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.