Background
As it celebrates the 2020 World No Tobacco Day, the World Health Organization (WHO) is engaging in a campaign to “protect children and young people from tobacco and related industries” [
1]. Smoking is a risky behavior that blocks the oxygen supply to multiple organs, including the lungs, leading to functional damage [
1]. About 90% of smokers begin smoking before the age of 18 [
2,
3]. According to the Korea Ministry of Health and Welfare, adolescents in Korea smoke to relieve stress, escape boring situations, and find new stimuli [
4]. Once this becomes a habit, they feel the craving for tobacco and continue to smoke [
4]. However, as smoking in one’s adolescence continues into adulthood, it may contribute to the development of drug abuse, depression, and other problematic behaviors [
5]. Some studies even report that the rate of premature death in smokers is more than six times higher than the average [
6].
According to the 15th Youth Health Behavior Survey, conducted in 2019, the rate of tobacco use in Korean adolescents was 9.3% in males and 3.8% in females [
7]. Despite various preventative measures, including warnings on the risks of using tobacco, as well as tobacco-cessation education, only 70.1% of the male students who used tobacco attempted to quit in the previous 12 months. Those rates were higher than the 66.5% of female students who attempted to quit smoking [
7].
In Korea, the number of adolescents who smoke cigarettes is ten times the number of those who only use e-cigarettes or heated tobacco products (HTPs) [
7], with approximately 75% of adolescents using both e-cigarettes and cigarettes [
8]. Adolescents who use e-cigarettes have been shown to smoke more frequently than adolescents who smoke regular cigarettes [
9]. In some countries, e-cigarettes are reported to be used for smoking cessation [
10,
11]; however, according to the WHO, the cessation effect of e-cigarettes has not yet been systematically evaluated [
12]. Korean adolescents who use e-cigarettes or HTPs have stated that they are used because they are perceived as less harmful to one’s health than cigarettes, do not smell, and can be smoked freely at school or home [
13].
According to a study by Myers et al. [
14], 60.9% of the high school students who smoke daily have attempted to quit. However, relapse is common in the process of quitting smoking, which highlights the importance of the factors that influence this process. Furthermore, smoking is a multidimensional behavior relating to genetic, psychological, environmental, and sociocultural characteristics [
15]. Therefore, it is necessary to identify the factors influencing smoking and attempts to quit smoking from a multidimensional perspective to reduce rates of adolescent smoking.
Previous studies that have examined smoking and quitting smoking in adolescents have generally focused on factors such as behavior [
16‐
21], perception and attitude [
3,
22], psychology [
23] and environment [
18,
23], and other specific subjects [
18,
24‐
26], indicating a general lack of studies from the multidimensional perspective. In addition, no studies have distinguished physical characteristics, including physical disorders and behavioral characteristics.
Thus, we aimed to identify the factors that influence attempts to quit using tobacco from a multidimensional perspective of psychological, physical, behavioral, and environmental dimensions to reduce rates of using tobacco in Korean adolescents.
Discussion
Adolescent tobacco users are at a significant risk of becoming subsequent tobacco users [
28]. In addition, tobacco may be a gateway to substance abuse, depression, and other problematic behaviors [
5,
29]. Therefore, the control of tobacco is especially important for adolescents.
This study has confirmed factors across multiple dimensions relating to attempts to quit using tobacco in Korean adolescents. The study found that the rate of attempts to quit in adolescent tobacco users was 68.2%. These results represent a 3.3% drop from 71.3% in 2018 [
7]. A recent study of 3.3 million American adolescents also indicated that only 57.5% of adolescent tobacco users had attempted to quit using tobacco [
30].
In the past 10 years, the rate of adolescent tobacco use in Korea dropped significantly, from 12.1% in 2010 to 6.7% in 2019 [
31]. This decline corresponds to efforts in preventing adolescent tobacco use, which have taken place since 2010. Several tobacco-cessation policies and stronger regulations on tobacco use were put in place, such as strengthening tobacco-cessation education in schools, expanding no-tobacco-use zones, raising tobacco prices, and placing warning images on cigarette packs [
32]. While the rate of adolescent tobacco use has decreased, the rate of quit attempts in adolescent tobacco users appear to be similar to, or lower than, the rates seen in existing studies [
9]. This may be related to levels of nicotine dependence throughout the period of tobacco use [
33].
This study has classified the factors influencing tobacco-use quit attempts in adolescent tobacco users into physical, psychological, behavioral, and environmental dimensions for analysis and found that behavioral and environmental dimensions effected significant results. Specifically, the influencing factors of behavioral dimensions were sports team participation, vigorous physical activity, and the type of tobacco product used; the factors in the environmental domain were warning images on cigarette packs and experience of secondhand smoking at home.
Adolescent tobacco users who participated in sports teams and engaged in vigorous physical exercise were more likely to attempt to quit using tobacco compared to their peers who did not. This is in line with the results of existing studies that indicated physical activity is related to tobacco-use quit attempts [
9]. Existing studies have found that levels of stress and depression were higher in adolescent tobacco users compared to non-tobacco users. This was generally caused by the burden of academics and the lack of coping abilities required to deal with stress [
34]. Particularly, Korean adolescents are choosing tobacco use as a method to relieve stress [
4], as well as to associate with their peer groups [
13]. Therefore, appropriate interventions are needed at the school and at the regional community level to relieve the stress faced by adolescents. Physical activity in adolescents has a positive influence on their mental health [
35]. Therefore, in addition to strengthening tobacco-cessation education, it is necessary to provide adolescents the opportunities to form groups and participate in various sports activities or other areas of interest.
In this study, the adolescents who used e-cigarettes or HTPs (without cigarettes) had lower rates of tobacco-use quit attempts compared to those using cigarettes. According to recent reports, e-cigarettes or HTP users are often used as smoking aids because of the perception that e-cigarettes or HTPs are not as harmful to health as cigarettes, do not smell, and are convenient for smoking freely at school and home [
13,
36]. Adolescent tobacco users may try e-cigarettes or HTPs as a tobacco-use cessation aid; however, they fail to quit and end up becoming dual users [
13]. Similarly, the number of adolescent dual users have increased overseas [
37], underscoring the need to review the use of e-cigarettes and HTPs. Recent research has suggested the negative health effects of e-cigarettes [
36,
38], indicating the need to clearly understand the conflicting evaluations on the effects of e-cigarettes and HTPs. In addition, the diversity of e-cigarette and HTPs is making consensus or regulation of these products difficult. In the future, it will be necessary to specifically examine administrative regulations on the production and sale of e-cigarettes and HTPs based on medical evidence. These efforts may help prevent and reduce tobacco use by adolescents.
The recognition of health hazards via warning images on cigarette packs appears to be the most significant factor in tobacco-use quit attempts in adolescent tobacco users. These have been found to have a positive influence helping adolescents understand the risks of using tobacco [
39]. Additionally, viewing health warning signs typically induces health behavior; thus, emphasizing these warning signs as much as possible is of utmost importance [
40]. The warning images on cigarette packs have also been found to be more effective for adolescent non-tobacco users compared to tobacco users [
32] and may be effective in encouraging tobacco-use prevention in adolescents. As the age of tobacco users continues to decrease in adolescents, it is also necessary to develop more effective warning images and messages that target this age group.
In this study, adolescents who experienced secondhand smoke at home had fewer tobacco-use quit attempts compared to those who had not experienced secondhand smoke at home. Adolescents are more likely to smoke if a member of their family smokes and are more likely to adopt an accepting attitude toward smoking [
41]. Exposure to secondhand smoking at home has been found to influence asthma, depression, and perceived stress in adolescents, which should act as a warning against smoking at home by adult smokers [
42]. Furthermore, exposure to secondhand smoking at home is associated with female and younger adolescents, as they tend to spend more time at home compared to older, male adolescents, making them more exposed to secondhand smoke when there is a smoker in their family [
9]. Therefore, family members quitting smoking is necessary to prevent adolescents from using tobacco and for adolescent tobacco users to try to quit using tobacco.
Our research has several limitations. First, there was no information on the individual duration of tobacco-use quit attempts, as this was not included in the raw datasets. Therefore, we were unable to evaluate the relationship between factors influencing tobacco-use quit attempts in adolescent tobacco users and the periods of successful tobacco cessation. Second, cigarette smokers, e-cigarette users, and HTP users were classified into one tobacco user group. Some people can use an e-cigarette to quit smoking. However, according to the results of previous studies in Korea, adolescents who use e-cigarettes showed a pattern of smoking more frequently and using more cigarettes [
9]. In addition, when HTPs were used, the purpose of the use was not smoking; there were many cases where it was used as a substitute for smoking [
36]. In our study, the number of exclusive e-cigarette users was considerably small, and most of the e-cigarette users were also using HTPs. Finally, it was not possible to clearly determine whether the e-cigarette users may be a group that previously used tobacco. It is necessary to investigate the purpose of e-cigarette use when collecting data from The Youth Health Behavior Surveys conducted in the future.
Despite these potential limitations, this study utilized national statistical data that represent the health behaviors of Korean adolescents to explore various aspects of the factors influencing tobacco-use quit attempts. As highlighted in existing literature, adolescent tobacco users need to be continuously monitored and provided with appropriate interventions.
However, most tobacco-cessation policies for adolescents that are currently implemented by the Korean government are mainly regulatory policies [
43]. This study confirmed that, although regulatory and deterrence policies related to the environmental dimension were showing an effect, adolescents’ healthy behavior, such as participation in sports activities and vigorous physical activities, was also an important factor influencing attempts to quit using tobacco. Therefore, it is urgent to develop specific policies encouraging individual healthy behaviors to promote Korean adolescent tobacco users’ attempts to quit tobacco.
As adolescents have been using tobacco for shorter periods compared to adult tobacco users, they have lower levels of nicotine dependence [
33], which may increase the likelihood of successful cessation of tobacco use. Schools and communities must provide various physical activity programs in addition to tobacco-cessation education, which can help develop an environment where adolescent tobacco users can escape the temptation of using tobacco. As government support and policy can influence tobacco-use cessation in adolescents, it is necessary to develop clear tobacco-cessation policies (i.e., clear agreement and regulation over the diverse range of e-cigarette products) and content that can induce attempts to quit among adolescent tobacco users.
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