Abstract

METHODS

RESULTS

Reasons for Smoking: Youth Interviews

The youth identified a number of factors contributing to their use of tobacco (Figure 1a). Failure to enforce a no-smoking ban in the home was the most frequently identified factor (10 youth, 11 quotes) and parental smoking was common (8 youth, 11 quotes). One youth recalled, “I smoked my first cigarette with my dad… it was better to have him show me what smoking was like rather than have it as something that is hidden” (23-year-old male). Another stated, “My mom would give me money to buy cigarettes” (22-year-old male). A third stated, “They [parents] say they don’t like me smoking, yet when they catch me, they just brush it off” (18-year-old male). Peers also played a significant role in initiation and continued use of tobacco. Half the youth reported first smoking with friends, all reported currently having friends who smoke, and nine identified tobacco use by friends as a negative influence. One shared, “When I didn’t smoke, everyone smoked… and blew it in my face” (21-year-old female). Another voiced concerns about maintaining friendships while quitting smoking stating, “I’m trying to figure out how I can still be cool with them but don’t do all the things that they do” (23-year-old female). Though sample sizes were small, females were more likely to report smoking with peers (6 of 6 females vs. 2 of 8 males), whereas males were more likely to report that their parents smoke or provide them with cigarettes (2 of 6 females vs. 8 of 8 males).

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Figure 1.

Youth with mental health concerns: Reasons for smoking.

Additionally, stress and affect, addiction, other substances, and media images were identified as driving tobacco use. The youth reported, “when I get stressed or angry… I go out and have a cigarette” (20-year-old female); “when I start to get frustrated or nervous, it just calms me down” (22-year-old male); and “hypermanic is when…I’ll smoke more” (23-year-old male). Unable to quit, the youth described smoking as follows: “first thing in the morning” (19-year-old male), “it made me addicted and now it’s hard for me to stop” (21-year-old female), and “I can’t stop because once I smell it… I want to go smoke” (16-year-old male). Tobacco was used with illicit drugs “to boost the high” (23-year-old female) or as a drug substitute, “smoking more when the cravings [for other drugs] were getting out of control” (23-year-old male). Three youth identified media images as triggers to smoke, “When I see it on TV or in the movies, like when I see someone else smoking” (19-year-old female).

Treatment Recommendations: Youth Interviews

The youth identified a variety of approaches for quitting smoking (Figure 2a). Notably, the most frequent were without help or assistance (cold turkey, don’t need any help) and nonpharmacologic methods (physical activity, new hobbies, talk about it, support from friends, education). Four youth reported positive, whereas seven reported negative experiences with nicotine replacement, including nausea and headache with the patch, aversion to the taste of the gum and lozenge, and finding the cost prohibitive. In contrast, physical activity was identified as a useful quit smoking strategy (14 quotes, 9 youth). One youth suggested, “I can work on my fitness, and that would stop the cravings for cigarettes” (20-year-old female). Another stated, “If I’m playing basketball most of the day, then I won’t smoke” (23-year-old male).

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Figure 2.

Tobacco treatment recommendations for youth with mental health concerns.

Criticism for smoking from clinicians, parents, and friends was viewed as counterproductive—the youth wanted nonjudgmental support (11 youth, 20 quotes). One youth voiced, “Instead of helping you quit, it’s making you so angry at them that you want to do it just to get back at them, you know for spite” (20-year-old female). Also unhelpful is ignoring youth smoking, as one youth described, “It hasn’t really been brought up. If they brought it up to think about it, it would still be hard, but it would do something, it would help just to talk about it” (16-year-old male).

The youth reported little knowledge of community resources for quitting smoking (7 youth, 8 quotes). Mental health clinics, in turn, were viewed as safe, comfortable, and accessible environments to work with youth facing similar struggles (9 youth, 15 quotes). One youth remarked, “There’s counselors around and there’s nice people…It’s a safe place to express your feelings” (20-year-old female). Another stated, “Here…everyone had things in common, but in school… people might think you’re different or strange” (18-year-old male). For delivering tobacco treatment, eight youth emphasized the value of in-person contacts preferable to phone or Internet-delivered interventions. Treatment recommendations did not differ by gender.

DISCUSSION

In seeking to inform the development of acceptable, feasible, and effective strategies for addressing tobacco use among youth with mental health concerns, this qualitative study gathered insights from youth and their treatment providers. Spanning the ages of 16–23, most of the youth interviewed were daily smokers, most had smoked cigars in addition to cigarettes, and nearly all reported experiencing negative health consequences of their tobacco use such as coughing, fatigue, and shortness of breath. The providers practiced in diverse treatment settings and represented a variety of professions. Consistently, across the interviews, there was general agreement that the level of personal reflection and clinical attention to youth tobacco use is currently inadequate in mental health settings.

The youth and clinicians discussed tobacco use within the context of psychiatric and substance use issues; however, the majority of statements focused more broadly. Overall, the factors the adolescents and young adults identified as contributing to their use of tobacco mirrored what has been reported in the literature with youth without mental health concerns (Tyas & Pederson, 1998) including peer influences and social situations; addiction; smoking for relaxation, which may in part be smoking to reduce withdrawal symptoms; and media influences. More unique, and of concern, were the harmful parental practices of tobacco use, provision of cigarettes to youth, and inconsistent enforcement of nonsmoking rules in the home. Males reported these practices more than females, whereas females reported greater peer influences than males. Parents may be more apt to accept or enable smoking among their sons than daughters, particularly in some cultural groups. Future research should examine the extent to which parental permissiveness regarding youth tobacco use is tied to beliefs that smoking is a form of self-medication among those with mental health concerns and/or a form of harm reduction relative to other substance use. In reality, the harms are substantial (Prochaska, 2010), and the youth largely expressed disappointment toward these permissive parental behaviors. The home environment is central to the youths’ experience and can support or undue treatment efforts. Critical to curbing youth tobacco use will be getting parents onboard with smoking restrictions in the home, especially parents who smoke, and engaging their support with cessation efforts.

The perception that females are more likely to smoke socially was reported prior in a qualitative study of college students; however, such perceptions were not supported by quantitative data on reported behaviors (Nichter et al., 2006). Longitudinal research with adolescents indicates that peers affect both current and future smoking behaviors, as well as the development of social networks (Hall & Valente, 2007). A broader understanding and characterization of the social networks of youth with mental health concerns and their influence on risk behaviors and behavior change are warranted.

The mental health providers similarly identified social and familial influences as significant in driving youth smoking, but not addiction, withdrawal symptoms, or media influences. Instead, the clinicians were more inclined to view youth smoking as a developmental phase, an assertion of autonomy, and a form of coping with mental illness. These differences point to areas of potential mismatch that may influence providers’ practices. Viewing youth smoking as a normative developmental process, closely tied to management of psychiatric symptoms, and supported by parents likely contributes to the general lack of attention to tobacco use in practice. The clinicians viewed tobacco as of lower priority relative to youth alcohol and illicit drug use. In the youth interviews, however, tobacco was identified as not only a gateway drug but also a maintenance drug in promoting continued use of other substances with synergistic effects. Of increasing concern is the co-use of tobacco and other substances. A recent study reported that half of young adult smokers in the general population also smoke marijuana (Ramo & Prochaska, 2012). Of further contrast, in the gestalt, the youth identified a greater variety of specific reasons for smoking than the clinicians, and the reasons tended to be more proximal and cue driven, suggesting early conditioning effects, whereas the providers had more global responses (Figure 1a and ​andb),b), which may reflect a more distant understanding of the varied tobacco using experiences of these youth.

Differences were also found in the tobacco treatment recommendations of youth and providers. The two most frequent suggestions—pharmacotherapy recommended by providers and cold turkey identified by the youth—were directly opposite. For youth under the age of 18, cessation pharmacotherapy is not recommended given limited evidence of efficacy (Tobacco Use and Dependence Guideline Panel, 2008). For young adult smokers, pharmaceutical companies might consider younger taste preferences and use patterns and smaller unit packaging to improve acceptability and affordability.

Also central in the word cloud for providers were referrals and groups, whereas the youth emphasized peer support and engagement in other behaviors (e.g., physical activity) and hobbies (Figure 2a and ​andb).b). Prescriptions for pharmacotherapy, groups, and outside programs require creating new connections and hence rely heavily on patient adherence. If the provider does not have buy-in from the youth, success is unlikely. The youth, on the other hand, recommended existing resources that are familiar and can be leveraged, enhanced, and built upon.

In terms of commonalities and consistent with clinical practice guidelines, both youth and providers recommended nonjudgmental support and motivational approaches, as well as physical activity promotion, and recommendations did not differ by gender (Tobacco Use and Dependence Guideline Panel, 2008). Motivational cessation approaches seem particularly relevant as less than a third of adolescent tobacco users intend to quit in the next month, and the proportion is even lower (19%) among adolescent smokers seen in inpatient psychiatry (Brown et al., 2003; Leatherdale & McDonald, 2005; Mermelstein, 2003; Prokhorov et al., 2001). Intervention strategies tailored to motivation are designed to be relevant to all smokers and not just the minority ready to take action and have demonstrated evidence for treating adolescent tobacco dependence (Grimshaw & Stanton, 2006).

The youth identified secondhand smoke as triggering their use of tobacco, and a majority reported aversion to the smell of smoking. Yet, neither youth nor providers recommended tobacco bans at treatment settings, nor other tobacco control policy approaches such as restricting smoking in the media and raising cigarette taxes. Until only recently, little advocacy has sought to protect patients, providers, and family members from secondhand smoke exposure in psychiatric treatment settings (Legacy Foundation, 2011). Consideration of secondhand smoke effects on youth initiation and relapse and its association with psychiatric disorders in youth is needed (Bandiera, Richardson, Lee, He, & Merikangas, 2011).

Strengths of this qualitative study include attention to an understudied issue in a vulnerable patient population, interviews with both providers and patients, and use of open-ended questions so that a variety of themes could emerge. Not only a number of parallels between the youth and provider interviews were identified but also important contrasts. Importantly, qualitative methods can enable a richer understanding of nuanced relationships useful for generating new testable hypotheses and shaping tailoring of treatment approaches. Study limitations included the small sample size; however, saturation of information was reached, which is demonstrated by the large number of quotes within topics. Within the word clouds, font size was not too variable, suggesting agreement in the reasons for smoking and recommendations for treatment. The word clouds, as a visual display of word frequency, are a useful adjunctive tool to be interpreted within the larger meaning and context of the words (McNaught & Lam, 2010). Although Figure 2 depicts the popularity of strategies, long-term tobacco abstinence will likely be supported through a combination of approaches.

Interventions delivered in health care settings offer the appeal of broad reach and integration within ongoing medical care. Yet, historically, tobacco use in the mental health setting has been normalized. A culture shift is needed. In this qualitative study, the providers interviewed were highly trained clinicians in high-performing clinical sites. As such, the findings reflect a best-case scenario and, notably, suggest great room and receptivity for improvement.

The adolescents largely viewed the mental health setting as a safe place to tackle issues with which they struggle such as smoking. To increase clinician prioritization and delivery of tobacco treatment, recent research in adult drug treatment programs supports the evidence of organizational interventions consisting of staff training, consultation, policy development, leadership support, and access to cessation medication (Guydish et al., 2012). An emphasis on tobacco treatment’s broader possible effects for enhancing sobriety and mental wellness may be particularly helpful (Prochaska, Delucchi, & Hall, 2004; Prochaska et al., 2008). At the patient level, clinical trials research is needed to evaluate the acceptability and efficacy of tobacco cessation interventions with youth in mental health settings.

FUNDING

This work was supported by the National Institute on Drug Abuse (#K23 DA018691;, #K05 DA016752;, and #P50 DA09253) and the State of California Tobacco-Related Disease Research Program (#13KT-0152).

DECLARATION OF INTERESTS

The authors have no competing interests to declare related to this research.

ACKNOWLEDGMENTS

REFERENCES