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Developing a nonsmoker image : making smoke-free decisions to consolidate a social identity in early.. 2004

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DEVELOPING A NONSMOKER IMAGE: MAKING SMOKE-FREE DECISIONS TO CONSOLIDATE A SOCIAL IDENTITY IN EARLY ADOLESCENCE by DOROTHY ROBERTA SWANSON-HOLM B.S.N., University of Victoria, 1988 M.S.N., The University of British Columbia, 1991 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September 2004 © Dorothy Roberta Swanson-Holm, 2004 II DEVELOPING A NONSMOKER IMAGE: MAKING SMOKE-FREE DECISIONS TO CONSOLIDATE A SOCIAL IDENTITY IN EARLY ADOLESCENCE Abstract Developing a Nonsmoker Image is a substantive middle range theory that outlines the most salient issues, patterns of concern, experiences, and actions of how young self-identified nonsmokers made personal decisions about tobacco use/non-use during the early stage of adolescent development. Smoking was perceived as a hindrance to a consolidated social identity and toward meeting a need for independence. This study, informed by constructivist and interactionist perspectives, was conducted according to the grounded theory method of research. The purposive sample consisted of 11 boys and 17 girls in grades 5 to 9 (10-14 years) representing diversity in smoking exposure profiles. Participants were White, English-speaking Canadians who attended public elementary or middle schools in British Columbia. Grades 5 and 6 participants reported never trying smoking (never smoker) whereas six of the 14 middle school participants reported trying smoking (trier). Data were collected according to a school-based approach via in-depth individual interviews. Each of these 28 informants were interviewed twice. All interviews were audio taped and transcribed verbatim to form the primary basis for data analysis. Informants spoke in voices that were rich, confident, straightforward, and honest. As well, a draw-and-write task, specifically designed for this study, was used during the interactive interview process. These drawings provided an additional cognitive perspective, adding enrichment to informants' stories. Artwork was examined for content, general tone, and participants' feelings in relation to written narratives that accompanied drawings. Artwork represented personal smoking-related images, smoke-free strategies, and anti-smoking signification which tapped a natural, powerful ability to think about complex ideas and smoking-related issues through analogic and metaphoric language. To develop a nonsmoker image, participants needed to deconstruct their perceptions of smoker images - these revealed interpersonal social dimensions (appearance, activity, alcohol and drugs, rebellion) and intrapersonal psychological dimensions (affect, control, pride, intelligence). Resultant images formed a foundation to reconstruct a nonsmoker identity. Accordingly, four separate identity profiles emerged from thematic analyses: the adamant nonsmoker, the reserved/indifferent nonsmoker, Ill the committed nonsmoker, and the committed empathic nonsmoker. To manage transitions from childhood to early adolescence, the basic social-psychological phenomenon, participants developed an integrated nonsmoker identity through social comparative judgements and cognitive processes. Conceptual categories and processes were inductively derived through constant comparative analyses represented by two major categories, Creating Meaning about Smoking and Reaching Commitedness about Nonsmoking; the core variable, Developing a Nonsmoker Image led to discovery of the basic social process. Important aspects about tobacco-related decisions and nonsmoker image development entailed maintaining an autonomous perspective and communicating a point of view (e.g., free choice, self-assertion), using communication patterns to express the notion of separateness (how one is different from others), and declaring personal desires, concerns, intentions, and preferences (e.g., self-control, self-efficacy, self-confidence). As a consequence of being exposed to everyday smoking situations, participants went through the established processes between themselves, family members, and others within their social-cultural contexts. The most important conditions - having social support, accepting and recognizing one's nonsmoker identity by self/others, and keeping mind/body busy with nonsmoking-related activities influenced transition throughout the entire process. This research emphasized the vantage point of the early adolescent as a way to improve our understanding of patterns of difference concerning social comparative processes and shared judgements in their smoking-related decisions. Supporting data are provided to enable appreciation for early adolescent nonsmoker perspectives and evaluate the implications for education, families, and tobacco control research. In light of the scholarly literature on early adolescents and smoking prevention, participants' accounts suggest that educative programming for health promotion needs an approach that respects early adolescents as a unique and separate group of interest and considers cognitive developmental levels. Recommendations address school-based health promotion intervention programs and educational health psychology research that consider the every day lived reality of adolescent life, an objective that has potential to work effectively with teens toward healthful living through a critical developmental period. iv TABLE OF CONTENTS Abstract ii Table of Contents iv List of Tables ix List of Figures x Acknowledgements xi Dedication xiii Chapter One Preface: Introduction to the Dissertation 1 Background to the Phenomenon of Interest 2 Scope of the Phenomenon 3 Statement of the Research Problem 6 Significance of this Study 8 Summary of Background and Investigative Perspective 9 Chapter Two Literature Review 11 Overview to the Preliminary Review of Literature 12 Smoking as a social-psychological phenomenon 12 Introduction to Selected Review of Literature and Context 13 Stages of smoking 14 Categorization of smokers 14 Smoking and gender-related differences 15 A Social Developmental Perspective on Early Adolescence 16 Early adolescence as a stage of development 16 Cognitive development 17 Transitions .18 Self and self-identity 18 A developmental perspective of self-identity 19 Overview of Social and Cognitive Risk Factors Predictive of Smoking 19 Social Domain 23 Parental Smoking and Nonsmoking Behaviour 24 Peer and Friend Influences 26 Gender Differences 29 Demographic Characteristics and Social-Environmental Factors Associated with Risks of Smoking 36 Advertising and Promotional Strategies in the Media 38 Cognitive Domain 41 Adolescents' Perceptions of Smoking in Family and Social Contexts 42 Knowledge About the Health Consequences of Smoking 45 School-Based Approaches to Smoking Prevention 46 Summary of Empirical Evidence of Smoking Influences in Adolescence 50 Research Concerning Adolescent Smoking and Nonsmoking: Strengths and Limitations 51 Studies over time 51 Methodological considerations 52 Self-report methodology 52 V Self-report and research on smoking 53 Inconsistencies in data 53 Elements of test construction and survey format 54 Specific adolescent concepts 55 Theoretical Stance: Grounded Theory as a Research Methodology 56 Theoretical Stance 56 Purposes of grounded theory 57 The Grounded Theory Method of Research 57 History of grounded theory 58 Differing versions of grounded theory 59 Use and approach to grounded theory in this research 60 Central features of grounded theory 60 Symbolic Interactionism: The Theoretical Context of Grounded Theory 61 Symbolic interactionism theory 61 Assumptions of grounded theory 63 Rationale for grounded theory in this study 63 Addressing gaps in current knowledge 63 Grounded theory as a suitable method 64 Chapter Three Grounded Theory: A Systematic Approach 65 Purpose and Objective of the Present Study 65 Research Questions 66 Overview: Methods of Generating Theory 66 Study Setting and Approaches 67 Study Setting 67 Rationale for a school-based approach 68 Approaches for Recruitment and Associated Strategies 69 Approach to school selection 69 Approaches to gain familiarity with the schools'contexts 70 Approaches to gain rapport within learning contexts 71 Approach for framing the drawing task 71 Approaches for Participant Recruitment 74 Participant candidates 73 Reply procedure and incentives 73 Students' approaches to welcoming the researcher 74 Household and family approach 75 Data Collection: Part One - Sampling 75 Initial sampling 76 Characteristics of the Study Sample 78 Smoking exposure profile 80 Data Collection: Part Two - Interviewing 82 Interviewing procedures 82 Interviewing methods 83 The interview guide 83 Initial interview questions 84 Generative questions 85 The draw-and-write task 86 Process of drawing 87 Purpose and aims of drawings 87 Developmental basis for drawings 87 Draw-and-write procedures 88 Interviewing process 89 vi Data Analysis 92 Overview of Analytic Operations and Procedures 93 Open coding 96 Selective coding 101 Consent and Ethical Considerations 105 Consent 105 Active and informed consent 106 Privacy 106 Confidentiality 106 Risks and benefits 106 Special considerations 107 Criteria for Evaluation 107 Rigor and Credibility 108 Data triangulation 109 Methodological and investigator triangulation 109 Theory triangulation 110 Summary 110 Chapter Four Findings: Narrative Thematic Analysis 112 Chapter Overview 112 Developing a Nonsmoker Profile 113 Participant Nonsmoker Profiles 114 Overall picture of sample as nonsmokers 114 Nonsmoker Typecasts 116 Refusal styles 116 The Adamant Nonsmoker: Profile of an Aggressive Refusal Style 118 The Reserved/Indifferent Nonsmoker: Profile of a Passive Refusal Style 119 The Committed Nonsmoker: Profile of an Assertive Refusal Style 120 The Draw-and-write Task 121 Value added and enrichment to understandings 121 Purpose of artwork as used in this study 122 Smoking-related messages 123 Understanding Smoking 126 What is Smoking? 126 Who is a Smoker? 132 Extrinsic Factors - Interpersonal Dimensions and Societal Images of Smoking and Nonsmoking 133 Appearance 133 Activity 135 Alcohol and drugs 136 Rebellion 139 Intrinsic Factors - Intrapersonal Dimensions and Psychological Profiles of Smokers and Nonsmokers 141 Affect 142 Control 145 Pride 148 Intelligence 150 Why does a Person Smoke? 150 Vll Physiological influences 153 Psychological influences 153 Social influences 155 Summary of the Major Findings of the Study 159 Discussion and Implications of Study Findings 161 Definitions about Smoking and Not Smoking: Experience and Context 161 Smoking and Notions of Seif-Control from Cognitive and Developmental Perspectives 167 Chapter Five The Basic Social Process and Grounded Theory 177 Synopsis of Conceptual and Theoretical Analyses 177 Overview of the Theory 178 Overview of The Basic Process 179 Personal and Environmental Factors 182 Overview of Processes 183 Creating Meaning about Smoking 185 Strategies for Creating Meaning about Smoking 191 Summary 196 Reaching Commitedness about Nonsmoking 198 Strategies for Refusing Smoking 199 Chapter Six Discussion of Major Findings and Theoretical Perspectives 205 Denouement 205 Limitations 207 Limitations Related to Sampling Procedures 207 Study setting and data collection 207 Theoretical Sampling and sample characteristics 208 Recruitment 209 Consent and ethical considerations 210 Methodological considerations relative to analysis 211 General comments 213 Chapter Seven Conclusions and Recommendations 215 Wrap-up of Major Findings: Tentative Conclusions 215 Recommendations for Further Work 216 References 221 Appendices 250 Appendix A: Drawing Task Homework Assignment 251 Appendix B: Letter of Introduction 257 Appendix C: Informed Consent Forms 258 Informed Consent Form for a Participant 259 Informed Consent Form for a Parent 260 Informed Consent Form - Signature Section 261 Appendix D: Reply Card 262 Appendix E: Household Information Sheet 264 Appendix F: Request For Study Findings 266 Appendix G: Nonsmoking Category Protocol 268 Appendix H: Biographical Questions 270 Appendix I: Interview Guide Topics and Probe Protocols 277 Appendix J: Locating the Researcher 280 viii Appendix K: Analytical Questions 297 Appendix L : Certificate of Approval 299 Appendix M: Drawings 301 ix List of Tables Table 4.1 117 Table 4.2 134 Table 4.3 152 Table 4.4 154 X List of Figures Figure 1 180 xi Acknowledgements The work herein was made possible only through the collaborative efforts of many people. Even though my name appears as authour and primary investigator, I owe great appreciation to numerous individuals and groups, all of whom provided encouragement, inspiration, and support throughout my "career" as a doctoral student. I would like to first acknowledge the 28 boys and girls who so patiently endured my inquiry into the lived teenaged experience. All participants volunteered their time willingly and graciously, and sustained this research endeavour with questions and personal interest. As well, I need to acknowledge the support provided by participants' parents and teachers, the School District Superintendent and administrative staff, and the principals from the middle and elementary schools. I owe considerable appreciation to my Spanish family who took residence both on Vancouver Island and the Mainland during the time of the study. I deeply appreciate all the help from Janet, Ana, and Roger Miralles Whitehead, all of whom volunteered countless hours toward my research in numerous and diverse ways. I have to give Janet special praise for her diligent, patient assistance on transcription- related tasks and functions, proofreading, and cataloguing references. Additional support came from Sally Crawford, the second major transcriptionist on this project for the hard work and enthusiasm with which she processed my seemingly never ending supply of microcassette tapes. Special thanks are due to my researcher supervisor and committee chairperson, Dr. Marion Porath. Before I commenced this research project, it was Dr. Porath who introduced me to the neo- Piagetian ways of being and stimulated my interest in early adolescent cognitive developmental theory. Dr. Porath served this project extremely well, in countless ways and for many years. Together we shared deep insight into the intricacies of the grounded theory method, signalled by "100 watt flashes" and instances of crystal clarity (aka "Waterford moments"). Additionally, I appreciate with sincere thanks the contributions of my other committee members, Dr. Kim Schonert-Reichl (ECPS) and Dr. Bob Sparks (Human Kinetics). This committee's skilful guidance, passion for excellence, wonderful humour, and sheer tenacity made this research endeavour one of the greatest journeys of my life. As well, I would like to recognize Dr. Heather Maclean, Director for the Centre for Research in Women's Health, University of Toronto, who contributed both expertise and thoughtful comments as external examiner for this dissertation. I must also acknowledge the oral examination committee members for their thought- provoking questions - Dr. Jean Shoveller and Dr. Chris Lovato (HCEP) and Dr. Deb Butler (ECPS). I gratefully acknowledge the contributions from organizations that funded aspects of my doctoral studies, including this research endeavour: The University of British Columbia (UGF Award) and the Canadian Institutes of Health Research (Canadian Tobacco Control Research Initiatives Travel Grant). Finally, I would like to acknowledge the gifts of friendship from my colleagues, especially to Dr. Lynda Christie for inspiring me to undertake doctoral studies in the HLDI Graduate Program. I certainly appreciate the support, encouragement, and loyalty of my close friends, one of whom shared with me an insightful rhyme toward the end of the dissertation process: True friends are like diamonds precious and rare, False friends are like autumn leaves found everywhere. Authour Unknown. Roberta Swanson-Holm September 2, 2004. Dedication I devote this work to my late parents: To My father who always encouraged my educational pursuits and love of learning Robert (Bob) E. Swanson, P.Eng October 26, 1905 - September 4, 1994 To My mother who taught me to live my life without regrets Dorothy E. Swanson December 18, 1928 - April 26, 2000. 1 Chapter One Preface: Introduction to the Dissertation The questions that led me to conceptualize the present study stemmed from both intellectual curiosity and clinical nursing practice. On the topic of smoking, what peaked my interest related to equity and representation in a world that recognizes smoking as a significant social issue, specifically for those young people who have made smoke-free choices. General knowledge tells us that smoking cigarettes is the primary cause of cardiopulmonary disease and death in present day society. Accordingly, smoking has become one of the most widely researched social-psychological behaviours in the humanities, biological, and applied sciences fields. Another point clearly supported by epidemiological data links an equally significant risk amongst nonsmokers for developing cancer-related events due to exposure to second-hand smoke and environmental tobacco smoke (ETS). Upon a review of the empirical based tobacco control literature, my learning came down to two fundamental outcomes. First, the ratio of nonsmokers to smokers is approximately 4:1. As well, statistics reflect a commonly held opinion by experts in health promotion - prevention initiatives do result in a greater proportion of youth who maintain their smoke-free decisions. However, the current state of affairs for tobacco control and prevention fields alike remains that education researchers craft effective counterattack strategies for all youth as too many adolescents start smoking during the critical phase of adolescent development. As I continued my investigation for answers, I thought of the deductive reasoning behind the statement that is credited to Dr. Sherlock Holmes, "What is significant, is that the dog did not bark." To fully embrace a preventive vantage perspective, it would appear counterintuitive to focus exclusively on young smokers as a credible and reliable approach to forestall smoking during adolescence. This line of inquiry led me to further reason that perhaps we need to embark on a dialogue with those early adolescents who do not smoke as another approach to achieve a deeper understanding aimed at guiding our development of effective preventative initiatives. I contend that a stronger prevention perspective is warranted, one that includes a different set of questions and with those adolescents who do not smoke. I submit the nonsmoker's perspective is seriously lacking and has been an uncharted line of inquiry in a dialogue about smoking as a social 2 phenomenon. Moreover, based on my cursory review of the literature, the eariy adolescent nonsmoker viewpoint has been systematically excluded from the majority of studies in tobacco control. Hence, my question became one of how to restore a balance for equity in a dialogue about smoking as a social phenomenon. What is significant, I believe, rests with the early adolescent nonsmoker perspective and experience as clearly, these young people would appear to be accomplished "experts" in maintaining a sm oke-f ree com m itm ent. Background to the Phenomenon of Interest Smoking is a widespread social phenomenon. Even though the prevalence of smoking has declined impressively over the past 20 years, the latest results from the Canadian Tobacco Use Monitoring Survey (CTUMS) for data collected in 2003 indicate over five million people (representing almost 21% of the population) age 15 years and older were current smokers. The percentage of smokers in the population can be further divided into five age categories as follows: 15 to 19 years (18.3%); 20 to 24 years (30.5%); 25 to 34 years (27.1%); 35 to 44 years (24.0%); and, 65 years and over (15.8%). This decline in rate is the likely result of two factors - lower rates for smoking are reported among older individuals as these are people who are more likely successful quitters, and a wide range of systematic, effectively implemented tobacco control measures (Health Canada, 1999). Geographically, prevalence rate differences over each of the provinces have remained fairly wide, from the lowest rate of current smokers (16%) in British Columbia to the highest (25%) in Quebec (CTUMS, 2004). Smoking prevalence rates are on a continual downward trend and rates continue to slump for both men and women (Burns, 1991). According to results from the CTUMS for data in 2003, approximately 23% of men were current smokers, higher than the proportion of women (18%). Most distressing though is the smoking prevalence rates for adolescents, one that has not declined vis-a-vis general adult population trends (Statistics Canada, 1999). Regrettably, smoking continues as an increasingly popular habit amongst young people. The decline in smoking among youth 15 to 19 years continued in 2003 to 18%, with 12% reporting daily smoking and 7% occasional smoking (CTUMS, 2004). This is a decrease from 22% in 2002, a 10 percentage point improvement from 28% in 1999 when CTUMS was first conducted. Slightly more teen girls reported smoking than boys (20% versus 17%). However, among daily smokers, boys smoke slightly more cigarettes per day (13.0) than girls (11.7). 3 Scope of the Phenomenon During this past century, cigarette smoking has accounted for an epidemic of remarkable proportions concerning death and disease. In 1964, The Report of the Surgeon General's Advisory Committee on Smoking and Health provided one of the first and most comprehensive summaries of health consequences due to smoking (United States Public Health Service, 1964). As additional evidence accumulated from subsequent epidemiologic and toxicologic investigations relative to health consequences due to smoking, the conclusions from the original Surgeon General's Report were strengthened and extended in additional studies (e.g., United States Department of Health and Human Services, 1989). Further, a causal link was established between smoking and many diseases, those of which include respiratory and coronary heart disease, and other cancers (Beck, Doyle, & Schachter, 1981; Dawber, 1980; Doll & Hill, 1964; Kannell & Thomas, 1982; United States Public Health Service, 1984). Moreover, involuntary exposure and inhalation of ETS is linked to morbidity rates for nonsmokers. Specifically, involuntary smoking is associated with an increased incidence of adult cases for lung cancer, as well connected to more frequent lower respiratory illnesses and impaired lung growth rates among children (Sherman, 1991). As a social phenomenon, one aspect of smoking includes those young people who are exposed to ETS and its serious consequences, in multiple settings, on a daily basis (e.g., automobiles, day care, work), including a school context. In 2000, an estimated 900,000 children under age 12 were exposed to ETS on a regular basis, and in their own homes, due to smoke from cigarettes, cigars or pipes. This estimate represents a staggering 25% of the 2.4 million homes in Canada where children under age 12 currently live. If that is not enough, an additional 736,000 children between 12 and 17 years have also been regularly exposed to tobacco smoke and in their own homes (Health Canada, 2000). In fact non- smokers (i.e., living with a smoker) exposed to tobacco smoke are at an estimated 30 to 50% increasing risk of developing lung cancer (Health Canada, 1996). As now there exists much greater knowledge concerning the process of smoking itself, subsequently we have gained extensive experience with current intervention methods for individual smokers, larger groups, and communities. Even though smokers, in the past, were unaware of the negative health consequences of smoking, published findings such as The Surgeon General's Report (1964) and statistics by Health and Welfare Canada have established an unequivocal causal relationship 4 between smoking and lung cancer (Boyle, 1997; Wynder & Hoffman, 1994). Cigarette smoking remains the leading cause of preventable illness and premature death (Canadian Cancer Society, 2000; Doll & Peto, 1978; Health Canada, 1998; Hirsch et al., 1997; Makomaski-llling & Kaiserman, 1995,1999). Lung cancer remains the leading cause of cancer death among Canadians - an estimated 7,000 female deaths, and 10,700 males (Carbone, 1992; Greenwald, 1995; Health Canada, 1998; National Cancer Institute of Canada, 2000). As most cases of lung cancer are directly attributed to smoking, this fact provides a compelling and obvious reason to counterattack smoking relative to implementing efforts aimed at prevention and encourage a health promotion focus. Unfortunately, the number of smokers is not limited to the obvious individuals who smoke cigarettes. Even so, 80 to 90% of lung cancers occur in active smokers, and approximately three to five percent of these cancers are reported in passive smokers (Hirsch et al., 1997). In a discussion about smoking and not smoking, an important aspect concerns the environment of both the nonsmoker and the person who smokes. As a cigarette burns, the smoke produced, yet not inhaled, is referred to as side stream smoke, representing 85% of smoke released into the smoker's environment (Canadian Cancer Society, 1995,1996). Cigarette smoke inhaled by the smoker is referred to as mainstream smoke. The National Cancer Institute of Canada (2000) estimates that approximately 330 nonsmokers die annually from inhaling second-hand smoke. Most troubling is that children are exposed to ETS - those exposed were reported to experience more frequent episodes of coughing, wheezing, ear infections, bronchitis and/or pneumonia, as well impacted by a potential for reduced lung function (Lesmes & Donofrio, 1992). ETS, as second-hand smoke, is the primary risk factor among nonsmokers and reason for contracting lung cancer (Health Canada, 1998). In Canada, among current smokers between the ages 15 to 17 years, 35% smoked their first cigarette by age 12; almost 80% tried smoking by age 14 (Health Canada, 2001). Adolescent patterns of smoking often continue into adulthood (Chassin, Presson, Sherman, & Edwards, 1990). Elsewhere, it is reported that more than 90% of smokers start smoking before age 19 (e.g., Battey et al., 1995; British Columbia Ministry of Health, 1998a; Canadian Cancer Society, 1995). Moreover, it is estimated that cigarette smoking will account for more than 50% of deaths before age 70 for those currently aged 15 years, if they continue to smoke (Villeneuve & Morrison, 1994). The developmental period of adolescence is a critical time where young people face choices concerning their future. However, efforts 5 to prevent young adults from becoming smokers are often met by the opposing force of the tobacco industry. This industry vigorously markets and targets their products at Canadian youth to perpetuate their market share and influence young people's choices about smoking, to replace those smokers who quit or die (British Columbia Ministry of Health, 1998b). The Youth Smoking Survey (Health Canada, 1996) was the first of its kind conducted and examined the smoking behaviour of Canadians ages 10 to 19. This survey, carried out between September and December 1994, with a sample divided into two age categories and methods, was implemented according to age classification. One early adolescent group (n = 14,200; ages 10-14) completed questionnaires (80% response rate) in the presence of a trained invigilator, while attending school. The other group of adolescents (n = 9,500; ages 15-19) responded to telephone surveys (81% response rate), again conducted by trained interviewers. These findings established a substantial, significant national data baseline concerning smokers and nonsmokers. Overall, seven percent of youth ages 10 to 14 were reported as current smokers, representing both males and females. Further, self- reported data indicated that in addition to current smokers, 15% of females and nine percent of males ages 13 to 14 considered themselves as 'beginning smokers'. Accordingly, a beginning smoker was defined as "someone who has not smoked 100 cigarettes in his/her lifetime but has smoked in the last 30 days" (Health Canada, 1996, p. 1). Given these reported age ranges, 100 cigarettes would appear to be a large number, especially when it is not known how many cigarettes it takes to establish nicotine dependence in adolescents (Winkelstein, 1992). It is widely accepted that adolescence is that critical time in life when young people begin experimentation, regular use, and dependence on cigarettes (United States Department of Health and Human Service, 1989). Smoking during adolescence places individuals at risk, both for immediate and long-term health consequences. At this age, smoking can potentially retard the rate of lung growth and level of maximal lung function. Consequently, smoking places adolescents at risk for respiratory symptoms (e.g., coughing, wheezing), and in turn places them at increased risk for chronic health conditions during their adult years (United States Public Health Service, 1984). Preventing young people from starting to smoke and supporting their smoke-free choices is a key strategy, and one with the greatest potential for promoting the best possible health of adolescents and future adults. Preventing youth initiation of smoking requires consideration of the risk factors characteristic of 6 young people in this age bracket. Young individuals are at higher risk for initiating smoking for a variety of reasons, the most common factors include developmental challenges and transitional events associated with adolescence, low socioeconomic status and income, increased stress, parental and sibling influences, and peer pressure (Canadian Cancer Society, 1995). As well, adolescence is a time where young people experience role confusion and uncertain identities - a transitional instance such as this may present smoking as an opportunity for an image or role as a smoker (Myers, 1998). A person's smoking-related decisions stem not so much from a single aspect of an individual's life. Rather, it is more plausible to expect such a decision is based on an array of social, psychological, emotional, and physical factors (Cinciripini, Hecht, Henningfield, & Kramer, 1997). Statement of the Research Problem In British Columbia, The Adolescent Health Survey (1993), first implemented in 1992, provided quantitative and qualitative data (n = 15,549) that focussed on smoking trends in teens ages 12 to 18 (grades 7-12). This was followed up in 1998 with The Adolescent Health Survey II which represents the largest youth survey ever conducted in BC (n = 25,838) and provides a comprehensive regional data base including high-risk behaviour patterns and trends associated with smoking, based on a 127-item questionnaire with a qualitative component. While such surveys can provide valuable information on issues such as smoking, data gaps remain today. More specifically, there exists a significant lack of information that is based on the nonsmoker's perspective. Information gained from the latter survey methods and others has guided professional health care and health education in a number of important ways. Previous studies have enlightened our perspective concerning the complex nature of smoking-related decisions, identified groups at potential risk, and provided a mandate for those of us who develop and implement prevention programs. However, the precise way that cognitive and social factors may or may not help adolescents nonsmokers to resist pressures to smoke, remains a problem of interest. Likewise, individual and group characteristics studied to date have been determined in advance by researchers, as well grounded in a less then complete understanding of nonsmoking behaviours. Put another way, it is entirely possible that other critical characteristics exist that are linked with being an early adolescent nonsmoker. Hence, by understanding how some eariy adolescents succeed in maintaining a smoke-free choice, we may then be in a better, more informed perspective, one that lends 7 a considerable advantage when it comes time to create necessary environmental supports to encourage their choices, and empower a commitment to a smoke-free decision. Hence our educational efforts aimed at health promotion become more appropriate and trustworthy. Until recently, research samples comprised of children and early adolescents have been systematically excluded from studies. Moreover, there is a paucity of research which examines smoking from the nonsmoker's perspective. A shift to include the perspective of nonsmokers can afford new and valuable insight from their experiences, along with an understanding of how nonsmokers manage to reject and abstain from smoking. I advance a research approach that is aimed at conducting a detailed examination of the lived experiences of early adolescent (ages 10 to 14) "nonsmokers" to explore cognitive and social-psychological factors relative to their smoking-related decisions and nonsmoker identities. A research directive that explores smoking from the perspective of nonsmokers has potential to inform the tobacco control research domain. As well, studies designed according to the naturalistic paradigm often permit researchers to investigate those aspects of daily lived experience that for the most part are usually taken for granted. Young people who successfully lead smoke-free lifestyles with nonsmoker identities could then be included to share their perspectives. Until recently, the collective viewpoint of early adolescent nonsmokers is one that has been under represented in a discussion about smoking as a social phenomenon. Only one study was found that used participant observation to explore specific aspects of social identities found to be associated with smoking among adolescents (Eckert, 1983), and one other was found that considered adolescents from a Canadian perspective (Johnson et al., 2003). Another qualitative study addressed nonsmoking during early-to mid adolescence, and even though this study was limited to girls, the study is unique as the findings represent a Canadian context (Dunn, 1998). In the United Kingdom, numerous researchers continue to employ qualitative approaches that yield study findings inclusive of the adolescent nonsmoker perspective (e.g., Amos, Gray, Currie, Elton, 1997; Lloyd & Lucas, 1998; Lloyd, Lucas, & Fernbach, 1997; Rugkasa, Kennedy, Barton, Abaunza, Treacy, & Knox, 2001; Rugkasa, Knox, Sittlington, Kennedy, Treacy, & Abaunza, 2001; Thrush, Fife- Schaw, & Breakwell, 1997). Although few researchers take on research efforts that focus exclusively on a cognitive-developmental perspective and include qualitative interview methods within an early 8 adolescent paradigm, one American-based study was found that disclosed children's notions about smoking (Meltzer, Bibace, & Walsh, 1984), yet subsequent studies have not followed to include an early adolescent developmental context relative to smoking-related decisions and social identity. Currently in British Columbia, nonsmokers at age 13 represent 89% of the school-based population. As well, 74% of 15-year olds were reported as nonsmokers (McCreary Centre Society, 2004). Until now, the perspectives of early adolescents have not received ongoing attention. I advance that continued work with this population could enlighten our understandings of smoking as a social phenomenon. The approach suggested for this research could provide new and valuable insight into the experiences of nonsmokers, one that is certainly long overdue, and could inform our understandings of how and why nonsmokers manage to avoid incorporating an activity such as smoking into their adolescent social identities. Significance of this Study Smoking is a choice that lies entirely within the individual. At first, individuals have no knowledge of smoking. Support of efforts to prevent smoking by children and early adolescents, and programs aimed to change societal norms regarding cigarette smoking, can limit the future adverse health consequences of smoking. Despite an increase in medical knowledge and an impressive reduction in the number of current smokers, cigarette smoking remains the single most important preventable cause of lung cancer and premature death. Studies designed to explore smoking prevention are most certainly welcomed by the scientific community and school-based health educators. It is imperative that school health educators and teachers work collaboratively to ensure that young people receive appropriate knowledge, based on a social-cultural cognitive developmental paradigm to ensure our educational efforts are salient for young audiences so that information can effectively shape their lifestyle choices. The elementary school system can support personal and social development by providing information on smoking. Empowering children allows them to exercise more control over their health and environment, and to make healthy choices. Such an approach is crucial when we endeavour to prevent young people from lighting up cigarettes for the first time. An investigation addressing the cognitive and social factors relative to early adolescents' decisions aimed at avoiding smoking is an important educational psychology research initiative. 9 Currently, a distinct gap exists in our understanding relative to the views and lived experiences of nonsmokers, one that is a considered a limitation. There is a clear need to describe those experiences and factors that contribute to and support the efforts and identities of adolescent nonsmokers. A detailed investigation into the experience of nonsmoking early adolescents would serve to extend our current understandings of cognitive and social factors that relate to the purposive avoidance of smoking behaviours. As such, the direction of this research has potential to assist educational initiatives in the health psychology and health promotion domains, and for subsequent studies. Summary of Background and Investigative Perspective Those people who smoke the largest numbers of cigarettes are at greatest risk, as are those who start smoking at younger ages. The burden of smoking-related illnesses can be significantly reduced and potentially eliminated through smoking cessation and prevention. After all, in an ideal smoke-free paradigm, mortality and illness due to smoking would not exist. Initially, a person has no knowledge about smoking. Support aimed at societal efforts to prevent smoking and social programs designed for changing young people's norms regarding cigarette smoking can certainly limit the future adverse health consequences of smoking. At the same time, smoking is a social behaviour - one that must be learned and arguably has potential to be extinguished permanently. Unfortunately, the rate at which early adolescents opt for smoking remains on a slow estimated rate of decline, with little in the way of dramatic change for the future. The flip side of the situation on smoking, however, is that we can only appreciate part of this social phenomenon when the perspective of nonsmokers is either not sought, or excluded altogether. Consequently, I contend that is would be reasonable to shift our focus toward an investigation with young people who make deliberate, conscious decisions to escape cigarette smoking, its associated behaviours, and social identity to better position ourselves vis-a-vis a shared understanding approaching how they manage to avoid integrating smoking behaviours into their lives, and the reasons why. Clearly, we need a deeper understanding of the patterns of association among factors such as cognitive or appraisal processes of making meaning out of smoking, social comparative judgements and processes, and individual differences, before we can make attempts at designing theoretically sound, developmentally appropriate, empirically based educative programs aimed to target smoking prevention 10 for young people within the context of their social-cultural world. This dissertation is presented over seven chapters. In Chapter One, an introduction of the study was established to situate the background to the present study. Chapter Two provides an overview of the empirical literature concerning social and cognitive influences oh smoking during the developmental period of adolescence. As well, the methodological stance is explicated by way of a synopsis of another literature review conducted to form a theoretical foundation for the current study. Next, Chapter Three lays out the methods as used to conduct the study, and addresses ethical considerations with attention devoted to children as research participants. Given the personal and theoretical stance of this investigation, the personal and theoretical juxtaposition of the researcher within this study is presented, whereby the chapter concludes by addressing the adequacy of the inquiry: The findings of the study are presented over two chapters. Chapter Four corresponds to a thematic analysis of informants' narratives and provides the background to situate their social-cultural context and shared lived experiences. As well, definitions of smoking, smoker and nonsmoker images, and reasons for smoking and not smoking are presented vis-a-vis participants' actions and intentions for consolidating a social identity. Chapter Five presents findings specific to early adolescent influence on personal smoking-related decisions, that is, how an early adolescent shapes agency, therein influencing the person's smoke-free goals and nonsmoker identity. Chapter Six presents a discussion of the major study findings and theoeretical perspectives, as well limitations of the study are addressed. The dissertation concludes in Chapter Seven with an exploration of study conclusions and recommendations for further refinement of study outcomes. 11 Chapter Two Literature Review The literature presented in this chapter provided the initial background and launching point to prepare a theoretical foundation for the present study. The literature was examined to locate scholarly papers concerning the area of interest for this study, gain familiarity with the substantive area, and ensure that I was knowledgeable and sensitized to data-based and theoretical literature in the field of tobacco control research. This chapter includes pertinent literature that was reviewed prior to commencement of this study and represents two overall aims: (1) to develop a theoretical foundation for a research proposal; and, (2) to provide background knowledge in the early phases of data collection and analysis. Before making any firm methodological decisions, I also undertook an extensive review of both the theoretical and data- based literature concerning adolescent smoking and not smoking at the time of crafting the research proposal. Subsequently, a synopsis of this additional literature as it pertains to methodology is presented in the second half of this chapter. Specifically, this review represents literature to frame the methodological and philosophical underpinnings of the study, as well as build a case to support my decision for grounded theory as the appropriate methodology to conduct this investigation. Finally, the literature was reviewed a third time during the process of data collection and analysis; however, this review was selective and theoretically directed to verify categories and understand conditions. At the end of the study, an extensive review of the literature was conducted one last time to connect and situate the theory within the context of other scholarly work, and to follow up literature since the preliminary literature review, one that was limited to theory or research and related to early adolescent smoking, not smoking, and specific constructs related to development and refinement of conceptual categories. A standard convention for initiating grounded theory research directs the researcher away from an excessive reliance on existing literature in order to remain open to the process of discovery required for the study (e.g., Glaser & Strauss, 1967; Glaser, 1978; Strauss & Corbin 1998). When the scholarly literature is critically evaluated, the researcher can also determine discrepancies and gaps in the extant literature (Charmaz, 1983, 2000). Hence, identification of such gaps and differences in knowledge provides an opportunity for further study. Another accepted paradigm standard regarding a literature review is to establish the 12 investigative context or background, social significance of the phenomenon, study aims and its significance. Specifically, the literature is not used to predetermine concepts, categories or hypotheses prior to the study (Glaser, 1992). Instead, the grounded theorist resists an extensive review of the literature until data collection and analysis have uncovered the core process that explains how the participants process the phenomenon or problem. By upholding methodological standards, the grounded theorist ensures that the emerging theory is truly grounded in the empirical data. Overview to the Preliminary Review of Literature The general perspective represented in this review relates to those factors which were found to predict the onset of cigarette smoking in children and adolescents. As well, a number of interpersonal behaviours and social-psychological environmental factors that increase an adolescent's chances of initiating cigarette smoking and experiencing the adverse effects of continued cigarette use is outlined. Accordingly, specific theoretical perspectives rendered in this review stem from factors related to social interaction and cognitive development. Specifically, as smoking is viewed as a social phenomenon data-based and theoretical studies included for review included concepts such as social identities, social learning, smoking intentions, social role modelling, as well as peers, friends, family and other social- cultural systems. As the population of interest concerns eady adolescents, data-based and theoretical literature relative to cognitive development and processes such as reasoning, attitudes, intentions, beliefs, knowledge, and school-based prevention-based smoking programs and initiatives was reviewed. As well, given that children and early adolescents are exposed to a variety of different messages originating in print media, television, and the entertainment (movie) industry, the literature was searched relative to general advertising and promotional strategies as these apply to tobacco control. There does not exist an accepted measure designed to specifically identify which study participants will proceed to becoming established smokers; hence studies which highlighted and presented findings consistently related to and predictive of child and adolescent smoking and nonsmoking were reviewed and are reported in this literature review. Smoking as a social-psychological phenomenon. The literature reviewed represents the perspective that conceptualizes smoking uptake behaviour in adolescence as one that progresses through a sequence of developmental stages, as part of a sequentially ordered process. Accordingly, 13 multiple social-cultural, psychological, and environmental factors influence this process, and entail many different functions at different points in the progression, different roles for different people, whereby some influences moderate the effects of others. Theoretical and empirical findings demonstrate that a multiplicity of complex etiological factors are associated with adolescent cigarette use. Inherent with most theories and cross-sectional, prospective, and causal processes studies are major limitations. Examples include but are not limited to, research that addresses only small portions of the total picture for adolescent cigarette use, and most theories do not impart specific knowledge concerning exactly what processes are used, how causal processes might be different for adolescents, and why. Findings from theoretical and empirical studies were reviewed; as well, Canadian-based epidemiological studies were located to situate a context for this study. Examples of surveys include The Adolescent Health Survey (McCreary Centre Society, 1993,1999, 2004), The CTUMS (Health Canada, 2004), and The Teen Smoking in British Columbia Survey (Angus Reid Group, 1997), all of which represent major sources of nation-wide adolescent data. Knowledge gained from these surveys is synthesized throughout this literature review to illustrate background and scope of the problem, representing the perspective that smoking is a social phenomenon. As well, selected literature was reviewed that delineated characteristics of child and adolescent smoking and nonsmoking behaviours, images, and social identities, a synopsis of which is included in this review. An analysis of the strengths and limitations of the commonly used study designs as reported in the literature is also presented. The next section address the theoretical foundation for a grounded theory study, and this method is discussed along with an exploration into the philosophical underpinnings that were used to design and conduct this study. A summary of the literature is provided to situate the context for the present study and concludes Chapter Two. Introduction to Selected Review of Literature and Context Due to the specific population and focus of this literature review, several important points need to be made explicit. First, recent research concerning the social-psychological factors related to smoking behaviour are grounded in theories that guided the work of Leventhal (1968), Bandura (1977,1999), Evans (1976), Evans et al., (1978), McAlister, Perry, and Maccoby (1979), and McGuire (1984). These authors view smoking as a social behaviour with social causes, functions, and reinforcements whereas previous theoretical research efforts primarily examined cigarette smoking from the standpoint of a 14 health behaviour. Accordingly, this review represents a wide and specific social perspective at both the level of the individual and for groups. Stages of smoking. The next point concerns a research focus on the different stages of smoking in adolescents. Numerous researchers demonstrated that young people progress through a series of stages of smoking onset (e.g., Elder & Stern, 1986; Flay, 1993; Flay, d'Avernas, Best, Kersell, & Ryan, 1983; Leventhal & Cleary, 1980). Becoming a smoker has been identified as a process, the stages of which are generally broken down into the corresponding stages: pre-contemplation (not even considering smoking), preparation and anticipation (contemplation to smoke), experimentation or initiation (with smoking), action or transition (becoming a smoker), and regular smoking or maintenance. During the pre-contemplation and preparation stages, attitudes and beliefs about smoking are formed. The young person may begin to view smoking as serving some purpose or function, such as a means to appear mature, bond with a peer group, cope with stress, or demonstrate independence (Perry, Murray, & Klepp, 1987). The experimentation stage includes the first few times a young person smokes; encouragement of peers is usually involved at this stage (Conrad, Flay, & Hill, 1992). Action or transition includes repeated yet irregular smoking and is generally in response to a particular situation (e.g., a social event) or to a particular individual (e.g., a date). Regular use occurs when a young person smokes regularly (usually weekly) and smokes in a variety of settings with a variety of people (Flay, 1993). Categorization of smokers. Most of the research concerning smoking initiation has consolidated all smokers together as one group, regardless of the degree of cigarette use, for comparison with nonsmokers. As such, only a small number of investigators even addressed the possibility that those factors which contribute to the first use of cigarettes may in fact differ from other factors that promote the maintenance of smoking. Among these studies, the results were inconsistent. For instance, the effects of parental smoking may be particularly clear in the preparatory stage, by moulding children's attitudes toward cigarette use (e.g., Flay, 1993; Leventhal & Cleary, 1980). In addition, the role of social models, such as family members and peers who smoke, has been found as a particularly influential source in prompting the onset of cigarette use (Chassin, Presson, Sherman, Corty, & Olshavsky, 1984). Yet other researchers (e.g., Ary & Biglan, 1988) found parental smoking unrelated to both the onset and maintenance of adolescent smoking. In fact, work by Ary and Biglan (1988) demonstrated that peer 15 modelling was a better predictor of continued smoking than of the onset of smoking behaviour. Although some researchers focussed on the onset of smoking and explored the passage from preparation to experimentation (initiation) of smoking, others investigated the shift from the experimentation stage to action (transition). In some cases, it was not entirely clear which stage or step was the focus of investigation. In other cases, the stages of smoking were redefined specifically for a particular study. A lack of specificity and differing definitions makes comparison of findings an extremely difficult, if not an impossible task. Regardless of the focus on stage of smoking, any study exploring the onset and uptake processes of smoking and any. research concerning the social influences on adolescent smoking progress was included as salient for this literature review to uncover as many factors associated with smoking as possible. Smoking and gender-related differences. The third point concerns gender in relation to smoking and gender differences. Some researchers reported differences in nonsmokers and smokers by studying gender-mixed groups of adolescents (e.g., Blackford, Bailey, & Coutu-Wakulczyk, 1994; Newman & Ward, 1989; Nolte, Smith, & O'Rourke, 1983a; West, Carlin, Subak, & Greenstone, 1983), yet these studies do not yield separate nor specific insights into the experiences of nonsmoking girls and boys. In truth, results of these studies were primarily discussed in relation to smokers; connections to specific factors or variables with nonsmokers were frequently reported indirectly. Even though a gender difference is seen with respect to smoking prevalence rates, the functional meanings of cigarette use and the progress to regular use may in fact indicate a difference other than gender. One study was found that specifically investigated smoking and nonsmoking female adolescents (Yankelovich, Skelly, & White, 1976); another was found that explored girts' constructions of smoking identities (Lloyd, Lucas, & Fernbach, 1997). Only one study was found that specifically explored nonsmoking female adolescents and used a qualitative method (Dunn, 1998). As a final note, in the literature there exist several studies examining gender difference designed to compare adolescent female smokers with their male counterparts (e.g., Chassin et al., 1981; Malkin & Allen, 1980; Pederson, 1986; Sarason, Mankowski, Peterson, & Dinh, 1992; Urberg & Robbins, 1981; Waldron, Lye, & Brandon, 1991); again, most were not reported explicitly about nonsmokers. Although these studies enlighten us about factors associated with adolescent female smokers, they do not, however, easily permit conclusions to be drawn about adolescent female nonsmokers. Few studies 16 systematically examined within-group differences with respect to gender. Moreover, smoker between- group differences were not necessarily compared or contrasted with nonsmokers directly within a particular research study. For the purpose of this literature review, factors significantly and consistently associated with adolescent smokers were interpreted here to mean that the same factors can be associated with nonsmokers. Using this premise, it is reasonable to assume that if a variable is predictive of smoking, then it could be said to be a valid predictor of nonsmoking. For instance, as will be described, adolescent smokers remain friends with more people who smoke, ergo one can reasonably assume that nonsmokers remain friends with fewer people who smoke. Accordingly, deductive logic would predict that nonsmokers remain friends with more people who do not smoke presumably on the basis of common association and shared or similar reasons for not smoking. There may, however, be dissimilar or more accurate predictors of nonsmoking that could likely be more aptly determined according to an exclusive exploration into the experiences of nonsmokers and by inclusion of social-cultural context as a potential influence. A Social Developmental Perspective on Early Adolescence. As explored in this literature review, the term "adolescence" is defined as the developmental period of transition between childhood and adulthood during which time a shift in growth and learning occurs involving pronounced cognitive, physiological, psychological, and social change (DiClemente, Hansen, & Ponton, 1996). Adolescence is a unique developmental period of accelerated development that begins at about 10 to 13 years of age and concludes between the ages of 18 and 20. Adolescents bring with them to this new period of development much of their childlike selves, gradually developing social and emotional maturity (Crockett & Petersen, 1993). Scholars (e.g., Kagan, 1971; Petersen & Leffert, 1995; Thornburg, 1983) have distinguished three distinct sub-phases within adolescent ages from 10 to 20: early adolescence (10-14 years), middle adolescence (15-17 years), and late adolescence (18-20). While these age distinctions are valuable as general guidelines, they may not, however, characterize the phases for a particular adolescent. Eady adolescence as a stage of development. Generally speaking, early adolescence is considered the time of transition from childhood into adolescence proper; the hallmark of this period is pubertal development. Thornburg (1983) argued for a definition of early adolescence as a separate 17 stage of development. The notion of transition is captured within a perspective that signifies a change in childhood. Specifically, the child ceases to be dependent, biologically immature, socially fettered, and psychologically insubstantial; yet, as young adolescents these people are still learning to become independent, mature, and resolute, even though they have not achieved young adulthood (Offer, Schonert-Reichl, & Boxer, 1996). Hence researchers do study adolescent development and most often differentiate this period into early, middle, and late adolescence due to age-associated differences in the social, cognitive, biologic, and emotional behaviours of adolescents. Further differentiation during adolescence is also shaped by superimposing chronological age as a quantitative measure of human maturity. Hence, it is possible for a young person of 10 years to be "categorized'' or "labelled" as an adolescent due to timing of biological events such as puberty. Conversely, another young person may not achieve early adolescence until age 14. Adolescence has long been viewed as an important period for the development of the self. Erickson (1950) considered issues of identity as particularly salient during adolescence. During this stage of development the adolescent attempts to establish a sense of self-identify and autonomy (independence). Adolescence is also a time of advanced cognitive functioning in which the ability to reason develops beyond concrete objects or symbols to abstractions, described as formal thought (Flavell, Miller, & Miller, 1993). In a move away from an individual perspective, one that makes the child the basic unit of study, many of today's theorists in the developmental psychology field observe that development during the school-age years is inextricably linked to the social-cultural learning environment. A typical proponent representing this perspective was Vygotsky (1978) who in his book Mind in Society, advocated an active account of interpersonal interaction; school and social experience as a system of developing a view for self and others, mastery and morality; and, social-cultural factors such as ethnicity, and social, economic, and occupational status as key elements of development. Cognitive development. During this time of development, the early adolescent begins to perform cognitive operations in one's head, thus permitting planning and predicting outcomes for a series of encounters or situations without actually having carried them out (Case, 1991). Moreover, this beginning ability to think abstractly permits the early adolescent to imagine activity or behaviour and simultaneously construct a prejudgement as to whether a particular course of action is advised or ill- 18 advised, leading to latent moral developments of the adolescent, which at once declare the person and one's acknowledgement of accountability to others. The capacity for abstract reasoning increases during adolescence (Keating & Clark, 1980). During early adolescence, the capacity to think hypothetically increases, as does the ability to use formal logic (Ihhelder & Piaget, 1958). This formal reasoning or formal logic allows the individual to go beyond the concrete to use verbal hypotheses and logical deductions (Petersen & Crockett, 1986). Most adolescents begin to imagine hypothetical situations and anticipate consequence. Accordingly, thoughts, actions, intentions, and knowledge concerning smoking are considered part of the social-emotional domain linked to the role of social and emotional thought development, a central conceptual structure associated with the neo-Piagetian paradigm (e.g., Case, 1991, 1996; Griffin, 1991; Porath, 2001, 2003). Transitions. Transition is implied during a developmental period marked by the termination of a stable life structure in order to manage or work toward a new phase (i.e., ultimately reaching adulthood). Throughout adolescence, young people experience changes and transition. One of the first transitional events is entry into the formal education system. Schooling, the ecological setting in which children learn, denotes the environment, size, philosophy, and characteristic transactions between students and teachers, and the culture of the school. The school-age period is the primary developmental epoch where all children spend most of their waking hours in the company of other children and adult teachers who are not members of their family of origin. During this period, children learn critical skills which involve self-and-other dynamics such as friendship formation, belonging to groups, becoming a friend, and making social comparative judgements. Self and self-identity. Overall, at this period the development of self and self-concept are contingent upon interpersonal interactions with people outside the student's family boundary, most especially among equals, denoted as peers (Combrinck-Graham, 1996). Self-esteem, or the global evaluative dimension of the self (e.g., self-worth or self-image) and self-concept or those domain- specific evaluations of self are essential characteristics of adolescents' self-understandings (Santrock, 1998). Social comparative judgements and self-evaluative processes, affiliation, and loyalty, and attribution of qualities evolve mainly in the context of peer cultures. Outcomes of successful peer relationships and results on successful peer connections echo cognitive development and academic accomplishments, as well as for interpersonal patterns established in the family. 19 Erickson (1968) developed a comprehensive and compelling theory on identity formation, which is considered as one of the most influential theories of adolescent development. Specifically, during the adolescent years, individuals experience identity versus identity confusion, the fifth developmental stage. At this time, adolescents look at who they are, what they are all about, and where they are heading in life. The transitional gap between childhood security and adult autonomy is what adolescents experience as part of their exploration into identity. As adolescents negotiate the numerous identity profiles within their social-cultural contexts, they often try on or test different roles. Those who successfully manage conflicting and differing identities emerge from adolescence with a new sense of self that is both satisfying and socially acceptable. However, when young people do not successfully resolve such a crisis in identity, they experience what is known in Erickson's model as identity confusion. Consequently, to manage this crisis, the adolescent either retreats into self isolation from family and peers or they become enmeshed in the peer culture and lose their identity to the group. A developmental perspective of self-identity. A more contemporary perspective is derived from an Ericksonian paradigm, one that considers Erickson's theory of identity development to match four ways to carry out an identity exploration or crisis: identity diffusion, identity foreclosure, identity moratorium, and identity achievement (Marcia, 1989). As part of an individual's identity development, commitment on part of the adolescent indicates a personal investment in what they are going to do. Diffusion states in adolescence describe an absence of crisis and meaningful alternative, although these have yet to be explored. Foreclosure is the term used to denote adolescents who have made a commitment, yet they have not experienced a crisis. Moratorium denotes the adolescent in the midst of a crisis but the individual has yet to define commitments or these are lacking. The outcome is identity achievement, the term coined by Marcia to denote the resolution of an adolescent's crisis cycle and secure a commitment. Marcia determined that three aspects of the young adolescent's development are key in identify formation - adolescents must be confident they are supported by their parents, and have established a sense of industry, and a self-reflective outlook for the future. Overview of Social and Cognitive Risk Factors Predictive of Smoking The effect of tobacco use on health and the health consequences of smoking are well known, yet experimentation with cigarettes is occurring at younger and younger ages, and initiation of smoking now occurs almost entirely during the adolescent years (Glynn, 1984). Adolescence represents the crucial 20 developmental phase for numerous and various interpersonal skills that play a vital role in the acquisition of social, cultural, and economic reinforcement (Elder & Stern, 1986). Acceptance by one's peers tends to be a major reinforcer driving much of adolescents' attitudes and behaviours. It is during this time that the interpersonal temptation to take up the cigarette habit becomes strongest, as same-age or older peers and siblings increase the pressure on nonsmoking youth. Adolescence is a time period when peer acceptance, compliance to group behaviour standards, and experimentation with substances, including tobacco, occurs (Bettes, Dusensbury, Kerner, James- Ortiz, & Botvin, 1990). In addition, the female adolescent is at greater risk for the development of health consequences due to smoking. For instance, girls who smoke are more likely to experience irregular menstrual periods and they are at an increased risk for developing cervical cancer (American Cancer Society, 1993). When using oral contraceptives, women who smoke increase their risk of experiencing a cardiac-related event (e.g., heart attack) and are at greater risk for strokes and blood clots in the lower extremities (Layde & Beral, 1981). The most common factor examined in the study of social-psychological risk factors predictive of smoking and the one that has accounted for the most heterogeneity (Flay et al., 1983), is the presence of family members and friends who smoke in the person's environment (Chassin, Presson, Sherman, Montello, & McGrew, 1986; Covington & Omelich, 1988; Croft, Hunter, Webber, Watson, & Bereenson, 1985; Friedman, Lichtenstein, & Biglan, 1985). Salient influences relative to social learning include measures of family (parents and siblings) modelling and parental attitudes toward tobacco use. Peer variables include measures of the number of peers and friends using tobacco (i.e., "peer modelling''), peer pressure or perceived "normative" pressure to engage in cigarette use, and the normative beliefs of the child/adolescent with respect to the number of peers who smoke (e.g., Friedman et al., 1985). Gender differences also exist in social influence models of smoking behaviour. Most investigators found that the smoking behaviour of parents, friends, and siblings (especially same-sex siblings) was highly associated with experimentation and initiation of smoking. It was suggested that early exposure to smoking role models affected the child's attitudes and beliefs toward smoking and could lead to imitative behaviour later on (Leventhal & Cleary, 1980). Smoking by parents and peers has been shown as the most consistent and strongest correlate with smoking and is often considered evidence that social bonding factors motivate people to become 21 cigarette smokers (e.g., Bell & Battjes, 1985; Best, Thomson, Santi, Smith, & Brown, 1988; Bonaguro & Bonaguro, 1989; Botvin & McAlister, 1982; Cleary, Hitchcock, Semmer, Flinchbaugh, & Pinney, 1988; Flay et al., 1983; Glynn, 1981,1984). The relationship to parents and peers has been often explained by reasoning that parents and friends who smoke personify norms and attitudes favourable to smoking, make cigarettes more readily available, or serve as role models for smoking. The association between friend and adolescent smoking reflects peer influence and it may also indicate that adolescents who smoke are more likely to choose friends who smoke (Fisher & Bauman, 1988). Chassin, Presson, Sherman, and Edwards (1991) speculated that parental smoking could create a risk for offspring smoking through genetic similarities in the reinforcement value of nicotine or due to a propensity to develop tolerance or withdrawal symptoms. However, the possible pathways between genes and behaviour are complex and require further study. Perceived school performance is an important factor because of its association with successful completion of a high school education, and conversely, the risk of dropping out of school. Referring to The Teen Smoking In British Columbia (1997) survey data, in the Vancouver region, 35% of students who assessed their performance in school as below average smoked cigarettes, compared with 16% of above average students. A similar pattern of relationship was found with students' expectations for completing their education. For example, of students who expected to achieve only a secondary or high school education, 30% indicated that they smoked cigarettes, compared with 18% of students who planned to pursue post secondary studies. Poor school performance is also associated with adolescent smoking. It has been established that adolescent smokers are generally low achievers in academics (Hover & Gaffney, 1988) and are nonparticipants in extracurricular activities such as sports (e.g., Bush & Lannotti, 1992; Eckert, 1983; McGee & Stanton, 1993). A strong association has also been reported between tobacco use and low school attendance (e.g., Meyers & Brown, 1994). Related to school performance, level of education and socioeconomic status (e.g., McAlister et al., 1979) were shown to be correlated with smoking behaviour. Other social demographic variables include family income and parents' occupations (e.g., Arkin, Roemhild, Johnson, Lueper, & Murray, 1981; Best et al., 1984; Flay, 1985). Adolescence is a time where individuals experiment with their own self-image, for instance trying on various roles, in an effort to establish a true sense of self. Adolescence is a time for many 22 experimental activities, and smoking may be one among many experimental or risk-taking actions (Leventhal & Cleary, 1980). Reported reasons by adolescents for experimenting with smoking include boredom, curiosity, anger, and relaxation (Sarason et al., 1992; Stanton, Mahalski, McGee, & Silva, 1993; Stone & Kristeller, 1992). Again, The Teen Smoking in British Columbia (1997) survey data point to a strong level of ambivalence about smoking. Although teens acknowledge the pleasures of smoking, they also recognize smoking as a self destructive behaviour. For some teens, this symbolizes one of its attractions - a way to tempt fate to engage in a behaviour that goes against age-expected norms (e.g., rebellion against authority, defiance of rules, those nominated as controversial), one that represents a break with childhood. The perceived instrumental value of smoking (Chassin, Presson, & Sherman, 1984; Covington & Omelich, 1988; Hunter et al., 1982) may also be predictive of smoking onset. Children ascribed different personality characteristics to smokers than to never smokers (Bland, Bewley, & Day, 1975; Bynner, 1970) and viewed smoking cigarettes as a way to project an image of maturity, independence, or toughness (Covington & Omelich, 1988; Leventhal & Cleary, 1980). The findings of one study suggested that adolescents perceived looking more mature as one of the major benefits of smoking (Evans, Henderson, & Raines, 1979). Important social environmental factors concerning opportunity and access to cigarettes include the media (e.g., billboards, newspaper and magazine advertisements) and the presentation and promotion of tobacco products in the community. Research suggests that the advertising and promotion of cigarettes strongly influence the initiation of smoking among young people during adolescence (Biener & Siegel, 2000; Sargent et al., 2000). Moreover, there was evidence to suggest that tobacco companies target adolescents in their magazine advertising (e.g., King III, Siegel, Celebuucki, & Connolly, 1998) and that cigarette advertising in magazines is likely to reach a substantive number of young people (King III & Siegel, 2001). An affirmative smoking influence also comes from parents or other adults who may not want their children to be smokers, a value which is misrepresented by their own behaviour. Theoretical and data-based studies which addressed cognitive factors include cognitive change measures such as beliefs and values (e.g., Ajzen & Fishbein, 1977; Perry & Jessor, 1985), emotions (Perry & Jessor, 1985), relevant attitudes (e.g., Ajzen & Fishbein, 1977; Botvin, Baker, Renick, Filazzola & Botvin, 1984), 23 knowledge of various factors related to tobacco use (e.g., Botvin, Eng, & Williams, 1980; Botvin et al., 1984; Flay et al., 1983; McCaul & Glasgow, 1985; Perry & Jessor, 1985; Perry, Killen, Slinkard, & McAlister, 1980; Schinke & Blythe, 1981), as well as intentions (e.g., Evans, 1976; Schinke & Gilchrist, 1983) related to tobacco use. Social Domain The utility of applying a social representations perspective in the area of smoking research acknowledges that beliefs are socially constructed and emphasizes the link of the role and relationship between self and others. Social representations include shared understandings of a social object and contain both explanatory and evaluative connotations. One paradigm frequently applied to smoking behaviour to account for reasons for smoking is the social learning model (Bandura, 1977; 1995). Using this theory, an emphasis is placed on the mutual and reciprocal interaction between an individual's behaviour and his or her social environment. Applying this theory to smoking, the smoking behaviours of adults (i.e., parents) and peers (i.e., friends) influence adolescent smoking behaviour by providing role models that establish the social outcomes and approval of cigarette smoking (e.g., Flay, 1993). Accordingly, the social influence model predicts that directly experiencing a behaviour and its associated rewards and punishments influences beliefs about the consequences of the behaviour and helps the person to formulate evaluative definitions of a behaviour. In other words, adults and peers may influence adolescents' smoking by providing evaluative definitions of smoking and by influencing the adolescents' expected consequences of smoking. As demonstrated in one longitudinal study, the only social factor that consistently predicted adolescent smoking progress seemed to be the smoking status of best friends (Wang, Fitzhugh, Eddy, Fu, & Turner, 1997). Participants in this sample (n = 7,960 representing an 87% response rate) ranged in age from 15 to 22 years. Although Wang and colleagues recognized the concept that adolescent behaviour is influenced by the behaviour of parents and peers, one that has been well documented, their longitudinal analysis, however, did not find support for social factors (as represented by parents and siblings) associated with adolescent smoking progress. Given the age and the developmental period of the participants in their study, it was suggested that such an influence may occur at an age prior to adolescence (Wang, Fitzhugh, Westerfield, & Eddy, 1995). 24 Parental Smoking and Nonsmoking Behaviour Children of smokers are reported almost twice as likely to smoke as children with parents who do not smoke (Bauman, Foshee, Linzer, & Koch, 1990). Parental smoking also appeared as the strongest influence for Caucasian and female adolescents, particularly in the early preparatory stages of smoking and during early adolescence (Bauman et al., 1990; Chassin, Presson, & Sherman, 1990; Dappen, Schwartz, & O'Donnell, 1996; Flay et al., 1983; Sussman, Dent, Flay, Hansen, & Johnson, 1987). Where parental smoking predicts smoking in only one gender, it is often in females (Chassin et al., 1986). Parental smoking is a key factor in children accepting smoking as normal (Lynch & Bonnie, 1994). Hansen and Graham (1991) demonstrated that children often imitated their parents' behaviour. Consequently, children who smoke imitate the smoking behaviour of their parents. In the area of adolescent cigarette smoking, parental smoking has been suggested as a strong influence in several studies (Charlton & Blair, 1989; Chassin et al., 1981; Males, 1995), although some researchers argue that parental smoking may predict smoking initiation less often than previously thought (Conrad, Flay, & Hill, 1992). Parental smoking may influence girls more heavily than boys (Charlton & Blair, 1989; Clayton, 1991), yet a clear pattern of relationship has not been confirmed. Specifically, there is evidence to suggest that giris are more heavily influenced by mothers' smoking than are boys (Chassin et al., 1986; Gritz, 1984), inasmuch as both giris and boys are influenced by parental smoking (Hover & Gaffney, 1988; Nolte et al., 1983a). Another study exploring the relationship between parental smoking and actual smoking transitions in children (Chassin et al., 1984) indicated for initial "never smokers," the association between parental smoking and transition to a higher level was significant for gids, yet for those who had initially tried cigarettes, the relationship was significant only for boys. Findings point to parental smoking as important in influencing both girls and boys to smoke, yet the influence may be different. Parental smoking appears to influence girls to smoke, whereas for boys, it is only among those who start to experiment that parental smoking is related to a faster adoption of higher levels of smoking. A review of the literature suggests that parents' smoking behaviour may also include other factors, such as parental influence and behavioural example (Farkas, Distefan, Choi, Gilpin, and Pierce, 1999) parental approval or disapproval of smoking (Nolte, Smith, & O' Rourke, 1983a; Newman & Ward, 1989); the style and extent of parental communication on health-related matters (Nolte, Smith, & 25 O' Rourke, 1983b); and the parent-child bond (Brook, Whiteman, Czeisler, Shapiro, & Cohen, 1997). Although some researchers report that parents' smoking is strongly associated with increased smoking risk to their children, this associated risk is not without controversy (e.g., Mittlemark et al., 1987). However, others found that the nature of parents' influence was associated with the parent-child bond (i.e., lower levels of attachment between child and parent) or when parents were less involved in the supervision of their adolescent children. There is some evidence to suggest the existence of a reciprocal relation between a child's behaviour and parenting behaviour. Work by some researchers (e.g., Brook, Whiteman, Gordon, & Brook, 1983; Rutter, 1979) has shown that childhood behaviour elicited parenting behaviour, and parenting behaviour affected the child's behaviour (Bell & Chapman, 1986; Lytton & Romney, 1991). As well, lack of perceived parental support predicted adolescent substance abuse, including smoking where adolescent substance abuse related to lower levels of parental support (Foxcroft & Lowe, 1995; Stice & Barrera, 1995). Adolescents who perceived lower levels of support from their friends, and those with lower expectations for academic and general success, were reported at an increased risk for smoking (D'Onofrio, Thier, Schnur, Buchanan, & Omelich, 1982; Jessor & Jessor, 1977). Some investigators contend that these "demoralized" adolescents were those with a greater need to define themselves as "tough" or "cool" (Leventhal & Cleary, 1980) or assert their independence from authority (Skinner et al., 1985). One process whereby the parent has an effect on the child is through the parent-child bond (e.g., Bowlby, 1988; Stice, Barrera, & Chassin, 1993). Some investigators (e.g., Brook, Whiteman, Balka, & Cohen, 1995; Foshee & Bauman, 1992) found that the greater the parent-child bond (i.e., attachment), the less likely the child was to engage in behaviour that contributed to cigarette use; conversely a weak parent-child bond predicts engaging in such behaviours. Children who believe their parents disapproved of their smoking were less likely to smoke than those who viewed their parents smoking (Health Canada, 1996). Additionally, lower levels of parental supervision and control, and inappropriate and harsh techniques of parental control were found to predict later smoking behaviour (Brook, Whiteman, Gordon, & Cohen, 1986). In 1983, Nolte and colleagues reported parental attitudes may exert a more powerful impact than parental behaviour as factors associated with youth smoking behaviour. Results indicated that a situation 26 where both parents smoked, yet were not upset if their adolescents smoked, 51.6% of adolescents reported smoking. Moreover, if parents were upset if their adolescents smoked, only 10.4% of their adolescents reported smoking. For nonsmoking parents, those upset at the notion of their children smoking, only 5.3% of their children reported smoking. If nonsmoking parents did not object to their children smoking, 23.3% reported smoking. Newman and Ward (1989) replicated the Nolte study with participants aged 13 to 14 (grades 7 and 8) from 12 schools (r? = 735) in and around one moderately sized mid-western city. Participants in this study were significantly younger than the original study (n = 5,409 central Illinois school age youth in grades 7-12). In addition definitions used by Newman and Ward varied slightly from those used by Nolte and colleagues. Newman and Ward classified participants as smokers if they smoked more than two cigarettes. Measures of parental attitude were derived from a question asking, "With regards to my smoking cigarettes, my parents/guardian: would threaten to punish me if I smoked told me never to smoke; told me how they feel if I smoke; told me they don't care if I smoke." Nolte et al. (1983) explored influences of individual parents. Due to the smaller replication sample size, Newman and Ward only explored the effect of "both" parents disapproving; one parent approving and one disapproving was classified as indifferent. From an educative perspective, the results of both studies suggested that when expressed, parental attitude appears to be important in moderating adolescent smoking behaviour. Moreover, parents' expressed opposition does affect smoking behaviour, regardless of actual parental behaviour. Another point concerned the apparent increase in permissiveness of parents toward their adolescents' smoking. Students in the Newman and Ward study were junior high school (rather than junior and senior high school students as in the original study) and it was anticipated that a greater degree of parental disapproval of cigarette smoking would have been expressed to younger adolescents. Rather these data indicated 34.2% of the sample reported parents as indifferent. It is possible that parental attitude may not be as salient to adolescents as it might have been at the time of the Nolte study in 1983. Peer and Friend Influences The nature of peer influences on adolescent smoking is complex (Stead, Hastings, & Tudor- Smith, 1996). To a large extent smoking behaviour among adolescents has been moulded by interpersonal influences (Aara, Hauknes, & Berglund, 1981). Specifically, peer group pressure has been widely accepted as a significant factor in the initiation of smoking, with many teenagers smoking because 27 it has been perceived as giving them status and acceptance by their peer group (e.g., Evans et al., 1978; Hover & Gaffney, 1988). Importantly, there appears further evidence that the influence of peers increases with age. In support of this pattern, Krosnick and Judd (1982) found that while parents and peers were equally important to smoking among 11-year olds, it was among 14-year olds that peers exerted a greater influence. The literature points to well documented evidence that friends play a highly significant role in the smoking habits of adolescents (Ary & Biglan, 1988; Chassin et al., 1986; Foshee & Bauman, 1992). For instance, Ary and Biglan (1988) found that smoking rates among teens are significantly related to the number of friends who are smokers and to the number of offers of cigarettes in the previous week. As with family influences, peer influences on smoking behaviour may be the result of peer pressure, role modelling, or simply the opportunity to experiment with cigarettes (Chassin, Presson, & Sherman, 1984; Morgan & Grube, 1989). Teens who do not start smoking, for instance, do not appear to experience situations with peers where they feel they ought to smoke (Friedman et al., 1985). The role of peer-group processes on induction to cigarette use is well documented. Friends' social influence about smoking and the individual's ability to resist such influence play a key role in adolescent smoking behaviour (Bauman & Fisher, 1986; Beal, Ausiello, & Perrin, 2001; Dappen et al., 1996; Ennett & Bauman, 1994; McGuire, 1968; Stacy, Sussman, Dent, Burton, & Flay, 1992; Stanton & Silva, 1992; Urberg, Chen, & Shyu, 1991; Urberg, Shyu, & Lang, 1990). Ennett and Bauman (1994) most recently examined the homogeneity of peer groups and considered both the influence and selection process. They report that peer groups may contribute more to nonsmoking than to smoking. Moreover, they suggest that while the adolescents' selection of peers provides some of the explanation for similar patterns of smoking behaviour, it is more the case that the peer groups' smoking behaviour plays a greater role in the adolescents' cigarette use. With specific regard to gender, one study found that grade eight female nonsmokers, quitters, and smokers all had a large proportion of friends who smoked compared with their male counterparts (van Roosmalen & McDaniel, 1989). Based on the findings of that study it would appear there was more indirect pressure placed on females to smoke by a single best friend, a group of friends, or a close male friend. Hahn, Charlin, Sussman et al. (1990) found that cigarette experimentation often takes place in same sex peer and sibling groups. Chassin, Presson, Sherman, et al. (1984) reported that peer 28 interactions are more important in the initial transition from abstinence to experimental smoking than in later transitions from experimental to regular smoking. However, Biglan and Lichtenstein (1984) found that the number of friends who smoke has been predictive of smoking rates over a time period as long as one year, and smoking among teens continues to occur most frequently in social situations. According to The Teen Smoking in British Columbia Survey (1997), very few teens were reported to start smoking regularly immediately following their first smoking experience. For almost all of them, there existed a period of time between experimentation and habituation which ranged from several months to several years. At approximately 12 to 14 years of age (grade 8 or 9), the time when teens enter junior high school and are around older peers, was frequently reported as a time for regularly taking up smoking. Participants in that survey often reported that all of their friends were smoking so they started to do it more regularly. Moreover, teens consistently reported that they smoke with friends as opposed to alone and described smoking as a social activity to share with their friends. When studying the role of the peer group in influencing the smoking behaviour of friends one implicit assumption is that children and adolescents who smoke 'cause' the uptake of smoking in non- smoking peers by utilizing coercive strategies (i.e., teasing, taunting, bullying, and rejection). Yet given the considerable knowledge of peer influence on smoking, less is known about the dynamics, mechanisms, and consequences of how peer influence operates on smoking behaviour. As Mitchell and West (1996) aptly point out, much of the available evidence for peer pressure to smoke largely depends upon the research method employed in a particular study. Often the evidence for peer pressure to smoke comes from cross-sectional studies which uncover a relationship between the smoking and nonsmoking behaviour of friends (e.g., Eiser, Morgan, Gammage, Brooks, & Kirby, 1991; Flay, 1993). Unfortunately, cross-sectional studies as designed cannot impart knowledge concerning the direction of causality nor can smoking progress be determined. Another method, the longitudinal study design, is also used in studying the role of the peer group influence in the smoking behaviour of friends. Results from longitudinal studies indicate friends' smoking precedes participants' smoking yet with a much reduced effect (Alexander et al., 1983; Ary & Biglan, 1988; Mittlemark et al., 1987). Even though friends' smoking predicts subsequent smoking behaviour amongst study participants, we are not able to infer that the smokers 'cause' smoking in their nonsmoking friends. In the case of research concerning initial smoking situations, findings provide little evidence of 29 either the need to gain friends' approval or of coercion from close friends (Friedman, et al., 1985). It is entirely possible that the cumulative evidence may instead suggest that the role of peer pressure has been overstated whereas the role of individual choice, particularly as it is rooted in friendship formation and maintenance, has been underestimated (Urberg, Degirmenciogiu, & Pilgrim, 1997). Evidence from one longitudinal study (Mitchell & West, 1996) suggests that adolescents make active choices about many aspects of their lives, including use of cigarettes. This finding regarding the mechanism of peer influence is in line with the notion that peer influence is largely the result of social selection. Thus, adolescents will either seek out or avoid contexts in which smoking occurs and they will choose friends who, like themselves, may or may not smoke (Fisher & Bauman, 1988). Regarding the mechanism of peer influence, another interpretation put forth by Urberg et al. (1990) found that adolescent smokers see their peers as not discouraging them from smoking as opposed to encouraging them to smoke. These authors suggest that having friends who are perceived as either positive or negative toward smoking does not simply translate into perceived direct pressures to smoke or not to smoke. Although peer smoking has been more strongly linked to adolescent smoking than parental smoking (Presti, Ary, & Lichtenstein, 1992), much of the available research supports the importance of both peer and parent/child relationship factors (Bertrand & Abernathy, 1993). For example, among grades seven and eight students, Gordon (1986) found that "triers" when compared with "never smokers" were more likely to predominate a smoking peer referent group, a best friend who smokes, siblings and/or parents who smoke; were more likely to experience peer pressure to smoke and believe that smoking would make them more relaxed; and were reported as more rebellious. Moreover, "current smokers" were found to be more likely than triers to report that the majority of their friends, their best friend, and siblings (girls) smoked and were more likely to believe that smoking would help them to relax. The current smokers were found to be less likely to believe that smoking is harmful and would make their parents angry. Gender Differences Gender is an important factor in young people's smoking behaviour. Gender differences have been shown to exist in age of first experimentation with cigarettes. For example, McNeill et al. (1989) found that being a girl was strongly associated with subsequent onset of smoking. Gender differences were also reported to exist in social influence representations of smoking behaviour. That is, initial 30 smoking experiences were found to occur most frequently amongst same-sex friends (e.g., Friedman et al., 1985) and same-sex sibling smoking behaviour was highly associated with both experimentation and initiation. Other social influences, such as smoking by family members, were a greater influence on girls than boys (Chassin et al., 1986; Malkin & Allen, 1980; Stanton & Silva, 1992; Swan, Creeser, & Murray, 1990). There is documented evidence to suggest that smoking by a male family member is associated with smoking behaviour in boys (e.g., Bewley & Bland, 1977; Minagawa, While & Charlton, 1993). Peer modelling appears to significantly impact on the odds that a child would try smoking, as well as the probability that he or she would progress toward smoking on a regular basis. There is a growing body of research indicating that the influence of peers is substantial throughout adolescence (Ary & Biglan, 1988; Chassin et al., 1986; Gordon, 1986). Additionally, some research evidence suggests that there are no significant gender differences in responsiveness to peer modelling (Ary & Biglan, 1988; McCaul, Glasgow, O'Neill, Freeborn, & Rump, 1982; Robinson, Kleges, Zbikowski, & Glaser, 1997; Santi, Best, Brown, & Cargo, 1991). A number of studies examined social-psychological factors associated with smoking, and fewer addressed gender differences (Ary & Biglan, 1988; Chassin, Presson, & Sherman, 1984; Chassin et al., 1986), yet here again, results were not consistent. The work of Chassin and colleagues (1984,1986) has demonstrated that in the early stages of cigarette smoking, girls were significantly more susceptible to social influence than boys. More specifically, Chassin et al. (1986) found boys and girls were more strongly influenced by peer smoking at different ages. Their participants (n = 3,819 in grades 6-11) were defined by six levels of smoking ranging from never smoker ("not even one puff) to regular smoker (more than one cigarette per week). During the one-year period of the study, transition to a higher level (dependent variable) was predicted by an increased number of smoking friends for girls at the younger ages and for boys at older ages. These findings suggest elementary school teachers ought to focus on peer pressure awareness and skills training with girls, whereas high school teachers need to emphasize these aspects for boys. Another study (Clayton, 1991) with a sample of grade six students (n = 882) classified participants as high-risk or low-risk based on whether or not they had experimented with smoking. Information was collected concerning self-efficacy, risk-taking orientation, number of refusals made in a hypothetical situation of peer pressure to smoke, and effectiveness of these refusals as judged by a rater. 31 Comparison of scores for high-risk and low-risk groups within genders revealed puzzling results. Results suggested that girls at higher risk of becoming smokers in fact made more refusal statements judged as more effective and made higher self-efficacy scores than low-risk girls. The opposite pattern of relationship was found for boys. In contrast, Ary and Biglan (1988) and Waldron and colleagues (1991) found little support for the hypothesis that girls may be more susceptible to peer influence than boys. Likewise, Sarason et al. (1992) found no significant differences between girls' and boys' reports of their reasons for starting to smoke. An alternative interpretation of findings concerning no differences may simply be a reflection of a general gender difference in rates of maturation. It is also possible that different social-psychological mechanisms are used by males and females, yet these were not tapped into given the scope of the questions and measures employed. Support for the premise that different mechanisms lead boys and girls to initiate smoking is provided by Urberg and Robbins (1981). In their study, participants rated the importance of 19 costs of smoking and 15 benefits. Smoking behaviour was not related to item ratings, yet gender differences in ratings were observed. For example, girls were more likely to endorse the benefits of smoking as represented by the following item statements, "Smoking shows that you do what you want," "girls like boys who smoke," and "smoking makes your parents mad." Girls were also more likely to consider detriment to athletic performance as an important cost of smoking. As well, as number of friends who smoke increased, boys agreed more and girls agreed less to the following statements: "Smoking gives you something to do when nervous," and "smoking makes you feel part of the gang." it would appear that not enough evidence exists to support the hypothesis that girls who smoke are more autonomous, self- confident, rebellious, and socially adept than nonsmokers, inasmuch as boys who smoke are more insecure and in need of social coping strategies than nonsmokers. Clayton (1991) reviewed salient findings in the literature addressing gender differences in social- psychological determinants of adolescent smoking. Based on this review, she concluded that research on social-psychological determinants of adolescent smoking suffers greatly from a lack of attention to group differences. One area that was suggested for investigating gender differences in determinants of smoking involved the realm of psychological traits, states, and behavioural abilities (i.e., refusal and interpersonal skills), and differences in perceptions of the costs and benefits of smoking. The work of previous researchers has indicated that a considerable proportion of young people, 32 particularly young girls, believe that cigarette smoking is an effective method of weight control, and interest in weight control has been associated with cigarette smoking (Charlton & Blair 1986; Feldman, Hodgson, & Corber, 1985; French, Perry, Leon, & Fulkerson, 1994; Robinson et al., 1997). To illustrate this pattern, Camp, Klesges, and Relyea (1993) found that concerns about body weight were associated with an increased probability of regular smoking. However, these investigators did not explore whether or not such concerns were also influential for smoking onset. Likewise, French et al. (1994) reported that girls who were preoccupied with dieting and weight were more likely to smoke, yet it was unclear whether these weight-related variables were important in the eady stages of cigarette use or only for regular smokers. Specifically, Camp et al. (1993) used a measure to study and assess both interest in dieting and history of weight fluctuations; children who were identified as concerned with dieting were also identified as more likely to exhibit a history of active weight suppression and recovery. French et al. (1994) used a series of questions to elicit information concerning symptoms of serious eating disorders which included responses relative to a participant's desire to be as thin as possible and a significant fear of weight gain. Even though the measures of dietary concerns used in these two studies differed, the pattern which emerged suggests that adolescents who are concerned with dieting are more at risk for cigarette use. A profile of the nonsmoking adolescent female was described as eariy as 1976 by Yankelovich, Skelly, and White. These investigators examined both nonsmokers and smokers in ways that were not repeated after the time of the study. The results of this study were based on in-depth interviews with a total of 826 teens (13-17 years of age) and young women (18-35 years of age), screened on the basis of their smoking patterns from a national probability sample of 3,000 households. This sample of teen-age girl nonsmokers was not homogeneous; rather they divided into two almost equal yet distinct groups. This sample comprised two groups, separated by the investigators and categorized as either "traditionalists" or "vulnerables." Over half (55%) of the first group of nonsmokers did not smoke due to their very traditional views and outlook and were categorized as "traditionalists." Traits associated with "traditionalists" included those individuals with strong religious convictions and a sense of respect for authority who would shy away from their peers who used tobacco, alcohol or drugs. The second group of nonsmoking teen girls was very different; that is, they shared in common more of the same values as the smokers and were all highly exposed to smoking in their social environment. This group was identified as 33 the "vulnerables" as, at first blush, they appeared to be ready candidates for the next new wave of smokers. In this group, one out of two reported that half or more of their males friends smoked and one third indicated that most of their girl friends smoked. A majority had one or more parents who smoked. Regardless of these social circumstances, the "vulnerables" were reported as girls who did not smoke. Moreover, "vulnerables" expressed concern about the addictive properties of cigarettes, promoted physical fitness and well being, and as well expressed the value of being in control of their lives. This group also appeared to discover a new cause and peer association, that of the anti-smoker, one that supported legislation to regulate smoking and to promote a smoke-free domain. Uncertainty remains as to whether or not these traits or characteristics would be applicable to adolescent females in this day and age. Clearly, the use of labels such as "traditionalist" and "vulnerable" conveys an image that nonsmokers are a multifarious group. Even though Yankelovich and colleagues (1976) recognized a distinct group of nonsmokers, subsequent investigators, with a few noted exceptions concentrated their research efforts almost exclusively on smoking and smokers. Lloyd, Lucas, and Fernbach (1997) conducted an exploration of girls which provides meaningful insight into the nature of adolescent girls' (ages 11-16 years) social representations of cigarette smoking, and constructions of their social identities in relation to smoking. Social representations of smoking were used as a reference point in analysing the social identities of adolescent girls who smoke cigarettes and those who do not smoke. Overall, the aim of these researchers was to establish how adolescent females construct two distinct social identities: a nonsmoking identity and a smoking identity. Smoking group membership was measured using a conventional five-response question; responses were combined into three categories in order to represent meaningful social groups. Individuals who responded, "I have never smoked" were differentiated from those who had experienced cigarette smoking and were labelled never smoked (n = 968). To identify the group of individuals who had experimented with cigarettes, responses to "I have smoked (if only a few puffs)," and "I have smoked one cigarette in the past 4 weeks" were combined and this group was labelled occasional smokers {n = 526). Finally, responses "I usually smoke one or more times a week," and "I usually smoke at least once a day" were combined to identify regular smokers (n = 229). The quantitative portion of the Lloyd et al. (1997) study based on a survey using a 13-item questionnaire, explored the nature of girls' perceptions of each of the two identities. A factor analysis 34 followed by orthogonal (Varimax) rotation was conducted, resulting in a three-factor solution. Two analyses of the questionnaire data resulted as follows: (1) the factor structure for the girl nonsmoker and girl smoker identities; and (2) differences between factor (scale) scores for these identities derived from the factor analysis. The factor solution for the girt nonsmoking identity accounted for 59.8% of the variance. The first factor ("mature") loaded seven items with the following descriptors: cool, tough, grown-up, happy, makes up own mind, exciting, and popular. The three items which loaded on the second factor, labelled "fun-loving" included: attractive to the opposite sex, likes the opposite sex, and likes partying. The third factor ("sensible") loaded with three items: healthy, cares about the environment, and clever. The factor analysis procedure used to analyse ratings of the girl nonsmoker identity was repeated for those of the girl smoker. Again, a three-factor solution for the girl smoker identity accounted for 62.3% of the variance, with the same items loading on each factor. The similarity of the factor solution and resulting factors enabled comparison between the two identities. Results indicated significant differences between them on all three factors. Girls rated the "mature" factor items higher for the nonsmoker identity than for the smoker identity. Likewise, the nonsmoking identity was rated higher than the smoker identity on items loading on the "sensible" factor. Only on the items which loaded on the "fun-loving" factor was the smoking identity rated higher than the nonsmoking identity. A fourteenth item, "breaks rules" was excluded from the preliminary factor analysis of the identity items due to inconsistent valuing. This item was included in an analysis to illustrate the influence of group membership. Rating of the nonsmoking identity varied significantly with smoking group membership. Gids who never smoked rated a girl who did not smoke as less likely to break rules; girls who never smoked viewed a girl who did smoke as more likely to break rules. Based on an analysis of the factors explored in this study of smoking and nonsmoking identities, results indicated that regardless of smoking group membership, there was consensus among all girls about the "sensible" and "fun-loving" factors that included smoking identities. For participants who smoke, cigarettes appear to be an important means of developing an adult social identity and one which is viewed as desirable. The nonsmoking identity was rated more "sensible" (i.e., items including healthy, cares about the environment, and clever) than was the smoker identity. Additional evidence for girls' constructions of nonsmoking and smoking identities emerged from a qualitative component of the study which included focus group discussions in order to ensure that 35 smoking biographies, social representations of smoking, social identities, health-related beliefs and values, and perceptions of anti-smoking education were all considered. The nonsmoker identity was viewed as conscientious about school work and interested in school life. Nonsmoking girls were likely to refer to girls who smoke as "stupid," and cite damage to health and the detestable smell as reasons for not smoking. These girls were not unlikely to maintain close friendships with those who smoked. During focus group discussions, the girl smoker identity was elaborated to include rebellion against authority, lack of interest in school work, and pursuit of "risky" behaviour. There was some evidence that girls who smoked (aged 14 to 15) participated in friendship groups that included both smokers and nonsmokers; issues relative to smoking created a sense of tension among group members. Lloyd et al. (1997) identified several of the meanings of smoking for adolescent girls and their results contribute to a greater understanding of the different meanings of smoking to adolescent girls. Knowledge of the constructions of different social identities is important so that smoking prevention programs can be devised that enhance the attractiveness of the nonsmoker identity. Based on their study, this research group recommends that future intervention programs aimed at smokers be devised to enhance the desirability of the social representations associated with the nonsmoker identity. A study by Dunn (1998) was specifically designed to explore the experience of adolescent female nonsmokers. The findings of this qualitative study revealed that girls proceeded through a three-phased process in order to remain a nonsmoker. The main theme underpinning the entire process was found to be the development of self-confidence. Of the 17 girls in this study, each possessed her own level of self-confidence which enabled her to commence the process initially by making sense out of smoking. Later on, the girls advanced to the next phase, rejecting smoking, but only once they had decided that smoking did not serve a purpose in their lives. Successfully completing phase two empowered these girls in two ways. First, their self-confidence increased; and second, each became known as a nonsmoker. Finally, the girls were then able to declare themselves to be nonsmokers, denoting the completion of the process of remaining a nonsmoker. In addition, three intervening conditions were identified which influenced both the development of self-confidence and the progression through the process of remaining a nonsmoker. These conditions were identified as being busy, having support, and peer pressure to fit in. By exploring the experience of being a nonsmoker from an adolescent female perspective, Dunn discovered that some girls do implement a process for remaining nonsmokers, yet these girls were quite 36 oblivious to the process they were using. The implication for education is that there is value in fostering an awareness in adolescents and the individuals who interact with them as the evidence would suggest that a process is in fact occurring that empowers teenage girls to successfully remain smoke-free. In their review of 27 prospective studies concerning the onset of cigarette smoking, Conrad and colleagues (1992) concluded there were too few studies which examined smoking onset by gender, and whatever findings existed were too inconsistent to make any firm statements about variations due to gender. Overall, Conrad et al. were able to state that factors that were consistently and positively associated with onset of smoking among adolescents included: low socioeconomic status, older age, being female, prior experience with smoking, intentions to smoke, positive attitudes toward smoking, drug use, greater attachment to or agreement with peers, having friends who smoke, having an older sibling who smokes, friends' approval of smoking, estimating a high prevalence of smoking among peers, receiving cigarette offers, having poor ability to refuse cigarette offers, lower academic expectations, and being rebellious. Parental smoking, however, has demonstrated little association by gender. Gender differences in smoking were also examined by Waldron (1991) and Grunberg, Winders, and Wewers (1991); however, adults rather than adolescents were highlighted. Waldron (1991) concluded that females may adopt smoking as a way to cope with stress and to control their weight, whereas males may be motivated more by rebelliousness or by the desire to maintain their athletic ability. No gender differences were found with respect to the smoking behaviour of friends, siblings, parents, or the attitudes of friends or parents toward smoking. Grunberg et al. (1991) discussed differences in the prevalence of tobacco use across countries and time, and highlighted some of the literature on sex differences with respect to the biological aspects of nicotine (i.e., metabolism and sensitivity). In summarizing the literature on gender differences in the initiation of smoking, these authors concluded the most influential social factors encompassed: perceptions of smoking as positive or negative, extent of social disapproval, advertising and media stereotypes, sex role, and perceived health risks and benefits. Demographic Characteristics and Social-Environmental Factors Associated with Risks of Smoking A number of relationships have been found between cigarette smoking and demographic characteristics, including age, place of birth, income adequacy, and ethnic background. However, some researchers find either no relationship between adolescent smoking and social class, or the influence of class may be stronger on adult than adolescent smoking (Glendinning, Shucksmith, & Hendry, 1994). 37 Oakley, Brannen, and Dodd (1992) found little influence of social class on adolescent smoking when conventional definitions of social class were used. However, when social class was measured in terms of material circumstances such as housing, a stronger relationship was demonstrated. The prevalence of smoking varies and as demonstrated previously, several patterns of behaviour were associated with smoking; these include risk-taking and rebellious behaviour (Conrad et al., 1992) and involvement in peer groups who smoke at a relatively early age (Brunswick & Messeri, 1984). Individuals who enjoy taking risks or those who were rebellious in nature were also found more likely to smoke (Chassin, Presson, Rose, & Sherman, 1996; Collins et al., 1987; Mosbach & Leventhal, 1988). The work of previous researchers indicates that the most important adolescent personality (social- psychological) predictors of the onset and maintenance of adolescent smoking behaviour are risk-taking, rebelliousness, deviance, low self-image, and impulsiveness (e.g., Castro, Maddahian, Newcomb, & Bentler, 1987; Collins et al., 1987; Conrad et al., 1992; Stacy, Sussman, Dent, & Burton, 1992). Other investigators suggested that smoking was a means of rejecting parental authority (Covington & Omelich, 1988), or it was a possible way of defining and maintaining a deviant self-image (Hirschman, Leventhal, & Glynn, 1984; Skinner, Massey, Krohn, & Lauer, 1985). Social environmental factors associated with less risk of smoking include academic achievement (Chassin, Presson, & Sherman, 1990; Gerber & Newman, 1989), healthy eating and physical activity patterns (e.g., Coulson, Eiser, & Eiser, 1997; Nutbeam, Aaro, & Catford, 1989), and the skills to resist offers of cigarettes (Conrad et al., 1992). One specific factor for female adolescents, involvement in sports, has been associated with nonsmoking (e.g., Swan et al., 1990). Level of educational achievement and academic performance were predictive in value to determine whether or not a person would become a smoker (Bartecchi, MacKenzie, & Schrier, 1994; Chassin et al., 1996; Choi, Pierce, Gilpin, Farkas, & Berry, 1997; Ellickson, Tucker, & Klein, 2001; Pierce, Fiore, Novotny, Hatziandreu, & Davis, 1989). The prevalence of smoking was most strongly related with the number of years of formal education achieved. The smoking status among those with different years of education indicated current smoking status decreased and never-smoking status increased as the level of education increases. That is, those with higher levels of education were less likely to take up smoking, and those who did were more likely to quit. As the vast majority of cigarette initiation occurs prior to the age when education is complete, a correlation to education reflects the environmental factors that predict 38 both educational achievement and nonsmoking status (Burns, 1991). Advertising and Promotional Strategies in the Media In the tobacco industry, advertising and promotional activities are the two major strategies employed to market cigarettes. Advertising and promotional activities can convey the impression that tobacco use is desirable and socially acceptable (Lynch & Bonnie, 1994). Promotional activities were also used as an alternate strategy for encouraging youth to smoke, hence maintaining cigarette sales. Tobacco corporations claim that the purpose of their advertising and promotional activities is to encourage brand-switching and to increase market shares of adult customers. Yet despite this claim, it is young people who are the tobacco corporations' key source of new consumers in North America, replacing adults who successfully quit or died (Kessler, 1995). A central concern of the public health sector is that the themes and images used by the tobacco industry are attractive to and promote the use of cigarettes by minors (Pierce et al., 1991). In Canada, legislation efforts successfully prohibit tobacco companies from marketing to minors directly. However, American-based evidence clearly implicates the tobacco industry's concerted efforts targeted at adolescents with promotional campaigns. According to Di Franza and colleagues (1991), one of the more audaciously controversial advertising campaigns of today's era was R. J. Reynolds Tobacco Company's introduction of the cartoon character named "Joe Cool Camel" for Camel cigarettes, modelled after Ian Fleming's Agent 007 - James Bond (Sean Connery) and Detective Sonny Crockett (Don Johnson) of Miami Vice. In each Joe advertisement, Joe Camel is seen as slick, self-confident, and most of all "cool" while smoking his tasteful cigarettes. Each advertisement appears with a distinct title which captures the intentions of R. J. Reynolds by promoting Joe Cool to teens as a "smooth character." An advertisement strategy with a spokes camel such as Old Joe accomplishes the goal of targeting teens because it displays a young-like cartoon character portraying a tough guy image. Teens look up to icons that take on an image of being tough, self-confident, and rebellious because they want to be what that image represents. Teens look up to figures that resemble a hero; if their "hero" is smoking, then it gives them more of an incentive to do so. Hence, advertising and promotional activities of this nature clearly conveyed the impression that cigarette smoking is a desirable and socially acceptable behaviour (Lynch et al., 1994). Study findings indicated children were as familiar with Joe Camel as Ronald McDonald (Fischer, Schwartz, Richards, 39 Goldstein, & Rojas, 1991). Additional support concerning successful advertising campaigns was found by Pierce et al. (1991) that demonstrated a relationship between age and product recognition. Among study participants aged 12 through 65 years of age, the Camel advertising campaign was most recognized by those children aged 12 through 13 years (34.2%) and persistently declined to less than 10% in participants 45 years and older. Advertising campaigns such as Joe Camel depicted as the "smooth character" created an icon that stood for freedom of expression, personal liberty, and the pursuit of happiness. Another promotional strategy targeting youth is tobacco company sponsorship of sporting, musical, athletic, entertainment, and other events in an endeavour to link tobacco products with images of physical skill, glamour, excitement, and fun. Typically, tobacco companies rely on poster advertisements prior to the scheduled event which are strategically placed in shopping malls and on billboards where youth spend time and meet friends. During the course of the event, specialty items which appeal to youth were on display for sale with a logo (e.g., Joe Camel) which appeared on T-shirts, baseball caps, and football jerseys. Advertisements in magazines were also reported as an effective communication strategy, one that young, healthy, adventure-seeking men and women smoke. These types of promotional and advertising strategies reach youth as they navigate through their adolescent years while in the process of developing a self-image (Di Franza et ai., 1991; Sparks, 1999). While it may not be possible to make a direct link between smoking onset and media influence, there certainly exists little doubt that the leaders in the tobacco industry believe that they are capable of promoting smoking among youth. Approving of cigarette advertising has been found to be associated with smoking initiation among youth (Alexander et al., 1983). Survey data indicated that the most advertised brands of cigarettes (e.g., Marlboro, Camel, and Newport) were the most popular among adolescent smokers (McNeill et al., 1989; Pierce, Choi, Gilpin, Farkas, & Berry, 1998). Others demonstrated that at least 75% of adolescents smoke one of three or four brands (Chapman & Fitzgerald, 1982). Data from the United States, England, Australia, and Canada demonstrate that tobacco advertisements and tobacco product logos were recognized by youth, even children as young as three years old (Aitken, Leathar, O'Hagan, & Squair, 1987; Chapman & Fitzgerald, 1982; Fischer et al., 1991; Hoek & Sparks, 2000). However, in a study conducted by Pierce et al. (1991), statistically significant differences by gender were not observed when 40 teenagers aged 12 to 17 were asked to identify the most advertised brand of cigarette; gender differences were not found in the market share of Camel and Marlboro cigarettes. There is strong evidence to indicate that some young people are lured to smoking by brand advertising which is supported by data indicating that adolescents consistently smoke the most heavily advertised brands of cigarettes. Moreover, following the introduction of advertisements that target young people, the widespread use of those brands increased (Di Franza et al., 1991). Awareness on the part of Canadian youth of events and activities sponsored or promoted by tobacco corporations is notable. For instance, in the Youth Smoking Survey (1996), 49% of all youth aged 10 to 14 and 51% of those aged 15 to 19 reported seeing advertisements for events sponsored by tobacco companies. There was very little difference between males and females in response to these statements. Another Canadian survey (Covell, 1992) looked at tobacco advertising using an Ontario- based convenience sample of youth aged 8 to 16 to examine age, gender, and product differences in the appeal of image advertising. Two advertisement types were examined: quality advertisements focussed on specific characteristics of the product and image advertisements that depicted a lifestyle that could be gained and/or projected by use of the product. Image-oriented tobacco advertisements were rated more favourably than quality-oriented advertisements; image advertisements were found the most appealing for females aged 11 to 14 compared with males of the same age. A growing body of research has suggested that tobacco advertising is a contributing factor to initiation of smoking during adolescence. Studies consistently document the high awareness and recall of tobacco messages and images among adolescents and even among young children (Fischer et al., 1991). Adolescents are known to be highly adept at decoding cigarette advertisements and aware of covert messages as early as the pre-teen years (Aitken, Leathar, & O'Hagan, 1985; Pierce, Lee, & Gilpin, 1994). It has been suggested that tobacco marketing has had a stronger influence on encouragement of adolescents to initiate smoking than demographic characteristics or exposure to other smokers in the peer or family network (Biener & Siegel, 2000; Evans, Farkas, Gilpin, Berry, & Pierce, 1995). Children are vulnerable to advertising. It has been demonstrated that advertising is one of the key factors in convincing youth to take up smoking (Clark, 1996; Health Canada, 1996; United States Department of Health and Human Service, 1994). It is believed that advertising and promotion efforts put out a positive influence on cigarette consumption (Warner, Goldenhar, & McLaughin, 1992). 41 Cigarette advertising and promotional activities appear to influence social-psychological risk factors for adolescent tobacco use; these mechanisms are multiple and complementary (United States Department of Health and Human Services, 1994). Most children/adolescents demonstrate some awareness and recognition of cigarette brands and advertisements and develop preferences for particular advertisements and adolescents perceive cigarette publicity as promoting benefits of smoking (Pierce et al., 1993). Advertising enhances the development of an ideal self-image by rendering qualities or advantages of smoking that adolescents would like to display. Those adolescents with a lower self-image feel that smoking is a means to narrow the discrepancy between their actual and ideal self-image whereby the ideal self-image closely resembles the same smoker images seen in print media (Botvin, Goldberg, Botvin, & Dusenbury, 1993). Adolescents with a larger discrepancy between their actual self- image and their ideal-self image were reported as more likely to have intentions to smoke (Botvin et al., 1993; Kannas, 1985). Overall, there exists strong evidence to support that the advertising and promotional efforts of cigarette companies are influential factors that increase the risk of smoking initiation among adolescents. Social-psychological risk factors such as having a low self-image, making positive attributions or benefits to smoking, and a perception that smoking is both normative and prevalent, are strong predictors of adolescent smoking intentions and smoking onset. The unfortunate irony is that while smoking is viewed by many adolescents as an act of defiance or rebellion, it also promotes the ploy of powerful tobacco corporations and their advertising schemes. Cognitive Domain The capacity to imagine hypothetical situations and anticipate consequences develops during the adolescent years. During early adolescence, the capacity to think in terms of hypothetical probabilities increases, as does the ability to use formal logic (Inhelder & Piaget, 1958). Using formal thought allows the adolescent to go beyond the concrete to use verbal hypotheses and deductive reasoning. The cognitive capacities of adolescents are more sophisticated than those observed in younger children. Although adolescents' ability to make decisions also increases, this improved ability does not consistently meet the challenges that are found in stressful and novel situations (Petersen & Leffert, 1995; Linn, 1983; Weithorn & Campbell, 1982). Both emotion and experience play a key role in the decision-making process. Adolescents are more likely to be in situations which they lack experience, and 42 this consequently taxes their cognitive abilities and decision-making skills (Crockett & Petersen, 1993). Concomitant with an increased decision-making ability over the period of adolescence, the awareness of risks and the ability to think about future also increases. The increase in these skills occurs over the junior high and high school years (Lewis, 1981). Some researchers (e.g., Weithorn, 1982) report that by age 14 years, decision-making and reasoning ability is as good as that seen in adulthood and involves the same flaws (Kuhn, Amsel, & O'Loughin, 1988). The development of abstract reasoning also affects adolescents' concept of themselves and their insight and judgement (Petersen & Crockett, 1986; Damon & Hart, 1982). Adolescents can better understand the perspective of others as well understanding what other people may want (Petersen & Crockett, 1986). Along with an ability to understand and take the perspective of others, young people also develop a greater understanding of moral issues over the course of adolescence (Petersen & Crockett, 1986). The development of moral thinking has been described by theory and supported by research. Kohlberg (1964, 1976) expanded Piaget's formulation of moral thinking to incluse six stages of moral reasoning. Further Kohlberg postulated the development of moral thinking occurs slowly and documented from the age of 10 or 11 years to young adulthood, although others noted a gradual shift from more primitive (preconventional) modes of reasoning to those that are more sophisticated (e.g., Hoffman, 1980; Petersen & Crockett, 1986). The meanings of and one's intentions concerning tobacco use established in our society become personally relevant during adolescence. For some adolescents, tobacco use becomes a mechanism to establish social relationships, display independence, and create a new mature identity. Furthermore, as many adolescents believe themselves to be all but invulnerable, with a short perspective on their future, limited abstract cognitive abilities, and high value placed on their associations with same-age peers, adolescents may view cigarette smoking as particularly functional and not potentially harmful. Adolescents' Perceptions of Smoking in Family and Social Contexts Traditionally, most research has been concerned with measuring children's attitudes and beliefs about smoking and the perceived image that goes with smoking (Bewley & Bland, 1977; Botvin, Botvin, & Baker, 1983; Kannas, 1985). These previous approaches tended to adopt the view of individualistic assumptions and concerned much of the social psychological literature on beliefs and attitudes. Social learning theory stresses the interrelationship between people, their behaviour, and the environment, yet 43 behaviour is largely determined by the environment where a person has the capacity to effect change to his or her environment. As well, social learning theorists contend that behaviour is influenced through the process of modelling. It is therefore the social network with which one is in contact, either through preference or circumstance, that personifies the behaviours most frequently observed and most completely learned (Bandura, 1977,1999). Researchers that cite the effect of parental smoking on adolescent experimentation with cigarettes exemplify the concept of behaviour initiation through modelling (e.g., De Moor, Elder, Young, Wildey, & Molgaard, 1989; Evans et al., 1978). Such studies found evidence that correlates parents' smoking behaviour with a greater likelihood of children' smoking compared with children in a nonsmoking household. Moreover, social learning theory maintains that performance of a behaviour depends on a person's self-efficacy; that is, the personal judgement of one's capabilities to establish and carry out courses of action required to attain designated types of performances (Bandura, 1977, 1995). Self- efficacy can be the determinant of initial experimentation with smoking as well as affect the decision to quit. In the case of adolescents who experimented with cigarettes, those with low self-esteem likely felt a greater need to define themselves as "tough" (Klesges & Robinson, 1995). If a child judged that cigarette use would result in such an image, then his or her perceived self-efficacy was aimed at achieving the behaviour. However, it is conceivable that the influence of many of these conjectured causal factors were enhanced through socially transmitted representations (e.g., that smoking makes you look "cool") and popular beliefs about smoking (Danesi, 1994). Most of the antecedents to smoking discussed previously were not identified as immediate or direct causes of children smoking (Urberg et al., 1990). Rather, it seems plausible that these factors function by influencing children's perceptions of, and beliefs about, the act of smoking. Researchers suggested parents and peers act as sources of information about cigarette smoking from which a child develops a set of expectancies (Eiser, 1985; Eiser et al., 1987). An important predictor of young people's smoking during adolescence is the young person's perception of parental attitudes toward the child's smoking behaviour. Others demonstrated that young smokers perceived less social pressure against and a greater support for smoking than did their nonsmoking peers (Chassin, Presson, Sherman et al., 1984; Eiser, Morgan, Gammage, & Gray, 1989), findings which support the notion that social influence processes are best understood in the context of young people's identification 44 with particular sub-groups. Survey data consistently demonstrated that young people overestimate the number of their peers and adults who smoke and those with the higher estimates were more likely to become smokers (Collins et al., 1987; Gerber & Newman, 1989; Leventhal, Glynn, & Fleming, 1987). If youth feel that peers approve of smoking and adults do not disapprove, then they are more likely to smoke. It is plausible that the perceived environment accurately reflects the real environment. Youth who start to smoke may be exposed to more smoking role models, more peer approval, and less adult disapproval than those adolescents who never start to smoke. Yet, it is just as likely that exaggerated norms promote experimentation independent of overt pressures to try smoking. The prevalence and acceptability of smoking implies that smoking prevention interventions might be successfully targeted at correcting these errors in perception (Hansen & Graham, 1991). Young people living with a family member who smokes downplay smoking risks and were less likely to believe that there were adverse consequences associated with smoking (Leventhal et al., 1987). According to an Ontario Health Survey in 1990, adolescent smokers (aged 12-17) were more likely to report living in households with at least one other smoker, and raised proportions of friends who smoked (Badovinac, 1993). Millar and Hunter (1991) found that younger household members' overall level of cigarette consumption and type of cigarette smoked were associated with older adult smoking behaviour. To explain the correlation between child and parent smoking behaviour, Millar and Hunter (1991) suggested that social pressures operating within family and household settings created homogeneity in smoking-related behaviours across members. This interpretation may also explain the ways in which the immediate social environment influences normative expectations about smoking behaviour. While young people grossly overestimate both peer and adult smoking, those with friends and family members who smoked overestimate those figures even more (Leventhal et al., 1987; Presti et al., 1992; Urberg et al., 1990). Hansen and Graham (1991) found correcting erroneous normative perceptions about the prevalence and acceptability of tobacco use and the establishment of conservative group norms was an effective means for preventing smoking behaviour in adolescents. Another consideration related to adolescent smoking was adolescents' perceptions of other smokers. Many at-risk adolescents estimated the prevalence of teenage smoking was twice as high as it really was, and overestimates of smoking predict future smoking and onset and subsequent increases in 45 smoking (e.g., Chassin et al., 1984; Collins et al., 1987; Sherman, Presson, Chassin, Corty, & Olshavsky, 1983; Sussman et al., 1988). For instance, Ajzen and Fishbein (1980) suggested that overestimates of peer smoking can lead to beliefs such as, "My smoking will make me more popular with my friends" and can eventually lead to the initiation of smoking. Knowledge About Health Consequences of Smoking Knowledge and attitudes about smoking are formed at a young age and set the stage for future encounters with tobacco products. There exists little in the way of research concerning young children's knowledge and conceptions of smoking which may be due to a lack of developmentally appropriate measures of children's knowledge and to the misperception that young children are not knowledgeable about tobacco. Shute, Pierre, and Lubell (1981) found that over 90% of preschool and first grade children correctly recognized cigarettes. Of those participants who had seen tobacco products in the home, almost one-half said they would use them, compared to 11% of participants who had not seen tobacco products in the home. In a more recent study, similar findings were demonstrated by Haln and colleagues (2000) which indicated a high level of recognition of cigarettes among five-and six year old participants using an interviewer administered pictorial inventory. It has been established that the children of parents who smoke are at higher risk for cigarette use than children whose parents do not smoke (Anderson & Henry, 1994; Hawkins, Catalano, & Miller, 1992). Likewise, adolescents who progressed from experimentation with cigarettes to established smoking were more likely children of parents who smoked (Distefan, Gilpin, Choi, & Pierce, 1998). A variety of personal factors were theorized as showing a direct influence on an individual's decision to smoke. Intentions to smoke (Chassin et al., 1981; Eckhardt, Woodruff, & Elder, 1994), beliefs about smoking, especially exaggerated estimates of adolescent smoking prevalence (Gerber & Newman, 1989; Hansen & Graham, 1991) and favourable attitudes toward smoking (Gerber & Newman, 1989; Hover & Gaffney, 1988), were credited with a stronger influence than knowledge concerning the health risks of smoking (Charlton & Blair, 1989; Conrad, Flay, & Hill, 1992; Presti et al., 1992). Yet some studies found little or no evidence that attitudes were predictors of smoking onset (Jarvis, Goddard, & McNeill, 1990; McGee & Stanton, 1993). The perceived positive functions of smoking as well as an expected utility of cigarette use are important predictors (e.g., Bauman, Fisher, Bryan, & Chenoweth, 1984; Eiser & van der Plight, 1984; 46 Leventhal & Cleary, 1980; Perry et al., 1987). The perceived positive functions and uses of smoking were related to a positive social image, bonding with peers, and being "mature,'' all of which were socially salient factors for adolescents. Adolescents who started to smoke were those with lower self-images and lower self-esteem than their non-smoking peers (Conrad et al., 1992). Self-efficacy in avoiding cigarettes seems to be closely associated with the ability to resist cigarette offers from peers (Stacy et al., 1992). It would seem that the personal factors most predictive of smoking initiation are those related to the social environment, peers, and functional meanings concerning cigarette smoking. Adolescent smokers also acknowledged the existence of a strong relationship between smoking and lung cancer, yet they rated themselves as only average in their likelihood of developing cancer (Reppucci, Revenson, Aber, & Reppucci, 1991). Even though studies consistently demonstrated that adolescent smokers and nonsmokers were cognizant of the long-term health consequences and effects of smoking (e.g., Blackford et al., 1994; Malkin & Allen, 1980), it remains uncertain as to why nonsmokers attend to this knowledge and smokers do not. Most explanations are confined to differences in young people's beliefs about the health implications of smoking. There exists evidence to suggest that adolescents overestimate the prevalence of smoking, as demonstrated by their thinking that the majority of adolescents and adults smoke (Chassin et al., 1981; Mittlemark et al., 1987; United States Department of Health and Human Services, 1989). Such evidence raises several questions about nonsmokers. One such question that could be posed asks, "How do adolescents maintain their nonsmoking status despite the belief that the majority of people smoke, in particular, those adolescents who are vulnerable to peer pressure?" School-Based Approaches to Smoking Prevention In the context of health education, "prevention" refers to any effort implemented to avert the use of tobacco and deter adolescent smoking behaviour. Pioneer work in the development of prevention program strategies was based on the premise that young people who smoked did not understand the health consequences of cigarette smoking. The thinking at that time was to address a deficit of information by presenting health information to young people that caught their attention and provided them with sufficient reasons not to smoke. This "deficit" oriented prevention model of the 1960s and early 1970s was predicated on the notion that improvements in knowledge would lead directly to changes in behaviour. Fear-arousal techniques were often implemented to persuade young people to believe that 47 smoking was connected to the risk of developing serious long-term physical health compromising effects including premature death in adulthood due to cancer and cardiovascular disease. Interventions designed to prevent adolescent smoking can be categorized into school-based programs, media campaigns, community-based initiatives, and environmental control measures. Of these, educational approaches are the most rigorously evaluated and most commonly used prevention strategy (Flay, 1993). Numerous educational efforts are represented in each category. For instance, media publicity may be supported by paid or unpaid broadcasts via television and radio. Preventative initiatives can also be implemented at the community level with programs sponsored by law enforcement agencies and public policy/activism approaches. Activism projects aimed at promoting behaviour change on a societal (community) level can lead to the type of environmental change necessary to sustain a permanent reduction in tobacco use in a particular community. Examples of environmental change measures may include restrictions on advertising, health warnings placed on cigarette packaging, bans on smoking, and formulation of smoking policies. Educational and media approaches place the onus of responsibility on the individual for resisting tobacco whereas public policy and activism enactment examine what communities and the society as a whole ought to do to protect vulnerable youth. While it is beyond the scope of this literature review to examine all program types and interventions, a summary of research evidence highlighting the effective elements of school-based programs is presented in the following section. Assessment of adolescent smoking emphasizes cognition in the context of one or more of the previously mentioned theories and specific self-reported behavioural skills. What an adolescent thinks or does has been of paramount importance in virtually all research into the effectiveness of prevention efforts. Only recently has measurement expertise moved to the activism and policy approach, away from the individual and more toward a community focus. Most major studies were of school-based programs using different variations on the social influences paradigm (e.g., Flay et al., 1989; Klepp, Tell, & Vellar, 1993; Nutbeam, Macaskill, Smith, Simpson, & Catford, 1993; Vartianen, Fallonen, McAlister, & Puska, 1990; Winkleby, Fortmann, & Rockhill, 1993). Some programs were stand-alone, others part of state or region-wide initiatives that also encompassed mass media, community projects, and legislation. Theoretical and empirical work in the area of smoking prevention over the past two decades has generated some consensus on the ideal approach, content, and delivery of school-based programs. 48 Programs which are based on a 'social-influences' approach or rooted in the origin of social learning theory concentrate on raising awareness of the social-cultural pressures to smoke and on developing skills to resist those pressures (Abernathy, & Bertrand, 1992; Botvin, Baker, Dusenbury, Tortu, & Botvin, 1990; Bruvold, 1993; Leventhal, Keeshan, Baker, & Wetter, 1991; Silvestri & Flay, 1989). The social influences model pinpoints the social environment as the most important determinant of smoking onset and concentrates on the development of norms and skills to identify and resist social pressures to smoke. Applied to smoking prevention, this approach assumes that young people who smoke may lack skills to identify and cope with various social influences that support smoking (Elder & Stern, 1986). Many of the social skills prevention programs were tested almost exclusively on white, middle- class adolescents in classroom settings. An important consideration in developing and implementing tobacco prevention programs is to demonstrate appreciation for cultural differences in our society and acknowledge that our communities are composed of individuals from varying ethnic, cultural, and linguistic backgrounds. It is imperative that a health message be perceived as salient and personally meaningful to program participants in order for the message to be effective. Cultural sensitivity in educational programs can be framed in a positive way by including images, words, or situations that are common in the daily lives of the intended audience. Several researchers cited elements that were essential to the development of an effective tobacco use prevention program (Flay et al., 1985; Glynn, 1989; United States Department of Health and Human Services, 1989). There exists considerable variation across school curricula, yet programs that ingrain skills necessary to resist social influences were included a fairly consistent set of components. Examples include instruction in resisting social pressures (e.g., advertising and promotional activities) and peer pressures to smoke and education that enhances general assertiveness, decision-making, and communication skills. Based on a review of the literature, a summary of guidelines and principles for effective implementation of prevention programs follows. In theory, prevention programs ought to start prior to experimentation with tobacco and continue through high school. In addition, the program needs to contain at least three informational components. First, information on the immediate physiological effects of tobacco (e.g., smelly clothes, bad breath, shortness of breath) need to be discussed. The nature of the information needs to address the significance of tobacco use as well as clarify 49 misconceptions as to social consequences of smoking. Put another way, the goal is to make not smoking "cool." Second, information concerning family, peers and media effects on tobacco use need to be given and strategies provided in order to better enable adolescents to resist these and other influences. Finally, instruction regarding specific behavioural skills (e.g., refusal skills to challenge offers to cigarette use), decision-making, and problem-solving methods require continual practice using interactive learning methods such as role play and student-led discussion (Bellew & Wayne, 1991; Silvestri & Flay, 1989). Role playing, a commonly employed method used in smoking prevention, is a good method for skill training as a way for participants to learn and rehearse ways to resist social pressures to smoke. The attitude change effects of role playing are established and well-known to social psychologists. Although McAlister, Vartiainen, and Lehtovuori (2000) support its effects they also insist health educators use caution when applying this technique with the caveat that role playing is appropriate only if participants do not take the role of the smoker. That is, if participants "play smoker" it may reinforce or increase their tendency to smoke. Prevention programs needs to include a focus on social norms, in particular those which address adolescents' tendency to overestimate smoking prevalence among peers (Conrad, Flay, & Hill, 1992). Information concerning short-term effects of smoking needs to be included (Sussman, Dent, Burton, Stacy, & Flay, 1995), yet information about long-term health risks were not likely to gain a significant effect (Bellew & Wayne, 1991). Ideally, prevention programs ought to concentrate solely on tobacco use, prevention, and cessation, and be kept separate from other drug or general health issues. One concern of a multi component health education curriculum was that tobacco control as one. component may be obscured by other health issues. However, results of some studies suggest that tobacco use prevention can be effective when appropriately embedded within broader curricula for preventing alcohol and drug abuse (e.g., Hansen & Graham, 1991) or within a school curriculum for general health education (e.g., Walter & Wynder, 1989). An expert advisory panel convened by the National Cancer Institute concluded that school-based tobacco prevention conducted within an inclusive comprehensive health curriculum appeared as effective as programs with an exclusive emphasis on tobacco, provided that the component regarding tobacco use received at least five classroom sessions in each of two years between Grades 6 and 9 (Glynn, Anderson, & Schwartz, 1991). 50 Summary of Empirical Evidence of Smoking Influences in Adolescence Based upon a review of the literature, clearly a complex array of social and cognitive factors contribute to the decision to smoke, and this complexity was confounded by differences in age and gender. Most researchers pointed to cigarette smoking as best conceptualized according to a series of stages, with initiation and maintenance having very different determinants. Evidence indicated that smoking was typically initiated or experimentation with cigarettes begins in the pre-adolescent and early adolescent years (as described and defined by those aged 11 to 14) or about grades 6 through 9. While different factors exert influences at these various ages, commonalities do exist. Generally speaking, it Is agreed that social pressure appeared as an important factor in the uptake of smoking. Two distinct types of normative influence were identified as important in determining smoking behaviour perceived approval and behavioural example. To support this suggestion, some researchers found that peer influence encouraged many children to experiment with cigarettes. However, others demonstrated that parental and sibling smoking behaviour were strongly related to the likelihood of young adolescent smoking, with older sibling smoking had an even greater influence than parental effects. Parental smoking has been documented as a strong influence in several studies yet some researchers suggest that it may predict smoking uptake less often than previously inferred. Smoking behaviour of siblings appears to be a strong influence. It has been also been suggested that parental smoking may influence girls more heavily than boys, yet no clear pattern of relationship has emerged. Parental attitudes toward smoking were also linked to initiation of smoking by children as were the attitudes of friends. It is possible that different factors exert differential influence on girls and boys and at different stages of smoking. Family influences may be more important in the experimentation stage than in the progression to regular smoking, and peer influences more important in the progression to regular smoking. However, in the literature there was little consensus, many predictive studies did not differentiate between the stages of smoking uptake. The nature of peer influence on adolescent smoking is complex. Although many studies confirm a very strong association between having friends who smoke and onset of smoking, the extent to which this reflects a causative link rather than merely a tendency to associate and select friends who share similar behaviours, beliefs, and intentions is argued. Peer influence may comprise both direct pressure 51 (i.e., taunting, teasing, encouragement to accept cigarette offers) and social or normative influence (i.e., beliefs about the views of others and motivation to conform with such perceived views). There was also evidence to suggest that advertising strategies by media and promotional campaigns of tobacco corporations affect recruitment of adolescents to initial smoking. Youth may also consider smoking as both a normative experience and a desirable adult behaviour due in part to the pervasiveness of cigarette advertising. In many cases, young adolescents were tacking the requisite skills to identify these influences and they lacked the knowledge and skills to resist these and other pressures to smoke. A nonsmoking lifestyle is perceived as ultimately preferable, yet the rebellious posture associated with smoking exerts a strong appeal, especially among high-risk youth. The number of children and adolescents who experiment with cigarettes is much higher than the number who become regular smokers which marks early adolescence as a critical time for developing the smoking habit. Prevention initiatives need to target both eady teens and experimental smokers to avert them from becoming habitual smokers insofar as the smoking initiation process begins at an early stage of adolescence or quite possibly, before. Interventions that hold the most promise are those based directly on findings from theory-based research and provide interventions linked with social influences, norms, and competencies for the maintenance of a nonsmoking lifestyle. Research Concerning Adolescent Smoking and Nonsmoking: Strengths and Limitations The research represented by this selected review of literature on adolescent smoking contributes to what is currently known concerning social, psychological, and environmental factors associated with the etiology of smoking onset, along with how some factors were predictive of smoking and others were not. Research which delineates variables such as levels of smoking and age affirmed that adolescent smoking is a complex social phenomenon. Obtaining quality data demands attention to the research design, instrumentation, and administration of research methods relative to smoking behaviour. Studies over time. Studies that use cross-sectional and longitudinal designs are useful to address and evaluate developmental issues. Longitudinal designs afford the additional advantage in that researchers can measure subtle developmental change within subjects whereas with a cross-sectional design, behaviour changes between subjects are measured at one point in time. Findings from studies designed using these two approaches impart meaningful insight into social-psychological behaviour. 52 However, with cross-sectional studies subjects are observed at different ages at the same time which confounds the age of the subject and the cohort; That is, adolescents would be from only one generation. A longitudinal design permits study of subjects from the same cohort who are observed over several different time periods, yet this design does not control for the effect of history or period. That is, different results could be obtained if individuals were studied during different time periods. Design deficiencies are important to note in a study concerning social-psychological variables and behaviour. Studies concerning smoking are a case in point. Given the generation which a particular study was in progress, certain attitudes and values observed during the 1970s and 1980s are not likely representative, may not be valid, or consistent with the generation of adolescents in today's age. Methodological considerations. One important data collection method, the self-report, has played a dominant role in smoking research in areas such as opinion and attitude measurement, personality assessment, social-psychological behaviour, and prevalence rates. In the literature, the terms "self- report," "self-evaluation," "introspective report," "subjective evaluation," and "self-appraisal" are used interchangeably. Self-report questionnaires (frequently called 'measures' rather than tests as no right or wrong answers exist) were used with study participants to elicit their preferences for different activities or describe how they might behave, a given situation. Self-report questionnaires are based on the premise that individuals know their own preferences, interests, and so on, therefore remain the best possible source of information about themselves. Assuming that participants possessed a reasonable amount of insight into their own behaviour and were willing to freely share that insight (presuming their insight matched the items appearing on a social-psychological measure), self-reports were judged as an efficient, economical, and effective method of gathering information. Self-report methodology. The traditional means of assessing adolescent smoking behaviour has relied heavily on the use of self-report measures. Validity is of particular concern when self-reports of a sensitive behaviour are involved due to a participant's unwillingness to admit such a behaviour which can contribute as a significant and potent source of measurement error (Bauman & Dent, 1982). The validity of behavioural measures is inextricably linked to reporting accuracy and the extent to which observer bias enters into the reporting. Study participants' ability to be unbiased observers of themselves may also vary. There is always the concern for the potential distortion of results obtained using a quantitative measure, especially self-reports. For instance, one consequence known as a 'response sef involves the 53 tendency of participants to use what are thought to be more socially desirable response set categories or to provide what might be perceived as the 'correct' response in a particular situation. Self-report and research on smoking. Self-report measures are a simple, efficient, and inexpensive data collection method, yet a number of factors often pose threats to validity. For example, adolescents often smoke infrequently and episodically. As a result, it may be a difficult task for them to characterize their 'usual' pattern of smoking. It is also possible that adolescents may not accurately recall the number of cigarettes smoked In recent days or weeks. Furthermore, study participants may also try to mislead the investigator and under report smoking behaviour out of embarrassment or in a deliberate attempt to please. Finally, it may also be that adolescents exaggerate smoking levels in order to appear older or uncooperative. While self-report measures are easily administered and relatively straightforward, their use however, has raised a concern relative to those respondents who reported what they believed to be the socially desirable response. Some researchers suggest that adolescents may be reluctant to accurately report their use of cigarettes due to the notion that smoking remains a socially proscribed behaviour among young people (Evans, Hansen, & Mittlemark, 1977; Kozlowski, Herman, & Frecker, 1980). Even though epidemiological studies and smoking surveys demonstrated evidence of a national decline in adolescent smoking, this trend might reflect more of a decline in the validity of self-reports than actual smoking rates (Mittlemark, Murray, Lueper, & Pechacek, 1982). Put another way, while smoking levels remain very high among adolescents, more than likely it was a case of disclosure rates that reflect such a decline. Inconsistencies in data. One interpretation offered for inconsistencies in data collected by self- report measures may be due to tendencies of adolescents to exaggerate their involvement in more socially unacceptable behaviours as a way of achieving status among their peers (e.g., over-reporting). A more generic explanation for inconsistent reporting is that some adolescents simply provide poor- quality data. Whether it was due to lack of motivation, limited reading or comprehension ability, or other reasons, adolescents who rescind reports of smoking were the more likely reason representing higher non-response rates (e.g., leaving more questions blank). It is also possible that some respondents may be confused by the question or what was asked relative to giving a response. Moreover, it is important to remember that consistency is not synonymous with accuracy as there is always the potential for 54 consistent distortion in reporting. The inconsistencies associated with the use of self-reports to measure smoking behaviour are not always due to dishonesty. Another critical point concerning the use of self-reports to measure smoking behaviour was advanced by Botvin and colleagues (1984) - smoking may not always be a socially undesirable behaviour. One such case may be in a situation where smoking is quite common or where there are few social sanctions against smoking. There may also be less pressure to under-report when participants are provided assurance that their responses will be kept confidential. In other situations, there may be considerable social pressures to under-report. Findings from some studies (e.g., Pechacek et al., 1984) are suggestive that over-reporting can occur, although it occurs at a very low frequency. Elements of test construction and survey format. Other problems with survey methods were related to the appropriateness of wording and questions. In particular, researchers highlight issues that may be of little concern to adolescents and may dodge issues that are salient and relevant to adolescents. Other investigators argued that self-report data collected from adolescents in their homes were less valid than those gathered in a school context (Kandel, 1978). The extent to which such a finding was true might be an implication for the generalizability of findings of a particular study. That is, data collected in a home environment were not generalizable to data collected in a school setting, especially if one considers that most studies of adolescents use data collected in schools. The school environment could therefore point to implications for the consistency of self-report behaviours (Tursz, 1997), particularly in studies concerning smoking, where the attitude of adults is one that considers smoking to be socially undesirable or inappropriate for young people during adolescence. Developmental factors influencing validity of adolescent self-reports abound. Comparing study findings and samples was difficult as self-report surveys vary considerably in terms of time period, geographic locations and regions, types of schools, method, and the operational terms used to define variables. Despite these difficulties, Pachacek and colleagues (1984) suggested, however, based on previous research investigators ought to continue using and relying on self-report measures as the primary data collection strategy with populations such as younger adolescents, particularly those in junior high school. As with the range of terms used to denote self-reports, a number of definitions also exist to identify people in the "smoker" and "nonsmoker" categories. The range in definitions for the term 55 "nonsmoker" can be defined rigidly as a total abstainer (e.g., never smoker), or more loosely, such as "trier" or "experimenter" groupings. The degree and nature of smoking are often defined according to the number of cigarettes smoked in a certain period of time. A standard definition does not exist and the number of cigarettes as well as the particular time frame varies from study to study. Numerous researchers demonstrated peer smoking was associated with adolescent smoking, yet it was sometimes difficult to compare study findings, again due to inconsistency in use of the term "peer," one that varied by researchers and studies in different ways. Typically, researchers use the survey method with a limited range of items on a particular instrument or questionnaire. Specifically, "peer smoking" may denote a response concerning peer influences, offers of cigarettes from peers, peer attitudes toward smoking, and/or friends/best friends who smoke. Moreover, study participants may be asked to respond about their own behaviour or about their attributions to the behaviour of others. However, by defining peer as a friend or best friends, other researchers found that the value of peer approval predicted onset of smoking more strongly for giris than boys (e.g., Best, Brown, Cameron, Manske, & Santi, 1995; Pomrehn, Jones, Ferguson, & Becker, 1995). Defined this way, peer approval was therefore an important factor related to the onset of smoking, it influenced girls and boys in different ways and to varying degrees. Specific adolescent concepts. Another issue concerns the research focus, as most studies to date involves the examination of close friends rather than the wider context of a peer group as one source of peer influence. The lack of research attention to the wider peer group signified that little was known about the role of peer influence from non-friends, such as important peer leaders or peers who were desired or sought as friends. Frequently, questionnaire items were framed in terms of "peer pressure" which raised the problem of children's images and meanings of the concept. In a child's mind, is peer pressure the same as teasing, taunting, or bullying, or is there another meaning? In the absence of a clear understanding of the concept, it is possible that adolescents who reported experiencing peer pressure may do so only in the context of a particular study or as an artifact of the research measures employed. Surveys and quantitative methods provides knowledge which was used to determine social- psychological factors and behavioural characteristics associated with smoking onset during adolescence. Results of this literature review indicated that research that included measures of social-psychological, 56 cognitive and behavioural factors were valued and needed. Due to the numerous difficulties inherent in the research designs used in previous studies and surveys of large populations, the limitations of methods and instrumentations, and inconsistencies between study findings, significant gaps in knowledge remain. Theoretical Stance: Grounded Theory as a Research Methodology The measurement of smoking behaviour is a complicated matter. Thus far, Information gained from quantitative research has guided health educators in a number of ways. Previous research has illuminated the complex nature of the decision to smoke in adolescence, identified groups potentially at risk, and provided direction to those developing and implementing prevention programs. However, the precise way that social and cognitive factors may or may not help nonsmoking adolescents resist pressures to smoke remains unclear. Moreover, individual and group characteristics studied to date are determined a priori by researchers, ones based on an incomplete understanding of smoking and nonsmoking behaviours. Consequently, there is a need to describe experiences that contribute to and support efforts to be a nonsmoker. Such an approach has the potential to provide new and valuable insight into the experience of nonsmokers and improve our understanding of how and why adolescent nonsmokers manage to avoid incorporating smoking into their lives. Theoretical Stance A distinct lack of tobacco control studies that evolve from a qualitative paradigm is considered a limitation. Qualitative research methods can potentially contribute knowledge relative to why, and how certain young people do not smoke. Moreover, these methods empower research participants to share their stories and lived experiences in detail. For instance, a qualitative study would permit a researcher to study how 10 to 14 year old "nonsmokers" succeed in remaining smoke-free. Further, qualitative methods can serve to complement quantitative studies, and new perspectives based on shared realities and lived experiences could then be applied and used to further direct research in tobacco control, provide much needed guidance for teachers, parents and families, and health psychology education promotion initiatives for unique and separate groups. A basic assumption guiding this research directive is that maintaining a nonsmoker identity is just as complex as remaining a smoker. Grounded theory, an approach to conducting qualitative research, utilizes a specific set of data collection and analysis procedures to develop an inductively derived theory 57 from the data. The generation of theory occurs during actual research whereby field work and interviews are the usual methods for gathering data, based on comparative analyses among or between groups of persons within a particular area of interest. Accordingly, the process for generating theory is both hierarchical and recursive as the researcher must systematically categorize data, hence limit theorizing until patterns emerge or earn their way into the categorizing analysis. Purpose of grounded theory. The primary purpose of grounded theory is to generate explanatory models of human social-psychological processes that are grounded in the data. A secondary purpose of grounded theory is to elaborate on and modify existing theories. Accordingly, the major distinguishing factor between grounded theory and other qualitative research methods is the emphasis on theory development, either substantive or formal (Glaser & Strauss, 1967). A substantive theory is one that is grounded in research and based on a specific content area (e.g., tobacco control). Consequently, substantive theory evolves from the study of a phenomenon situated in one particular situational context (e.g., 10-14 year old early adolescent "nonsmokers"). This is off set by formal theory, one that involves a conceptual area (e.g., stress, cognitive appraisal, coping). In other words, a formal theory emerges from a study of a phenomenon examined under several types of situations. The Grounded Theory Method of Research Grounded theory refers to a specific general methodology for conducting a qualitative study (Glaser, 1978). The researcher's purpose in using this method is to generate exploratory theory that furthers one's understanding of social and psychological phenomena (Strauss & Corbin, 1990,1998). Grounded theory places great emphasis upon attention to participants' own accounts of social and psychological events as one aspect of the detailed and close inspection of a specific problem domain. The generation of theory occurs during actual research (Strauss & Corbin, 1994), and is inductively derived based on comparative analyses among or between groups within a substantive area using methods of field research for gathering data (Morse & Field, 1995). The grounded theory method is particularly suited for discovering the complex interactional processes underlying human behaviour and their meanings as related to the social context where they actually occurred and for articulating those processes conceptually. The researcher thus generates grounded theory when one is concerned with "the discovery of theory from data" (Glaser & Strauss, 1967, p. 1) rather than with the testing or verification of existing theories. 58 History of grounded theory. Grounded theory was first developed in the 1960s by two sociologists, the now late Anselm Strauss and his co-founder Barney Glaser, during their studies of institutional care provided to terminally ill patients (Charmaz, 2000). The history to the development of grounded theory as a methodology originates in the symbolic interactionist perspective of Herbert Blumer and the case-study approach of the so-called Chicago School (University of Chicago school of social psychology and sociology) in the 1920s and 1930s (Bogdan & Taylor, 1975). A brief overview of the respective origins of the developers' educational backgrounds follows to situate the theoretical foundations for a grounded theory study. Strauss came from the Chicago School which has a long history and tradition in qualitative research methods (Strauss & Corbin, 1990). While studying at the Chicago School Strauss' thinking was influenced by the writings of social interactionists such as Robert Park and the ideas of George Herbert Mead, one of the principal exponents of the symbolic interactionist perspective. Another influence came from Herbert Blumer who popularized Mead's (1934) work and who first coined the term 'symbolic interactionism' in 1937. In contrast, Barney Glaser received his sociology training at Columbia University and was influenced by Paul Felix Lazarsfeld, an early innovator in the use Of qualitative methods in sociology. At that time, Glaser realized the need for an explicit and systematic set of techniques and procedures for both coding and testing hypotheses generated from qualitative research methods (Strauss & Corbin, 1990). During the early days of co-founding grounded theory, Glaser and Strauss (1967) observed that sociological practice relied almost exclusively on quantitative methods; the status of qualitative methods was at an all-time low. Accordingly, both sociologists challenged the hegemony of the quantitative paradigm whereby they argued for a radical change of philosophy, one aimed at generating more explanatory, contextual models of human social-psychological behaviour. Their principal concern, one which they articulated in their publication The Discovery of Grounded Theory. Strategies for Qualitative Research (1967), was to liberate researchers in sociology from the theoretical shackles of a few 'grand* theories. Hence, they chose the term 'grounded theory' In order to convey their notion of theory that is generated by or grounded in an iterative process involving the continual sampling and analysis of qualitative data gathered from field work (Glaser, 1999), an idea that is now a central tenet of the naturalistic paradigm (Charmaz, 1995). 59 Following the development of their method, both Glaser and Strauss held appointments at the University of California, San Francisco where their respective research and teaching interests (ed to the introduction of grounded theory to the faculty and students in the university's School of Nursing. As a result, grounded theory has gone global among many disciplines (Glaser, 1999), and is widespread in particular fields such as health psychology (Charmaz, 1990,1995, 2000; Rennie, Phillips, & Quartaro, 1988), nursing (Chenitz & Swanson, 1986; Morse, 1989,1991; Morse & Field, 1995; Strauss & Corbin, 1990,1994,1997,1998) and organizational research (Martin & Turner, 1986; Turner, 1981). Differing versions of grounded theory. Since the publication on the method of discovering grounded theory, the original work of Glaser and Strauss (1967) has evolved into differing versions, referred by some (e.g., Stern, 1994) as the Glaserian and Straussian iterations. For instance, Glaser (1978) published Theoretical Sensitivity in an attempt to provide more precise and rigorous refinements on the method. Likewise, Strauss followed suit with an independent publication Qualitative Analysis for Social Scientists in 1987. Additionally, Strauss, with former student and colleague Juliet Corbin, co- published Basics of Qualitative Research in 1990. A formidable debate ensued concerning which version captured the true essence of the grounded theory method. In a subsequent publication Glaser (1992) viewed the Strauss and Corbin (1990) rendition as a significant departure from the original method, one that he named "full conceptual description'' (p. 124). In full conceptual description, Glaser contended there is "forcing" of data and theory using an approach to data analysis that is preconceived and verificational in nature rather than allowing "emergence" of data oriented to discovery and inductive theory generation (p. 2). Nevertheless, Strauss and Corbin (1990) maintain a position on their rendition as one that is a refinement of the grounded theory approach, one that offers a straightforward, step by step procedure for analyzing qualitative data. For instance, their approach introduced new procedures for initial coding as a way for reassembling data in new ways: axial coding and dimensionalizing. Strauss and Corbin (1990) advocate the use of a coding paradigm aimed at making connections between a category and its subcategories by specifying a category (phenomenon) in terms of causal conditions giving rise to the category, its context (a specific set of the category's properties), the action/interaction strategies by which ft is handled, managed and carried out, and the consequences (or outcomes) of those strategies (p. 97). 60 Further, Strauss and Corbin proposed that researchers develop a "dimensional profile" to divide properties of a category into dimensions that lie along a continuum. The intent behind techniques such as these is to make researchers' emerging theories more precise, complex, and dense. Glaser (1992), however, stresses a coding strategy through the process of constant comparative analysis and raises sharp differences with Strauss and Corbin (1990) about forcing data and paradigmatic analysis through methodological strategies (e.g., axial coding), which he warns can lead to clumsy categories and scientists terms. For Glaser (1992), the use of systematic comparisons is sufficient as "categories emerge upon comparisons and properties emerge upon more comparison. And that is all there is to it" (p. 43). Devers and Robinson (2002) aptly make the point that although constant comparison and paradigmatic analysis are two basic strategies for grounded theory analysis, researchers typically use one or the other. Both analytic strategies are accepted and recognized in the qualitative research community, yet the decision as to which coding strategy will be used is at the researcher's discretion. Use and approach to grounded theory in this research. While it is not within the scope of this research to elaborate on the debate between grounded theory originators and the respective merits of each of their restatements and refinements, one point can be made explicit concerning methodology. As applied and used in this research, this study represents the basics of the grounded theory method in its original form. As well, in those instances where clarification was needed, given the context of a perceived departure from the original version, the approach taken in this study reflects more of a contemporary Glaserian iteration. For example, as a novice-grounded theorist, I found the presentation and discussion by Glaser (1978,1992) beneficial in explaining the two major, steps within the data coding process and delineating criteria for selecting the core category. Another instance of clarity was derived from Glaser (1992) concerning the writing of theoretical memos, the process for sorting memos, and the writing up of the theory. Central features of grounded theory. In the spirit of the original version, a critical characteristic of the whole grounded theory methodology is the dynamic relation between data analysis and data collection. An important analytic strategy in grounded theory is one of continually sifting and comparing elements (i.e., basic data instances, cases, emergent categories and theoretical propositions) through the entire course of the research endeavor. By making such comparisons, the researcher is sensitized to similarities and differences as a part of the exploration of the full range and complexity of the body of 61 data where comparisons are used to promote conceptual and theoretical development. This comparative analysis is a central feature of grounded theory and is often referred to as the constant comparative method (Glaser & Strauss, 1967; Glaser, 1978,1992). Another central feature of grounded theory is theoretical or purposive sampling, a term that is used to refer to the simultaneous process of collecting, coding, and analyzing of data to establish a subsequent sampling plan (Glaser, 1992). In theoretical sampling, one specific process referred to as open sampling, is defined as sampling that admits persons, places, and situations to the study in order to capitalize on the opportunities to best gather the most relevant data concerning the phenomenon or problem under investigation. In the case of this study, open sampling occurred in conjunction with open coding. As implied by the classification of method, open coding is another process of naming and categorizing phenomena (Glaser, 1992). As the purpose of grounded theory is to construct theory from the data itself, solid rich data are required to elicit thorough, accurate, and complete development of analytic and conceptual issues (Glaser & Strauss, 1967). Data collection is shaped by analytic interpretations and discoveries, and hence, directs the grounded theorist to sharpen one's observations. In order to explain and interpret emerging ideas, the grounded theorist continues to collect data until one is able to adequately substantiate explanations and theories (Charmaz, 1995; Glaser, 1978,1992). Symbolic Interactionism: The Theoretical Context of Grounded Theory As noted previously, grounded theory has its roots in the social sciences. Most notably, symbolic interactionism is one theoretical framework from which to approach the study of human behaviour. Symbolic interactionism is rooted in the pragmatic philosophical tradition (with its emphasis on studying process, action, and meaning), articulated by John Dewey (1930) as founder of the Chicago school of pragmatism (1894-1904) and from the works of Chicago School sociologists such as Charles Horton Cooley (1902), G. H. Mead (1934), Robert Park (1915), and William Isaac Thomas (1937). Mead (1934) established a theoretical position on the interrelationship between mind, self, and society, one which represents the clearest and most influential presentation (Taylor & Bogdan, 1998). Symbolic interactionism theory. Symbolic interactionism, as surmised by Mead and later described by one of his students, Herbert Blumer, represents the philosophical foundations for grounded theory as a methodology. Mead (1934) postulated that people come to define themselves through social 62 interaction with others in the forms of social roles, expectations and learned perspectives. While {Stumer's (1969) concept of self was similar to that of Mead, he emphasized the premise that people who associated with each other are engaged in a process of interpretative interaction. Accordingly, the symbolic interactionism perspective is based on the premise that the individual's social world is enacted and hence involves the interplay of significant symbols, gestures, and systems of meanings embedded within a significant social context. Applying the symbolic interactionist perspective, Blumer (1969) argued for three central principles: (a) human beings act toward things (objects, institutions, cultures, groups) on the basis of the meanings that the things have for them, (b) this attribution of meaning to objects through symbols is a continuous, interpretive process, and (c) meaning attribution is a product of social interaction in human society. These symbols can be defined as language, signs, gestures, or anything that conveys meanings, and the meaning is constructed in social interaction. The symbolic interactionist places primary importance on the social meaning people attach to the world around them. As such, people do not simply react to stimuli or act out cultural scripts - it is the meaning that defines action - people team how to see the world from other people. Moreover, as social actors we develop shared meanings of objects and people in our lives whereby meanings are social constructions that arise during interaction. The dynamic processes of interpretation acts as an intermediary between meanings (or tendencies to act in certain ways) and the action itself. That is, people are constantly defining and interpreting things as they confront and navigate through different situations. Different people say and do different things by reason that they have had different experiences and have learned different social meanings. The specific techniques of grounded theory based on symbolic interactionism were developed and refined by Glaser and Strauss (1967). Accordingly, this theoretical orientation requires the researcher to engage in interpretative work, unraveling the multiple perspectives and common-sense realities of the research participants by examining their social interactions within the context of their everyday lives and naturalistic surroundings. When applied this way, symbolic interactionism directs the researcher to grasp behaviour as it is understood by the participants, learn about their world, discover their interpretation of self in the interaction, and share their definitions. In other words, grounded theory studies use this orientation as a theoretical framework (Chenitz, 1986). In the case of grounded theory, this leads to a research model that is flexible, and carried out in everyday contexts, where the aim Is the 63 co-construction of participants' symbolic worlds and social realities. Assumptions of grounded theory. As applied and used In this study, grounded theory serves as an appropriate method for conceptualizing behavioural differences and similarities within a particular group of nonsmoking early adolescents. In order for the researcher to empathize with child participants and discern their understandings, this researcher made the following assumptions: (a) realities are constructed; (b) participants are active agents making sense out of their realities as they are encountered; (c) realities are multiple and need to be perceived holistically; and (d) realities are shared and mutually i shaped by the researcher and study participants (Lincoln & Guba, 1965). Rationale for Grounded Theory in this Study A research study that is conducted from the vantage point of the early adolescent is justified to improve our understanding of social comparative processes and shared judgements in early adolescents' smoking-related decisions. Before preventive interventions can be developed and tested, experiences that shape and sustain health promotion behaviours, such as a person's decision to be a nonsmoker, must be clearly identified. The meaning smoking has for early adolescents cannot be assumed from the meaning it has for adults. Further, this research directive was premised on the view that maintaining a nonsmoking lifestyle is as complex as becoming a smoker and a process, in some form or another, is experienced by early adolescents who maintain a smoke-free choice. Addressing gaps in current knowledge. Despite the research-based evidence that points to a multiplicity of personal and environmental factors linked to adolescent cigarette smoking, a theoretical foundation to base interventions for early adolescents is seriously lacking. Little is known about the experiences and situations early teens perceive as relevant to nonsmoking due to existing theoretical approaches which have been deductively derived and have primarily involved older adolescents and young adults as research participants. Moreover, inductive theory development that takes into consideration the perceptions of individuals' experiences and factors associated with nonsmoking is lacking for all age groups. Previous research in this domain has relied on the quantitative paradigm; this may be due in part to the focus of inquiry. Correspondingly, few educational psychology and health education studies are based on children's accounts of their everyday lives and experiences. In truth, the methods employed, the research populations and participants studied, and the way data are explained are all impacted by 64 how one views children. This point is aptly illustrated by Morrow and Richards (1996) in stating there are "so few attempts to understand children's lives in their own terms, and taking children's own words at face value, as the primary source of knowledge about their experiences'' (p. 97). In actuality, the child's world is often understood by the voices of parents - we do not discover the perspectives of children. Instead we learn about adults'concepts of childhood. Grounded theory as a suitable method. Nevertheless, it is possible that certain research questions best suited to the qualitative paradigm are being avoided. It may well be that to this point, researchers have assumed that the key theoretical foundations of the qualitative paradigm are difficult to adopt, and most especially when children are involved as research participants. Moreover, there is an excruciating need to broaden the disciplinary base of health promotion. Qualitative approaches have appeal to researchers conducting health promotion education research and create possibilities for a critical research perspective (e.g., Maclean, 1991 [diet and self care in diabetes using a phenomenological perspective]; Maclean, 1998 [women's experiences with breast-feeding using qualitative interviews]; Maclean & Eakin, 1992; Eakin & Maclean, 1992 {Issues for qualitative research in health promotion]). Accordingly, using early adolescents as informants of their own experience through qualitative interviews has been documented as both credible and dependable (Deatrick & Faux, 1991; Sorensen, 1989). Clearly, early adolescents' perceptions and views can and ought to be elicited on a range of issues and their voices need to be heard. In this chapter literature was presented that provided background to the phenomenon under study relative to key factors concerning smoking during the developmental phases of adolescence. As well, strengths of previous studies were discussed to lend support and build a case to carry out a study to explore understandings of smoking and not smoking amongst early adolescents. Additionally, I defend the choice for using grounded theory as a qualitative research method to explore the phenomenon under study, and explain how grounded theory was developed as a research methodology. In the next chapter how grounded theory was both applied to the study design and carried out within a school situation and context is explained and discussed. A fundamental premise of this research conceptualizes social meaning as one that is both actively constructed and inextricably related to the social-cultural environment. Accordingly, a school-based approach to participant selection and field work that involved in-depth interviews and a drawing task were chosen for the present study. 65 Chapter Three Grounded Theory: A Systematic Approach In the previous chapter an overview of the grounded theory method and its assumptions was presented. In Chapter Three, the way in which grounded theory was applied to this study is described. The purpose and objective of the study and statement of the research questions are featured initially. Then, an overview of grounded theory methods as used in this study is presented outlining step by step the sampling techniques, characteristics of the study sample, data collection procedures, and data analysis operations. Finally the chapter concludes with an explanation concerning consent and ethical considerations for protecting human subjects as child participants in a research study, and methods for evaluating the quality of this inquiry are discussed vis-a-vis rigor and credibility. This chapter is organized into two separate sections according to the procedures used in this study for data collection and data analysis. A central feature of the grounded theory approach is that data collection and data analysis occur simultaneously; however, for the purpose of presentation each process is outlined separately. To provide a context for the study and the sample, the study setting and approaches used to access and recruit participants is presented initially. This is followed by the stages involved with data collection and will be presented in two parts. The first part is organized according to the procedures used relative to sampling. As the primary source of data was interviews from individual participants that were transcribed verbatim, the second section is organized according to the procedures, methods, and processes implemented for interviewing. Finally, the analytic operations and procedures used during data analysis concludes the section concerning the overall research design and methods according to the grounded theory method. Purpose and Objective of the Present Study The intent behind this study was to explore early adolescents (10-14 year olds) to learn about and gain a shared understanding of the processes underlying their nonsmoking behaviour. Another aim is to contribute theoretical knowledge, specifically, to generate a theory about how young people make smoke-free goals and consolidate a social identity as nonsmokers. In this study early adolescent nonsmokers were viewed as a unique group and used a social-psychological developmental perspective. This investigative effort was undertaken to achieve an enhanced understanding of social comparative judgements and processes as a beginning step toward designing developmental^ appropriate educative 66 prevention programming in a school context. Previous studies concerning smoking initiation demonstrate that the vast majority of people who become addicted smokers started smoking regularly before the age of 18 (Flay, 1993). The onset of smoking amongst the adolescent population in British Columbia (BC) occurs at approximately 13 years of age (Angus Reid Group, 1997). Findings from previous BC based studies highlight the importance of promoting nonsmoking lifestyles early in children's lives. Preventing youth from starting to smoke and supporting their choice for a smoke-free lifestyle is an important educative initiative that takes a view to promote the best possible health for adolescents as future adults. Research Questions The following research questions were addressed in this social-psychological study. For early adolescent nonsmoker study participants: 1. What contributes as experience relevant to making a decision about not smoking? 2. What contextual factors influence a decision about not smoking? 3. How do nonsmokers manage to avoid integrating smoking behaviours into their lives? That is to say, if a process or processes exists, then: (a) What process(es) do nonsmokers use? (b) How do they go about making their nonsmoking choices and decisions? Overview: Methods of Generating Theory To carry out the aims of this study, this researcher employed a naturalistic qualitative research design and used the grounded theory method from interactionist and constructivist perspectives. As noted previously, specific fundamental analytical commitments shape grounded theory which clearly differentiates its methodological stance from other forms of thematic analysis traditionally associated with the qualitative paradigm. These methods, constant comparison and theoretical sampling, were used primarily as a means of generating theory and building conceptual and theoretical depths of analysis; however, both are more than mere procedural methods for selecting and processing data. Using the constant comparative method, the grounded theorist is sensitized to similarities and differences as part of the exploration of the full range and complexity of the body of data where comparisons are used to promote conceptual and theoretical development. Theoretical sampling involved the active sampling of new cases as data analysis proceeds. 67 Given that the goal of grounded theory is the elaboration of a conceptually rich, dense, and contextually grounded account (Glaser & Strauss, 1967), the researcher was directed to sample multiple cases in order to extend or modify the emerging theory. Accordingly, sampling is often explicitly driven by theoretical concerns, with new informants being selected for their potential for generating new theory by extending and deepening the researcher's emergent understanding. The researcher is therefore concerned with selecting participants who are willing and able to both tell their stories and to relate their experience and knowledge in depth (Sandelowski, 1995). In other words, when selecting a sample, the researcher's primary concern relates to quality of information (i.e., adequacy and appropriateness of informants' experience) rather than concerns that pertain to quantity (i.e., number of participants). Study Setting and Approaches The process used for recruitment of participants and associated strategies is presented and discussed. A description of the study setting is introduced first as a way to situate the context of the sampling procedures used in this study. Next, appears a description and presentation of the characteristics of the total study sample which concludes this first section. In the first main section of the chapter, the initial sampling procedures and related criteria used in the study are presented. Theoretical sampling will then be introduced as a way to situate the context of the sampling procedures used in this study. Study Setting The researcher conducted individual interviews at participants' schools, both of which were situated in two suburban communities within a public school district located midway on the east coast of Vancouver Island, British Columbia. Data collection occurred over a four-month period. The researcher maintained temporary residence in the community, beginning March 2002. Living in the community prior to the commencement of formal school-based data collection afforded an opportunity to make observations of the ways of life for participants and their families (Geertz, 1973). As a researcher living in a small suburban town (population approx.18,000) within the school district community (population approx. 52,000), I was able to access local information (newspapers, community events, internet sites), gain a feel for suburban and rural community life through visits made at local places of interest (stores, restaurants, coffee shops, book stores, office supply/service outlets, community centres), and conduct observational tours of neighbourhoods (driving, walking, cycling, 68 photographing) where students attended schools. Rationale for a school-based approach. Formal school-based interviews commenced in April 2002 and completion coincided with the school year end in June. Given that eariy adolescents spend most of their waking hours in the company of peers and adults who are not their family members (Combrinck-Graham, 1996), it seemed appropriate and feasible to situate data collection (participant recruitment and interviews) in an ecological setting where early adolescents would be most familiar and easily accessible (Donaldson, 1978). Moreover, the advise of some investigators (e.g., Kandel, 1978) working in adolescent contexts argued that self-report data collected from participants in their own homes were less valid than those collected in a school-based context. While this point may be more applicable to studies involving quantitative measures, the principle applied here relates more to convenient access and logistics concerning time (e.g. interviewing participants while in school versus after school) which has an implication for location (i.e., parents may not desire any researcher in their homes), and I was not too keen about conducting home-based interviews, given the potential risks involved (e.g., finding a stable, consistent interview setting and my personal nature as a female researcher who did not want to give the appearances of intruding on a participant's home life or imposing on their personal time). Further, Tursz (1997) advocates a school environment as one that ensures consistency of self-report behaviours. Although this point is certainly valid concerning psychometric methods used to solicit self-report data, the principle applied to this qualitative study relates more to trustworthiness or a genuine, credible sense of an accurate and as reat-to-life look at students as possible, while they attend school. Additionally, I deliberately sought permission to conduct interviews during school time so as to minimize any inconvenience for participants and to allow them to maintain a sense of control over the interview experience. As well, I remained acutely aware of the need to both create and sustain an atmosphere that was perceived by informants (as well parents, teachers, school administrators) as safe and comfortable. Thus, the most natural and obvious choice was a school context, one which provides a high level of continuity and is certainty conducive to carrying out field work that necessitates a private, individualized interview setting. As one of the tenets of naturalistic inquiry is the importance of observing people in their natural setting, conducting field work (i.e., interviews and nonparticipant observations) in a school context provided a realistic and everyday look into the participants' usual learning and social 69 contexts. Approaches for Recruitment and Associated Strategies Numerous approaches were taken relative to school selection, participant recruitment, and management of the study setting. Over the course of this study what approaches and strategies were used along with a statement of rationale for each are presented in the following section. Approach to school selection. Due to the focus and interest concerning early adolescents aged 10 to 14,1 made a purposive decision to recruit a middle school versus a high school. My reasons were two-fold. First, I could anticipate that conducting a study inclusive of grade 7 to 9 students could be one way to "bracket" (i.e., control) the confounds (i.e., influences) of older peers, such as a high school context. Accordingly, I could anticipate a somewhat "cleaner" or truer, more genuine picture of eariy adolescent school life. Second, I was sensitive to the notion of peer pressure, or at least what we (i.e., adult researchers) think the notion involves. Thus, in the absence of a physical presence of peers that were older than participants, I based my decisions for school selection and on that reasoning. The same logic was also applied to selecting an elementary school, one that would match a transition from grade 6 into a new school structure, hence by default, students in grades 5 and 6 were the oldest in the elementary school. Upon discovering the existence of the Community Organization for Drugs and Education Services [CODES] Counter Attack program as a peer led school-based program operating in some school structures, I purposively sought out this particular middle school as one that both subscribed to the program and experienced success with its implementation (i.e., the program needed to be established, actively supported, and well organized). These students and the group liaised with the middle school youth and family counsellor who organized this advocacy group or club. I use the term 'advocacy' to avoid the negative and oppressive tone associated with another term commonly used to denote such groups (e.g., 'activist'). As well, during the time I met this group the term 'advocacy' seemed more in keeping with their overall mission or goal. Once I learned more about the program and its members, I could clearly appreciate they had embarked upon a crusade of sorts and certainly supported a prevention focus. The CODES group, as they were known by others and amongst themselves, was comprised of students who were passionate (varying from very interested to vehemently opposed) about preventing 70 high-risk youth behaviours such as smoking and drinking and driving. Participants organized school- sponsored activities throughout the year and attended regular meetings at school, as well provincial seminars and workshops. At the time of this study, the majority of the COOES group school and community-based activities (in terms of smoking some members used descriptors such as, "the tobacco war" or "the cigarette war") were directed at preventing drinking and driving and fleshing out issues relative to notions of driving while impaired (or DWI charge under the Criminal Code ofBC). Hence, this counter attack focus was derived in part through the Insurance Corporation of British Columbia (ICBC) Counter Attack Road Sense Society of British Columbia (CARS BC) Program, a provincially funded, organized, and recognized school-based, peer led group or project carried out by the CODES group. Approaches to gain familiarity with the schools' contexts. Prior to receiving the official letter of permission from the school district to conduct this study, I was granted permission to make contact with school principals whose names were suggested by the school district superintendent. This provision was made as the school board was extremely interested in my study, yet the formal procedure for approvals was scheduled at the next board meeting for the middle of March, 2002. Anticipating approval, yet given the time needed for the board of trustees to issue permission, I would only have access to students for three months (April to June 30). Hence, it was agreed that direct student contact via interviews required written parental consent. However, there was no reason to deny my access to schools for the purpose of meeting staff and conducting informal field observations on school property. The district also required I provide confirmation of a negative criminal record check from my local police detachment, one which I provided prior to making contact with schools, as this was another condition for working with students in school settings. I began this study by performing informal walkabouts to conduct informal, nonparticipant observations at schools that were suggested by the superintendent. After making these initial school visits, I settled on one elementary school and one middle school both in the same district, yet situated in two geographically distant locations within the township community. Next, I met the teachers to introduce my study and purpose, as well establish parameters for participant, teacher, and parental involvement. At the elementary school, all grades 5 and 6 teachers agreed so i was to have access to four separate classes. At the middle school, initially I worked with three teachers and their home room classes. Later, as the theoretical needs of the study became more explicit, I later added eight classes 71 which represented non-core curriculum subjects taught by these teachers. Thus, by the end of the study I spent my time between 15 different classrooms, over two schools. Approaches to gain rapport within learning contexts. During this time as I awaited return of parental written (active) consent, I spent one full week conducting informal nonparticipant observations at both schools. As the elementary school was smaller, I spent two full days there and followed this with three days at the middle-school, returning the following week to conduct half-day observations at each school to make comparative observations based on field note themes identified the week prior, while the other half of each day was spend conducting two interviews per day. As another way to develop both rapport and an interactive, trusting researcher-participant relationship, as the researcher-as-observer I focused on spending time with early adolescents in their respective schools. In the elementary school, I spent time with the grade five and six students by engaging in non-core teaming activities (e.g., sports, music, art) and classroom periods. 1 also sat at tables with students in the library and the computer resource room to participate with them and to listen to them talk about their learning activities. Additionally, I shared in social activities on occasions, such as lunch and recess breaks, sitting with and eating among the students, as a chance to listen to them talk about themselves and about events and experiences unrelated to the study such as music, movies, video games, and sports. I also spent time in the staff lounges and between classes. I engaged in similar observational activities and experiences at the middle school during both classroom periods and school-wide events. As a way to gain familiarity with school learning, topics of study, and general interactions of students in class, I made nonparticipant observations throughout the day. This was valuable as the students soon came to recognize me, hence when it came to interviews, I was not a total stranger. Approach for framing the drawing task. As well as conducting interviews, a drawing task was designed specifically for use in this study as a participant-centered activity and adjunct to the interviewing process. The actual task, design, and administration are outlined in the section concerning interviewing methods. The task is mentioned here relative to crafting the context for which the task was situated at the time of interviews. During my initial encounter at school while making my early informal nonparticipant observations in the respective school contexts, I took cues from the environment which led me to construct the 72 contextual details for the drawing task scenario. Although I determined the purpose for the task a priori and how I wanted it structured, I did not, however, have an exact schema for the task's context (i.e., what the task was going to represent contextually or what scenario or script I would use to tap understandings of smoking and not smoking). After a few days at both schools, I developed a plan. Prior to conducting this study and previous to my arrival at the school, the elementary school principal held a school-wide drawing contest as a way to heighten student awareness on the concept of bullying as unacceptable school behaviour. The principal selected the winning contestants' drawings and framed and displayed these drawings in the main foyer and throughout the classroom corridors. Additionally, at the middle school, the CODES group had organized a guest speaker to talk with the whole school about drinking and driving as a campaign as part a semester long counter-attack awareness on high-risk social behaviours. The CODES group and their peer counsellor/coordinator, as well as the school's peer counsel met with me so I could hear their ideas for crafting a scenario for my drawing task. One of the grade 9 members met with me the next day to show me the campaign implemented by the CODES group and peer counsel the year before. In cooperation with the provincial Liquor Control Board (LCB) branch associated with the school community, the CODES campaign was to run a drawing contest aimed at drinking-driving over November and December, 2001. The contest at the middle school involved students taking LCB brown paper bags home to create a drawing or artwork on the bag, one which demonstrated a counter attack message. At the end of the contest, all the paper bags (n * 1,100) were returned for eventual distribution throughout local liquor stores over the Christmas holidays, and check out clerks used these bags to package purchased liquor items. I was duly impressed with both the concept and the prize winning entries (they showed me colour 5" x 7" photographs that were circulated to the schools in the form of posters). Based on these two school-based activities, I used the schema for contest to inform a true-to-life scenario in which to situate the drawing task. As applied to the drawing task, I was scripted as the "school principal" holding a smoking awareness campaign and the study participants were cast as "contestants" submitting posters aimed to explore their perceptions of cigarette smoking and ideas for an anti-smoking campaign. Rather than displaying their posters, the contestants and their artwork would return to me as "the principal" to provide an explanation and rationalization for the message captured in their posters (see Appendix A). This drawing task became one of the scheduled activities during 73 participant second interviews. Approaches for Participant Recruitment Participant candidates. Initial contact with each class was made to introduce myself and the study. A study information packet was accessed by each student who indicated an interest as a study participant candidate. On site visits were made at the elementary school during home room classroom period and at the middle school during Career and Personal Planning (CAPP) period. At this initial visit I provided a self-introduction which included my background and purpose for conducting the study (Appendix B). Additionally, I provided an explanation of the recruitment strategy and indicated why a school-based approach was chosen to access potential participants. I also highlighted points concerning self-selection whereby direct contact with students was deliberately sought in order that students would initiate an interest as participants and then approach their parents for permission, in contrast to a community-based approach (e.g., advertisements in the local newspaper or flyers posted at community centres) that would likely target parents who could then nominate or suggest that their child contact the researcher. A brief overview of the study was provided, in addition to details concerning the nature and level of involvement required of a participant. As parental consent was a condition for participation, an information package was prepared by the researcher for students to take home. Each information package was enclosed in a coded envelope and included an informed consent for both the parent and participant and an informed consent signature form (Appendix C), a letter of introduction (Appendix B), a reply card (Appendix D), a Household Information Sheet (Appendix E), and a request for study findings (Appendix F). Reply procedure and incentives. Each student who indicated an immediate interest as a study candidate received an information packet. At the time of the on site introduction, all interested students were encouraged to complete a reply card. As an incentive to participate, regardless of participation or non-participation status, each student had his or her reply card entered into a prize draw which was held at the completion of the study. One prize was available for each grade. The prize was a collection of three gift certificates (a $ 35 total value), one for each of the following: one large pizza, two rentals at a video store outlet, and one pre-paid gift card for any purchase (valued at $15) at a local department store. 74 Completed reply cards were returned, in the envelope provided, by students to their home room teacher. Reply cards were designed as a fun and easy way for students to indicate their interest as volunteers for the study. Additionally, they served as a way for the researcher to locate students during the school day according to the master class schedule and match students by home room teacher, as a means to log returned consent forms by student name, and to track the return of household information documents according to code number. All reply cards were collected from the home roo