Snus user identity and addiction. A Swedish focus group study on adolescents
© Edvardsson et al.; licensee BioMed Central Ltd. 2012
Received: 1 March 2012
Accepted: 7 November 2012
Published: 13 November 2012
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© Edvardsson et al.; licensee BioMed Central Ltd. 2012
Received: 1 March 2012
Accepted: 7 November 2012
Published: 13 November 2012
The teenage years are the years when adolescents seek their identity, and part of this involves experimenting with tobacco. The use of tobacco as such, and norms among their friends, is more important to the adolescents than the norms of parents when it comes to using tobacco or not. The aim was to explore the significance of using snus for adolescents, and attitudes to snus, as well as the reasons why they began using snus and what maintained and facilitated the use of snus.
Adolescents who use snus were interviewed in focus groups. The material was analysed using content analysis.
Four groups of boys and one group of girls were interviewed, a total of 27 students from the upper secondary vocational program. Three themes related to the students’ opinions on and experiences of using snus were found: Circumstances pertaining to snus debut indicate what makes them start using snus. Upholding, which focuses on the problem of becoming addicted and development of identity, and approach, where the adolescents reflect on their snus habits in relation to those around them. A number of factors were described as relevant to behaviour and norm building for the development into becoming a snus user. Attitudes and actions from adults and friends as well as – for the boys – development of an identity as a man and a craftsman influenced behaviour.
The results showed that development of identity was of major importance when adolescents start using snus. The adolescents were initially unable to interpret the early symptoms of abstinence problems, but subsequently became well aware of being addicted. Once they were stuck in addiction and in the creation of an image and identity, it was difficult to stop using snus. These factors are important when considering interventions of normative changes and tobacco prevention in schools as well as among parents.
Adolescence has been identified as the period in life when experimentation with tobacco increases dramatically. Swedish studies indicated that the use of snus is introduced later than smoking among adolescents [1, 2]. In grade 2 in upper secondary school (age 17), 24 per cent of the boys and seven per cent of the girls used snus in Sweden 2011, and the trend is slowly decreasing .
Smokeless tobacco use occurs in a number of countries around the world, and smokeless tobacco comes in a variety of ways. The products contain unhealthy substances at different levels, and nicotine, that get the user hooked on the addiction . Snus (the traditional Swedish type of oral moist snuff) is forbidden for export outside Sweden. The use of snus increases the risk of reversible and irreversible oral lesions, ventricle, and oesophagus [5–8], and it also increases the risk of dying from a heart attack or stroke [9, 10]. Using snus during pregnancy increases the risk of premature delivery and pre-eclampsia .
Social identity and belonging to a group are important during the adolescent years, a time when it is common among teenagers to experiment with tobacco. This could be part of the adolescent seeking his/her identity. Friends have an important role in a young person’s life, and the group norms, attitudes and behaviour of the friends have a stronger impact on the adolescent than those of his/her parents . According to Tajfel's theory, a social identity is created in three steps. The first is categorization, the grouping of yourself in a hierarchy based on how you feel other people see you, secondly identification when you are compared with others, and - finally - by social comparison when you identify yourself with other people in the same group, such as those who have the same profession or nationality, and where you perceive your own group in a more positive way than other groups .
Why adolescents start using tobacco is determined by multiple factors. According to Ajzen’s Theory of Planned Behaviour (TPB), behavioural intention is the most important predictor of behaviour. Behaviour intention is predicted by attitudes towards the behaviour, subjective norms, and perceived behaviour control. Each of these three variables reflects a set of underlying accessible beliefs, which include behaviour beliefs, normative beliefs, and control beliefs for perceived behaviour control . More recent research on smoking has used TPB as a rule of thumb for understanding the motivation behind whether you start smoking or not. TPB demonstrated that the intentions to smoke were normally directed by attitudes and perceived behaviour control . Another factor that complicates the picture of the onset of snus use is the development of nicotine addiction. Studies indicate that occasional smoking during adolescence can cause a rapid development of nicotine addiction, even before smoking becomes a daily habit . A Swedish study showed that adolescents who are exclusively using snus had a two to fivefold higher risk of becoming addicted to nicotine compared to those who were only smokers .
As far as we know, there are no previous studies on adolescents’ experiences of snus usage.
The aim was to explore the significance of using snus for adolescents, and attitudes to snus, as well as the reasons why they began using snus and what maintained and facilitated the use of snus.
The study was performed in the county of Kronoberg in southern Sweden, with 185 000 inhabitants in eight municipalities. There are 19 upper secondary schools in the county, both private and municipal ones. A majority of the students (66 percent) went to schools in the largest municipality with around 83 000 inhabitants.
Focus group interviews are defined as a scientific method where data is collected through group interaction on a topic decided by the scientist . This method was selected for studying the contents, i.e. the views, attitudes, opinions, and arguments the participants expressed in a group. Focus group interviews will also give insight into the ideas and concepts used in a cultural context . The method gives a variety of opinions as well as close contact with the snus-using adolescents for increased knowledge without the purpose of reaching consensus or influencing them in any direction.
The participants were recruited through the school nurse who had a relatively good knowledge of the students' tobacco habits, as she had regular individual health discussions with them on general life habits. The school nurse received oral information by phone from the first author (IE) and instructions in writing on the selection. Inclusion criteria were that the participants used snus on a regular basis but did not smoke. They should not have a chronic illness such as asthma or diabetes, as health reasons may have influenced their choice to use snus instead of smoking. Adolescents using snus were invited into the study and received information in writing on the purpose of the group interview, on the procedure, and that all the material would be treated as strictly confidential. The adolescents gave written, informed consent to their participation. In total, 27 adolescents participated, aged 17–19, divided into five groups with four to six students in each group. Four groups of boys, and one group of girls from three schools were included in the study. The groups were based on the respective schools and the participants knew each other to some extent. They were all recruited from vocational upper secondary programs, such as building, farming, vehicle and animal care. As seen in a local questionnaire study, most snus users attended vocational programs .
IE acted as moderator of the focus group discussions during the interviews. The role of the moderator was to be prepared to guide the discussions if the group deviated from the subject, ask clarifying questions when necessary, and ensure that all the participants got a chance to voice their views. An assessor (LL) listened, observed, and took notes. Both were unknown to the participants. A guide with questions was developed with five different topics of interest: how they started using snus, circumstances that enabled the onset, students’ views on prevention, attitudes to snus use and speculations about the future. Each topic had open questions and they were constructed based on earlier questionnaires used in upper secondary school . The interviews were conducted during school hours in a room at the students’ schools and lasted about 40–60 minutes each.
Example of the analysis process
We use snus in the vehicle program. Truck drivers, vehicle mechanics, and construction workers
The trade you belong to is associated with snus use.
Snus is used in certain professions
Before the students were approached, the principals of the schools sanctioned the study at their schools. The participating adolescents were informed in advance, and at the time of interview, about confidentiality and that participation in the study was voluntary. Before the interviews started, the participants gave their written informed consent for participation. If any of the respondents needed support after the interview to give up their tobacco use, the school nurses would assist them.
The study was conducted in agreement with Swedish Laws on Research Ethics and was approved by the Regional Ethics Committee at Linköping University (approval number 175–09).
The eight categories and three themes in the analysis
Influence from significant others
Caught in addiction
“I was with friends who were using snus, and then they gave me some and I bought a box myself and then I had started”."
“Then you felt so bloody sick, but still, the next time you still wanted it and then you felt just as sick again… but then it’s like you get going on it”
“You talk to those who are over 18 and then it’s not a problem; it’s fixed. That’s why you have older friends who can buy it.”
“He did not check my ID and he did know I was younger… so he told me to put it in my pocket before I went away.”
“I felt more motivated to quit before my parents found out, because I thought there would be a hell of an uproar at home, but when I noticed that they did not care, it felt like… to hell, it doesn’t matter.”
“There is nothing positive about using snus, you know. Really! You learn to like it as times goes on, sort of, and then you feel that you need another one. No… there is nothing positive whatsoever, really, but it’s the thing you kind of do and then it get you addicted to it.”
“That’s nearly all it’s about when you’re young, and it should be as cool as possible and when you think it’s super-cool and then as you get older you realize you’re stuck on it, so it’s not so cool anymore.”
“Yes… but I don’t use snus that much, I don’t take a lot of it, but when I feel that I am getting into a bad temper, I take some snus and then I can manage for another good while, and sometimes I don’t need any snus because I feel happy.”
“Well, it’s just… ah… it is manly!”
“Well, it’s just like that, that farmers should use snus.”
“Well, bimbo… these little girls… mammies’ girls, you see them… they smoke… they would probably not ever consider using snus, but I guess they are more into smoking…”
“It gives an extra energy kick.”
“In school, you are not allowed to smoke– but it is okay to use snus, and you just throw it in the bin.”
“People around you are not harmed. Snus doesn’t smell and you don’t see it under the lip.”
“We normally treat those who ask… it’s only because you want to be kind, and they will have to face the consequences if they want it, as it’s not our problem.”
“If someone who is 12 or so comes, I don’t give them snus. They should at least be in ninth grade and be snus users… I don’t think I would give them something that would make them addicted.”
Girls reported that it seldom occurred that someone asked them for snus, so they rarely had to treat others to it, and they did not feel they influenced others to start.
“I think I will actually continue using snus for the rest of my life.”
“The idea is that I will be free from nicotine later… by the summer holidays.”
The study shows that the process of becoming a snus user contains several steps. As a beginner, you have to endure a number of physical symptoms such as nausea, dizziness and vomiting, which resolve after training some time. Certain circumstances are required for becoming a snus user – friends who use snus, access to snus, and that using snus becomes an important part to the person’s identity. Snus is most often used in a social context that promotes participation and belonging to a group. The picture becomes more complicated by an addiction that develops gradually.
This study shows that being a snus user functions as a social identity and can be seen as an expression of belonging to a group and be like one’s friends. Studies have also shown that adolescents start smoking, and continue smoking, to develop a desired social identity among important groups of friends . The peer group is important for socialisation of the adolescent, while they try to find out what works in different social contexts and for themselves. They adapt their behaviour to that of others in the same category, which is an oblivious process. Many adolescents believe that it is more important to imitate peers than adults . According to Tajfel’s theory on social identity, people identify with those they feel are most like themselves, and join the group that positively affects their social identity . An individual selects his/her social identity based on what is in agreement with his/her expectations and subjective norms. This is also confirmed by our results that the adolescents reported that using snus is part of the picture regarding their choice of profession. Friends give support to and nourish their new identity as a future grown-up . The adolescents in the study also reported that “all” the friends were using snus around them, and that it was their own choice and that their parents had no say in this.
The adolescents were at an age when their identities were developed and they had selected professions that were traditionally male, and the boys felt that using snus was something very manly and closely connected to the future professional role, such as being a farmer or a car mechanic. In Sweden, using snus is considered traditional manly behaviour, which is not the case for smoking, and this is confirmed by studies on tobacco habits [1, 3]. The study found that it was important to the boys to identify and position themselves as “a real man”, which in part was demonstrated by the use of snus. According to Connell’s theory on the hierarchy of masculinity, there is an overall culturally and collectively preserved male norm based on a historical ideal on what a “real man” should like and how he should behave . The boys said that girls who used snus were not attractive. This could possibly be interpreted as a male desire to keep the snus as a symbol of masculinity, and that girls should not be associated with “their” symbol. Boys thought that girls who used snus were unwomanly, and it was more accepted if they smoked. This is coherent with a cultural stereotype image in Sweden, and possibly in most countries in the world, about was is considered manly and womanly .
With their use of snus, the girls wanted to convey that they were independent and had an identity of their own. It made them different and special, and they described themselves as “tomboys”. The girls expressed their desire to revolt against the norm that it is manly to use snus. This may be a sign of liberation, a diversion from the expected picture of how girls should be. There are rules for how a man and a woman should be, but the social construction is created and re-created depending on the culture we live in .
The results demonstrated that the perceived expectations by the adolescents of important people around them made them try snus and eventually learn to like it. To start smoking was not viewed as an alternative. Snus was the first choice as the attitudes from their surrounding were seen as positive. These circumstances are in agreement with Ajzen’s Theory of Planned Behaviour (TPB) . The positive attitude towards using snus, as well as the experience of subjective norms, were the strongest factors that made it easier for them to start using snus. The adolescents’ experience that everybody around them was using snus strengthens the theory that attitudes and norms lead to intentions and behaviour. The adolescents had also considered the consequences of their beliefs, and this influenced their attitudes to the behaviour .
The adolescents in the study described how they gradually got stuck in an addiction and were unaware of the fact that the abstinence symptoms they felt could be nicotine addiction. Many of those interviewed had their own experiences of addiction and abstinence symptoms, which they found difficult to endure. A study has shown that early symptoms of addiction are important to the development of tobacco use, and that adolescents find it hard to understand what abstinence symptoms are and what they mean . Adolescents addicted to nicotine do not need to be daily users of tobacco. Just feeling a strong craving for nicotine is reason enough to smoke a cigarette. The first symptom of addiction starts with a strong desire to smoke, followed by nicotine abstinence, which leads to smoking more and more often until you eventually become a daily smoker with an addiction and problems to control the smoking . There is also a strong connection between early symptoms of nicotine addiction and lifelong smoking . It can be assumed that the process is similar for snus users, but studies on this are lacking. A Swedish study of adolescents showed that snus-using adolescents had a four times higher risk of nicotine addiction compared to smoking adolescents .
The parents did not react as strongly as the adolescents had expected, and if they had made it clearer that it was not acceptable to use snus, this would probably have made more of them quit using snus. Similar results were seen in a Swedish study on smoking adolescents who wanted the parents to have explicit non-smoking norms, and that compliance was based on good mutual relationships .
In this study, both boys and girls reported using snus less if they were distracted by an activity. Furthermore, the girls said they used snus to control their feelings, to reduce their bad temper or if they were sad or angry. A Swedish study on smoking adolescents highlighted the positive effects of nicotine, that it both “increased the well-being” and could “handle negative emotions” . Girls also reported that smoking was a way to handle stress and negative feelings.
A weakness in the results is that the adolescents only represented the practical upper secondary program, and that there were few girls. However, in academic programs, and among girls, only a minor part of nicotine users prefer snus, making it difficult to recruit informants. The findings are not intended to be generally applied, but rather to give in-depth information on the attitudes and opinions of a group of adolescents. It is up to the reader to decide the extent to which the results can be applied to other groups or circumstances.
The results showed that the interviewed adolescents identified themselves as snus users in their future professional roles. For an added dimension in the results, it would have been interesting to include adolescents from the academic program in the study. On the other hand, the results become more specific with adolescents only from the vocational program.
Focus group interview is a qualitative research method, which is used for collection of data on attitudes, experiences and opinions of groups . Through the interviews, knowledge was acquired from discussions between adolescents, who were given the opportunity to describe and discuss their snus use habits in their own words. The method gave insight into what it is like to be a snus user and how it started. Since focus group interviews rely on discussions among participants, group members may influence each other as to how they respond to ideas and comments that arise during the discussion . However, it is important to bear in mind that data acquired from a focus group are group data, which reflect the collective ideas shared and talked about by the group. In a focus group, the participants are in a more natural environment than during individual interviews. They are together with their friends and can both influence and be influenced by each other, which is what happens in real life .
The interviews were semi-structured and the discussion was based on open questions made up in advance. Thus, the person conducting the interviews may have influenced how the respondents express their experiences. The questions were not asked in a certain order or literally, which gave room for spontaneity, but still with some structure. To make the group discussion easier, boys and girls were interviewed in separate groups, which is recommended in studies with expected differences between the sexes .
The purpose of qualitative content analysis is to acquire both knowledge of and an understanding of the phenomenon studied . As we set out to identify variations with regard to differences and similarities of a text, content analysis with an inductive approach was selected. Graneheim and Lundman highlight the importance of the communication for the interpretation as one of the characteristics of content analysis . Texts based on interviews are formulated through interaction between the respondent and the person conducting the interview. The analysis is an unprejudiced description of the variations by identifying differences and similarities in the text, and they are expressed in categories and themes where context is very essential.
The analysis highlighted characteristic and representative elements in order to increase the dependability of the results. To ensure as high credibility as possible, two of the authors (IE, LL) made the analysis independent of each other.
This study has several implications for preventive and promotional work. The results showed that development of identity was of major importance when adolescents start using snus. The adolescents were unable to interpret the early symptoms of abstinence problems but subsequently were well aware of being addicted. Once they were stuck in a developed addiction and the creation of an image and identity, it was difficult to stop using snus. These factors are important when considering interventions of normative changes and tobacco prevention in schools as well as among parents. It is important to see snus as an addictive product whose health effects are not researched enough at present. We think that using snus should not be seen as a more healthy alternative to smoking, and parents should be involved in the message of a tobacco-free adolescence. A Totally tobacco-free school time, i.e. that nobody smokes or uses snus in school, contribute to a change of norms and attitudes towards a tobacco-free life, and it furthers a more healthy adolescence.
Research funding support for this article was received from County Council of Kronoberg, Region Skåne, Sweden and The Swedish National Institute of Public Health. There are no conflicts of interest to declare. Many thanks to the adolescents who shared their experiences of using snus with us. We also wish to thank Dorthe Geisler who transcribed the recorded interviews.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.