The Experiences of South-Western Taiwanese Male Adolescents Controlling Their Smoking After Exposure to an Education Program

Tobacco use is the most preventable cause of chronic diseases and cancers worldwide. In south-western Taiwan, tobacco use has become one of the top risk behaviors. Smoking in young people has been associated with alcohol addiction and drug abuse in later life; and most smokers start young. Initiation of cigarette smoking at an early age leads to more life-years of tobacco use, makes quitting harder, and increases the risk for serious health consequences. How adolescent boys effectively control their tobacco use is still uncertain. The article explores on the experience of 12 adolescent boys in south-western Taiwan controlling tobacco use as a result of participating in a smoking prevention education program. In addition to the use of interviews and focus groups as the traditional method of data gathering, the lead author also included the use of participants’ paintings as representations of the participants’ lived experience of the phenomenon. The findings of the study suggest that adolescent boys with smoking experience in Taiwan had the desire to control their smoking behavior after obtaining information through a local education program. In addition, they chose suitable methods for controlling their smoking based on the information that had been provided.


Introduction
Adolescents in Taiwan are increasingly experimenting with tobacco. By 2010, the number of high school students in the country had tried more than one cigarette by the age of 18 was 66.4% of Taiwanese teenagers (Department of Health, 2013). Initial experimentation with tobacco by adolescents can have a long-term impact on their lives and on society (Lam et al., 2005;Naing et al., 2004). Moreover, regular smoking is sometimes related to more serious drug and alcohol use (Pelzer, 2011;Wang, 2008) and other youth-specific social problems. This article is part of a larger study conducted by the lead author that initially investigated the motivation behind why south-western Taiwanese adolescent males chose to smoke tobacco. It was identified that there was no study that explored if adolescent Taiwanese boys would be affected in controlling their smoking behavior if they were involved in an education program. In addition, the smoking prevalence of male adolescents is 2 times that of female adolescents (Ministry of Health and Welfare, 2012). The goal of this article, therefore, is to explore on the experiences of controlling tobacco use among adolescent boys in south-western Taiwan who have been involved in an education program regarding smoking.

Societal Background
Adolescence is a critical stage for physical and psychological development. It is a time when adolescents seek freedom, autonomy, and excitement (Johnson, Kalaw, Lovato, Baillie, & Chambers, 2004;Pelzer, 2011) and demonstrate a dislike of rules. Smoking is one of the behaviors that teenagers use to express their freedom. Most adolescents in Taiwan begin smoking between the ages of 11 and 14 and become regular smokers by 18 (Wang, 2008). Other than the psychological characteristics of adolescence, adolescent smoking was associated with parental smoking, peer-group smoking, stress, poor self-esteem, body image dissatisfaction, risk-taking behavior, and poor physical health (Croghan et al., 2006;Johnson et al., 2004;Teevale, Denny, Nosa, & Sheridan, 2013). However, recent studies have also identified a number 569668S GOXXX10.1177/2158244015569668SAGE OpenGuo et al.

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1 Chang Gung University of Science and Technology, Chiayi, Taiwan 2 Queensland University of Technology, Brisbane, Australia of variables associated with quitting smoking/intention to quit smoking of youths, including parental smoking behavior, youth's perceived confidence to quit and perceived importance of quitting, past quit attempts, physical activity, and knowledge of the harmful effects of tobacco use (Doku, Raisamo, & Wiium, 2012;Savvides et al., 2014;Wong et al., 2011).
During recent years, antismoking has become a world trend and one strongly encouraged by the government in Taiwan (Wang, 2008). Yet although significant efforts have been made to reduce the prevalence of smoking in adolescence (Wakefield, Dphil, Nichter, & Giovino, 2003;Wilson et al., 2012), smoking rates at this life stage remain high worldwide. Since 1990, various antismoking campaigns have been implemented including the enactment of the Tobacco Hazards Act in 2009 by the Taiwanese government (Department of Health, 2013). However, despite these efforts, by 2010 the percentage of boys smoking had risen to 24.6 (Department of Health, 2013). To date, few studies related to the control of smoking behavior among adolescent boys have been undertaken, although some quit attempts have been reported in adolescent boys and girls (Stanton et al., 2001;Wang, 2008). Moolchan and Schroeder (2004) investigated African American youth (n = 140) and European American (n = 570) daily smokers' efforts at self-quitting (total n = 980). They found that there was no significant difference at self-quit attempts in gender or age distribution according to ethnicity. Elsewhere, it has been suggested that a greater focus on educating boys' programs could be beneficial in adolescent's self-quit attempts (Vuckovic, Polen, & Hollis, 2003).

Objective
The objective of this research was to understand the lived experiences of smoking among male adolescent, in particular around controlling tobacco use of 12 adolescent boys in south-western Taiwan who were involved in a smoking prevention education program.

Method
Qualitative methodology was used in this study. The purpose of using qualitative inquiry is to gain an understanding (Runswick-Cole, 2012) of adolescent male's experience of controlling smoking through establishing the meanings, thoughts, and ideas of phenomena rather than predict outcomes from data. Through the qualitative methodology, the meanings of the controlling smoking were established by indepth semi-structured interviews and drawings.
Participants in this study were high school students aged between 13 to 18 years who self-identified as having smoked on more than two occasions, were current smokers, and willing to share their experiences of smoking. Ethics approval was granted from the Human Research Ethics Committee of the University Hospital. Once ethics approval had been obtained and permission from the president of the high school was received, the researcher circulated a flyer inviting interested students to be part of the study. Acceptance of the invitation required the students to contact the researcher by phone to express a personal interest in being interviewed about their experiences of smoking. Prior to the commencement of the study, informed consent was obtained in writing from the participants and their guardian(s). Twelve participants in total chose to be involved in the study. Participation was voluntary. All participants completed the study.
As this study is based on the lived experience, an interpretive research was considered appropriate for the inquiry. To obtain multiple perspectives about how adolescent males control their smoking behaviors, three sources of data were collected: (a) individual participant interviews, (b) one focus group, and (c) individual participant paintings/drawings.

Participants
As part of a larger study investigating smoking behaviors in Taiwanese adolescent males, this study sample consisted of 12 adolescent boys with smoking experience. The larger study was a two-group longitudinal research designed to examine the effects of the smoking education program on tobacco use. The inclusion criteria of this study were Taiwanese boys who had experience of smoking, were aged between 13 and 18 years, and who had initiated cigarette smoking between 11 and 14 years, as this indicated the participants were habitual smokers. All of the participants' fathers were smokers, and 2 of the participants had parents who both smoked. Eleven of the participants' family economic status was below the average. Their fathers' careers were either fishermen or laborers. The average number of cigarettes smoked by the participants was from 5 to 10 daily. All of them participated in the smoking education program.

The Smoking Education Program
This study was designed to elicit an in-depth understanding of the lived experiences of adolescent male smokers in terms of the control of smoking while participating in an education program that focused on the potential illness consequences of smoking. The smoking education program included three sessions (risks of tobacco use, government laws, and media influence) and each session was taught by local doctors and nurse practitioners from local hospitals for 1 hr each in the classroom of a local high school. Diversified teaching and learning materials have been used, including slides, videos, learning sheets, and small-group content discussions in each session. Through this work, adolescents' awareness of tobacco's severe health risks was expected to be improved. In Table 1, the flow for the program is summarized with the topics for the education program and the questions used in the interviews.

Data Collection
Each participant was involved in two-face-to-face audiorecorded interviews at the research site, each of which lasted between 30 and 45 min. The interviews were designed to gain the participants experience by encouraging in-depth data. As a result, open-ended questions were used. All interviews were audio-taped and observation field notes were written during each interview. The first interview was to provide the participants an opportunity to describe their experiences of their feeling about smoking. The rationale of the focus group which was conducted after the second education session provided a chance for drawing their experiences of controlling smoking. Such an activity allowed time for quiet reflection on their experiences of controlling smoking and for them to share their experiences with friends. The focus of the second interview was to provide an opportunity for participants to share their experiences of controlling smoking. All data were de-identified and kept securely in locked filing cabinets. All data were collected over a 9-month period in 2012 by one researcher, thus following a consistent approach to data collection. Pseudonyms were used in place of participants' true names to assist in confidentiality of data.

Data Analysis
All interviews were transcribed verbatim and the lead researcher listened to the audio while reading the transcripts several times, until experiences could be described and "essences" were identified. These were then clustered into common themes resulting in five defined categories or themes. These were controlling by sleeping or eating, controlling by experiencing distraction with leisure activities, thinking of family or friends, thinking about wasting money, and thinking about physical weakness or stunted growth.

Findings
The participants indicated how smoking became their daily habits and were unaware of the harm to their health during the first interview. After being exposed to the smoking education program, all participants indicated that they would like to quit/control smoking; however, they still had tobacco dependence. The participants described their experiences of controlling tobacco use that were categorized into the following themes.

Controlling by Sleeping or Eating (n = 8)
Control over smoking was associated with sleeping and eating. Steven, who was curious about tobacco, generally controlled smoking by eating: I eat fruit or snacks . . . and after eating food, I did not want to smoke. Similarly, Peter noted, When I desire to smoke, I eat something (snacks, fruits, or chewing gum) As a result of such activities, the participants experienced positive feelings even where the desire to smoke persisted. John also said, I loved playing on the computer. When I concentrated on playing, I never thought of smoking. Nobody could make me move from the chair. For these adolescent males, playing computers, video games, Wii, and mobile phone games had become another method for controlling smoking. Steve pointed that when I playing computer games, I forgot to smoke. Maybe it was because playing games had lots of fun and I did not feel bored. I really loved games.
Sky and Bill both indicated that when I concentrated on hearing music or reading novels, I would not smoke. I really liked to listen to music and read novels. In general, when I listened to music and reading novels, maybe I concentrate on the atmosphere, I forgot smoking.
Regardless of the activity they chose, if the participants enjoyed their activity, they became so involved and distracted with the activity that their desire to smoke disappeared during this time. John faced a similar situation to David: John's girlfriend did not like smoking. He never smoked in front of her. As John described it, I loved my girlfriend and so I did not want to disappoint her . . . Although smoking made me happy and I felt cool, I would not like to let her down. Therefore, I hoped to find a way to quit and control smoking. Steve also indicated that my best friend smoked, so I started smoking. If my best friend did not smoke, maybe I would not have the chance to take up smoking. Peer pressure has been influential for these male adolescents, both negatively and positively. Negative influences were experienced from friends who also smoked. The pressure the participants felt to continue smoking was increased due to the pressure they felt from their others peers who also smoked. Positive peer pressure, however, also assisted in the desire to give up smoking, particularly when trying to impress family or girlfriends who did not like smoking.

Thinking About Wasting Money (n = 8)
Many of the participants thought about the waste of money in smoking. Peter explained, I would like to quit smoking because it costs money and affects health. All the money I spent on cigarettes came from my daily living allowance. Therefore, sometimes, I went hungry without eating my breakfast in order to save money to buy cigarettes. Steven faced the same situation: I need to save my breakfast money to buy cigarettes. One pack of cigarettes was about $100 NT. Although I was hungry, I still bought cigarettes because of my craving for tobacco. Smoking really wasted my money. However, as the cigarette became more and more expensive, I did not have money to buy it, and I will quit it. I could not stand to be hungry.
There was difficulty in balancing their budgets between food and cigarettes. In the end, the cost of cigarettes also played a role in them wanting to control their smoking or even quit.

Thinking About Physical Weakness or Stunted Growth (n = 11)
A number of participants felt their health had become worse since they had taken up smoking. Most thought that their height had not increased from the point that they took up smoking. They thought about physical weakness or stunted growth after smoking and felt upset. George stated, After smoking, I was breathless when I ran. I never had this experience before I smoked. Furthermore, John, Steven, and Peter also indicated, My height did not grow after smoking. Steven even mentioned that I was only 163 cm in height, short in my class. I was worried that I would not find a girlfriend. It was so bad that I did not keep growing after smoking. Steven portrayed himself as follows: My height did not increase after smoking. Also, I could not sleep at night, which meant my spirits in the morning were low and I was tired. I tried to control smoking because of these reasons.
John also found a similar situation

Discussion
The findings of this study revealed five themes reflecting the behaviors of the participants in their experiences of living with controlling tobacco use. The participants had also become motivated in their desire to control or quit their smoking after only two sessions of the education program. They recognized links between the information given in the sessions, for example, side effects of smoking and the things they were personally experiencing such as not eating properly, which in turn became a motivation for them to want to quit smoking. The provision of education assisted the participants to become more motivated to change their smoking behaviors as indicated in the data analysis.
The themes identified were congruent with other international studies. The participants in this study indicated that smoking could be controlled by sleeping or eating. Although no studies indicated youth smokers controlled their smoking by sleeping, Larson et al. (2007) found that adolescents eating breakfast, lunch, and dinner regularly had a significantly low percentage of cigarette use. In addition, frequent consumption of fast-food meals was significantly and directly related to smoking frequency and overall young people ate more junk food to stop smoking (Larson et al., 2007). Their results were consistent with this study as most participants interviewed identified that they liked to eat fast food to control smoking.
Most participants (n = 10) also stated that smoking can be controlled by participating in leisure activities, rather than concentrating on the need to smoke. In the Larson et al. (2007) study, physical activity was significantly associated with smoking behaviors, demonstrating that participation in team sports reduced the smoking rate in adolescents. As a result, if adolescents were encouraged to find an activity they enjoyed, this could provide significant support during their efforts to reduce or quit smoking. However, in this study, some participants controlled smoking via sleeping or eating resulting in weight gain. These adolescent boys found a negative way to control smoking. The nurse educators could encourage them choose a suitable activity to help them control smoking and become healthy.
Family and friend awareness were factors influencing male adolescents' smoking habits. Jamil, Khan, Atta, Shahzada,& Younis(2012) revealed friends and brothers rather than parents or teachers as significant influences on adolescents' tobacco use. Nargiso et al. (2012) also found that close friends were significantly associated with smoking behaviors, while family environment had no significant effect. This was congruent with the results found in this study where participants indicated their desire to "not disappoint" their girlfriends.
Some participants indicated that they controlled their smoking behaviors by thinking about wasting money, which is similar to the results in a study by Lovato et al. (2010) who found that students smoked less cigarettes in areas where the cost was higher than other areas. In addition, some participants believed that smoking made them become physically weak or stunted. There are not many studies to demonstrate this; however, Gold et al. (1996) did conclude that the growth of lungs was in fact stunted in adolescents who smoked. Furthermore, smoking may not actually increase appetite as one participant (David) had indicated, because middle adolescents (13-17 years) generally experience weight gain naturally associated with growth and development (Stang & Story, 2005).

Conclusion
As previously described, self-awareness and friends exert a great influence on teenage boys. Whether such boys smoke depend on their strength of their social bonds with their friends; to develop effective health education programs for young Taiwanese smokers, finding suitable strategies is important. Strategies employed by participants to stop or prevent a return to tobacco use included thinking of "family or friends," "finding activities," "thinking about wasting money," and "thinking about physical weakening or stunting." For many of the participants, the above strategies are the most effective ways to quit or to have motivation to stop smoking. Vuckovic et al. (2003) suggested that teen smokers need to be provided with valuable information such as useful quit tips to have motivation to stop smoking, but they have not said what useful quit tips are. Therefore, those above strategies in this present study might be used as quit tips for male adolescent smokers. In addition, this study demonstrated that the provision of knowledge to participants in a way they could personally relate to it can assist in the motivation to reduce or quit smoking. This research will help health-related workers understand how adolescent boys contribute to control of smoking, how they think about smoking, and how smoking cessation programs can be developed for adolescent boys.

Limitations of the Study
The study is limited by the small number of participants (n = 12) involved. The focus of the study was restricted to persons who were involved in smoking control. Further studies could be undertaken involving physical activity, healthy diet, economic factor, and family members concerning the impact on their respective lives.