Risk perception and moralization among smokers in the USA and Denmark: a qualitative approach

Does Ostracism Help Smokers Quit?

Research on the effects of stigmatizing on smokers shows that it is stressful to be reminded of one's devalued status and stigmatization might help or hinder quitting intentions. In this study, we asked smokers (N=277) to play an online ball-tossing Cyberball game, ostensibly with non-smoking strangers. Participants were randomly assigned to an ostracism (included or excluded) and concealment (smoking status concealed or revealed) manipulation. We found that exclusion led smokers (directly or via threat appraisals) to be more stressed, cognitively depleted, rejection sensitive, have fewer positive cognitions, see themselves at greater health risk, feel more internalized stigma, and be more interested in quitting, with stronger effects when their smoking status was revealed instead of concealed. These results suggest that concealment is imperfect in protecting against stigma and that exclusion (although stressful and cognitively taxing) can lead to cognitions, attitudes, and intentions helping smokers quit and thus leave their devalued identity. The results do not imply that one ought to stigmatize; stigmatizing smokers might be unethical or create barriers to health-seeking behaviors which could counteract structural efforts to help smokers quit. Future research should examine the role of self-affirmation to increase the effectiveness of health messages perceived as stigmatizing or identity threatening.

Environmental determinants of infectious and chronic disease prevention behaviours: A systematic review and thematic synthesis of qualitative research

Regulatory health policies facilitate desired health behaviours in communities, and among them, smoke-free policies and COVID-19 restrictions have been widely implemented. Qualitative research studies have explored how these measures and other environmental influences shape preventive behaviours. The objective of this systematic review was to synthesize previously published qualitative research, generate across-study themes, and propose recommendations for behaviour change interventions. We used a comprehensive search strategy, relevance screening and confirmation, data extraction, quality assessment, thematic synthesis, and quality-of-evidence assessment. In total, 87 relevant studies were identified. Findings were grouped under six overarching themes and mapped under three categories: (i) the political environment, (ii) the sociocultural environment, and (iii) the physical environment. These findings provide insights into the environmental influences of behaviour and indicate future interventions may be more effective by considering moral norms, community norms, policy support, and group identity.

Using Moralization as a Persuasion Strategy in Public Health Messages: A Cross-Sectional, Experimental Study on Vaping

Using moralization in anti-vaping public health messages as a persuasion strategy was recently recommended to address the current vaping epidemic. However, previous findings indicated this could lead to moralized attitudes in the general population, which can be very difficult to change and could severely affect social cohesion and distort risk perception. Since the safety and efficiency of using electronic cigarettes as smoking cessation devices are still being investigated, we conducted a cross-sectional, experimental study on a convenience sample of 612 Romanian never vapers, never smokers to assess how exposure to moralizing public health messages about vaping might influence their trust in future scientific results about this topic. Participants were randomized into six groups according to the type of message ("moral," "immoral," "neutral") and the type of effects of vaping on smokers' health, documented in a future fictitious study ("health benefits," "health risks"). Results showed that the type of message moderated trust in future scientific results after controlling for participants' general trust in science. When vaping was framed as immoral, trust in future scientific results showing health benefits was decreased, and vice versa. Implications are discussed for using moralization strategically in public health messaging to curtail or promote certain health behaviors.

Reminders of a Stigmatized Status Might Help Smokers Quit

As members of a devalued group, it is not surprising that smokers experience stigmatization and discrimination. But it is not clear if smokers react to these experiences by moving toward or away from their group membership and identity as smokers. Guided by the identity threat model of stigma (Major and O'Brien, 2005) we examined the process of stigmatization and its emotional, cognitive, attitudinal, and behavioral consequences. We experimentally examined how reading a stigmatizing newspaper article or a control article (Experiment 1) and recalling one's experience with smoking discrimination or a control prompt (Experiment 2) affected smokers' responses. We also examined the role of cultural contexts (U.S. vs. Denmark; only in Experiment 1) and smoking identity. In Experiment 1, we used a community sample of smokers from the U.S. (N = 111) and Denmark (N = 111). We found that reading the stigmatizing article (compared to the control) caused more rejection sensitivity (U.S. participants only) and more intentions to quit smoking (both U.S. and Danish participants) for smokers low in smoking identity. In Experiment 2, we used an online sample of 194 U.S. smokers and found that recalling instances of mistreatment made smokers more stressed, rejection sensitive, and interested in smoking cessation, when smokers appraised the stigma cue as threatening. Thus, we generally found that identity threat moved smokers toward leaving their stigmatized group (e.g., quitting smoking) rather than away from it. Our studies highlight the importance of understanding psychological process by which smokers distance themselves from their spoiled identity.

Urban-rural differences in related factors of second-hand smoke exposure: a cross-sectional study of adult non-smokers in Northeast China

BACKGROUND

this study aims to examine the different factors associated with exposure to second-hand smoke (SHS) between urban and rural areas and to facilitate a reduction in SHS exposure in Northeast China.

METHODS

a multistage stratified random cluster sampling design was used in this 2012 cross-sectional survey in Jilin Province, Northeast China. A total of 13 056 non-smokers were included in this study. The Rao-Scott χ2 test, multiple regression analysis and discriminant function analysis were used.

RESULTS

the SHS prevalence among adult non-smokers was 60.2% in urban areas and 61.8% in rural areas. In urban areas, males were more likely to be exposed to SHS, while in rural areas, females were more likely to be exposed to SHS (P < 0.05). Increasing age was a protective factor against SHS exposure both in urban and rural areas (P < 0.05). Tobacco-relevant knowledge was positively associated with SHS exposure. Among urban non-smokers, high education level and engagement in manual work were risk factors for SHS exposure, and retired subjects were less likely to be exposed to SHS (P < 0.01).

CONCLUSIONS

non-smokers from urban and rural areas differ in the factors associated with SHS exposure, and urban-rural differentials, especially with regard to gender, should be considered in tobacco control.

Perceived social benefits versus perceived harms of smoking among Indonesian boys aged 12-16 years: A secondary analysis of Global Youth Tobacco Survey 2014

INTRODUCTION

Smoking among boys has not been prioritised as a gender issue despite its high prevalence worldwide. In Indonesia, steep increases in prevalence have been observed in adolescent boys. This study explored how smoking-related beliefs are associated with smoking among this group.

METHODS

Data extracted from the Global Youth Tobacco Survey Indonesia 2014, provided a nationally representative sample of 2729 male students aged 12–16 years. Measures of smoking-related beliefs were derived from eight survey items using principal component analysis. Associations between resulting components and smoking outcomes were modelled using logistic regression.

RESULTS

Smoking prevalence was found to be almost tripling between ages 12 to 16 years. Smoking-related belief items clustered into two components: perceived social benefits and perceived harms. The four beliefs representing smoking’s perceived social benefits and measures of smokers in the boys’ social circles increased with age while the four beliefs representing smoking’s perceived harms remained stable except an item of safe to smoke for one or two years, which increased with age. The two components of smoking-related beliefs were associated with smoking in opposite ways that represent boys’ masculine tendency for risk-taking and risk minimisation. For example, score increases for perceived benefits were positively associated with susceptibility to future tobacco use (OR=1.6; 95% CI: 1.3–1.9) but an increased score of perceived harm was negatively associated with susceptibility to future tobacco use (OR=0.8; 95% CI: 0.7–0.9).

CONCLUSIONS

Indonesian boys experience a rapid increase in smoking outcomes and smoking reported among their social circle. The sustained high percentage of smoking harms but also increased social benefits are similar to the concept of risk minimisation that is closely related to the masculine tendency to undermine health hazards of tobacco. Therefore, it is important to focus on these highly gender-related issues within the country.

DOES IT HELP SMOKERS IF WE STIGMATIZE THEM? A TEST OF THE STIGMA-INDUCED IDENTITY THREAT MODEL AMONG U.S. AND DANISH SMOKERS

Research shows that smokers feel stigmatized, but does stigmatizing smokers do more harm than good? The model of stigma-induced identity threat was used to experimentally examine how U.S. and Danish smokers respond to stigma-relevant cues. Heavy smokers (112 Americans, 112 Danes) smoked a cigarette while giving a speech that was either video (stigma-visible condition) or audio recorded (stigma-concealed condition). Smokers high in self-concept reacted to the stigma-visible (as opposed to the stigma-concealed) condition with greater physiological reactivity (b = -2.80, p = .05), cognitive depletion (U.S. smokers, b = -0.06, p = .11), self-exempting beliefs (b = 0.32, p < .001), and less interest in stopping smoking (b = 0.28, p = .02). Thus, stigmatization led smokers toward emotional, cognitive, and attitudinal reactions that might make them less likely to quit. Future research should examine when smokers respond to stigmatization by quitting rather than with resistance or indifference.

Boy Smokers' Rationalisations for Engaging in Potentially Fatal Behaviour: In-Depth Interviews in The Netherlands

Adolescent smokers engage in cognitive rationalisation processes that lower perceptions of personal vulnerability to the health consequences of smoking. There is, however, hardly any evidence that provides in-depth insights on adolescents’ recurring rationalisations. Therefore, we explored how boy smokers deal with the knowledge that they are engaging in potentially fatal behaviour. Interviews were held with 16 boy smokers aged 16 to 17 years old. The qualitative analysis focussed on combining boys’ reasons about why they think they will not experience severe health consequences into coherent rationalisations that recurred among interviewees. Three rationalisations emerged from the analysis. First, boys trivialize the immediate consequences and think these can be compensated for and are outweighed by the benefits of smoking. Second, boys assume that smoking will only take place during adolescence and they will, therefore, recover from the damage inflicted. Third, boys believe that they have control over the amount and frequency of smoking and, thereby, can ensure that they will not experience fatal consequences. Boys’ recurring rationalisations build on their view that they are supposed to have fun and will not become typical adult smokers. Interventions should address these rationalisations in order to increase adolescents’ perceptions of personal vulnerability, and thereby contribute to decreasing adolescent smoking.

Qualitative study of Singaporean youths' perception of antismoking campaigns: what works and what does not

Background

Youths are more likely to rebel against messages perceived to inhibit their independence. In order for antismoking campaigns to be effective with this population, adopting evidence-based strategies is crucial. In this study, we examined youths’ reaction to past and ongoing antismoking campaigns, and delineate effective and ineffective components of campaigns as identified by them.

Methods

12 focus group discussions were conducted with 91 youth smokers aged 15–29 years. Data were analysed using qualitative content analysis. A codebook was derived through an iterative process. The data were coded systematically by three coders, using Nvivo V.10.

Results

Fear appeals that had no immediate relevance to youths, and campaigns involving humour or sports/dance activities that distracted youths from the antismoking messages, were deemed ineffective. In contrast, elements identified to be efficacious were: positive tone, low-fear visual images, ‘low-controlling language’ and a genuine spokesperson. Youth tended to favour campaigns circulating on social media platforms. Importantly, youths voiced a lack of tangible support for their efforts to quit smoking.

Conclusions

Participants expressed a preference towards antismoking messages that were less authoritative, and perceived a distinct lack of support for their intentions to quit smoking. There is room for incorporating suggestions by participants in future antismoking campaigns. Future research is needed to identify barriers to accessing available support.

Perspectives on Smoking Initiation and Maintenance: A Qualitative Exploration among Singapore Youth

Studies among adolescents have shown that several important interpersonal, intrapersonal and environmental factors are associated with smoking behaviour. The current qualitative research project aimed to explore the determinants of smoking initiation and maintenance, from a youth perspective, among young people who smoked, living in a multi-ethnic Asian country. Focus group discussions (FGDs) were conducted with youths in Singapore in youth-friendly and accessible locations. Young people, from a variety of social contexts-varying on age, gender, ethnicity and educational level, were included in the study. All FGDs were conducted in English and participants were recruited using a mix of network and purposive sampling. All FGDs were audio recorded and transcribed verbatim. The data were analyzed using qualitative content analysis, allowing themes to emerge from the data with the goal of answering the research question. Ninety-one youth smokers (54 males, 37 females), aged between 14 to 29 years, participated in the study. The majority were males (59%) and of Chinese ethnicity (52%). Participants identified multiple personal, social, and familial influences on young adults' smoking behaviors. Peer and family influences, as well as risk minimization, played a key role in smoking initiation and maintenance. While young people were aware of policies that restricted smoking, these did not directly affect their decision to start smoking. The theory of triadic influence provided a promising theoretical framework to understand smoking initiation and maintenance in a sample of young adult smokers from a multi-ethnic Asian country. It also provides actionable information for initiatives to prevent smoking in young people, which includes their perspectives and emphasizes an inclusive approach without stigmatizing those who smoke.

Does moralization motivate smokers to quit? A longitudinal study of representative samples of smokers in the United States and Denmark

INTRODUCTION

Moralization refers to the gradual cultural and personal process by which objects or activities move from being morally neutral to morally contemptuous. Research suggests important cross-cultural differences in how smokers react to being targets of moralization. However, research has not examined whether smokers who agree with moralized sentiments about smoking are more willing to quit or reduce their smoking. Additionally, the mediating role of perceived personal risk has not been examined.

METHODS

In this study, representative samples of smokers in Denmark (a smoking lenient country; N = 429) and the United States (a smoking prohibitive country; N = 431) completed surveys 6 months apart.

RESULTS

As expected, Danish smokers (compared to U.S. smokers) moralized less and estimated that their personal risk of lung cancer was smaller. Furthermore, moralization at T1 predicted an increase in perceived personal risk at T2 (for Danish smokers and marginally for U.S. smokers), a decrease in smoking behaviors (for Danish smokers only), and an increase in quitting intentions (marginally for Danish smokers only). For Danish smokers, perceived personal risk mediated the relationship between moralization and quitting intentions.

CONCLUSIONS

Moralization predicted an increase in perceived personal risk, an increase in quitting intentions, and a reduction in smoking behaviors, especially for the Danish sample. Future research should examine the effects of moralization in different cultural contexts.

Smoking, self-regulation and moral positioning: a focus group study with British smokers from a disadvantaged community

Smoking in many Western societies has become a both moral aand health issue in recent years, but little is known about how smokers position themselves and regulate their behaviour in this context. In this article, we report the findings from a study investigating how smokers from an economically disadvantaged community in the East Midlands (UK) respond to concerns about the health impact of smoking on others. We conducted ten focus group (FG) discussions with mixed groups (by smoking status and gender; N = 58 participants) covering a range of topics, including smoking norms, self-regulation, and smoking in diverse contexts. We transcribed all FG discussions before analysing the data using techniques from discourse analysis. Smokers in general positioned themselves as socially responsible smokers and morally upstanding citizens. This position was bolstered in two main ways: 'everyday accommodation', whereby everyday efforts to accommodate the needs of non-smokers were referenced, and 'taking a stand', whereby proactive interventions to prevent smoking in (young) others were cited. We suggest that smoking cessation campaigns could usefully be informed by this ethic of care for others.