A total of 22 participants (12 classified as low motivation smokers and 10 as high motivation smokers) were recruited until saturation was reached. 13 smokers participated in focus groups (4 groups held in total) and 9 performed individual interviews.
As the data revealed no differences between the two predefined groups in terms of their motivation to quit smoking (indicating a potential lack of reliability of the screening instrument in this group of smokers), the three main themes identified through the thematic analysis process - plans to quit smoking; evaluative beliefs about smoking; and perceived effectiveness of tobacco control policies and services on individual smoking behaviour - are presented with illustrative quotes for both groups, with differentiation between groups highlighted only where dictated by findings.
Plans to continue/quit smoking (PRIME theory)
Barriers undermining motivation to quit
In accordance with PRIME theory [
16], several barriers to quitting were apparent which may have reduced motivation to quit, and enhanced motivation to continue to smoke as part of smokers’ overall plans. The main reasons given as to why smokers did not want to quit immediately were that they felt no detrimental health effects, they enjoyed smoking a lot, and that they would eventually quit in the future. Low motivation smokers also noted that they simply did not want to quit enough to actually do it:
“Health reasons will be the main reason I give it up, but right now I don’t even think about it … I’m quite happy smoking, I like smoking” (High motivation smoker, Female, Age 23, Focus group).
“I’ve not had any real reason to I suppose. No driving reason to stop doing something I enjoy” (Low motivation smoker, Male, Age 25, Interview).
“I’ve been thinking about it, but I don’t want to stop. That’s the point.” (Low motivation smoker, Male, Age 33, Focus Group).
Probing deeper into motivation for quitting, many stated that any desire to quit was based more on what they ‘ought’ to do, rather than what they actually ‘wanted’ to do; as PRIME theory [
16] states, ‘wanting’ to change behaviour is a fundamental factor required to elicit behaviour change:
[Do you want to stop?] “Erm … I’m not sure. Maybe. I think I should stop, but I don’t think I will.” (Low motivation smoker, Female, Age 24, Interview).
“No, I don’t want to stop. But I know I have to stop.” (High motivation smoker, Female, Age 23, Focus Group).
Factors likely to increase motivation to quit
The main methods believed by participants of both groups to increase motivation to quit in the future were: ‘wanting’ to quit enough, emergence of detrimental health effects, financial concerns, pregnancy/starting a family, and social disapproval.
“It’s just wanting to do it and having the willpower to do it. (High motivation smoker Female, Age 24, Interview).
“I don’t want to be one of those people who are in their 60s who have an artificial voice box, it’s not good.” (Low motivation smoker, Male, Age 22, Interview).
“It’s like burning money away. Three and half, four and a half grand a year if I smoke 10 to 20 fags a day.” (Low motivation smoker, Male, Age 25, Focus Group).
During discussions, smokers were very quick in identifying these factors, and appeared confident that they would quit ‘one day’ due to any one of the reasons they identified.
Evaluative beliefs about smoking
As PRIME theory [
16] states, evaluative beliefs about smoking can impact upon a smoker’s motives and desires to continue/quit smoking. As such, the following sub-themes represent smokers’ evaluative beliefs about smoking:
Reasons for smoking
The most common reasons for smoking mentioned were enjoyment of smoking, boredom, force of habit, dependency, stress, seeing others smoke, and association with alcohol. In discussions, smokers were very keen to openly discuss why they liked smoking. Additionally, low motivation smokers noted more practical reasons than high motivation smokers for smoking, such as having more breaks at work and something to do with their hands:
“If you’re at work and smoke, you tend to get a lot more breaks at work. I work in a job where I don’t get many breaks anyway, apart from smoking.” (Low motivation smoker, Male, Age 25, Focus Group).
All smokers stated they were addicted to smoking in some manner; however, the perceived nature of this addiction differed. Although many noted the biological addiction to nicotine, most thought themselves to be more psychologically addicted to the habit of smoking. During discussions, smokers disagreed about the nature of their addiction, and were willing to discuss this freely with other group members:
“It might be a psychological addiction where I have a pint in my hand and think ‘I’ll have a fag’. Whereas if I have a bottle of beer at home, I won’t take a cigarette.” (Low motivation smoker, Male, Age 40, Focus Group).
“I’d always say mine is habitual rather than dependence. It’s a routine that I do every day.” (High motivation smoker, Female, Age 23, Focus Group).
Perceptions of being a smoker
Many smokers, in particular low motivation smokers, had positive evaluations about being a smoker and stated that they enjoyed being a smoker. In some focus groups, smokers encouraged each other to recall stories of smoking experiences, and to further highlight the benefits of being a smoker and things they would miss if they quit. Perceived benefits of being a smoker across both groups were that it was sociable, provided an opportunity to escape, and there was a clear in-group favouritism towards other smokers:
“I’m very suspicious of non-smokers… you go to a pub and like the non-smokers are always a bit square, and a bit boring, and the smokers are always having a good time.” (Low motivation smoker, Female, Age 35, Focus Group).
“I’d probably miss the social aspect of it. There’s something about being a smoker in a social situation because you’re in that group and there’s kind of a nice side to it.” (High motivation smoker, Male, Age 29, Interview).
By contrast, some participants illustrated their dislike of being a smoker, in one case in the context of expressing disapproval of a relapse following a successful quit attempt:
“I don’t like being a smoker myself, especially as I’d quit, and then ended up smoking again.” (High motivation smoker, Female, Age 28, Focus Group).
Smokers stated that if they were to quit, they would miss the physical action of smoking and the social aspect associated with smoking; thus reinforcing their positive evaluations of being a smoker:
“I just like the action of smoking, especially when I’m drinking.” (Low motivation smoker, Male, Age 25, Interview).
Cognitive dissonance of attitudes towards smoking
Cognitive dissonance, whereby smokers held beliefs about smoking which conflicted with their behavioural actions and led to rationalisation of their behaviour, was apparent in many smokers. Although most smokers enjoyed smoking, some negative attributes of smoking were noted, mainly with high motivation smokers regarding moral norms:
“I would never smoke around children. Never. And I don’t like smoking around people who don’t smoke.” (High motivation smoker, Female, Age 23, Focus Group).
Although some negative attributes were noted, these were not sufficiently compelling to encourage a quit attempt in the immediate future. Furthermore, all smokers stated reasons why they ought to quit smoking, most commonly for their health, and to save money:
“Logically we should all quit because it’s stupid killing yourself” (Low motivation smoker, Male, Age 40, Focus Group).
However, these reasons were often counteracted with statements to justify their smoking habit, and positive appraisals of their behaviour related to positive reasons for smoking; thus reinforcing smokers’ continuation of smoking behaviour and inhibiting the opportunity for making a quit attempt:
“Even if you don’t do anything you’re going to die aren’t you? It’s the old joke isn’t it? If you give up drinking, smoking, relationships, will you live longer? No, it’ll just seem like it” (Low motivation smoker, Male, Age 48, Focus Group).
“I would feel that I definitely ought not to smoke, but that just makes it more attractive.” (High motivation smoker, Male, Age 22, Focus Group).
“If I took away the element of it being carcinogenic and all the detrimental impacts it has on your life, I’d say I enjoy it.” (High motivation smoker, Male, Age 22, Interview).
Perceived effectiveness of policies and services
Attitudes towards tobacco control policies
As PRIME theory [
16] states, environmental cues can influence the decision to smoke by triggering impulses. However, point of sale displays and packaging of cigarettes were perceived to have little effect on smokers’ purchasing behaviour, as price, taste, and brand familiarity were said to influence purchases the most. Additionally, proposed tobacco control policies were believed to be ineffective in affecting purchases for most smokers. Plain packaging of cigarettes was predicted to have no effect on the brand or quantity of cigarettes bought, neither were hidden sales displays, but these policies were noted to have some potential in deterring younger smokers or preventing impulse purchases:
“If people think the same way as I think, you’re going to buy cigarettes whether they’re hidden under the counter or there in front of them.” (High motivation smoker, Female, Age 28, Focus Group).
“It [hidden sales displays in Canada] really inhibited you from buying something spur of the moment. You really needed to know exactly what you wanted.” (High motivation smoker, Male, Age 22, Interview).
“It will work from the point of view of some kids who are drawn to shiny things … but I don’t think it’s going to make much difference to established smokers.” (Low motivation smoker, Male, Age 40, Focus Group).
Many smokers stated that price increases of cigarettes needed to be more drastic in order to effectively reduce the number of purchases made:
“The incremental rises are pathetic, it doesn’t deter anyone”. (Low motivation smoker, Male, Age 40, Focus Group).
“If it gets to £4 a pint, I won’t drink alcohol. And then it gets to four and you’re like ‘if it gets to £5, that will be the final straw’. And it’s the same with cigarettes … you find a way”. (Low motivation smoker, Male, Age 48, Focus Group).
[Would you keep paying it?] “Yeah, I think I probably would. Because the inclinations are so small really. It’s not going to go from £4 to £10, it’s slow, incremental.” (High motivation smoker, Female, Age 23, Focus Group).
Attitudes towards NHS SSS
Differences between groups were apparent in attitudes towards NHS SSS. Low motivation smokers were more dismissive towards these stating that quitting was ‘a personal thing’, and were less willing to use such services, whereas high motivation smokers appeared generally more appreciative of the assistance on offer, and although none had actually used NHS SSS, they stated they would use it if they felt the need to (e.g. to combat the nicotine addiction using harm reduction methods or if an unassisted quit attempt had failed). However, during discussions, it was apparent that there was a clear lack of knowledge regarding what NHS SSS were, and how to access them. Only after the facilitator had explained what they offered, was there some appreciation and willingness to use a service if required:
“I think if I seriously wanted to quit, and I thought that I wouldn’t be able to do it myself, I would be very willing to go and use that kind of service.” (High motivation smoker, Female, Age 23, Interview).
“If I was going to try and stop the nicotine addiction, then it would be a good idea to go to somebody who knows what they’re doing.” (High motivation smoker, Male, Age 29, Interview).
When asked about the potential quit methods smokers would most likely use, the majority across groups stated that they would prefer to ‘go cold turkey’:
“I’d be quite happy going cold turkey and seeing what happens.” (Low motivation smoker, Male, Age 25, Interview).
“I think I’d probably wake up and think ‘right, last packet of cigarettes’ and then no more.” (High motivation smoker, Female, Age 24, Interview).
However, some high motivation smokers also suggested being offered a sympathetic and supportive approach by health professionals would help them to quit, suggesting that these smokers might benefit the most from increased encouragement to access NHS SSS:
“You can go to your doctor or your chemist and there’s a lot more encouragement and advice to help you pack in. That wasn’t true say five years ago… That’s a far more sympathetic approach than trying to put the cost up.” (High motivation smoker, Male, Age 52, Interview).
Attitudes towards NRT
Smokers displayed differing opinions regarding NRT; some believed they were an effective cessation tool whereas others did not:
“I whacked one on in the morning and was like ‘yeah, shall we just have a fag?’ So we took them off and had a fag” (Low motivation smoker, Female, Age 35, Focus Group).
“You honestly do not feel the need, that craving, to smoke. It’s really difficult to want to smoke while having that patch.” (High motivation smoker, Male, Age 22, Interview).
Many smokers had negative views towards NRT stating that they were concerned about the side effects (including taste and irritability), and also that it simply didn’t work as it was believed to only treat the nicotine addiction and not the habitual aspects of smoking, whereas others liked the relief and confidence it provided; highlighting the individual preferences for quit support that need to be considered by health professionals:
“The plastic thing that makes you feel sick. The sweets are disgusting.” (High motivation smoker, Female, Age 24, Interview).
“I’d probably use other means, because it just seems a bit clinical. Because I don’t smoke for the nicotine, I smoke for everything else with it.” (High motivation smoker, Male, Age 22, Focus Group).
“It does give you the idea that stopping smoking is possible, from a position where you think it’s going to be really hard.” (High motivation smoker, Male, Age 29, Interview).