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Stories of nicotine dependence told by teenage girls : a narrative inquiry Moffat, Barbara Marian 1999

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STORIES OF NICOTINE DEPENDENCE TOLD BY TEENAGE GIRLS: A NARRATIVE INQUIRY by BARBARA MARIAN MOFFAT BScN, The University of Toronto, 1989 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES (School of Nursing) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August, 1999 © Barbara Marian Moffat, 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of ScJ^^f] ^ A ^ ^ The University of British Columbia J • Vancouver, Canada Date ,AlAO 9W?9 DE-6 (2/88) A B S T R A C T The prevalence of smoking cigarettes has increased among teenage girls over the last decade. Smoking onset typically begins during adolescence and is associated with subsequent nicotine dependence. Much of the research on tobacco use neglects the perspective of teenage girls. While nicotine dependence is well documented among this population, little is known about the meaning that teenage girls ascribe to nicotine dependence. In this qualitative study, narrative inquiry was used to explore the meaning of nicotine dependence among teenage girls within the context of their lives and patterns of smoking. Twelve teenage girls, aged 14 to 17, participated in this investigation and all had recent experience with smoking. Data analysis of in-depth interviews focused on structure, content and interpersonal factors as well as the language used in stories about nicotine dependence. The study findings point to the importance of semantics and identity issues as teenage girls tell stories about nicotine dependence. In addition, this investigation provides important insights into how teenage girls portray themselves and others with regards to nicotine dependence. Three narratives emerged in this inquiry that include Invincibility, Giving In and Unanticipated Addiction. In the first narrative, those who felt invincible described how they were in control of their smoking and not addicted to cigarettes. In the second narrative, participants who were giving in told stories about yielding to external forces and smoking. In the third narrative about unanticipated addiction, storytellers described their surprise upon realizing that they were addicted to cigarettes. In addition, two sub-narratives entitled Needing to Quit and Repeating History are presented. In the first sub-Ill narrative, Needing to Quit, participants described how they knew that they needed to quit smoking and how they would quit later. In the second sub-narrative about repeating history, participants contrasted their mothers' nicotine dependence with their own smoking. The findings in this study have vital implications for health-care professionals who work with teenage girls who smoke and provide direction for ongoing smoking-cessation interventions for both social smokers and regular smokers. Including "the voices" of teenage girls is paramount in our continued efforts at tobacco reduction within this population. TABLE OF CONTENTS Abstract List of Tables Acknowledgements CHAPTER I: INTRODUCTION Background Problem Statement Purpose of the Study Research Question CHAPTER II: REVIEW OF THE LITERATURE Introduction Trends in the Literature Smoking Patterns Social Influences Familial Influences Psychological Factors Health Beliefs and Attitudes Nicotine Dependence Conclusion CHAPTER III: RESEARCH METHODS Research Design Interviews as Speech Events The Joint Construction of Meaning Narrative Analysis Structure Content Interpersonal Factors Sampling Selection and Criteria Data Collection Data Analysis Ethical Considerations Summary CHAPTER IV: FINDINGS Overview Demographic Characteristics V General Characteristics of the Interviews 57 Structure 59 Content 61 Interpersonal Factors 63 Voice and Identity 65 The Storytellers 67 The Narratives 75 Invincibility 75 Giving In 81 Unanticipated Addiction 87 , The Sub-Narratives 93 Needing to Quit 93 Repeating History 99 Summary 102 CHAPTER V: DISCUSSION AND IMPLICATIONS Introduction 104 Summary of Findings 104 Narrative Inquiry as a Method 105 Member Check 108 Evaluation of Narrative Analysis 110 The Meaning of Nicotine Dependence 114 The Meaning of Stopping and/or Quitting 115 Resisting a Smoking Identity 117 Stress in the Lives of Teenage Girls 121 The Role of Mothers 125 Not Recognizing Addiction 130 Planning to Quit Later 131 Unsuccessful Quit Attempts are Wasted Time 135 Program Implications 137 Summary of Implications 139 REFERENCES 140 Appendix A: Letter of Introduction 152 Appendix B: Sample Guiding Questions 153 Appendix C: Interview Synopses 154 Appendix D: Informed Consent Form for Participant 167 Informed Consent Form for Parent 168 Informed Consent Form Signature Section 169 LIST OF TABLES Table 1: Demographic Characteristics of the Study Participants Vl l Acknowledgments I am extremely indebted to a number of individuals who contributed to making this thesis a rewarding experience. To begin, I would like to thank Dr. Joy Johnson, my thesis chairperson, for her unfailing enthusiasm for this study, her incredible generosity and her gentle reminders to "remember the research question." Her mentorship along with her expertise in nursing research and this area under study were greatly appreciated. In addition, I would like to thank the other two members of my thesis committee. I am most indebted to Dr. Joan Bottorff for her sensible advice early on "to stay focused" and her insightful comments, questions and support throughout the entire process. Finally, I wish to thank Dr. Pam Ratner for her thought provoking questions as the third perspective during the different stages of this thesis and her much appreciated editorial contributions. At this time, I would also like to acknowledge the support of X i Eta Chapter of Sigma Theta Tau and the Logan M Findiay Fund. These awards definitely eased my decision to pursue my thesis full-time, which was truly a privilege. In addition, I am forever grateful to my parents who have always encouraged and supported my academic endeavors. I also thank my sisters for their ongoing interest in my studies and their numerous long distance telephone calls during this endeavor. Finally, I extend heart-felt thanks to a close friend, Anne Bruce, who provided useful feedback and a welcome sense of humour, which helped me through this journey. Obviously, this project would not have been possible without the participants in this study. I am eternally grateful to them all for sharing their stories and for their ongoing interest and enthusiasm in this study. 1 CHAPTER 1: INTRODUCTION Background The health implications of smoking are well established and smoking has long been recognized as the most significant preventable cause of death. Several types of cancer, cardiovascular disease and respiratory disorders are directly associated with smoking. It is estimated that one half of all smokers in Canada will die as a result of tobacco use i f they continue to smoke (Peto, Lopez, Boreham, Thun, & Heath, 1992). The increase in tobacco-related morbidity and mortality among Canadian women corresponds directly to the increase in smoking prevalence among this population. It is now recognized that lung cancer is the leading cause of cancer deaths among Canadian women (National Cancer Institute of Canada, 1999). Although the overall smoking prevalence rate has declined in Canada since the 1980's, it is of particular concern that the adolescent population is not following the national trend. To the contrary, Canadian figures indicate that the prevalence rates of smoking among adolescent females, aged 15 to 19 years, increased from 21% in 1990 to 29% in 1994; among male adolescents, smoking rates increased from 20% in 1990 to 26% in 1994 (Health Canada, 1996). Similarly, figures from the United States indicate that smoking prevalence among high school students increased from 27.5% in 1991 to 36.4% in 1997 (Centers for Disease Control [CDC] , 1998). Adolescence is often described as a period of questioning, exploring and risk taking. It is during adolescence that smoking initiation usually occurs (Chen & Millar, 1998; Health Canada, 1996), putting many youth at risk for nicotine dependence. While • 2 not all smokers become nicotine dependent, nicotine is known to be highly addictive for some adolescent females. There is some debate in the literature regarding terminology when referring to the adolescent population. Danesi (1994) differentiates between the terms "adolescence" and "teenagerhood," suggesting that the former term focuses on psychosocial behaviors, while the latter refers to a socially constructed category which focuses on socio-semiotic characteristics. Use of the term "teenager" will be the preferred term throughout this thesis, particularly because the intention of this work is to understand the meanings and symbols that female teenagers attribute to nicotine dependence. At the same time, it is recognized that much of the literature favors the term "adolescence." Nicotine dependence is currently understood as an interaction of multiple factors; some of these factors increase the risk of nicotine dependence for teenage girls in particular. Specific biopsychosocial factors may be related to smoking among this group. For example, some female teens who smoke cite the fear of possible weight gain as a deterrent to smoking cessation. In addition, evidence suggests that the nature of nicotine dependence differs for women and men, specifically related to withdrawal symptoms and success at cessation. Research indicates that women experience more difficulty stopping smoking than do men, and that women smoke for a longer period of time (Flay, 1993; Pierce & Gilpin, 1996). Lovato, Shoveller, Ratner and Johnson (1998) reported that boys who experiment with tobacco are less likely than girls to make the transition to regular tobacco use. The trajectory of nicotine dependence has been widely researched. In addition, there is increased evidence of nicotine dependence among the teenage population. 3 However, there are significant gaps in understanding this phenomenon among teenagers. For example, the perceptions of female teenagers regarding nicotine dependence remain unclear as little is known about the meaning of nicotine dependence among this population. Two Canadian studies related to youth smoking are cited throughout this literature review. The first important source of data on Canadian youth is the Youth Smoking Survey (YSS), which was conducted by Statistics Canada on behalf of Health Canada in 1994 (Health Canada, 1996). A total of 23,700 adolescents, aged 10-19 years, were divided into two groups. The younger group, aged 10-14 years, completed questionnaires in class while the older group, aged 15-19 years, was interviewed by telephone as a supplement of the Labour Force Survey. The response rate was 80% for the younger group and 81% for the older group. Overall, 86% of individuals in the older group were still attending school at the time of the survey. By collecting data from the older group by means of telephone surveys, the sample also included adolescents who were no longer at school. The survey addressed the need for information on attitudes and use of tobacco products among Canadian youth. In addition, it was the first survey in Canada to provide national estimates of smoking prevalence for youth aged 10-14 years. Accordingly, the YSS provides baseline data on Canadian youth smoking behavior, and knowledge and attitudes towards smoking. The results of the YSS include important findings (Health Canada, 1996). To begin, the survey revealed the increased prevalence of smoking that occurs with age. The age of smoking initiation among female youth was 2% among those aged 10-12 years, 14% among those aged 13-14 years, 22% among those aged 15-17 years, and 27% among 4 those aged 18-19 years. In addition, the findings demonstrated that most Canadian females experimented with smoking before the age of 15 years and that daily smoking among female teens increased with age. Furthermore, approximately two thirds of current smokers in each age group reported attempting to stop smoking at least once. Multiple quit attempts, that is three or more attempts, were reported by 39% of current smokers aged 13-14 years, 30% of those aged 15-17 years and 34% of those aged 18-19 years. The second study, Tobacco Use in BC 1997, is a survey that was conducted on behalf of the Heart and Stroke Foundation of BC and Yukon, the BC Ministry of Health, and the Ministry Responsible for Seniors (Angus Reid Group, 1997). The study included telephone surveys with 1,448 teens between 12 and 19 years of age, as well as four focus groups with male and female adolescent smokers. Participants in the focus groups were recruited from the survey sample and additional random screening within the Greater Vancouver area. According to the findings, 40% of current teen smokers had smoked their first cigarette by the age of 13 years and 83% had smoked their first cigarette by the age of 15 years (Angus Reid Group, 1997). In addition, the findings revealed a significant increase in smoking among older teens. Smoking prevalence was 6% among teens aged 12-14 years, compared to 25% among teens aged 15-18. The smoking prevalence rate among young adults aged 19-24 was the highest of all groups at 31%. The study also identified demographic characteristics that were associated with subgroups considered to be vulnerable for smoking acquisition. The findings in this study revealed that smoking was more prevalent among teens living in low-income households and teens from aboriginal backgrounds than it was among other groups of teens. 5 Problem Statement Female teenagers who smoke are at risk of becoming nicotine dependent. Empirical studies indicate that female adolescents may indeed be nicotine dependent. For example, it is recognized that some female teens experience difficulty stopping smoking. A consistent definition of nicotine dependence among teenagers is not provided in the literature. Nicotine dependence is recognized as a complex process among youth. As a result, a precise definition of nicotine dependence is problematic. While dependence is characterized by compulsive use and by withdrawal when tobacco is absent, such definitions have tended to be based on measurements used with adults who smoke. However, smoking patterns among teenagers differ from smoking patterns among adults, particularly regarding the frequency and quantity of cigarettes. It may not be appropriate to compare the smoking behavior of teenagers with that of adults in conceptualizing nicotine dependence among the teenage population. Rather, continued research on adolescent nicotine dependence must focus exclusively on the teenage population. In some literature, the terms "dependence" and "addiction" are used interchangeably. Similarly, both of these terms are used as synonyms in this thesis. It appears that teens hold incongruous attitudes and beliefs regarding smoking. While it seems that most teenagers are aware of the hazards of smoking, they may minimize the health risks and consequences related to smoking, or they attribute these risks to the future (Angus Reid Group, 1997). Some teenagers seem to accept the risks of smoking for themselves; however, findings from focus groups revealed that participants did not want their own children nor their younger siblings to smoke. In addition, most teens from the survey indicated that they did not expect to be smoking when they were 30 6 or 40 years of age. At the same time, some teenagers confirmed that stopping smoking was very difficult. There are further indications to suggest that teenagers may have misperceptions regarding the nature of nicotine dependence. Specifically, there are reports that adolescents who smoke overestimate both the prevalence of smoking and the number of individuals who stop smoking. In addition, it is suggested that young smokers are overly confident about their own ability to stop smoking (Hines, 1996; Stanton, Lowe, & Gillespie, 1996), which is contradicted by the descriptions of their numerous attempts to stop smoking. Given the recent trend that reflects an increase in smoking prevalence among this population, uncovering the meaning of nicotine dependence among female teens has vital health implications. Furthermore, it is a public health responsibility to gain a better understanding of perceptions of nicotine dependence within the context of these young women's lives. There has been a lack of research that speaks to the meaning of nicotine dependence from the teenager's point of view. This study was therefore warranted because of the recognized need to explore teenage girls' perceptions of nicotine dependence. Moreover, it was believed that this study would provide significant insights and a better understanding of nicotine dependence among this population. In addition, it was expected that the findings would be beneficial in addressing nicotine dependence before the onset of heavy addiction. By understanding the complexity of nicotine dependence among this population, health professionals will be better prepared to design appropriate interventions and promote cessation among this population. Finally, it was 7 anticipated that the findings would contribute to a perspective that would assist with the development of appropriate health promotion messages for young women. Purpose of the Study The purpose of this study was to examine teenage girls' perceptions of nicotine dependence among those who smoke. It was expected that the research findings would uncover subjective meanings, personal beliefs and attitudes related to smoking behavior and nicotine dependence. In addition, it was anticipated that this research would provide an understanding of the fabric of female teens' thought processes regarding smoking while incorporating smoking into their daily lives. Research Question This study addressed the following research question: What meaning does nicotine dependence hold for teenage girls within the context of their lives and smoking patterns? 8 C H A P T E R II: R E V I E W OF T H E L I T E R A T U R E Introduction This chapter presents a review of research findings related to the profile of an adolescent female smoker. They are reviewed to ascertain factors pertaining to regular smoking among teenage girls, and to specifically investigate teenage girls' perceptions about nicotine dependence. The preliminary literature search included CINAHL (1966 to 1999), MEDLINE (1966 to 1999) and HEALTHSTAR databases (1975 to 1999) and consisted of keywords "nicotine dependence" and "adolescent females." The results were sparse until the keyword "tobacco use disorder" was used. The majority of articles in that particular search covered topics of prevention, initiation and cessation. Although the majority of articles did not specifically address the research question, this search was nonetheless fruitful. Additional keywords were used in attempts to narrow the search, using the terms "beliefs," "health beliefs," "attitudes" along with "tobacco use disorder" and "adolescents" (CINAHL, 1960 onward); however, the results were extremely limited. During this process, the growing body of literature on smokeless tobacco was noted. With the exception of two articles, these studies are excluded from this review. In addition, this review includes articles in English only. The studies cited in this review were conducted in North America, England, Australia, and New Zealand between 1982 and 1999. The second phase of the literature search focused on the PSYCHINFO (1967 -1999) and SOCIOFILE (1974 - 1999) databases using the previously mentioned keywords with the addition of "risk perception," "nicotine dependence," and "addiction." 9 Generally, the results were limited. The Social Science Citation Index was used to determine whether certain authors had subsequently been cited in a study with an adolescent population. This search strategy also led to other relevant articles. This search process did not locate a single study dealing exclusively with teenage girls' perceptions of nicotine dependence. Similarly, it was challenging to find articles that focused solely on teenage girls who smoked regularly. Rather, it was often necessary to extract findings regarding regular smokers from articles focusing primarily on initiation or cessation. Furthermore, in a number of studies, although males and females are included in samples, grouped data are presented; researchers do not consistently consider gender differences nor adequately separate findings based on gender. For the purpose of this literature review, adolescence is defined as the developmental period between the onset of puberty and adulthood; it is characterized by extensive physical, psychological, emotional and personality changes (Anderson, 1998). It usually begins between 11 and 13 years of age with the appearance of secondary sex characteristics and it spans the teen years ending at 18 to 20 years of age with the completion of development of adult form. While adapting to the psychosocial changes that are associated with physical maturation, developmental tasks include identity formation and development of self-worth and self-efficacy (Nightingale & Wolverton, 1993). Adolescents may also be defined by what they are not, that is, they are neither child nor adult (Nightingale & Wolverton). Adolescence is portrayed in the literature as a stage of development associated with experimentation. It is during this developmental stage when smoking initiation most frequently occurs, viewed by some as part of a "rite of passage" (Prokhorov, Pallonen, 10 Fava, Ding, & Niaura, 1996). While some address feelings of invulnerability and invincibility that often accompany adolescent risk behavior (Cohn, Macfarlane, Yanez, & Imai, 1995), Greaves (1996) contextualizes the female adolescent experience. She suggests that young women may initiate smoking at a time when confusion, self-doubt and suppression of thought and speech replace the assertiveness, strength and clarity of early childhood. The profile of the adolescent female "regular smoker" is presented in this literature review. Findings from the literature are organized using the following five headings: smoking patterns, social influences, familial influences, psychological factors and health beliefs and attitudes. The final section of this review, entitled nicotine dependence, presents research findings related to perceptions of nicotine dependence. Throughout this review, studies are critiqued and gaps in knowledge are identified. To begin, several significant trends that were observed in the published literature are highlighted. Trends in the Literature Several trends are noted in the literature and require comment. Firstly, different terms designate the stage of "regular" smoking. It is also described as "established," (Choi, Pierce, Gilpin, Farkas, & Berry 1997), "the persistence of smoking" (Chassin, Presson, Rose, & Sherman, 1996), and "non-occasional regular smoking" (Hill, Boudreau, Amyot, Dery, & Godin, 1997). Regular smokers are referred to as "adopters" (Croft, Hunter, Webber, Watson, & Berenson, 1985) and "maintainers" (Stern, Prochaska, Velicer, & Elder, 1987). For the purpose of this literature review, it is assumed that these terms are used synonymously. In addition, a variety of measurement 11 methods are used to determine smoking status. These range from the dichotomy of smoker vs. non-smoker to various stage models of smoking acquisition, which use specific definitions to describe smoking status at particular stages of development. As a result, there is no standard definition of regular smoking for the adolescent population. Definitions include smoking one cigarette per day for at least 30 days (Rainey, McKeown, Sargent, & Valois, 1996), to smoking 5 to 15 days or more in a 30 day period (Escobedo, Marcus, Holtzman, & Giovino, 1993), to smoking monthly or more (Chassin, Presson, Sherman, & Edwards, 1990). Furthermore, these definitions are different from those used to describe adults who smoke regularly (Chassin et al., 1990). It is recognized from the outset that the findings on regular adolescent smokers will be influenced by the definition or classification criteria used. Secondly, it is acknowledged that not all regular smokers develop nicotine dependence. However, isolating the non-dependent smokers from dependent smokers is problematic and frequently not even addressed. On the one hand, there may be a tendency to overestimate the number of dependent smokers in some literature by considering all regular smokers to be dependent. On the other hand, late experimenters may subsequently become nicotine dependent (Chassin et al., 1996). Accordingly, nicotine dependence may be underestimated because this subgroup is often excluded from studies. In addition, measures of nicotine dependence for adolescence are not well developed. In summary, it is difficult to ascertain precise numbers of nicotine dependent adolescents as many adolescents who smoke are in the process of becoming regular or addicted smokers. The studies in this review on adolescent smokers are primarily longitudinal, prospective and cross-sectional designs. Cross-sectional design analyses are noted to be 12 limited due to an inability to reflect changes in smoking through time. Some retrospective data is included, yet recall ability is questionable when it is greater than one year (Stanton, McClelland, Elwood, Ferry, & Silva, 1996). Several studies include secondary analyses of earlier databases. Finally, most researchers examine regular smoking among adolescents using quantitative methods. There is a noticeable dearth of qualitative research on adolescent smokers. Smoking Patterns Smoking is believed to progress through a temporal series of stages. Flay (1993) proposes a five-stage model of unidirectional progression: preparation, initial trying, experimentation, regular use and nicotine dependence. It is estimated that adolescents move from initiation to regular use within two years (Leventhal & Cleary, 1980), although variation is recognized within this time frame. For some adolescents, the stages of smoking are not clearly defined and do not always occur as outlined above. For example, McNeill (1991) observed that 50% of British schoolgirls who were current smokers (n=191) had taken up daily smoking within a year. In addition, findings emerged to suggest that the schoolgirls moved in and out of smoking. Similarly, results of a study in British Columbia indicated that participants in focus groups had erratic smoking patterns and reported lack of money as a reason for temporarily stopping (Angus Reid Group, 1997). A stage model therefore may not be applicable to all adolescent smokers. A group of studies have focused on acquisition factors that contribute to future nicotine dependence. Smoking onset is estimated to peak at the age of 13; furthermore, the age of onset has declined over time (Angus Reid Group, 1997; Chen & Millar, 1998; Flay, 1993; Health Canada, 1996). Initiation in early adolescence is associated with 13 subsequent heavy smoking (Chen & Millar; Eiser & Sutton, 1977; Escobedo et al, 1993) and less probability of stopping (Chen & Millar; Ershler, Leventhal, Fleming, & Glynn, 1989). Chassin et al. (1990) also link early initiation to greater likelihood of becoming an adult smoker with stable progression of smoking increasing the risk of regular adult smoking. It is believed that the physiological effects of nicotine are greatest during experimentation and the early stage of regular smoking (Flay et al., 1983). As the development of regular smoking progresses, the activity no longer occurs for social reasons alone. Evidence strongly supports that the reasons for continued smoking are associated with the pharmacological effects of nicotine. In addition, provincial findings confirm that teens list "out of habit," and "to relax or reduce stress" as two of the three most important reasons for smoking (Angus Reid Group, 1997). Pierce and Gilpin (1996) analyzed birth cohorts to predict duration of smoking. Interestingly, the researchers suggested that increased smoking related to addiction is "apparent" to youth, yet not easily avoided; however, they did not specify how addiction was apparent. The researchers concluded that women smoke for approximately 30 years, which is consistent with other findings (Russell, 1990). Prokhorov et al. (1996) suggested that until recently skepticism existed regarding adolescents' ability to develop nicotine dependence. Others have claimed that adolescent smokers have been overlooked (Rojas, Killen, Haydel, & Robinson, 1998). Nicotine dependence has been measured empirically among adolescents and evidence supports the claim that some adolescents are nicotine dependent. Stanton (1995) used the DSM-III-R criteria for establishing nicotine dependence with a group (n=321) of 18-year-old 14 adolescents and established a 19.3% rate of dependence. Degree of dependence has also been measured by other researchers (Prokhorov et al.; Rojas et al.). Studies link frequency and intensity of smoking with degree of withdrawal symptoms and dependency among adolescents (CDC, 1998; McNeill, West, Jarvis, Jackson, & Bryant, 1986). McNeill et al. studied withdrawal symptoms among adolescent females (n=T 16) and found that 74% of the daily smokers experienced adverse effects compared to 47% of the occasional smokers. There is evidence that adolescents have a desire to stop smoking. The literature describes accounts of unsuccessful attempts to stop smoking among this population (McNeill et al., 1986; Stanton, Lowe, et al., 1996). This further supports the argument that adolescents are nicotine dependent. Similarly, the British Columbia report revealed that quitting smoking was an emergent concern among teens (Angus Reid Group, 1997). Some findings suggest that nicotine dependence may differ for males and females. It is believed that more females smoke to relieve or avoid withdrawal (Stanton, 1995). Rojas et al. (1998) found more depression symptoms among female smokers compared to male counterparts and female non-smokers. The causal order of smoking and depression is not clear. Chen and Millar (1998) identified that depression and chronic stress were significantly associated with decreased likelihood of stopping smoking among females; similar findings were not found among male smokers. In summary, a review of the patterns of smoking reveals that acquisition and cessation factors are linked to nicotine dependence among adolescent females. However, this section of the literature discloses little about teenagers' beliefs or attitudes towards 15 nicotine dependence with the exception of suggesting that addiction is "apparent" to youth. Social Influences Social factors also influence smoking behavior. The social context of adolescence is a critical backdrop in this discussion. Much of the literature relevant to smoking among adolescents explores the influence of social networks, especially on initiation to smoking. While peer pressure is believed to influence smoking onset (Blackford, Bailey, & Coutu-Wakulczyk, 1994; Covington & Omelich, 1988), social influences are thought to be complex during regular smoking as well. Adolescent females who smoke tend to have more close friends who smoke. Research indicates that the majority of smokers report that their best friend smokes and that most of their close friends smoke (Health Canada, 1996; Pallonen, Prochaska, Velicer, Prokhorov, & Smith, 1998). As a result, smokers are more likely to be exposed to others' cigarettes (Stanton, McClelland, et al., 1996). Other studies confirm these findings (Choi et al, 1997; Croft et al., 1985; Engels, Knibbe, Drop, & de Haan, 1997). Perceiving most friends as smokers may influence future cigarette smoking behavior. There is strong evidence that adolescents overestimate the prevalence of smoking, as discussed in greater detail in a later section on health beliefs and attitudes. This may function to normalize smoking behavior. Eiser (1985) refers to the "intergroup phenomenon," in which an individual is attracted to a group, not simply influenced by a group. This theory is further supported by Engels et al. (1997), who explored the dynamic nature of friendship in a longitudinal, prospective study. These researchers proposed that the similarities in smoking behavior within groups were related to the selection of, friends 16 with similar attitudes, preferences, or behavior, hence "group homogeneity." Furthermore, there was no evidence for "deselection," or ending existing friendships as a result of smoking status. Urberg, Degirmencioglu, and Pilgrim (1997) studied the influence of "best friends" and "friendship groups" during adolescents' transition to cigarette and alcohol use. Their research further supports the theory that some adolescents seek and select substance-using peers. The findings revealed that "friendship groups" predicted transition to current cigarette use, whereas "best friends" did not. Similarly, a two-wave longitudinal study found that the smoking status of "four best friends" was the only constant social factor that predicted progress to more advanced stages of smoking (Wang, Fitzhugh, Eddy, Fu, & Turner, 1997). By excluding regular smokers at the beginning of the study, Wang et al. purported to minimize selection of smoking friends. The findings revealed that female adolescents with three or four best male, friends or a boyfriend that smoked were at risk of becoming regular smokers. Finally, Choi et al. (1997) found that having a best friend that smoked was a strong predictor of established smoking. Despite different approaches used to examine social networks and the variance in the findings, researchers conclude that female smokers socialize with others smokers. Covington and Omelich (1992) explored the impact of smoking within a group compared to smoking alone and found that regular smokers believed that cigarettes were instrumental to group cohesion. Additional findings revealed that there was no difference between small, intimate groups and large casual groups, suggesting that the kind of group had little impact on the perceived consequence of smoking. Furthermore, when students perceived that they were pressed into a decision to smoke, they believed their parents 17 would be less upset than if smoking had been a free choice. In contrast, individually initiated smoking was associated with taking greater responsibility for the physical and the addictive consequences. Other findings derived from this study are considered later in this review. School performance may be a factor related to established smoking. Adolescents that perceive their academic standing to be average or below average are more likely to progress to established smoking than those who perform better than average (Choi et al., 1997; Escobedo et al., 1993). A higher grade point average was associated with a lower cumulative percentage of cigarette use in data collected in 1981 (Krohn, Naughton, & Lauer, 1987). Schulenberg, Bachman, O'Malley, and Johnston (1994) found that plans to attend college during high school had a negative effect on post-high school cigarette use. Finally, Choi et al.'s longitudinal study found that educational level was a stronger predictor of cessation than smoking uptake as individuals with higher education were more likely to stop smoking. It is noteworthy that researchers generally use high school students in their samples. As a result, individuals who are no longer at school are not represented in these findings. Researchers often refer to attrition rates in longitudinal studies to reflect individuals who are no longer at school. It is known that smoking prevalence is greater among certain populations, including individuals with less education who are no longer at school (Fiore, 1992). Involvement in extracurricular activities is linked to a lower rate of smoking. Students who participate in school sports are less likely to be regular, heavy smokers (Escobedo et al., 1993). It may be that adolescents that are active in sports are less likely 18 to smoke, or that such activities are incompatible with smoking. In one study, patterns of tobacco and alcohol use among adolescents that had different levels of physical activity were examined (Rainey et al., 1996). Results indicated that smoking occurred less often among athletic groups than among nonathletic groups and that sedentary non-athletes were the heaviest smokers. A positive association between smokeless tobacco and activity level was also demonstrated, reflecting the geographic location of the sample. Data were collected from students in South Carolina, which is known to have a high prevalence of smokeless tobacco use. Concern about weight is also related to smoking for some adolescent females. It is recognized that smoking uptake causes some people to lose weight (Richmond, Kehoe, & Webster, 1993; Talcott et al., 1995) and, as a result, smoking is perceived to facilitate weight control. Data collected from schoolgirls in the UK and in Canada was analyzed to examine the association between smoking and weight loss. The study revealed that sustained cigarette use was linked to anxiety about body shape regulation, worry about being fat, and fear of losing control of eating (Crisp et al., 1998). Both samples demonstrated an association between smoking and weight loss of approximately seven kilograms from the time of puberty. Smoking was also more likely to occur among those that reported vomiting after meals. In addition, the reasons for smoking and consequences of stopping were similar for the two samples. The researchers recognized a highly significant association between smoking and alcohol as a possible complicating variable in this study. Adolescent females are exposed to a media-saturated culture on a regular basis, which acts as a powerful force in smoking uptake. Smoking has been promoted as a way 19 for young women to achieve glamour, slimness and success. Experimental smokers whose ideal self-image is similar to models in advertisements are more likely to continue smoking (Gritz, 1984). Interestingly, the BC provincial survey suggested that adolescents appear to deny the impact of the media (Angus Reid Group, 1997). It appears that social factors play a large role in reinforcing regular smoking. It may be that perceptions of nicotine dependence are buried within these social forces as they are virtually absent from this body of literature. Greaves (1996) argues that regular smokers use smoking to control and adapt to their environment and suggests that these issues may be relevant to young smokers. As smoking progresses, it appears that the act of smoking acquires different meanings for adolescent females. The fact that some adolescent females do not recognize the media to be influential may in fact be a significant finding, as well as be related to their perceptions of nicotine dependence. While this literature explores the complex nature of social factors that are associated with female teenagers who smoke, it does not adequately reveal information regarding these factors from the perspective of female teenagers. Nor does this literature sufficiently link social factors and perceptions of nicotine dependence. A qualitative study is well suited to providing an in-depth exploration of the context of social factors from the perspective of female teens. Such a study might uncover a better understanding of these social factors and might shed light on the meaning of nicotine dependence among female teens. Familial Influences Exposure to cigarettes at home is associated with regular smoking among adolescents. The adolescent population is identified to be at "high risk" when parents or 20 siblings smoke (Croft et ai., 1985; Flay et al., 1983; Millar & Hunter, 1991), which is further intensified when friends smoke (Choi et al., 1997). For example, Chassin et al. (1996) found that for adolescents that smoked, the relative risk of smoking in adulthood was 5.0 when parents smoked, compared to 2.4 when parents did not smoke. Similarly, Flay et al. found that there was a greater effect when both parents smoked. Wang et al.'s (1997) findings suggest that females were more likely regular smokers when their fathers smoked, and that their mothers' smoking status was not significant, whereas Flay et al. identified smoking by the same sex parent as the most significant factor. In contrast, a longitudinal study by Ary and Biglan (1988) found that parental factors were not related to continued smoking. However, the researchers noted a significant attrition rate at their one-year follow-up, which included 68% of the original sample. Furthermore, the researchers observed that "problem" adolescents were less likely to be included in the follow-up assessment. Consequently, these findings ought to be viewed with caution. Sibling smoking status is also considered in some studies. Krohn et al. (1987) reported that having a brother that smoked had more influence on adolescents' smoking than having parents or sisters that smoked. There is also evidence to suggest homogeneity in smoking behavior in household smoking. Adolescents tended to smoke with similar frequency and to select the same brands as adults in their homes (Millar & Hunter, 1991). Leventhal, Glynn and Fleming (1987) suggested that simply having a smoker in the family initiated a complex process of motivating a young person to downplay smoking risks. Despite a lack of consensus on the most influential family member, the above findings illustrate the importance of familial influence on adolescent smoking. 21 While adolescents may be influenced by the adults in their lives, they do not always recognize these influences. Blackford et al. (1994) found that parental smoking was identified as a reason for smoking by less than 1.6% of teenage respondents. Some researchers suggest that adolescents downplay the importance of parental smoking. Meier (1991) explored attitudes towards smoking and found that parental smoking had no impact on children's attitudes, whereas having a sibling that smoked was associated with less negative attitudes. In contrast, focus groups held in British Columbia with male and females smokers indicated that some participants thought it was "wrong" that their parents had smoked in front of them (Angus Reid Group, 1997). These findings have limited generalizability, however, because of the convenience sampling method used. Parenting styles may be related to substance use among adolescents. Cohen and Rice (1997) conducted a cross-sectional study where parents and students completed the same survey. Tobacco and alcohol use by students were associated with perceptions of relatively low parental authority and high permissiveness, whereas perceptions of authoritarian parenting were associated with lower substance use. Interestingly, parental perceptions of parenting style were not associated with reported substance use; the researchers suggested that parents were unaware of their children's substance use. They considered students' perceptions to be more accurate, while recognizing the potential for bias. The cross-sectional design of this study does not permit conclusions regarding long-term outcomes. Parental level of education is believed to be relevant to smoking behavior of adolescents. Choi et al. (1997) analyzed the educational level of the "responsible adult" in the household and found that, while it was not significant in predicting progression to 22 established smoking among older adolescents, it was related to later transition to smoking among 12 to 13 year old experimenters. Interestingly, when the responsible adult had at least 16 years of education, this subgroup of 12 to 13 year old experimenters was more likely to progress to established smoking than if the responsible adult had less than high school education. On the other hand, Blackford et al. (1994) found that parental level of education was not significant with respect to adolescent cigarette use. Instability in the home environment may also be linked to adolescent smoking. Castro, Maddahian, Newcomb, and Bentler (1987) found that disruptive family events such as divorce, relocation, accidents and illness were linked to adolescent cigarette smoking. Surprisingly, Blackford et al. (1994) found that teenagers from two parent families in northern Ontario smoked more often than teens from single parent households or teens living on their own, which the authors attributed to access to money. It is clear that the familial influences on teenage girls that smoke are significant. It may be particularly revealing that adolescents do not perceive it as such. Familial factors may well be associated with teenage girls' perceptions of nicotine dependence and, as a result, deserve further exploration. Psychological Factors A review of psychological factors provides important insights regarding the adolescent world. Stress is a recurring theme and is accompanied with consequences. Similarly, stress is cited as a reason for smoking by adolescents (Wills, 1985). The BC provincial survey findings revealed that "stress" was the third most common reason adolescents gave for smoking (Angus Reid Group, 1997). Escobedo, Reddy, and Giovino (1998) found that smoking initiation occurred rapidly among adolescents that 23 experienced frequent stressful events. Therefore, it appears that stress factors are significant for adolescents that smoke. It appears that gender can interact with personality factors. One group of researchers explored the differences among smokers and nonsmokers and examined shyness, sociability, loneliness, and hopelessness (Allen, Page, Moore, & Hewitt, 1994). Researchers found that female smokers scored lower on shyness and higher on sociability than three other groups, namely, female nonsmokers, male smokers and male nonsmokers. The researchers admitted, however, that norms for these personality characteristics did not exist. In another study, self-esteem was associated with smoking behavior as more teenage girls with low self-esteem intended to smoke than did their male counterparts (Murphy & Price, 1988). Self-esteem generally may be lower among females than males (Chubb, Fertman, & Ross, 1997; Murphy & Price). It may be that smokers are "externally oriented," that is, they do not accept responsibility for their health and tend to attribute smoking behavior to chance or to other individuals (Eiser, Morgan, & Gammage, 1987). The results of one study suggest that externally oriented youth are more likely to take up smoking (Clarke, Macpherson, & Holmes, 1982). Furthermore, it is believed that teenage girls that believe they have less control over their lives and health tend to smoke more than females who have a stronger internal locus of control (Greaves, 1990). Gilchrist, Snow, Lodish and Schinke (1985) examined the relationship between social skills and future smoking in Grade 6 and Grade 7 students. Although Gilchrist et al. focused on skills used by non-smokers, their findings may also be applied to smokers. According to their findings, smokers were less assertive, less able to follow through with 24 personal choices and more compliant when faced with peer pressure. The researchers noted an unexpected finding indicating that smokers were better able to use consequential thinking. Although these findings pertain largely to the early stages of smoking, given the age of the sample, these social skills may also be relevant to regular smokers. The researchers acknowledged that their sample was small (n=129) and homogeneous. That is, the subjects came from two schools and were predominantly white and middle class. As a result, these findings may not be generalizable. Some literature links teenage smoking with rebelliousness, non-conformity, and misbehavior and smoking is often viewed as part of a cluster of risk-taking behavior. Sussman et al. (1993) identified that "high risk" youth, including adolescents that "take risks and drugs," were more likely to smoke cigarettes. More females than males reported membership in this high-risk group. In addition, a strong correlation between age of initiation of cigarette smoking and alcohol use was observed (Daughton, Daughton, & Patil, 1997). Smoking is believed to contribute to other substance use (Berman & Gritz, 1991; Lindsay & Rainey, 1997). Some researchers have examined the connection between smoking and mood disorders, particularly depression and anxiety. Smoking is believed to contribute to affect regulation. Escobedo et al. (1998) found that adolescents with depressive symptoms were more likely to start smoking and to become regular smokers. Furthermore, there was a greater likelihood of rapid transition from experimentation to regular use among adolescents that were depressed or anxious. The rate of depressive symptoms and anxiety among non-smokers was 13% compared to 20% among smokers. Similarly, Fergusson, Lynskey, and Horwood (1996) gathered data from a birth cohort in New Zealand and 25 found that 16-year-old adolescents that were depressed were 4.5 times more likely to be nicotine dependent than those without depression. The researchers suggested that this association was likely the result of antecedent factors such as social and childhood factors. The relationship between psychological factors and smoking is not consistently supported. One study found that there was no correlation between smoking and depression (Allen et al., 1994). Similarly, another study found that there was no association between smoking and either depression or generalized anxiety in a study of adolescent females (Crisp et al., 1998). The relationship between mood disorders and smoking may only apply to some adolescents. Despite mixed results and inconclusive findings, personality factors appear to be associated with regular smoking among teenagers. The following section on health beliefs and attitudes delves deeper into teens' perceptions of regular smoking. Health Beliefs and Attitudes This section focuses on studies that explored adolescent health beliefs and attitudes regarding smoking in general, and nicotine dependence more specifically. To begin, the literature demonstrates clearly that adolescents are aware of the health risks associated with smoking and that some adolescents become regular smokers despite knowing the health consequences (Blackford et al., 1994; Covington & Omelich, 1992). Findings from the Bogalusa Heart Study conducted in 1976 - 1977 provided solid evidence of health awareness among children aged 8 to 17 years. The youth clearly indicated that smoking caused cancer and heart disease, and that people died from smoking (Hunter, Croft, Vizelberg, & Berenson, 1987). 26 School prevention programs are designed to increase knowledge about the hazards of smoking and to prevent the onset of smoking. However, school programs are only one source of information regarding smoking. Adolescents may also acquire knowledge that reinforces beliefs and values about smoking outside the classroom. Engels et al. (1997) applied social learning theory to smoking behavior and suggested that adolescents received information that was interpreted normatively by observing the positive and negative physical or social outcomes of smoking behavior in others, such as peers, family members and other role models. Canadian figures suggest that 90% of youth aged 10-19 years believe that people can become addicted to tobacco (Health Canada, 1996). While many studies include questions about the addictive nature of cigarettes, this information is obtained by survey items with Likert-type response scales. As an example, in one study adolescents were asked to rate how much they agreed with statements such as believing cigarettes to be addictive (Greening, 1997). However, it is unclear if teenagers apply this knowledge to themselves. Furthermore, it is questionable whether this is the best method to gain insight regarding knowledge about addiction among the teenage population. When adolescents were asked about stopping smoking, 80% to 87% cited their reason was to be more healthy (Crisp et al., 1998) and in a study of occasional and daily smokers, the most important reason for stopping was health concerns (Stone & Kristeller, 1992). Similarly, findings in the survey of British Columbia youth revealed "health" to be the main reason for stopping (Angus Reid Group, 1997). One researcher suggests that the fact that many adolescents have tried to stop smoking independently demonstrates 27 acknowledgment and acceptance of the need to stop smoking (Stanton, Lowe, et al., 1996). Other researchers have gleaned information about the motivations for smoking. In one study, adolescent female smokers indicated they "like it" and it "relaxes you" as the most important reasons (Crisp et al., 1998). In addition, the researchers noted that personal reasons for smoking were weighted more heavily than social reasons. Other research has confirmed these findings as regular smokers list pleasure and addiction as the most important reasons for smoking (Sarason, Mankowski, Peterson, & Dinh, 1992; Stone & Kristeller, 1992). Sarason et al.'s findings illustrate gender differences noting that more females (29%) indicated that they smoke for pleasure than do males (19%). Fishbein (1982) highlighted the difference between "personalized" and "general" beliefs about smoking, which may be relevant to this body of research. Perhaps some female teens hold personal beliefs about smoking that differ from the general beliefs of the population at large. For instance, themes of minimizing health risks and denial emerge throughout this research. While teenagers appear to be aware of risks, they often minimize the severity of those risks. Thus, it appears that nicotine dependence among teenagers is more complex than Fishbein's proposed "personalized" and "general" beliefs. Some researchers have approached adolescents' attitudes regarding smoking in terms of perceived costs and benefits. Hill et al. (1997) examined the stages of smoking acquisition in a sample of 296 students and found that perceived advantages and disadvantages of smoking differed by stage. As smoking acquisition progressed, attitudes towards smoking became increasingly favorable. The results of other studies support 28 these findings (Krohn et al, 1987; Meier, 1991). Meier found that Grade 11 students tended to have fewer negative attitudes toward smoking than did Grade 7 students, with the exception of younger students that admitted to having smoked. In addition, smoking status was found to correspond to attitudes regarding advertising, as 85% of the non-smokers believed that advertising should be banned compared to 35% of the smokers. Krohn et al. (1987) analyzed data from a two-wave longitudinal study on smoking attitudes and behavior among adolescents. Among regular and experimental smokers, smoking behavior was found to be more predictive of attitudes regarding the effects of smoking than were attitudes predictive of future cigarette use. Covington and Omelich (1992) highlighted a general lack of understanding of smoking among students in Grades 6, 8 and 10. The researchers investigated the causal roles of perceived costs and benefits of cigarettes and future intentions to smoke. This is one of a few studies to explore the concept of addiction among adolescents. Perceived costs included affective costs resulting in "self-upset" or upsetting peers or parents, perceived likelihood of becoming addicted and potential health dangers of smoking. Perceived benefits consisted of attaining maturity, autonomy and affiliation. As mentioned earlier in this review, these researchers also explored the nature of the group and the presence or absence of circumstances that might deflect personal responsibility for smoking. With regard to costs, Covington and Omelich (1992) found that adolescent smokers anticipated less parental upset, less negative reaction from peers and less self-blame than the non-smoking group. Affective costs decreased with age, irrespective of smoking status. The non-smoking group perceived greater health risks from smoking and 29 a greater likelihood of addiction. In addition, younger students were more sensitive to general health risks than older students. Perceptions of the consequences of addiction were less reliably differentiated among subjects with some history of smoking. Grade 10 students were more aware of the possibility of becoming addicted than were younger students. Finally, recognition of general health risks and possible addiction increased as individuals accepted personal responsibility for smoking. With respect to benefits, Covington and Omelich (1992) found that regular smokers were more likely to believe that cigarettes were important to group affiliation, autonomy and maturity compared to nonsmokers. Grade 8 students in particular accepted the affiliation view whereas Grade 10 students perceived greater benefits to their autonomy. Overall findings indicated that the perceived costs accounted for about 75% of the variance in smoking intention, while the perceived benefits accounted for approximately 25% of the variance. In addition, "self-upset" in the form of guilt explained more variance in smoking intention than did all other variables combined. The findings specifically related to addiction are particularly insightful and highlight misperceptions that some adolescents may hold (Covington & Omelich, 1992). While "fear of addiction" was not related to intentions to smoke among non-smokers, awareness of the addictive consequences of smoking was associated with intentions to smoke among regular smokers, suggesting a "resigned" attitude, which the researchers compared to learned helplessness. Further indications of misperceptions about addiction emerge from the findings. For instance, following the example of a close friend was associated with perceptions of less likelihood of addiction than was smoking alone. Also 30 troublesome were perceptions of lower health risks and less chance of becoming addicted when smoking occurred in a group as opposed to smoking alone. Leventhal et al. (1987) suggested that environmental factors and smoking may obscure the risk of addiction and minimize the sense of vulnerability to illness. These researchers refer to "invulnerables" as individuals that believe they are less likely to get "sick" from smoking. It is noted that the theme of invulnerability is often associated with adolescents. The findings from Covington and Omelich's (1992) study point to the potential misperceptions about nicotine dependence among some adolescents and the need for further study. Other researchers approach smoking from the perspective of risk perceptions (Cohn et al., 1995; Virgili, Owen, & Severson, 1991). Similar to Covington and Omelich's study, Virgili et al. found that Australian male and female high school students that were current smokers perceived less personal risk with smoking, less severe health consequences and greater benefits relative to risks than did experimenters, ex-smokers, and never smokers. In addition, smoking was perceived as more difficult to avoid among current smokers than it was among experimenters, ex-smokers and never smokers. In contrast, Cohn et al. found that current adolescent smokers were less optimistic about avoiding cancer and nicotine addiction than non-smokers in a study that compared overall adolescent risk perception with parents' perceptions. Additional study findings revealed that teenagers viewed 14 different health-related activities, including smoking, as less harmful than adults, leading researchers to conclude that youth minimize the harm associated with occasional health-threatening activities. Another study confirms that adolescents tend to minimize health risks (Greening, 1997). 31 Greening and Dollinger (1991) also examined perceptions of adolescents by investigating vulnerability to smoking-related causes of death. They found that smokers did not differ from non-smokers on perceived risks for smoking-related deaths with the exception of a subgroup of smokers who reported "high attention to the news" and high sensation-seeking males who might be especially vulnerable to denying potential risks. The researchers hypothesized that smokers who were informed of risks might deny their personal vulnerability because of anxiety about mortality or other contributing cognitive factors. In a later study, however, Greening (1997) found that adolescent smokers reported greater personal vulnerability to smoking-related causes of death than nonsmokers, which is similar to Cohn et al.'s findings cited earlier. These studies reflect the variety of approaches used to measure the perceived costs and benefits of smoking, which may also account for the variation noted in the findings. A number of studies point to adolescents' frequent overestimation of smoking prevalence (Leventhal et al., 1987; Virgili.et al., 1991), which supports a belief that everyone is smoking. An increase in perceived frequency of smoking was greatest between Grades 6 and 7 and was higher for smokers than nonsmokers. Stanton, Lowe, et al. (1996) report that students underestimate the number of their peers who have tried to stop smoking and overestimate their success, which further suggests potential misperceptions. Findings from a focus group reinforce the hypothesis that students (14-16 years old) think it is easy to stop smoking and that it can be done "at will," which is not apparent in empirical findings. The purpose of the focus group was to design a questionnaire. Additional qualitative research might contribute to further understanding such beliefs. 32 Adolescent smokers reportedly believe that they will not be smoking in the future (Meier, 1991) and that they will be successful at stopping smoking (Hines, 1996). Greening (1997) found that adolescents that perceive the long-term risks to be "severe" are more likely to report intentions to stop smoking in the near future. In contrast, they found that smokers that do not plan to stop smoking minimize the severity of long-term risks. This body of literature clearly illustrates the contradictions that exist in teenage beliefs and attitudes regarding nicotine dependence. Qualitative research may permit further exploration of these beliefs from the perspective of female teenagers. The adolescent "voice" is vital to providing a better understanding of beliefs about nicotine dependence. This literature provides a beginning understanding of beliefs regarding nicotine dependence. This knowledge has been gained primarily by survey data based on researchers' a priori conceptualizations. Significant gaps remain in our knowledge about teenagers' beliefs regarding nicotine dependence. Specifically, important aspects of teenagers' beliefs about nicotine dependence may be missing. While a few qualitative studies have explored certain aspects of adolescent smoking, no qualitative studies have yet explored nicotine dependence from the perspective of female teenagers that smoke. Nicotine Dependence Although some researchers have addressed nicotine dependence among adolescents, they offer little information to explain cited findings regarding perceptions of addiction. For example, an earlier study by McNeill et al. (1986) was one of the first studies to consider withdrawal symptoms in a sample of schoolgirls in southern England. 33 Six withdrawal symptoms were listed and a "Yes/No" response was used to indicate the presence or absence of symptoms among students that had tried to stop smoking. Withdrawal symptoms were linked to smoking levels and serum cotinine levels and depth of inhalation was assessed by self-report. The researchers suggested that the correlation between nicotine intake and the reported depth of inhalation revealed that students that thought that they inhaled deeply might expect unpleasant effects upon stopping smoking. These findings were subsequently cited to suggest that the majority of young smokers "perceived themselves" to be dependent on their cigarettes (McNeill, 1991). Aside from asking about the presence of withdrawal symptoms, it is questionable whether the original study investigated females' perceptions of nicotine dependence. Furthermore, one might challenge whether the presence of withdrawal symptoms in adolescent females can be equated with perceptions of addiction. A study by Daughton et al. (1997) is one of a few studies to specifically explore perceptions of addiction. These authors investigated perceptions of alcohol and cigarette dependency. Students (n=284) were asked if they "would find it difficult to go without cigarettes (or alcohol) for 3 days." Among the smokers, 60% indicated that they would have difficulty refraining from cigarettes for three days. Self-reported difficulty was assessed using a three-point Likert-type scale with responses ranging from "not difficult" to "extremely difficult" and self-reported addiction five years later was assessed by four options from "no chance" to "already hooked." Although alcohol use was more prevalent than smoking, smokers were more concerned about future risks of cigarette dependence and anticipated more difficulties abstaining from smoking than alcohol users anticipated from alcohol abstinence. Moreover, students that smoked recognized that they were 34 addicted or anticipated addiction five years later. The researchers did not explore perceptions of addiction in any detail. A qualitative design would certainly be better suited to exploring similar perceptions of nicotine addition more fully. Another large study of smoking beliefs among adolescents in England (n= 10,579) purported to explore perceived dependence on cigarettes by asking two closed-ended questions (Eiser et al., 1987). The first question was, "If you wanted to stop smoking altogether, how difficult would you find it?" followed by four responses. The second question inquired about the presence of cravings with five possible responses. The anticipated difficulty associated with stopping smoking was related to two belief statements: finding smoking enjoyable and finding smoking calming. Frequent cravings were associated with depth of inhalation, having a brand preference, being female, and beliefs that smoking aided in coping. Students that perceived themselves to be addicted tended to have external control beliefs regarding their health, and they viewed their present and future health as a matter of luck, and more the responsibility of others. In addition, there was a positive association between perceived addiction and cigarette consumption. The researchers concluded that pharmacological rewards were present among adolescent smokers, despite consumption levels that were lower than adult standards. Beliefs about nicotine addiction and risk factors related to smoking were investigated in a longitudinal study by Leventhal et al. (1987), which focused specifically on the "accuracy of smoking beliefs" with study findings at two-year follow-up. The initial sample over-represented Grades 6 through 10 but included Grades 4 to 12. At follow-up, students were asked about the difficulty of stopping smoking along with open-35 ended questions regarding how light and heavy smokers felt when they stopped smoking. Responses were determined for "correctness," thus a negative statement reflected knowledge about addiction, and an addiction knowledge scale was created. No difference was noted between the older and younger students, whereas addiction knowledge was greater for nonsmokers and those with non-smoking family members. Addiction knowledge was also greater for students that indicated that a parent had successfully stopped smoking. In contrast, knowledge was not enhanced for students that had a parent, peer or sibling that had been unsuccessful at stopping smoking. Among students that attempted to stop smoking, 47% reported difficulty; however, their addiction knowledge scores were no different than those that had stopped smoking without difficulty. As intriguing as these findings might appear, it is increasingly clear that additional information is needed to better understand addiction in the context of adolescents' lives. No studies were located that asked teenagers directly about their personal addiction to cigarettes. Two studies, however, are included in this review as examples that perceptions of nicotine dependence have indeed been investigated. In the first study, findings are reported from an American survey conducted in 1987 that considered smokeless tobacco addiction among adolescents (Riley, Woodard, Barenie, & Mabe, 1996). In addition to asking about difficulties with cessation, a question was specifically phrased, "Do you think you are addicted to smokeless tobacco?" This simple and direct question is absent from the previously mentioned studies on cigarette use among adolescents. The second study by Eiser and van der Pligt (1986) pursued perceptions of nicotine addiction among adult smokers. Individuals that had previously contacted a 36 television company for help with stopping smoking received a questionnaire in the mail. The measure of perceived addiction included the question, "How addicted do you think you are to smoking?" followed by four responses ranging from "not at all" to "extremely." Additional questions required responses that measured smoking either as a "sickness" (concern with health consequences) or as "hooked" (lack of ability/motivation to stop). Although the former group showed no more self-reliance about stopping, the latter group was found to be more pessimistic. There is a lack of clear understanding about the perceptions of nicotine dependence among female teenagers that smoke. To gain a better understanding of nicotine dependence, it may be beneficial to explore the meaning of nicotine dependence through open-ended questions during in-depth qualitative interviews Conclusion In summary, many of the published research findings support the claim that adolescents might not fully understand the nature of addiction; nor do health professionals fully understand adolescents' perceptions of nicotine dependence. The literature, as reviewed, is clearly fragmented with glaring gaps. It appears that adolescents hold illogical, erroneous and often times contradictory beliefs about nicotine dependence. Some researchers report that adolescents believe they can become addicted, others suggest that this is not the case. There are frequent reports that adolescents believe they can stop smoking without difficulty. It may be that some adolescents underestimate the power of nicotine addiction. Conclusions from this review confirm that nicotine dependence is indeed well established in many female adolescents that smoke. However, the meaning of nicotine 37 dependence to teenage girls is one area that remains unclear. Furthermore, there is evidence to suggest that female smokers respond differently to cigarettes than do males, and that female smokers may in fact be more vulnerable to nicotine dependence than males. Much of this literature appears to avoid direct questions regarding nicotine addiction. Eiser (1978) suggested that smokers' preparedness to label themselves "addicted" may make it more difficult to persuade smokers to stop independently. It is clear from this literature review that the term "addiction" vis-a-vis smoking is used sparingly among the adolescent population. However, semantics must not inhibit future research on teenagers' perceptions of nicotine dependence. What are teenagers' perceptions of nicotine dependence? No studies were found that dealt specifically with this question. It is certain that a different research design would be required to answer such a research question. It is the author's contention that we could learn much from in-depth qualitative studies that explore the meaning of nicotine dependence from the perspective of teenage girls. It is expected that these research findings will provide a better understanding of nicotine dependence among female adolescents. Furthermore, building on our current level of knowledge regarding youth nicotine dependence will contribute to the relevancy of youth smoking prevention and intervention programs. 38 CHAPTER III: RESEARCH METHODS Research Design Nicotine dependence is a complex phenomenon experienced by teenage girls that smoke. Smoking onset and the trajectory of nicotine dependence among teenage girls have been studied largely through survey research. There is a noticeable lack of qualitative research on the smoking behavior of this population. Furthermore, it is recognized that little is known about youth nicotine dependence, particularly as it is perceived by teenage girls. A qualitative method is an appropriate choice when little is known about a phenomenon (Morse & Field, 1995). Qualitative research can result in a rich description of a particular area under study. Moreover, it is noted that survey interviews are not suitable for certain questions, such as those related to how individuals perceive, give meaning and express their understandings of themselves, their experiences and their worlds (Mishler, 1986). Therefore, a qualitative approach was selected in this investigation using narrative inquiry to explore the meaning of nicotine dependence among teenage girls. Narrative inquiry is one of many modes of transforming knowing into telling. This methodology is an approach to interviewing that has been used by researchers from a variety of disciplines (Mishler, 1986; Sandelowski, 1991). A wide range of research studies and theoretical orientations have used narrative analysis (Lieblich, Tuval-Mashiach, & Zilber, 1998; Mishler). In addition, there is a growing interest in the use of narrative data in qualitative research (Mishler, 1995; Polkinghorne, 1997). 39 Within nursing, there is considerable recognition of the importance of narrative as a mode of inquiry for knowledge development (Sandelowski, 1991; Vezeau, 1994) when knowledge is expanded to include the human dimension of "verstehen," or understanding, which is neither exact nor static (Bartol, 1989). While it is recognized that narrative includes a variety of approaches to generate data including diaries, personal letters and conversations (Lieblich et al., 1998; Vezeau), the focus of this study is on data collected through interviews. In this mode of inquiry, the storyteller and the listener are both crucial to the narrative. To begin, it is understood that the storyteller has knowledge and that the other listens to the story. Polkinghorne (1997) describes storytellers as "actors" in narrative research, who are given their own speaking roles in the drama and who interact with the "researcher protagonist." Thus, storytellers are contributors to the story's denouement. An underlying assumption in narrative inquiry is that individuals construct and express meaning through storytelling. Narrative inquiry focuses on how individuals express their understanding of events and experiences. That is, the narrative is viewed as a representation of a personal reality at a particular moment in time. Specifically, the narrative is a process in which the narrator, in this study a teenage girl, actively constructs who she is by what she tells, what she emphasizes and how she emphasizes it. In this way, narrative inquiry focuses closely on the identity of the storyteller, by carefully considering how the narrator presents herself to the listener. At the same time, it is recognized that narrative inquiry permits the recognition of self in others' stories, which can be useful when working with individuals or groups of 40 people. For example, the World Health Organization (WHO, 1992) used prototype stories in a study that examined cultural variations in adolescents' early sexual experiences. The implications of this study for health education and AIDS-prevention programs focused on ways to reframe "typical" stories and on how to encourage "adolescents to reexamine their old stories by telling them new ones." It follows that narrative inquiry is an appropriate method for the population of female teenage smokers in view of the importance of identity issues around cigarettes and the potential for learning about nicotine dependence through the stories of others. Narrative inquiry involves an attentive exploration of the use of language and close attention to linguistic features that appear routinely in speech. While language has many purposes, one important purpose is that of the narrative account. Narrative account, or storytelling, involves knowledge of linguistic forms and narrative structure (Berman, 1995). This method focuses on aspects of meaning in language use. It is of paramount importance to understand how youth use language to describe nicotine dependence so as to reveal a better understanding of nicotine dependence from the youth's perspective. This also requires listening carefully to "the voices" of the storytellers (Gilligan, 1982). From this viewpoint, narrative inquiry, as a method, is considered particularly well suited to exploring the meaning of nicotine dependence among teenage girls. Narrative inquiry differs from traditional scientific inquiry (Mishler 1986; Vezeau, 1994). Mishler claims that there is a "gap" between research interviewing in surveys and in naturally occurring conversation. As a result, he proposes that discourse and meaning be restored to a central place in theoretical and empirical studies of human experience and action through the use of narrative inquiry. 41 In narrative inquiry, the interview is a form of discourse between speakers in which an interviewer and a respondent talk together (Mishler, 1986). The meanings of questions and responses are contextually grounded and jointly constructed by the two speakers. According to Mishler, interviews are speech events and the discourse of interviews is constructed jointly by the interviewer and the respondents. Interviews as Speech Events Mishler (1986) describes interviews as "speech events" that lead one back to the interview, to the questions and responses of the interviewer and the participant. A speech event is based on the theory of language, speech and social interaction and serves different analytic purposes. Interviews are types of discourse guided by norms of appropriateness and relevancy shared by the speakers in which meaning is created between the researcher and the participant. While speech is the intended object of study in this inquiry, Mishler (1986) warns against taking transcripts too seriously as "reality." That is, ambiguity and complexity are present in all discourse. However, Mishler claims that these ambiguities can be resolved through the discourse. The Joint Construction of Meaning The interviewer and participant jointly construct the interview (Mishler, 1986). In this way, questions and responses are formulated in, developed through, and shaped by the discourse between interviewers and respondents. The relevance and appropriateness of questions and responses emerge through and are realized in the discourse itself. Variations across interviews are unavoidable and significant for analysis. It is precisely 42 these variations that enhance the individual nature of each interview and become the objects of inquiry. Mishler (1986) proposes a circular process through which meaning and answers are created in the discourse between the interviewer and the participant as they make continuing sense of what they are saying to one another through a process of reformulation. An analysis of the relationship between questions and responses creates the dialectical nature of the interview in narrative inquiry. Assessing meaning requires an analysis of the interview process to understand how meaning is grounded in and constructed through the discourse. For example, terms take on a specific and contextually grounded meaning within the developing discourse, as it is shaped by the speakers. Narrative Analysis Mishler (1995) proposes an approach to the analysis of spoken narrative that considers three elements concurrently. These three elements include structure, content, and interpersonal factors, which provide the framework for describing the narrative analytic approach. Structure To begin, structural analysis refers to how parts of the text are internally connected through syntactic and semantic devices. Narratives are understood as stories with a temporal ordering of events and an effort to make sense out of such events. In the telling of a story, events are selected, given cohesion, meaning and direction (Sandelowski, 1991). Therefore, temporal ordering connects events, and results in sense and order. However, narratives are not time-bound; rather, events may be described in a perceived and retrospectively constructed sequence. For example, it is recognized that 43 stories are recollections and recreation of past episodes (Polkinghorne, 1997). In this way, the temporal frames for storytellers and listeners may draw on the past, present, and future. In sum, the narrative transforms a succession of actions and events into a coherent whole in which these happenings gain meaning as contributors to a common purpose (Polkinghorne). There is an important distinction to be made between narratives and stories (Mathieson & Barrie, 1998). Narratives have an expansive and open-ended quality while stories appear to be self-contained and paragraph-like vignettes. This distinction has been adopted in this study and the terminology hereon will reflect this differentiation. Polkinghorne (1997) emphasizes the importance of "plot" in the narrative structure. It is presupposed that all stories have a plot. According to Polkinghorne, a plot functions to configure events into a story in four ways, by: (a) marking the beginning and end of the story; (b) providing criteria for the selection of events to be included; (c) temporally ordering events into an unfolding movement culminating in a conclusion; and (d) clarifying the meaning that events have as contributors to the story as a unified whole. Content While the first focus of narrative is on structure, the second focus is the interpretation of the content of the narrative. Interpretation includes exploring themes and their relations to each other. A thematic analysis of the narrative illuminates general cultural values and sheds light on personal identities (Mishler, 1986). Analysis simultaneously respects the particularities of each account and at the same time, analysis relates an individual story to general cultural themes and values. 44 Interpersonal factors Interpersonal factors that influence the interview context are the third focus of narrative analysis. That is, one asks how the narrative might be constructed differently from a similar story, told in different contexts, such as between peers. Context is a critical element to an unfolding story that is influenced by a variety of factors, including how a participant is feeling that particular day (Mishler, 1986) and the reality that an exchange is being audiotaped. The participant is the narrator, subject of the investigation and a collaborator. The participant controls the flow and content of the interview. A story is the narrator's presentation of events at a given moment in time, which is shaped by the unique context of the interview. An interview between the same individuals the following day might result in a different version of this story as the context would be expected to differ. Finally, stories by nature are fluid; "people live stories, and in the telling of them, reaffirm them, modify them and create new ones" (Clandinin & Connelly, 1994, p. 415). The researcher, on the other hand, becomes the audience to whom the participant is presenting herself, and the effects of this unique context on the narrative are considered during analysis. Furthermore, it is recognized that the interviewer brings skills and an orientation to the interview that can influence the narrative (Mathieson & Barrie, 1998). It is also recognized that the interviewer has a personal interest in the interview. Thus, the interviewer is an integral part of the participant's account. People by nature lead storied lives and tell stories of those lives, whereas narrative researchers describe such lives, collect and tell stories of them, and write narratives of experience (Clandinin & Connelly, 1994). It follows that researchers do not "find" 45 stories; rather, researchers "make" stories by retelling accounts through analytic descriptions. Therefore, researchers are storytellers and through concepts and methods of analysis, they construct the story and its meaning (Mishler, 1995). Mishler (1986) situates narrative inquiry within the larger sociocultural and sociopolitical contexts aimed at the empowerment of participants, with a focus on constructing coherent worlds of meaning and making sense out of experiences. In this inquiry, the context was one of making sense of the experience of nicotine dependence. Sampling Selection and Criteria Sampling in narrative inquiry requires the inclusion of individuals that are best able to tell a story that will inform the research question. Therefore, sampling proceeded in a manner to ensure that this process of selecting participants would enhance the stories that enriched the researcher's understanding. To this end, sampling was purposive and included teenage girls, aged 14-18 years, with recent experience with smoking. The prevalence of smoking increases with age and is known to be 25 percent among this age group within British Columbia (Angus Reid Group, 1997). It is further estimated that approximately two thirds of these teens smoke daily (Health Canada, 1996). Recruitment for this study took place in several ways. Letters of introduction and fliers about the study were circulated within the community with the intention that teenage girls would hear about the study and consider participating in interviews. In this printed material, the researcher invited teenage girls to participate in face-to-face interviews. In the early phase of the study, letters were circulated to households within the immediate vicinity of the researcher, which resulted in two interviews. Fliers were also posted in community centers throughout the city and in an aquatic center. This led to 46 five telephone calls from interested teenage girls, two of whom were eligible to participate. The other three girls who phoned the researcher had minimal experience with smoking, such as once having had "a puff and were therefore not eligible for this study. In other instances, family members had seen the flier and had passed the information on to potential participants. In addition, the researcher contacted several nurses working in the community and obtained names of teenage girls that were interested in hearing about the study. Finally, recruitment through word of mouth was ongoing throughout the study. That is, acquaintances of potential participants made initial inquiries of these girls. Once interest and verbal consent were established, the researcher made contact with these girls. The letter of introduction (Appendix A) described the purpose of the study as an exploration of teenage girls' attitudes regarding smoking. There was no mention of smoking status in this letter. Teenage girls that were interested in participating were invited to telephone the researcher if they wished to hear more about the study. The researcher offered participants an incentive, in recognition of their involvement in the study, in the form of a gift certificate from a music store. This detail also appeared in the letter. At the time of telephone contact, the researcher then determined eligibility by asking two questions. First, the potential participant was asked if she had ever smoked. If the response to this question was affirmative, then the second question followed, that is, whether she was willing to participate in a tape-recorded interview. All participants were informed that their written consent would be required along with written consent from a parent. The appropriate arrangements were made to fulfill this final detail. Participants were assured that written material about the study would not refer to smoking status. Mechanisms were put in place to assure participants about confidentiality, as outlined in 47 the section on ethical considerations. None of the eligible teenage girls declined participation in this study. After each interview, participants were given letters of introduction and were asked to circulate these letters among their peers, thus sampling was expanded using a snowball sampling technique. This led to two referrals only. It may be that the success of the snowball sampling was limited because some girls were not aware of the confidential nature of the study. Therefore, some girls may have been concerned about their parents discovering their current smoking. In total, this study included 12 participants. This sample size and the quality and richness of the interviews were reviewed and deemed as "adequate" to inform the research question. That is, clear and common stories became evident early on in the analysis. Furthermore, the majority of storytellers in this sample were able to provide rich stories. Narrative inquiry does not concern itself with claims of reaching "saturation." That is, an investigator cannot claim to have heard every story about a particular experience or phenomenon. Rather, the investigator focuses on finding "common stories" in narrative inquiry. Claiming saturation reveals a lack of understanding of the meaning of key concepts in certain kinds of qualitative work (Sandelowski, 1994). Data Collection Data collection proceeded in an organized fashion. Preparing for interviews included developing a series of open-ended questions that were used initially to guide interviews and to probe the narrative (Appendix B). These probes addressed topics related to nicotine dependence and included topics such as becoming a smoker, changes in smoking over time, plans to smoke in the future, attempts to stop smoking and 48 relationships with other smokers. In addition, probes were used to explore the meaning of smoking and nicotine dependence within the daily lives of teenage girls. All participants were interviewed once. Ten interviews were face-to-face while two interviews were conducted over the telephone. The interviews ranged in length from 35 to 60 minutes. These interviews occurred over a period of five months, which allowed the researcher an opportunity to conduct concurrent analysis and to pursue further theoretically-based sampling. In addition, there was a minimum of one follow-up telephone call with all participants in the form of a member check to validate the findings. Interviews took place in participants' homes and in the home of the researcher when it was the preferred choice of the participant. All attempts were made to ensure that complete privacy was maintained during the interview. Ensuring privacy during the interview process minimized the likelihood that family members would be aware of the content of the interview. Privacy also seemed to enhance the overall comfort level for participants, as many revealed information to the investigator that they claimed their parents did not know. It was evident in several interviews that some parents were not aware of the extent of their daughter's current smoking. It was also recognized that the participants might feel awkward with the interview process. Attempts were made to create an interview atmosphere that was as comfortable as possible. To ease into the interview gradually, demographic information was obtained prior to initiating audiotaping. The tape-recording was started when the interviewer described the intent of the interview, that is, the telling of a story about nicotine dependence. The interviewer then preceded to tell a personal story about caffeine 49 addiction as an example of a story with a beginning, middle and end. At that point, participants were asked to tell their story about nicotine dependence. The interviewer suggested that participants begin their story by describing their first cigarette. All interviews were audiotaped and transcribed verbatim soon after the interview took place. Observations were noted immediately after each interview. A summary of field notes was made to include thoughts, ideas, general impressions and contextual observations related to the interview. These field notes were later incorporated into the analysis. Data Analysis The analysis of the data was conducted in a systematic fashion. To begin, special attention was given to the accuracy of the transcriptions. The transcripts included pauses, repetitions, false starts and asides, which are inherent in the structure of language as structure. All the transcripts were reviewed with the tapes to ensure their accuracy. Not all of the interviews were relevant to the topic of nicotine dependence. The analysis began by locating parts of the interview that met a specific criterion, namely the presence of topics related specifically to nicotine dependence. The stories included personal attitudes, beliefs, experience or knowledge about nicotine dependence. Alternatively, some participants told a story about another person that was nicotine dependent, which was viewed as part of the narrative. In other circumstances, participants did not tell a personal story about nicotine dependence; rather, they talked about their beliefs surrounding nicotine dependence and about others that were addicted. These stories were included as part of the narrative. Topics not related to nicotine dependence, 50 on the other hand, were not coded, because they were not considered part of the narrative about nicotine dependence. A holistic-content perspective was integrated into the analysis of the data as outlined by Lieblich et al. (1998) using a five-step process, which included: 1. Reading the transcripts several times until patterns emerged in the form of foci of the entire story. Reading or listening with an open mind and allowing the text to "speak." Paying attention to certain aspects such as those used at the beginning or end of a story. 2. Writing initial and global impressions, noting unusual features of the story such as contradictions or unfinished descriptions which may have been "no less instructive" than that which was clear. 3. Deciding on themes to follow in the story as it evolved from beginning to end. A theme was distinguished by the time devoted to it, its repetitive nature and the number of details provided. Omissions or a brief reference to a subject were also interpreted, on occasion, as indicating focal significance. 4. Marking various themes in the narrative with colored markers and reading each one separately and repeatedly. 5. Following each theme throughout the story, noting where it appeared for the first and last times, the transitions between themes, the context for each one and the relative salience of the theme in the text. Throughout this process, the analysis occurred concurrently on the three levels mentioned earlier in this chapter: structure, content, and interpersonal factors. The structural analysis focused on how teenage girls constructed their stories of nicotine 51 dependence. The analysis of the content focused on the themes, meanings, and identities related to nicotine dependence. Finally, the analysis of interpersonal factors considered the influence of the interview context or the investigator, the storyteller and the setting. Ideas were generated inductively from the data and then discussed with the author's thesis supervisory committee members. By re-listening to the tapes and re-reading the interviews and by meticulous and systematic analysis, more ideas were developed. In several cases, the content of the stories was coded using several colors to reflect the presence of two different narratives and/or a narrative and a sub-narrative occurring concurrently. Simultaneously, coding included an analysis of the structure of the narrative in each interview. These codes identified digressions from the narrative, verb tenses, the use of "voice," significant statements, frequently used words, observed features of the discourse and contextual observations. In the final step, the analysis of each interview was synthesized. At this stage, the research narrative drew together the diverse actions and events that contributed to the research outcome, the findings (Polkinghorne, 1997). Thus, this phase of the analysis incorporated the above mentioned components of the analytic process. In the end, three common narratives appeared that affirmed a "communal" story; several participants had similar stories. In this way, narratives about nicotine dependence emerged from this analysis as common stories among female teens. At the same time, the analysis uncovered two sub-narratives, which substantiated the narratives. According to Polkinghorne (1997), the research process needs to be reported as a temporal whole in which the knowledge claim is a conclusion whose meaning is 52 dependent on the developing actions and events of the whole research process. Consequently, the description of the findings was composed using a narrative with ample, verbatim quotations from the interviews to illustrate the narratives and the sub-narratives. In each narrative and sub-narrative, a paradigm case was constructed from the data to illustrate the "common story." These findings are presented in Chapter IV. A synopsis of each interview was also compiled (Appendix C). The interview synopsis was subsequently read to each participant along with the three paradigm cases of each narrative. The participants were then asked to indicate which case best represented her "story." This process of validation with participants is discussed in Chapter V. Throughout the research process, the researcher worked closely with her supervisory chairperson. The transcripts were reviewed together and the preliminary was coding discussed. Subsequent discussions ensued regarding the coding and interpretation of the stories. Ethical Considerations Permission was obtained from the University of British Columbia, Behavioral Sciences Screening Committee for Research and Other Studies Involving Human Subjects before conducting this study. Written, informed consent was obtained from all participants and from a parent of each participant before the interview (See Appendix D). Parental consent was required because the participants were under 19 years of age. The content of both consent forms was identical and described the purpose of the study as an exploration of teenage girls' attitudes regarding smoking. 53 It was expected that some parents might be aware of their daughter's smoking but perhaps not the amount smoked. Issues of confidentiality were strictly honored and the participants maintained control over their continued participation in the discourse. Summary Narrative inquiry was used in this inquiry to investigate the meaning of nicotine dependence among teenage girls. Narrative analysis is useful in capturing the continuity and change in a phenomenon under study by engaging participants in a project in which they are already engaged, by virtue of being human and storytellers (Sandelowski, 1991). Adolescence is noted to be a period of constant change and challenges. This method of inquiry was found to be particularly suitable for this population and the research question, one that focuses on identity and on language. As expected, narrative inquiry permitted meanings and particular words to emerge that shed light on the identities of teenage girls that smoke. As researchers, we need to listen to the "voices" of teenage girls and to hear their stories to gain a better understanding of nicotine dependence from their perspective. All interpretation involves human fabrication and the making sense of meaning (Sandelowski, 1991). The interviewer therefore created "the space" for the construction of the narrative that allowed meanings to emerge. Lieblich et al. (1998) refer to narrative inquiry as suitable to researchers who can "live with ambiguity." It is therefore recognized that any conclusions drawn are interpretive and can change and change again with further readings. At the same time, interpretive decisions are not "wild." All interpretation in narrative inquiry is grounded in the data. Finally, it is recognized that the findings in Chapter IV do not encompass all stories about nicotine dependence. Narrative inquiry has provided a "window to 54 understand" the common experiential components of nicotine dependence in teenage girls and the context within which it occurs. 55 C H A P T E R IV: FINDINGS Overview The purpose of this investigation was to explore the meaning of nicotine dependence among teenage girls within the context of their lives and their smoking behavior. In this chapter, findings from the interviews emerge as stories about nicotine dependence. An in-depth analysis of these stories about nicotine dependence has resulted in the identification of three narratives, namely, Invincibility, Giving In and Unanticipated Addiction. Briefly, in the first narrative, the participants that are described as invincible presented themselves as in control of their smoking. In the second narrative, the girls that were giving in described yielding to external forces and smoking. In the third narrative of unanticipated addiction, the participants described surprise upon discovering that they were addicted to cigarettes. In addition, two sub-narratives appeared regularly as tangents or digressions from these stories about nicotine dependence and served to substantiate the narratives. These sub-narratives are entitled Needing to Quit and Repeating History. This chapter begins with a brief description of the demographic characteristics of the sample (See Table 1). A short commentary on the general characteristics of the interviews follows. Next, there is a discussion regarding the three components of narrative analysis within these interviews, namely, structure, content and interpersonal factors. Then, an analysis of the use of voice by the storytellers as it relates to identity is presented. The storytellers are introduced in the form of prose poetry, created by excerpts from the interviews. A detailed synopsis of each interview is located in Appendix C. Finally, the chapter concludes with a detailed account of each narrative and sub-narrative. 56 Demographic Characteristics Table 1 includes demographic information that pertains to the 12 participants in this study. This information was obtained before beginning the tape-recorded interview. Participants have been listed alphabetically according to their pseudonym. Table 1. Demographic Characteristics of the Study Participants Name Age Age first tried a cigarette Number of cigarettes in past week Number of quit attempts of > 24 hours Number of friends that smoke Family members' smoking status Amy 17 14 1 None Few No Azuki 15 13 60 4 Most No Caitlin 14 12 30 2 Few No Jackie 16 13 0 2 Most Yes Kelli 17 12 65 2 Most Yes Kristi 15 14 12 3 Most Yes Lauren 17 11 300 3 Most No Megan 15 12 0 None Few No Naomi 16 13 0 1 Few Yes Nicky 16 12 0 None None Yes Shannon 16 12 2 2 Most No Tara 16 11 200 4 Most Yes The participants ranged in age from 14 to 17 years with Caitlin being the youngest. The age at which they tried their first cigarette ranged from 11 to 14 years. However, several participants indicated that they had tried a puff when they were younger. It is noteworthy that Lauren and Tara both started to smoke when they were 11 57 years old and that they were also the heaviest smokers in this sample. This finding corresponds to research that links age of onset and subsequent heavy smoking (Chen & Millar, 1998; Eiser & Sutton, 1977; Escobedo et al., 1993). Jackie was a former smoker and had "stopped" smoking six months before the interview. Amy, Megan, Naomi, Nicky and Shannon described themselves as "social smokers." Two of the 12 interviews were conducted in Ontario. The remaining ten interviews occurred in the Lower Mainland of British Columbia. Two participants lived in a suburb of Vancouver and a decision was made to conduct their interviews over the telephone. Two interviews took place in separate locations on the East-side of Vancouver, an area of lower socio-economic status, generally, than that of the West-side. The remaining six interviews took place on the West-side of Vancouver. Of these six, four participants chose to be interviewed in the home of the researcher, indicating that they would be more comfortable with the subject matter in this setting. With the exclusion of one participant, who was born in Germany, all participants were born in Canada. Two participants were of Japanese origin. One half of these participants were living in a single-parent household. One half of the participants lived in homes where family members smoked. One participant indicated that none of her friends smoked, four said that few of their friends smoked and seven claimed that most of their friends smoked. General Characteristics of the Interviews The interviews varied in terms of the quality of the storytelling as well as the participants' ability to tell a personal story about nicotine dependence. That is, some 58 storytellers had experienced nicotine dependence, whereas other participants told stories about people they knew who were nicotine dependent. One out of the 12 interviews was disappointing and appeared to resemble a question and answer session in which it was difficult to locate a story about nicotine dependence. It is worth noting that this participant was the youngest in the sample. This was also one of the first interviews. The researcher had initially approached the participant's mother, who was an acquaintance, about the study. The participant's mother was extremely enthusiastic about having her daughter participate in this study, while the participant herself may well have been less enthusiastic. Therefore, with one exception, the participants appeared to be motivated to be involved in the study. This was particularly true for those that had seen the flier and had taken the initiative to contact the researcher themselves. All the participants were aware of the gift certificate from the outset, which provided further incentive to participate in this study. The quality of the stories in the telephone interviews was excellent. Both participants were 17 years of age and "good" storytellers. The obvious disadvantage of this approach, however, was that the researcher was unable to note observations that are an integral part of face-to-face interviews. For example, while it was audible that one of these storytellers was smoking during the telephone interview, the researcher was not able to observe this activity. During one of the face-to-face interviews in the participant's home, another storyteller smoked four cigarettes during the interview. As outlined in Chapter III, the interviews were analyzed concurrently for structure, content and interpersonal factors (Mishler, 1986). At this time, general 59 observations as they pertain to each of these three components are presented with examples drawn from the interviews. Structure Narratives about nicotine dependence were easily located in the interviews. Most of the stories were presented with an obvious beginning, middle, and end. In these stories, the narrator began with a tale about her first cigarette with a statement such as, "When I was in Grade 6" and closed with a statement such as "and here I am today." Milestones such as specifying Grades and the age of the progression of smoking were utilized, giving the stories a "rehearsed quality" (Mathieson & Barrie, 1998). In some interviews, the ordering of the story was not linear. For example, several narrators returned to the sensations of the first cigarette part way through their stories. One storyteller was exceptional in that she started her story by describing how her mother used to smoke when she was younger. Significant statements were frequently emphasized at the end of the stories and served as a "resolution," such as the storyteller who closed her story by referring to how she started to smoke, "So I think it's basically how it started, it was just a mild curiosity.. .because it was never anything I wanted to do." Elsewhere storytellers used bookmarks at the beginning and the end of the story, which isolated the story. For example, one social smoker attempted to explain what she thought it would be like to be nicotine dependent. Her story began and ended with "I don't know." These storytellers constructed their stories by means of various linking words such as, "like" and "and so," which contributed to the flow of the story. Other terms such as "right, so," "you know" and "you know what I mean" actively engaged the listener in 60 the telling of the story. The narrator often used word repetition for emphasis, such as "really, really needing cigarettes," smoking "more and more," and having it "build up and build up" to describe addiction. The use of adjectives such as "totally," "constantly," and "majorly" [sic] reinforced the strength of the stories about nicotine dependence. The stories about nicotine dependence were generally told in an animated manner. Some storytellers hastened the delivery of familiar stories whereas they tended to speak with hesitation when pondering their future with regard to smoking. The pitch and intonation of the stories varied significantly, particularly in the telling of stories about others who were addicted. The use of the phrase "I don't know" was significant throughout these interviews, suggesting that many storytellers did not know about cigarette addiction and/or did not know what would make them stop smoking. Finally, there were many protracted pauses throughout the interviews as the narrators took time to reflect. The stories were enhanced through overgeneralization and exaggeration. Some participants observed that most people smoked at their school. In one story, the estimated percentage of smokers at school escalated from 35 to 50%. Another participant informed the listener that she went through a period where she smoked five packs a day and drank 17 cups of coffee daily. A variety of verb tenses were used in these stories. One storyteller, a former smoker, changed the verb tense from past to present midway through her story, thus making her story more vivid. This participant explained how she used to smoke and that she would smoke more in the summer time because there was no school. The storyteller then switched her story using the present verb tense as she described spending time at her 61 friend's house, "Her mom knows I smoke, so I can smoke there too," as though reliving the days when she used to smoke. The structural analysis included an examination of the choice of words used in these stories. To begin, storytellers did not talk about "nicotine dependence;" rather, they talked about "cigarette addiction." The social smokers described "doing it" while those that had experienced unanticipated addiction referred to their "smokes." While a number of storytellers made analogies between cigarette addiction and food, others used vague terms such as "stuff," "or something," "type thing," and "whatever." Content The content or meaning of the interviews is presented in greater detail in the stories that follow. This analysis included the exploration and interpretation of themes in the interviews and their relationship to one another. A few comments are deemed worthwhile at this time. For the most part, the content of the interviews was clear and it was obvious that the storytellers were presenting themselves in a way that fit a particular narrative. Occasionally, however, it was difficult to ascertain the identity being revealed in the story. That is, during the analysis, there were instances when it was unclear if the participants, particularly the social smokers, were presenting themselves as part of the narrative on Invincibility or as Giving In because there was ambiguity in some stories. For example, one participant presented herself as "pretty good" about keeping herself from getting "too much" when referring to cigarettes, and able to "catch" herself before becoming addicted. At the same time, she described smoking regularly during the Christmas holidays, "getting used to it" and starting to like it. In the end, it appeared that 62 she was presenting herself as having two concurrent narratives. Another participant explained, "I know that I have that control. If I'm at a party and I feel like one, I'll have one, but that's also I guess the image." In this second story, the participant presented herself as both invincible and as giving in to the image of smoking. Indeed, most storytellers often presented with two narratives although there was always a dominant narrative within each interview. Five participants presented stories with a dominant invincible narrative while there was frequently a significant giving in narrative in these interviews as well. Often times, there was movement back and forth between these two narratives. Five other participants told stories predominantly using the narrative of unanticipated addiction, again with a significant giving in narrative woven throughout their stories. Finally, two participants told their stories primarily using the giving in narrative while the unanticipated addiction narrative was secondary within their stories. These narratives illuminated and explained one another. There were occasions when the content shifted during the interview suggesting an evolving story. For example, one participant's story regarding her mother's cigarette addiction changed during the course of the interview. Initially, her mother was described as not addicted. Midway through the interview, the storyteller questioned whether her mother was addicted if she only smoked one cigarette at night as a "ritual." By the end of the interview, the participant indicated that she was trying to convince her mother that she was addicted. Furthermore, several storytellers had plans for quitting that changed during the interview. Indeed, these changing stories may well have transpired for the sake of the listener. However, what remains most obvious is the fluid nature of these stories 63 about nicotine dependence and the equivocation with which the participants described their status. Several storytellers contradicted themselves during the course of the interview. One storyteller initially described how quitting for her friend was "easy" and later "not easy." In another story, a participant told an account of sharing her first cigarette. By the end of the interview, she described feeling guilty about having had a whole cigarette herself that first time. Another participant indicated that she once quit for two months using the patch. She later stressed that people did not "quit," but that they "stopped" when using nicotine replacement therapy. Despite the contradictions within these stories, there was consensus among all the storytellers that cigarette addiction was not "cool." Interpersonal Factors It is imperative to consider the influence of the interview context on the structure and the content of these interviews. That is, the narrator was telling her story about cigarette addiction to the listener, a nurse, during a tape-recorded interview. Undoubtedly, the stories that were told and the meaning of what was told were shaped by the relationship of this dyad within the setting that had been created. In several instances, references were made to the researcher's initial story about caffeine addiction. Several participants wanted to give a 'good story' as illustrated with comments such as, "Is that what you wanted?" and "I don't even know if I'll be good for your study." Without question, a different story would have emerged in a different context, such as between two friends. A few storytellers began their stories somewhat tentatively, while guiding questions and probing served to draw out the story. As a result, the presence of the 64 listener is more apparent in some interviews than in others. In addition, there was considerable laughter, particularly early in the stories, as well as pauses, which suggest some discomfort on the part of the storytellers. The researcher usually closed the interview by asking the participants if there was anything that she ought to know about nicotine dependence. At this time, the participants tended to summarize the critical points of their stories about nicotine dependence. For example, one storyteller indicated that she disagreed with smoking and another indicated that smoking was a personal choice and not one that people were pushed into. Generally speaking, the interview setting was conducive to the interview. On one occasion, a participant was distracted by her younger brother and his friend who were playing in the background. This participant requested that the interview be stopped briefly while she asked them to play elsewhere. When interviews occurred in the investigator's home, attempts were made to minimize interruptions such as a telephone ringing. With one exception, telephones rang during the interviews at the participants' homes. What is interesting is that only one participant made reference to the telephone ringing. That is, most participants appeared to be unaware of the telephone and remained engaged in their storytelling. Finally, certain stories may have evolved because of the context of the interview. In particular, the narratives of Invincibility and Needing to Quit allowed the storytellers to present a strong-willed and committed persona. It is acknowledged, however, that the stories may have been embellished or edited for the sake of the listener. The discussion of the context of these stories is expanded within the description of the individual narratives. 65 Voice and Identity The data analysis included consideration of the use of voice among the participants to explore how the girls chose to tell their stories and how they presented themselves. In these narratives, the use of voice revealed and reinforced the narrator's identity, that is the "who am I" with regard to nicotine dependence. In these stories, "I" was the dominant pronoun. However, this pronoun was frequently contrasted with "others." For example, the invincible voice referred regularly to "others," "them," "they" or "the people" as those who were addicted. In contrast, when the narrative voice of unanticipated addiction referred to others, it was primarily in reference to those who were both addicted and less often to those who were "controlled smokers." At other times, the participants used the first person as a way of trying a different smoking identity for fit. One participant, who smoked occasionally, imagined . "If I was a smoker" while the smoker who was "totally addicted" attempted to understand social smoking. Moreover, all storytellers compared the amount that they smoked to others. Making an observation about one's own or another's smoking usually led to a comment on addiction articulated using the third person. For example, one participant observed that "some people may smoke all their lives and never be addicted to it" while another girl commented, "People with addictions do stupid things sometimes to get it." The pronoun "we" was the voice of experience that spoke knowingly, such as the occasional smoker who stated on behalf of others, "We're not having, like, a pack a day, we don't have time" or the storyteller who spoke for her friends, stating, "We all try to quit." 66 The pronoun "you" was used frequently throughout the stories about nicotine dependence. In this way, the storyteller engaged the listener and presented a story that resembled a personal theory on nicotine dependence, such as, "a cigarette every so often, doesn't get you addicted." Thus, this pronoun generalized statements giving them greater impact. This pronoun was also used to express truisms, such as the storyteller that described the importance of being "ready to quit." She said, "You've got to make sure that you are really, really prepared and really ready to quit. You have to really want it, or else you are not going to do it." At times, "you" took on a moral tone such as the storyteller who claimed, "You have to give people other, healthier options." A change in pronouns occurred during several stories. This shift is particularly revealing and either reinforced separateness or suggested belonging to a certain group. One storyteller described being different from her peers, "If we are all at a party, they will all smoke. If we are at school, then they won't." The same storyteller later suggested that she might, in fact, be a part of that group when she introduced the pronoun "we." "At parties, we, like some of my friends, they smoke when they drink." A shift in voice may also be related to a change in the narrative voice. In the following example, the neutral noun "people" changed into the pronoun "you," as the story became more personal. "When people were first starting to try it, if you started smoking, you'd started hanging around the area where the smokers hung out, that sort of turned into your group of friends." Another participant switched from 'I" to "you" while making a statement that she generalized to others, as she described her continued smoking. "I just kept on doing it. So around even your second cigarette, you don't just feel dependent yet, but you want it." 67 One former smoker continued to identify with smokers. She began her story about the school "punishment" for people that were caught smoking. According to this participant, she had not had a cigarette in more than six months. "The teachers know that lots of the people smoke and they know we're not going to stop." In this way, her identity appeared to remain with those that smoked, despite the fact that she called herself a former smoker. There was substantial evidence of self-talk in these stories as well, which gives the impression the participants had preoccupying thoughts about nicotine dependence. One participant described experiencing unsuccessful quit attempts and asked herself, "I'm like, do I really want to go through that again?" Another storyteller described how she started to realize that she enjoyed smoking: "As soon as I realized that, I'm like, wait a second, I'm starting to like this and I know it's wrong." In summary, listening to the voice of the storyteller provided important insights into the identity of the storyteller. It is critical to listen carefully to these voices and to observe the subtleties in their voices in order to speak about the stories of these young women. The storytellers will now be introduced, as they "speak in their own voices." The Storytellers In this section, the 12 storytellers are introduced. An individual sketch of each storyteller has been crafted using interview data; each participant is presented in the form of prose poetry. In this way, it is anticipated that the reader will acquire an impression of the essence of the storyteller as she presented herself during the interview. That is, it is the storyteller who is the speaker in each poem. Thus, in presenting data as prose poetry, the narrator is present. Sandelowski (1994) supports "celebrating the art," which includes 68 experimenting with forms of representing findings that best relate the experiences that the investigator wishes to convey. Poetry has been used in research as an alternative form of presenting interview data. Richardson (1992) notes that poetry commends itself to multiple and open readings. In addition, Richardson identifies how this form of presenting data enables the researcher to "better step into the shoes of the Other" (p. 135) by being more closely attuned to lived experiences as felt by the other. In this way, we see the storytellers differently, beyond the data. By settling words together in new configurations, the relations created allow the reader to hear and see the world in a new dimension (Richardson, 1993). A poem as "findings" reconstructs ideas of validity and reliability from "knowing" to "telling" (Richardson, 1993). Poetry is thus a "practical" and "powerful" way of working with interview data. The storytellers are presented in alphabetical order, corresponding to the order of their stories, written in prose, in Appendix C. Amy If everybody around is eating, you don't want to sit there. It's the same thing. You just try it, it's the temptation. A cigarette every so often doesn't get you addicted. A lot of people are social smokers. I don't think it's that big a deal. If you are bumming, you don't have the incentive to do it enough, to develop an addiction. Azuki I like the feeling of it going down my throat. Never thought I was going to get addicted. I see other girls smoking. You just kind of get hooked on that. Even walking, I have one. It's just natural. Those smoking, cancer video things just made me want one. Used to like running, used to be very good. I'd have to think about my priorities. Caitlin I have enjoyed it more. I'm more addicted. I'll probably stop in about a year. It's like 50 percent the actual nicotine, and 50 percent the actions of what you're doing. There's not a certain person. Whoever smokes, just gets addicted. Jackie They'd always have cigarettes. They'd be handing them out. I'd always just have my hand out. I just started smoking. I was kind of addicted. You are always going to be around it. Even if you choose not to, you might re-think it just because it is everywhere around you. I might start again when I'm getting ready to go to college. Rem-it just kind of progressed. It's really habitual. Don't know if it calms me. The pill, the gum and the patch, Don't want to be dependent on a patch. One friend used Zyban. I think I might try that. Went down from regular, to light, to extra light, to ultra light. I will be quitting. I really want to. Kristi My first cigarette I didn't even inhale. At the time I thought I was cool. Now I am completely addicted. If it was raining outside, I would want to go out. Usually I don't want to go out in the rain, but I have to have this. I don't want to stop, but I have to because it's just going to get harder later on. It has to be my own choice. 72 Lauren I was just stressed out and sad all the time. Had nothing to do over lunch or recess. So I took up smoking. I knew I would end up smoking. I don't know why I like it. It's just something I do -almost like my trademark. It's not something that I can just say, "Okay, fine, enough. At times I want to give it up. I always have money for my smokes. Kind of shows me that I do have the power to budget Megan I tried it. Some people say you either like it or you don't. I was just in the middle. I didn't not like the taste of it. Every once in a while, I would have a couple. I wasn't addicted. It just clicked in my head. 73 Naomi I sort of got used to it in social situations. Was going through what I call my stage. Enjoyed the way it made me feel, well, look. Falling in love with that image. If I am at a party and I feel like one, I'll have one, But that's also I guess the image. I have two sides. One says, "Who cares five times a year," the other one says "Why, why even that?" Nicky The stress is so incredible when you're twelve. You just need it. They're not like drugs or anything. They're just cigarettes. Don't use it for stress release. Just do it on special occasions. It's not really addictions if you can control them. It's always going to be around. I don't intend ever to get addicted. I know it's going to ruin my life if I do. Shannon It was never a pressure thing, just my decision, I think, mostly. As soon as I realized, "I'm starting to like this and I know it's wrong," I caught myself before it got to be a problem. It kind of taught me to be a bit more aware. I try to teach myself, but then you never know. I'll share with somebody, it's no big deal. Tara Mild curiosity, tried one, instantly liked it. Didn't think the addiction would really kick in. Addicted two months into it, without even knowing. I really, really want it. I really, really need it. I was never going to smoke. I am a vocalist, trained in voice. Smoking is the worst thing I can do. Need to quit, but wanting to is different. Knowing the next cigarette's the last, that scares me. 75 The Narratives "Whenever a novel abandons its themes and settles for just telling the story, it goes flat." (Milan Kundera, 1988, p. 83) In the following section, three narratives identified within the interviews are described. These descriptions are written primarily in the present tense because the storytellers most often used the present verb tense to tell their stories. The first narrative is that of Invincibility. Invincibility In the narrative about invincibility, girls present themselves as "in control" of their smoking and not addicted. In this narrative, the stories are about smoking socially at parties, when drinking alcohol, and at school dances. The story line is: Sometimes I smoke. Smoking is stupid. People who smoke are losers. Other people get addicted. In this narrative, the storytellers describe how they are in control of their smoking. An exemplar of invincibility is found in the story told by Megan, as outlined in Appendix C. Invincibility is portrayed in this story, which has been reconstructed from the interviews. It begins with trying cigarettes. I tried smoking when I was going through 'my stage.' But I never really liked it enough to become addicted. Actually, it made me feel sick. And, I never smoked that much. One night when we were all at a party, I had five cigarettes. All of a sudden I realized what I was doing and said to myself, "This is gross." So, I stopped myself before becoming addicted. I've learned by seeing what it does to other people and just know that it's not worth it. I only do it socially. I never do it alone and I don't ever buy them. It's not an addiction if you can control it. I can smoke and not get addicted because I know I'm in control of my life. Hence, the story concludes with ongoing controlled smoking as girls continue to "do it." 76 Throughout this narrative, girls clarify that they smoke, "but not as a habit," that smoking is "not everyday" and that they "haven't smoked that much." Girls qualify when they smoke with various adverbs: "rarely," "seldom," "just socially" and "very random." Smoking is described in terms of what it is not. Smoking would "not be just by itself and "not for stress release," "not as a habit" and "not usually" at school. Smoking is portrayed as "always a personal decision" and "never a pressure thing." Girls describe how they remain in control of smoking. To begin, smoking involves bumming cigarettes from others. Accordingly, "If you are just bumming, you don't have the incentive to actually do it enough to develop an addiction." For another, I didn't [smoke] often, maybe two or three times a week. So that was sort of my rationalization, like how can I be addicted if I don't even buy cigarettes, I just get one from a friend once in a while. Experiences with cigarettes are portrayed as unpleasant. Stories depict getting a "head rush," "headaches," and feeling sick from smoking. Girls report having "to force" themselves to inhale and as having difficulty smoking the whole cigarette. These storytellers often use the past tense as they describe having smoked more at another time. Smoking was "a phase," "the age," "the stage," and a "stupid little Grade 8 thing." Invincibility surfaces after an event involving more smoking when "it just clicked in my head." One girl explains, "I looked at my fingers and I said, 'this is disgusting,' and I put it out and I walked out of the room and I said, T am never smoking again.' And I haven't since." Girls describe having to learn about smoking. "You have to learn like the way I have learned through all my physical activities." Learning by observing the mistakes of others who are addicted is also woven into stories. These storytellers "know better." One 77 participant notes, "I'm very honest with myself. I saw other people getting addicted and I didn't want to be one of them." There is certainty and clarity in this narrative voice that extends into the future as well. One participant affirms, "I'll catch myself in time before it gets to be a problem." When girls refer to stopping or quitting smoking, their experience is "easy" because "I'm just that kind of person." Alternatively, girls recognize and act on the realization that they are starting to like smoking. One girl describes how she cut back in her smoking before becoming addicted, hence re-gaining that sense of control. Another girl indicates that she "just realized" that smoking made her sick. These girls say that they are "too busy to bother" smoking and that they have "better things to do than stand in the rain." They prefer activities that are "more fun." One participant anticipates remaining a social smoker at university, adding that she will be preoccupied with her studies. She explains, "I'm going into sciences and I know I won't have time [for smoking] with the studying." These storytellers, who say that they have not experienced cigarette addiction, acknowledge not knowing what cigarette addiction would be like. At times, they imagine that it is associated with guilt, feeling stupid, and perceived as an expensive "burden." One participant concludes, I think it must be really frustrating to have something like that be out of your control and know that you're hurting your body but will not be able to do anything... .Actually, just the other day, two girls walked in during lunch hour. We were just sitting in one of the classrooms and my friend goes, what stinks, looks around and it was them, so that must have been embarrassing for them. Thus, cigarette addiction is portrayed as frustrating and embarrassing. Other storytellers convey sadness or depression when they describe cigarette addiction. One participant 78 suggests "People who are really addicted don't want to admit it because everyone knows that it's not really a good choice to make." However, in other stories, cigarette addiction is described as not a big deal. Rather, "it's just another thing that you put in your purse." Thus, these storytellers hold a range of opinions on the experience of cigarette addiction for others. Some stories about cigarette addiction focus on the importance of image. One participant describes it as "falling in love with that image.. .making that be part of you. If you let go of that, you let go of that security." Moreover, "others" follow what "the images tell us to do," and "they" smoke. There are elaborate accounts of recognizing addiction in "others," where the use of the third person dominates. These stories involve observing the smoking behavior of others, "I sit next to a girl in my Spanish class. She'll be in the middle of class and she'll need to have a cigarette and [she's] also trying to get herself off of it, but can't." Girls notice that "others" smoke "when they are coming to school in the morning" and that "they" smoke alone. The inability to run in track or for the bus without getting "really out of breath" is "feeling" cigarette addiction. "Other" girls who start smoking in Grade nine and who buy their own cigarettes, later become addicted. Various distancing devices reinforce this narrative. To begin, cigarette addiction is kept at a distance from those who are invincible. In seeing "other friends" get addicted or having family members that are addicted, girls learn and emphasize that "it's not worth it." Furthermore, in telling stories about "others," the narrator is removed from cigarette addiction. In addition, those who are addicted to cigarettes are characterized as "weak," 79 "ignorant," "followers," having "the most psychological problems" and "pretty messed up." Some of the storytellers take an analytical approach to nicotine dependence and suggest various theories regarding cigarette addiction, thereby providing additional distance. A "medical perspective" explains how cells start needing nicotine and "having a special gene" prevents cigarette addiction. These theories are applied to "others," as nicotine is something "they need in their system." Language is used to distance the narrator from nicotine dependence. One participant repeatedly states, "I am not addicted, I was never addicted" as she reassures herself and the listener of her story. A repetitive theme reinforces this narrative, that is, knowing "it's really bad and so unhealthy." Frequently, the terms "smoking" and "cigarette addiction" are used interchangeably suggesting that the difference between the two terms is neither understood, nor relevant for those who are invincible. In this narrative, there is an undercurrent that downplays cigarette addiction. Stories of disbelief describe how people who are "so-called addicted" may just be saying that they are addicted because they want that image, or that "people just get addicted because they've got nothing better to do" and "just make it bigger than it is." Cigarette addiction is described as "just the force of habit." One participant tries on cigarette addiction and imagines, "I really need a cigarette, is just a common thing to say. If I said something like that, I'd seem to be putting on an act." In the dialogue about stopping smoking, moral tales abound emphasizing the importance of wanting to stop. These stories are accompanied by suggestions of what "others" have to do to quit, such as change their lifestyle or eat food when they get 80 cravings. Unequivocally, these storytellers choose adjectives that portray the negative image of cigarette addiction along with its "disgusting," "stupid," "gross," "dumb," "sick" and "nasty" properties. One girl adds, "You get nothing.. .it's not a drug, it's not alcohol, it's nothing. Like you're putting a burning thing up to your mouth." Finally, this narrator may no longer know "others" who are addicted, I've seen people from my elementary school on the bus and they're just totally different and it's so sad. You just see them smoking. I used to know you, you were in my elementary school and you were just so innocent. It's high school that ruins them. This reinforces the difference between those who are invincible and those who are addicted. The voice in this narrative is self-assured and the stories are persuasive. These participants present themselves as strong-willed and as having "no intention" to become addicted. Compounded with techniques of distancing, the storytellers accomplish two important functions. First, they assure the listener that they are in control of their smoking and will not become addicted. Second, this narrative convinces the listener that "others" become addicted. Despite the assuredness in this voice, there is an inherent paradox related to the smoking identity of the narrator. T smoke, but I am not a smoker' is how girls present themselves in this narrative, as they resist the smoking identity. In summary, the Invincibility narrative provides important insights into the experiences of young women who see themselves as "in control" of their smoking and immune to addiction. Their stories inform the listener about the role of cigarettes in their lives. At the same time, several of these storytellers describe how they give in to cigarettes. 81 Giving In In the narrative about giving in, girls describe yielding to outside forces. These storytellers present themselves as weak when they encounter cigarettes; they do not resist the temptation to smoke. Invariably, these girls describe how they are exposed to cigarettes that are readily available. In addition, they anticipate and accept an uncertain future with regard to smoking and nicotine addiction. Accordingly, the story line is, Everybody smokes. I can't say "no." Cigarettes wil l always be around. Jackie's story (Appendix C) provides an excellent example of this narrative. This narrative unfolds as girls recount regular exposure to cigarettes in their daily lives. The following story has been constructed based on the data. Seeing cigarettes is just so normal. All my friends have been smoking for longer than me and most are older. I guess that I was sort of curious about it. One day, one of my friends gave me a cigarette. At first, I didn't really want it, but I didn't say anything because everybody was watching me, type thing. It made me cough but I got used to it. I like the way it makes me look. My friends would always give them out, so I never had to ask for one. I always smoke more with my friends because they smoke a lot. A few months ago, I stopped after watching one of those scary videos. Then, one day when I was really stressed after a test, my friend handed me a cigarette. The next thing I knew, I was smoking it. I'd like to think that I could just say "no" but I'm not sure. As this story ends, the narrator's continued smoking seems likely. Early in this narrative, girls describe giving in to curiosity. One participant recalls how "the curiosity got the better of me." Being exposed to cigarettes heightens the storyteller's curiosity. That is, the visual impact of this exposure is powerful. Seeing others smoke is described as "normal." One participant explains, "I see other girls smoking and then you just kind of get hooked on that." Some girls explain how they are lured by the image of smoking and like the "look." According to one participant, "If I'm at a party and I feel like one, I'll have one, but that's also I guess the image." These 82 stories also highlight the pleasant smell of cigarettes. "You can smell it, like if you are sitting down somewhere and you can just smell everyone smoking." Thus, the result of such exposure to cigarettes is the continual temptation to smoke. "If you always see it around you, you're always tempted, just like, oh give me a drag and then, oh, can I just have that." This storyteller gives in to the temptation and smokes. Ongoing exposure to cigarettes is described as inevitable. Descriptors of the omnipresence of cigarettes run throughout this narrative. "You are always going to be around it. And even then, if you choose not to, a couple of weeks or maybe even a month later, you might re-think it, just because it is everywhere around you." Another participant appears resigned. "Once I get out of the situations and when that will be, I don't know. I guess you'll always have situations." These storytellers present themselves as powerless regarding this exposure and appear to accept the ongoing temptation to smoke. The consequence of regular exposure to cigarettes is a common theme in this story. "It's most likely if your parents smoke, and if you have friends that smoke, you have a higher chance of smoking." However, some appear only partially aware of the impact of this exposure. One storyteller does not link seeing her mother smoke with wanting to smoke herself, When my mum's smoking, it doesn't bother (me), it doesn't make me want to have a cigarette. It's sort of just a comforting smell, that's really familiar, that I recognize.. ..I guess I've always just been used to it because she always smoked. This participant gives in to what she has always known, and smokes. Stories about giving in emphasize the availability of cigarettes. "My friends would always be handing them out." Some storytellers do not appear to actively seek cigarettes; 83 rather, they accept cigarettes when they are offered. "I barely ask, it's just like, do you want one, okay, why not?" Friends and family members act as "providers" and are commonly described as "older," "quite addicted" and "regular smokers." Exposure and availability of cigarettes are closely connected for one participant who explains why she smokes, I guess it's because a lot of my friends smoked, so I thought that if I did become a smoker, it would just be easy. If I didn't have any, I would have people to ask and just because, it's awkward if you're a smoker and nobody else is. Thus, this storyteller rationalizes giving in to smoking as a practical decision that is "easy." Peer pressure is a powerful force in some of the stories about giving in. These girls describe smoking because of the influence of friends or older relatives who encourage them to smoke. They frame these stories in such a way that their giving in appears to be primarily due to the influence of others. One participant starts smoking because friends "wanted me to do it, too." Others smoke "just because everyone was smoking." Another storyteller speaks abstractly. "It was more the situations, probably if it was just me, I probably never would have bothered [smoking]." Thus, these storytellers credit "others" or circumstances for their smoking; they follow the smoking patterns in their environment and adjust their smoking accordingly. "I started meeting people, and then they ended up smoking and I'd hang out with them and they'd smoke, and so that got me to smoke even more." Hence, the narrator attributes increased smoking to other people. At other times, storytellers claim to be unaware of the process of giving in. In one story, a participant explains, "I don't really remember why I kept smoking or why I 84 actually started the habit of smoking." A former smoker suggests, "Maybe if I started smoking again, and someone actually came up to me and pointed out the reasons why I stopped in the beginning, then I might re-think." These stories reinforce the unconscious nature of giving in for some girls. In this narrative, smoking is portrayed as fulfilling a purpose, a way to "fit in" which is "less awkward" to justify giving in. At parties, one girl smokes "to relax and to let myself go." She adds, "It's like holding a drink, you're just not sort of standing there, you've got something." Another participant was attending a new school and smoking facilitated making friends. "I didn't really know anyone, so I started smoking again, and then I started meeting people." For others, smoking is "a cure for boredom." Some girls describe how they smoke because of uncomfortable feelings. These storytellers give in to cigarettes to deal with the stress in their lives. One participant acknowledges starting to smoke, and smoking more at times described as "very emotional." The storytellers describe how they smoke to comfort themselves when they are nervous and sad. One participant explains, "The ones you have alone, maybe you're sort of sad and you're just, I want to get out and it's a way to, sort of. Also, when you're nervous, it sort of calms you down." In this way, the storyteller acknowledges the calming effects and the "escape" provided by giving in to cigarettes. These stories are told in a manner that reinforces the passive nature of giving in. To begin, these tales are constructed using passive verb structures. Girls describe how "that got me to smoke," "situations keep me still having some" and "it just kind of progressed." The narrator describes smoking as an event that simply "happens." One participant adds the she "just happened to do it young." Some give in to cigarettes as "just 85 habit" and as a "crutch." One participant knew that she would "end up smoking." The following story exemplifies the passivity inherent in giving in. We all went out. We were going to another friend's house who lives downtown and then we were waiting for the bus, and our feet were so tired because we were walking around everywhere and we were all so hungry. And we weren't going to eat until we got downtown and then they were just smoking, and then my friend said, oh, you looked so stressed out, do you want some of my cigarette, and I was just, sure. I thought about it, like about to say no, but then I don't know. I just kind of reached over and the next thing I knew I was smoking it. This narrator illustrates how giving in happens quickly, albeit with fleeting thoughts about saying no. The storyteller suggests "not knowing" she was smoking until afterwards. Another participant describes getting sick of smoking after "an overload" when she smokes a lot of cigarettes in the evening. Nonetheless, she gives in and smokes the following day. She explains, "I don't want the taste of cigarettes.. ..I'll still have one though." Another storyteller explains, "I have two sides, one says who cares [if I smoke] five times a year, the other one says, why, why even that." Despite the conflict, the narrator in this story just ends up smoking. The narrative of giving in is infused with tales about attempting to stop smoking. While several storytellers indicate that they 'stopped' smoking, they continue to give in and smoke socially. One former smoker explains her experience after stopping, "Every once in a while when I saw people and they'd offer me a cigarette, then I would smoke." Another participant describes how she stopped for six days and then "I got myself in a stressful situation and just needed that cigarette and said just screw it." Some participants recognize the possibility of becoming nicotine dependent. This possibility is suggested in statements such as, "I'm not addicted now, but I could be later" reinforced with comments regarding addiction such as "hopefully not" and "I'd like to 86 feel that I could stop now." One former smoker who was once "kind of addicted" talks of resuming smoking in the future because of the stress of going to college. Hence, there is a quiet acceptance of nicotine dependence in stories about giving in. In response to recognizing the likelihood of future smoking and possible nicotine dependence, various techniques are used throughout this narrative. To begin, storytellers remind the listener that cigarettes are ubiquitous and impossible to avoid. Generous reports relay the prevalence of smoking at school where comments such as "at least half the kids there smoke" and "everyone's doing it" normalize smoking. Language is carefully chosen in this narrative and non-committal descriptors are couched in stories. Storytellers use phrases such as "why not smoke," "who cares" and "just because," which justify why the narrator gives in and smokes. Girls describe "not really" being bothered by other people's smoking or not really even noticing it once they have stopped smoking or "only" smoking socially. Several remain nonchalant and commit to neither liking nor disliking smoking; rather, they "sort of get used to it." Another expresses her ambivalence towards smoking using a double negative, "I didn't not like the taste of it." Finally, some participants minimize their smoking stating, "I know I will probably not smoke that much" and "I'll probably smoke whenever." Such vague terminology adds to their uncertain future about giving in because "you never know." I mean I'd like to say no, there's no way, right. And, I'm pretty sure no way but I can't guarantee no way because you never know what situations or what's going to happen or so many things can turn and change and stuff. Hence, smoking in the future can best be summarized by "it just depends." Such language demonstrates a resigned acceptance about giving in. 87 To conclude, these girls portray themselves as destined to always having cigarettes in their world and as unable to resist smoking. In addition, these narrators frame these stories to persuade the listener that giving in to cigarettes serves a purpose. Thus, the narrator 'creates space' for ongoing smoking as she accepts the prospect of continuing to smoke. By giving in, these girls are quietly accepting the possibility of becoming nicotine dependent, that is, the narrator does not convince the listener that it is otherwise. It follows that some of these storytellers also have a story to tell about unanticipated addiction. Unanticipated Addiction In the narrative about unanticipated addiction, the storytellers describe recognizing nicotine dependence in themselves. In these stories, the participants acknowledge their need for cigarettes. Hence, this realization represents a turning point within the stories about smoking as the narrator incorporates and presents a smoking identity to the listener. An element of surprise is introduced into these stories; becoming addicted is not expected. The script in this narrative is: I tried smoking and immediately liked it. I didn't want to become addicted but I really need my smokes. The stories told by Kelli and Tara provide model cases for this particular narrative (see Appendix C). As the story opens, early experiences with smoking are described as favorable. Unanticipated addiction is encapsulated in the story that follows. I first tried smoking with my friends because I was curious. Right from the start I enjoyed it. It felt nice and tasted good. I used to hang out in coffee shops where everybody smoked. That's when it got bad. It was never anything that I wanted to do. It's funny, I never thought I'd become addicted. One day when I ran out of smokes, I just went all strange. That's when I realized that I was addicted. It's something that my body needs right now. It would be really hard for me to quit. 88 I've tried to stop so many times. I am not proud of my habit. I used to be able to run and was very good at it. Now I can't even handle running. By the end of this story, the storyteller expresses discontent with her cigarette addiction and recognizes the impact that smoking has had on her life. In this narrative, smoking onset occurs smoothly and continued smoking is pleasurable. It didn't take that much, because I remember, like, the first time I tried a cigarette, I liked it. And even though it hurt my lungs, I still liked the feeling and the look of it and everything, so I just kept on doing it. So around, even your second cigarette, you don't just feel dependent yet, but you want it. These storytellers enjoy the sensations of smoking such as "the feeling of it going down my throat." At times, the storytellers are unable to elaborate on what they like about smoking. "I don't know if there's anything I like about smoking, I don't like the effects of smoking, but the actual act of it, it's just, I don't know, it's just something I do." Cigarette addiction is described as something that occurs easily. One girl observes, "It's not a hard thing to get addicted to begin with." This comes in contrast to accounts of stopping smoking, described as "really hard" and "stressful." In reflecting upon becoming nicotine dependent, one storyteller recalls, It wasn't even that I needed the nicotine the minute it was wearing off, it was that I needed it at certain times of the day. I'd expect to have it, so, you know, after you eat a meal, or when you wake up, or before you go to bed, right, so it started off like that. I think that I was probably addicted about two months into it, without even knowing it. Hence, this storyteller smoked for some time without realizing she was addicted. Recognizing addiction in oneself serves as a 'wake up.' This moment of recognition occurs when girls find themselves without cigarettes. One storyteller recalls, "When I actually didn't have any, I couldn't stand it. It's like, oh my God, what's going 89 on. And so then I knew." Alternatively, some stories depict situations where the girls are not able to smoke. One participant recalls babysitting her cousin for four days. Although she was able "to deal with" not smoking for several days, the situation was "awful." Another participant recognized that she was addicted during a family car trip when she was "twitching" and "aching for a cigarette." She explains, "I was saying every five minutes that I had to pee even though my parents knew I just wanted a cigarette, just so I could go have that smoke." The delivery of these stories is animated as storytellers emphasize their need for cigarettes. Other participants realize they are addicted when they contemplate stopping. One girl remembers, "When someone said, could you go days without a cigarette, I said, yes, but then after thinking about it, I realized that no, I couldn't." In another story, one girl describes never wanting to stop until one year after starting, at which point she discovered that she was unable to stop smoking. Some stories recapture other factors that contribute to recognizing nicotine dependence in oneself. One girl observes, "I noticed I was smoking more." Another participant recalls how, "every time we had a break, I'd be outside. That's when it got bad." Another reports that she was "constantly looking at the clock, waiting for break." The storytellers portray surprise upon realizing that they are addicted, stating emphatically that they never expected this to occur. To the contrary, one participant affirms, "I thought that I would be someone who smoked two cigarettes a day." In some stories, the narrators appear puzzled by their addiction. One participant attempts to make sense of her dependence, "Before I started, like there was nothing to miss, but now it's just weird." The cigarette in the morning is her favorite, yet she indicates, "I don't know 90 why." For another, "It's just, you're almost excited about it, it's weird." Finally, another participant adds surprise both at starting to smoke and at her subsequent addiction, stating "It was strange though because I didn't really think that I was going to start and that the addiction would really kick in." Those who told a story of unanticipated addiction indicated that they had an acute awareness of no longer having control over their smoking. While attempting to stop, one participant explains, "The first and foremost thing in your mind, is having a cigarette." Furthermore, she knows she can no longer smoke socially. She describes her friend, who smokes socially, I don't understand it at all because I was never that way, and I don't think that I could be that way now that I have the full-fledged addiction. I don't think even if I quit 'and then started smoking socially that I could just leave it at that. I think that I'd flip immediately back to full time. How she does it, I don't know. Thus, in unanticipated addiction, the narrator acknowledges that she cannot return to former patterns of smoking, nor can she ever be one of those "controlled smokers." The storytellers provide vivid descriptions of "needing" to have cigarettes along with the impact of cigarette addiction on their daily lives. One narrator describes "feeling" dependent, "If I was inside and even if it was raining outside, I would want to go out and usually I don't want to go out in the rain, but, like, I have to have this." In addition, cigarettes are described as "something my body needs." The storytellers illustrate their experiences with withdrawal. One girl explains, "If I'm at school and I'm sitting through class, it's like, I don't know if I'm going to get through this day," while another describes how she gets "shaky and frustrated, angry and [has] mood swings constantly." 91 Language is used to reinforce the "need" for cigarettes in unanticipated addiction. Words used to describe addiction in this narrative are simple and concrete. One girl describes having "the real thing" when referring to addiction. Descriptive phrases such as "full-fledged," "totally addicted" and "constantly craving cigarettes" underscore the strength of nicotine dependence. Word repetition emphasizes the need for cigarettes and one girl explains, "I'm used to having a cigarette right now, and I really, really want it, or I really, really need it." Some describe their experiences with chain smoking. Smoking identities are powerfully portrayed in this narrative. One participant refers to cigarettes as her "trademark." Some experience restrictions on their smoking because they are not allowed to smoke at home. Rather, they have to "take advantage" of smoking elsewhere to satisfy their addiction. In addition, unanticipated addiction produces an identity conflict. The storytellers emphasize that they are "not proud" of their addiction; several indicate that they are embarrassed by their "habit." Stories of conflicting identity arise as girls describe the incompatibility of their addiction and a "career preference as a vocalist," the physical stamina required for being "in the circus" or for other physical activities. One girl reflects on this conflict and says, "I'd have to think about my priorities, what I want to be, whether I want to be athletic or just smart, and then if I choose [to be] athletic, then that [smoking] always ruins the body." While unanticipated addiction is acknowledged as part of the storyteller's identity, it remains problematic. One participant describes addiction as "just a pain." Distancing strategies are employed to remove the narrator from nicotine dependence. The storytellers frequently describe others who smoke more than they do, which serves to minimize their own smoking and addiction. 92 I think when they smoke a lot, because, well, I think I smoke a lot, but not as much as some people. There's this one girl who's in grade eight and she smokes about a pack of cigarettes a day which to me is a lot. And I think that is just really gross. In this way, telling tales about 'others' who are addicted also normalizes cigarette addiction. One participant shares a story about someone who is sick and still smokes: "An old friend of my mom's had emphysema and they asked him to quit, the doctor said, we can get you a lung transplant if you quit smoking, and he didn't do it, and I was so shocked." Thus, a story about someone else "who doesn't care" temporarily distracts from the storyteller's dependence and lessens the severity of unanticipated addiction. Another strategy that is used in this narrative is the proactive stance taken by the storytellers that claim they are protecting others from unanticipated addiction. In this story, the narrator acts knowingly and 'altruistically' and vows to neither buy nor provide cigarettes for those who are younger. It's something I don't really agree with honestly, and my boyfriend's little sister, she had a couple of cigarettes at her school and she's like, can I borrow a smoke. And I'm like, no, you can't. I sound like a hypocrite, I can't support you, you're a minor, wait, so am I, but I don't want anybody else to go through it.... No, I can't do that. The narrator who is a "minor" herself notes the irony in not supporting another minor. Another storyteller once thought that she would "buy cigarettes for young kids" because others had done that for her; however, she is adamant that her perspective has changed and that she would not repeat what others did for her. In conclusion, these storytellers inform the listener that they never thought that they were going to become addicted. Once the storyteller recognizes that she is nicotine dependent, this narrative reinforces the dissonance inherent in being nicotine dependent. As the narrator grapples with conflicting identities, she attempts to convince the listener 93 that others are worse off. In addition, the narrator protects others from unanticipated addiction as a way to assuage her guilt. These storytellers all know that they need to quit and they all have a story to tell. The Sub-Narratives "Digression means abandoning the story for a moment. Digression enhances the discipline of the composition rather than weakening it." (Milan Kundera, 1988, p. 84) The following section focuses on two sub-narratives, Needing to quit and Repeating history. These stories appear frequently in the interviews as digressions from the central narrative. Needing to Quit Needing to Quit is a sub-narrative that surfaces routinely in the interviews as the narrator spontaneously tells the listener, "I know smoking is bad for me. I know I need to quit. I'll quit later." In addition, the storyteller describes how others frequently reinforce this message. At the surface, the story appears simple; however, this story unfolds with complexity. The following constructed story about "Needing to Quit" is based on the interviews. I don't want to smoke anymore. Actually, I'm trying to quit right now. And I've tried to quit so many times. I really wish I could quit because I don't want to have to depend on stuff. I wouldn't want to smoke when I'm an adult. Quitting has to be my choice. I don't want to stop but I know I have to. It'll be harder later on because the addiction is worsening. I'm not ready to quit now and my friends tell me that you have to be totally ready before you quit. Hopefully I will this summer. This sub-narrative occurs following tales about being nicotine dependent. It is frequently interspersed throughout the interviews, reappearing on several occasions as 94 segments of the story. The reasons for needing to quit are articulated early on in the story. The narrator presents the incongruity between smoking and lifestyle choices such as difficulty with physical activities and reduced range in one's singing voice. In addition, the storyteller emphasizes how "bad" smoking is and knowing about the adverse health consequences. Previous attempts to quit smoking reinforce the intensity of needing to quit as the storytellers incorporate their experiences into this story. Often the terms "stopping" and "quitting" are used interchangeably and reports of frequent attempts ensue. One girl emphasizes she has tried to quit "so many times" and "I'll quit and then the next morning I'll say, well, I really want one." However, two storytellers make a clear distinction between "stopping" and "quitting." One maintains, I want to quit. I don't want to stop again, that's what I did there, I stopped, I didn't even really quit, because it only lasted two months....in my mind, quitting means it's over with, stopping is just not as effective. Accounts of unsuccessful cessation attempts predominate in this sub-narrative. These attempts are described as "frustrating," "wasted time," and "horrible." I have tried to quit before and I've gone through all that for you know maybe a week. And then I started again. So it was a week .wasted of frustration, for getting nothing done. So I look at it that way now and I'm like, do I really want to go through that again? Thus, unsuccessful attempts are portrayed as futile. As a result, several of the storytellers suggest that people "almost avoid quitting." Other individuals that relapse are described as "blowing it" and are portrayed as rarely successful. These stories include contradictions and result in conflicting stories about needing to quit. While the storytellers describe knowing that they have to quit, this is not equated with wanting to quit. One participant states clearly, "I know I need to quit, but wanting to 95 is a different thing. And I don't really want to." Others are less clear and an ongoing and often circular dialogue flows through the sub-narrative. Some of the girls describe wanting to quit but not wanting to stop smoking. Some indicate that they do not want to smoke anymore, yet they do not want to stop smoking. Another participant indicates that "at times I want to quit," yet remains silent about not wanting to quit at other times. One girl describes this conflict, I don't know, I just want to quit. I don't want to go into post secondary school as well, like smoking and I mean, I can see myself smoking more there because of the studying all the time and stuff like that. In response to such conflict, the storytellers emphasize the importance of being "completely ready," "one hundred percent sure" and "wanting to quit" before a quit attempt is made. Despite an apparent urgency in the stories about needing to quit, planning to quit is frequently delayed. The storytellers provide excuses for not quitting until later. One storyteller postpones quitting until after her exams "when I have nothing kind of holding me back or no excuses." Another participant describes her sister who routinely postpones her quit date until the beginning of the following month, which exemplifies the repetitive nature of this story. A lack of certainty about quitting also allows the storyteller to delay quitting. It would have to probably be further on in my life, or definitely if something happened, I don't know, hmm, maybe (pause). The other reason I want to quit is because cancer is very, like there's a lot of it in my family and it's genetic so, I don't want to get lung cancer or anything. It's really scary. This storyteller is hesitant about the probability of quitting and remains unclear about when this might occur. At the same time, she creates a comfortable distance from quitting by pushing it to some time in the future despite being "scared" of the consequences of 96 smoking. Another storyteller is also vague as to when quitting might occur: "I wouldn't want to be an adult smoking.. ..I'd want to quit before that." There is also recognition that "it's just going to get harder later on" and that the addiction "is worsening." One storyteller is adamant that she would quit "in an instant" if she was "completely ill" and when she has children because "it's easier to put other people first." One participant is clear that she would quit "out of consideration for a boyfriend" while another storyteller describes once "stopping" for a month because her boyfriend told her to try. These stories include different strategies for quitting. In this way, the narrator reassures the listener that she is indeed thinking about quitting. These strategies are based either on personal experience or on observing others who have quit successfully. Most of the storytellers indicate that they prefer the approach of cutting back gradually rather than quitting 'cold turkey.' There are mixed reports on the effectiveness of the patch (nicotine replacement) and on Zyban, referred to as "the pill." One storyteller describes adverse experiences with nicotine replacement therapies, adding that the next time "I'm going to do it by myself and for myself and not use any of the aids., .if you're still addicted to nicotine, just getting it from another Source, it's not really quitting, like it's stopping, but it's definitely not quitting;" Finally, several participants describe switching to lighter brands of cigarettes. Thoughts about quitting evoke strong feelings for some, adding complexity to these stories. These feelings are presented as obstacles to quitting. One girl describes her fear about quitting smoking: "I don't think I'm to that point where I know the next cigarette's going to be the last cigarette, that scares me, that thought alone scares me, without even contemplating quitting." Some speak on behalf of others: "A lot of people 97 are scared to stop, like with my friends, because they think that they'll put on weight." Others express regret about not having quit earlier, "I wish I would have quit earlier, got it over with." In contrast to feelings about quitting and perhaps in response to such feelings, considerable joking transpires in the tales about quitting. To begin, the stories are often told with laughter. One participant describes regular quit attempts with a group of friends in a joking manner, which lightens her frustration about trying to quit. This adds levity to the stories about quitting and temporarily removes the listener from the seriousness of nicotine dependence. Girls describe how they "joke," "tease" and "bug" others about quitting. It's not like I seriously sit down and you say you should quit kind of thing, it's just like, I'll bet you ten bucks, if you try kind of thing, like I'll give you ten bucks if you do it man, really, like try it. And so, it's just more like a joke. The participants also observe how others joke about quitting. "She sort of jokes about it, maybe it hasn't hit her yet." One participant links joking with the guilt associated with nicotine dependence: "They know they have to quit, but they just feel so guilty about it, so it's either guilt or they'll just joke around." In this way, joking about quitting softens the reality of nicotine dependence. Others reinforce the message about needing to quit. Well-intentioned friends suggest quitting: "A lot of people that I'm friends with but not really close to, they're like, you have to stop, but, I don't know, for some reason, it just doesn't hit me." Thus, some messages are ignored. Similarly, one former smoker "bugs" her friends about quitting, but "it doesn't really work, they don't seem to care." Family members, teachers and coaches also convey this message. At times, videos on smoking have the opposite 98 effect from that intended and remind some girls about wanting a cigarette. Some participants describe how they "ignore" these videos. However, one of these participants considers the hazards of smoking involuntarily. "Every time I take a puff of a cigarette, I think about what it's doing to my lungs, just automatically. I don't try to, I don't want to, but it just happens." She adds, "If I thought about it more, then I'd come to the conclusion that I'd want to quit, indefinitely." Finally, the social smokers observe that other people always talk about how they must quit. It appears that this comment is heard with such frequency that it tends to lose its sincerity. "They always say, oh I should quit because I am so out of shape, I can't come up stairs without getting out of breath." Thus, those who listen appear to stop believing the intent of those who always say that they need to quit. The context of this story about needing to quit deserves mention. That is, these tales arise as the storytellers tell the listener what is expected and what will please. Thus, this sub-narrative functions to assure the listener that the narrator has a plan, albeit vague. Furthermore, this need to quit is future oriented, which is congruent with the developmental stage of adolescence. These stories about quitting often shift during the course of the interview, suggesting a certain ambivalence towards quitting as the participants articulate the conflict involved in needing to quit. The paradox is powerful, that is, not wanting to smoke anymore, but not wanting to stop right now. Despite a somewhat inconsistent logic in this sub-narrative, this story often ends on a hopeful note. One participant sums it up well, "We have to quit, you know, we will one day." Finally, some of these storytellers may be similar to their mothers, as in the story about repeating history. 99 Repeating History In the sub-narrative entitled, Repeating history, the storyteller links her mother's nicotine dependence with her own smoking. Identity issues arise in this story with the underlying themes of distancing from one's mother and the individuation of the storyteller. A constructed story follows and begins with learning about smoking from one's mother. I remember seeing my mom smoke when I was little. The smell of cigarettes has always been familiar. My mom smokes to relax when she comes home from work. She doesn't smoke that much but I think that she is addicted. I tease her about it, I say, "Hey, Mom close the door, I'm getting a head rush." Actually, it bugs me when she smokes. She has tried to quit a few times, but can't. When she found out that I smoked, she wasn't too happy and tried to get me to stop. We don't really talk about it anymore. I smoke socially. I don't think I'll have time to smoke much later because I'll be too busy studying. I don't know if it's hereditary or not, but both my mom and me. She uses it for the stress factor. I just smoke socially. Our emotional state is very similar. As the story about repeating history draws to a close, there are hints that the storyteller may well develop a smoking pattern similar to that of her mother. Childhood recollections of mothers that smoke are presented early in the story. One participant describes her thoughts after seeing her mother smoke. I guess it was kind of learned through my mom as well, when I saw her doing it, I kind of thought, well, it can't be that bad, you know, if she's doing it and my dad doesn't say anything about it. Well then, maybe I won't get in trouble if I do it. I mean, I knew it was bad, but I didn't think it was really devastating, whereas with other stuff, I knew I'd get in trouble. As a result, deciding to smoke was perceived to result in less trouble than other activities largely because the mother smoked. These storytellers note their mothers' smoking patterns. Girls describe how their mothers smoke to relax after work, with friends and as a ritual before going to bed. One participant emphasizes, "My mother always said that she always felt so much more relaxed." Another participant notices her mother would 100 always "disappear." "She was never one to smoke in front of us. She always went to the living room fireplace, never smoked in the car. You'd just see her disappear." Some storytellers respond to their mothers' smoking by teasing and by patrolling. In one story, a girl recalls having "fun" while placing "No Smoking" signs strategically throughout the house, including in her mother's sock drawer. Another teases her mom about the "stink" of her cigarette, telling her about the rush she gets from the smoke. Others patrol their mothers' smoking. One participant tells her mother who is "not very addicted" that she has to stop smoking and refers to the "humongous arguments" that they have about it. Her mother's smoking "bugs" her and she will "get on her" if her mother's smoking starts to interfere with her physical fitness. In another story, one girl catches her mother smoking during her mother's quit attempt. "She only smoked when everyone went to bed and then I smelled it one night and I went downstairs and caught her smoking." Ironically, this participant was smoking herself at the time. The story about repeating history shifts when the girls tell tales about their mother finding out that they smoke. Typically, mom "wasn't too happy." In one story, a mother had been smoking out on the balcony for several years out of consideration for her daughter and later found out that her daughter had been smoking throughout this period. On learning about her daughter's smoking, this mother made her daughter smoke on the balcony for six months before they moved their smoking indoors. This storyteller describes how her mother understands her addiction, "being a smoker herself." Another participant adopts the language of her mother in her story. When she found out that I was smoking in that summer with my cousin, she was like, it's your decision we're not going to help you with it, but there's nothing we can really do about it, but it's not worth it. I admit it's not worth it. 101 Later this participant describes smoking as a "personal decision." Dialogue about smoking continues between mothers and daughters. In several stories, girls describe how their mothers encourage them to quit by trying "a fake cigarette" to help with the hand actions. Another participant says, "she tried to make me stop it and stuff, but she couldn't." Others maintain that smoking is something that they have talked about in the past; however, some of the storytellers are vague as to whether their mother knows about their current smoking. Finally, one storyteller adds, "As a matter of fact, I don't like to talk about it with my mom." Mothers act as providers of cigarettes either knowingly or unknowingly. Some of the girls describe stealing cigarettes from their mother or from a friend's mother. One participant stresses that she does not want to smoke in front of her mother. Sometimes I kind of forget and I go and pick up her cigarette when my mom's not looking and it's sort of, oops, you know.. ..I wouldn't want to smoke in front of her, it's embarrassing, sort of. I don't think she'd allow it. In another story, a girl explains that her mother buys her a carton of cigarettes a week. She shares her mother's theory, "She'd rather buy them for me because she knows I need them, than for me to go out and do anything like steal for them or do anything stupid for them." Another participant reports that her mother sometimes buys cigarettes for her, but that she usually pays for them. While some of the storytellers see the similarity between their mothers' smoking and their own, others do not appear to see the comparability. One participant describes how her mother smokes because of stress and recognizes that she also smokes when she gets stressed. Another storyteller questions the hereditary nature of addiction because her mother smokes to relax. She smokes socially and notes, "If you have a history with it, it 102 might come up." In contrast, one storyteller reacts angrily to her mother's occasional smoking; however, this storyteller describes how she smokes "on special occasions." Another participant indicates how she has learned from seeing her mother's battle with cigarette addiction and portrays herself as able to "catch" herself before becoming addicted. "I am not addicted because I've seen what my mom went through to definitely know better.. ..I think my mom was really good in that respect, seeing what it did to her." Therefore, in this final story, the narrator presents herself as different from her mother. Stories about repeating history reinforce identity issues that arise within the mother/daughter dyad. Not surprising, some participants distance themselves from their mothers by not wanting to talk about smoking with their mothers. Several of the participants describe "escaping" by smoking when they are angry with their mother. As such, these storytellers are in the process of establishing their own identities, including their identities with regard to smoking. While some of these storytellers have already determined their smoking identity, others are still in the process of clarifying it. In conclusion, the narrators tell stories that portray the profound similarity in smoking between mothers and daughters. Despite strategies such as teasing and patrolling their mothers' smoking, the double standards are apparent. Furthermore, there is considerable silence and much that is not stated regarding the similarity. It may be that the narrator is quietly accepting the fact that she will likely continue the smoking pattern of her mother and that history does repeat itself. Summary The narratives and sub-narratives as outlined in this chapter provide important insights into the lives of teenage girls that smoke. Their stories enhance our 103 understanding of their smoking behavior as well as their perceptions of nicotine dependence. Furthermore, how these storytellers present themselves and how they choose to tell their stories reinforce their identity. While it is clear that each participant has a unique story, the commonality of the stories across storytellers is profound. As revealed in these stories, many teenage girls that smoke have a personal story to tell regarding nicotine dependence. Finally, the cultural and societal aspects of being an adolescent in today's world are embedded within these narratives. 104 CHAPTER V: DISCUSSION AND IMPLICATIONS Introduction This final chapter begins with a brief summary of the findings from Chapter TV followed by a discussion of the strengths and limitations of the methodology and consideration of the evaluation criteria used in this investigation. The most relevant findings have been selected for discussion purposes in which implications for nursing practice and research have been incorporated. Finally, the chapter concludes with additional implications for programming. Summary of Findings As demonstrated by the findings in Chapter IV, the teenage girls that participated in this study presented themselves in a manner that corresponded to a particular narrative with regards to nicotine dependence. In this way, the participants told stories about nicotine dependence in which they portrayed themselves as invincible, as giving in, or as experiencing unanticipated addiction. In the first narrative, those who were invincible described how they were in control of their smoking and not addicted to cigarettes. In the second narrative, the participants who were giving in told stories about yielding to external forces including the potential for addiction. In the third narrative of unanticipated addiction, the informants described their surprise upon realizing that they were addicted to cigarettes. As highlighted in the previous chapter, there were also occasions when the participants presented themselves with two concurrent narratives, such as the girls that described how they were invincible and giving in at the same time, or giving in and dealing with unanticipated addiction. In addition, two sub-narratives ran consistently throughout these stories about nicotine dependence. In the first sub-narrative 105 about needing to quit, the participants described how they knew that they needed to quit smoking and that they would quit later. In the second sub-narrative entitled Repeating history, the participants contrasted their mothers' nicotine dependence with their own smoking. It is important to reflect upon the implications of the selected method on the findings in this inquiry. Narrative Inquiry as a Method The strengths and limitations of using narrative inquiry in this investigation are now considered. Narrative inquiry was selected as the method for this study, which focused specifically on the meaning of nicotine dependence among teenage girls because it is particularly well suited for research projects examining semantics and issues of identity. The most significant findings within these two areas have been selected and will be discussed in greater detail in this chapter. Narrative inquiry resulted in many rich stories about nicotine dependence. Through in-depth analysis, important findings were subsequently revealed regarding how teenage girls told stories about nicotine dependence. At the same time, the stories portrayed a great deal about the storytellers and added layers of complexity to the narratives. The confusion within some personal accounts about nicotine dependence revealed the contradictions and uncertainty, which may be masked in more reductionistic methodologies. It is obvious that there is not a single perspective on nicotine dependence. Rather, the narratives described in this study reflect evolving and varied perspectives on nicotine dependence. Teenagers are storytellers by nature. By asking the participants to tell a story about nicotine dependence, the investigator made a request that was not too unusual, 106 albeit a request with a particular focus. However, there was no obligation for the participants to tell the story in a particular fashion, nor was there a right or wrong approach to the telling of their story about nicotine dependence. While guiding questions were used initially to assist the narrator, the unstructured nature of this method of inquiry enhanced the natural development of many of the stories. An additional strength of this methodology was the "space" created for the participants to reflect upon the meaning of nicotine dependence in their lives. In health care, narratives are noted for their healing properties and the potential they hold for making meaning out of life events (Vezeau, 1994). In the field of psychology, personal narratives are viewed as central to the development of self, which also points to the potential therapeutic benefits inherent in this methodology. Within nursing, inquiry into the therapeutic value of storytelling has generally been limited to theoretical discussions of their clinical application (Banks-Wallace, 1998). In this investigation, several participants informed the researcher that they had found the interview process "interesting," beneficial and thought provoking. One participant indicated that she had never had the opportunity to talk about her smoking in such detail. It is clear that the use of narrative inquiry has tremendous potential for enhancing insight into certain health-related behavior such as smoking within this population. There were also limitations to the use of narrative inquiry in this study. First, the youngest participant in this study did not provide a story about nicotine dependence. That is, her responses to the guiding questions were brief and her participation in the interview minimal at best. It is recognized that the size of the sample was small, hence the following comments ought to be interpreted with caution. Age may be an important 107 consideration in selecting a mode of inquiry, as demonstrated by this study participant, aged 14, who had difficulty telling a story about nicotine dependence. In other words, this method may be more appropriate for older teenagers. On the other hand, it may be that some teenage girls are not able to tell a story about nicotine dependence. A second limitation with this method relates to instances when the participants were involved in storytelling, but not stories that pertained to nicotine dependence. In this situation, the investigator appeared more prominent in the interview in her attempts to gently bring the storyteller back to the area under investigation. As a result, the presence of the investigator may have had a greater role in the developing story, which demands particular attention in this mode of inquiry. In this situation, the story about nicotine dependence was not as spontaneous as it appeared in other interviews. In addition, there may have been an element of social desirability with some participants who may have wanted to please the researcher by their story. It is not assumed that the sample in this study reflects all stories about nicotine dependence. Moreover, it is recognized that a particular story is missing in this investigation. It appears that this sample represents social smokers and regular smokers who considered themselves to be addicted. Likely there is another group of smokers comprised of teenage girls that smoke regularly but do not consider themselves to be addicted. All efforts were made to recruit participant(s) that fit that particular profile by asking participants if they knew anyone with a similar smoking pattern. Interestingly, several participants asked the researcher if this individual had be to female because several participants knew males that smoked regularly but did not consider themselves to be addicted. However, the participants in this study did not know girls that were regular 108 smokers but not "addicted." While this finding demands caution on account of the sampling, it does support other research findings suggesting gender differences in nicotine dependence (Gritz, Nielsen, & Brooks, 1996). To summarize, narrative inquiry as the methodology of choice for this investigation was appropriate for the research question and the teenage population despite the discussed limitations. Member Check A member check involves returning to the study participants to validate the research findings. The purpose of the completed check was to ensure that the participants agreed that the interview synopsis prepared by the investigator represented the content of the interview, thus enhancing the credibility of the interpretation. A member check was conducted over the telephone and the findings of this process now follow. To begin, the investigator read the synopsis of the interview to each participant and then requested her feedback and commentary. On no occasion did any of the participants disagree with the synopsis of their interview. To the contrary, their comments suggested that the interpretation and synopsis of the interview were accurate. For example, comments ranged from "excellent, that's it," "that story was so accurate. You did a really good job," "that's really good," "that's it exactly," "that's good", "sounds good," to "Yep." One participant laughed while the synopsis was being read and later admitted that hearing it had reminded her how she had initially felt "awkward" and could "picture us sitting on the couch with the tape recorder." However, she assured the investigator that she was happy with the synopsis. Another participant "liked" how the synopsis emphasized other things "beyond the addiction" and she reinforced some of the key components of her interview during this member check. 109 The second stage of the member check consisted of reading the three constructed stories from the narratives to each participant who was then asked to specify which story best represented her own story. The participants were informed that stories had been constructed from all the interviews and that the stories were somewhat exaggerated. The stories were read sequentially, starting with Invincibility, followed by Giving in and finishing with Unanticipated addiction. This phase of the member check was particularly illuminating. All of the participants that had told clear stories about unanticipated addiction identified with "story number three," or "behind the last door." One participant was less clear and said, "None really, but I guess number three." Another participant indicated "None really, except for the coffee shop" in reference to the third story. Indeed, it was recognized that this participant's story about nicotine dependence included no element of surprise. Only one participant identified with the second story of Giving in and she also indicated that she identified with Unanticipated addiction. While it is recognized that the constructed story about giving in was exaggerated, it is nonetheless salient that the remainder of the participants identified only with the Invincibility narrative. This finding will be further expanded in the section on "Resisting a Smoking Identity." It is vital to acknowledge how some social smokers present themselves as in control of their smoking habit and thus not at risk of becoming nicotine dependent. Additional comments made during this member check are also noteworthy. According to one participant, "It was a good experience." She asked the researcher how many other teenage girls had been in her "group" and whether anyone else had told a similar story. In addition, she asked if other people had "talked as much as I did?" The 110 notion of "talking a lot" is intriguing. This participant had the perception that she had talked a great deal, while in fact other participants had been more verbose. Other participants expressed interest in the overall progress of the study and wished the researcher "good luck." They all conveyed interest in receiving the two page summary of the findings at the completion of the project. To conclude, the researcher completed the member check with the distinct impression that the participants had benefited from and enjoyed their contribution to this study. Evaluation of Narrative Analysis Certain measurements of rigor are not appropriate for narrative inquiry. The nature of storytelling implies that stories change with each telling. Thus, a decision was made to consider one interview as appropriate; the participants were not asked to repeat their story in a second interview. Nor was the investigator interested in capturing the "truth-value" of the stories. Rather, these stories were interpreted as representations of a personal reality at a particular moment in time. In using narrative analysis, the researcher does not attempt to answer questions with certitude; rather, the purpose of the narrative is one of exploration. Accordingly, outcomes do not pertain to "certainty" about a phenomenon. Therefore, it is this reconstruction of meaning not "truth" or "certitude" that the researcher attempted to understand and interpret theoretically in this investigation. The interpretations contained within this study did not occur in isolation. Rather, the analysis was discussed with the author's supervisory committee members throughout the process and final conclusions were read and approved by all committee members. The transcripts and tapes of the interviews were available to committee members, which I l l strengthened an accurate assessment of the credibility of the analysis and the links between the data, findings and interpretation. In addition, this analysis incorporated the participation and comments of teenage girls in validating the synopses of interviews. Research findings are credible when participants are able to recognize themselves within the final story, as was the case in this investigation. Of course, the data in this investigation does not encompass all possible meanings of nicotine dependence held by teenage girls that smoke. However, the sample does include diversity with regards to age, smoking experience, ethnic background and geographic location. Mathieson and Barrie (1998) suggest that narratives are both case studies and social conventions. In this way, narratives juxtapose individuality and generalizability. Thus, it is plausible that the narratives of this study represent the experiences of many teenage girls regarding nicotine dependence. At the same time, there were differences in how some participants experienced nicotine dependence. For example, one storyteller was atypical in that she conveyed no surprise about becoming addicted. Confirmability, or the freedom from bias, was addressed throughout the research process. The use of regular memos clarified assumptions that might affect the inquiry. In addition, consultation with committee members and peers was useful in striving for confirmability (Morse & Field, 1995). It is expected that an investigator might have a particular bias in an area under study. The notion of bias is particularly relevant in qualitative research. It is essential to be aware of how our biases shape our interpretation of the data. 112 Lieblich et al. (1998) propose an approach to evaluating narrative studies that considers four specific criteria. These four criteria include: width, coherence, insightfulness and parsimony. Each of these four criteria is now discussed separately as it pertains to this research study. To begin, width relates to the comprehensiveness of the evidence. Accordingly, data analysis in this investigation included careful consideration of the structure, the content and the interpersonal factors in the analysis of each interview. In addition, a detailed description of each narrative and sub-narrative was provided. These descriptions were grounded in the data and were substantiated by numerous verbatim quotations, which served as additional evidence to support the researcher's interpretation. Prose poetry was also included, using "the voices" of the participants. Finally, each interview was presented in a synthesized version to reflect the content of the interaction between the investigator and each participant. The second criterion is that of coherence which refers to how different parts of the interpretation create a complete and meaningful picture. Coherence was considered at two levels. The first level consisted of examining how the different parts fit together internally and was implemented throughout the entire process of analysis. This resulted in a "coherent" interpretation, one that made sense. In the second level, the researcher explored how the complete picture worked externally by considering existing theories and existing research. External consideration is demonstrated in the final section of this chapter in which selected findings are discussed within the context of the published literature. 113 The third criterion is that of insightfulness which relates to the sense of innovation or originality in the presentation of the story and its analysis. In considering the usefulness of findings, one asks if the reading of the narrative leads to greater insight for others, namely, the participants and other researchers. It is this researcher's contention that this criterion was met. That is, for the most part, the participants recognized themselves in the stories about nicotine dependence. Furthermore, it appears from many of their comments that insight was gained by participating in this study and by telling a story about nicotine dependence. It is my belief that adolescent girls that smoke may gain additional insight by hearing other girls' stories about nicotine dependence. In this way, such stories might be useful in the recognition of "self' in others' stories, which has important implications in the area of tobacco use and youth. At the same time, the findings provide insight to our current understanding of the meaning of nicotine dependence from the perspective of teenage girls. The fourth and final criterion is that of parsimony, which refers to an analysis based on a small number of concepts. In this study, the analysis focused on three narratives and two sub-narratives, in which the concepts of identity and dependence were highlighted. Lieblich et al. (1998) relate parsimony to elegance or aesthetic appeal which may rest in the domain of the reader to determine through reading the narratives and sub-narratives contained in Chapter IV. To conclude, by striving for quality in narrative inquiry and meeting the evaluation criteria as outlined above, the study findings propose a plausible interpretation of the meaning of nicotine dependence among teenage girls. At this time, the meaning of nicotine dependence is considered more closely. 114 The Meaning of Nicotine Dependence Traditionally, adult models of cigarette dependence have been proposed as a way to understand adolescent nicotine dependence. Both issues of age and gender have typically been omitted in these models addressing dependence. Dependence is understood in terms of compulsive use and withdrawal. However, it is evident that patterns of adolescent smoking are usually not as well established as those of adults. Addiction models need to consider developmental issues of adolescence including identity formation as well as complex social factors. As a result, adult addiction models are not always appropriate for the teenage population and not merely "transferable." Moreover, women's smoking has often been framed using a male-centered approach without consideration of the unique experiences of women (Greaves, 1996). For these reasons, it is essential to consider other approaches to understanding the complex nature and meaning of nicotine dependence among female teens that smoke. More specifically, it is indispensable to investigate the female, teenage perspective. It is clear from the findings in this study that teenage girls have much to share about the meaning of nicotine dependence in their lives that further challenges the appropriateness of traditional views about cigarette addiction. The narratives described in this investigation encapsulate some of the meanings of nicotine dependence from the female, teenage perspective. It is noted that nicotine dependence held different meanings for the participants in this study. For some teenage girls, cigarette addiction was related to the quantity of cigarettes; for others it was related to smoking patterns such as smoking at certain times of the day, or smoking regularly. Others emphasized the aspect of not having control over cigarettes. It is vital to recognize 115 these individual interpretations of nicotine dependence in order to intervene accordingly. In addition, some participants described becoming addicted within months after starting to smoke which challenges the notion that adolescents usually become addicted two years after first starting to smoke. There remains much to understand about adolescent nicotine dependence. In particular, we need to pay attention to how teens talk about nicotine dependence to increase our understanding of the complexity of the concept and the variance in perceptions. While the narratives and sub-narratives in this study may serve as listening devices, it is evident that we have but a beginning understanding of teenage cigarette addiction. Further research is imperative so that we may increase our understanding in this complex area. A close look at semantics related to smoking cessation now follows. The Meaning of Stopping and/or Quitting In narrative inquiry, the researcher considers language use closely. Perhaps the most compelling finding in this investigation in terms of semantics was the varied use of the terms "stopping" and "quitting." Some participants referred to "stopping" smoking to mean that they still smoked socially. For other participants, "stopping" smoking implied the possibility of resuming smoking later on. While some used the terms "stopping" and "quitting" interchangeably, a few participants were adamant that "stopping" had a temporary quality to it, and that "quitting" was permanent. Finally, one participant considered the use of nicotine replacement therapy as "stopping" smoking, not "quitting" smoking. In quantitative studies, the categorization of adolescent smokers is problematic. For example, the category "ex-smoker" does not represent a permanent behavioral 116 category (Lloyd, Lucas, Holland, McGrellis, & Arnold, 1998). A longitudinal study suggested that adolescent quitters are more likely than adults to cycle between cessation and relapse (Pallonen, Murray, Schmid, Pirie, & Luepker, 1990). Clearly, qualitative research is best suited to exploring this phenomenon of stopping/quitting more closely. It is essential to be attuned to the multiple meaning of such terms. Exactly what does it mean when a teenage girl says that she has stopped smoking? It is of particular interest to note that, despite a small sample size, the term "stopping" took on different meanings. This semantic idiosyncrasy reinforces the importance of listening carefully to the choice of words and understanding the meaning of those words as girls speak about nicotine dependence. Other researchers have identified the importance of semantics as adolescents speak about their smoking behavior (Lovato et al., 1998; Nichter, Nichter, Vuckovic, Quintero, & Ritenbaugh, 1997). These authors have focused primarily on how teenagers use language to describe their smoking behavior. Careful attention to language has vital implications for health-care providers that work with teenagers who smoke. To begin, this will permit a better understanding of the use of language as it relates to attitudes and behaviors regarding smoking and nicotine dependence within this population. We must understand what it means to these young women when they describe "stopping" or "quitting" smoking, particularly in our efforts to promote smoking cessation. In addition, using the language of teens when working with them is important and will diminish the communication gap that already separates adult health-care providers from this younger population. Ongoing research in this area of language use would likely elucidate other important findings. Obviously the participation 117 of teenagers is required in future research as they inform us what stopping and quitting means to them since this will, in turn, inform our smoking reduction efforts. Resisting a Smoking Identity The narratives in this investigation point to the identity of the storytellers. Identity formation is a major developmental issue in adolescence and includes experimentation as part of a search for identity (Erikson, 1950). Erikson (1971) describes identity as a process both within the core of the individual and the core of the communal culture, giving meaning and continuity to individual existence. Issues surrounding identity formation and smoking are paramount for teenage girls as reflected in the findings that emerged in this investigation. Many of the participants portrayed themselves as invincible, resisted the smoking identity and did not identify themselves as smokers. Adolescent smoking has been viewed from the perspective of social identity in literature which focuses on how adolescents share significant characteristics with members in their group and internalize the social representation of the group (Eiser, 1985; Lloyd et al., 1998). The terms 'image' and 'identity' are used together by Lloyd et al. who suggest that creating an image is central to adolescent development and identity formation in which cigarettes are a tool to manage an image. Similarly, cigarettes are interpreted as a vehicle for self-identification (Aloise-Young & Hennigan, 1996; Gray, Amos, & Currie, 1997). The development of the concept of self-image or "becoming a smoker" includes iconic, kinesthetic and autonomic components in integrating smoking with a variety of coping responses before fully developing this self-concept of being a smoker (Leventhal & Cleary, 1980). In other words, becoming a smoker is a multidimensional process that 118 evolves over time. Greaves (1996) describes how girls may be creating their own psychosocial identities through smoking. While the focus on smoking identity in the literature may differ somewhat, the commonality is recognizing that teenage girls are in the process of identity negotiation with regards to smoking. Pipher (1994) hypothesizes that many adolescent girls lose their "true self." Accordingly, culture splits adolescent girls into true and false selves with pressures from school, magazines, music, television, advertisements and movies which cause girls to abandon their true selves and take up false selves as they sense the pressure to be someone that they are not. Pipher suggests that smoking is one way that girls lose their true self. Similarly, smoking is interpreted as a behavior that can be "tried on" in much the same way that one assumes a new identity through altering clothes or changing crowds of friends (Nichter et al., 1997). Indeed, the study findings in this investigation concur with Nichter et al.'s research. Study participants described smoking as a way to take on a different identity, which included trying to look older or having a certain image. Adolescent smoking is understood as a form of resistance to authority at school and at home (Wearing, Wearing, & Kelly, 1994). As such, smoking provides space for teenage girls to construct one aspect of their public identity that resists passivity and compliance. Consistent with this idea, several of the participants in this investigation referred to smoking as a way "to be bad." While teenage smoking is viewed as a mark of independence (Balch, 1998), the reality of exerting independence in this way, is the increased likelihood of developing dependence on cigarettes when being "in control" of smoking evolves into "being controlled" by cigarettes (Daykin, 1993; Greaves, 1996). Interestingly, women that were 119 addicted to cigarettes in one study also used constructions of control in their discourse about smoking (Gillies & Willig, 1997). The theme of "having control over smoking" is present in published research findings (Lloyd et al., 1998; Nichter et al., 1997). This corresponds to the Invincibility narrative in which teenage girls portrayed themselves as being "in control" of their smoking and extends our understanding of these girls who present themselves as immune to addiction. What is particularly significant is the extent to which some of the participants resisted the smoking identity, as if trying to convince themselves that they did not smoke. While many engaged regularly in the activity of smoking, they did not consider themselves "to be" smokers. Interestingly, teenage girls in one study referred to a range of smoking behaviors when describing "others" who smoked (Nichter et al., 1997). In this way, the term "smokers" included "others" who were smoking socially, smoking now and then, and smoking half a pack daily. Thus, it appears some teenagers attribute the label of "smoker" to describe others more readily than to describe themselves, which corresponds to some of the participants in this study. However, Nichter et al. did not expand on the nature of the identity of girls who were self-defined "casual smokers." Further research into exploring the identity of social smokers would be beneficial. Adolescent girls' smoking identities based on their smoking status were examined in another study (Lloyd, Lucas, & Fernbach, 1997). Statistical analysis predicted membership in the "never smoked" and "regular smoker" groups but not the "occasional smoker" on the basis of social identities. Occasional smokers were characterized by having an ambivalent attitude towards smoking and viewed smoking as something that 120 they might take up in the future. These authors underscore the importance of targeting the occasional smoker to encourage smoking cessation. Adolescent smokers have an irregular pattern of smoking (Lloyd et al., 1998; Nichter et al., 1997; Sargent, Mott, & Stevens, 1998) and occasional smokers are described as having a "transient identity" (Lloyd et al.). It may be that such patterns of smoking reinforce teenage girls' perceptions of being "in control." However, there is evidence to support the claim that controlled smoking can lead to nicotine dependence. For example, "light" female adolescent smokers (six cigarettes/day) report symptoms of dependence comparable to adults (Husten, Chrismon, & Reddy, 1996). In addition, low level smoking is a strong predictor of future smoking (Nichter et al.). There are signs of conflict within the identities of some teenage girls that smoke. That is, some hold negative images of smoking and of smokers, while smoking themselves, pointing to contradictory and internally inconsistent images of smoking (Lloyd et al., 1998). Allbutt, Amos, and Cunningham-Burley (1995) describe how many young smokers feel ambivalent about their smoking as well as about others who smoke. In this investigation, it was primarily a sense of conflict that surfaced as several participants recognized the incompatibility between their smoking and other activities such as sports. It is also noted that girls struggle with considerable dissonance and increasing stress in resolving their identities (Greaves, 1996). Working with these young women to resolve such conflict may be a window of opportunity in terms of cessation interventions. The implications for nursing practice are clear. To begin, nurses frequently maintain close contact with teenage girls that smoke. As a result, nurses are in an 121 excellent position to convey and disseminate clear messages about the implications of social smoking that include the potential risk of developing dependence. By working closely with teenage girls that believe that they are in control of their smoking, nurses might begin by exposing this incongruent identity and support teenage girls as they work towards smoking cessation. This might also include using the Invincibility narrative as a listening device to promote the recognition of "self' in the stories of others. In this way, cigarettes might not become integrated into the identity of these young women. Nurses who work in the community are well situated to develop and implement creative recruitment strategies for young women "who are not smokers" in order to facilitate quitting early on. While research recognizes the importance of tailoring cessation programs for the heavily addicted adolescent smoker (Sussman, Dent, Severson, Burton, & Flay, 1998), it is vitally important to consider cessation programs for all adolescents who smoke including those who are putatively "in control" of their smoking (Lovato et al., 1998). Successful quitting is enhanced by early intervention when smoking behavior is less integrated into adolescents' repertoires (Kviz, Clark, Crittenden, Freels, & Warnecke, 1994). In addition, light smokers are more successful in quitting smoking (Parker, 1994). By promoting smoking cessation among social smokers, it is expected that a more congruent and ideally stable identity of a non-smoker will develop for these young women. Stress in the Lives of Teenage Girls A pervasive theme of stress ran throughout many of the stories about nicotine dependence. When the participants in this investigation referred to stress, they attributed stress to school, various social pressures, family conflict and family illness. Several 122 participants anticipated experiencing stress while at college or university. Nichter et al. (1997) suggest that stress is a vague term used to refer to a variety of factors. In their study, it was determined that the participants used the term stress to describe being overwhelmed, anxious or angry and that participants identified family fights, fitting in, and schoolwork as significant sources of stress. While stress may be a "vague" term, it is certainly an area of great concern for young women and deserves serious attention. Change is viewed as a major source of stress and it is recognized that adolescence is a period that involves numerous physical, social and psychological changes. It has been suggested that teenage girls in the nineties may be under more stress than their predecessors. Pipher (1994) postulates that young girls have less varied and effective coping strategies to deal with the stress in their lives as well as fewer internal and external resources to rely on than girls did previously. Furthermore, teenage girls tend to report more stressful experiences in their lives than do boys (Byrne, Byrne, & Reinhart, 1995), particularly girls in early adolescence (Compas, Orosan, & Grant, 1993). Greaves (1996) suggests that smoking may be used by adolescents to adapt to their environments. Stress is often cited as a reason for smoking among teenagers (Angus Reid Group, 1997; Wills, 1985). Family conflict is related to higher perceptions of stress (Weigel, Devereux, Leigh, & Ballard-Reisch, 1998) and researchers identify family conflict as a predictor of regular smoking among adolescents (Castro et al., 1987; Flay, Hu, & Richardson, 1998). In another study, early adolescents that had a parent who smoked and that experienced low family cohesion reported twice the rate of smoking in later adolescence (Doherty & Allen, 1994). The participants in this study referred to smoking 123 after having arguments with their mothers or friends and one participant described leaving the house to smoke when everyone at home was fighting. In another study, male and female adolescents that smoked perceived more stress in their lives, reported less problem-focused coping, had more cathartic coping strategies and perceived smoking as a coping resource compared with adolescents that did not smoke (Dugan, Lloyd, & Lucas, 1999). These researchers found no gender difference between perceived stress and smoking. Stress reduction, relaxation and controlling one's mood are important attributes of the smoking experience for adolescents (Balch, 1998; Crisp et al., 1998; Nichter et al., 1997) . It is documented that girls that smoke occasionally also articulate these benefits of smoking (Nichter et al.). Similarly, the participants in this investigation that were "not smokers" described how they smoked to relax. Research also supports the association between watching others smoke and stress reduction, as occurs when children watch their parents smoke (Lloyd et al., 1998; Nichter et al., 1997). Likewise, the participants in this study described observing others smoking to relax, particularly their mothers. It is believed that stress is heightened in the absence of cigarettes. In this way, stress levels increase when those who are addicted to nicotine are unable to smoke (Nichter et al., 1997). The participants in this study described considerable stress when they were unable to smoke or were attempting to stop/quit. Not surprisingly, mood alterations are cited by adolescents as the most common reason for relapsing following a period of abstinence (Lloyd et al., 1998). High emotional stress and few coping resources are associated with lower rates of quitting smoking (Sussman, Dent, Nezami, et al., 1998) . It appears obvious that a much larger issue demands our attention, namely, 124 acknowledging the stress in the lives of these young women. A comprehensive and sensitive understanding of the social and cultural context of being a teenage girl today is crucial to properly address the area of stress and smoking within this population. The area of stress management is a relatively new area of research. Most researchers that have examined stress management skills and smoking have focused on adults (Lloyd et al., 1998). A stress management component is frequently integrated into adult smoking cessation programs, and structured stress reduction programs have been shown to be beneficial for adult smokers. In one study, adherence to a meditation program was associated with smoking cessation (Royer, 1994). Balch (1998) recommends the introduction and communication of stress management interventions for adolescents, particularly during high stress times of the school year. Stress management programs might include a broad range of options that would appeal to as many teens as possible. By intervening early and suggesting alternative ways to deal with stress, young women might become familiar with modes of relaxation other than smoking, hence be better equipped to handle future stress. Ideally, the use of stress management tools would reduce the prevalence of smoking among teenagers. Research suggests that lower emotional distress and greater coping and social skills are associated with higher cessation rates (Stein, Newcomb, & Bentler, 1996). The relationship between perceived stress and perceived support has been examined by Weigel et al. (1998) in their study of adolescents. Their findings suggest that perceived support from mothers resulted in lower perceived stress. The role of the mother in teenage girls' stories about nicotine dependence is considered next. 125 The Role of Mothers The sub-narrative Repeating history sheds light on the complex role of mothers in girls' stories about nicotine dependence. The process of gaining autonomy from parents is an important phase of adolescent development (Erickson, 1950) in which relationships with mothers undergo change. Pipher (1994) notes that girls may struggle with their love for their mother and their desire to be different from her at the same time. The findings in this investigation revealed that some girls were cognizant of the similarities and differences between themselves and their mothers. What are particularly relevant to this discussion are the ways the girls contrasted their smoking to that of their mother's. On the one hand, the social smokers in this study whose mothers smoked considered their mothers to be addicted or formerly addicted while they believed their own smoking to be in control. On the other hand, the participants that considered themselves to be addicted to smoking noted the similarities shared with their mothers who also smoked. The influence of parental smoking on children has been documented in the literature, yet remains contradictory. Parental smoking is believed by many researchers to be a strong influence on the smoking behavior of children. Rowe, Chassin, Presson, and Sherman (1996) describe "epidemic" models of influence in which the rate of transition from never-smoker to occasional smoker among adolescents occurred more quickly when parents smoked compared to when parents did not smoke. Kandel and Wu (1995) noted a significant, dose-related association between maternal and children's smoking. In another study, parental smoking predicted the transition from experimental to regular smoking among females, but not males (Flay et al., 1998). In contrast, Wang, Fitzhugh, Westerfield and Eddy (1995) found that parental smoking had little effect on adolescent 126 smoking status. Likewise, parental smoking had a minor, indirect effect on adolescent smoking in another study (Flay et al., 1994). Finally, some adolescents may reject parental smoking through individuated identity or through forming negative views about smoking (Lloyd et al., 1998); however, this group of teenage girls was not included in this current investigation. A sensitivity model has been proposed to explain adolescent nicotine dependence. This model considers environmental factors along with biological factors involved in nicotine dependence. Pomerleau, Collins, Shiftman, and Pomerleau (1993) propose that vulnerability to nicotine dependence may be related to early exposure contributing to physiological changes in which receptivity to nicotine is enhanced. As such, this theory may provide an opportunity to identify adolescent girls at risk for smoking and developing nicotine dependence by considering their exposure to parental smoking. In the current investigation, several participants that considered themselves to be addicted remarked upon the pleasant memories of the smell of their mother's cigarettes. While some research suggests that teenagers may be unaware of the influences of parental smoking (Blackford et al., 1994), most of the participants in this investigation appeared to be aware of this influence. Bandura's (1977) modeling theory has also been applied to parental/adolescent smoking. According to this theory, direct observation and imitation of parental smoking contributes to the acquisition of smoking. Most regular smokers in the current investigation had memories of their mother's smoking and recognized smoking as a way for their mother to deal with stress. Similar findings are reported by Nichter et al. (1997). While Bandura's theory may describe smoking acquisition, the theory offers less insight 127 into nicotine dependence among adolescents (Eiser, 1985; Wang et al., 1997). Eiser proposes that cigarette addiction consists of a set of behaviors and affective responses that are also learned through the accounts of others, including adults, enabling teens to interpret their own experiences with cigarettes. Indeed, many participants in this investigation had vivid accounts of their mother's addiction, which likely contributed to their beliefs about nicotine dependence. The challenge that lies ahead is to determine how nurses might work with these young women so that they use what they have learned about their mother's cigarette addiction as a deterrent to smoking. In this investigation, some girls were critical of their mother's smoking and verbalized their concern about the associated health risks. This corresponds to focus group findings in which some participants thought that it was wrong that their parents had smoked in front of them (Angus Reid Group, 1997). Pipher (1994) notes that most adolescent girls are critical of their mothers; they closely observe their mothers and feel strongly about their behavior. Parallels with several of the participants in this investigation are apparent. Having stressful relationships with parent(s) has been associated with adolescent smoking. While the findings of one study indicated that the heaviest smokers described stressful relationships with their parents (Nichter et al., 1997), this investigator did not find similar evidence. Although the participants mentioned arguments with their mothers, this is not unusual in this developmental stage. At the same time, it is recognized that the absence of such evidence does not eliminate the possibility of stressful relationships. In one study, teens raised in single-parent families were more likely to become smokers than those raised by both biological parents, independent of gender and grade, 128 suggesting that the effects of divorce affect the emotional well-being of adolescents (Lloyd et al., 1998). In another study, however, there was a higher prevalence of smoking among adolescents living with both parents (Blackford et al., 1994). In this current investigation, one half of the teenage girls was living in single-parent households and no conclusions can be drawn on account of the sampling method used. However, one social smoker referred to the conflict when her parents lived together and suggested that the family stress had since subsided. According to most of the participants in this study, they discussed smoking with their mothers; they described how their mothers knew about their smoking and disapproved. Few studies have examined mother-daughter communication regarding smoking. In one study, children reported having few and unsatisfactory discussions with their parents about smoking and other high-risk activities, whereas their parents were more likely to believe that they talked about these issues and affected their children's subsequent behavior (Lloyd et al., 1998). In another study, Presti, Ary, and Lichtenstein (1992) found that a greater proportion of regular smokers indicated parental awareness than did experimental smokers, which corresponds to the reports of the participants in this study. Some of the social smokers in this investigation appeared not to disclose how much they smoked to their parents. Chassin, Presson, Todd, Rose and Sherman (1998) explored the relationships among parental smoking, parenting behavior related to smoking and smoking across two generations. In addition to finding that parental smoking was a significant unique predictor of adolescent smoking, adolescents were more likely to smoke when their mothers provided relatively less support and less consistent discipline. Parental strategies 129 involved discussion and punishment upon learning about their children's smoking. Finally, when mothers smoked, their children believed that they were less likely to be punished for smoking. The authors suggest that mothers that smoke may be sending mixed messages to their children who interpret their parents as being more tolerant of smoking. Indeed, several participants in this investigation inferred similar sentiments. In this investigation, many of the informants reported that their mothers had encouraged them to quit. One former smoker was motivated to quit, in part, because her parents disapproved; another participant described how her mother wanted to help her quit. Perceived family encouragement to quit has been cited as a reason to quit (Chassin, Presson, & Sherman, 1984; Dozois, Farrow, & Miser, 1995), and it is believed that parents can be supportive when their children want to quit smoking (Lovato et al., 1998). Perhaps the most discouraging element in the mother's role was that they served as the provider of cigarettes for two of the participants in this investigation. It is unwise to generalize this finding; nonetheless, it deserves serious attention. While blaming mothers is not in order, it seems advisable to include mothers in discussions of tobacco access. Professionals are cautioned to be sensitive to maternal cigarette addiction and may need to provide support for their quit attempts. Both mothers and daughters may want to quit smoking. Future research is required to determine ways to facilitate cessation among mothers and daughters. Nurses can raise awareness about the impact of maternal smoking, convey messages about the implications of providing cigarettes, and provide information about available resources. Fostering and facilitating productive dialogue between daughters and 130 mothers is paramount. It may be that teenage girls are our best informants in terms of how we ought to proceed from here. In the final sections, a discussion is provided of three interrelated findings that frequently occurred together in participants who considered themselves to be addicted. These include: Not Recognizing Addiction, Planning to Quit Later and Unsuccessful Attempts are Wasted Time. Not Recognizing Addiction In the narrative Unanticipated addiction, most of the participants described how, for some time, they did not know that they were addicted. Their stories provide insight into the events that surround recognizing that one is addicted. Typically, these girls realized that they were addicted once they experienced withdrawal symptoms while trying to quit smoking or when in a situation in which they were unable to smoke. Adolescents that smoke tend to underestimate the addictive nature of tobacco and become addicted to cigarettes before they realize the full consequences of their behavior (Hines, 1996; Lamkin & Houston, 1998). In this investigation, one participant informed the researcher that she had initially thought she would keep her smoking to "two cigarettes a day." Most emphasized their surprise upon realizing that they were addicted. It is also appropriate to question whether all the teenage girls who portrayed themselves as invincible in this study could continue to remain in control of their smoking. The concept of gradual addiction to nicotine may be poorly understood by teenagers who smoke at low levels (Nichter et al., 1997). However, withdrawal has been documented in teenagers that smoke fewer than seven cigarettes a day (McNeil et al, 1986). It is believed that some teenagers who have not yet tried to quit smoking, may not 131 realize that they are addicted (Nichter et al.). While all the participants in this investigation that considered themselves to be addicted had made several attempts to quit smoking, the social smokers maintained a more erratic pattern of smoking. It may be that the narratives in this study will be of value to other teens and will promote the recognition of the early signs of addiction. While measurement tools have been used to determine degrees of nicotine dependence in teenagers that smoke (Prokhorov et al., 1996; Rojas et al., 1998), perhaps the focus of our attention ought to be spent developing measurement tools that are "teenager-friendly." Such tools could be designed for teen use and could facilitate recognition of early signs of dependence. It may be possible to teach teenagers to identify the signs of nicotine addiction, which may be the first step in interrupting the transition to regular smoking (Lovato et al., 1998). Teenagers have an obvious role in the development of such tools. Several participants in this study clearly articulated that they wanted to prevent other people from becoming addicted. Enhancing dialogue between teenagers that are addicted to cigarettes and those that consider themselves to be social smokers might be beneficial. This strategy might diminish the apparent gap between "us" and "them" and emphasize the reality that everyone that smokes is at risk of becoming addicted to cigarettes. Without question, the availability of cessation programs for teenagers early in the addiction trajectory could facilitate cessation before "heavy" addiction sets in. Planning to Quit Later In the sub-narrative Needing to quit, the participants indicated that they wanted to quit smoking, but at a later date. While initially there appeared to be a lack of urgency to quitting immediately, what frequently emerged later in the stories were germinating plans 132 to quit and previous cessation experiences. It is the researcher's contention that talking about quitting in stories may have been beneficial for some participants, particularly when their plans to quit became solidified, hence more real during the course of the interview. At the same time, it is recognized that some of this discussion may have occurred for the benefit of the researcher. The notion of planning to quit later corresponds to the published literature on adolescent smoking (Balch, 1998). Pallonen (1998) suggests that readiness to quit smoking is lower in adolescents compared to the adult population. Youth that smoke have been reported to spend relatively little time preparing to quit and more time cycling between quitting and relapsing than do adults (Pallonen, Murray, & Schmid, 1994). However, it is reported that female teens do not expect to be smoking when they are adults, particularly once they become parents. In one study, it was reported that adolescents believe that they can stop smoking without difficulty (Hines, 1996). Similarly^  findings from focus groups revealed that some adolescents want to quit as young adults before any damage is done; at the same time, they also know that their addiction would be stronger (Balch, 1998). In addition, focus group findings revealed that some youth believe that smoking is less serious than other health issues, such as other addictions, depression, or suicide (Balch). A similar sentiment was expressed by several of the participants in this investigation; several expressed regret at not having quit earlier. Some studies have focused specifically on teens' plans regarding smoking in the future. In one longitudinal study, Flay (1993) found that 5% of adolescent smokers thought that they would be smoking in five years, whereas 75% were found to be smoking at an eight-year follow-up. Meier (1991) reported that over 50% of the smokers 133 enrolled in her study believed that they would not be smoking in the future. It appears that some adolescents may not be aware of the strength of cigarette addiction. However, in another study, the majority of high-school seniors that smoked recognized that they were addicted or expected to be "hooked" five years later, thus were less optimistic, perhaps because they were older (Daughton et al., 1997). Several girls in this investigation emphasized the importance of being ready to quit. Research supports that planned action as a precursor to quit attempts is most successful (DiClemente et al., 1991). Several participants in this investigation described spontaneous quit attempts in which they were ill prepared for subsequent withdrawal symptoms and the ongoing temptation to smoke. Nurses have a key role in providing support to teens, which includes emphasizing the importance of planned action, an essential component of effective smoking cessation. Smoking cessation has been associated with age. Success was predicted, in one study, by older age of smoking onset and younger age at quit attempt (Ershler et al., 1989). Breslau and Peterson (1996) also confirm that smoking cessation is significantly higher in smokers who start to smoke after the age of 13. The findings of this research have obvious implications for practice. The significance of encouraging quitting smoking now as opposed to later cannot be overstated. Ensuring that teenage smokers are aware of such information is vital. Plans to quit smoking are individual. Most participants in this investigation preferred the idea of cutting down slowly rather than quitting "cold turkey" and several had already changed to lower nicotine brands. Similar strategies have been reported elsewhere (Gillespie, Stanton, Lowe, & Hunter, 1995). Some of the participants in this 134 investigation preferred trying to quit on their own, which is congruent with Gillespie et al.'s findings. These authors point to the need for developing self-motivation, personal skills and respecting the independence of young people. One participant in this investigation referred to frequent quit attempts with her friends. Similarly, Gillespie et al. found that the help of a friend was often recommended as a method for quitting by teenagers. Clearly, teenagers describe a range of approaches to quitting smoking. Cessation interventions must be flexible to accommodate the individual preferences for quitting and must correspond to the smoking behavior. Delaying quitting is not a logical solution for teenagers that smoke. Some of the participants in this study may not have been fully aware of the implications of delaying quitting, particularly the fact that quitting becomes more difficult with time. While some teenagers may not be ready to quit smoking, nurses are in a position to plant seeds about quitting such that this course of action becomes more realistic in the near future. How can we work best with this population to move teenage girls from pre-contemplation into contemplating quitting smoking? By working more closely with this population, strategies may be revealed that will promote cessation now as opposed to some time in the future. Benefits may evolve simply from talking about quitting, as believed to have occurred in this study, which may contribute to concrete plans to quit. Furthermore, the data indicates that most of the young women in this study wanted to quit smoking. While it is recognized that the sample is small, it is not unreasonable to assume that other teenage girls also want to quit smoking. Young women need and warrant support in their efforts to quit smoking and nurses are skilled in their ability to provide such support. 135 Quitting smoking must become a desirable and viable option for all teenage girls that smoke. Unsuccessful Quit Attempts are Wasted Time Research suggests that adolescent smokers frequently try to quit smoking but are often unsuccessful. All of the regular smokers in this investigation had made several attempts to quit smoking and one of the participants had been smoke free for six months. Their stories, however, expressed discouragement about how they or others had wasted time during previous quit attempts and emphasized the futility of these attempts. It is clear that the participants in this study did not have a comprehensive understanding of the process involved in quitting smoking, which frequently consists of many attempts. Most likely, other teenagers that smoke also have limited knowledge regarding quitting smoking. Other researchers confirm that adolescents are not aware that aborted quit attempts prepare individuals for eventual successful quitting (Balch, 1998). On a positive note it is documented that quitting temporarily reduces the probability of adolescents' smoking in the long term (Chassin et al., 1990). Believing that quit attempts are wasted time may contribute to a sense of resignation with regards to cigarette addiction. It is vital to minimize such negative thinking. Nurses might begin by highlighting the positive aspects of all attempts to quit smoking and emphasize that several attempts are usually necessary. In addition, teens must be assured that they can learn from their previous quitting experiences, which will help them with future attempts. Clear information must be disseminated to all teenagers that are trying to quit so that they are aware of and prepared for withdrawal as well as the 136 inevitability of persistent cravings. Teens must be encouraged and supported to try again and nurses can foster confidence in these individuals. It is documented that female teens may experience more severe withdrawal than their male counterparts (Pirie, Murray, & Luepker, 1991). Recent research suggests the appropriateness of nicotine replacement treatment such as the nicotine patch for adolescents, despite a five percent long-term cessation rate with the sample (Smith et al., 1996). Nicotine patches are now available over the counter. It may be tempting "to treat" adolescent nicotine dependence particularly with the recent availability of medication such as Bupropion (Zyban); however, careful follow-up is essential. While pharmacological treatment may be beneficial for some teenage girls to deal with physical addiction, it must be viewed as an adjunct to dealing with the complex nature of nicotine dependence. One participant in this study provided an explicit description of the uncomfortable side effects that she had endured from both the nicotine patch and "Zyban," which may have contributed to her perception of having wasted time during her quit attempts. Her story is unlikely an isolated case. It is essential that similar medical treatment be critically examined and scrutinized as appropriate for the adolescent population. While results from a recent clinical trial with Bupropion resulted in significantly higher long-term rates of smoking cessation than either the nicotine patch alone or placebo, attrition in the Bupropion group was noted to be high (Jorenby et al., 1999). Some of the noted side effects of Bupropion were insomnia, anxiety and dizziness. Finally, this research was conducted with adults; it is not clear if the findings are generalizable to adolescents. Clearly, ongoing research in this area is paramount. 137 Gritz et al. (1996) point to the concern about weight gain as an issue for women that are trying to quit smoking. Interestingly, the fear of weight gain associated with cessation emerged only once in this current investigation; one participant indicated that her friends thought that they would put on weight if they quit. Nonetheless, there are benefits to promoting exercise with cessation efforts. In an earlier study, Eiser (1978) suggested that the label "addicted" might make it more difficult to persuade adult smokers to stop smoking. It may be that the term held greater negative connotations during the seventies. In addition, adults that have a long history with smoking may experience difficulty "being persuaded" to stop smoking. The participants in this study used the term "addicted" to describe their smoking and/or others' smoking. It is obvious from their stories that they did not require persuasion to quit. Rather, these young women wanted to quit smoking, as demonstrated by their previous attempts; they need ongoing support in their efforts. Program Implications To date, much of the focus of teenage smoking has been on prevention rather than on cessation. In addition, most cessation interventions have been imported from the adult population and have not been rigorously evaluated (Houston, Kolbe, & Eriksen, 1998). Smoking cessation programs, demonstrated to be effective with adolescents, are absent in the literature. It is crucial to examine current cessation strategies for the adolescent population and to seriously determine if, in fact, they work and how they might be improved. It is evident that ongoing development and evaluation of existing adolescent cessation programs are essential. Needless to say, the adolescent voice is paramount in this discussion. 138 Recruitment and retention have been identified as problematic areas in cessation programs with this population (Lamkin & Houston, 1998; Lovato et al., 1998). Some literature supports incorporating incentives into programs to enhance overall success with participation and retention (Gillespie et al., 1995). Assessing the smoking pattern of all adolescents is a critical component such that cessation programs include every type of adolescent smoker, even the most occasional smoker. Effective messages conveying the importance of quitting must appeal to the adolescent population and must be accompanied by information about available resources. Finally, misinformation must be addressed immediately, such as any myths that may exist about addiction and nicotine replacement therapy. Additional strategies to enhance smoking cessation among youth are frequently cited in the literature. A few of these include: (a) making tobacco-using role models less salient and tobacco-abstaining role models more salient, (b) focusing on the immediate consequences of cessation rather than the long term consequences and emphasizing benefits such as fresh breath, a better sense of taste/smell, going out with non-smokers and the potential for saving money, and (c) challenging inflated estimates of prevalence and perceived approval of tobacco use among peers. As demonstrated by the findings in this investigation, an area for future research consists of incorporating family factors into smoking cessation programs. Such family-based efforts at cessation could dovetail with programs aimed at improving parenting and general family well being. However, challenges remain for program planners. In some instances, parents might not know about their child's smoking, in which case protecting a youth's confidentiality would be preferable regarding participation in a cessation 139 program. In addition, while outreach for cessation programs fits logically in the school system, this approach excludes teens who are no longer in school. All efforts must be made to reach these teens as well. Finally, nurses have an important role to play as advocates and in policy development to ensure that adequate funding and resources are available to promote tobacco reduction among the teenage population. Summary of Implications In this chapter, key findings were selected and discussed in light of the existing literature. First and foremost, it is vital to listen to teenage girls when they describe their smoking behavior and beliefs about nicotine dependence, particularly their use of language regarding smoking cessation. In addition, attending to teens that resist a smoking identity is essential. The significance of addressing stress, the role of mothers and beliefs about smoking cessation are particularly noteworthy. The study findings have contributed to the phenomenological mission of nursing inquiry and have resulted in a better understanding of the lives of teenage girls who smoke and negotiate their smoking identity. While our task as health-care providers remains challenging, the direction for practice is clear. We must continue to listen to the voices of these young women as they speak about smoking and nicotine dependence. 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In recognition of your participation, you will receive a $20.00 gift certificate from Virgin Records. To learn more about this study and to find out if you qualify, please phone Barbara at XXX-XXXX. 153 Appendix B Sample Guiding Questions 1. Some people describe their first cigarette as unpleasant. Thinking back to your first cigarette, can you describe what it was like for you? Were you alone/with friends? When was that? 2. Tell me about the times that you usually smoke now? (When, where, with whom?) 3. Of the people you spend most of your time with, do many of them smoke? 4. Thinking back to last week, can you tell me approximately how much you smoked? Describe some of those occasions. 5. Describe for me what you see as the benefits of smoking? (What do you like about smoking?) 6. Describe for me what you see as the disadvantages of smoking? (What do you not like about smoking) 7. Have you ever tried to stop smoking? If so, what was that like for you? 8. What would it be like for you to stop smoking? 9. Do you know other people who have stopped smoking? What was it like for them? 10. Some people talk about being addicted to cigarettes. Can you tell me what that means? What is it like? Who becomes addicted to cigarettes? 10. What is it like for you when you are unable to have a cigarette, such as when you are at school? 11. Tell me about smoking later on. For instance, do you think that you will be smoking in five years from now? 12. What sorts of things might help you stop smoking? 13. Why do you smoke? Tell me about the reasons that you smoke? How do you feel about smoking? 14. Can you tell me what smoking cigarettes means to you? Can you tell me what nicotine dependence means to you? Appendix C Interview Synopses 155 Amy Amy smokes seldom. She smokes when she is with her friends that smoke such as at semi-formals where cigarettes are passed around. She does not smoke the whole cigarette because it gets too strong closer to the filter. Smoking gives her a head rush and a headache. However, she smokes because of the temptation. According to Amy, addiction is about repeated use. Becoming addicted is like the force of habit, for example, when other people are walking to school in the morning, they just take out a cigarette. People who smoke first thing in the morning are addicted as are the people who smoke alone. Smoking once a week is not addiction. Smoking once a day with friends because they all smoke is not addiction either because it does not involve buying a pack. Bumming cigarettes means that a person does not have the incentive to do it enough to develop an addiction. People her age do not smoke that much because they do not have time. They might smoke eight cigarettes a day, but they can still be addicted. In Grade 9, people make a choice whether or not they are going to buy a pack and that step is an important trigger in developing the addiction. People who start to smoke in Grade 9 are addicted later in High School, whereas people that start in later grades, like a particular group of girls at her school, smoke to look cool. Smoking later on is all about the image. People her age do not think much about smoking nor about who does or who does not smoke. Things like university applications are more important. Amy knows a few people from camp who used to say that they needed a cigarette and it always seemed like an act. The comment did not fit into the camp setting. It may be that they just said that they needed a cigarette. Smoking is a stress reliever for other people, although Amy does not smoke to deal with stress. When other people crave cigarettes, it adds to their stress if they do not have a cigarette. Without having personal experience, Amy does not know what addiction feels like. She has had the temptation to smoke, but not the craving. It may be that people view their addiction as a burden, having to spend their money on cigarettes. Amy feels that it is not a big deal, just another thing you put in your purse. She notices the effects of cigarette addiction in others who are out of shape. They feel it in their lungs and they say they have got to quit smoking. That's feeling an addiction. If she smoked, she'd be concerned about the lack of stamina and the money. 156 Azuki Azuki first started smoking at a friend's house when she was drunk. Her friend was a year older and smoked regularly. The next day, Azuki tried smoking again and it hurt her throat. She does not remember why she continued smoking. She thought that she would be someone who smoked two cigarettes a day, but not become addicted. Now she is addicted. The habit set in about two months after starting, but Azuki did not know that she was addicted for so long. Once, she found herself without cigarettes and could not stand it. Her favorite cigarette is the first one in the morning and she now smokes about a pack every two days. She smokes to relieve stress, especially after she has a fight with her mother. If Azuki is mad at a coach at circus school, she smokes. She does not mind if she gets into trouble. She does not care what the coach thinks, probably because smoking is so bad for you, which to Azuki is the same as getting into trouble. Azuki stopped smoking last summer for a month because her boyfriend at the time told her to try to quit for a month. The first two weeks were the most difficult and she sucked on a lot of lollipops and ate more, even though she was not hungry. She just needed something in her mouth. When the month was up, she started smoking again because she missed it and thought that she just deserved it because she was able to stop for so long. From this experience, she knows that cold turkey works for her. With cutting back, it is a hassle to count and keep records of the number of cigarettes. Addiction means not being able to stop or quit unless you are ready and even then it is still really hard because of the habit. People that smoke two cigarettes a day are probably not addicted because it would be easier for them to stop than for a regular smoker. People get stressed out and want more nicotine. The brain gets used to that amount of nicotine and then people need to smoke more to keep it up. Seeing other young girls smoke hooks people into smoking. The image for young girls to smoke is starting to change, and this image is about more than just smoking. The image of someone who is addicted to cigarettes shows someone who is weak and does not have the willpower to quit. Azuki does not feel ready to quit now. She would first need to clarify her priorities such as whether she is going to become an athlete or be smart. If she decides to become athletic she will quit because smoking ruins the body. 157 Caitl in Caitlin had her first cigarette in Grade 7 and started to smoke in Grade 8. She smokes less when she is at boarding school, usually two or three cigarettes after school. When she is at school and cannot smoke, she just deals with it. When she is at home and with her friends, she smokes about a pack every two days. She now enjoys smoking more and considers herself a bit more addicted. This means that she wants to smoke more often and that it would also be much harder for her to stop. She has never tried to stop smoking but imagines that stopping would be stressful. Caitlin says that she plans to stop in about a year. At that time, she will cut back until she doesn't need cigarettes as much any more. Caitlin describes being addicted as the habit of doing it and getting addicted to the actions. It's 50 percent the actual nicotine and 50 percent the actions. She believes that it takes about a year to become addicted and that people cannot get addicted after one cigarette. Addiction occurs with smoking enough and starting to need cigarettes. Everyone who smokes enough just starts to need cigarettes. 158 Jackie Jackie had her first drag in Grade 7 and coughed. She didn't really want to smoke but it looked cool because all her friends were doing it. She did it because people were watching. Later that day, she tried again and started smoking. She stopped for awhile when her friend who got her started moved away. Jackie also moved and then started to smoke again because she didn't know anybody. She was used to seeing cigarettes and her parents smoke. She started to meet people who ended up smoking and that got her to smoke even more. For about a year, she smoked a pack in less than a week. Jackie smoked at school and in the evenings when she was out. She smoked more in the summer. Jackie was kind of addicted. She used to think about cigarettes in class and would constantly look at the clock waiting for break. She smoked when she was stressed about a test, or nervous about visiting someone she didn't really know, or when everyone was yelling at one another at home. She knew she needed one and would go out for a walk. Sometimes she smoked out her bedroom window. She would get angry and frustrated when she had no cigarettes or no money or was too young to buy them. At first, Jackie did not know she was addicted. People would ask her if she could go several days without smoking. When she realized that she could not, she knew she was addicted. Being addicted means she would have cravings, would get cigarettes and smoke them. She used to get cravings from seeing others smoke and from smelling cigarettes. About six months ago, Jackie stopped smoking. She stopped hanging out with a lot of "those people," which got her off smoking, but now she hangs out with people who smoke. She stopped by cutting down for a couple of months, not buying her own and telling her friends not to give her any if she asked. Her friends helped her stop. At first, Jackie ignored the scary videos at school, but after a while the videos influenced her decision to stop. One day, her PE teacher saw her cigarettes on the tennis court and also encouraged her to stop smoking. Another time, Jackie cut down when her parents suspected she was smoking. They were constantly asking her if she smoked and telling her that she smelled like smoke. Her mom knows that she used to smoke. The first few weeks after stopping were difficult and she was moody. Initially it was awkward seeing her parents smoke but now she doesn't really even notice. It does not really tempt her when other people are smoking, although she is not sure why that is. People get addicted a lot faster when cigarettes are available. There is also a greater chance of becoming addicted when friends, parents, older people and relatives smoke. Friends can also influence people to stop smoking. At times, Jackie's friends offer her a cigarette, but she says no. The last time she had a cigarette was around Halloween when she was out with friends. Someone handed her a cigarette when she was hungry and tired. She just reached over and the next thing she knew was smoking it. It wasn't really what she was looking for and she realized she didn't really need it. Jackie may start smoking again in about five years when she is getting ready for college because college will be stressful. If she starts again, she would not be thinking of the reasons why she stopped. However, in 15 years, she will have realized and will have stopped again. She has learned that she is in better health from stopping. 159 Kelli One weekend, Kelli tried smoking with a friend when she was 12 years old. They were with her friend's older cousin who smoked. The cousin was going into modeling and this glorified smoking. Kelli loved spending time with her. At the end of the weekend, the cousin bought a pack for Kelli and her friend to share. Kelli had one and then threw the rest away because she thought it was gross. A few months later, Kelli became close to another girl who smoked and Kelli started to smoke. This friend lived close to school and they went to her friend's house at lunchtime. Her friend's older sister would give them cigarettes and later bought cigarettes for them. Gradually the smoking increased and Kelli now smokes about four packs a week. Most people in her Grade do not smoke. People make fun of her when she comes into class smelling like smoke, which is embarrassing and makes her feel stupid. In Grade 9, Kelli realized that she was addicted. She had to spend all her allowance on cigarettes and always needed to know how many cigarettes she had left. Smoking is a habitual thing. She enjoys the social aspect of smoking. She also smokes frequently in the evening in her bedroom while doing her homework. She does not know if it calms her but sees it as just habit. She thinks that others who smoke off and on are not addicted but could become addicted if they continue to smoke regularly. Kelli does not think that she could ever smoke off and on. Starting young leads to a greater chance of physical addiction. Her mom smokes and Kelli may have learned about smoking from her. When she was younger, she thought that smoking could not be all that bad if her mom smoked and if her dad didn't say anything. Smoking did not seem as bad as other stuff. At first, her mother tried to get her to stop but was not able to. Sometimes her mom buys cigarettes for her, but most of the time Kelli pays. Kelli has tried to quit twice. Once she was dating an anti-smoker who talked her into trying to quit. That time, she used Nicorette and quit for six days. The withdrawal was horrible. She started again when they broke up. More recently, she quit when she was sick of smoking and was starting to get the flu. Three days later she started again when she felt better. She is surprised how tough it is to quit. A friend recently quit using Zyban and Kelli might try it later. She does not want to become dependent on the patch. In the meantime, she has cut down to Ultra light. Kelli plans to quit smoking. She would quit again out of consideration for a boyfriend. She wants to quit hopefully this summer when finals and provincials are over, when she has nothing holding her back and no more excuses. While Kelli does not want to smoke at college, she sees herself smoking more because of the studying. A five day hike is planned later this summer with a group of guy friends who do not smoke. They have told her she needs to quit three months beforehand if she wants to join them. Kelli realizes she should quit smoking immediately. Her perspective on smoking has changed. When she was younger, she always thought that she would buy cigarettes for other people. Now, she will not buy cigarettes if a little kid asks because smoking is stupid and she is not proud of it. She talks to her younger brother about it and thinks she has gotten through to him because he tried smoking but now he thinks it is gross. 160 Kristi When Kristi had her first cigarette, she did not inhale. Looking back, she thought that she looked cool. The following day she had her second cigarette. Right from the beginning, Kristi liked the look and the feeling of smoking. She started to smoke because her friends were smoking and they wanted her to smoke. Most of her friends have been smoking for longer than she has been smoking. Sometimes, Kristi smokes a lot in the evenings when she is with friends and that it is like an overload. The following day she does not want the taste, but she still has a cigarette. Kristi smokes alone when she is bored, sad, or nervous. She also smokes when she is angry with friends or with her mom. Kristi now considers herself completely addicted. Addiction means really needing it and being dependent on cigarettes. Once, she was babysitting her cousin for four days which was awful because she was not able to smoke in front of her cousin. Kristi dealt with it for a few days but then had to go out for a cigarette. She asked her uncle to look after her cousin. Addiction is partly the nicotine and partly the habit, or having something in your hands. It is also partly the routine of having them at certain times in the day. Her girlfriend says that she is addicted to the image of smoking and Kristi kind of agrees with that. Some people are more vulnerable to becoming addicted if they are easy and have the type of personality that can be convinced "to be something," like her friend. Kristi is embarrassed by her smoking and not proud of her habit. She does not want to depend on something to keep her going. Right now she does not like to talk about it with her mom or her teacher. When the teacher asks who smokes, Kristi does not put her hand up. Kristi's teacher told her mom about seeing Kristi smoking. The counselor at school tells the students not to smoke and the counselor smokes. Kristi feels like saying something about this. Kristi would not want to smoke in front of her mom but she sometimes forgets and picks up her mom's cigarette by mistake when she is at home. The smell of the cigarette smoke at home is familiar and comforting, although it does not make her want to have a cigarette. Kristi has tried to quit many times and feels that it is hard with other people smoking. The videos in class don't really work for her. Some of her friends are afraid of quitting because they don't want to gain weight. Most of her friends are trying really hard to quit. A few times, Kristi has been quite serious about stopping. She is trying to quit right now and her mother has said that she will help by getting those fake cigarettes to help with the habit of the hand movement. Although Kristi does not want to smoke, she does not want to stop smoking right now. She is aware of her smoker's cough. She cannot think of what would make her quit smoking now, although the thought of lung cancer, which is hereditary, is scary. She may stop later on. 161 Lauren Lauren was six when first tried smoking. Her older sister was having a party when Lauren grabbed some guy's cigarette. They thought she was so cute. When her sister found out, she yelled at them. Lauren always smoked and got drunk at these parties. She was "the party favour." In Grade 6 she tried again with a friend and was caught by her friend's mom. While her friends were on a popularity hunt in Grade 8, Lauren was stressed, always sad and had nothing to do. She took up smoking. She enjoyed the first one she had alone as it brought back good memories of how cute she used to be. Her sisters smoked and were her role models. Lauren knew that she would smoke. In Grade 9, her mom was diagnosed with cancer. Lauren told her parents she smoked soon afterwards. Smoking was her finger to authority. Her parents were anti-smoking. Lauren smoked with her two sisters, 8 and 20 years older, when visiting their mother at the hospital; smoking was their "crutch." The day of her mother's wake, her sister bought her a carton. For a while, Lauren smoked up to five packs a day. Lauren recognized the addiction in Grade 9 when everything blew up. She remembers twitching during a family car trip. She kept telling her parents that she had to pee but really wanted a cigarette. Her sisters used to react the same way. Addiction is not being able to give up cigarettes without repercussions. Her addiction is largely emotional because she started at an emotionally charged time. She does not deny the physical addiction. Cigarette addiction is amplified with other addictive substances. Lauren does not understand people who only smoke when they drink; she always smokes the same amount. Cigarettes are her trademark. Everyone knows she is a chain smoker. When her friends are trying to quit, they visit over the phone. She is unsure why she likes smoking; it is just something that she does. Smoking is a cure for boredom. She smokes most when driving and watching a movie in bed. She does not like the effects of smoking. Several years ago, Lauren had bronchitis so she quit. She used the patch and stopped for two months. Lauren could not find any patches because of all the New Year's resolutions, so she started again. Last January she quit again. She had an emotional outburst followed by clarity and awareness of her repressed emotions around her mother's illness when her family fell apart. Her duty had been to keep everybody happy. She was also supporting her best friend whose brother had been killed by a drunk driver. Her uncle was also diagnosed with lung cancer. Lauren then recognized she did not need to do certain things, such as smoke. She started on the patch but had a reaction and looked like a patch work quilt. Her doctor put her on Zyban but she became unstable emotionally. She was so stressed and depressed that she started smoking. She now smokes Matinee, about two packs a day. The last quit attempt was empowering. Lauren could be in her car with friends who smoked, making it more valid. Lauren would stop again if she got sick with bronchitis. She will quit by herself and for herself and not use any aids but her decision to quit may take a long time. Quitting means going cold turkey. Using aids means still being addicted to nicotine which is stopping not quitting." Every six months, her father tells her she needs to quit. Lauren works at home for her father's business. She smokes in her bedroom only, out of respect for her father and his girl friend who is an ex-smoker. Lauren is not very good with money, but since she has to have her smokes, she has the power to budget for her smokes. 162 Megan Megan had her first cigarette when she was 12 during a school trip to France. She knew she was going to try smoking at some point, and felt that she might as well try it, which she did along with two other Canadian students. They were at a skating rink at the time and noticed that some of the French students were smoking in the viewing gallery. The Canadians approached the French students and asked for a cigarette. The following day, she shared a cigarette. She neither liked nor disliked smoking. She found herself somewhere in the middle. In Grade 9, Megan smoked socially and did not really smoke at school. She was never addicted. Several of her friends were also social smokers and Megan would smoke with them when they were at a party. In Grade 10, two of her close friends started to smoke regularly. Megan knew that her friends were not addicted because they would go several days without smoking. Her friends were smoking for something to do. Megan would sometimes smoke with them and sometimes not. In preparing for a semi-formal, Megan realized she could not smoke her friends' cigarettes as they were now smoking regularly, so she bought her own cigarettes to share with some other friends. That evening involved some drinking. Some of her friends smoke when they drink alcohol. She smoked 12 cigarettes that evening. At one point she looked down, saw the cigarette in her hand, asked herself what she was doing. She put out the cigarette and left the room. It just clicked in her head and she has not had a cigarette since that evening. Megan does not believe that people her age are addicted to cigarettes. She thinks that people her age, or, acquaintances just say that they are addicted and act as though they are addicted. They smoke for something to do, because they are bored, think it's cool or for the image. Her friends and other people smoke when they are at school but they do not smoke when they're at home with their parents, or on the weekends, and she knows that her friends are not addicted. Addiction involves the body craving and needing cigarettes regularly and this happens when people have smoking in their habit for long enough. It can get to a point where people don't want to do it anymore, but the body craves it and cannot function without it. It may be that people just start doing it more and more until their body relies on it. People who have been smoking completely regularly since Grade 6 or 7 at home and with parents knowing could be addicted. One girl her age who is no longer at her school might be addicted. This girl started smoking when she was in Grade 6 and smokes with her mother. Cigarette addiction has been covered in school but it's difficult for Megan to imagine what it is like. To really know addiction, you need to experience it. People continue to smoke because they want to, not because they are unable to stop smoking. If people really want to stop, they will be able to even if they are so-called addicted. 163 Naomi Naomi first tried smoking with friends in Grade 8 when someone brought a cigarette to school. She and her friends used to always try to hide their smoking and they would smoke behind the bushes. She continued smoking for two years and smoked up to three cigarettes a week. Naomi could have continued smoking this amount for another year without becoming addicted because she smoked so seldom. However, she smoked more than her friends did at that time. Naomi has never smoked alone and has never bought cigarettes. She recalls once stealing a cigarette from a friend's parent. This scared her because she felt that this was leading to other uncharacteristic behavior. Her decision to stop smoking at the end of Grade 9 makes her feel proud. She stopped smoking because she was going into the Trek Program, an outdoor school program. In addition, she saw other friends getting addicted. Naomi was also motivated to quit after talking to her best friend's father who used to smoke heavily. He explained the medical perspective about how cells become addicted to nicotine. Stopping smoking was not hard for Naomi. However, Naomi continues to smoke socially when she goes to parties, which happens about five times a year. Cigarettes and alcohol are present together at parties. She considers smoking as sort of a treat and compares it to having a piece of chocolate cake once a month. Cigarette addiction is having a certain amount of cigarettes a day and just having to have a cigarette. Addiction varies according to the individual. Cigarette addiction is like falling in love with the image of smoking, which is associated with looking cool. Smoking is also a security thing. Addiction means being out of control, for instance, when someone can't say they'll quit and really mean it. Naomi feels that addiction must be embarrassing for her classmates, especially when they smell of cigarettes. Naomi's mother smokes one cigarette every night before going to bed as a ritual. Naomi tries to convince her mom that she is addicted and teases her about the stink of the cigarette. Now that Naomi is no longer used to smoking, she finds that the smell of her mom's cigarette gives her a headache. Naomi is aware that she has a history with smoking and also wonders if heredity plays a part in cigarette addiction. She plans to caution herself in a year and a half in preparation for university because she knows that this is a time when a lot of people start smoking. Naomi does not think that she will have time to smoke since she plans to study sciences in university. At the same time, she recognizes that she may smoke at university with the social situations. 164 Nicky Nicky had a puff of a cigarette when she was about seven with her mother and uncle who wanted to turn her off smoking. She did not think about smoking again until she was 12. She was really stressed and needed a release. Her mom always used to say that she smoked to relax. Nicky stole cigarettes from her mom and smoked early in the morning when walking the dog. It was never a big deal. It was more of a temptation and an escape. Her parents may have caught her. It was never really discussed afterwards. Now Nicky just smokes on special occasions. She has been so comfortable smoking and not getting really addicted because she knows that she is so in control of her life. At New Years, smoking made her sick. She has had a few lately and wonders if it is really worth it. She is disgusted by smoking and does not think that she will really ever smoke ever. It no longer relaxes her. Cigarettes are so unhealthy and Nicky is such an active person. She works out to get rid of her stress and has learned through all her physical activities. She plans to work as a lifeguard and knows she will not smoke that much. She could have smoked more and perhaps become addicted if she had been better at making friends. Most of her friends who she knows from life guarding do not smoke. As for her few friends who do smoke, her friends tell them to quit. Nicky and her mother argue over her mother's smoking. Her mom smokes about once a week. One time Nicky told her mom that she had to stop smoking and her mom spassed on her. Her mom smokes to relax after work and as an escape. While this bothers Nicky, she has done the battle thing, which does not work. Her mom is not very addicted. Instead, she is addicted to the relaxation. Nicky will get on her when the smoking starts to interfere with her mom's physical fitness. Nicky no longer knows the people that she used to go to school with, who now smoke. Some of them smoke a lot, have lost a lot of weight and have gotten caught up in the whole high school thing, which is sad. They do not have extracurricular activities. Others follow what the images portray and the images, especially on American television, do not give other options. Cigarette addiction begins by first needing a little bit, then needing more and more. It also means needing cigarettes all the time. Addiction is all about control and eventually getting out of control. It is not an addiction if it is controlled. Some people get really sick of smoking at first and then become addicted when they get used to it. People get addicted because they have got nothing better to do. Nicky recently heard about some smokers who do not become addicted because they have a special gene. Her mom might have that gene. If people had more control of their lives, they might know when enough was enough. It may be partly the fault of parents when they let their kids go do whatever. Some people make the temptation and the addiction bigger than it is. She knows a few people who joke about quitting. Some of her aunts and uncles smoke and feel guilty about it. They also joke about it. Her uncle who smokes about three packs a days and is overweight saddens her. In order to get rid of cigarettes, people have to do something else or change their life structure. Smoking is always going to be around. Nicky does not intend to ever get addicted because she knows that it will ruin her life if she does. 165 Shannon During a summer spent at a cabin after Grade 6, Shannon started smoking with her cousin. She recognizes this as earlier than most people. Her cousin is a few years older and Shannon smoked to be like her cousin because she idolized her and wanted to be with her cousin's friends. She smoked about four cigarettes a day that summer, half the amount that her cousin smoked. When Shannon returned home, she was unable to continue smoking because of her parents. She was shocked that she missed smoking for the first couple of weekends. Shannon is a social smoker. Starting smoking is a personal choice and not something that people are pushed into. The commercials portray it as though people are pushed into it, which is not the case. This past Christmas, she started to smoke more regularly because of the parties. She became aware that she was smoking more, starting to find it nice and that it was just an all right kind of thing. Smoking was no longer a whatever kind of feeling. She knew this was wrong and caught herself before becoming addicted. Since the holidays, she has cut back and now smokes about two cigarettes a week. Shannon does not buy her own cigarettes. Sometimes she asks for them, but most often they are offered. Shannon has too much going on with school and inter-mural sports to become a regular smoker. Her parents know that she smoked that one summer and told her that it was her decision. They know that Shannon now finds herself in situations where people smoke and they probably know that she smokes. Shannon remembers that her Mom used to smoke when she was little. Shannon has also learned from her Mom's battle to quit smoking. She remembers putting the "No Smoking" signs that she got from the school smoking people on the doors at home and in her mom's sock drawer and recalls her mom saying that she was trying to stop. Later Shannon felt badly for giving her mom such a tough time. Her mom quit smoking last summer. People who are dependent on social situations and do not have their own ideas may be more prone to becoming addicted. These are people who do not involve themselves in other things. Most of her friends smoke more than she does and most are addicted. It is sad that people her age are talking about quitting because she associates cigarette addiction more with adults. The topic of quitting came up among her friends on New Year's Eve. Despite their attempts, only one of her friends has been successful. She has seen what her friends have gone through as well as her cousin. There is a possibility that Shannon may smoke later to relieve stress but she doubts that this will happen. She attributes her social smoking to situations and recognizes that these situations will always be there. Shannon likes to feel that she could stop smoking if she wanted to because she doesn't smoke a lot. Smoking is wrong and she has learned to know better. 166 Tara Tara had her first cigarette with friends when she was 11 and immediately liked the taste, the smell and just started smoking. She had mild curiosity but did not think that she would become a smoker. Looking back, she thinks she became addicted within a few months and not after a year as she originally thought. She once stopped smoking for several months without much difficulty, but she was smoking less at that time. Her cigarette addiction is now worse and quitting would now be much more difficult. Recently she cut back and is now smoking 3A of a pack a day. The health effects of smoking go against her career preference as a vocalist. She has been home schooling and has been a little sick over the last few years. Tara associates smoking with boredom, an activity for the hands and stress. Women smoke because of idleness, boredom and stress. Her mom and her mom's boyfriend also smoke. Her mother buys her a carton a week because her mother prefers to do that, instead of having the money come from elsewhere, such as stealing. Her mom recognizes that Tara's addiction is a real thing and that Tara needs cigarettes, since she herself is a smoker. Initially her mom was upset when she found out that Tara was smoking. Tara had already been smoking for 2 years and it was too late. The idea of quitting scares Tara and she does not feel ready, although she would like to quit. Quitting is difficult because everyone around her smokes. She and her friends are trying to quit and frequently try together. Her friends are older, mostly male and all but one friend smokes. Smoking becomes a chain reaction when they play role-playing games (RPG's). Her approach to quitting is to cut way back, and then quit, as she knows a few people who have quit that way. In the past, Tara has experienced withdrawal like the shakes, mood swings and flipping out on people. She describes these quit attempts as wasted frustration and getting nothing done. There is a difference between stopping as she once did and quitting. However, Tara would quit smoking if she were pregnant or seriously ill. It is easier to quit for something else. She was shocked when a friend of her mom's who had emphysema did not quit after the doctor told him that he could get a new lung if he quit smoking. Her sister and brother-in-law quit smoking without much difficulty because they really wanted to quit. One of her boyfriend's roommates also quit smoking. Tara does not understand how people are able to smoke occasionally, such as her girl friend. After stopping that one time for two months, Tara decided to have a cigarette and then it was "bang, in my face." Soon, she was smoking constantly, two packs a day. Others who smoke two cigarettes a day have a different addiction that is also psychological and physical. Everyone gets addicted to a certain level of nicotine. Tara does not agree with smoking and urges those under 19 not to start. Her boyfriend's younger sister has tried smoking yet Tara will not give her cigarettes. Tara and her boyfriend are constantly on her case and tell her that they try to quit and that it's just a pain. Tara worked briefly in the drug, alcohol, and tobacco prevention programs with the schools and cut back in her smoking at that time by only smoked during breaks. 167 1 of 3 Appendix D Informed Consent Form for Participant Project Title: The Meaning of Nicotine Dependence among Teenage Girls Co-Investigator: Barbara Moffat, RN, BScN, MSN student, Phone XXX-XXXX Faculty Advisor: Joy Johnson, RN, PhD, Associate Professor, Phone 822-7435 The purpose of this study is to explore teenage girls' attitudes and beliefs about smoking cigarettes. You have been invited to participate in this research study. Participation in this study is entirely voluntary. The information you provide may increase our understanding of nicotine dependence among teenage girls and contribute to helping those who wish to stop smoking. This research is being conducted by Barbara Moffat for a graduate thesis under the advisement of Dr. Joy Johnson whose telephone number is included above. Your involvement in this study will include a maximum of two audiotaped interviews with the investigator. It is expected that each interview will last approximately 45 minutes. You will be free to refuse to answer any question without consequence, and you may withdraw from the study at any time. You may also ask to withdraw any specific part of the information from the study at any time. At the completion of each interview, the investigator will make notes in a book and a secretary will type the recorded interview. All identifying information on the notes will be deleted and replaced with code names so that only the investigator will know who was interviewed. The master list of code names will be kept in a file in a locked drawer and only the investigator will have access to this drawer. When the study is over, the master list will be destroyed and the audiotapes will be erased. The notes will be kept for future teaching and for research purposes for a limited time, and then destroyed. You will be offered a gift certificate from a music store in the amount of $20.00 to recognize your participation in this study. At the completion of the study, you may receive a two-page summary of the study if you are interested. If at any time you have any questions regarding this study, you or your parent may contact the co-investigator, Barbara Moffat, or the faculty advisor listed above. If you have any concerns about your rights or treatment as a participant in this research, you may call Dr. Richard Spratley, Director of the UBC Office of Research Services and Administration, at 822-8598. 168 2 of 3 Appendix D Informed Consent Form for Parent Project Title: The Meaning of Nicotine Dependence among Teenage Girls Co-Investigator: Barbara Moffat, RN, BScN, MSN student, Phone XXX-XXXX Faculty Advisor: Joy Johnson, RN, PhD, Associate Professor, Phone 822-7435 The purpose of this study is to explore teenage girls' attitudes and beliefs about smoking cigarettes. Your daughter has been invited to participate in this research study. Participation in this study is entirely voluntary. The information your daughter provides may increase our understanding of nicotine dependence among teenage girls and contribute to helping those who wish to stop smoking. This research is being conducted by Barbara Moffat for a graduate thesis under the advisement of Dr. Joy Johnson whose telephone number is included above. Your daughter's involvement in this study will include a maximum of two audiotaped interviews with the investigator. It is expected that each interview will last approximately 45 minutes. Your daughter will be free to refuse to answer any question without consequence, and she may withdraw from the study at any time. Your daughter may also ask to withdraw any specific part of the information from the study at any time. At the completion of each interview, the investigator will make notes in a book and a secretary will type the recorded interview. All identifying information on the notes will be deleted and replaced with code names so that only the investigator will know who was interviewed. The master list of code names will be kept in a file in a locked drawer and only the investigator will have access to this drawer. When the study is over, the master list will be destroyed and the audiotapes will be erased. The notes will be kept for future teaching and for research purposes for a limited time, and then destroyed. Your daughter will be offered a gift certificate from a music store in the amount of $20.00 to recognize her participation in this study. If at any time you have any questions regarding this study, you or your daughter may contact the co-investigator, Barbara Moffat, or the faculty advisor listed above. If you have any concerns about your daughter's rights or treatment as a participant in this research, you may call Dr. Richard Spratley, Director of the UBC Office of Research Services and Administration, at 822-8598. 169 3 of 3 Appendix D Informed Consent Form Signature Section Project Title: The Meaning of Nicotine Dependence among Teenage Girls I have read the attached information and have had the chance to ask questions about my participation. I have received a copy of this consent form after signing it today. I, , freely consent to participate in this study. Signature of the Participant I have read the attached information and have had the chance to ask questions about my daughter's participation in this study. I have received a copy of this consent form after signing it today. I, , freely consent/do not consent to my daughter's participation in this study. Signature of the Parent Signature of the Investigator Date 


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