Health and Performance Related Reasons for Wanting to Quit: Gender Differences Among Teen Smokers

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

SUBSTANCE USE & MISUSE

Vol. 38, No. 8, pp. 1095–1107, 2003

Health and Performance Related Reasons for

Wanting to Quit: Gender Differences

Among Teen Smokers

A. Thiri Aung, M.D., Norval J. Hickman III, B.A.,

and Eric T. Moolchan, M.D.*

National Institutes of Health, National Institute on

Drug Abuse, Intramural Research Program,

Teen Tobacco Addiction Treatment Research Clinic,

Baltimore, Maryland, USA

ABSTRACT

Adolescents frequently state health as a broad-ranging reason for

wanting to quit smoking. Much less is known regarding

performance-related reasons. We hypothesized that more male than

female smokers want to quit for performance-related reasons

(e.g., to improve athletic performance). As part of a telephone

*Correspondence: Eric T. Moolchan, M.D., NIH, NIDA, IRP, Teen Tobacco

Addiction Treatment Research Clinic, 5500 Nathan Shock Drive, Baltimore, MD

21224, USA; Fax: (410) 550-1656; E-mail: [email protected].

1095

DOI: 10.1081/JA-120017652 1082-6084 (Print); 1532-2491 (Online)

Copyright & 2003 by Marcel Dekker, Inc. www.dekker.com

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screen to determine eligibility for participation in a cessation

trial in Baltimore, Maryland, 1999–2001, 509 teenage smokers

[mean age 15.78� 1.65 years (range 11–21), 60.9% female, 32.6%

African-American] were asked the open-ended question: ‘‘Why do

you want to quit?’’ Responses were subsequently grouped into

categories that included health, performance, cost, social influences,

setting an example for others, self-efficacy, cosmetics, no perceived

positive reinforcement, or unknown reasons. Health was the most

commonly stated primary and overall reason for wanting to quit

among both boys and girls. Sixty-five percent of teen smokers

endorsing health reasons were girls, and 51% of those endorsing

performance-related reasons were boys ð�22 ¼ 7:78, p ¼ 0:02Þ.

Recognizing the greater concern for performance-related issues

among boys is important for designing and engaging young smokers

into cessation interventions.

Key Words: Adolescent smoking; Reasons for quitting; Gender;

Health; Performance.

INTRODUCTION

Approximately three million American adolescents smoke (Centre forDisease Control, 1998). Seventy percent of teen smokers wished they hadnever started smoking (Centre for Disease Control, 1998) and self-initiated successful quit rates of less than 5% have been reported(Lamkin et al., 1998; Stanton et al., 1996; Zhu et al., 1999). Hence, over-coming barriers to participation is key to implementing effective smokingcessation interventions for youth (McCormick et al., 1999). In thatregard, aligning treatment designs and recruitment messages with theprimary reasons adolescent smokers give for wanting to quit shouldenhance teenagers’ adherence to such clinical interventions.

Various studies have reported that the primary reasons adolescentsstate for wanting to quit are health-related (Dozois et al., 1995; Stone andKristeller, 1992; Sussman et al., 1998). Teen smokers may be endorsinghealth reasons because they have heard from multiple authoritativesources that smoking is harmful and they may perceive it to be themost legitimate reason. There is, however, a need to question the meaningof ‘‘health’’ in the adolescent context because adolescent smokers aremore likely than nonsmokers of the same age to doubt that smokingwould cause their death, even if they continued to smoke for 30 or 40years (Arnett, 2000). Furthermore, the operationalization of health as aconcept may vary throughout adolescence (Fairclough Norman, 1992).

1096 Aung, Hickman, and Moolchan

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This and the illegality of teenage smoking may influence how healthand smoking related issues are discussed with an authoritative figure(Stubbs Michael, 1983).

Rather limited attention has been devoted to other potential reasonsthat could have been mislabeled under the more general term of ‘‘health’’.One example is performance-related reasons, such as to improve endur-ance in sports or the ability to participate in other desired activities.Subtle distinctions in either perceived need for treatment or engagementcould distinguish performance from health-related benefits. Performance-related reasons deserve a separate focus because they offer the possibilityof a more immediately measurable and specific internal motivator to quitsmoking than do general health-related reasons, and intrinsic motivatorshave been found to correlate with smoking cessation success (Curry et al.,1997). It is likely that potential improvement in activities of daily life ismore operational in the immediate context of a teenager than a healthconcern that would only manifest decades later. Because adolescentswho smoke are less physically fit than nonsmoking adolescents (Cohen,1993), enhanced performance might serve as an immediate marker ofhealth improvement. Furthermore, independently of health effects,performance-related benefits have been found to motivate adults forcessation and prevent future relapse (King et al., 1996; Marcus et al.,1991; Marcus et al., 1995).

Among adult smokers, men’s decisions to quit were more influencedby intrinsic motivators (health concerns and self-control) while womenresponded more to extrinsic motivators (immediate reinforcement andsocial influence) (Curry et al., 1997). However, inconsistent gender-specific reasons for wanting to quit among young smokers have beenreported. Fisher and colleagues (1999) reported that girls were morelikely to globally endorse health reasons for quitting than boys. On theother hand, Sussman et al. (1998) reported that improvements inendurance were more important to girls than boys, whereas social factorswere more important reasons for boys than girls. Hence, gender differ-ences in reasons for quitting deserve further study. Supplanting thesereports, our preliminary clinical observations led us to hypothesize thatboys seeking cessation treatment are more likely than girls to cite perfor-mance improvement as a reason for wanting to quit.

METHODS

Data for this analysis were obtained from the initial assessment ofcallers being screened for a randomized, double-blind, placebo-controlled

Gender Differences Among Teen Smokers 1097

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nicotine replacement therapy trial of adolescent smokers through theTeen Tobacco Addiction Treatment Research Clinic (TTATRC) inBaltimore, Maryland. Baseline data reported here were collected betweenAugust 1999 and August 2001.

Sample

Teenagers were recruited using multimedia (various print materials,local radio, television), contact with school personnel, and communityoutreach through local churches and youth groups. Five hundredand nine teenage smokers who wanted to participate in a study tohelp them quit smoking called the 1-800-NO-SMOKE line to completea 15–20minute screening interview. Table 1 provides demographiccharacteristics of the sample.

Procedures

Data were collected by a licensed social worker and other trained staffwith experience in eliciting clinical information from substance users viatelephone interviews. The brief phone screen was administered using aquestionnaire designed to obtain demographic characteristics, probesmoking behaviors and ask the open-ended question: ‘‘Why do youwant to quit smoking?’’ Teen smokers were encouraged to cite the mostimportant reason first, and then an unlimited number of reasons asallowed by the time frame of the interview. The first reason teens gavefor wanting to quit was considered the primary reason for seekingsmoking cessation. Responses were grouped into categories a posteriori

Table 1. Selected sample characteristics.

N¼ 509 Mean (SD) or % (n)

Age 15.77 (1.65)

Girls 60.9 (310)

African-American 32.6 (164)

Cpd 14.54 (8.63)

FTND score 5.93 (2.15)

Quit attempts 3.36 (3.20)

FTND score¼Fagerstrom test for nicotine dependence.

Cpd¼ cigarettes per day.


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because we wanted to obtain spontaneous qualitative data from teensmokers, without directly prompting them to specific categories ofresponses. To maintain inter-interviewer consistency, only one staffmember categorized the responses into distinct categories. The categorieswere: 1) health (e.g., ‘‘reduce risk of getting lung cancer,’’ ‘‘quitting is goodfor my health,’’ ‘‘bad for my asthma,’’ ‘‘health reasons’’); 2) performance(e.g., ‘‘to run faster,’’ ‘‘to increase endurance,’’ ‘‘to be better at sports,’’‘‘breathe better’’) (we included here some reasons that might appearhealth-related but for our purposes were more performance-related); 3)cost; 4) social influences (e.g., ‘‘my mom told me to call,’’ ‘‘others gettingsick because of my smoking,’’ ‘‘afraid of harming a younger sibling orchild,’’ ‘‘exposing others to smoke,’’ and ‘‘setting a good example foryounger sister’’); 5) self-efficacy (e.g., ‘‘I feel controlled by smoking,’’‘‘to prove that I could do it’’); 6) cosmetics (e.g., ‘‘guys don’t like girlswho smoke,’’ ‘‘bad breath’’); 7) no perceived positive reinforcement (e.g.,‘‘tired of smoking,’’ ‘‘I don’t like it anymore’’); 8) role-modeling; 9)unknown.

Nicotine dependence in this context is seen as loss of autonomy oversmoking due to the psychological and physiological effects of tobaccouse, resulting in a barrier to quitting (DiFranza et al., 2002). Degree oftobacco dependence was assessed over the telephone using theFagerstrom Test for Nicotine Dependence (FTND), a six-item paperand pencil questionnaire (score range 0–10) (Heatherton et al., 1991).The FTND has been used with teenagers (Moolchan et al., 2000;Moolchan et al., 2002), and its administration over the telephone hasbeen reported to be reliable among adult smokers (Clark et al., 1996).

Statistical Analyses

Data were analyzed using SPSS 10.1. Chi-square tests were used todetermine if reasons for quitting correlated with gender, and one-wayanalyses of variance (ANOVAs) were used to determine whether reasonsfor quitting were associated with potential confounding variables, i.e.,age, FTND scores, number of past quit attempts, and current tobaccoconsumption.

RESULTS

Adolescents’ mean age was 15.78� 1.65 years (range 11–21),60.9% (310/509) female, 32.6% (164/509) African-American (AA), and


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67.4% (345/509) nonAfrican-American (nonAA) (1.0% Alaskan,Eskimo; 1.4% Hispanic; 65.0% European American). As a group,teens smoked 14.54� 8.63 cigarettes per day (CPD), reported3.36� 3.20 quit attempts in the past, and had a FTND score of5.93� 2.15, indicating substantial nicotine dependence (Table 1). Whilethere is no standard cutoff for high or low nicotine dependence on theFTND, one scoring system is: 1–2¼ very low dependence; 3–4¼ lowdependence; 5¼medium dependence; 6–7¼ high dependence;8–10¼ very high dependence (Fagerstrom et al., 1991).

There were no significant gender differences in age, nicotine depen-dence levels, number of past quit attempts, or current tobacco consump-tion. Socioeconomic status and grade in school were not obtained at thisearly prescreening phase of the treatment trial.

We examined the primary reasons for quitting: health, performance,and other reasons. The other categories were collapsed into an‘‘other reasons’’ group because of the small frequency in each group.Health was the most commonly stated primary reason for wantingto quit smoking among both boys and girls (49.9%). The secondmost commonly stated reason was performance-related (19.6%)(Table 2). Overall, teens endorsed a mean of 1.44� 0.31 (range 1–5)reasons per person. In comparing the endorsement frequencies of eachcategory, we found that the ranking of categories by frequency wassimilar to the ranking by primary reason, with health beingthe most frequently cited reason, followed by performance and cost(Table 2).

Table 2. Reasons endorsed by teen smokers.

Primary reason

Reason

(unlimited number

of responses)

% (N ) N¼ 509 % (N) N¼ 509

Health 49.9 (254) 60.5 (308)

Performance 19.6 (100) 28.7 (147)

Cost 9.8 (50) 19.8 (101)

Social pressure 7.9 (40) 12.6 (64)

Cosmetics 5.3 (27) 11.6 (59)

Lack of positive reinforcement 4.9 (25) 6.9 (35)

Self-efficacy 2.2 (11) 3.3 (17)

Role-modeling 0.2 (1) 0.2 (1)

Unknown 0.2 (1) 0.2 (1)


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Although both boys and girls overwhelmingly endorse health reasonsfor quitting, there were significant gender differences, with more girls(53.2% vs. 44.7%) endorsing health reasons while more boys (25.6%vs. 15.8%) endorsed performance-related reasons ð�2

2 ¼ 7:78, p ¼ 0:02Þ(Table 3). However, reason for quitting did not correlate with ethnicity(Health reasons: nonAA 49.3%, AA 51.2%; Performance reasons:nonAA 20.7%, AA17.5%; Other reasons: nonAA 30.0%, AA 31.3%;�2

2 ¼ 0:74, p ¼ 0:69). There was also no association between reason forquitting and age, FTND scores, number of previous quit attempts, orcurrent tobacco consumption (data not shown). Since potential con-founding variables did not correlate with gender or the primary reasonfor quitting, adjustments were not made in reported analyses.

DISCUSSION

Our findings are consistent with previous reports of teen smokers’primary endorsement of health-related reasons for wanting to quit. Ourresults extend those findings by pointing to a significant gender differencein performance-motivated quitting, which held across age and the twoethnoracial groups. Although the majority of teenagers calling to requesttreatment cited health reasons for wanting to quit, and the most commonreason for wanting to quit among both boys and girls was health, boyswere more likely to cite performance-related reasons than girls.Conversely, girls were more likely to endorse health reasons for wantingto enroll than boys.

This is consistent with trends found in adult smokers where femalesreport more medical symptoms and utilize more medical services (tenHave et al., 2001). Similar patterns have been reported in youth,with girls being more likely to approach parents, physicians, and other

Table 3. Gender differences in reasons endorsed by teen smokers.

% (N )

Chi-square p-value

Female Male

N¼ 310 N¼ 199

Health 53.2 (165) 44.7 (89) �22 ¼ 7:78 0.020

Performance 15.8 (49) 25.6 (51)

Others 31.0 (96) 29.6 (59)


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healthcare professionals for health information whereas boys were moreinclined to obtain such information ‘‘anonymously’’ from sources with-out personal identifiers, such as from newspapers, the internet, and ‘‘800’’(toll-free) telephone numbers (Ackard and Neumark-Sztainer, 2001). Thepossibility that boys might be relatively less inclined to seek help fromhealth-related channels because of their perceived demands of maintain-ing a masculine attitude and self-image of invincibility needs to be bornein mind when targeting smoking cessation and other health interventionsto boys.

Our findings and experiences in the TTATRC indicate that boys whosmoke pose a recruitment challenge (only 39.1% of those who called in torequest treatment were boys). Corroborating our clinical impressions, thecurrent data now confirm that boys are more likely to engage in quittingfor performance reasons than girls. This suggests that cessation interven-tions and programs aiming to recruit male teen smokers might benefitfrom enlisting the help of coaches and other sports-related venues (Centerfor Disease Control).

Because our sample included both European American (65.0%) andAfrican-American (33.0%) smokers, findings from this study are general-izable to many inner city settings where busy practitioners might counselteens toward smoking abstinence. Compared to the prevalence of ado-lescent smoking in the 1999 Youth Risk Behavior Surveillance data(Center for Disease Control, 2000), our sample of treatment requestersconsisted of a higher proportion of European Americans, a similar per-centage of African-Americans, and a smaller number of Hispanic teensmokers. One limitation of the study is the lack of data on socioeconomicstatus and educational level of the teen smokers, although treatment trialparticipants were mostly from lower middle-income families.

In addition, our findings reflect only reasons for wanting to quitamong teen smokers who were motivated enough to request treatmentover the telephone and therefore do not reflect the views of teen smokersin the precontemplation or contemplation stages of change (Prochaskaand DiClemente, 1983). Another potential limitation of this study is thesocial desirability bias: teen smokers may have overreported health-related reasons for wanting to quit because of its perceived ‘‘correctness.’’It is also possible that the ‘‘primary’’ stated reason might not have beenthe most important, but the one perceived by the teen as most acceptableto the interviewer. Additionally, the low mean total number of reasonsendorsed might have been due to the rapid pace of the telephone inter-view. However, the fact that most teen smokers endorsed only oneresponse supports the notion that these are the true motivators fortheir quit attempt. This should be assessed through future studies that


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examine the relationship between stated reasons for wanting to quit andoutcomes in smoking cessation interventions targeted to young smokers.

ACKNOWLEDGMENTS

We thank Dr. Jennifer R. Schroeder, Mr. Aleksandras Radzius, andthe staff of the Teen Tobacco Addiction Treatment Research Clinic fortheir contributions to this project and manuscript. This work was sup-ported by National Institute on Drug Abuse Intramural funds.

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Cohen, S. B. (1993). Adolescent tobacco use and physical activity. JAMA270:938–939.

Curry, S. J., Grothaus, L., McBride, C. (1997). Reasons for quitting:intrinsic and extrinsic motivation for smoking cessation in apopulation-based sample of smokers. Addict. Behav. 22:727–739.

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RESUMEN

Los adolescentes suelen citar la salud como amplia razon para mos-trarse dispuestos a abandonar el habito de fumar. Mucho menos cono-cidas son las razones relacionadas con el desempeno. Planteamos lahipotesis de que hay mas fumadores que fumadoras dispuestos a aban-donar el habito por razones relacionadas con el desempeno (por ejemplo,la mejora del desempeno atletico). Como parte de una encuesta telefonicapara determinar la idoneidad para participar en un ensayo sobre el aban-dono del habito de fumar, se hizo la siguiente pregunta de respuesta librea 509 fumadores adolescentes [60.9% mujeres y 32.6% afroamericanos]:¿‘‘por que desea dejar de fumar’’? Las respuestas se agruparon luego encategorıas que comprendieron salud, desempeno, costo, influenciassociales, buen ejemplo para otros, autoeficacia, razones esteticas, percep-cion de una falta de refuerzo positivo o razones desconocidas. La saludfue la razon primordial y general mas comunmente citada por los varonesy las ninas para dejar de fumar. Sesenta y cinco por ciento de los fuma-dores adolescentes que adujeron razones de salud eran ninas y 51% dequienes adujeron razones de desempeno eran varones (�2

2 ¼ 7.78,p¼ 0.02). Es importante reconocer la mayor preocupacion de los varones


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por las cuestiones relacionadas con el desempeno para formular inter-venciones conducentes al abandono del habito de fumar y hacer partici-par en ellas a los fumadores jovenes.

RESUME

C’est souvent la sante qui est invoquee de facon generale chez lesadolescents comme motivation pour arreter de fumer. On en sait beaucoupmoins sur les raisons concernant les consequences sur leurs performances.Notre hypothese est que plus de fumeurs garcons que filles veulent arreterde fumer pour des raisons liees a leurs performances (par ex., pour ame-liorer leurs performances sportives). Lors d’un sondage telephonique deselection pour la participation a un test de sevrage, 509 adolescents [60.9%de filles et 32.6% de noirs-americains] ont du repondre a la question areponse libre: hhPourquoi voulez-vous arreter de fumer? iiLes reponsesont ensuite ete groupees dans des categories telles que sante, performances,cout, influences sociales, desir de servir d’exemple, auto-discipline, raisonsesthetiques, le fait que fumer n’apporte rien de positif, ou raisons incon-nues. La sante est la raison principale et generale la plus frequemmentinvoquee pour les deux sexes. Les filles representent 65% des adolescentsfumeurs qui citent des raisons de sante et les garcons representent 51% deceux se referant a des raisons liees a leurs performances (�2

2 ¼7.78,p¼ 0.02). II est important de reconnaıtre que l’interet porte aux perfor-mances est plus important chez les garcons pour encourager les jeunes aarreter de fumer et en trouver les moyens.

THE AUTHORS

A. Thiri Aung, M.D., is a VisitingFellow at the Teen Tobacco AddictionTreatment Research Clinic, IntramuralResearch Program, National Instituteon Drug Abuse, Baltimore, Maryland.She is a coinvestigator on a smokingcessation trial assessing the safety, effi-cacy, and tolerability of nicotine replace-ment therapy in adolescent smokers.


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Norval J. Hickman III, B.A., is aresearch associate and study supervisorin Psychiatric Epidemiology atWashington University School ofMedicine. Mr. Hickman is currentlyinvolved in the Missouri Family Studylooking at health, behavior, andlifestyle among a majority AfricanAmerican sample. He will enter into adoctoral training program in ClinicalPsychology at San Diego in the fall of2002.

Eric T. Moolchan, M.D., is a physician-scientist and director of the TeenTobacco Addiction TreatmentResearch Clinic, Intramural ResearchProgram, National Institute on DrugAbuse (NIDA, IRP) in Baltimore,MD. He develops and overseesresearch protocols, with a chief focuson nicotine and tobacco and a second-ary focus on other drugs of abuse(cocaine, opioids, and marijuana).Dr. Moolchan is also Visiting AssistantProfessor in the Division of AdolescentMedicine, Johns Hopkins UniversitySchool of Medicine.


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Documents

Health and Performance Related Reasons for Wanting to Quit: Gender Differences Among Teen Smokers