Adolescents And Tobacco Use Systematic Review Of Qualitative Research Methodologies And Partial Synthesis Of Findings

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Substance Use & Misuse, 42:1269–1321
Copyright © 2007 Informa Healthcare
ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080701204904
Adolescents and Tobacco Use: Systematic Review
of Qualitative Research Methodologies
and Partial Synthesis of Findings
RAOUL A. WALSH AND FLORA TZELEPIS
Centre for Health Research & Psycho-oncology, The Cancer Council NSW,
University of Newcastle and Hunter Medical Research Institute, Newcastle,
New South Wales, Australia
After a brief overview of adolescent tobacco control, methodological features and con-
tent areas of 78 qualitative studies of adolescent smoking published in English prior
to September 2002 were assessed. Narrative syntheses of three content areas—peer in-
fluences, access/sales issues, and dependence/addiction—were also undertaken. Many
studies failed to provide sufficient sampling and subject characterization details and
more effort was required to demonstrate data validity and reliability. Syntheses of the
content areas revealed important common themes. Relationships to quantitative re-
search were informative and suggested other research questions. The review highlights
the heuristic value of qualitative research on adolescent smoking. Funding was provided
by The Cancer Council New South Wales and NSW Health/Hunter Medical Research
Institute.
Keywords adolescents; smoking; tobacco; qualitative; research; review; methodology
Introduction
A central aim of tobacco control polices throughout the Western world has been to prevent
adolescents from experimenting with tobacco and from progressing to regular smoking
(Reid, McNeill, and Glynn, 1995). An analysis of nonprofit tobacco research funding in
North America documented that 39% of non-laboratory studies, where subject age was
specified, involved participants under 18 years of age (Maule, 2001).
Reflecting the importance of adolescence, there have been a large number of reviews of
tobacco control efforts in this age group over the past decade (Bruvold, 1993; Epps, Manley,
and Glynn, 1995; Fritz, 2000; Lantz et al., 2000; Lynagh, Schofield, and Sanson-Fisher,
1997; Rooney and Murray, 1996; Sowden, Arblaster, and Stead, 2004; Stead, Hastings,
and Tudor-Smith, 1996; Sussman, Lichtman, Ritt, and Pallonen, 1999; Thomas, 2004; U.S.
Department of Health and Human Services [USDHHS], 1994; Vickers, Thomas, Patten, and
Mrazek, 2002; Wakefield and Chaloupka, 2000; Warner, Jacobson, and Kaufman, 2003).
These reviews have concentrated exclusively or mainly on quantitative studies.
Reducing adolescent tobacco use has been identified as a difficult area where many
questions remain about policy and program efficacy (Sutton, 2000). School-based programs
Address correspondence to CA/Prof. Raoul A. Walsh, Centre for Health Research & Psycho-
oncology, Locked Bag 10, Wallsend NSW 2287, Australia. E-mail: Raoul.Walsh@newcastle.edu.au
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1270 Walsh and Tzelepis
involving information on the social influences on tobacco use, modeling and practice of
resistance skills, and peer and parent involvement in program delivery have been recom-
mended (USDHHS, 2000). Whether such programs alone have any long-term impact is
unclear since effectiveness appears to dissipate in 1–4 years (Tengs, Osgood, and Chen,
2001).
Multicomponent, community-wide tobacco control programs, particularly those in-
cluding mass media campaigns, may be effective in preventing the uptake of smoking,
although the gains are modest (Sowden et al., 2004; Wakefield and Chaloupka, 2000).
Overall, difficulties encountered in smoking prevention have encouraged the view that adult
smoking programs should be emphasized ahead of prevention in adolescents (Hill, 1999).
However, this position remains a controversial one, rejected by others in the field (Myers,
1999). Recent encouraging evidence indicates there may be a dose–response relationship
between the level of exposure to the “truth” antismoking advertisements and adolescent
smoking prevalence (Farrelly, Davis, Haviland, Messeri, and Healton, 2005).
Two broad areas offer potential for improving adolescent smoking control efforts. The
first involves enhanced diffusion of effective programs such as state-of-the-art tobacco pre-
vention curricula (USDHHS, 2000). The second involves new research designed to evaluate
improved adolescent smoking interventions, especially in non-school settings (Lichtenstein,
1997). Qualitative research could help inform studies in both these research areas (Backer,
2000; Lisnov, Harding, Safer, and Kavangh, 1998; Miller, 1998). For example, Goldman
and Glantz (1998) reviewed the results of 186 focus groups to help identify advertising
strategies that would be expected to be effective. Industry manipulation and second-hand
smoke themes were nominated as potentially most promising. Nichter, Nichter, Thompson,
Shiffman, and Mosicki (2002) argue that qualitative research is necessary in its own right
and is very urgently needed in the development of youth tobacco surveys.
Qualitative Research—Current Issues and Potential
The potential value of qualitative research is now acknowledged by researchers, includ-
ing those with predominantly quantitative training (Dixon-Woods and Fitzpatrick, 2001).
Qualitative approaches deserve to be an essential component in health research, not just
because they enable access to complex areas not amenable to quantitative research but also
because qualitative description is a prerequisite of good quantitative research (Pope and
Mays, 1995).
Notwithstanding this growing acceptance, qualitative methods have been subject to
ongoing criticism. Qualitative research often employs small, opportunistic sample sizes
and this raises questions concerning whether the findings are representative of the target
population (Bertrand, Brown, and Ward, 1992; Daly and Lumley, 2002). The possibility of
undue subjectivity on the part of the researcher in analyzing results has also been identified
as a potential problem (Bertrand et al., 1992; Ezzy, 2001). Ezzy (2001) argues that concerns
about researcher bias often arise because of the use of an outdated natural science model
rather than an interpretative social science model.
It is somewhat paradoxical that researchers with different perspectives can view similar
qualitative features as either positive or negative. For example, Ritchie (2001) notes that the
tendency for people to build on others’ comments during social interaction is exploited in
focus groups. In contrast, Sussman, Burton, Dent, Stacy, and Flay (1991) report that focus
groups may induce certain group effects, including collective endorsement of more extreme
responses, that might bias results.

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Adolescents and Tobacco: Qualitative Research 1271
Issues such as whether quality criteria should be applied to qualitative research, which
criteria are appropriate, and how they should be assessed are hotly debated (Mays and Pope,
2000). Some advocate distinctive criteria for qualitative research, while others emphasize
criteria of quality common to both qualitative and quantitative research (Mays and Pope,
2000). A number of structured approaches to judging validity and reliability in qualitative
research are available; however, most frameworks fail to specify how judgments should
be made or whether or not a standard has been reached (NHS Centre for Reviews and
Dissemination, 2001).
The recent increase in the number of published qualitative studies has not yet led to the
building of a cumulative knowledge base or to much theoretical development (Britten et al.,
2002). Petticrew (2003) argues that research syntheses are essential for putting studies into
their scientific context. However, such syntheses may not be very informative, partly because
they fail to draw on all the available evidence including qualitative information (Petticrew,
2003). For example, in a recent Cochrane Review of cancer communication, only 9 of over
1,500 identified studies met their inclusionary criteria (Scott, Harmsen, Prictor, Sowden,
and Watt, 2004). Even when researchers do not actively exclude studies, searching for and
identifying appropriate qualitative research remains difficult because registers do not exist
and search tools require substantial improvement (Dixon-Woods and Fitzpatrick, 2001).
Having identified relevant studies, a daunting array of theoretical and practical problems
await reviewers who attempt secondary syntheses of qualitative data (Dixon-Woods and
Fitzpatrick, 2001).
We could not identify a published listing of qualitative research on adolescent tobacco
use, let alone a review of this topic. Therefore, the study objectives were:
1. to list peer-reviewed publications reporting qualitative data relevant to adolescent to-
bacco use,
2. to assess methodological features of such studies,
3. to summarize the main tobacco-related content areas addressed, and
4. to attempt a narrative synthesis of three content areas with emphasis on identifying
consistent and divergent findings.
Method
The following databases—Medline, PsycINFO, Current Contents, Embase.com,
AUSTHealth, CINAHL, and ERIC—were searched for peer-reviewed journal publications
in English reporting qualitative data derived from adolescents about tobacco use prior to
September 2002. These combinations of keywords were used: qualitative, focus groups, in-
terviews,ethnograph/y,lifehistory/ies,narrative,anthropology,smoking,cigarette,tobacco,
cigar, smoke, youth, adolescent, adolescence, teenager. Any study including a majority of
subjects in the 10- to 20-year-old age group was included. Reference lists were checked for
additional reports. Requests for assistance in locating suitable publications were also made
via Globalink and direct researcher contact.
Titles and/or abstracts were reviewed to select potentially eligible papers. Studies were
excluded where qualitative data on substance use did not include any substantial, discrete
focus on tobacco use, data were only derived from non-adolescents, or where responses to
open-ended survey questions were analyzed using a quantitative method.
The assessment of the quality of studies was hindered by the lack of agreed meth-
ods (Dixon-Woods and Fitzpatrick, 2001). Although considerable overlap exists between
different assessment frameworks, no criteria appear in all frameworks (NHS Centre for
Reviews and Dissemination, 2001).

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We decided to draw on assessment criteria proposed by two related expert groups, the
Cochrane Qualitative Methods Network (1999) and the Health Care Practice Research and
Development Unit (2002). The number of criteria assessed was reduced for three reasons.
Firstly, the lists of criteria were too lengthy to be reported in the required detail. Secondly,
as Abdullah (2003) has argued, review processes can set up too many evaluative criteria.
Thirdly, as already discussed, some criteria required problematic value judgments. Other
qualitative reviewers (Boulton, Fitzpatrick, and Swinburn, 1996) have reported low initial
levels of agreement on several evaluative and descriptive items.
In total, 29 variables were assessed. These variables, grouped in seven broad categories,
are outlined in Table 1, together with details of the assessment. All studies were coded
completely, using the same approach.
One of the variables assessed was the main content area(s) of the study. For this variable,
a list of tobacco-related content areas was developed at the study’s commencement. The
list was added to during the study as new areas were identified. In some instances there was
overlap between the content areas. For example, family and peer factors frequently related
to access/sales issues. Where there was a discrete focus on a content area such as peer
influences in a paper that also reported on access/sales issues, both content areas were coded
separately. However, if a study was restricted to an overarching focus on access/sales issues,
family/cultural aspects and peer influences were not coded separately where discussion of
these areas was subsumed under the access/sales context. The pregnancy and environmental
tobacco smoke areas included their respective health risks. The content area health risks
was not coded separately in these instances. The final list of 19 content areas included under
the main content areas variable is also itemized in Table 1.
Data extraction of all the variables was undertaken by one author with checking by the
other. In addition, we undertook a narrative synthesis of three content areas: peer influences,
access/sales, and dependence/addiction issues.
Narrative Syntheses
Given the disparate number of content areas, it was judged too difficult and lengthy to
synthesize all content areas. The three content areas were chosen because of their impor-
tance in the adolescent tobacco control field and also because they could demonstrate how
a basic synthesis might be undertaken. The aim of these syntheses was to examine relation-
ships including consistent and divergent findings within the various studies. Unlike some
other researchers (Thorne et al., 2002), we did not seek to apply these syntheses to test
or generate new overarching theories. For this reason and because there is no agreement
that metaethnography (Noblit and Hare, 1988) is the preferred approach (Sandelowski and
Barroso, 2003), we did not incorporate all the elements of this approach in our syntheses.
Although Walsh and Downe (2005) list several metastudies that have demonstrated
that it is possible to synthesize the results of qualitative health research, meta-analytic
approaches have yet to be fully developed in the qualitative area and many strategies seem
best suited to integrate the results of a small number of similar studies (Thorne et al., 2002).
We did not identify any published qualitative synthesis in the tobacco control area. Nichter,
Quintero, Nichter, Mock, and Shakib (2004) have recently included tobacco prevention as
one exemplar to introduce the range of research issues that a qualitative researcher may
focus upon during initial formative research. By its nature, however, the Nichter et al.
(2004) paper was not designed to present a comprehensive review of qualitative research
on adolescent smoking.

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Table 1
Study variables examined in seven broad categories and assessment criteria useda
Category Variables
Study details Author, publication year, location, data collection year(s)
Type of data • Format: full report, brief, or letter
• Non-adolescent-derived data source also included
• Non-demographic quantitative data items
Setting and sample • Setting and sample descriptions
• Mode of sampling: purposive, convenience, naturally occurring group, or random
Sample numbers and background • Number: by gender, total; presented exact sample size; female-only sample
• Age
• Participation: reasons for nonparticipation; consent rate
• Racial/ethnic focus: background, % of groups
• Definition of smoking status: full, partial, or none, with breakdown in defined groups
• Other demographic variables
Data collection methods • Format: number and size of focus groups
• Approach used in focus groups/interviews
• Pilot testing
• Attempts to establish researcher–participant partnerships
• Data recording method
• Length of interaction
Data analysis • Quality of analysis description: absent, poor, good, very good. Poor = general statement, sometimes referenced,
usually indicating that the data were coded and categorized but without details; good = description of the initial coding
or categorization method used, how themes or content areas were developed, and how the final categorization(s) or
summary was arrived at; very good = good plus two or more of four features (below) to establish validity
• Validity strategies: raw data extracts, triangulation, contradictory findings sought/discussed, member checking
• Reliability strategies: any checking by >1 researcher; interrater reliability
• Software package used
Main content areasa
• 19 Content areas: access/sales issues, brand preferences, cessation, cigar use, dependence/addiction, environmental
tobacco smoke, family/cultural aspects, health risks, image issues, marketing/media including movies, other drugs, peer
influences, pregnancy, prevention methods, program development, program evaluation, sources of smoking messages
excluding marketing, reasons for smoking/non-smoking, and school policies
a
Descriptions of the main findings and conclusions of each study were also prepared. These are available on request from the corresponding author.
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In undertaking the syntheses, the sections related to the content area of interest in each
relevant paper were carefully read several times. A list of content subareas or themes were
developed by noting each time a paper raised a new subarea not previously covered. When
a later paper presented material relevant to a previously listed subarea, this was examined
to determine in what way(s) it was consistent with or divergent from the previous findings.
Obviously, the new finding might also represent an elaboration on a previous finding or a
new insight on the subarea.
Results
A total of 142 publications were identified. Publications were excluded for the following
reasons: 28 exclusively quantitative data, 9 exclusively or mainly non-adolescent data, 8
quantitative analyses of open-ended responses, 7 no relevant or no qualitative data, 6 agency
reports, 3 no original data, 2 data on other drug use, and 1 examined focus group effects.
This left 78 eligible publications.
Table 2 summarizes the variables extracted from the studies. Most of the data extraction
required only careful attention to the study’s descriptive detail. Three variables in particular
did require evaluative judgements in the assessment process: the mode of sampling, quality
of analysis description, and the main content area(s). For example, in many publications,
it was difficult to be certain of the sampling strategy; in particular, the distinction between
purposive and convenience participant selection was not clearly established. Despite this
difficulty, a judgment was made about the sampling strategy employed in each study.
Seeking researcher consensus was the commonest way of addressing data reliability.
In some studies, the wording suggested high agreement between researchers; for exam-
ple, “very similar results” were obtained (Rugkasa, Knox, et al., 2001), while in others
the description was vague; for example, “Generally, some analysis was made with other
researchers. . . ” (Lotecka and Lassleben, 1981).
Table 3 details the assessment for each study individually. Each study has been listed
alphabetically and allocated a number. Henceforth, these numbers are used in the Results
section when tabulated studies are referred to.
Main Content Areas
Table 3 also presents the content areas addressed within each study. While 5 studies focused
on a single area, most (73) studies reported on multiple content areas. The average number
of content areas addressed per paper was 4.6 (median 4.5, range 1 to 10). In addition, a count
was made of the total number of publications presenting qualitative data relevant to each
content area. This count provides some indication of the priority attached to the different
content areas by participants and researchers. A listing of the content areas by number of
publications reporting on each area is detailed in Table 4.
Narrative Syntheses
As previously discussed, there is a lack of consensus about standards for qualitative re-
search. For this reason, the methodological assessment was not used to cull studies from the
subsequent narrative syntheses. This is in line with the recommendation by Sandelowski
and Barroso (2003) for a more inclusive approach. Results of the syntheses of the three
content areas—peer influences, access/sales issues, and dependence/addiction issues—are
presented in narrative form below.

Table 2
Summary of findings in relation to the extracted variables: Number (percentage) of studies
Variable Number (%)a
Study details
Author (publication year) See Table 3
Location U.S.A. 39 (50), UK 23 (29), Australia 5 (6), Canada 5 (6), Other 4 (5), Not stated 2 (3)
Data collection year(s) Pre-1990 4 (5), 1990–1994 8 (10), 1995–1999 33 (42), 2000–Aug 2002 33 (42)
Type of data
Format Full 74 (95), brief 2 (3), letter 2 (3)
Non-adolescent-derived data source 11 (14)
Non-demographic quantitative data
items
33 (42)
Setting and sample
Setting descriptions 33 (42)
Sample descriptions See Table 3
Mode of sampling Purposive 32 (41), convenience 28 (36), naturally occurring group 13 (17), random 5 (6)
Sample numbers and background
Number- by gender, total See Table 3
Exact sample size 60 (77)
Female-only sample 12 (15)
Age See Table 3
Reasons for nonparticipation 6 (8)
Consent rates 10 (13)
Racial/ethnic focus 25 (32)
Definition of smoking status Full 21 (27), partial 30 (38), none 27 (35)
Other demographic variables 54 (69)
Data collection methods
Format Focus groups only 48 (62), in-depth interviews only 13 (17), focus groups plus in-depth interviews
11 (14), interview plus observations 3 (4), focus groups plus role-plays 2 (3), focus groups plus
Internet groups 1 (1)
(Continued on next page)
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Table 2
Summary of findings in relation to the extracted variables: Number (percentage) of studies (Continued)
Variable Number (%)a
Number of focus groupsb
1–178 (range), 25.2 (mean), 10 (median)
Size of focus groupsc
2–14 (range)
Approach used in focus
groups/interviewsd
Structured or semistructured guide 48 (60), broad themes 11 (14), audiovisual or visual stimulus 6
(8), discussion guide and audiovisual or visual material 4 (5), narrative material 2 (3), no details
in at least one format 9 (11)
Pilot testing Protocol 4 (5), protocol adapted during data collection 12 (15), pilot study 1 (1)
Attempts to establish
researcher–participant partnerships
None 38 (49), matching of interviewer backgrounds with participants 25 (32), specific measures
(e.g., time in school prior to data collection) 10 (13), nonthreatening settings 5 (6)
Data recording methode
Audiotapes 59 (75); audiotape and/or videotape 5 (6); audiotape, videotape, and diaries 1 (1);
videotape 1 (1); not stated in at least one format 13 (16)
Length of interaction See Table 3
Data analysis
Quality of analysis description Absent 20 (26), poor 27 (35), good 6 (8), very good 25 (32)
Validity strategies Raw data extracts 72 (92), contradictory findings 43 (55), triangulation 38 (49), member checking
8 (10)
Reliability strategies Checking >1 researcher 27 (35), interrater reliability values 4 (5)
Software package used NUDIST 18 (23), Ethnograph 6 (8), unnamed software 1 (1)
Main content areas See Tables 3 and 4
a
n = 78 for each variable except where noted.
b
Excludes 5 studies, where number of adolescent focus groups was unclear.
c
Excludes 20 studies, where size of focus group/s was not provided.
d
n = 80.
e
n = 79.
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Table 3
Variables extracted from qualitative studies of adolescents and tobacco use
Study number
Author (year of
publication)
Location
Year data collected Type of data
a) Setting
b) Sample
c) Sample selection
a) Sample size; gender
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
a) Data collection method
b) Discussion approach
c) Research partnership
d) Recorded
e) Duration
a) Description of quality
of analysis
b) Support for analysis
c) Two or more coders
d) Qualitative software Main content areas
1. Aitken, Leathar, and
O’Hagan (1985)
UK, Glasgow
Not stated
Qualitative &
quantitative
Adolescents
a) Primary & secondary
schools
b) Students
c) Random
a) n= 247; Female &
male
b) 6, 8, 10, 12, 14, 16
Years
c) Not stated
d) None
e) Inner-city &
suburban
a) 24 Focus groups
b) Loosely structured &
visuals
c) Not stated
d) Audiotaped
e) 75–90 Minutes (aged
10–16) 30 minutes
(aged 6 & 8)
a) Poor
b) C, Q, T
c) Not stated
d) Not stated
Image issues
Marketing
2. Alexander, Allen,
Crawford, and
McCormick (1999)
USA, Maryland
(Baltimore),
Texas (Houston),
Alabama, New Mexico
Not stated
Qualitative
Adolescents
a) Middle & high schools,
recreation and other
local community
centers
b) I: Adolescent smokers
FG: Adolescents
c) Convenience
a–c) I: n= 87; 54%
female; 13–19 years;
47% African
American, 41%
White, 11%
Hispanic
FG: n = 227; 53%
54% Hispanic, 46%
Native American
d) Partial
e) I: urban & rural; FG:
rural
a) 87 Interviews & focus
groups
b) Specific questions
c) Interviewer matched by
gender & ethnicity to
extent possible
d) Audiotaped
e) Not stated
a) Very good
b) C, Q, T
c) Yes
d) NUD*IST
Access/sales issues
Family/cultural aspects
Peer influences
Reasons
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Table 3
Variables extracted from qualitative studies of adolescents and tobacco use (Continued)
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
3. Allbutt, Amos, and
Cunningham-Burley
(1995)
UK, Scotland
1992–1993
Qualitative
Adolescents
a) Schools, colleges,
youth clubs,
community centers
b) Youth
c) Convenience
a) n= 234; 60% female
b) 11–20 Years
c) Asian,
Afro-Carribbean
included
d) Full
e) Parental home
ownership, fathers’
occupation, city &
rural
a) 28 Focus groups
b) Topic guide
c) Research presented as
study of young
people’s interests
d) Audiotaped & notes
e) Not stated
a) Very good
b) C, Q
c) Not stated
d) Not stated
Dependence/addiction
ETS
Image issues
Marketing
Other drugs
Peer influences
Reasons
4. Amos, Gray, Currie,
and Elton (1997)
UK, Scotland
Not stated
Qualitative &
quantitative
Adolescents
a) 10 Schools
b) Students
c) Convenience
a) NA 4–8 per group;
female & male
b) 12–13 & 15–16 Years
c) Not stated
d) None
e) None
a) 36 Focus groups
b) Visual materials
c) Not stated
d) Audiotaped
e) 35–50 Minutes
a) Good
b) T
c) Uncertain
d) Not stated
Image issues
5. Armstrong and Miller
(2001)
USA
Not stated
Qualitative
Adolescents
a) Via various sources
including referrals
from individuals
known to researchers
b) Youth
c) Convenience
a) n= 15–16; 44–47%
female
b) 10–16 Years
c) Not stated
d) None
e) None
a) 15–16 Interviews
c) Not stated
d) Audiotaped
e) 45 Minutes
a) Good
b) Q
c) Yes
d) Ethnograph
Health risks
Image issues
Peer influences
Reasons
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6. Balch (1998)
USA, Oak Park,
Denver and Delaware
1995 & 1996
Qualitative
Adolescents,
school health
providers
a) Marketing recruitment
company database,
school & community
contacts
b) Current smokers
c) Convenience
female & male
b) 14–18 Years
c) Hispanic, African
American, Asian,
other
d) Full
e) Inner suburbs
a) 9 Focus groups
b) Discussion guide
c) Not stated
d) Audiotaped &
videotaped
e) 2 Hours
a) Absent
b) C, Q
c) Not stated
d) Not stated
Access/sales issues
Cessation
Health risks
Image issues
Peer influences
Prevention methods
Program development
Reasons
7. Banwell and Young
(1993)
Australia, Melbourne
1988
Qualitative
Adolescents
a) Housing project,
religious groups,
unwed mothers,
netball team, high
school, technical and
Catholic colleges,
community services
b) Female adolescents
c) Purposive
a) n= 83 females
b) 13–18 Years
c) 87% Australian born
d) Partial
e) Parents’ country of
birth, parents’
occupation, school
attendance
a) 14 Focus groups
c) Not stated
d) Audiotaped
e) 1–2 Hours
a) Poor
b) C, Q
c) Not stated
d) Not stated
Brand preferences
Health risks
Image issues
Marketing
Peer influences
Reasons
8. Barg and Lowe
(1996)
USA, West
Philadelphia
1994–1995
Qualitative &
quantitative
Adolescents,
school staff
a) Public middle school
b) Seventh graders
c) Random
a) Not stated; female &
male
b) Not stated
c) African American
d) None
e) Urban
a) 3 Focus groups
c) Not stated
d) Not stated
e) Not stated
a) Absent
b) Q
c) Not stated
d) Not stated
Cessation
Health risks
Peer influences
Program evaluation
9. Barnard and Forsyth
(1996) UK, Scotland,
Dundee 1995
Qualitative &
quantitative
Adolescents
a) 5 Schools
b) S1–S5 students
c) Random
a) n= 123; female &
male
b) 11–17 Years
c) Not stated
d) None
e) Urban & suburban
a) 27 Focus groups
b) Semistructured
c) Not stated
d) Not stated
e) 30–60 Minutes
a) Absent
b) Q, T
c) Not stated
d) Not stated
Access/sales issues
Brand preferences
Image issues
Marketing
Peer influences
1279

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
10. Bell, Pavis, Amos, and
Cunningham-Burley
(1999)
UK, Scotland
1995–1996
Qualitative &
quantitative
Adolescents
a) 2 State comprehensive
schools
b) Initially secondary (S4)
students
c) Convenience-natural
a) n= 89; female &
male
b) 17 Years
c) Not stated
d) Full
e) School retention,
friends’ smoking,
urban & rural
a) 89 Interviews
b) Semistructured
c) Not stated
d) Audiotaped
e) 30–50 Minutes
a) Poor
b) Q, T
c) Not stated
d) Ethnograph
Cessation
Other drugs
Peer influences
Reasons
11. Booth-Butterfield,
Anderson, and
Williams (2000)
USA
Not stated
Qualitative
Adolescents
a) Several public, middle
& high schools
b) Students
c) Convenience
female & male
b) Not stated
c) Mostly White
d) Partial
e) None
a) 13 Focus groups
c) Interviewer’s gender
matched group in most
cases
d) Audiotaped
e) ≈1 Hour
a) Very good
b) C, Q
c) Yes: over 80%
agreement
d) QSR NUD*IST
School policies
12. Brown and
D’Emidio-Caston
(1995)
USA, California
1993 (students)
Qualitative &
quantitative
Adolescents,
educators &
administrators
a) 23 Elementary, middle
or high schools
b) Grade 5–12 students at
risk of substance abuse
or thriving
c) Purposive
a) n ≈ 240; female &
male
b) Not stated
c) Not stated
d) None
e) Academic
achievement,
commitment to
school, leadership at
school
a) 40 Focus groups
b) Semi-structured guide
c) Not stated
d) Audiotaped
e) 30–60 Minutes
a) Very good
b) Q, T
c) Yes
d) Not stated
Other drugs
Prevention methods
Program evaluation
School policies
1280

13. Brown, D’Emidio-
Caston, and Pollard
(1997)
USA, California
1993 (students)
See study 12 See study 12 a–d) See study 12
e) None
a–e) See study 12 a–d) See study 12 Other drugs
Program evaluation
School policies
14. Canto et al. (1998)
USA, Washington,
DC
Not stated
Qualitative &
quantitative
Adolescents
a) A youth agency
b) Latino youth
c) Purposive
a) n= 52; 44% female
b) 10–21 Years
c) Latino
d) None
e) None
a) 6 Focus groups
b) Discussion guide
c) Spanish-speaking
moderator
e) Not stated
a) Poor
b) T
c) Yes
d) Not stated
Access/sales issues
Health risks
Reasons
15. Crawford and
Tobacco Control
Network Writing
Group (2001)
USA, 11 states
1996
Qualitative
Adolescents
a) Schools, teen
community centers,
recruiting agency
b) Adolescents
c) Convenience
a) n= 1175; 54% female
b) 11–19 Years
c) 31.5% African
American, 16.9%
Hispanic, 19.6%
American Indian,
28.6% White, 3.4%
Asian/Pacific
Islander
d) Full
e) Urban & rural
a) 178 Focus groups
b) Discussion guide
c) Most moderators
matched by gender &
ethnicity
d) Audiotaped or
videotaped
e) 40–90 Minutes
a) Very good
b) C, Q
c) Yes
d) QSR NUD*IST
Health risks
Marketing
Peer influences
School policies
Sources of messages
16. Crawford, Balch,
Mermelstein, and
Tobacco Control
Network Writing
Group (2002)
USA, 13 sites
1998
Qualitative &
quantitative
Adolescents
a) High schools,
community centers,
market research firm
b) Current smokers or
experimenters
c) Purposive
a) n= 785; female &
male
b) 12–19 Years
c) White, African
American, American
Indian, Asian
American/Pacific
Islander, Hispanic
d) Full
e) Urban, suburban &
rural, socioeconomic
level
a) 129 Focus groups
b) Discussion guide
c) Moderators typically
matched by gender &
ethnicity
d) Audiotaped
e) ≈1 Hour
a) Very good
b) C, Q, T
c) Yes
d) QSR NUD*IST
Access/sales issues
Health risks
Prevention methods
1281

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
17. Deering et al.
(1993)
USA, Washington,
DC;
Chicago; Houston;
Los Angeles;
Maryland
1990–1991
Qualitative
Adolescents,
parents &
grandparents
a) Via leaders of
community based
organizations
b) Youth engaging in
high-risk health
behaviors
c) Purposive
a) n= 160; female &
male
b) 10–18 Years
c) African American,
White, Hispanic and
American Indian
d) None
e) Public assistance,
single parent
households, truants,
drop outs, gang
membership, alcohol
abuse, drug use,
arrest records, family
high-risk behavior,
urban & rural
a) 24 Focus groups
b) Discussion guide
c) Community leaders
recruited and led
groups, moderators
matched by sex &
ethnicity to extent
possible
d) Audiotaped
e) Not stated
a) Absent
b) C, Q
c) Not stated
d) Not stated
Health risks
Other drugs
Program development
Sources of messages
18. D’Emidio-Caston and
Brown (1998)
USA, California
1993–1994
Qualitative
Adolescents
See study 12 a–e) See study 12 a–d) See study 12
e) Not stated
a) Good
b) Q
c) Not stated
d) Not stated
Other drugs
Program evaluation
Reasons
School policies
1282

19. Denscombe
(2001a)
UK, Leicestershire,
Rutland
1997
Qualitative &
quantitative
Adolescents
a) FG: 11 schools I: 5
schools
b) Year 11 students
c) Purposive
a & b) FG: n= 123;
female & male;
15–16 years I: n =
20; 50% female; not
stated
c) White, South Asian
d) Partial
e) Urban, suburban,
rural
a) 20 Focus groups & 10
interviews (gender
pairs)
b) Not stated
c) Interviewer matched by
sex
d) Audiotaped
e) FG: ≈1 hour I: 40–75
minutes
a) Poor
b) C, M, Q, T
c) Not stated
d) Not stated
Health risks
Other drugs
20. Denscombe (2001b)
UK, Leicester,
Leicestershire,
Rutland
1997–1998
Qualitative &
quantitative
Adolescents
a) FG: 11 schools
I: 5 schools
b) Students
c) Purposive
a & b) FG: n= 123;
female & male;
15–16 years I: n =
20; 50% female; not
stated
c) White, South Asian
d) Partial
rural
a) 20 Focus groups & 10
interviews (gender
pairs)
b) FG: agenda of items I:
semi-structured
c) Student data stimulated
discussion, interview
moderator matched by
gender
d) Audiotaped
e) FG: ≈1 hour I: 40–75
minutes
a) Very good
b) C, M, Q, T
c) Not stated
d) Not stated
Peer influences
21. DiFranza and
Coleman (2001)
USA, Massachusetts
Not stated
Qualitative &
quantitative
Adolescents
a) 10 Communities
b) Smokers
c) Convenience
b) 12–19 Years
c) Not stated
d) Full
e) Urban
a) 10 Focus groups
c) Not stated
e) Not stated
a) Poor
b) C, Q, T
c) Not stated
d) Not stated
Access/sales issues
1283

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
22. Dunn and Johnson
(2001)
Canada
Not stated
Qualitative
Adolescents
a) Via ministers, parents,
youth workers, initial
participants
b) Non-smokers
c) Purposive
a) n= 17 females
b) 13–17 Years
c) white
d) Full
e) Friends’smoking,
middle to
upper-class,
suburban, two-parent
household
a) 17 Interviews
c) Not stated
d) Audiotaped
e) 30–45 Minutes
a) Very good
b) C, M, Q
c) Not stated
d) Not stated
Health risks
Image issues
Peer influences
Reasons
23. Fergus, Rowe, and
McAllister (2002)
Australia, southeast
Queensland
Not stated
Qualitative
Adolescents
a) A state high school
b) Student smokers
c) Purposive
a) n= 5; 60% female
b) 15–17 Years
c) Not stated
d) Partial
e) Urban
a) 5 Interviews &
observation
b) Semi-structured
c) Not stated
d) I: Not stated O: Notes
e) Not stated
a) Absent
b) C, Q, T
c) Not stated
d) Not stated
Cessation
Health risks
Peer influences
Reasons
School policies
24. Frohlich et al.
(2002) Canada,
Quebec
1999
Qualitative &
quantitative
Adolescents
a) Schools
b) Experimental smokers
& never smokers
c) Purposive
a) n= 48; female &
male
b) Not stated
c) Not stated
d) Partial
e) Urban, suburban,
remote
a) 8 Focus groups
c) Not stated
d) Audiotaped
e) 35–75 Minutes
a) Very good
b) C, Q, T
c) Not stated
d) Not stated
Access/sales issues
Image issues
Other drugs
Peer influences
Reasons
School policies
1284

25. Gittelsohn et al.
(1999)
USA, Maryland
(Baltimore), Texas
(Houston), Alabama,
New Mexico
1996
Qualitative
Adolescents
a) Local high schools,
recreation centers,
other community
locales
b) Grades 7–12
adolescents
c) Convenience
a) n= 121; 51% female
b) 13–19 Years
c) 34% African
American, 30%
White, 21%
Hispanic, 15%
American Indian
d) Full
e) Urban & rural, tribes
a) 121 Interviews
c) Interviewers matched
by gender & usually
by ethnicity
d) Audiotaped
e) Not stated
a) Very good
b) C, Q
c) Yes
d) QSR NUD*IST
Brand preferences
Health risks
Marketing
26. Gittelsohn et al.
(2001)
USA, Baltimore City
1996
Qualitative
Adolescents
a) I: Recreation & youth
centers
FG: High school,
youth centre
b) Teenagers
c) Convenience
a–c) I: n= 21; 67%
57% African
American, 43%
White FG: n = 125;
46% female; 13–18
years; African
American, White
d) Full
e) I: none FG:
household smoking,
single-parent
household
a) 21 Interviews & 18
focus groups
b) I & FG: Discussion
guides
c) Interviewers matched
by gender & ethnicity
in most cases
d) Audiotaped
e) I: 1.5 hours FG: not
stated
a) Very good
b) C, Q, T
c) Yes
d) QSR NUD*IST
Access/sales issues
Other drugs
Peer influences
Reasons
School policies
27. Gray, Amos, and
Currie (1996)
UK, Scotland
1993
Qualitative
Adolescents
a) 6 Schools
b) Year 1 & 4 secondary
school students
c) Convenience
female & male
b) 12–13 & 15–16 Years
c) Not stated
d) None
e) None
a) 20 Focus groups
b) Visual materials
c) Not stated
e) 1–1.5 Hours
a) Poor
b) C, Q
c) Not stated
d) Not stated
Image issues
Marketing
1285

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
28. Hastings, Ryan, Teer,
and MacKintosh
(1994)
UK, Glasgow
1993
Qualitative &
quantitative
Adolescents, adults
a) Via door to door
canvassing
b) Youth & adults
c) Purposive
a) n= 117 (includes
adults); female &
male
b) 10–15, 18–24, 35–55
Years
c) Not stated
d) None
e) Socioeconomic group
a) 18 Focus groups
(includes adults)
b) Audiovisuals
c) 5 Hours allotted to
relax youth
d) Audiotaped
e) ≈5 Hours for youth
a) Absent
b) C, Q, T
c) Not stated
d) Not stated
Brand preferences
Image issues
Marketing
Peer influences
29. Hawkins and Hane
(2001)
USA
Not stated
Qualitative
Adolescents
a) An area middle school
b) Students
c) Convenience
a) n= 28 females
b) 12–13 Years
c) 61% Caucasian, 39%
of color
d) None
e) Urban
a) 4 Focus groups
b) Discussion guide &
visuals
c) Not stated
d) Audiotaped
e) 60–75 Minutes
a) Poor
b) Q
c) Yes
d) Not stated
Image issues
Marketing
30. Heimann-Ratain,
Hanson, and Peregoy
(1985)
USA, Maryland
1982
Qualitative &
quantitative
Adolescents
a) Public schools & Girl
Scouts
b) 6th graders
c) Convenience
a) n= 64; female &
male
b) ≈11 Years
c) Black & White
d) None
e) Urban & rural,
socioeconomic status
a) 8 Focus groups,
role-plays
b) Visual materials
c) Moderators matched by
Black or White
d) Not stated
e) 1–1.5 Hours
a) Absent
b) Q
c) Not stated
d) Not stated
Health risks
Peer influences
Program development
31. Jackson et al.
(1995)
USA, Craven County
Not stated
Qualitative
Adolescents
a) 4 Middle & 3 high
schools
b) Grade 8 & 9 students
c) Convenience
b) 11–17 Years
c) 53% White, 37%
Black, 10% Hispanic
or Asian
d) Full
e) Friends’ smoking
a) 7 Focus groups
c) Student facilitators
e) Not stated
a) Poor
b) C, Q
c) Not stated
d) Not stated
Access/sales issues
Cessation
ETS
Health risks
Marketing
Prevention methods
Reasons
School policies
1286

32. Kegler et al.
(1999)
USA, Oklahoma
1996
Qualitative
Adolescents
a) Public schools, summer
job programs
c) Purposive
a) n= 119; 51% female
b) 13–17 Years
c) American Indian
d) Full
e) Tribal background,
smokers in home,
urban & rural
a) 16 Focus groups
b) Discussion guide
c) Not stated
d) Audiotaped &
videotaped
e) ≈90 Minutes
a) Very good
b) C, Q
c) Yes
d) NUD*IST
Access/sales issues
Health risks
Image issues
Peer influences
Reasons
33. Kegler, Cleaver, and
Kingsley (2000)
USA, Oklahoma
Not stated
Qualitative
Adolescents
a) Schools, summer job
programs
b) Middle school students
c) Purposive
a) n= 144; 50.7%
female
b) 11–17 Years
c) American Indian
d) None
e) Tribal background
a) 20 Focus groups
b) Discussion guide
gender & ethnicity in
90% of groups
d) Audiotaped
e) 90 Minutes
a) Good
b) Q
c) Yes
d) NUD*IST
Access/sales issues
Peer influences
Reasons
34. Kegler, Cleaver, and
Yazzie-Valencia
(2000)
USA, Oklahoma
1996–1997
Qualitative
Adolescents
a) Public schools, summer
job programs
b) Grade 6–11 students
c) Purposive
a–c) As above
d) Full
e) Tribal background,
live in Indian
community, smokers
in home, urban &
rural
a–b) As above
c) Not stated
d–e) As above
a) Very good
b) C, Q
c–d) As above
Access/sales issues
ETS
Reasons
35. Kegler et al.
(2002)
USA, 6 sites
1996–1997
Qualitative
Adolescents
a) Middle & high schools,
community based
organizations &
churches
c) Convenience
a) n= 889; female &
male
b) Not stated
American Indian,
Hispanic,
Asian/Pacific
Islander, White
d) Partial
e) Urban & rural, tribal
background
a) 132 Focus groups
gender & ethnicity in
most cases
d) Audiotaped
e) 40–90 Minutes
a) Very good
b) C, Q
c) Not stated
d) NUD*IST
Access/sales issues
Health risks
Reasons
1287

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
36. Lawson (1994)
USA
Not stated
Qualitative
Adolescents
a) Public health center
b) Pregnant smokers
c) Purposive
a) n= 20 females
b) 16–18 Years
c) 70% White, 30%
African American
d) Full
e) Education, marital
status, religious
affiliation, times
quit, age of smoking
initiation, cigarette
brand preference
a) 20 Interviews &
observation
b) Structured guide
c) Data collected over 2
years
d) Audiotaped
e) I: 1–2 hours O: over 1
year
a) Absent
b) Q
c) Not stated
d) Not stated
Cessation
Image issues
Other drugs
Pregnancy
Reasons
37. Lloyd, Lucas, and
Fernbach (1997)
UK, East Sussex
Not stated
Qualitative &
quantitative
Adolescents
a) 4 Secondary schools
b) Year 7 & 9 students
female
b) Not stated
c) Not stated
d) None
e) None
a) 32 Focus groups
b) Not stated
c) Not stated
d) Audiotaped
e) Not stated
a) Poor
b) T
c) Not stated
d) NUD*IST
Image issues
Reasons
38. Lotecka and
Lassleben (1981)
USA, San Diego
County
Not stated
Qualitative &
quantitative
Adolescents
a) 3 High schools
b) I: Grade 9–12 students;
FG: Student smokers
a) Estimates: FG: n=
33; I: n= 97; female
& male
b) Not stated
c) Not stated
d) Full
e) None
a) Focus group/s (no.
unclear) & 97
interviews
c) Mutual respect,
“hanging out” with
participants
e) Not stated
a) Poor
b) C, Q, T
c) Uncertain
d) Not stated
Cessation
Image issues
Peer influences
Reasons
1288

39. Lovato et al. (1994)
USA, San Diego
County
Not stated
Qualitative &
quantitative
Adolescents,
parents, counselors
a) Migrant education
program
b) High school students
c) Purposive
a) n= 20; not stated
b) 14–17 Years
c) Hispanic
d) None
e) None
a) 2 Focus groups
b) Not stated
c) Hispanic bilingual
moderators &
notetakers
e) ≈1.5 Hours
a) Absent
b) T
c) Yes
d) Not stated
Program development
40. Lucas and Lloyd
(1999)
UK, East Sussex
Not stated
Qualitative &
quantitative
Adolescents
a) Secondary schools
female
b) Almost 14 years
c) Not stated
d) Full
e) None
a) 13 Focus groups
b) Not stated
c) Not stated
d) Audiotaped
e) Not stated
a) Poor
b) Q, T
c) Yes. Interrater
reliability: 85% to
almost 100%
d) NUD*IST
Image issues
Peer influences
Reasons
41. Luke et al. (2001)
USA, 8 sites
1996
Qualitative
Adolescents
a) Schools, community
organizations,
commercial
establishments
b) Teenagers
c) Convenience
a) n= 793; 53% female
b) 11–19 Years
c) 36% African
American, 26%
White, 16%
Hispanic, 16%
American Indian,
6% Asian/Pacific
Islander
d) Full
e) Urban & rural
a) 125 Focus groups
b) Discussion guide &
visuals
c) Not stated
d) Audiotaped or
videotaped
e) 1–2 Hours
a) Good
b) Q
c) Yes, inter-rater
agreement 90% or
greater in training
coders
d) NUD*IST
Image issues
Other drugs
Reasons
42. Malone et al. (2001)
USA, San Francisco,
Oakland
Not stated
Qualitative &
quantitative
Adolescents
a) Schools, community
centres
c) Convenience
b) 14–18 Years
c) African American
d) Partial
e) Urban
a) 6 Focus groups
c) African American &
White non-Hispanic
co-moderators
d) Audiotaped
e) Not stated
a) Very good
b) C, M, Q, T
c) Yes
d) NUD*IST
Access/sales issues
Cigar use
Health risks
Marketing
Other drugs
Prevention methods
School policies
1289

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
43. Markham,
Featherstone, Taket,
Trenchard-Mabere,
and Ross (2001)
UK, inner city
Not stated
Qualitative
Adolescents
a) 6 Schools &
1 youth club
b) Youth
c) Purposive
b) 14–15 Years
c) Bangladeshi
d) Partial
e) Inner city
a) 7 Focus groups
b) Discussion guide
c) Facilitator met
participants a day or
more prior
d) Audiotaped
e) 45 Minutes to 2 hours
a) Very good
b) C, Q
c) Not stated
d) Not stated
Cessation
Health risks
Image issues
Peer influences
Reasons
44. McCool, Cameron,
and Petrie (2001)
New Zealand,
Auckland
Not stated
Qualitative
Adolescents
a) 5 Schools
b) Students
c) Convenience
b) 12 & 13 Years
c) 14% Maori, 61%
Caucasian/European,
9% Pacific Islands,
11% Asian, 5% other
d) None
e) None
a) 10 Focus groups
b) Theme list
c) One ethnic group
conducted by
21-year-old male of
similar background
d) Audiotaped
e) 40–50 Minutes
a) Poor
b) C, Q
c) Not stated
d) Not stated
Image issues
Marketing
Reasons
45. McFeely (2001)
UK, Sheffield
Not stated
Qualitative
Adolescents,
health
professionals
a) Schools, youth clubs,
special unit for young
people excluded from
school
b) Young people
c) Convenience
not stated
b) Not stated
c) Not stated
d) None
e) None
a) 5 Focus groups
b) Broad themes
c) Not stated
d) Not stated
e) Up to 40 minutes
a) Very good
b) C, Q
c) Not stated
d) Not stated
Cessation
Peer influences
Program development
Reasons
1290

46. McKenna and
Williams (1993)
USA, FG: Chicago
& Washington I:
Nine U.S. cities
FG: 1991; I:1992
Qualitative &
quantitative
Adolescents
a) Not stated
b) Adolescents
c) Purposive
a–c) FG: not stated;
10–17 years; African
American, White I:
n = 240; female &
male; 10–15 years;
White, other
d) Partial
e) City, suburban &
rural
a) 10 focus groups & 240
interviews
b) FG: Not stated I:
Audiovisuals
c) Not stated
d) Not stated
e) Not stated
a) Absent
b) Q, T
c) Not stated
d) Not stated
Health risks
Peer influences
Program development
47. McVea et al.
(1999)
USA, Midwest
1997–1998
Qualitative
Adolescents,
administrators/
teachers, support
staff
a) A high school
b) Grades 10–12 students
c) Purposive
a) n= 64; female &
male
b) Not stated
c) Not stated
d) Partial
e) None
a) 7 Focus groups
c) School student
moderators in 6 of 7
student groups
d) Audiotaped
e) 35–75 Minutes
a) Poor
b) C, M, Q
c) Uncertain
d) Not stated
ETS
Health risks
Image issues
Marketing
Peer influences
Program development
Reasons
School policies
48. Mermelstein and
Tobacco Control
Network Writing
Group (1999)
USA, 11 sites
1996
Qualitative
Adolescents
a) Professional marketing,
youth organizations,
community-based,
schools
b) Adolescents
c) Convenience
a) n= 1175; 54% female
b) 11–19 Years
White, Native
American, Hispanic,
Asian/Pacific
Islander
d) Full
rural
a) 178 Focus groups
b) Discussion guide
c) Moderators matched
gender & ethnicity of
almost all groups
d) Audiotaped or
videotaped
e) 40–90 Minutes
a) Very good
b) C, Q
c) Yes
d) QSR NUD*IST
Image issues
Peer influences
Reasons
Sources of messages
1291

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
49. Michell and Amos
(1997)
UK, Scotland
1995
Qualitative &
quantitative
Adolescents
a) 1 Secondary & 1
primary school
b) Final primary year &
second secondary year
students
a) n= 76; female &
male
b) 11 & 13 Years
c) Not stated
d) None
e) Secondary-
unstreamed
classes
a) Focus groups & 76
interviews
b) Topic guide
c) Researcher spent one
term at schools.
Introduced as
interested in teenage
lifestyles
d) Audiotaped
e) FG: average 45 minutes
I: Not stated
a) Absent
b) C, Q, T
c) Not stated
d) Not stated
Image issues
Peer influences
Reasons
50. Michell (1997a)
UK, Scotland
1995
Qualitative
Adolescents
As above a–e) As above a) 21 Focus groups & 76
interviews
b–d) As above
e) FG: as above I: 20 to
over 60 minutes
a–d) As above Image issues
Other drugs
Peer influences
Reasons
51. Michell (1997b)
UK, Scotland
1995
As above As above a) n= 76; 50% female
b–e) As above
a–e) As above a–d) As above As above
1292

52. Michell and West
(1996)
UK, Scotland
1994
Qualitative &
quantitative
Adolescents
a) A secondary school
b) 1st & 3rd year
secondary school
students
a) n= 45; female &
male
b) 12 & 14 Years
c) Not stated
d) Partial
e) None
a) Role-plays & focus
groups
b) RP: Developed scene
FG: Role-plays
starting point
c) Introduced as interested
in teenage lifestyles,
worked with students
for 2 weeks prior
d) RP: Videotaped FG:
Audiotaped
e) Not stated
a) Absent
b) C, Q, T
c) Not stated
d) Not stated
Peer influences
Reasons
53. Moffat and Johnson
(2001)
Not stated
Not stated
Qualitative
Adolescents
a) Via flyers
b) Recent smokers
c) Convenience
a) n= 12 females
b) 14–17 Years
c) Not stated
d) Partial
e) None
a) 12 Interviews
b) Narrative inquiry
c) Participant chose
setting, researcher
disclosure
d) Audiotaped
e) ≈1 Hour
a) Very good
b) M, Q
c) Not stated
d) Not stated
Access/sales issues
Cessation
Image issues
Peer influences
Reasons
54. Murphy (2000)
USA, Utah
Not stated
Qualitative &
quantitative
Adolescents
a) Not stated
b) Youth
c) Convenience
a) Not stated
b) 9–17 Years
c) Not stated
d) Partial
e) Urban & rural, at-risk
& low-risk youth
a) 8 Focus groups
b) Audiovisual materials
c) Not stated
d) Not stated
e) Not stated
a) Absent
b) Q, T
c) Not stated
d) Not stated
Program development
55. Nash (1987)
UK, London
Not stated
Qualitative
Adolescents
a) A secondary school
b) Year 4–5 smokers
c) Purposive
b) 14–16 Years
c) Not stated
d) Partial
e) None
a) 7 Interviews &
observation
b) Unstructured
interviews, structured
observation
c) Not stated
d) I: audiotaped O:
videotaped & diaries
e) I: 30 minutes to 2 hours
O: during 6 months
a) Absent
b) Q, T
c) Not stated
d) Not stated
Image issues
Peer influences
Reasons
School policies
1293

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
56. Nichter et al. (1997)
USA, Tucson
Not stated
Qualitative &
quantitative
Adolescents
a) 2 Junior high & 2 high
schools
b) I: 10th & 11th graders
FG: Student smokers
a) I: n= 205 females
FG: n = 60 females
b) Mean = 16.02 (G10)
& 16.99 (G11) years
c) 68% White; 13%
Mexican American;
3% Asian American;
3% Native
American; 13%
unknown
d) Full
e) Parents’ education,
urban & suburban
focus groups
b) I: Semistructured FG:
Not stated
c) Trained ethnographic
interviewers
d) Audiotaped
e) I: ≈1 hour FG: Not
stated
a) Very good
b) Q, T
c) Uncertain
d) Not stated
Brand preferences
Health risks
Image issues
Other drugs
Peer influences
Reasons
57. Oakley, Brannen, and
Dodd (1992)
UK, West London
Not stated
Qualitative &
quantitative
Adolescents
a) 6 Secondary schools
b) Students in last
compulsory year
c) Random
a) n≈ 64; female &
male
b) 15–17 Years
c) Not stated
d) None
e) None
a) 64 Approached for
interviews
b) Not stated
c) Not stated
d) Not stated
e) Not stated
a) Absent
b) Q, T
c) Not stated
d) Not stated
Access/sales issues
ETS
Health risks
Other drugs
Peer influences
Reasons
58. O’Loughlin,
Kishchuk, DiFranza,
Tremblay, and Paradis
(2002)
Canada, Montreal
Not stated
Qualitative
Adolescents
a) 3 High schools
b) Student smokers
c) Purposive
b) 14–17 Years
c) Anglophone,
Francophone, ethnic
minorities
d) Partial
e) Language, urban &
suburban
a) 6 Focus groups
b) Semistructured guide
c) Bilingual moderator
d) Audiotaped
e) 40–60 Minutes
a) Very good
b) C, Q
c) Not stated
d) Not stated
Access/sales issues
Cessation
Peer influences
Reasons
1294

59. Parker, Sussman,
Crippens, Scholl,
and Elder (1996)
USA, Los Angeles
Not stated
Qualitative &
quantitative
Adolescents
a) 3 Junior high schools
b) 7th graders
a) n= 211; 52% female
b) Mean = 12.6 years
c) 46% African
American; 42%
Latino; 12% other
d) Partial
e) Family & friend
smoking, urban
a) 10 Focus groups
c) African American
female facilitators
d) Audiotaped
e) 45 Minutes
a) Poor
b) Q
c) Yes. Inter-rater
agreements = 0.81 &
0.80
d) Not stated
Prevention methods
Reasons
60. Pavis,
Cunningham-Burley,
and Amos (1996)
UK, Scotland
1995
Qualitative &
quantitative
Adolescents
schools
b) Secondary (S4)
students
a) n= 106; 46% female
b) 15 Years
c) Not stated
d) Full
e) Academic
attainment, daytime
occupations, close
friends’ smoking,
educational
aspirations, rural &
urban, income,
leaving patterns
a) 106 Interviews
b) Semistructured
c) Not stated
d) Audiotaped
e) 20–50 Minutes
a) Poor
b) C, Q, T
c) Not stated
d) Ethnograph
Peer influences
Reasons
61. Pavis, Cunningham-
Burley, and Amos
(1998)
UK, Scotland
1995
Qualitative &
quantitative
Adolescents
schools
b) Initially secondary (S4)
students
b) 16–17 Years
c) Not stated
d) Full
e) Academic
attainment, daytime
occupations, rural &
urban, income,
leaving patterns
a) 98 Interviews
b) Semistructured
c) Interviewers gender
matched. Non-home
interviews requested
by some in second
round of interviews
d) Audiotaped
e) 20–50 Minutes
a) Poor
b) Q, T
c) Not stated
d) Ethnograph
Brand preferences
Other drugs
Peer influences
Reasons
1295

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
62. Peracchio and Luna
(1998)
USA, Midwest
Not stated
Qualitative
Adolescents
a) 1: A large public high
school 2: A large
public grammar school
b) 1: High school students
2: Grade school
students
c) Convenience
a) 1: n= 106; 55%
female
b) 15–18 Years
c) 25% of color
d) Partial
e) Urban & suburban
a) 2: n = 104; 52%
female
b) 7–11 Years
c) Not stated
d) None
e) Household smoking
a) 1: 20 Focus groups 2:
16 Focus groups
b) 1: Discussion guide 2:
Audiovisuals
c) College student
moderators in
congenial settings,
moderator matched by
gender
e) 1: ≈50 Minutes 2: ≈40
Minutes
a) Poor
b) C, Q
c) Uncertain
d) Not stated
Health risks
Peer influences
Prevention methods
Program development
Reasons
63. Plumridge, Fitzgerald,
and Abel (2002)
New Zealand
1999
Qualitative
Adolescents
a) A Secondary school
b) Year 10 non-smokers
c) Random
a) n≈ 20; ≈55% female
b) 14 & 15 Years
c) Not stated
d) Partial
e) urban
a) 6 Focus groups
b) Theme list
c) Not stated
d) Audiotaped
e) Not stated
a) Poor
b) Q
c) Uncertain
d) Ethnograph
Image issues
Peer influences
Reasons
64. Rissel, McLellan, and
Bauman (2000)
Australia, Sydney
1998
Qualitative &
quantitative
Adolescents,
health workers
a) High schools
c) Purposive
a) n= 65; female &
male
b) Mean = 15.6 (Y10)
& 16.5 (Y11) years
c) Predominantly
Vietnamese &
Arabic
d) None
e) None
a) 5 Focus groups
b) Discussion guide
c) Multilingual consent
letters
d) Not stated
e) Not stated
a) Absent
b) T
c) Not stated
d) Not stated
Image issues
School policies
1296

65. Rissel, McLellan,
Bauman, and Tang
(2001)
Australia, Sydney
1998
Qualitative
Adolescents,
health workers
a) 3 High schools
b–c) As above
b) 15–17 Years
c–e) As above
a–c) As above
d) Audiotaped
e) 40–60 Minutes
a) Poor
b) Q
c) Yes
d) Not stated
Image issues
Peer influences
Reasons
School policies
66. Rugkasa, Knox, et al.
(2001)
UK, Northern Ireland
Not stated
Qualitative
Adolescents
a) I: 18 Youth clubs
FG: Via market
research company
b) Youth
c) Convenience
a & b) I: n= 85; 52%
female; 10 & 11
years FG: n = 18;
56% female; 16
years
c) Not stated
d) Partial
e) I: Single parent,
parental
unemployment,
family smoking,
urban
focus groups
b) I: Topic guide
c) Attempt to establish
prior friendly relations
d) I: Audiotaped
e) I: 20 to over 60 minutes
b, d–e) FG: Not stated
a) Poor
b) C, Q, T
c) I: Yes FG: Uncertain
d) I: NUD*IST FG: Not
stated
Health risks
Image issues
Peer influences
Reasons
67. Rugkasa, Kennedy,
et al. (2001)
UK, Northern Ireland
Not stated
Qualitative
Adolescents
a) 18 Youth clubs
b) Youth
c) Convenience
b) 10 & 11 Years
c) Not stated
d) Partial
e) Urban & rural
a) 85 Interviews
b) Topic guide
c) Not stated
d) Audiotaped
e) 20–60 Minutes
a) Poor
b) C, Q
c) Not stated
d) NUD*IST
Health risks
Image issues
Peer influences
Reasons
68. Seguire and Chalmers
(2000a)
Canada, western city
Not stated
Qualitative &
quantitative
Adolescents
a) 6 High schools
b) Current or former
smokers
c) Purposive
a) n= 25 females
b) 17–19 Years
c) Not stated
d) Full
e) Levels of addiction,
family smoking
a) 25 Interviews
b) Semistructured guide
c) Not stated
d) Audiotaped
e) 30–40 Minutes
a) Very good
b) C, M, Q, T
c) Yes
d) Not stated
Cessation
ETS
Image issues
Peer influences
Pregnancy
Reasons
1297

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
69. Seguire and Chalmers
(2000b)
Canada, western city
Not stated
Qualitative
Adolescents
a–c) As above a) As above
b) 18–19 Years
c) Not stated
d) Partial
e) None
a–d) As above
e) Not stated
a) As above
b) C, Q
c–d) As above
Cessation
Health risks
Image issues
Peer influences
Reasons
70. Spigner and
Gran-O’Donnell
(2001)
USA, Seattle,
Washington
1995–1999
(different years
specified in abstract,
title & introduction)
Qualitative
Adolescents
a) Via informal networks
of community leaders
b) Youth
c) Convenience
a) n= 190; 49% female
b) 12–19 Years
c) 25% Samoan, 9%
Mien, 18%
Vietnamese, 15%
Filipino, 8% Laotian,
8% Chinese, 17%
Cambodian
d) Partial
e) English-speaking,
working class
a) 26 Focus groups
(includes 1 interview)
b) Not stated
c) Facilitators matched by
gender & as much as
possible ethnicity.
Partnership with
cultural groups.
d) Audiotaped
e) 45–60 Minutes
a) Poor
b) Q
c) Yes
d) QSR NUD*IST
Access/sales issues
Image issues
Marketing
Prevention methods
71. Stewart et al.
(1998)
Australia,
Geelong & China,
Beijing
1998
Qualitative
Adolescents
a) Personal &
professional contacts
of authors
b) Young women
c) Convenience
a) n= 16 females
b) 12 & 13 Years
c) 50% Australian, 50%
Chinese
d) None
e) None
a) 4 On-line & 2
face-to-face focus
groups
b) Smoking scenario
c) Not stated
d) FF: Audiotaped OL:
Word file
e) FF: ≈1.5 Hours OL:
Almost 2 hours
a) Absent
b) C, Q, T
c) Not stated
d) Not stated
Cessation
Health risks
Image issues
Marketing
Peer influences
Reasons
1298

72. Stoltz and Sanders
(2000)
USA
Not stated
Qualitative &
quantitative
Adolescents
a) 2 Middle, 2 high & 1
continuation high
schools
c) Purposive
a) n= 47; female &
male
b) Not stated
c) Not stated
d) None
e) None
a) 5 Focus groups
b) Conceptual mapping &
laddering
c) High school student
assistant leader in 4 of
5 groups
d) Not stated
e) Not stated
a) Poor
b) Q, T
c) Not stated
d) Not stated
Cigar use
Other drugs
Reasons
73. Swart (1998)
South Africa
Not stated
Qualitative
Adolescents
a) Not stated
b) Standard 7 student
smokers
c) Purposive
b) 14–16 Years
c) Not stated
d) Partial
e) None
a) 1 Focus group
b) Semi-structured
c) Mutually agreed venue
d) Audiotaped
e) ≈70 Minutes
a) Poor
b) Q
c) Not stated
d) Not stated
Access/sales issues
Cessation
Health risks
Peer influences
Reasons
School policies
74. Taylor et al. (1999)
USA, Southwest
Not stated
Qualitative
Adolescents
a) A middle school
b) 10–15 Years
c) 57% African
American, 25%
Hispanic, 13%
European American,
5% other
d) Partial
e) Urban
a) 63 Interviews
c) Not stated
d) Audiotaped
e) Not stated
a) Good
b) Q
c) Yes
d) Not stated
Health risks
Image issues
Peer influences
Reasons
Sources of messages
75. Tingen, Gramling,
Bennett, Gibson, and
Renew (1997)
Not stated
1996
Qualitative
Adolescents
a–b) Children of
professional health
care workers in a
university setting
c) Claimed “purposive”
but no reason given for
selecting children of
university health care
workers
b) 10 & 11 Years
c) 33.3% African
American, 8.3%
Asian, 41.7%
Caucasian, 16.7%
Hispanic
d) Partial
e) None
a) 3 Focus groups
c) Not stated
d) Audiotaped &
participant journal
e) ≈30 Minutes
a) Poor
b) M, Q
c) Not stated
d) Ethnograph
Health risks
Program evaluation
1299

Table 3
Study number
Author (year of
publication)
Location
a) Setting
b) Sample
c) Sample selection
b) Age
c) Ethnicity
d) Smoking status
e) Other variables
d) Recorded
e) Duration
of analysis
76. Wakefield, Reid,
Roberts, and Mullins
(1998)
Australia, Adelaide
Not stated
Qualitative
Adolescents
a) A public hospital
antenatal clinic
b) Pregnant smokers
c) Purposive
a) n= 14 females
b) 15–19 Years
c) Australian born
d) Partial
e) Family/partner
smoking, financial
status
a) 2 Focus groups
b) Not stated
c) Not stated
d) Not stated
e) Not stated
a) Absent
b) None
c) Not stated
d) Not stated
Cessation
Peer influences
Pregnancy
Reasons
77. Way et al. (1994)
USA, Greater Boston
Not stated
Qualitative &
quantitative
Adolescents
a) 2 High schools
c) Purposive—all students
in top 10% of
Children’s Depression
Inventory from
randomly selected
group
b) Not stated
c) 53% White, 21%
African American,
16% Puerto Rican,
11% Haitian
d) Partial
e) Urban & suburban
a) 19 Interviews
c) Not stated
d) Not stated
e) Not stated
a) Very good
b) C, Q, T
c) Yes
d) Not stated
Other drugs
Peer influences
Reasons
78. Yerger, Pearson, and
Malone (2001)
USA, San Francisco
1999
Qualitative
Adolescents
a) Schools & community
centres
b) Adolescents
c) Convenience
b) 14–18 Years
c) African American
d) Partial
e) Urban
a) 6 Focus groups
b) Not stated
c) Not stated
d) Audiotaped
e) 2 Hours
a) Poor
b) Q
c) Not stated
d) Qualitative software
Cigar use
Other drugs
NA: Not available.
I = interviews; FG = focus groups; FF = face-to-face focus groups; OL = on-line focus groups; O = observation; RP = role-plays.
C = contradictory findings sought and/or discussed; M = member checking; Q = quotes; T = triangulation.
1300

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Table 4
Adolescent tobacco-related content areas: Number of publications
presenting qualitative data on each content area
Number (percentage) of
Adolescent tobacco-related publications presenting
content area qualitative data on area
Reasons 52a
(67)
Peer influences 48 (62)
Family/cultural aspects 43 (55)
Image issues 38 (49)
Health risks 30 (38)
Other drugs 20 (26)
Access/sales issues 19 (24)
Dependence/addiction 19 (24)
Cessation 16 (21)
Marketing/media/movies 15 (19)
School policies 15 (19)
Program development 9 (12)
Prevention methods 8 (10)
Brand preferences 6 (8)
Environmental tobacco smoke 6 (8)
Program evaluation 5 (6)
Sources of messages 4 (5)
Cigar use 3 (4)
Pregnancy 3 (4)
a
Includes 11 with only female subjects.
Peer Influences
The peer influences category was subdivided into three subareas for the synthesis: peer
influence on smoking initiation and maintenance, processes of peer influence, and peer
influence on smoking cessation. These syntheses are presented below.
Peer Influence on Smoking Initiation and Maintenance. Several studies reported that peers
encouraged smoking initiation among adolescents (5, 6, 7, 24, 33, 48, 73). In a U.S. study
of 11- to 19-year-olds, peer support for starting to smoke was more frequently reported by
Hispanic and White adolescents than for other ethnicities (15).
Many of these studies reported that adolescents primarily experienced smoking as a
social and group activity carried out with their smoking peers (3, 5, 6, 10, 23, 32, 33, 43,
47, 48, 55, 57, 58, 60, 61, 62, 66, 68, 69). Adolescents in U.S., UK, and Canadian studies
indicated that smoking provides a common activity through which they can bond with peers
as well as “break the ice” in new social situations (43, 47, 68, 69). For instance, opening a
conversation by asking for a cigarette facilitated social interaction among a new group of
peers (43, 68, 69).
Studies also reported that smoking is influenced by adolescents’ need to gain peer
acceptance and a sense of social belonging by “fitting in” to a group of peers (2, 5, 15, 20,
22, 26, 32, 45, 46, 47, 48, 53, 56, 62, 68, 69, 71). All ethnic groups (i.e., African American,

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Hispanic, American Indian, White, Asian/Pacific Islander) in a U.S. study emphasized that
fitting in influenced adolescent smoking initiation (15), while this was important to females,
especially White females, in another U.S. study (26).
Smoking is a vehicle through which adolescents can enter and subsequently belong to a
group (69). For instance, in a Canadian study of 17- to 19-year-old females, one participant
found herself “outside of the crowd” and thought that maybe she could fit in with this group
by smoking, as “all of the popular girls smoked” and she “wanted to be accepted by them”
(68). Furthermore, the desire to find appropriate friends when moving to a new school was
stated by some adolescents as a motivating factor for smoking (53, 55, 68), while smoking
because adolescents wanted to be accepted by older, more sophisticated peers was also
mentioned (3, 26, 56, 62).
The influence of group norms on adolescent smoking was recognized by some ado-
lescents. For example, in a Canadian study of 13- to 17-year-old females, one participant
stated that “. . . some people do it [smoke] to fit in to the norm of their group because they
don’t think they’ll fit in to any other groups” (22). Furthermore a female in a U.S. study
increased the number of cigarettes she smoked a day just because her friends increased (77).
Conforming to group norms is also a feature of non-smoking peer groups (40, 62). A UK
study of adolescent females reported that never-smoking girls would react unfavorably to a
group member who started to smoke and thought the smoker would almost inevitably leave
their group to join other smokers (40). Adolescents reported that smokers and non-smokers
chose to join a particular peer group with the awareness that the friends they associated with
will impact on whether or not they smoke (7, 20, 52). Non-smokers reported sometimes
using strategies such as avoiding smokers and smoking areas as a way to prevent themselves
being exposed to smoking (22, 38, 50, 51, 52).
Researchers have highlighted the importance of peer group structure on adolescent
smoking. In the UK, students reported a hierarchical peer group structure: “top,” “middle,”
and “bottom” (49–51). “Top” girls, low-status students (mainly girls), and “troublemakers”
(mainly boys) were identified as being most likely to smoke (49–51). “Middle” students and
loners were perceived as unlikely to start smoking (49–51). A similar peer group structure
was described in a New Zealand study where adolescents reported that smoking could carry
both high and low status, with non-smokers being typically between the extremes (63).
However a small “super-cool” group of non-smokers was identified in the New Zealand
study (63).
Youth recognized that movement between friendship groups was an important factor
in adolescent smoking (20). For example, in a UK study of 14- to 15-year-old Bangladeshi
adolescents, two females reported quitting smoking because they felt out of place with
their new non-smoking friends (43). Adolescent school-leavers often find themselves in
new social settings (e.g., work, college) where they meet new people (10, 61). In a UK
study, many respondents reported that changes in their friendship networks and/or social
activities influenced changes in their smoking behavior (61). For instance, one participant
recommenced smoking because “Just with working and people at my work and that. There
is not anybody that does not smoke and just being in the staff-room and just sitting beside
smokers” (61).
Processes of Peer Influence. The term peer pressure is generally defined as peers plac-
ing direct coercive pressure on others to smoke through bullying, teasing, and threats. In
17 studies, adolescents mentioned the notion that teenage smokers directly coerced their
non-smokingpeersintosmoking(2,3,15,26,30,32,33,40,49–52,65,66,71,73,74). How-
ever incidents of coercive peer pressure were rarely reported in these studies. Furthermore,

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diverging adolescent views emerged within studies. For instance, in UK studies, direct peer
pressure was mentioned only by a small number of low-status students (49–51). “Top girls”
and “troublemakers,” who were also likely to smoke, did not believe their peers had pres-
sured them into smoking (49–51). Similarly, in the United States, males, but rarely females,
identified instances of coercive peer pressure (2, 26), while no Hispanic or American In-
dian adolescents explicitly mentioned peer-related coercion to smoke (2). In two studies,
students produced stereotypical scenes of peer pressure during role-plays that included bul-
lying, teasing, taunting, enticements, and rejection (30, 52). However, in subsequent focus
groups, Michell and West (1996) discovered that students had based their role-plays on
their expectation of what might happen and not on their own personal experiences of what
really happened.
In many studies, adolescents emphasized that non-smokers were not pressured into
trying a cigarette by their smoking peers, emphasizing that any offers of cigarettes were
open to rejection and individuals had a choice about their smoking behavior (2, 3, 7, 8,
15, 20, 43, 46–53, 56, 66, 67). Adolescents in several studies described social interactions
in which exposure to friends who smoked motivated them to try cigarettes (2, 24, 26, 32,
45, 56, 66). For example, in a U.S. study of grades 10–11 females, girls explained that
because their friends smoked and they were around them, they “just decided to try it.” One
participant stated, “It’s like ‘monkey see, monkey do.’ You just see your friends doing it and
you want to do it too” (56). The perception that everyone smoked tobacco was mentioned
by adolescents (32, 53, 56).
Peer Influence on Smoking Cessation. Adolescent smokers recognize that having a social
network of smoking friends makes stopping smoking difficult (3, 5, 6, 43, 47, 58, 68, 69,
76). In a UK study, one male smoker aged 14–15 years stated, “You feel unsociable once
you’ve been smoking for a while and you give up and everybody is offering you fags and
that. You feel unsociable” (3). The difficulty of quitting smoking when your friends smoke
was also reported in a U.S. study of 10th- to 12th-grade students, with one participant stating
“I got totally trying to quit. . . but its like when you get in a car and everybody’s just lightin’
one up automatically. It’s like, ya know, a mutual thing and not to mention, ya know, it’s
everywhere ya go” (47). In a U.S. study of 10- to 16-year-old adolescents, the fear of losing
friends was mentioned as a reason for continuing smoking (5). A male smoker in a UK
study who had tried unsuccessfully to stop smoking believed he would have to develop new
peer affiliations to quit smoking (43).
Although adolescents thought that the emotional support of friends and family was
important for quitting smoking (6, 68), peers were reported to encourage smokers to quit
smoking with low frequency (7, 22, 38). For example, only a few non-smokers in Australian
and Canadian studies encouraged their friends to quit smoking (7, 22). In a U.S. study of
five ethnic groups, American Indian males were most likely to report antismoking support
from peers in relation to cessation (15). There was mutual respect between non-smokers and
smokers in relation to their right to choose whether or not they smoked (20, 22). Adolescent
smokers reported smoking less when they were around friends who did not like or approve
of smoking (6).
A couple of instances of friends successfully supporting each others’ cessation attempts
were reported. One female in a U.S. study indicated that “We used to smoke in eighth grade
but we quit. We talked about it and found out that none of us really liked it, but we just
smoked ’cause everyone else did. So we all quit” (56). Similarly, in a UK study it was
reported that an influential friend decided to stop smoking and persuaded the whole group
of friends to quit together (43).

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Access/Sales Issues
Of the 19 papers that reported qualitative data on the issue of tobacco access/sales to
adolescents, only one study (21) focused exclusively on this issue. Two studies (34, 35)
concentrated on family-related aspects of tobacco access, while another study (42) examined
access to cigars.
Overall, access to tobacco products is not perceived to be difficult by adolescents
in these studies. Only three studies (14, 24, 70) reported any data that contradicted this
position to any significant extent. Focus group participants in one study (14) reported that
laws prohibiting sales to minors were strictly enforced in two of three U.S. states; however,
this finding contrasted with their quantitative data, which indicated that 81% of survey
respondents were not asked for identification when purchasing cigarettes. A Canadian
study (24) reporting on four contrasting communities noted that in one remote Quebec
township it was nearly impossible to procure cigarettes from the town’s stores. In fact, one
of the preadolescent participants was quoted as saying “. . . it’s become so hard for us to buy
cigarettes unless we’re 18, and you just can’t get any if you are under 18.” Nonetheless, the
study’s quantitative data demonstrated that 37% of preadolescents had tried smoking. In
addition, it was reported that 11- to 12-year-old participants discussed their perception that
there was a tacit understanding in the town that around the age 14–15 it was permitted for
teens to smoke. The only other finding that lent some support to the view that restricting sales
to minors is effective came from part of a quotation in one study (70) where a participant
concluded “But it [tobacco access policies] stopped a few of my friends from starting.”
However, even this quotation was presented in a context of “general cynicism” about such
policies.
Studies, especially DiFranza and Coleman (2001) and Kegler, Cleaver, and Kingsley
(2000), detailed a multiplicity of sources and strategies used by adolescents for obtaining
cigarettes even in high-enforcement localities. For example, an earlier study (31) reported
that “. . . many store owners and clerks simply do not check the age of buyers.” Later studies
(16, 21, 42) note that adolescents are adept at locating stores and clerks that will sell tobacco
products to underage purchasers. Importantly, Kegler, Cleaver, and Kingsley (2000) note
that no American Indian youth in their study spoke of buying their first cigarette. This
finding was borne out in many studies. For example, a U.S. teenage girl described regular
exposure to cigarettes in this way “I barely ask, it’s just like, ‘Do you want one?’ Okay,
why not?” (53).
A Scottish study (9) described in more detail informal networks that exist among friends
involvingthepurchaseofpopularcigarettebrands,theirsale(mostoftensingly),andsharing.
The importance of friends as a source of cigarettes was emphasized by both the qualitative
and quantitative results of DiFranza and Coleman (2001). In two Quebec communities,
Frohlich, Potvin, Chabot, and Corin (2002) emphasize the role of older adolescents in
obtaining cigarettes for younger children.
Eleven studies (2, 21, 26, 31, 33–35, 53, 57, 58, 73) that examined the role of parents
and family all identified relatives as an important source of cigarettes. Initially, access
often involves stealing cigarettes or butts from ashtrays, and later some family members
are involved in buying or providing money for cigarettes for their older children. These
cigarettes then become available to other adolescents (21). A study including results from
Hispanic youth noted the role of adolescents being asked to light cigarettes for adults in
smoking initiation (2). The same study reported that Hispanic parents and other adults were
prepared to buy cigarettes for adolescents because they saw the acquisition of smoking as
an inevitability and as the “lesser of two evils” compared with other forms of drug-taking.

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Among American Indian adolescents (34), other relatives, rather than parents, are reported
to be more involved in supplying cigarettes. Siblings and cousins were mentioned as a
common source of supply by American Indian, Hispanic, Asian/Pacific Islander, and White
youth, but not by African American youth (2, 33, 35). In one of these studies, the theme of
relatives’ open cigarette packs serving as an opportunistic source of supply emerged less
strongly for Asian/Pacific Islander groups (35).
In relation to family members as a source of cigarettes, the qualitative and quantitative
findings of one study (21) appeared to be somewhat at odds. In the survey component, most
adolescents indicated they “hardly ever” were given or stole cigarettes from parents or other
relatives. However, the focus group findings highlighted the importance of the family as a
point of access throughout adolescence. This apparent contradiction could be explained by
a number of factors: firstly, taking cigarettes from ashtrays would not be recorded as a gift
or a theft by survey respondents; secondly, it only requires a small percentage of parents
to buy cigarettes for their children, for these parents potentially to act as a supply source
for many, unrelated adolescent friends; and thirdly, the survey respondents’ mean age was
16 years (range 12–19 years) and many may have developed other strategies for acquiring
cigarettes by mid-adolescence. Finally, only three (9, 57, 73) of these access studies were
conducted outside North America, so it is unclear how much the findings can be generalized
to other parts of the world.
Dependence/Addiction Issues
There was wide variation in the degree of concentration given to the dependence/addiction
issue, ranging from studies where this area was the major focus (53, 58, 66) to others where
dependence represented a small part of the findings (22, 35, 42, 45, 47, 71). Adolescent
views about nicotine dependence appear to be mediated, at least in several studies, by age
(3, 66) and smoking status (26, 32, 46, 47, 53, 60).
In studies where the issue of dependence arose, adolescents seem to be widely aware
of the addictive nature of tobacco, specifically nicotine. In younger adolescents and in older
non-smoking adolescents, views about dependence are frequently shaped by observations
of parents, other family, and friends who exhibit symptoms, especially when trying to quit
(22, 26, 66). Two idiosyncratic beliefs were expressed: some participants in the Malone,
Yerger, and Pearson (2001) study thought nicotine was an artificial additive that was not
present in cigars, and in the Rugkasa, Knox, et al. (2001) study some 10- to 11-year-olds
thought they might become addicted because of exposure to environmental tobacco smoke
from adult smoking.
Apart from these unusual beliefs, the extent to which adolescents relate to the issue of
dependence/addiction and possess a sophisticated understanding of the concept has been
examined further. Although most adolescents perceive nicotine dependence as a potential
negative consequence of smoking, they do not necessarily see it is as personally relevant,
especially at a young age or early in their smoking career. Armstrong and Miller (2001)
reported that reasoning about addiction was generally less developed than reasoning about
other aspects of smoking. They found little evidence that understanding of this concept
increased in sophistication with age. Participants were familiar with the issue of craving
but could not explain why craving might be relevant to addiction. Craving was associated
with emotionally charged situations, partying being particularly nominated by females (38).
Scottish youth (3) spontaneously identified nicotine as a highly addictive drug; however,
particularly in their middle age group (13- to 15-year-olds), there was disagreement about
the relative roles of addiction versus habit, with non-smokers and some regular smokers

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tending to emphasize the former. Occasional smokers tended to downplay the importance of
addictive features such as loss of control. This dichotomy in beliefs about whether smoking
is an addiction or a habit was less evident in the 16- to 20-year-olds, with addiction being
more strongly endorsed. Other studies (32, 58, 60, 68, 69) have also highlighted the great
salience of the addiction issue for regular smokers. In a Scottish study (60), only regular
smokers who sometimes smoked alone reported that they “need a cigarette.”
Late adolescent females who were current or former smokers used powerful metaphors
to describe the hold they perceived nicotine had over them and their sense of powerlessness
in relation to smoking (68, 69). These perceptions were strengthened by the experience of
frequent, unsuccessful quit attempts in late adolescence.
In a Northern Irish study of 10- to 11-year-olds from economically deprived areas
(66), the investigators observed interesting differences in the degree of relevance attached
to nicotine dependence by the preadolescent participants in adult and child smokers. While
adult smokers were clearly perceived as addicted, child smokers were perceived in terms
of social relations. In this young age, addiction was largely irrelevant to their ideas about
youth smoking and to their experiences with peers. Smoking by early adolescents was seen
more as a habit that young smokers were getting used to.
It is not clear whether there are substantial gender or ethnic differences in awareness
of dependence/addiction issues. Only two U.S. studies (26, 32) provided data that sug-
gested the presence of gender differences. Kegler et al. (1999) noted that non-smoking
males did not discuss addiction as a reason for smoking and that, overall, females had
more extensive discussions about addiction; several admitted they were addicted and some
nominated addiction as the reason they were unable to quit. Gittelsohn, Roche, Alexander,
and Tassler (2001) also highlighted the importance of fear of addiction as an impetus to
quitting in African American female smokers. In that study, parental addiction emerged as
a salient influence on decisions not to smoke among all African American groups where
non-smokers were present. In contrast, White teens, including-non smokers, tended to em-
phasize the calming effects of parental smoking. Kegler et al. (2002), while noting that the
addictive nature of cigarettes was discussed by at least some groups across all ethnicities
and both genders, also noted that the issue of addiction emerged as a stronger theme among
Asian/Pacific Islander groups.
Adolescents’ views about the speed with which nicotine dependence can develop pre-
sented some valuable contrasts. Some data suggested that adolescents believe dependence
occurs quickly; for example, 11- to 12-year-olds (3) and the non-smokers and many smok-
ers aged 10–17 (46) endorsed this belief. However, another strong theme emerging in two
studies of female adolescent smokers was the unanticipated nature of addiction (53, 68).
In one of these studies (53), the participants indicated that, early in their smoking career,
they had perceived addiction as something that occurred in other people, not themselves.
This lack of anticipation of addiction relates to the earlier discussion about the greater
salience of the addiction concept for regular as opposed to experimental or occasional
smokers. There may also be a link to the finding among 10- to 11-year-olds that they
perceive an age threshold for addiction; that is, addiction is seen as largely relevant only to
adults (66).
Although nicotine dependence is largely seen as a negative feature of smoking, ado-
lescent smokers appear to balance this against the pleasurable aspects of smoking (47,
58, 69). Furthermore, there is evidence from two studies (47, 66) that features of depen-
dence/addiction itself may be viewed in a positive way by some smokers. For example,
McVea, Harter, McEntarffer, and Creswell (1999) noted different perspectives on addiction
among 10th- to 12th-grade smokers and non-smokers. Smokers were more likely to perceive

Adolescents And Tobacco Use Systematic Review Of Qualitative Research Methodologies And Partial Synthesis Of Findings

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