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Smoking Cessation in Adolescents
The Role of Nicotine Dependence, Stress, and Coping Methods
Lorena M. Siqueira, MD;
Linda M. Rolnitzky, MS;
Vaughn I. Rickert, PsyD
Arch Pediatr Adolesc Med. 2001;155:489-495.
ABSTRACT
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Objectives To compare perceived reasons for continued smoking and withdrawal symptoms
between current smokers and quitters in an inner-city adolescent population.
To examine the relationship of nicotine dependence, stress, and coping methods
between smokers and quitters and, using the Transtheoretical Model of Change,
among adjacent smoking cessation stages.
Design A cross-sectional study using a self-administered questionnaire.
Participants The study comprised 354 clinic patients between the ages of 12 and 21
years who reported past or present smoking.
Main Outcome Measures Demographic characteristics, smoking status, perceived reasons for continued
smoking, attempts to quit, and withdrawal symptoms, as well as standardized
scales assessing nicotine dependence, stress, and coping methods.
Results The overall prevalence of smoking in this population was 26%. Smokers
were significantly more likely to report smoking more cigarettes per day as
well as higher levels of physical addiction (P<.01),
greater levels of perceived stress (P<.02), and
less use of cognitive coping methods (P<.02) than
quitters (P<.005). However, comparison of consecutive
stages revealed a significant difference only between precontemplation and
contemplation in cognitive coping methods (P<.01).
Three of 20 withdrawal symptoms (cravings, difficulty dealing with stress,
and anger) were reported more frequently among current smokers who had attempted
to quit in the last 6 months than among former smokers (P<.01).
Conclusion Interventions for inner-city adolescents who smoke should be designed
to target those with the highest levels of nicotine dependence, stress, and
decreased use of cognitive coping methods because they are the least likely
to quit on their own, rather than developing stage-specific models.
INTRODUCTION
IN 1998, more than 4 million adolescents in the United States were current
cigarette smokers.1 Although only 5% of daily
smokers enrolled in high school think that they will be smoking in 5 years,
75% of these adolescents still smoke 5 to 7 years later.2
Most report that they would like to quit but are unable to do so. In fact,
among high school students who had smoked daily at some point, 72.9% had tried
to quit smoking, and 13.5% were former smokers.3, 4
Most research on smoking and adolescents has concentrated on factors that
lead to smoking, to develop more effective primary prevention programs. However,
our understanding of why adolescents quit and how we can influence this behavior
is limited.5, 6
Once smoking behavior becomes established, regular smokers are more
likely than beginning smokers to report that they smoke because they are addicted.2, 7 Among adolescents, nicotine dependence
is related to both the intensity and duration of smoking.8
Studies among adults suggest that lighter smokers and those who have smoked
for a shorter period of time are more likely to quit than heavier smokers
and those who have smoked for a longer period of time.9, 10
However, despite this relationship between continued smoking and nicotine
dependence, cessation studies using medication for nicotine dependence have
had limited success in adolescents.11, 12
Therefore, it is important to address other factors that are responsible for
continued smoking.
Stress is associated with continued use of cigarettes in both adults
and adolescents.13, 14 When adolescents
are given 2 choices ("It relaxes or calms me" and "It's really hard to quit")
and asked why they continue to smoke, they frequently report that they use
smoking to relax.15 Among adults, stress levels
are inversely related to the duration of smoking cessation, and those who
continue to smoke report higher levels of stress.16
In another study, the degree of perceived stress was the only variable that
prospectively predicted success with quitting, with lower levels associated
with higher quit rates.17
Coping processes have been defined as ongoing cognitive and behavioral
strategies to manage external and internal demands.18, 19
Among adult quitters, studies have noted that any productive attempt to cope
with relapse crises is better than no coping attempt.20
Others have indicated that all coping strategies are equally effective and
that using multiple cognitive or multiple behavioral strategies is just as
effective as using a combination of these methods.21, 22
In designing cessation studies, it has been suggested that rather than
classifying smokers into groups (ie, smokers vs quitters), interventions should
be tailored to match the individual smoking cessation stage of change using
the Transtheoretical Model of Change (TMC).23, 24
Unfortunately, only a limited number of studies have evaluated the adult data
on smoking cessation stages in adolescent smokers and former smokers.25, 26 To the best of our knowledge, differences
in nicotine addiction and stress by individual stages of change have not been
evaluated in adolescents.
Implications of the TMC model are that smokers use different coping
mechanisms to move along the continuum toward smoking cessation. Studies report
that adolescents use cognitive and behavioral processes similar to those used
by adults. However, in the early stages of cessation, adolescents tend to
use behavioral processes more often.25 Examples
include self-liberation (choosing and committing to change) and counter-conditioning
(substituting alternatives for behavioral problems, such as relaxation or
positive self-statements). Other types of coping (eg, anger or avoidance coping)
have not been evaluated.
Our interest was to study these concepts in a primarily inner-city minority
adolescent population, as opposed to the white adolescent majority, to develop
effective intervention programs that target both contributing psychosocial
factors and nicotine dependence. Smoking rates in youths from minority backgrounds
(22.7% among African American youths and 34% among Hispanic youths), although
lower than in white adolescents (39.7%), have increased steadily during the
last decade.27 Because little research exists
on the development of culturally appropriate cessation programs, those directed
at minority groups have used either a self-help approach or materials developed
for the white population.28
We first examined the perceived reasons for continued smoking, attempts
to quit, and withdrawal symptoms among current smokers and compared these
attitudes and behaviors with those of subjects who reported quitting smoking.
We then evaluated the relationship of nicotine dependence, stress, and coping
methods to the outcome of being a smoker or quitter and subsequently looked
at the relationship of these variables to the smoking cessation stages of
change. Specifically, we hypothesized that smokers would have higher levels
of nicotine dependence and stress and use less effective coping methods than
those recalled by subjects who had quit smoking. We also hypothesized that
there would be significant differences between adjacent smoking cessation
stages on the various standardized scales, with values increasing or decreasing
along the continuum depending on the scale (precontemplation [PC] vs contemplation
[C]; C vs preparation [P]; P vs action[A]; A vs maintenance [M]).
SUBJECTS AND METHODS
STUDY POPULATION
All English-speaking adolescents between the ages of 12 and 21 years
who came to our urban, university-based, multidisciplinary ambulatory clinic
were eligible to participate in this cross-sectional study. Adolescents served
by the clinic are among the poorest in the state of New York. Most come from
the surrounding communities (east and central Harlem and the South Bronx),
and others come from all 5 boroughs of New York City. Forty-seven percent
of the adolescents served are African American or African Caribbean, 46% are
Hispanic, 5% are white, and 2% are Asian or Pacific Islanders. Eleven percent
are younger than 15 years, 45% are between 15 and 17 years, 31% are between
18 and 19 years, and 13.6% are age 20 years and older. Eighty-two percent
of the patients are female.
The study was approved by our institutional review board and conducted
from June to August 1998. A trained research assistant approached subjects
consecutively in the waiting room and asked if they would be willing to fill
out a survey. The need for parental consent was waived by the board to enhance
accuracy of results. Subjects were assured that participation was voluntary
and that no identification data were required on the questionnaire. The study
was briefly outlined, and written consent was obtained. No incentive was offered.
Subjects were given the option of filling out the questionnaire in the waiting
area or in a clinic office.
The self-report measure was customized after pilot testing (n = 30)
was completed to ensure readability, ease of understanding, and completion
time. This measure assessed demographic characteristics (age, sex, ethnicity,
school enrollment, employment status, and subjective assessment of religiosity).
In addition, consistent with Pallonen et al,26
participants were asked to select their smoking status from "never tried a
cigarette or other tobacco product" (never smoker; n = 357), "tried smoking
a few times in the past" (experimenter; n = 330), "currently smoke" (current
smoker; n = 275), and "used to smoke frequently but I quit" (quitter; n =
79). We report only the results related to smokers and quitters because this
was the focus of our study (N = 354).
Subjects were asked to provide the age of first cigarette use and the
age at which they become a regular smoker. In addition, they were asked for
the average number of cigarettes smoked per day in the past month, the number
of cigarettes smoked in the past 24 hours, and if they had attempted to quit
for 24 hours or more in the last 6 months (by definition, all those in the
P stage said yes to this question). They were then asked to choose the reasons
why they continued to smoke, why they wanted to quit, and why they smoked
again after 1 or more attempts to quit; how successful they would be if they
tried to quit in the next 4 weeks; and who or what would help them quit. The
choices were compiled from reasons given by adolescents during previous work
with this population by the first author (L.M.S.). Former smokers and those
who had made an attempt to quit were asked to pick, from a list of 20 items,
withdrawal symptoms they had experienced. These symptoms included those listed
in the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition. Former smokers were asked to recall the average number
of cigarettes smoked per day. Then each subject completed standardized measures
of nicotine dependence, perceived stress, negative life events, and coping
methods.
Finally, subjects were asked about their current stage of smoking cessation
and were classified into the following stages: (1) not seriously considering
quitting in the next 6 months, or precontemplation [PC; n = 119]; (2) seriously
considering quitting in the next 6 months, or contemplation [C; n = 83]; (3)
able to quit for 24 hours or more in the last 6 months and planning on quitting
in the next 30 days, or preparation [P; n = 73], (4) completely stopped smoking
within the last 6 months, or action [A; n = 33]; (5) completely stopped smoking
more than 6 months ago, or maintenance [M; n = 46].
MEASURES
The Perceived Stress Scale is a 10-item measure of perceived stressful
life situations assessed on a 5-point Likert scale and is a commonly used
research instrument.26, 29 As an
example, one item asked subjects how often in the last 30 days they had been
upset by an unexpected event. Scoring was from 0 to 4 on a 5-point scale,
and the scores ranged from 0 to 40.26 This
scale has been shown to have reliability and validity in previous studies
with adolescents.29
The Negative Life Events Scale is a 20-item checklist of which 11 events
involve family members (eg, "Somebody in my family had a serious illness")
and 9 involve the adolescent (eg, "I had a serious accident"); the scale concerns
events that took place during the last year. This scale has been shown to
have reliability and validity in previous research studies with adolescents.
Based on a total set of 20 items, the score ranges from 20 to 40.30
We used a 47-item scale to assess 8 coping measures developed by Wills
et al,31 which uses a 5-point Likert scale
and has also served as a research instrument to measure coping strategies.
These strategies have been divided into positive and negative methods by the
developers of the measure, who have used these scales in school-based studies
of adolescents. Positive coping methods include parental support, behavioral
coping, and cognitive coping. Higher scores on these subscales suggest that
the probability of substance use or abuse is reduced (protective). The negative
or ineffective methods of coping are avoidance, anger, helplessness, substance
use, and peer support coping. Higher scores reflect increased risk of substance
use. We excluded substance use coping from further analysis because it includes
the use of cigarettes, which was related to the outcome variables.
The Fagerstrom Test for Nicotine Dependence (FTND) is a 6-item self-report
measure of nicotine dependence.32 It is a revision
of the Fagerstrom Tolerance Questionnaire, which was developed to assess self-reported
nicotine dependence and has demonstrated strong correlations with cotinine
levels.10 This questionnaire and a modified
version of it have been used to assess nicotine dependence among adolescents.8, 33 A score of 7 to 10 on the FTND scale
is considered to represent a high degree of nicotine dependence; a score of
4 to 6, moderate dependence; and below 4, light dependence. We added the past
tense to each of the questions posed to former smokers to obtain a retrospective
report of their nicotine dependence.
ANALYSIS
 2 Analysis was used to examine the associations between
categorical demographic variables and both smoking status (smokers and quitters)
and smoking cessation stages (PC, C, P, A, and M). The Mann-Whitney rank sum
test was used to compare age and the scores on the standardized scales between
the 2 smoking groups. The Kruskal-Wallis nonparametric analysis of variance
with contrasts was used to compare scale values between smokers and quitters
and then to compare age and scale values among contiguous stages. A significance
level of P< .05 was employed for decision making
in our statistical analyses using 2-tailed tests, and the Bonferroni adjustment
was made for multiple comparisons. Data were analyzed on a personal computer
using BMDP statistical software (Los Angeles, Calif).34
RESULTS
Although adolescent smokers and quitters did not differ significantly
by sex, race, educational level, employment status, or subjective assessment
of religiosity (Table 1), smokers
as a group were slightly younger than quitters (mean ± SD, 17.6 ±
2.1 years vs 18.2 ± 1.7 years; P<.05).
The demographics of the study sample did not differ significantly from that
of the clinic population.
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Table 1. Demographic Characteristics by Stages of Change*
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SMOKING ATTITUDES AND BEHAVIORS AMONG SMOKERS AND QUITTERS
The major reasons smokers acknowledged for continuing to smoke were
as follows: "relaxes me," 73%; "have a habit," 56%; "I am addicted," 29%;
"I'm bored," 22%; and "everyone around me smokes," 17%. Fifteen percent or
less said that it was to help them concentrate, was for the pleasure of smoking,
or was due to peer pressure. Quitters asked to recall the reasons they smoked
were significantly less likely (P<.01) to say
that they had a habit (31%) or were addicted (11%).
Sixty-nine percent of the current smokers had attempted to quit for
24 hours or more in the last 6 months, and more than half (58%) of these smokers
felt that they were unlikely to succeed if they tried to quit in the following
month. Of those who had attempted to quit but were still smoking, a larger
percentage than that of former smokers reported experiencing 3 of the 20 withdrawal
symptoms (Table 2). These included
cigarette cravings (47% vs 18%; P<.001), difficulty
dealing with stressful situations (33% vs 11%; P<.001),
and feelings of anger (19% vs 6%; P<.01).
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Table 2. Withdrawal Symptoms Stratified by Smoking Status*
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When subjects were asked why they started smoking again after attempting
to quit, significant differences between smokers and quitters were obtained
for 2 responses: 83% of smokers vs 17% of quitters chose "because of stress"
(P<.001), and 25% vs 9% chose "after a fight"
(P<.005). No significant differences were obtained
for "because my friends smoke" or "I was bored."
Among the reasons for quitting or wanting to quit, quitters more frequently
acknowledged that others wanted them to quit than did current smokers (P<.01). There were no differences in concerns regarding
current or future health or cost.
When asked who or what would help them if they chose to quit smoking
or who had helped them quit, "doing it on my own" was the most common choice
by both groups (82% of quitters vs 72% of current smokers). Only 10% of current
smokers said that they would use a program, and 8% chose "with the help of
medication." Only 33% of current smokers and 28% of quitters acknowledged
being advised to quit by a health professional.
STRESS, COPING, AND NICOTINE DEPENDENCE AMONG SMOKERS AND QUITTERS
In comparing all scale values between smokers and quitters, we found
a significant difference in each of the measures used. Although most of these
adolescents had mild nicotine dependence on the FTND scale, there was a significant
difference between groups (mean ± SD, 2.9 ± 2.4 vs 1.7 ±
2.3; P<.001). Measures of stress included the
Perceived Stress Scale (mean ± SD, 21.6 ± 6.6 vs 19.1 ±
6.7; P<.01) and the Negative Life Events Scale
(mean ± SD, 25.8 ± 3.4 vs 24.6 ± 3.0; P<.01). Among the coping subscales, only cognitive coping (positive
method) was significantly different between these groups (mean ± SD,
18.5 ± 5 vs 20 ± 5.5; P<.05).
STRESS, COPING, AND NICOTINE DEPENDENCE AMONG STAGES OF SMOKING CESSATION
We then compared demographics and median scores on the standardized
scales between each pair of adjacent smoking cessation stages. Those in the
various stages did not differ significantly by age, sex, race, educational
level, employment status, or subjective assessment of religiosity.
Sixty-two percent of those in the PC and 74% in the C stage had attempted
to quit for 24 hours or more in the last 6 months. A significantly larger
percentage of those in the PC than the C stage recalled having had intense
cravings (P<.001), difficulty dealing with stress,
subjective depression, irritability, and feelings of sadness and anxiety (P<.05).
There was no significant difference in the FTND scores between adjacent
stages (Figure 1) despite the visual
difference between stages C and P. Those in the PC stage reported smoking
an average of 10 cigarettes a day in the last month (range, 0-30). Those in
the C and P stages used an average of 3 cigarettes (range, 0-30). Quitters,
all in either the A or M stage of smoking cessation, reported having used
an average of 3.5 cigarettes a day (range, 0-20). Those in the PC stage had
smoked the longest (mean ± SD, 3.5 ± 2.5 years), current smokers
in other groups were intermediate (mean ± SD, 2.6 ± 2.4 years),
and quitters had smoked for the least amount of time (mean ± SD, 2.2
± 1.9 years) (P<.001).
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Figure 1. Fagerstrom Test for Nicotine Dependence
by smoking cessation stage. A significant difference is noted between groups
(P<.001), but not between adjacent stages.
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Although there was no significant difference between adjacent stages,
there was a gradual decline in the scores for the scales assessing stress
along the continuum (Figure 2).
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Figure 2. Perceived Stress Scale and Negative
Life Events Scale by smoking cessation stage. A significant difference is
noted between groups (P<.001), but not between
adjacent stages.
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We found a significantly lower score for cognitive coping between subjects
in the PC and C stages when looking at contiguous stages (mean ± SD,
18 ± 4.9 vs 20 ± 4.7; P<.05). There
was no significant difference between adjacent stages for any of the other
coping strategies studied (Table 3).
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Table 3. Coping Methods and Stages of Smoking Cessation*
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COMMENT
All smokers acknowledged that having a "habit"or being "addicted" kept
them smoking, in addition to showing dependence on the FTND scale and reporting
withdrawal symptoms. As in adults, those using the least number of cigarettes,
those with lower levels of addiction, and those smoking for shorter periods
of time were more likely to quit on their own. Despite the controversy around
the definition of cravings in those who abstain, this symptom was the most
commonly reported and has been associated with failure in smoking cessation.2, 35, 36 Most of these inner-city
adolescents wanted to quit on their own rather than with the use of medication.
A study of adolescents' attitudes toward methods of quitting showed that teens
rated the likelihood of success as the most important criteria for choosing
a particular method.37 However, although most
of the adolescents we studied acknowledged that they would be unlikely to
succeed if they attempted to quit in the near future, they indicated that
they would choose to quit without assistance.
It is disturbing that only a third of the subjects who smoked reported
being asked by a physician to quit. Studies in adults have shown that 10%
to 25% of smokers who are advised to quit by their physicians may quit or
reduce the amount they smoke, stressing the need for pediatricians and other
health professionals to address the issue.6, 38
Several national medical organizations have guidelines to help provide anticipatory
guidance, screening, and referrals.39, 40
Given that most adolescents want to quit on their own, developing skills in
motivational interviewing and brief office interventions may be the most effective
means to enhance quit rates.41, 42, 43
The adolescents in this study most often attributed the role of cigarettes
in helping them to relax as the reason to continue smoking (73%). Stress was
also acknowledged as a common cause for relapse after previous quit attempts
(49%). The perceived stress score was significantly higher in smokers than
in quitters but not significantly different between consecutive stages. Unfortunately,
the measures employed in our study to evaluate stress do not provide numeric
cutoffs to guide the health care provider about when counseling may be required,
especially for the adolescent smoker. Therefore, it is difficult to determine
the clinical significance of our findings. However, our data are consistent
with reports suggesting that individuals with higher perceived stress scores
and more negative life events are less likely to quit smoking.14, 26, 29
Reports justifying why people continue to smoke may be subject to strong rationalization
bias.44 Although smokers may state that they
smoke to relieve stress, a study by Cohen and Lichtenstein16
suggests that quitting smoking results in decreased stress, at least in those
who want to quit. Whether the higher level of perceived stress among current
smokers is related to withdrawal symptoms (when not smoking) followed by a
subjective sense of relaxation (when smoking) remains to be determined. Prospective
studies should be conducted to determine the direction of the relationship
between stress and continued smoking.
Cognitive coping was the only coping method that showed a significant
difference between smokers and quitters. The measure used, which is consistent
with other research in this area, does not guide the health care provider
to select this coping strategy as opposed to another. We believe that using
this coping method possibly aids adolescents attempting to quit smoking to
reframe stressful events or tempting situations; the method reduces their
need to reach for a cigarette to cope with stressors. The scope of strategies
in this method include thinking about the health benefits of not smoking,
evaluating the social benefits of quitting (eg, pleasing a parent or loved
one), using distraction strategies such as thinking about alternative pleasant
activities, or a simple delay in smoking cigarettes. Increased use of cognitive
coping may effect a move from precontemplation to contemplation among these
minority adolescents and may keep those in maintenance from relapsing.
Using the TMC model, we noted that a smaller percentage of inner-city
adolescents were in the earliest stage of change (PC) than that reported in
studies with the white population, but that the percentages were similar for
the C and P stages and higher for the A and M stages.26
These data are consistent with results of surveys demonstrating that white
youths have lower quit rates than youths from minority backgrounds.45, 46 This relationship may, however, be
related to the younger age of initiation among whites.47
Among our minority adolescents, even those who reported that they were not
seriously considering quitting in the next 6 months (PC) had made spontaneous
attempts to quit in the recent past. This "desire not to quit" may therefore
be related more to feelings of lower self-efficacy in quitting than a desire
to continue smoking.
Because scores on the standardized scales for nicotine dependence and
stress were higher among all substages of smokers (PC, P, and C) than quitters
(A and M) and were not significantly different between adjacent stages, interventions
for these factors could possibly be designed for smokers as a group. A recent
study noted that interventions mismatched to stages were as likely to be successful
as matched interventions, and questioned the validity of this model in designing
interventions.48 We therefore suggest that
for those smokers least likely to quit on their own (ie, those with higher
levels of addiction and stress), improving motivation and feelings of self-efficacy
while teaching stress reduction techniques and improved use of cognitive coping
skills may improve quit rates. This should include a discussion of the possible
role of cigarettes in inducing stress symptoms and the reduction of these
symptoms after quitting smoking.
Certain limitations in this study require comment. Because the sample
is composed mainly of inner-city adolescents from minority backgrounds, these
results cannot necessarily be generalized to adolescents residing in other
geographic areas. However, no other study has looked at stages of smoking
cessation in minority adolescents, nor at the role of nicotine dependence,
stress, and coping in the ability to quit in this population. Because this
was a cross-sectional study, the number of cigarettes used and the level of
nicotine dependence among former smokers were elicited by recall. Although
we did not use any biochemical assessments of smoking status, studies have
shown little discrepancy between self-reports and biochemical assessments
of adolescent cigarette smoking.49, 50, 51
However, recall bias by former smokers is possible, so the number of cigarettes
smoked and number of withdrawal symptoms may have been underreported. Therefore,
the results of former smokers should be cautiously interpreted. In addition,
our sample was composed mainly of women, and future studies will need to evaluate
differences between the sexes in stress, coping, and nicotine addiction as
they relate to smoking cessation in minority youths. Finally, because our
study was cross-sectional, it is limited in its ability to predict progression.
CONCLUSIONS
These inner-city adolescent smokers did have nicotine dependence as
evidenced by their reports of withdrawal symptoms and scores on the FTND scale.
Smokers least likely to quit on their own were those who reported more withdrawal
symptoms during their attempts to quit, higher levels of perceived stress,
and less use of cognitive coping. Our results suggest that interventions for
these factors should be designed for smokers as a group, rather than by stages
of change on the TMC model.
AUTHOR INFORMATION
Accepted for publication December 12, 2000.
Presented as a poster at the Society for Research on Nicotine and Tobacco,
Arlington, Va, February 18-20, 2000.
From the Department of Pediatrics, Mt Sinai School of Medicine, New
York, NY.
Corresponding author: Lorena M. Siqueira, MD, Mt Sinai Adolescent
Health Center, Box 1005, 320 E 94th St, New York, NY 10128 (e-mail: Lorena_Siqueira{at}mssm.edu).
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