Adolescents’ attitudes towards tobacco use and oral health: Four “portraits”

Abstract

Attitudes are important factors that can identify the uptake of smoking in adolescence. This study analyses interviews with 18 young at-risk patients, in an attempt to understand adolescents’ attitudes about tobacco use and oral health. The findings are presented with the aid of four “portraits”: The tobacco user, The tobacco tester, The tobacco ambivalent and The tobacco rejecter. These categories were constructed to show typical aspects and differences between the participating youth. Attitudes to tobacco use, although generally negative, varied over the four portraits. Arguments for not using tobacco were based on knowledge about harmful physiological influence and on emotional factors. The outlook of one's family and friends on tobacco was described as an important influence on one's own standpoint. All of the adolescents have taken part in school teaching about tobacco and oral health, which was described as boring. They want teaching to be based on dialogue. The portraits stress different circumstances in life as important for their attitudes towards tobacco use. Common to them is the need to receive relevant information, and to work actively in an educational situation. To arrange such teaching situations requires an understanding of the variations in adolescents’ experience and attitudes.

• Attitudes
• adolescent
• tobacco
• oral health education
• qualitative method

Introduction

Many young people start using tobacco even as early as the age of 11–14 (Tomar & Giovini, 1998; Rolandsson & Hugoson, 2000). Over a third of all children in ninth grade in the Swedish school system use tobacco regularly, some even on a daily basis (CAN, 2004). Several epidemiology studies (Hirsch, Livian, Edward & Noren, 1991; Byrappagari, Mascarenhas & Chaffin, 2006) have identified smokers as a higher risk category for caries than non-smokers.

In a review of empirical studies, Mayhew, Flay and Mott (2000) describe the development of tobacco use in five stages from pre-contemplation, when adolescents have never smoked and have no desire to start smoking in the near future, to the final stage, when adolescents have established a daily smoking habit. Different factors have been discussed as influencing smoking initiation in adolescence, such as rebelliousness, risk-taking and low self-esteem (Koval & Pederson, 1999). Factors in the social environment identifying the uptake of smoking in adolescence are attitudes, both one's own and those in one's surroundings, norms and relationships, such as having friends who use tobacco, as well as tobacco use in the family (Rolandsson & Hugoson, 2001). Widén and Erlandsson (2007) discuss, referring to Irwin and Millstein (1986) and Irwin (1990) adolescents’ risk-taking behaviour, holding that such behaviour is determined by the interaction between maturation, individual values, peer group characteristics, and individual risk perception.

We consider an attitude to be comprised of a cognitive, an emotional and an intentional component (Aronson, 1984; Hammarström, 1995). Several studies describe how attitudes influence the individual's actions and thoughts (Ajzen & Fishbein, 1980; Nilsson et al. 2006).

In Sweden, dental professionals have educated schoolchildren regularly about oral health and tobacco. Opinions about the effects of various health-promoting methods differ (Rooney & Murray, 1996; Sussman, Lichtman, Ritt & Pallonen, 1999). Programmes based on social-psychological methods, focusing on social norms, seem to be more effective than traditional means of health education (Tones & Tilford, 2001). In recent years, the empowerment model has often inspired tobacco-prevention work. This model focuses on individual behaviour, self-confidence and counteracting group pressure (Naidoo & Wills, 2000).

According to Rolandsson, Hallberg and Hugoson (2006) most previous research regarding tobacco use among adolescents has been based on quantitative methods. Hence, these studies are limited in the sense that psychosocial interactions are not considered. Attitudes can be measured this way, but thinking and values more deeply rooted in the person cannot be assessed (Kvale, 1993). Studies of differentiated needs and/or methods appear to be lacking in the literature. To reduce tobacco addiction it is crucial to gain a fuller understanding of how young people conceive tobacco use and addiction before they are actually ‘trapped’. In this way, appropriate and effective health promotion measures can be created and implemented.

The aim of the present investigation was to understand young people's attitudes and thoughts about tobacco use, oral health and their valuations of their body, self and relation to others. This includes the questions:

• What can be learned from young at-risk patients′ attitudes and thoughts about tobacco use and oral health?

• Which similarities and differences can be found in the young at-risk patients′ attitudes to and thoughts about tobacco use and oral health?

Method

All the Dental Health Service clinics in the county of Uppsala took part in an intervention study, conducted in 2005 (Hedman, Riis & Gabre, forthcoming). Patients born in 1989 and 1992 who were judged by dentists or dental hygienists as potentially at risk for dental disease—301 young adults—were included. The aim was to evaluate the effectiveness of two methods of health education. Effects were set to be attitudinal changes regarding tobacco use and oral health, which were measured by means of a pre- and a post-questionnaire. Our interest in this study is focused on thoughts; hence, a qualitative method was required.

Study population

This study population consisted of 18 at-risk young people aged 12 and 15 years, chosen from the 301 participants in the intervention study (Hedman et al., forthcoming). The interview study was conducted after the finalization of the intervention. Six persons were selected from each condition in order to assess eventual influences from the intervention.

Ethics

The Ethics Committee at the Faculty of Medicine, Uppsala University, Sweden approved the study. Informed consent was obtained from all participating persons, schools and parents before the onset of the study.

Procedure

The informants were sent an information letter describing the purpose and procedure of the study. It was emphasised that participation was voluntary and that confidentiality would be upheld during all collection, analysis and storing of data as well as in reporting. After this, the informants were contacted by telephone and asked again if or not they were interested in participating in the study. Since the informants were still minors, parental consent was sought. All 18 young at-risk people and their parents agreed to the participation.

Interviews

Data were collected in semi-structured interviews, which were performed in conversations with open-ended questions and conducted by a dental hygienist (EH) trained in qualitative interviewing. Typical questions included, what do you think of when I say tobacco? Tell me about your self. Tell me about your family and friends and their attitudes to tobacco? What might influence you not to use tobacco/to use tobacco? Describe in what way you have received information about tobacco and oral health. What do you think about tobacco when it comes to the future? Often the same themes appeared repeatedly, giving opportunities to control statements. To enhance validity, the interviewer made brief summaries after each subject/question area, and asked the informants to verify or reject them. The interviews were tape-recorded and transcribed verbatim by a secretary, yielding 216 pages. Before the tape recorder was turned on, there was an informal conversation to inform the interviewee again of the purpose of the study. The interviews lasted approximately half an hour, and took place at a local dental clinic or in school or at the interviewee's home.

Method of analysis

Initially, distinguishable pieces of information in the direct answers to the interview questions were named and provisionally categorized. Some 30 categories and sub-categories could be identified at this stage of the analysis. Two coders (EH, UR) studied the material thoroughly, red it several times, took different perspectives on it and sought distinctly different and distinctly similar ways in the adolescents’ answers. They made four successive trials with the material, looking for clusters in the answers. They worked independently of each other during the clustering trials but conferred with each other in between. In the fourth contact with the material four “portraits” crystallized. Nissen (1993) studied young Swedish hackers and he used the concept of “ideal type”. From 15 interviews and 11 variables, he created three fictional portraits: “The professional”, “the citizen” and “the esteemed visitor”. Nissen summarized his variables into three patterns, each characterizing a group of individuals (p. 245). From Nissen's method, which we chose to take advantage of, is that a “portrait”, is a comprehensive picture that can say something important and essential about reality, without being directly attributable to that reality. Our fictional portraits allow us to illustrate individual features without these features being lost in statistical aggregations. In our presentation of results, we use authentic quotations but let them represent the fictitious portrait at hand.

Results

The findings are presented with the aid of four portraits: The tobacco user, the tobacco tester, the tobacco ambivalent and the tobacco rejecter. These categories were constructed as a means of showing typical aspects but also differences between the participating youth.

The tobacco user is a girl, 16 years old, attending senior high school. Her feeling is that there may be aspects that are both positive and negative about tobacco use. She has used tobacco for approximately three years, and she plans to quit some time in the future. Smoking bans are partly positive and something she can accept. “The tobacco user” describes herself in a social way; a party girl with lots of friends. She spends her leisure time with friends and many of them use tobacco, as do her parents. The outlook of the family and friends on tobacco is described as very important and an influence on her own standpoint:

Both my mom and dad smoke so I've grown up with it. When I wanted to give it a try my mother said go ahead and see what you think. She felt her children should be able to decide from their own experiences, so I got hooked pretty fast. My dad was against my using tobacco, but he both smokes and uses moist snuff so he doesn't really have any say, and it's my life so I decide myself.

“The tobacco user” describes her first experience of tobacco as disgusting:

Then you really don't want to do it anymore but there was something that attracted me and it got to be a habit and then you just continue.

She remembers the influence of her friends, the importance of group pressure and of how difficult it is to say no. She talks about girls and about how they are more exposed to group pressure than the boys are:

There's more group pressure on us girls than on boys. Boys have the sense to quit, they say one thing and then they can quit. Guys have more say, we girls have such a hard time resisting. I started out smoking at parties, and then many of my older friends smoked and I got cigarettes from them, then I took more and more, then you buy your own, you sort of increase the dose all the time. If I hadn't started smoking at parties I don't think I would have started at all.

The knowledge about the damage from using tobacco is well known and something “The tobacco user” has learned from newspapers, other media and friends. She knows that tobacco is harmful to the teeth. She describes her own oral health as good, and she thinks that teeth are very important for her well-being as well for her looks. She does not see herself as a tobacco user in the future. She describes the ordinary lectures in school about tobacco and oral hygiene as passive and boring.

When the teachers stand there and talk about how dangerous it is to smoke, or they show a film, I just tune out, don't listen, it's nothing new, nothing that has to do with me.

Nevertheless, she says that more teaching is desirable, especially for those who have not started using tobacco and she calls for information that is active and relevant.

The tobacco tester is a boy, 16 years old and attending senior high school. He emphasizes that pressure from friends is very important in starting to use tobacco.

My friends tested it and you want to do what everybody else is doing but it wasn't more than once or twice and at parties.

He is negative to tobacco use even though he thinks it can be exciting and attractive-looking. One's group and one's friends are important factors for whether or not a young person starts to use tobacco, he feels. He says:

It's about group pressure, even if they don't say outright they're going to have a smoke. It's more like everybody goes outside and smokes, and then you go outside yourself and do it. Maybe they ask and then it's easy to just give it a try and then it gets to be more times, then it's like standard and not like the group decides and says you have to smoke but more like a question of company and being social. You go outside with others and have a nice time and in that situation it's hard not to test it's like and take up a cigarette.

Smoking bans are good and something he can accept, but the fact that tobacco is expensive has influenced him a lot:

My father smokes so I know how much money he throws away on tobacco, a few thousand a month that motivates me not to start smoking. My mom has never smoked, she doesn't like it and she influenced me a lot right from the beginning, she's talked a lot to us kids and commented on people who smoke that it's stupid and that sort of thing. Another thing is that I would never want to disappoint my mother.

“The tobacco tester” describes himself as a happy, talkative guy who likes school. Many of his friends smoke or use moist snuff. He does not see himself as a tobacco user in the future. In his free time, he likes to be with his friends, to workout and play rugby. His parents do not like tobacco, even if his father is a smoker. He does not have much knowledge about how the mouth and the teeth are influenced by tobacco. He knows about the damage of tobacco to the body in general. He thinks that teeth are important and he considers his oral health to be good. He has received information about tobacco in school, from the dental health service, and through his parents, which he finds both bad and good. The information by the dental health service he describes as good, saying:

She showed us directly what would happen in our mouths and talked in a way I understood and it felt like she cared.

In general, he would like more information where he could be active and find facts for himself:

We could work a little more on finding information and doing our own research, learning where to find out more from books and the Internet. Then I think we would discover much more than when we just listen to someone who already knows everything.

The tobacco ambivalent is a boy, 12 years old, studying at the elementary school. He is negative to tobacco use and has no experience of it, although he is curious about it. He says that tobacco use can be cool, attractive and tough and that he is going to try it sometime even if he does not see himself as a tobacco user in the future:

I think maybe I'll smoke in some form when I'm older even though I don't want to at the same time, but I just get a feeling that I'd like to give it a try. In that case it will probably be cigarettes.

He describes himself as a positive, kind, timid and curious person. He spends his leisure time in front of his computer, and likes to swim and in the wintertime, he goes skiing. Many people in his surroundings smoke, but very few of his closest friends use tobacco. His parents are quite negative to it:

Mom and Dad have said that I shouldn't start smoking, so that makes me think twice. Dad is trying to quit but it's really hard, and I figure if he's trying to quit then I shouldn't go and do something so unnecessary as starting myself.

According to “the tobacco ambivalent”, there are both positive and negative aspects inin using tobacco and he is uncertain about the effects of tobacco bans. Smoking can make people feel good or calm, and it can protect an individual from harassments:

I know someone who was picked on who got cool and felt much better, so yeah, it can help against being bullied. You kind of get cool and belong.

The problems of tobacco he feels are related to people's health. He also states that the rainforest will be damaged by circumstances connected to the production of tobacco. ‘The tobacco ambivalent’ is aware of the problem of passive smoking, even if he is sceptical to the danger:

They say it's dangerous, but can that really be true, I mean if you're just standing next to it?

His knowledge about tobacco has been acquired from the Internet, the school, his dentist and his parents. He does not know much about in what way the mouth is influenced by tobacco. He feels good teaching should not be about trying to scare kids away and he likes to discuss the economic aspects of being a tobacco user:

In our class we were allowed the whole time to ask questions and discuss with each other, which was interesting. The money aspect, how much it costs, that influences me a lot. I think it's interesting to discuss how much it costs, when you could use the money to buy a trip or something. That makes it very clear and easy to talk about practically everyone has an opinion.

His teeth are important to him and he considers his oral health to be good.

The tobacco rejecter is a 16-year-old girl who studies in senior high school. She is absolutely sure she will never use tobacco, not now and not in the future.

I know I will never start smoking or using snuff, it's a huge mistake, stupid and not especially smart.

She renounces the idea entirely because she thinks tobacco is disgusting, unhygienic, expensive and unhealthy. Teeth are important for her looks and she considers her oral health to be good. She has no friends who use tobacco, but one of her parents smokes.

My dad has influenced me the most, tobacco has made him sick, he has a hard time breathing and he coughs in that really scary way when he doesn't get enough air.

She considers tobacco to be a drug and the person who uses it as a victim, easily influenced by others. Smoking bans are good and something she supports. It is an effective way to decrease the tobacco use in society, she believes. However, to get results it is important to introduce total bans against tobacco everywhere, not only in restaurants In 1993 a tobacco law was introduced in Sweden (SFS, 1993) with clear limits to smoking in public places. She says:

I think all sales of tobacco should be forbidden. I want the people who sell tobacco to young people to get tough punishment, then there would be less smoking too.

She describes herself as kind, but not a wimp, and ambitious with a strong will.

Lots of friends ask if I want to taste or try it, but when I say no I mean it, even though lots of girls are sensitive to group pressure.

She likes school and it is a very important part of her life. In her spare time, she likes to do sports like working out and riding. Her knowledge about tobacco and its effects on the oral health is in some way superficial.

If you use moist snuff your whole mouth gets eaten away so you can put a finger way in. It gets corroded and is really disgusting.

She is satisfied with the tobacco education in school, even though she thinks it can contain more warning examples. About the dental health workers, she says:

It was a good talk I had with the dental hygienist about what I thought about tobacco and how I view it in the future. The dental care clinic visited our school a long time ago too, we got to dye our teeth to see where we hadn't brushed well. That was really good, you saw so clearly where you'd missed.

In general, she calls for information that is active and based on dialogue and her own search for knowledge.

Comprehensive understanding

The attitudes to tobacco use and oral health varied among the four groups. The arguments for not using tobacco were based partly on facts and knowledge about harmful physiological effects and partly on emotional factors such as smelling bad and feeling unhygienic. “The tobacco rejecter” was the only one to bring up solely negative aspects about the use of tobacco, while the others maintained that there could be aspects that were both positive and negative. The outlook of one's family and friends on tobacco was described as very important and an influence on one's own standpoint. “The tobacco user” and “The tobacco tester” emphasized the influence of people in their surroundings and group pressure as factors for whether or not one starts smoking or using moist snuff. The portraits came up with several ideas about effective teaching and it appears that adolescents ask for active teaching and the opportunity to search and discuss questions about life style with others.

Discussion

The attitudes to tobacco use and oral hygiene, although on the whole negative, varied among the four portraits. The adolescents in this study, as in other studies (Marklund & Törnell, 1996; Nilsson et al., 2006) talk about physical damage and the price of tobacco as strong arguments for not using tobacco, but also emotional issues like the bad smell and the fact that it is unhygienic to use tobacco. All four portraits emphasized social pressure as a factor for whether or not one starts smoking or using moist snuff. Parents’ influence is well studied, and parents who do not allow their children to use tobacco have more seldom children who smoke even if they smoke themselves (Di Franza et al., 2002).

None of the portraits sees themselves as a tobacco user in the future. “The tobacco user” is the only one who says yes to tobacco, even if she feels she will quit some time in the future. “The tobacco ambivalent” wants to test tobacco, is curious and wants to know what it is like and think it is cool, attractive and tough. All of the portraits emphasize the importance of their friends’ and parents’ attitude to tobacco use, and furthermore they all point out that group pressure is greater for girls than for boys. Group pressure and looking for an identity are evident, especially for “the tobacco user” and for “the tobacco tester”. They also describe how group pressure makes them want to try smoking, and the importance of being strong. Differences between girls and boys have been found in several studies, both when it comes to tobacco use and other health-related behaviour (Nilsson et al., 2006; Östberg, 2002). Common to all four portraits was that the use of tobacco is normally related to something else, such as family, friends, the environment or a particular activity. Hence, the use of tobacco is not something univocal but it is always a part of a social situation. “The tobacco user” and “the tobacco tester” describe themselves as very social and that their friends mean a lot to them.

“The tobacco rejecter” repudiates tobacco use the most and she is very supportive of all kinds of bans on tobacco use. She describes herself as kind but also decisive person. Everyone considers their oral health as good or fairly good, and they think their teeth are important for their health and looks; interesting here is if health-promoting work is so effective that even at-risk patients consider their oral health as good. Common reasons for not using tobacco are health-care related reasons as well as emotional factors like tobacco smelling bad and feeling unhygienic. “The tobacco ambivalent” also mentions environmental reasons. All of the adolescents have taken part in the school education about tobacco and oral health, which they described as passive and boring. Only “the tobacco rejecter” was satisfied with the education she received (Table I).

Table I.  The typical characteristics of the four “portraits”.

Characteristics	The tobacco user	The tobacco tester	The tobacco ambivalent	The tobacco rejecter
Mostly negative attitude to tobacco	×	×	×	×
Not a tobacco user in the future	×	×	×	×
Assents to tobacco use	×	−	−	−
Family negative to tobacco use	−	×	×	×
Clearly positive to bans on tobacco	−	−	−	×
Points out the importance of group pressure on starting to use tobacco	×	×	−	×
Points out the importance of friends and parents on starting to use tobacco	×	×	×	×
Gives environmental reasons for not wanting to use tobacco	−	−	×	−
Gives looks as a good reason for not using tobacco	–	–	−	×
Has a desire to be active in his or her learning	×	×	×	×
Describes himself or herself as social	×	×	–	−
Describes himself or herself as knowing one's mind and having a strong will	−	–	−	×
Describes himself or herself as curious	–	−	×	–
Rates his or her oral health as good/fairly good	×	×	×	×

Did the portraits have any messages to the educationalist? We believe so. All the portraits came up with several ideas about effective teaching about tobacco and oral health and they agreed regardless of “portraits”: Good teaching must be based on dialogue and an active search for knowledge. Teaching must be perceived relevant by students and be understandable, trustworthy, positive and not just scaring. It appears that adolescents ask for active teaching and the opportunity to search and discuss questions about life style with others. This wish is in line with empowerment methods emphasizing interaction, which we discuss in another article (Hedman et al., forthcoming).

This study was based on adolescents with a high risk of oral diseases, which could mean an overrepresentation of young people born outside Sweden and a larger percentage of tobacco users. This proved however not to be true. With ten percent young people born abroad, this was in agreement with the share of young people in the county in school year nine who were not born in Sweden (Skolverket, 2005).

The adolescents in this study do not seem to differ in any decisive way from young people in other studies. They who use or have tested tobacco describe themselves as more social than those who do not or have not. “The tobacco user” wanted to quit her use of tobacco and none of the portraits sees themselves as tobacco user in the future. They wish to receive information during respective dialogue and an education that is active. Similar results have recently been reported by Nilsson et al. (2006) and Östberg (2005).

The qualitative approach we used in this study was effective. Moreover, the interview method enabled relaxed discussions and allowed for probe questions. A dental hygienist with prior understanding of the field carried out the interviews. This facilitated the conversation but entailed a risk that the interviewer might take things for granted. There was also a risk that the informants, when confronting a dental hygienist, would adjust their answers to what they anticipated she wished for (Kvale, 1996). However, doubtful statements could be followed up and the informants of both genders were comparatively talkative. Before the conduction of the main study a pilot study was performed, in which the interviewing procedure was tried out and after which a few questions were altered. Furthermore, the analysis was performed in cooperation with a second judge, a frequently used reliability and validity assessment procedure in qualitative research (co-judging).

This project has generated many questions, especially regarding the role of education in promoting young people's health. Since tobacco use originates in a social context and since it turned out that many of the young people had a boyfriend or girlfriend, perhaps teaching them in “couples” would be a way, or by involving family and friends through new health-promoting teaching methods. Also the young people's knowledge surrounding tobacco was often superficial and they lacked an understanding of context, which further accentuates the importance of health-promoting efforts on the part of the National Dental Health Service and the need of a good working alliance between youth and teaching dental staff.

Knowledge is not accomplished by the individual for himself. Even learning of factual knowledge is a process requiring social interaction (Wertsch, 2002). However, learning is also a process in which the individual expresses herself emotionally and develops as a person. We have shown that there are different kinds of young at-risk patients and that the different personalities stress different circumstances in life as important. Common to all of them however is a desire to be informed about tobacco and oral health questions, to receive information they perceive as relevant and to work actively in an educational situation themselves. To arrange teaching and learning situations that fulfil such criteria requires an understanding of the variations in experience, attitudes, values and habits of young persons in the care of the Public Dental Health Service.

Acknowledgements

The authors would like to thank the County of Uppsala and Public Dental Health Service for financial support. The authors also thank Barbara Rosborg for revising the English text.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.