaged groups. We aimed to identify and bring together systematic reviews with a focus on reducing risk behaviours in disadvantaged groups and highlight where evidence is lacking. We searched MEDLINE and Embase up to October 2020, with supplementary searching in Epistemonikos and Health Systems Evidence. We included systematic reviews that reported behavioural outcomes and targeted smoking, excessive alcohol use, unhealthy diet, or physical inactivity in groups with the following characteristics: low income or low socio-economic status (SES), unemployed people, homeless people, care leavers, prisoners, refugees or asylum seeker, Gypsies, Travellers, or Roma, people with learning disabilities and people living in disadvantaged areas. Reviews that included primary studies from any high-income country were eligible. Reviews were mapped based on the disadvantaged group(s) and behaviour(s) targeted. Ninety-two reviews were included, with the majority (n = 63) focusing on people with low income or low SES. We identified gaps in the evidence for care leavers; Gypsies, Travellers, and Roma and limited evidence for refugees and unemployed people. Few reviews targeted alcohol use. There was limited evidence on barriers and facilitators to behaviour change. This suggests there is insufficient evidence to inform policy and practice and new reviews or primary studies may be required.

Addressing Ethnic Disparities in Adolescent Smoking: Is Reducing Exposure to Smoking in the Home a Key?

INTRODUCTION

Smoking among New Zealand (NZ) adolescents has declined since 2000, but ethnic disparities remain pronounced. To inform prevention efforts, we investigated exposure to and relative importance of known predictors of adolescent smoking and how these have changed over time, for Māori (NZ's indigenous population) and adolescents overall.

METHODS

We used repeat cross-sectional data, 2003-2015, from a national survey of 14- to 15-year olds (N = 20 443-31 696 per year). For the overall sample and for Māori and non-Māori, we calculated adjusted odds ratios (aORs) to assess the association between regular smoking and risk factors each year: one or more parents smoke, best friend smokes, older sibling(s) smoke, and past week exposure to smoking in the home. We calculated population attributable risk (PAR) for risk factors in 2003 and 2015.

RESULTS

Between 2003 and 2015, aORs for exposure to smoking in the home increased from 1.7 (95% CI 1.6% to 1.8%) to 2.6 (2.1% to 3.1%) overall and from 1.8 (1.6% to 2.1%) to 3.4 (2.5% to 4.5%) for Māori; aORs for "best friend smokes" also increased, while aORs for sibling smoking and parental smoking did not change meaningfully. PAR for exposure to smoking in the home increased from 17% to 31% overall and from 28% to 57% for Māori, while PARs for other risk factors decreased.

CONCLUSIONS

Exposure to smoking in the home has become more strongly associated with adolescent smoking over time and is an increasingly important risk factor at the population level (independent of parental smoking), particularly for Māori.

IMPLICATIONS

Our findings have implications for reducing smoking uptake and ethnic disparities in NZ, and potentially elsewhere, given the similarity in risk factors and trends for adolescent smoking internationally. Our findings suggest that reducing second-hand smoke exposure in homes will likely reduce uptake of smoking. Because Māori children are both more exposed and appear to be more strongly influenced by exposure to smoking in the home, interventions to reduce indoor smoking could have differentially positive effects for Māori. Greater research and policy attention to reducing smoking in homes is warranted.

Situation, Impacts, and Future Challenges of Tobacco Control Policies for Youth: An Explorative Systematic Policy Review

Background: Tobacco use in youths is a major public health challenge globally, and approaches to the challenge have not been sufficiently addressed. The existing policies for tobacco control are not well specified by age. Objective: Our study aims to systematically investigate existing tobacco control policies, potential impacts, and national and international challenges to control tobacco use targeting the youth. Data sources: We used the statistics of the Global Youth Tobacco Survey (GYTS), studies, and approaches of tobacco control policies targeting youth. Considering country, continent, age, and significance, PubMed, Health Inter-Network Access to Research Initiative (HINARI), Scopus, the Cochrane Library, Google, and Google Scholar were searched. The related keywords were tobacco control, youth, smoking, smoking reduction policies, prevalence of tobacco use in youth, classification of tobacco control policies, incentives to prevent young people from using tobacco, WHO Framework Convention on Tobacco Control (FTCT), etc. The search strategy was by timeline, specific and popular policies, reliability, significance, and applicability. Results: We found 122 studies related to this topic. There were 25 studies focusing on situation, significance, and theoretical aspects of tobacco control policies associated with youth; 41 studies on national population polices and challenges; and 7 studies for global challenges to overcome the youth tobacco epidemic. All national policies have been guided by WHO-MPOWER strategies. Increases in tobacco tax, warning signs on packaging, restriction of tobacco product advertisements, national law to discourage young people, and peer-based approaches to quit tobacco are popular policies. Smuggling of tobacco products by youth and ignorance of smokeless tobacco control approach are major challenges. Limitation: Our study was flexible for the standard age of youth and we were not able to include all countries in the world and most of the studies focused on smoking control rather than all smokeless tobaccos. Conclusion: The policies of tobacco control adopted by many countries are based on the WHO Framework Convention on Tobacco Control but not necessarily focused on youth. Due to the physical and economic burden of tobacco consumption by youth, this is a high priority that needs to be addressed. Youth-focused creative policies are necessary, and more priority must be given to tobacco prevention in youth. Tobacco control should be a social, public health, and quality-of-life concern rather than a business and trade issue. Implication of key findings: There is limited research on how and in what ways tobacco control policies reach young people and their engagement with these policies from physical, physiological, and psychological aspects. Analysis of these aspects, popular polices practiced in different countries, and creative strategies support the need to review current practices and future ways to discourage youth from tobacco use.

Evidence From Qualitative Studies of Youth About the Impacts of Tobacco Control Policy on Young People in Europe: A Systematic Review

INTRODUCTION

A range of tobacco control policies endeavor to prevent smoking uptake in young people, yet relatively little is known about how such interventions impact young people's engagement with smoking. We reviewed existing qualitative evidence on young people and smoking in Europe to assess whether, in what ways and why young people comply with, adapt to, resist, or circumvent tobacco control policies in their respective countries.

METHODS

We undertook a systematic review of academic literature presenting qualitative research from Europe on smoking and young people (11-18 years), published from 2000 to 2015. Bibliographic searches (PubMed, PsycInfo, SSCI) produced 1357 records, from which 43 relevant articles were assessed for quality and 39 included in the review.

RESULTS

Most studies were from the United Kingdom (27), with a small number (one or two each) from other European countries (Denmark, Sweden, Switzerland, Belgium, Cyprus, Greece, Hungary, Ireland, and Spain). Only 16 articles (11 from United Kingdom) provided any evidence about the impacts of tobacco control policies on young people's smoking. These focused on smoke-free legislation (four), age of sale laws (four), plain packaging (three), and black market tobacco (one).

CONCLUSIONS

There is very little qualitative evidence exploring the impacts of tobacco control on youth smoking in Europe. To develop more effective smoking prevention policies that take account of local political, social, and cultural contexts, more qualitative research from a wider range of European countries is needed to understand how tobacco control impacts on young people's social worlds and smoking behaviors.

IMPLICATIONS

Smoking is the leading cause of premature mortality in Europe. However, there is little qualitative evidence exploring the impact of tobacco control policies on young people in Europe. Most comes from the United Kingdom and focuses on a narrow range of policies. Thus, we have a limited understanding of how and in what ways tobacco control policies reach young people, their engagement with these, and how local context affects their impact. More qualitative research is needed, from a wider range of countries and on a broader range of tobacco control policies, to strengthen the evidence-base for reducing youth smoking.

Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers

This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.

The "here and now" of youth: the meanings of smoking for sexual and gender minority youth

BACKGROUND

The mainstream tobacco field in the USA tends to situate youth as passive, particularly in terms of their susceptibility to industry manipulation and peer pressure. However, failing to acknowledge youths' agency overlooks important meanings youth ascribe to their tobacco use and how those meanings are shaped by the circumstances and structures of their everyday lives.

METHODS

This article is based on analysis of 58 in-depth qualitative interviews conducted with sexual and gender minority youth living in the San Francisco Bay area in California. Topics covered in interviews focused on meanings of tobacco in the lives of youth. Interviews lasted approximately 2.5 h and were transcribed verbatim and linked with ATLAS.ti, a qualitative data analysis software. Following qualitative coding, narrative segments were sorted into piles of similarity identified according to principles of pattern-level analysis to interpret to what extent meanings of smoking for young people may operate as forms of resistance, survival, and defense.

RESULTS

Analysis of our participants' narratives highlights how smoking is connected to what Bucholtz calls the "'here-and-now' of young people's experience, the social and cultural practices through which they shape their worlds" as active agents (Bucholtz, Annu Rev Anthropol31:525-52, 2003.). Specifically, narratives illustrate how smoking signifies "control" in a multitude of ways, including taking control over an oppressor, controlling the effects of exposure to traumatic or day-to-day stress, and exerting control over the physical body in terms of protecting oneself from violence or defending one's mental health.

CONCLUSIONS

These findings call into question the universal appropriateness of foundational elements that underlie tobacco control and prevention efforts directed at youth in the USA, specifically the focus on abstinence and future orientation. Implications of these findings for research, prevention, and policy are discussed, emphasizing the risk of furthering health inequities should we fail to acknowledge the "here and now" of youth.

The influence of racism on cigarette smoking: Longitudinal study of young people in a British multiethnic cohort

INTRODUCTION

Studies, predominantly from the US, suggest that positive parenting, social support, academic achievement, and ethnic identity may buffer the impact of racism on health behaviours, including smoking, but little is known about how such effects might operate for ethnically diverse young people in the United Kingdom. We use the Determinants of young Adult Social well-being and Health (DASH), the largest UK longitudinal study of ethnically diverse young people, to address the following questions: a) Is racism associated with smoking? b) Does the relationship between racism and smoking vary by gender and by ethnicity? (c) Do religious involvement, parenting style and relationship with parents modify any observed relationship? and d) What are the qualitative experiences of racism and how might family or religion buffer the impact?

METHODS

The cohort was recruited from 51 London schools. 6643 were seen at 11-13y and 4785 seen again at 14-16y. 665 participated in pilot follow-up at 21-23y, 42 in qualitative interviews. Self-report questionnaires included lifestyles, socio-economic and psychosocial factors. Mixed-effect models examined the associations between racism and smoking.

RESULTS

Smoking prevalence increased from adolescence to age 21-23y, although ethnic minorities remained less likely to smoke. Racism was an independent longitudinal correlate of ever smoking throughout adolescence (odds ratio 1.77, 95% Confidence Interval 1.45-2.17) and from early adolescence to early 20s (1.90, 95% CI 1.25-2.90). Smoking initiation in late adolescence was associated with cumulative exposure to racism (1.77, 95% CI 1.23-2.54). Parent-child relationships and place of worship attendance were independent longitudinal correlates that were protective of smoking. Qualitative narratives explored how parenting, religion and cultural identity buffered the adverse impact of racism.

CONCLUSIONS

Racism was associated with smoking behaviour from early adolescence to early adulthood, regardless of gender, ethnicity or socio-economic circumstances adding to evidence of the need to consider racism as an important social determinant of health across the life course.

New Zealand policy experts' appraisal of interventions to reduce smoking in young adults: a qualitative investigation

OBJECTIVES

Reducing smoking in young adults, particularly young Māori and Pacific, is vital for reducing tobacco harm and health inequalities in New Zealand (NZ). We investigated how NZ policy experts appraised the feasibility and likely effectiveness of interventions designed to reduce smoking prevalence among 18-24 year olds.

DESIGN

We used a qualitative design, conducting semistructured interviews and applying thematic analysis.

PARTICIPANTS

We interviewed 15 key informants, including politicians, senior policy analysts and leading tobacco control advocates. Participant selection was based on seniority and expertise and ensuring diverse perspectives were represented.

INTERVENTIONS

We examined nine interventions that could either promote greater mindfulness or introduce barriers impeding smoking uptake: smoke-free outdoor dining and bars; no tobacco sales where alcohol is sold; social marketing campaigns; real life stories (testimonials); life skills training; raise purchase age to 21; tobacco-free generation; smokers' licence; make tobacco retail premises R18.

RESULTS

The policies perceived as more effective denormalised tobacco; made it less convenient to access and use; highlighted immediate disadvantages (eg, impact on fitness); aligned with young people's values; and addressed the underlying causes of smoking (eg, stress). Participants highlighted some political barriers and noted concerns that some interventions might widen ethnic disparities. Exceptions were social marketing campaigns and extending smoke-free regulations to include outdoor areas of cafes and bars, which participants saw as politically feasible and likely to be effective.

CONCLUSIONS

Our findings suggest the merit of an approach that combines social marketing with regulation that makes accessing and using tobacco less convenient for young adults; however, political barriers may limit the regulatory options available in the short term. Strategies to support self-determination and address the underlying causes of smoking in young people warrant further investigation. Determining policy acceptability to Māori and Pacific, and likely effectiveness for these populations, should be key priorities.

Smoking to fit a stigmatised identity? A qualitative study of marginalised young people in Australia

In countries with comprehensive tobacco control, smoking is increasingly denormalised, with smokers subject to social stigmatisation. Qualitative research and commentary about denormalisation and stigma has largely focused on the impact on current or former smokers. Little attention has been given to the interaction between existing stigma among socially marginalised and disadvantaged young people and its role in smoking uptake, maintenance and resistance to quitting, or remaining a non-smoker. This article draws on a qualitative (grounded theory) study of young people aged 16-25 years who attended social services for at-risk youth in an inner city area in Australia, to explore the intersection between stigmatised identity and smoking in a context of increasing smoking denormalisation. Drawing on theoretical conceptualisations of stigma, we outline processes by which participants accept and apply social labels, internalise or distance themselves from stigmatised identities, and the influence of labelling on smoking trajectories, to demonstrate how the persistent dilemma of stigma shapes and reinforces smoking behaviour. The study highlights the need for tobacco control initiatives to align and integrate with broader initiatives to address structural inequality and social disadvantage.