A Review of Qualitative Research on Teenage Smoking Habits

A Review of Qualitative Research on Teenage Smoking Habits Grand Canyon University: NRS-433V-O103 Introduction to Nursing Research September 20, 2012 Introduction The purpose of this document is to summarize the contents of the research article, explain the research methods implemented, and offer insight on how the findings contribute to nursing practice. Second, there will be an explanation of ethical considerations associated with the conduct of nursing research. Finally, the source document, “What Determines Teenagers' Smoking Behaviour? : A Qualitative Study” will be attached for review. Summary

The articles purpose was to study smoking behavior among Malaysian teens. The specific areas of interest included: smoking initiation, cigarette consumption, intention to stop smoking, and attempts to stop smoking. The first stage of teen smoking behavior begins with casual experimentation and is followed by the maintenance phase when everyday ritual smoking is present. The future dependence on smoking can be predicted by the individual’s actions during experimentation with cigarettes. Curiosity, peer pressure, and parental smoking were all reported reasons that teens decided to try cigarettes.

In children less than thirteen year old, it was concluded that parental smoking played the largest role in behavior choices. This finding suggests that children are modeling the parents’ smoking behavior. However, older teens in secondary school reported peer pressure to be the reason for choices regarding cigarettes. Seventy-four percent of the participants reported that they smoked less than five cigarettes daily. This same portion or participants admitted that they smoked because they experienced physical symptoms of nicotine withdraw when they didn’t smoke daily.

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Consumption of cigarettes in this group was reported as a social activity among friends but mostly in secluded areas, to avoid getting caught. Most all adolescents that were active in this study reported that they had intended to quit smoking in the future. The majority of participants had no clear plan on how they were going to stop and most had admitted to several failed attempts to stop smoking without help. Aspects to consider: relationships, athletic involvement, health concerns, lack of finances, and parental concern are all reasons that would cause a teen smoker to consider quitting.

The participants that were able to stop smoking had a plan and picked a specific quit date. Methods of Study This information was collected and processed through a qualitative study. Specifically, it involved twenty-six teens from three public schools. Twenty-thee members of this sample group were smokers while three of the members had stopped smoking. Information was gathered through three focus group interviews, three in-depth interviews over twenty months, and questionnaires.

The questions were asked in a non-formal conversational manner with important points or answers recorded on a document designed to evaluate and sort information (site). The Social Cognitive Theory was used to organize collection of information and analysis. This theoretical framework was chosen based on the need for an explanation of teen smoking related to individuals, heath behaviors, and environments. The expectation is that Social Cognitive Theory would offer more insight on how these three elements would interact with each other simultaneously.

Contribution to Nursing Smoking tobacco continues to be one of the top causes of preventable causes for death in America. There are 430,000 deaths, one point five million years of potential life lost, and fifty billion of lost medical debt related to tobacco use (Hollis, J. , Pollen, N,… 2005). Nurses that identify younger clients at risk for tobacco can contribute to decline in morbidity related to smoking and assist in the decrease of medical debt. “The younger that youth are when they start using tobacco, the more likely they'll be addicted (CDC, 20012). The study offers insight to nursing practice for specific tailoring of a care plan for teens who smoke, parents who smoke, and how to target the education for quitting. The areas that affected teen’s interest in quitting included: athletic improvement, parents disapproval, health concerns, and lack of finances. Nurses can use the information from this study to reinforce the health promotion and benefits of being a non-smoker. The recognition of how parents affect smoking behaviors will aid the nurse in preparing education that is directed at the entire family to deter childhood and teen smoking.

The contribution to patient care can be seen with health promotion assessment use. The conclusions were clear about teens needing a plan to quit after they reached the maintenance phase of smoking. This result alerts nurses to assess smoking in younger adolescence and offer assistance with smoking cessation. Ethical Issues First, The Research and Ethic Committee of University Kebangsaan Malaysia gave approval before the study was started. Second, The Ministry of Education Malaysia offered authorization for interviews in the school system for children who were not involved in some type of major examination.

Third, all of the teens along with parents provided a written and signed consent for participation. The confidentiality of current smoking status was kept intact and privacy was maintained. Lastly, at the conclusions of each interview the teens were offered smoking cession counseling at a doctor’s clinic. To ensure reliability of the study, several schools were used and different types of data collection utilized. There was self-reflexivity in minimizing opinions of the researchers. Validation was offered by minimal prompting, statement clarification, and rephrasing of questions. Conclusion

The study identified factors like nicotine addiction, personal, and environmental issues that influence of smoking behaviors in teens. These areas should be of great priority when developing smoking cessation programs for teens. The Social Cognitive Theory utilized in this study is an aid that helps nurses to understand smoking behaviors in teens and how to address barriers to break those influential factors. Since this study was done in one region of Malaysia, it may not apply to all areas outside of it. This was a very small study that cannot be applied to all cultures, geographic locations, and race.

A better perspective would have been attained by selecting a wider group with random geographic location and equal gender participation. The male to female ratio for the study was unequal and this causes a shift in the standard deviation when scrutinizing the study from a statistical view. Having unequal gender numbers could cause a type I or II error which makes the information not entirely reliable (Grove, S. , 2012). References Center for Disease Control. (2012, January). We can make the next generation tobacco-free. Retrieved from http://www. cdc. gov/Features/YouthTobaccoUse/ Grove, Susan K. (2012).

Statistics for Health Care Research: A Practical Workbook [1] (VitalSource Bookshelf), Retrieved from http://pageburstls. elsevier. com/books/978-1- 4160-0226-0/outline/11 Hollis, J. , Polen, M. , Whitlock, E. , Lichtenstein, E. , Mullooly, J. , Velicer, W. , & Redding, C. (2005). Teen Reach: outcomes from a randomized, controlled trial of a tobacco reduction program for teens seen in primary medical care. Pediatrics, 115(4 Part 1), 981-989. Tohid, H. , Ishak, N. d. , Muhammad, N. , Hassan, H. , & Omar, K. (2011). What determines teenagers’ smoking behavior? : A qualitative study. International Medical Journal, 18(3), 194-198. 194

PSYCHIATRY Article Ititernational Medical Joumal. Vol. 18, No. 3, pp. 194 - 198 , September 2011 What Determines Teenagers' Smoking Behaviour? : A Qualitative Study Hizlinda Tohid", Noriah Mohd. Ishak^', Noor Azimah Muhammad", Hasliza Abu Hassan^', Farah Naaz Momtaz Ahmad'', Khairani Omar'* ABSTRACT Objective: The study aimed to explore smoking behaviour among Malaysian teenagers that were related to their smoking initiation, cigarette consumption, quit intention, and quit attempts. Methods: It was a qualitative study that used multiple case study design, involving 26 teenagers (23 smokers and three former smokers) from three public schools.

Data was collected via questionnaires, three focus group interviews and three in-depth interviews over 20 months, A standardised semi-structured interview protocol was utilised. Results: Among the participants, 74% of them started smoking after the age of 12 years old. The majority (20/23) of the teenage smokers admitted to smoking every day and 74% of them smoked not more than 5 cigarettes a day. All of the smokers had the intention to quit but only 22 out of the 23 teenage smokers had attempted quitting. Sixty percent of these teenagers had more than three quit attempts.

In general, this study captured the complexity of the teenagers' smoking behaviour that could be influenced by multiple factors, including behavioural (e,g, nicotine addiction), personal (e,g, conception of smoking and quitting, curiosity, sensation seeking, knowledge about smoking cessation, stress, maintaining athletic performance, and finance,) and environmental (e,g, socialisation, peer pressure, parental smoking, parental disapproval, and boy- or girlfriend aversion) factors. Conclusions: This study described the complex and multidimensional nature of teenage smoking behaviour.

The findings also correspondingly matched the Social Cognitive Theory (SCT), therefore suggesting the theory's suitability in elucidating smoking behaviour among the Malaysian teenagers, KEY WORDS smoking, teenagers, smoking initiation, cigarette consumption, quit smoking INTRODUCTION Adolescence is a crucial time in which a relatively dependent child transforms into a relatively independent adult. During this transitional period, many teenagers often experiment risky behaviours as a proclamation of their autonomy.

This risky behaviour includes cigarette smoking, using illicit drugs and cirinking alcohol. (Epps, Manley, & Glynn, 1995; Kulig, & American Academy of Pediatrics Committee on Substance Abuse, 2005) Experimenting with cigarette smoking is an initial stage of teenagers' smoking behaviour before it becomes established. (Nichter, Vuckovic, Quintero, & Ritenbaugh, 1997; Seguire, & Chalmers, 2000; Curry, Mermelstein, & Sporer, 2009) This smoking initiation predicts their long-term tobacco use and heavier levels of dependence. (Breslau, & Peterson, 1996; Escobedo, Marcus,

Holtzman, & Giovino, 1993; Chen, & Millar, 1998) Their experimenting behaviour may be influenced by various factors including curiosity, peer pressure, parental smoking, sensation seeking, social norms for smoking, and misconception of smoking (e. g. belief that smoking provides benefits, such as coping, sense of belonging, style, relaxation, and coolness). (Dijk, de Nooijer, Heinrich, & de Vries, 2007; Naing et at. , 2004; Khairani, Norazua, & Zaiton, 2004; Vuckovic, Polen, & Hollis, 2003; Nichter, Vuckovic, Quintero, & Ritenbaugh, 1997) These factors could cause teenagers to continue smoking.

Teenage smoking maintenance is also influenced by nicotine addiction. It has been shown to be substantially significant among teenagers even with low cigarette consumption. (The National Health and Morbidity Survey, 2009; Hammond et al. , 2008; Khairani, Norazua, & Zaiton, 2004; Naing et al. , 2004; DiFranza et at. , 2007; Balch et al. , 2004; Amos, Wiltshire, Haw, & McNeill, 2006) This may be due to a very rapid loss of autonomy over tobacco even with minimal exposure to nicotine in adolescents, as demonstrated by the DANDY study. (DiFranza et al. , 2007; DiFranza et al. , 2002)

Consequently, majority of teenage smokers struggle to quit smoking. (Balch et at. , 2004; McVea, Miller, Creswell, McEntarrfer, & Coleman, 2009; Amos, Wiltshire, Haw, & MeNeill, 2006; Seguire, & Chalmers, 2000) Thus, smoking behaviour among teenagers is a complex phenomenon, since it is influenced by multiple factors. This complexity requires great understanding of the behaviour from those who are involved in the care of these teenagers. This comprehension would certainly help the care providers to curb teenage smoking, which is a dangerous, addictive and destructive behaviour. US Department of Health and Human Services, 2004) Therefore, many studies have Received on Augtist 28, 2010 and accepted on November 29, 2010 1) Department of Family Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Jalan Yaacob Latif, Bandar Tun Razak, 56000 Cheras, Kuala Lutnpur, Malaysia 2) Pusat PERMATApintar Negara, Universiti Kebangsaan Malaysia Bangl, 43600 Selangor, Malaysia 3) Setapak Health Clinic, Kuala Lumpur, Malaysia Correspondence to: Hizlinda Tohid (e-mails; hizlinda2202@gmail. com) 2011 Japan International Cultural Exchange Foundation & Japan Health Sciences University

TobitJ H, et al. 195 Table 1. Participants' gender, status of smoking and types of interviews TYPES OF SCHOOL MALE GENDER FcEeM. . AALIEE SMOKERS STATUS OF SMOKING NON SMOKERS FOCUS GROUP INTERVIEW TYPES OF INTERVIEWS IN DEPTH INTERVIEW SCHOOL 1 URBAN 9 3 9 3 1 3 SCHOOL 2 SEMI-URBAN 7 7 1 SCHOOL 3 RURAL 7 7 1 TOTAL 3 23 3 23 3 3 3 been carried out to examine the phenomenon of teenage smoking. In Malaysia, majority of such studies were quantitative studies. (Naing et al. , 2004; Hoi, & Hong, 2000; Khairani, Norazua, & Zaiton, 2004; Zulkifli, Rogayah, Razian, & Nyi Nyi, 2001)

Nevertheless, studies that qualitatively describe Malaysian teenagers' smoking behaviour are still lacking. This deficiency may affect our understanding of the matter in great depth and holistically. Thus, this study aimed to explore smoking behaviour among Malaysian teenagers related to their smoking initiation, cigarette consumption, quit intention, and quit attempts. This information could provide us with better conception about their smoking behaviour, and subse-' quently eould help us to identify areas for improvement. METHODS

This study used a multiple case study design, involving 26 teenagers (23 smokers and three former smokers) from three public schools (urban, semi-urban and rural). Data was collected via selfadministered questionnaires, focus group interviews (FGI) and indepth interviews (IDI) over a period of 20 months, between 2008 until 2010. Theoretical framework This study utilised the Social Cognitive Theory (SCT) to guide the researchers in data collection and analysis. The SCT was also used for 'analytieal generalisation' in which findings of the study were mapped against the theory.

It was chosen as the study's theoretical framework due to its appropriateness and comprehensiveness in capturing a complex phenomenon of eigarette smoking that is influenced by multiple factors. (Baranowski, Perry, & Parcel, 2002) The SCT describes how individuals, environments and health behaviour interact with each other simultaneously (reciprocal determinism). (Baranowski, Perry, & Pareel, 2002) Study population Twenty six teenagers (23 boys and three girls, as shown in Table I) were selected via purposive and snowballing sampling, based on predetermined criteria.

The teenage smokers and former smokers were sampled because their experience in cigarette smoking and smoking cessation was crucial for this study. These teenagers were 16 years old Malays, recruited from three different (urban, semiurban and rural) public schools from 2 states in Malaysia. Recruitment of teenagers Teenagers were recruited with the assistance from school counsellors from eaeh sehool. An agreement for no disciplinary action against teenagers who were willing to participate in this study was made with the counsellors prior to the recruitment.

The students' smoking status was also eoneealed from other school staff to avoid stigmatisation. Twelve teenagers who were selected from one of the schools were introdueed to the main researcher during an informal meeting for study briefing (refer to Table 1). The teenagers were invited to participate and were given parental packages, which comprised of an acknowledgement letter to parents, the study's information sheet, and a parental consent form. Subsequently, dates for tbe FGI and IDI were set. The completed parental eonsents forms were eolleeted prior the interviews by the school counsellor.

The other 14 teenagers (7 students from each remaining school, as shown in Table 1) were reeruited by sehools' counsellors, who had training in qualitative research and were well informed about the study. Similar method of obtaining eonsent from their parents was carried out by these counsellors. Data collection Three in-depth interviews and three focus-group interviews were carried out (refer to Table 1). Prior to the interviews, all participants were given a brief overview of the study and the process of the interviews. Written eonsents from eaeh partieipant were also obtained.

They were then required to answer a brief self-administered questionnaire on their socio-demography, smoking status and smoking behaviour (age of initiation, cigarette consumption, quit intention and quit attempts). The interviews were conducted in Malay language and eaeh interview lasted less than two hours. A semi-structured interview protocol was used to guide interviewers in questioning the participants. Anti-smoking posters and pamphlets were also used to facilitate discussion. Data analysis During eaeh interview, the conversation was recorded using digital voice recorders.

The voice recording was subsequently transeribed into text by using Microsoft Office Word 2007. The transcribed text was reviewed against the audio-recordings for several times until the accuracy of the transcripts was ensured. Any uncertainty during the transcription, assistance from other researehers was sought to ascertain its accuracy and reliability. (Yin, 2003; Yin, 1994) The transcribed text was then imported into NVIVO 7. The main researcher then analysed the data to identify themes and categories ('thematie analysis') that would explain patterns of pereeption related to teenagers' smoking behaviour.

In order to ensure high reliability of the eoding proeess, tbe coded data was eross-checked by two experts in adolescence health. Kappa was calculated by using the Cohen kappa formula to determine the reliability index, which was maintained above 0. 8. The process of transcription and analysis was repeated for every interview and 'cross-case conclusion' was drawn between the analyses of eases. Findings of the study were also mapped against the SCT for 'analytical generalisation'. Ettiical issues, reliability and validity Approval from the Research and Ethic Committee of Universiti Kebangsaan Malaysia was obtained prior to the study.

Authorisation for interviewing teenagers from the schools was also acquired from the Ministry of Education Malaysia that limited interviewing students who were not sitting for any major examination (i. e. exeept students aged 15 and 17 years old). Apart from these, all of these teenagers and their parents were required to provide written eonsents for their participation. The confidentiality of the participants, e. g. obscuring teenagers' status of smoking from the knowledge of their parents and other sehool staffs, was also guaranteed throughout the study.

Finally, medical responsibility of the main researcher in preventing smoking-related illnesses, as she was also a medieal doctor, was realised by offering teenagers consultation for smoking eessation at her clinic. This was done at the end of each interview to prevent any biased answers from the partieipants. Validity and reliability of the study were ensured via a number of methods, ineluding; (1) triangulation of sourees of data (teenagers from three different sehools), as well as methods of data collection 196 What Determines Teenagers' Smokitig Behaviour? Table 2. Smoking behaviour of the teenagers who smoked

TEENAGERS WHO SMOKED (N = 23) AGE OF INITIATION (YEARS) NUMBER OF CIGARRETTES SMOKED/DAY STAGE OF CHANGE NUMBER OF QUIT ATTEMPTS FGD(n = 21) IDl(n = 2) TOTAL < 12 5 1 6 > 13 16 1 17 20 2 1 3 PRE COMTEMPLATION 5 1 7 CONTEMPLATION 4 4 PLANNING II 12 0 1 1 1-3 7 1 8 S4 13 1 14 (questionnaire, three FGI and three IDI), (2) self reflexivity in minimising biases that the researchers may bring into the study due to our previous involvement in managing problematic teenagers and chronic smokers, (3) 'procedural validity' via rephrasing of questions, elarifying of statement and minimal prompting as ecessary,(Fliek, 2009) and (4) inter-coder agreement or reliability index of above 0. 8. RESULTS Twenty three boys and three girls were interviewed (referred to Table 1), in which two of the boys and one of the girls were former smokers. The remaining 23 teenagers were smokers at the time of the interviews. These teenagers' smoking behaviour (age of smoking initiation, cigarette consumption, intention to quit and history of quit attempts) is summarised in Table 2. Age and reasons of smoking initiation Six of the 23 (26%) teenage smokers in this study started smoking during primary school (before the age of 13).

The youngest age of smoking initiation was 10 years old. Nevertheless, 74% of these teenage smokers started smoking when they were in the secondary school. Most of the teenagers admitted that curiosity ["Felt curious to try (smoking)"], sensation seeking ["Just for fun"], parental modelling of smoking ["Sinee my father smokes... I always watch him smoking. When he smokes, it looks pleasurable... gratifying"], peer pressure ["Peer influence"], and misconception of smoking ["Style (because of smoking). Siyle"] were common factors for them to experiment with smoking.

The teenagers who started smoking before the age of 13 claimed that curiosity and smoking modelling by parents were their main reasons for experimenting with smoking. This is contrary to those who started smoking at the age of 13 years or older. These teenagers admitted that peer pressure was the major factor for them to start smoking. Cigarette consumption Majority (20/23) of the teenage smokers in this study admitted to smoking every day and 74% of these teenagers smoked not more than 5 cigarettes a day.

The teenagers believed that their daily smoking behaviour was mainly due to nicotine addiction in which they described substantial physical (e. g. tiredness, lethargy, flu-like symptoms) and psychological (e. g. slow thinking, depressed, craving) withdrawal symptoms that they experienced during smoking abstinence ["My brain feels slow"; "(If I stop smoking) I feel restless. "]. The daily smokers also admitted to smoking when they were with their friends. They claimed this behaviour could be due to a number of reasons: a) sharing the cost of cigarettes with their friends, thus tend to smoke together, as explained by a teenager: Between 14 of us. we shared RMI per person, we can get 2 big boxes of cigarettes. " b) socialisation, as one teenager noted: "When we hang around (with friends), we smoke, sis" c) peer pressure, as a teenager claimed: "When we see our friends smoked, the desire to smoke is too intense. " d) sense of belonging, for example: "We all belong to a gang who shared our cigarettes together" However, three of the current smokers admitted to smoking only once a week. They stated that they particularly smoked during stressful period ["Especially when I am doing something. When it's hard then I'll smoke. ]. A few of the teenagers reported that the national anti-tobacco policy, as well as the school regulations had restricted their smoking behaviour. These teenagers admitted to commonly smoke in secluded areas outside of public view, such as in school toilets and stairways of shopping malls. The restrictive environment for public smoking was believed to influence tbeir cigarette consumption. Intention to quit All teenage smokers in this study had the intention to quit smoking. However, 7 of them (30%) did not plan to quit within the next 6 months (in the pre-contemplation stage).

Twelve of them (52%) were in the planning stage, but none had set their quit dates. The smokers diselosed that a number of factors could influence tbeir desire to quit, which included: a) impaired athletic performance, as one of the teenagers claimed: "When (I) sprint... I will hecome breathless" b) boy- or girlfriend aversion, for example: "Maybe (I get the desire to stop smoking) from my girlfriend. If she said "If you do not stop smoking, we should break-up". Huh. (I feel like to quit smoking)" c) parental disapproval, as noted by one boy: If mother scolded me for smoking, until she cried.. I would feel ? ike I want to quit, but it was temporary only. Afterwards.. I continue smoking" d) concern about health, shown by one of the teenagers' excerpt: "Smoking can make me feel breathless, sis (that's why I feel like to quit)" e) finaneial problems, as a teenager stated: "(I) think about my parents, sis. My mother and my father are not wealthy, (when I) think about that, it could (trigger my desire to quit)" Similar motivating factors were also reported by former smokers in this study prior to their successful smoking cessation.

Nevertheless, these former smokers admitted that only personalised motivating factors could render them to quit successfully. Their personalised motivators were parental disapproval ["(Parental disapproval) effective, it's effective. I've stopped smoking. "], maintaining athletic performance ["(I) stopped smoking (for athletic performance). I got selected (to play football for my district) afterwards"]. and saving money /"/ stopped (smoking) to save money to buy a motorbike"]. Previous quit attempts Almost all (22/23) teenage smokers in this study had attempted smoking cessation prior to the interviews.

The teenagers deseribed that quitting was very difficult because of withdrawal symptoms that they experienced during the quit attempts ["(If I stop smoking) I feel restless"]. Sixty percent of the teenage smokers had actually attempted to quit four times or more. All of the teenagers claimed that they never reeeived any professional helps when they made their attempts to quit in the past. Majority of them declared that they sought their friends' advice on how to quit and among the common methods that they had tried were drinking a lot of water, chewing gums and taking sweets, as one of the teenagers said:

Tohid H. et al. 197 "Usuatty (I) asked my friends how to quit. They advised me to drink a tot of minerat water. " DISCUSSION In Malaysia, the mean age of smoking initiation among teenage smokers is between 12-14 years old, (The National Health and Morbidity Survey, 2009; Hammond et at. , 2008; Khairani, Norazua, & Zaiton, 2004; Naing et at. , 2004) whieh is concurrent with the findings of this study. The common reasons for smoking initiation, such as curiosity, peer pressure, and parental smoking, reported by tbe participants in tbis study were similar to otber studies. (Naing et at. 2004; Kbairani, Norazua, & Zaiton, 2004) This study also suggested that curiosity and parental modelling of smoking bebaviour could be teenagers' main reasons for experimenting smoking at younger age (less tban 13 years old). In contrary, peer pressure was found to be a major factor for teenagers wbo started smoking at seeondary sehools. However, the significance of tbese associations should be confirmed by future quantitative studies. Cigarette consumption reported by teenagers in this study was found to be lesser tban tbose of Malaysian adults, who averagely smoke between 11 to 14 cigarettes per day. World Health Organization (WHO) Framework Convention on Tobacco Control, 2010) Tbis may be due to a number of factors as suggested by tbese teenagers, such as; (a) insufficient fund to purchase cigarettes, (b) 'occasional' smoking, and (c) restrictive environment for smoking. Nevertheless, underreporting of smoking behaviour by these teenagers may also explain the lower estimated number of cigarettes smoked by them. Tbis is because teenagers have a tendency to report socially desirable behaviour and attitudes. (Hammond et at. , 2008; Klein, Havens, & Carlson, 2005)

Insufficient fund to purebase cigarettes were described by some of the teenagers in this study, who claimed that they had to share their pocket money with their peers to buy cigarettes. Tbis is to ensure their continuous supply of cigarettes and to develop bonding among tbe peers. (Vuckovic, Polen, & Hollis, 2003; Amos, Wiltsbire, Haw, & McNeill, 2006; Niehter, Vuckovic, Quintero, & Ritenbaugh, 1997; Seguire, & Cbalmers, 2000) Tbis practice in turn increases tbe level of acceptance by peers and promote sense of belonging tbat is pertinent to teenagers' psychosocial development. Mermelstein, 2003; Vuckovic, Polen, & Hollis, 2003; McVea, Miller, Creswell, McEntarrfer, & Coleman, 2009; Nicbter, Vuckovic, Quintero, & Ritenbaugh, 1997; Seguire, c& Chalmers, 2000) However, some teenagers in this study, who had no financial constraint because they had personal income (e. g. from part-time job or significant allowance from parents), admitted to smoke only wben socialising and facing adversities (e. g. relation problems, inability to cope witb academic or part-time job). (Vuekovic, Polen, & Hollis, 2003; Balch et at. , 2004; Amos, Wiltshire, Haw, & McNeill, 2006; Hoi, 8L Hong, 2000;

Khairani, Norazua, & Zaiton, 2004; Niehter, Vuckovic, Quintero, & Ritenbaugh, 1997; Seguire, & Chalmers, 2000) These teenagers can be defined as occasional smokers, whose smoking was apparently influenced by peer pressure and tbeir inability to control themselves over smoking or to cope with stress. (Vuckovic, Polen, & Hollis, 2003; Seguire, & Chalmers, 2000; Patten et al. , 2003; Niehter, Vuckovic, Quintero, & Ritenbaugh, 1997; Mermelstein, 2003; McVea, Miller, Creswell, McEntarrfer, & Coleman, 2009; Khairani, Norazua, & Zaiton, 2004; Balch et at. , 2004; Amos, Wiltshire, Haw, & McNeill, 2006; Hoi, & Hong, 2000) Teenagers' smoking in esponse to hardship shows that smoking is their way of coping since it calms them through nicotine effects on the central nervous system. (Niebter, Vuckovic, Quintero, & Ritenbaugh, 1997; Curry, Mermelstein, & Sporer, 2009) In addition, smoking creates a social space in which they can calm down and relieve tension. (Niehter, Vuckovic, Quintero, & Ritenbaugh, 1997; Curry, Mermelstein, & Sporer, 2009) Apart from financial constraint and occasional smoking, restrietive environment for public smoking was also found to be responsible for tbe partieipants' low cigarette consumption in this study.

Therefore, these teenagers commonly smoked in secluded areas outside of public view, sucb as scbool toilets and stairways of shopping malls. These findings are consistent with a number of other studies that have found restrictive environment to be effective in reducing teenage smoking. (Wakefield ct at. , 2000; Lipperman-Kreda, & Grube, 2009; Crawford, Balcb, Mermelstein, & Tobacco Control Network Writing Group, 2002) Majority of teenage smokers bave intention to quit. (Khairani, Norazua, & Zaiton, 2004; Krishnan M, 2003; Mermelstein, 2003; Naing ct at. 2004; The National Health and Morbidity Survey, 2009) Tbis was also found by tbis study, in wbich almost all teenagers who smoked eonsidered to quit smoking sometime in the future. They admitted that a number of factors could trigger tbeir quit intention, wbich include; (a) athletic performance, (b) boy- or girlfriend aversion, (c) parental disapproval, (d) concern about bealtb, and (e) money saving. Tbese faetors were similarly found to motivate teenagers to eease smoking by previous studies. (Vuckovic, Polen, & Hollis, 2003; Mermelstein, 2003; McVea, Miller, Creswell,

McEntarrfer, & Coleman, 2009; Balcb ct al. , 2004) However, tbe teenagers reported tbat these extrinsie motivations were insufficient to keep them from total smoking abstinence. Nevertbeless, excerpts made by tbe former smokers in this study suggested that teenagers would only stop smoking when they are desperate to change due to compelling personal reasons. This finding is supported by McVea et al who found only 'emotionally compelling and inescapable quit reasons' were the most motivating reasons for teenagers to stop smoking. (McVea, Miller, Creswell, McEntarrfer, & Coleman, 2009)

Even though majority of tbe teenagers in this study had intention to quit smoking, they did not have any quitting plans, not even setting their quit dates. These findings are similar to those reported by Mermestein. (Mermelstein, 2003) It is possible tbat the teenagers were; (a) not ready to quit (Balch ct al. , 2004) (e. g. some of the teenagers in the eurrent study would only quit when they experience major life transition, such as after graduation and tnarriage), (b) ambivalent about quitting (MeVea, Miller, Creswell, McEntarrfer, & Coleman, 2009; Patten et al. 2003) (e. g. a number of teenagers repetitively answered, "I am not sure" when they were asked about tbeir plan to quit smoking), and (c) very confident that they could control themselves over smoking (Niehter, Vuckovic, Quintero, & Ritenbaugb, 1997; Amos, Wiltshire, Haw, & McNeill, 2006) (e. g. a teenager assertively admitted that he could stop stroking on his own without relying on helps from other). The later seems to be related to teenagers' belief tbat 'quitting is just a matter of will power'. (Amos, Wiltsbire, Haw, & McNeill, 2006; Balcb el at. 2004) After all, these teenagers' ehanees for successful quit attempts would be reduced if they did not have strategic quitting plans. Multiple unsuccessful quit attempts were also reported by many teenagers in tbis study, in which the findings were concurrent with other studies. (World Health Organization (WHO) Framework Convention on Tobacco Control, 2010; The National Health and Morbidity Survey, 2009; Klein, Havens, & Carlson, 2005; Balch ct at. , 2004) This could be due to several reasons which can be summarised into three categories; (1) nicotine addiction,(Amos,

Wiltsbire, Haw, & McNeill, 2006; Balch et al. , 2004; DiFranza et at. , 2007; DiFranza ct at. , 2007) (2) factors related to environment and situation which could promote teenage smoking (e. g. strong peer pressure, poor support from friends, smoking tnodelling by family members, stress etc, as higbligbted by tbe current study), (Balch et at. , 2004; Crawford, Balch, Mermelstein, & Tobacco Control Network Writing Group, 2002; McVea, Miller, Creswell, McEntarrfer, & Coleman, 2009; Nicbter, Vuckovic, Quintero, & Ritenbaugb, 1997) and (3) personal factors (e. g. oor risk assessment, poor knowledge, poor self efficacy and control, mi,sconception about smoking and quitting, strong belief in unassisted quit attempts etc, as found by this study) (Niehter, Vuckovic, Quintero, & Ritenbaugb, 1997; Balcb ct at. , 2004). These tbree categories appear to matcb tbe model of the Social Cognitive Theory. Overall, this study provides beneficial information for future development of interventions of smoking cessation for teenagers. Nevertheless, appropriate eontext which is similar to tbose of this study should be taken into consideration before applying such information since this is a ease study.

Interviewing only teenagers aged 16 years old also limits the findings of this study. This is because teenagers at different stages of adolescence (early, middle and late) may bave different developmental characteristics which may influence their pereeption and attitude towards cigarette smoking. Teenagers from different stages of adolescence should then be included in future studies as differences in tbeir perception, attitude and bebaviour could be explored. CONCLUSION This study bad captured tbe complexity of tbe teenagers' smoking bebaviour that could be influenced by multiple factors.

Tbese faetors included behavioural (e. g. nicotine addiction), personal and environmental factors matched the Social Cognitive Theory (SCT). These 198 What Determines Teenagers' Smoking Behaviour? multiple factors should be considered in developing interventions for smoking cessation suited for teenagers. The corresponding mapping of the findings against the SCT also supports the use of the SCT in helping us to comprehensively understand teenage smoking behaviour and to overcome the influential factors. FUNDING This work was funded by the Universiti Kebangsaan Malaysia UKM-GUP-TKS-07-12-097 and FF-127-2008). DECLARATION OF INTERESTS All authors declare that they have no conflicts of interests. ACKNOWLEDGEMENTS The authors would also like to express gratitude to the Ministry of Education Malaysia, the Ministry of Health Malaysia and the school counsellors who had helped us throughout the study. REFERENCES Amos A. Wiltshire S, Haw S. McNeill A. (2006). Ambivalence and uncertainty: experiences and altitudes towards addiction and smoking cessation in the mid-to-late teens. Heatiti Educ Re. s. 21. 181-191. doi:l0. 1093/her/cyh054 Baick GI.

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