Study area

The study was performed in the county of Västerbotten, situated in the north of Sweden. Västerbotten has 256 000 inhabitants living in 15 communities, an area close to 60 000 km². There are fifty 7-9^th grade schools in the county and the settings are more rural in the inland and more urban by the coast. An intervention programme called Tobacco Free Duo has successfully been targeting adolescent tobacco use in the county since 1993 [7].

Study design

Our main research interest was youth perceptions of smoking. A qualitative research design was used to reach an in-depth understanding of the youths' experiences, attitudes and beliefs as well as their wishes and concerns for the future. Focus group discussions were regarded the most appropriate method of data collection. The methodology builds on group interaction and is especially valuable for capturing how views are constructed and negotiated [8, 9]. The group discussions were part of a larger study on smoking and gender with youth in five European countries.

Sampling of informants

The informants were purposively selected to capture diversity with an aim of representing boy and girl smokers who were 15-16 years of age. We limited our study to smokers since non-smokers could only have reflected on what they believe about others. We considered schools to be the best source for recruitment since they provided a well-functioning network that allowed us to easily reach young smokers who were willing to participate. Thus, we selected four schools; three in urban settings representing areas with different socio-economic statuses, and one in a more rural area. Student social welfare staff, school nurses, teachers and youth club leaders helped distribute written information and an invitation letter to smoking youth. A smoker was defined as someone who smokes on a regular basis, at least once a week. This may have influenced the selection process and given us well-known adolescent smokers. However, the recruitment method varied and in some cases young people who had decided to participate brought additional participants from among their peers.

Data collection

The first author (MN) performed the data collection over a period of two months. This was preceded by pilot sessions used for testing the research tools. All the discussions were conducted within the school setting during school hours. They were held privately in special rooms without any school staff present. To be able to evaluate gender differences, the groups were homogenous with regard to sex and there were five to six participants in each group. The discussion guide was thematic, flexible, and covered areas such as use of tobacco, perceptions, and tobacco-related attitudes and changes over time. Even though the school setting meant that the participants might know each other, this was not perceived as a limitation but as a positive factor to create a good discussion atmosphere. All discussions were tape recorded and the length varied between 55 to 90 minutes. The first interview was transcribed, preliminary analysis done, and discussed in the research group to allow for an emergent design with revisions and further elaborations in the forthcoming discussions. After additional three focus groups a new peer debriefing session took place to discuss and make decisions for further revisions in the data collection strategy.

In total eight focus group discussions were conducted, one girl- and one boy-group at each of the selected schools. The total number of participants in the groups was 44 out of which 21 were girls and 23 boys.

Data analysis

All focus group discussions were transcribed verbatim. A descriptive content analysis guided by Graneheim and Lundman was employed. Meaning units were identified, condensed and coded for creating categories, and themes describing both the manifest and the latent meaning were created [10]. Open Code software was used to facilitate the coding procedure [11]. An example of the analysis process is given in Figure 1, showing condensed meaning units with corresponding codes, sub-categories and a category.

Members of the research team were involved in the coding and analytical phase and contributed to the interpretation based on their differing professional expertise. Peer debriefing sessions were also used to help evaluate the main researcher's role in data collection and the analytical process.

Ethical considerations

The school headmasters of each selected school sanctioned the study before students were approached. The school administration facilitated giving written and verbal information to parents and students about the aims of the study, its methodology, terms for volunteering, assurance of privacy, confidentiality in presentation of results, and the names and addresses of the responsible researchers. Since smoking is part of many teenagers' lives the research topic was not regarded as very sensitive. The participants had all reached an age (15-16) where they could make a mature and independent decision about their study participation. The study was approved by the Research Ethic Committee at Umeå University (dnr 02-251 § 270).

Gaining control

Young smokers reflected on the process of becoming a smoker and described feelings that were both complex and contradictory; uncertainty about some aspects of life was combined with great certainty about others; feelings of curiosity and a wish to challenge existing norm systems were accompanied by feelings of fear, vulnerability and a need to comply with peer conceptions about attitude and image. Smoking was described as a short cut to handling this vulnerability and reaching social and adult status, making them feel more confident. During early smoking, cigarettes had the positive function of helping to build image and identity. One person called the cigarettes "my trademark". When reflecting on other smokers, early testers were described as having low self-esteem and thus a need for adopting something that would make them accepted and to belong to a group.

G1: My God, you were so frightened...you were older, but more frightened.

G2: Yes, but when one starts the seventh grade, everything is new. You are the youngest at school...and you are supposed to be older and things like that. But you are so little, you know, and you need something to hold in your hand. Yes, well it can't be explained. Because the seventh grade was still bloody terrible. You're really a scared little scumbag that has to prove yourself to everybody all the time.

Focus group no. 7

Our informants described smoking initiation as a social game. The first cigarettes were often part of an imitation of older friends, testing how to perform and inhale for later practice "in public".

G1: When you first smoked you got dizzy and had to sit down.

G2: It was a guy who taught me to smoke...or take a deep drag. Anyway he had smoked for a long time... and he said that you never faint from a nicotine kick but you can throw up. So it was. Okay, I stood by the sink. So I stood there and leaned against the counter instead and a friend, she had to sit down on the floor and lean against the wall because it started spinning around so much.

Focus group no. 5

Once they were established smokers, the young smokers described a culture of giving and getting cigarettes back. They spent a lot of time with other smokers at school and during spare time in what could be described as a "smoking community". The girls talked about smoking and sharing cigarettes as social putty while boys described it as nice having friends to smoke with. The description of themselves belonging to a "smoking community" with good friendships was common for girls and boys. The ones not being part of "the smoking community" according to young smokers meant the ones who were not "real" smokers; only smoking now and again and smoking on the sly. They described these younger ones, not belonging to their group, with a slight contemptuous attitude.

B: Okay, they try to make it look like they are so terribly grown-up and experienced but they really are small, skinny young teens wearing short t-shirts with like bare stomachs. You don't respect them. They are the biggest fools in the world, who haven't understood anything, who try to be something they are not. Thinking that they are more than what they are.

Focus group no. 8

The young smokers described several perceived positive functions of smoking with friendship being one of the most important. As part of the smoking community you spent lots of time together and made close friends. But the cigarette was also described as a loyal friend, something to pass time with and keep you occupied. The drug effect or "nico-kick" was perceived positively and described as a way to increase well-being. The girls described it as a way to handle stress and negative emotions.

Becoming a part of the self

When reflecting on what facilitated the process of becoming a smoker, the young smokers described a normalization of smoking that for many started in early life. Almost all of the informants' parents were smokers and/or snus users.

B: Nicotine really flows in our house, that's how much my parents smoke. Nicotine has flown in my veins since mama smoked when she was expecting me. It's my fate.

Focus group no. 4

The study participants described many early memories that influenced them and most likely contributed to an internalization and identification as a smoker-to-be. When they were children, they described their parents smoking, observed that they relaxed and seemed to feel good, and perceived smoking as a natural part of their parents.

G: I have grown up with mama smoking, it has always been that way. It was like normal--like I eat or mama smokes. So that's just the way it is. I don't think so much about it 'cause I'm so used to it. And that makes it okay for me, from her that I smoke, it's like the way it is. So if I would say ten things that I relate to mama then smoking would be one of them, but that's not at all bad. It's like you have a certain type of perfume. Smoking becomes part of you, something like Göran Persson (Sweden's former Prime Minister) and politics. It's about the same thing. And even if I don't think about it, it becomes like just a part of me too.

Focus group no. 7

Parental smoking gave access to cigarettes. For many, the first cigarette smoked was a cigarette picked up secretly at home. Cigarettes from parents continued to be one of the main sources for many, either given or secretly taken. The provision of cigarettes at home was perceived as an open or hidden permission to smoke and contributed to the normalization of smoking. Many described acceleration in smoking when parents permitted, or even more when they smoked together with their children. The informants stated that when parents allowed their children to smoke the school lost its potential power to intervene against their smoking. It was stressed that smoking parents weakened their position in making their child smoke free. Getting hold of cigarettes outside their homes were described as easy; the word on where to buy cigarettes spread quickly or you could get or buy cigarettes from friends.

Another facilitating factor was the perceived peer influence/pressure emanating from the notion that everybody smoked, or at least all significant ones did. Older, nice friends were smoking role models or even introduced them to smoking.

G: "Perhaps not always the coolest ones, but like the older friends who are okay and all that. And then it's that, that has been important. That they are okay and that they are smoking.

Focus group no. 5

The informants expected adults to act against smoking but adults were often described as passive, doing nothing or more or less resigned. The majority of the young thought that significant adults like parents and teachers should intervene. "It's what they should do; it's part of the package of being an adult". When they did not act it was regarded as acceptance and as facilitation. The young smokers knew that smoking was not allowed at the school, but they regularly saw school staff smoking on the school premises and not following the regulations themselves. Some gave examples of smoking school staff gossiping about what teachers were doing when no students were present. Both being examples of adults undermining trust and rules. Others described parents smoking on the sly as an example of undermining trust and respect. Informants said that when their mothers and fathers gave different messages and set different rules, they lost their chance to intervene. Another factor of inconsequence facilitating was also parents' cigarettes being available at home. Many youth thought it strange that parents said you should not smoke and then had no control of the cigarettes at home. "They deny and supply at the same time". The young smokers felt that inconsequential and deceitful role models were dangerous.

Feelings of dissociation and distance within themselves as well as in relation to others accelerated smoking. They described distance as being part of life today--"times have changed"--with adults being busy, often lacking energy to intervene, and parents losing power in relation to their children. The informants stated that young people of today decide for themselves and that their own will and choice have to be accepted; they don't listen and they don't care. They also meant that parents were wrong intervening when they scolded them loudly and started conflicts about smoking, when they nagged or punished them. These actions resulted in obstinacy and the young smoking even more. Many informants experienced their parents giving up their children's smoking. The parents were irritated when teachers phoned home and perceived the telephone calls rather than the smoking to be the problem. They described their parents having "zero check" of what was going on, being disengaged, and without the possibility of exercising any influence.

Many youth disregarded smoking risks as a means of facilitating smoking. The knowledge of health risks was not homogenous; some seemed well informed while others were ignorant and made "logical somersaults" to facilitate continued smoking.

G: I don't think that smoking causes illness. My mother hasn't smoked and my grandmother hasn't either, but she has cancer. Like skin cancer or breast cancer or something like that. And if you can get it without smoking why should I get it just because I smoke, since I could get it just as well without smoking? So like I see it, smoking doesn't have anything to do with it. Like neither mama nor grandma has smoked even once during their lives, like I really don't think they have tasted it at all. And anyway, if they got cancer, why should I get it? I don't think the chances are any bigger just because I smoke. I think I can get cancer just as well without smoking. So it doesn't make any difference.

Focus group no. 1

Risk denial didn't seem to depend on level of knowledge. Expressions such as life being full of risks, being part of the package, "live hard and die young" were common. Many used myths of youth as a way to consciously underestimate and reduce risks. They found them comfortable to use as then they did not have to think about or stand up for their smoking.

Concerned adults make a difference

When discussing prevention the young people constantly came back to the role of adults. On one hand, they often said that adults cannot do much about youth smoking. On the other hand, they listed what adults should and should not do, what they wanted from adults, and the possible impact. In general they emphasised their right to self-determination, including the right to smoke if they wanted to. Most of them said that their parents could not do much about their smoking. At the same time they stressed an adult's duty to care and used forcible words when they discussed adults that did not care. The young smokers expressed the view that parents had an assignment and an obligation to do all they could to support their children to not start smoking: "It's a parental duty". They found it tiresome if and when their parents "bothered" about their smoking. But a general expression was that the opposite would be worse and leave a feeling of being forgotten and not important. Common advice to parents was to act on suspicion and not be gullible, believing everything their children said. All the students had given false stories about their smoking to their parents when they first began smoking. A boy told his parents the following:

B: Oh no! My friends smoke and I told them not to and they blew smoke at me.

Focus group no. 3

All smoked during school hours and most of them did so at the school. They knew that smoking was not allowed within the school premises and shared the view that they expected teachers to intervene. As with their parents, they perceived it as a teacher's responsibility and expressed feelings like "Good teachers care and then you respect them". Many expressed sympathetic feelings for the teachers having to intervene all the time. They thought it prevented smoking, especially during smoking initiation when one was not an established smoker and were still smoking on the sly. If the teachers' obligation to act was not there, it was perceived as that they did not care about the young smokers.

B2: It might happen one out of a hundred times that a teacher tells you not to smoke at the schoolyard.

B4: Comes up to you and says--"Now you have to..."

B1: "... go..."

B2: And there are some teachers that go by and look the other way, since they are tired of saying something. Then there are others that say "How are things going?" And they just sit there beside you when you smoke. Some don't give a shit or act like they don't see. Somehow it feels strange that they don't even care. Then they can't really care about you in anything else either, it feels like that.

Focus group no. 2

The young smokers reflected on the wish and need for trustworthy adults. That meant being consistent, expressing what they expected from the young, as well as giving relevant information and living up to their expectations of being a consequent role model. The young tended to lose respect when adults disappointed their expectations. An example given was "Adult smoking on the sly sucks, it's pathetic".

The young smokers stated that the adults' attitude when they intervened determined the outcome. "Over-angry" or distant adults triggered defiance reactions. They asked for "Respect please" and when they felt respected, the young smokers were respectful in return. The young people talked about close relations, "closeness meaning so much, almost everything " when it came to smoking. Close relations were important reasons to hide smoking, to smoke less and or try to quit smoking. Many told about loved grandparents not being aware of their grandchildren smoking and stated that the grandparents would be so disappointed if they knew. They expressed mixed feelings of not wanting to cause concern or worry, and feelings of being close to betraying trust.

When looking to the future, the informants reflected on being a parent themselves. At the same time as talking about themselves being a caring, observant, engaged parent not wanting their child to smoke, many realized the difficulties parental practices could bring.

B: Then I get a call at home from the school and hear that my son smokes...Then I hang up the phone and go and lie down and pretend that I'm dreaming. Ugh! It must be so damn difficult having a child that smokes, when all you want is what is best for them.

Focus group no. 2