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Keywords:

  • Attitude;
  • youth;
  • smoking;
  • salutogenic;
  • sense of coherence;
  • prevention;
  • health promotion

Abstract

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

Purpose

This review examines recent literature with the purpose of uncovering associations between attitudinal factors and smoking among youth populations.

Organizing Construct and Methods

Researchers conducted an integrative review of the literature in late 2012 and early 2013. As inclusion criteria, potential articles were measured against the following statement: “There is valid evidence of (an) attitudinal factor(s) potentially associated with smoking among youth.”

Findings

Researchers employed the salutogenic model as a theoretical framework to analyze search results. The narrative synthesis indicates that primary attitudinal factors protective against smoking among youth include the following: (a) a perception that there is little benefit to smoking, (b) a belief that smoking is likely harmful and addictive in the short term, and (c) a denial that smoking provides stress abatement, makes one look cool or more grown-up, or is common and accepted. Moreover, research signals that youth who smoke often demonstrate essentially the opposite beliefs and attitudes.

Conclusions

Findings suggest attitudinal factors play a role in protection against youth smoking. Those youth who assign realistic values to smoking risks and benefits are more equipped to engage in the health-protective behavior of not smoking. Youth, adolescents, and young adults appear vulnerable to inappropriate designation of risk and benefit values of smoking. Theoretical interpretation suggests that bolstering attitudinal factors during youth might counteract immature risk assessment. These findings justify further research related to protective mechanisms against youth smoking and youth-based smoking prevention interventions.

Clinical Relevance

The establishment of associations between attitudinal factors and protection against smoking can help determine interventions effective in reducing smoking among youth.

Tobacco use is now the leading single worldwide cause of death, responsible for more human mortality annually than that from the sum of the human immunodeficiency virus, tuberculosis, and malaria (Frieden, 2010). The socioeconomic impact of smoking is staggering and well publicized. Although worldwide economic cost is difficult to assess, recent estimates suggest a single nation, the United States (US), independently spends an annual $102 billion on healthcare costs to counteract the effects of smoking and second-hand exposure, with additional annual lost wages estimated at roughly $97 billion (Curry, Keller, Orleans, & Fiore, 2008). The measurable impact of smoking, however, is not relegated solely to loss of life or financial burden. Smokers and former smokers consistently score lower in quality of life ratings as compared to never-smokers—an onerous denouement, considering that quality of life is an important meter of health status (Cahall, 2004; Condon, 2013).

Neither the financial cost nor the deleterious impact on quality of life addresses the sum of cumulative suffering smoking causes individuals, families, and society. Discouraging smoking initiation and encouraging smoking cessation therefore justifiably receives attention at the national level in many countries around the globe. Although nations estimated to take adequate steps to curb tobacco use total approximately a mere 10% worldwide (Frieden, 2010), the deleterious impact of smoking remains a notable health concern even in those countries. For example, in the US, even though anti-smoking efforts are great, smoking is still the greatest preventable factor contributing to morbidity and mortality in that nation (U.S. Department of Health and Human Services [USDHHS], 2012). Healthy People 2020 confirms that smoking cessation therefore appropriately remains one of the highest healthcare priorities in the US (USDHHS, n.d.). Unfortunately, once smoking becomes habitual, cessation is a notoriously difficult task, boasting abysmal 12-month abstinence rates of 15.2% among those who use assistance (such as medications) and 7.0% among those who do not (Zhu, Melcer, Sun, Rosbrook, & Pierce, 2000).

Unless exposed through passive smoking, never-smokers shrewdly circumvent numerous challenges related to smoking cessation and avert potentially negative consequences to health and life. In light of the foregoing, interventions must be refined to ensure smoking prevention in youth and consequently create future generations of never-smokers. Ninety-nine percent of daily smokers begin before the age of 26 years, reinforcing the importance of aiming smoking deterrent programs at youth (USDHHS, 2012). By admission of the USDHHS and Howard Koh, Assistant Secretary for Health, “The simple fact is that we cannot end the tobacco epidemic without focusing our efforts on young people” (Koh, 2012, forward e).

Since abundant sources affirm the importance of smoking prevention efforts among youth, it is imperative to identify effective strategies that those in healthcare and education arenas can utilize to bolster health-seeking, tobacco-resistant behaviors in this vulnerable population. Valid associations exist between situational factors and smoking initiation, such as socioeconomic and socioenvironmental elements, educational attainment, peer influences, affective processes, and heritable traits (USDHHS, 2012). Based on these factors, numerous youth-based interventions aimed at reducing the prevalence of tobacco use (i.e., mass media campaigns, family and social influence interventions, and governmental regulations of the tobacco industry) have been utilized with variable success. For example, in the US, such interventions and considerable effort succeeded in achieving a rapid decrease of smoking prevalence from 1997 to 2003. Unfortunately, in that nation the decline slowed considerably from 2004 to 2010 (USDHHS, 2012). Commenting on this relative stagnation, the U.S. Surgeon General's office asserted that, although evidence-based strategies to prevent youth smoking are effective, they simply lack sufficient or consistent effort of application (USDHHS, 2012).

Consideration of the US’ ineffective suppression of the smoking epidemic despite substantial effort (Frieden, 2010) can potentially yield necessary changes in strategy for any nation interested in smoking deterrence. Although the 2012 report of the U.S. Surgeon General's office with regard to preventing youth smoking addresses interventional deterrents (USDHHS, 2012), it lacks emphasis on explicit attitudinal factors, known to have significant effect on behavior expression (Glasman & Albarracin, 2006). It is possible that implementation of smoking deterrent interventions bereft of attitudinal factor inclusion is one reason outcomes of efforts to reduce the smoking epidemic have become sluggish in the US. This review examines recently published research to identify associations between attitudinal factors and protection against youth smoking worldwide. The premise for the review is as follows: Identifying protective attitudinal factors could be useful in developing youth-based interventions for smoking prevention, most effective for application when life attitudes are in the early process of formation.

Theoretical Framework

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

Antonovsky's salutogenic model, a medical sociology theory used to describe and predict whether individuals stay well in the environment of hazardous influences, is a health-based framework with numerous applications (Alivia, Guadagni, & Roberti di Sarsina, 2011). The model approaches life, wellness, and illness from a health-oriented perspective and encourages a search for reasons that an organism readily adapts to environmental and situational challenges with intact function (Antonovsky, 1987). In contrast, the pathologic perspective, common in medical arenas, tends to blunt the ability of providers to engage effectively in health promotion activities (Skylar, 2012). Rather than employing a pathologic model that dwells on illness, the salutogenic model examines reasons for a person's pursuit of wellness.

The salutogenic model contends people may use general resistance resources, such as money and social support, to cope with stressors (Antonovsky, 1987). The primary explanation for one's ability to achieve tension management during stressful situations stems from the confidence that internal and external environments can be controlled with satisfactory result. This confidence is influenced by the person's sense of coherence, which largely determines the status of one's mental and physical health (Antonovsky, 1987). Antonovsky (1987) described the sense of coherence as a person's ability to process life stressors in a manageable, meaningful, and comprehensible manner that ultimately contributes positively to the health of the individual. In 1993, Antonovsky further described the sense of coherence not so much as a coping strategy, but as a “locus of control” or “mastery orientation,” much like a prevailing attitude. The theory asserts that certain personal attitudinal characteristics are important in demonstrating whether and to what extent one will make choices compatible with optimal health (Alivia et al., 2011). The most important of these factors, the motivational factor Antonovsky (1987) deems “meaningfulness,” facilitates determination to move toward a state of health or illness. Antonovsky (1987) developed a 29-point questionnaire (and an abbreviated 13-point version), in the format of a Likert scale, capable of measuring the strength of the sense of coherence with reasonable validity.

Antonovsky (1987) posited that the sense of coherence begins to develop in childhood and does not fully stabilize until around 30 years of age. The ability of most youth to adequately judge, process, and act on tension management and accordingly initiate independent health-seeking behaviors is limited, at least in part, by the immature developmental state of the sense of coherence (Antonovsky, 1987). Valid associations between the sense of coherence and youth health behaviors have been established. For example, Nilsson, Starrin, Simonsson, & Leppert (2007) published a study demonstrating a weaker sense of coherence associated with alcohol-related problems among youth. Of the various scales that measure sense of coherence, the 13-point scale has demonstrated validity when used in adolescent applications (Hagquist & Andrich, 2003).

This review of literature employs salutogenic model application in an examination of smoking prevention among youth and identification of effective interventions to foster improved population outcomes. Working knowledge of salutogenesis, in an exploration of young people who are successful in resisting smoking, may provide important clues to help determine what factors and attitudes contribute to their decision not to smoke. Information gleaned from efforts to understand youth smoking resistance could contribute to constructing evidence-based interventions and education programs, recommended by the Institute of Medicine as mandatory curriculum in all middle and high schools (Bonnie, Stratton, & Wallace, 2006). As a result, interventions may more effectively achieve the goal of minimizing smoking among young people.

Methods

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

An integrative review of the literature (Whittemore & Knafl, 2005) was undertaken in late 2012 and early 2013. The investigation emphasized determination of attitudinal factors associated with the presence of smoking among youth, particularly those related to health-seeking behaviors of smoking prevention or smoking cessation. The authors utilized three scholarly databases: Cumulative Index to Nursing and Allied Health (CINAHL) Plus with Full Text, Medline, and the Cochrane Library. Articles considered included original qualitative and quantitative research and syntheses in peer-reviewed journals and were limited to those published since 2007 in order to isolate the most recent research. The key search terms “smoking prevention” or “smoking cessation” and “attitude” were applied to all text so that potentially beneficial information would not be overlooked.

The initial search yielded 336 articles. The conclusion statement “There is a valid finding of (an) attitudinal factor(s) potentially associated with the behavior of smoking” was used to guide an abstract review to eliminate all but 91 potentially germane submissions. Articles exemplifying attitudinal factors with a negative association to smoking were considered, as were those with a positive association, in order to provide a comparative perspective. Attitudes of young people would have little effect on environmental or situational factors, such as parental smoking. Therefore, an effort was made to uncover perceptions and beliefs about such factors. For example, a result such as “Youth with many friends who smoke are more likely to smoke” was not included in the search results, since the finding is a situational factor, but the result “Youth who believe smoking is accepted by their friends are more likely to smoke” was included, because the finding is an attitudinal factor. The Institute for Clinical Systems Improvement (ICSI) grading scale (ICSI, 2012) provided guidance to eliminate nonrigorous research. The scale designates a “-” for a research article if two of the following criteria are met: (a) Inclusion and exclusion criteria are unclear or adherence to criteria is inadequate; (b) serious questions of bias exist; (c) there is clinical insignificance, lack of power, or sample size; (d) there is a lack of generalizability to other populations; and (e) other characteristics of poorly designed studies are present, such as the use of inappropriate statistics. After eliminating articles with a “-” grade on the ICSI scale, 33 satisfactorily rigorous articles remained. Of these, only nine showed statistically significant (p = .05 or less) attitudinal factors that could be categorized as either contributing to providing youth protection against smoking or contributing to youth starting or continuing to smoke.

Results

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

The search yielded nine articles that addressed attitudinal factors related to youth and smoking (Table 1). Two of the studies are from participants in Asian countries and two are from European countries; five of the studies consider subjects in the US. The ages of the subjects are generally from 6th grade (approximately 11 years of age) through college students and young adults, around 29 years of age. Significant, common themes emerged regarding the association of attitudinal factors with smoking among youth.

Table 1. Results From Literature Search
 Author (date)Sample size, study design, purpose, and settingFactors that may be “protective” against youth ever smokingFactors that may contribute to youth starting smoking or currently smoking
1Carpenter et al. (2009)Analysis of South Carolina Youth Tobacco Survey, 2005–2007. 7,385 survey results of students in grades 6–12 were evaluated with various data synthesis techniques. Comparisons were made between attitudes of those who never smoked with those who smoked only 1–2 days in the last month.Viewpoint that smoking is addictive, harmful, and with few social benefits (more friends and is cool)View that smokers are less likely to be addicted than other drugs of abuse, that smokers have more friends, that smoking is cool, that it is safe to smoke short term and then quit
2Chang (2009)Participants in two studies: Taiwanese high school students in 2005. Study 1: 1,200 students were surveyed concerning associations between smoking and behavior. Study 2: 333 students participated in an experiment regarding influences of advertising on attitude toward smoking.High disagreement with external positives (smoking makes me feel more at home in a group and like an adult, etc.), internal positives (smoking helps one feel more relaxed and calm), and internal negatives (smoking reduces pressure, nervousness, and stress); concern for short-term health consequences (but not long-term)High agreement with external positives (smoking makes me feel more at home in a group and like an adult, etc.) were most predictive, but also internal positives (smoking helps one feel more relaxed and calm) and internal negatives (smoking reduces pressure, nervousness, and stress)
3Dijk et al. (2007)Longitudinal study of 1,335 smokers in six European countries from 1998 to 2001. The experimental group received 3 years of intervention in four arenas: school, individual, parental, and out-of-school. Questionnaires were completed at four times to ascertain influence of various factors on smoking or smoking cessation.Perception of less influence from smokers, higher self-efficacy, perception of more disadvantages of smoking, belief in successful refrain from smoking in stressful situationsN/A
4Fritz et al. (2008)64 smokers from two high schools in the midwestern United States in an unspecified year took part in the Computerized Adolescent Smoking Cessation Program (CASCP). Quantitative and qualitative data were collected to identify adolescents’ perceptions toward smoking and potentially effective cessation strategies.N/APerception it is for pleasure or fun or increases popularity, as a means to relax, or for emotional reasons such as stress reduction and gaining confidence; assumptions that most teens smoke
5Ling et al. (2007)Data from 9,455 participants of the 2002 California Tobacco Survey, completed in 2002 and 2003 by young adults (18–29 years) in California was analyzed to assess determinants of smoking behavior or abstinence in young adults.Support for anti-tobacco industry; mistrust of tobacco industryAdvertising receptivity
6Parkinson et al. (2009)Surveyed were 2,002 youth 13–17 years of age from Thailand and Malaysia in 2005. Data were analyzed to determine association between beliefs and smoking status.N/ABelief one looks more attractive as a smoker, the belief that society accepts smoking as a norm
7Schleicher et al. (2008)Analysis of validity of 9-factor scale for Smoking Consequences Questionnaire-Adult, which examines smoking expectancies. Completed by 315 college freshman and sophomore smokers at a midwestern U.S. university in 2001 and 2002.N/AUse of smoking as a relaxant when stressed, feeling part of a group, smoking helps one cope
8Thompson et al. (2007)In 2002, 40 undergraduate smokers from 12 public and private colleges in Washington and Oregon, USA, participated in a qualitative study to ascertain physical, psychological, and social influences on smoking.Belief that less than 50% of students smoke and belief that smoking as a habit is not acceptable by othersBelief that smoking is easy to stop
9van Zundert et al. (2007)Analysis of 2004 (and forward) longitudinal study survey data from 998 Dutch adolescent regular smokers was used to perform structural equation analyses to determine effects of smoking cessation–specific parenting.Perception that there are few benefits of smoking and many advantages of quitting smokingPerception that there are many benefits of smoking

A number of attitudinal factors relate positively to protection against smoking, including emphasis on a young person's understanding of significant risk or harm from smoking in the short term. Protective factors for youth include perceiving few advantages of smoking and many advantages of not smoking (Chang, 2009; Dijk, Reubsaet, de Nooijer, & de Vries, 2007; van Zundert, van de Ven, Engels, Otten, & van den Eijnden, 2007). Disbelief smoking makes one feel more at home in social settings, makes one feel more like an adult, makes one feel relaxed and calm, or provides stress abatement also contributes to resistance to youth smoking behaviors. (Chang, 2009). Youth are less likely to smoke if they perceive that even one to five cigarettes daily is harmful and addictive, like other drugs such as heroin (Carpenter et al., 2009). According to Thompson et al. (2007), college students who maintain a perception that less than 50% of students smoke, and that others do not approve of smoking, are less likely to engage in the activity. Dijk et al. (2007) further highlight the protective nature of higher self-efficacy and less perceived influence of smokers as deterrents to the activity. Mistrust of the tobacco industry and support for the anti-tobacco industry were negatively associated with smoking among young adults, according to Ling, Neilands, and Glantz (2007).

Youth who smoke are more likely to believe it makes them more appealing to others, as demonstrated by the positive association between the behavior and the perception of making one appear more grown up, cool, or attractive (Carpenter et al., 2009; Chang, 2009; Fritz, Wider, Hardin, & Horrocks, 2008; Parkinson et al., 2009). Data confirm that youth who smoke believe it is helpful in social and stressful situations. For example, multiple authors found that perceived benefits of smoking include a feeling of belonging or increased popularity (Chang, 2009; Fritz et al., 2008; Schleicher, Harris, Catley, Harrar, & Golbeck, 2008; van Zundert et al., 2007). Another factor associated with smoking among youth is the perception that it is common and accepted (Fritz et al., 2008; Parkinson et al., 2009). Ling et al. (2007) found an association between smoking and advertising receptivity among young adults, which could have an attitudinal component. Of particular concern is the misconception among smokers that it is easy to stop and is not very addictive, an association identified by both Carpenter et al. (2009) and Thompson et al. (2007).

Discussion

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

Significance of Findings and Implications for Practice

From a salutogenic perspective, wherein the emphasis is on promoting a person's efforts to maintain health or move toward a higher level of health, Antonovsky (1987) did not see worldview as being as contributory to health-seeking behaviors as social and cultural factors. However, the work of more recent theorists acknowledges the interplay of personal choices, attitudes, and health behaviors with plausible frequency and validity. For example, Carpenter et al. (2009) explained that attitudes may exceptionally influence worldview in earlier developmental periods, lending credence to the idea that attitudinal factors are important in choices affecting health among the young. Likewise, the work of Glasman and Albarracin (2006) stresses the association of personal behaviors with the development of stable and accessible attitudes, such as repeated expression of the attitude, high amount of thought about it, confidence in the attitude, one-sidedness related to it, and behavior relevance of the attitude.

The literature review uncovered many attitudinal factors manifested by young people who are able to resist smoking. Youth who are able to perform appropriate risk analysis, and therefore wisely assess smoking as harmful and not substantially beneficial, demonstrate a higher level of smoking resistance (Carpenter et al., 2009; Chang, 2009; Dijk et al., 2007; van Zundert et al., 2007). Self-efficacy and confidence in one's self, separate from the influence of others, are findings revealed as protective elements against smoking (Thompson et al., 2007). Such attitudinal factors highlight potential adjuncts to change and successful youth transitions to adulthood (Morton & Montgomery, 2013), so it is reasonable to expect they may be protective against harmful health detriments of smoking.

The review of the literature iterated numerous pitfalls for young people in the fight to abstain from smoking. Perhaps the most intuitive of attitudinal factors associated with smoking among youth is the perception that it provides substantial immediate benefit when compared with not smoking. An example of such an attitudinal factor is the tendency of young people to believe smoking provides stress abatement, helps one gain popularity or “look cool” (Carpenter, et al., 2009; Chang, 2009; Dijk et al., 2007; Fritz et al., 2008; Parkinson et al., 2009; Schleicher et al., 2008; van Zundert et al., 2007). More than one of the studies highlight abundant misconceptions related to the highly addictive nature of smoking among young people (Carpenter et al., 2009; Thompson et al., 2007). Despite sound supportive research (Riggs, Chou, Li, & Pentz, 2007) and copious advertising aimed at youth to the contrary, many adolescents still tend to perceive cigarettes as nonaddictive and, therefore, easily fall prey to the trap of believing they can surrender the habit without difficulty (Amos, Wiltshire, Haw, & McNeil, 2006). Interestingly, Ling et al. (2007) found that youth who have higher advertising receptivity are more likely to smoke. On the other hand, youth who are able to resist smoking are known to have a higher level of support for the anti-tobacco industry and higher mistrust of the tobacco industry (Ling et al., 2007). It is possible some youth are more susceptible to advertising from cigarette promoters than to the messages and media utilized in anti-smoking campaigns. Investigations concerning reasons for this disparity may prove helpful.

Lack of resistance to smoking appears influenced by a young person's perception that others approve the behavior and it is a common activity (Fritz et al., 2008; Thompson et al., 2007). Alexander, Piazza, Mekos, and Valente (2001) found there is indeed an increased risk for smoking among 7th through 12th graders when attending a school with a higher rate of smoking, when two or more of the youth's best friends are smokers, when half or more of the people in the peer network smoke, and when those in school perceived as popular smoke. Whether a young person chooses friends who are smokers or begins smoking due to influence of the peer group is unknown. It is also unknown whether popular students establish school norms or whether they smoke out of desire for popularity. Regardless of the direction of causality, it may be significant that, as demonstrated by the findings of the literature review, not only actual prevalence of smoking among peers, but also the appearance of prevalence and acceptability, affect youth smoking.

Young people who choose not to smoke seem more able to assign realistic values to the risks versus benefits of smoking than do those who smoke (Chang, 2009; Fritz et al., 2008; Schleicher et al., 2008; van Zundert et al., 2007). Codern et al. (2010) explained that there tends to be disparity in assignment of risk assessment values for a given behavior of even mature people when compared with experts. For example, past experience, emotion, and worldview appear to confound values of factors in risk analysis among non-experts (Codern et al., 2010). Youth are even more vulnerable to deleterious risk management processing than adults (Slovic, Finucane, Peters, & MacGregor, 2004). This potential risk-benefit misappropriation among young people is consistent with the conclusion of Slovic et al. (2004) that many youth tend to give no thought to how much they will smoke or to how their future selves will feel about it; they simply engage in the activity for the present enjoyable experience.

Expanding on the concept of the protective nature of appropriate risk assessment, Goto, Takahashi, Nishimura, and Ida (2007) asserted that those who value future and more certain rewards are more likely to abstain from smoking. In agreement with this assertion is the salutogenic concept that crucial motivational factors, in part, determine one's ability to withstand stressors (Antonovsky, 1987). However, as already noted, the sense of coherence, which should provide some protection against harmful behaviors, does not fully develop until well into adulthood. (Antonovsky, 1987). Failure to protect the individual from harm is more likely to occur while the immature sense of coherence is at higher risk for assigning inappropriate values to the risks and benefits of smoking. Indeed, almost all habitual smoking begins by 26 years of age (USDHHS, 2012). Therefore, by the time one is mature enough to accept that smoking truly is harmful, quitting is likely to be a difficult, if not prohibitive, task (Zhu et al., 2000).

Assimilating the concepts discussed, it is reasonable to conclude that this trio of factors makes for an unfortunate mix: (a) Almost all smoking begins by 26 years of age (USDHHS, 2012); (b) a person's sense of coherence does not fully develop until around 30 years of age (Antonovsky, 1987); and (c) smoking is a very difficult habit to stop (Zhu et al., 2000). Reassuringly, the fact that some youth appear to have a stronger and more mature sense of coherence than others suggests that the sense of coherence may be trainable and influentially steered toward maturity. Youth-based educational programs that place greater emphasis on health-seeking behaviors and bolstering the sense of coherence at a young age may be a helpful complementary strategy to break the current stagnation in anti-smoking efforts lamented by the USDHHS (2012) and for any nation interested in repressing the smoking epidemic.

Project Weaknesses and Limitations

The literature search uncovered a comparatively small number of useful studies. Although limiting the findings to studies published since 2007 generated an existent review, important older studies may have been overlooked. Furthermore, unpublished studies were not included in the search, and so it was not possible to round out the selections with other potentially valid data. Moreover, whereas careful effort was made to fairly consider all valid search results, the possibility of selection bias exists. Additionally, prior to publication, the ICSI began transition to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessing research quality (ICSI, 2013). Hence, new criteria for determining high-quality research may have yielded different studies for inclusion.

The premise of this review postulates that it may be possible to increase the effectiveness of anti-smoking interventions, aimed primarily at youth. Consequently, the review's focus is to recognize an association between attitudinal factors and protection against youth smoking that may be utilized in anti-smoking intervention optimization. The study subjects of the nine search articles appropriately hail from varied nations. It is difficult to know whether the findings generated from research in diverse nations can be extrapolated effectively for intervention refinement in any given nation and, further, whether the sum of the findings can be generalized for worldwide application.

The topic of the sense of coherence is complex and its terminology is not accepted widely as vernacular in the scientific community. To yield relevant and useful findings required thoughtful extrapolation of published studies to the target population. Although care was taken to conduct the review as objectively as possible and the results seem valid, it is important to acknowledge they are somewhat subjective due to the lack of explicit research on salutogenic factors related to smoking resistance among youth. However, the results obtained at minimum merit further investigation and specific examination of associative factors through future rigorous research.

Conclusions

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

Health detriments related to smoking are at present among the most troublesome socioeconomic problems facing the world. Accordingly, a vast range of information and study data related to smoking cessation and prevention exists. Although much knowledge is available about smoking initiation and cessation, there is still a need to establish consistent scientific findings that identify specific characteristics and attributes of smoking resistance potentially applicable to those most at risk for starting smoking: youth, adolescents, and young adults.

This review of the literature found that, although some information about attitudinal factors and protection against smoking among youth exists, work is still needed to more definitively establish and verify an association between the two. From the studies examined, it is clear that some youth conduct a realistic risk-benefit analysis of smoking behaviors while others do not. Youth who resist smoking tend to choose not to smoke because they perceive the benefit is not worth the risk, while others process information with the opposite conclusion and begin to smoke. A study of this information-processing disparity and possible explanatory factors may help reveal and solidify important attitudinal components related to protection against smoking in youth. It is hoped that correlation from current theorists and further validation from work specifically designed to challenge the concept will emerge. Eventually, interventions may be trialed in pilot studies designed to establish the validity of incorporation in measures intended to bolster the young person's protective attitudinal factors and sense of coherence.

Acknowledgment

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References

The authors wish to acknowledge the input and review of Jason A. Gregg, DNP, APRN, FNP, Assistant Professor of Clinical Nursing, UC College of Nursing, University of Cincinnati.

Clinical Resources

References

  1. Top of page
  2. Abstract
  3. Theoretical Framework
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgment
  9. References