Health Promotion International Advance Access originally published online on September 5, 2005
Health Promotion International 2005 20(4):360-366; doi:10.1093/heapro/dai019
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Mixed messages: a qualitative study of the meanings and context of high school students' tobacco use in Turkey
1University of Dumlupinar, Dumlupinar, Turkey and 2Simon Fraser University, Faculty of Health Sciences, Simon Fraser University, West Mall Centre 2812, 8888 University Drive, Burnaby, BC V5A 1S6, Canada
Address for correspondence: Kitty K. Corbett, Faculty of Health Sciences, Simon Fraser University, West Mall Centre 2812, 8888 University Drive, Burnaby, B.C. V5A 1S6, Canada, E-mail: kcorbett{at}sfu.ca
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SUMMARY |
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Although smoking by adults in Turkey is a widely practiced, socially accepted habit, social influences on tobacco uptake by Turkish youth have been studied little. This paper reports findings from interviews (42 10th graders plus 10 other students and 24 adults) and three focus groups in a study with high school students in Dursunbey, Turkey. Interviewees reported that youth smoking is not culturally acceptable, but that contradictory messages and pressures abound. A context in which smoking is embedded in men's and women's social environments influences many youth to become smokers. Smoking is expected of men by the time they enter military service or are economically independent. Smoking by women, especially professionals, is increasingly common. Although virtually all adults disapprove of youth's smoking as age-inappropriate behavior, ubiquitous counterexamples of adult smoking in homes, schools, coffee houses and media dilute tobacco controls. Few youth or adults expressed concern about the relationship of tobacco to health. Sanctions in family and school environments are little enforced. Students' smoking-related attitudes and behaviors appear modeled more after behavior of their teachers than their less-educated parents, and smoking is common by teachers at school. Reduction of smoking by Turkish youth calls for comprehensive, sustained programs to de-normalize tobacco use in family, school and other settings, with special attention to smoking uptake by young women.
Key words: smoking; adolescents; Turkey; qualitative methods
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INTRODUCTION |
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To be effective, tobacco control efforts in developing countries need culture-specific information about tobacco use and related risk factors (Nichter, 2003
; Unger et al., 2003; Currie et al., 2004). Most tobacco users begin at a young age, and studies worldwide suggest shared categories of factors underlying tobacco uptake, ranging from gender expectations to interpersonal and intrapersonal influences (US Department of Health and Human Services, 1994; Tyas and Pederson, 1998; Centers for Disease Control and Prevention, 2001; Jamner et al., 2003; Currie et al., 2004). Beyond these broad strokes, for much of the world there is little knowledge of cultural and environmental influences on tobacco use (Unger et al., 2003). In countries like Turkey, few studies have addressed the social context in which youth make decisions about smoking.
Smoking in Turkey is a widely accepted practice. Turkey has one of the largest markets for tobacco products in the world (Karanci and Rustemli, 1987; Dagli, 1999). Between 1999 and 2001 annual cigarette consumption increased 21% (Hammond and Purcell, 1999). Recent adult smoking rates are 50.9% for males and 10.9% for females (Shafey et al., 2003). Smoking historically has been a habit of men but smoking by women, especially in urban areas, is rapidly increasing (Kocabas et al., 1994; Firat, 1996). While smoking is less approved for non-professional women, Turks increasingly accept it in professionals in medicine, teaching, journalism and politics (Kocabas et al., 1994; Bilir et al., 1997; Bilir et al., 2000). Bilir et al. reported that 34.4% of female physicians and 44.3% of female teachers nationwide were smokers (Bilir et al., 2000).
Turkey passed comprehensive tobacco control legislation in 1996 that, among other provisions, mandated counter-advertising and warnings on cigarette packages, and banned advertising and promotion of all tobacco products, sales to minors, and smoking in public areas, public transport, government offices, hospitals and schools in which five or more people work (Emri, 1997). Nevertheless, smoking remains common in public and selling cigarettes to minors is routine. Recent nationwide data on 10th graders found that 33% of young men and 18.3% of young women were daily smokers; 58% of students had ever tried smoking (Erbaydar et al., 2002). In the district reported on here, a survey of 10th graders found that 55% of young men and 9.5% of young women had smoked in the past 30 days (Yuksel, 2003). Compared with the Young People's Health in Context findings from 15-year-olds from 35 countries, Yuksel's finding that 83% of 10th graders (median age 16 years) had ever tried smoking is very high, close to rates of the second- and third-ranked countries (Currie et al., 2004).
This study addresses social influences on smoking by Turkish youth. Its objective is to describe adolescents' smoking, with attention to gender differences, in the context of social environments in the district of Dursunbey.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSDISCUSSIONREFERENCES |
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Data came primarily from interviews and focus groups conducted to enhance ethnographic understanding of tobacco-relevant perspectives, experiences and life contexts of Turkish youth. As an increasing number of studies have found, qualitative methods are valuable for discovering and contextualizing tobacco-related meanings and perspectives (Mermelstein, 1999
; Nichter et al., 2002; Hsia and Spruijt-Metz, 2003; Johnson et al., 2003; Nichter, 2003; Kishchuk et al., 2004; Nasrabadi et al., 2004). The interviews were part of a larger study that included a survey in 2002 of all 10th graders in five high schools in Dursunbey, a district in the Balikesir province (Yuksel, 2003). Dursunbey, about 200 km south of Istanbul, has an urban population of 14 774 and 33 000 in rural areas. Its high schools draw students from the city, neighboring towns and villages. Interviews averaging 45–60 min occurred at the high schools. Ninety-minute focus groups took place in a student's house or a pastry shop. Informal conversations and observations supplemented students' statements. Fifty-two students and 24 adults were interviewed. In 2002, 42 of the 10th graders surveyed (median age 16 years) volunteered for interviews. Eight of the 14 females and 25 of 28 males were smokers. To clarify themes, 10 of the 42 were interviewed more than once; young people who spoke freely were those invited to do a second interview. Another 10 youth (five females and five males; seven were smokers) from other grades were interviewed to explore older students' insights. Interviews were also conducted with school principals (five), vice-principals (four), teachers (six), school counselors (three) and parents (six); 63% of the adults were smokers.
Formative research for the 2002 study included three focus groups in 2001. One included seven women and two men in 10th and 11th grades in Dursunbey; all but one were smokers and none participated in the 2002 interviews. The other groups occurred in the city of Izmir. Participants, six females and six males, were from mixed grades. Topics that surfaced in focus groups informed the content of the subsequent survey and interview guide.
The interviewer (H.Y.) asked students, in Turkish, about smoking-related topics including: reasons for smoking; smoking among peers and family; influences on smoking; perceptions of adults' attitudes about smoking; whether smoking is a problem; the typical subject's day related to smoking; and smoking-related messages in school, home and media. Semi-structured interviews facilitated exploration of topics from interviewees' perspectives. Thematic and content analysis was employed on transcriptions of interviews and field notes. A priori constructs derived from Social Cognitive Theory included categories of environment, situation, observational learning and emotional coping (Bandura, 1986). Emergent codes were generated during review of data (Crabtree and Miller, 1999). Transcripts, codes, coded segments and key organizing themes were affirmed by a US-based Turkish sociologist.
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FINDINGS |
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Interviewees reported that it is not culturally acceptable for young people to smoke, but all were aware of conflicting pressures about tobacco use. Adolescents' immediate environments provide them with social and behavioral cues that foster smoking. Despite legislation prohibiting sales to minors, cigarettes are readily available to all from assorted vendors. Tobacco use is an emblem of social bonding and a marker of social status, and normative in social life from hospitality rituals to religious celebrations. At weddings, affluent families offer guests Parliament and Marlboro; poor families offer Turkish brands, Maltepe and Samsun. Cigarettes are so instrumental in social settings that many non-smokers carry cigarettes to use as a token of exchange and courtesy in social interactions. Youth associated smoking with occasions marked by routine tobacco use (e.g. coffee house gatherings), unusual stress (e.g. preparing for examinations), special occasions (e.g. weddings) and with idleness, ‘having nothing to do’ and ‘passing the time’. Some interviewees also associated smoking with the context of little opportunity and a sense of hopelessness about Turkey's current situation.
Rather than being associated with good health, non-smoking by youth was most often framed in terms of appropriate gendered and age-graded behavior. Smoking is considered disrespectful in the presence of an older authority figure, smoker or not. As a young woman reported, smoking could bring shame on one's family: "My grandma saw the cigarette packs that my friends put in my backpack... Her biggest concern was, ‘What would other people think about me if they were to see me smoking?’ rather than my health". Few youth acknowledged a strong relationship between smoking and health consequences, especially if smokers smoked less than one pack a day, or for a few years: "If you smoke few cigarettes a day it would not hurt;" "If you quit smoking your body will recover itself, so it is okay to smoke for awhile." One student said, "My father does not want me to smoke. He has been smoking one pack a day more than 20 years. Yes, he coughs and stuff but he seems fine to me. And I don't smoke as much as he does". Becoming a smoker is anticipated by many students, regardless of the (ir)rationality of the practice: "My father told me that I have intelligence, so why would I want to smoke? I told him even doctors smoke. It has nothing to do with intelligence".
Smoking behaviors vary by gender. Particularly in small towns, the sexes often separate for evening relaxation. A common male activity entails spending time in coffee houses where smoking is ubiquitous. Dursunbey has more than 78 ‘Kiraathane’ (coffee houses) and three ‘meyhane’ (taverns or bar-restaurants). Coffee houses are usually full and dense smoke is always present. Prohibition of minors in such locales is not strictly enforced, and many adolescent males mentioned going to coffee houses as a daily routine after school. Smoking is associated with male identity in these contexts, and passage to manhood for many boys is marked by smoking in these settings. An analogous activity for women is small gatherings in homes for social teas. This context formerly reinforced non-smoking as normative for women but is reported to be changing, with smoking more common at teas attended by young, mostly unmarried females.
For males, becoming a smoker remains the norm. If men do not smoke and drink, they risk being described as effeminate; as the Turkish saying goes, ‘He is like a girl. He does not smoke and drink’. Traditionally, smoking openly is not socially acceptable for males before they have served in the Turkish armed forces. It is understood that young men should not start smoking until they start earning their own salary and after they have performed their military service, around age 20. One male informant noted, ‘My father tells me to smoke when I grow up, with my own money’. However, experimentation with tobacco use when young is a strong probability for boys, and when older adolescent males take up smoking, little note is given to it. The most common reasons youth gave for male peers' smoking were trying to look grown up and urbane, to gain acceptance to a group, to emulate friends and adult role models, curiosity, rebelliousness towards parents and teachers, stress reduction and relaxation.
Not long ago, it was considered inappropriate for Turkish women to use tobacco at all. Some people still consider women who smoke in public to have low moral character. Social pressure from families is a commonly cited reason why young women do not smoke, but it is also a reason given for why others do. Family pressures, several informants said, can make smoking more appealing to young women who are rebellious, resisting pressures of their society, or responding to the pull of modernity. Young women as well as men see smoking as a marker of sophistication and maturity, to show they are separate from their parents and able to make their own decisions. As one young woman explained: ‘Smoking is a way of freeing ourselves from family and social pressure’. Some reported taking up smoking as resistance to pressures from family if not the broader society: ‘My family was seeing me like a child. I wanted to show them that I was grown up....It was giving me pleasure because my parents prohibited me from smoking’. Many said their lives were mundane but stressful, and smoking was ‘the only excitement’ in their life. One informant claimed she could differentiate female smokers from non-smokers easily: ‘I can understand a smoker from their face: if they enter into so many friend groups, if they have a boyfriend, if their parents put a lot pressure on them, if they are talkative, and their dress is non-conservative, they are most likely to be smokers’. Another informant described her frustration with gendered social pressure:
What does a man have that I don't have? I am in the electric department [at school] like the boys. We make the same engines. Boys can go to the coffee house at 10 in the evening, but I cannot. When I make this kind of comparison, I realize that we are not treated equally. It is unfair.
Almost all parents oppose children smoking, yet a great many parents smoke. As one young male noted: ‘When the people who we respect and love smoke, we think there is nothing wrong with smoking’. Adults influence youth when elders smoke, and when adults ask adolescents to buy cigarettes for them. Seeing older relatives smoking and enjoying themselves makes youth curious about what smoking offers: ‘We decided to buy a cigarette pack and smoke. It made us feel grown up. We were used to seeing adults smoking while they are sipping their tea or coffee with great pleasure, and we were envious of that’. Another adult remembered seeing his father and grandfather breaking the Ramadan fast together with cigarettes, rather than food, ‘I wondered what the magic and power of cigarettes were, so that my father and grandfather would prefer smoking to eating, and bonded them together in a special way which was not available to me as a child’.
Parents' and teachers' disapproval of smoking was apparent in youth's stories of hiding tobacco use from respected elders. As a 16-year old male student explained, ‘My parents don't know that I smoke; I use chewing gum and brush my teeth to conceal the smoke’. Young women mentioned smoking in front of an open window, using chewing gum, brushing their teeth, using wet towels to clean the air, and using perfumes to mask the evidence. Youth reported that out of respect, even grown children will not smoke in front of their parents, uncles and aunts, and grandparents. Adult interviewees indicated that this deference is waning as the current generation becomes bolder and less mindful of their elders.
Parents' opposition to their children smoking is often backed by punishment. Consequences can be severe at first: ‘I started smoking regularly when I was 14. When my mom caught me smoking the first time she beat me up, my weekly allowances stopped, I was not allowed to go to gatherings in friends’ houses'. When parents find out about their children's tobacco use, they punish them or try to talk them out of it. If unsuccessful, most take the approach described by one informant: ‘Don't do it, but if you do it, don't do it where I can see you’. Most discipline wanes quickly as parents become resigned to their sons, if not their daughters, smoking. A young woman said, ‘Now my parents know that I smoke and they tell me that I am not allowed to smoke in their house’. A male said, ‘First, families get very upset but later they understand that you are addicted’. Adults' ambivalence turns to acceptance if not approval. As a principal stated, ‘Yes, smoking is very common among our students, but at least they are not into drugs like in the big cities in Turkey’.
Smoking is not allowed at school. Some youth said that they buy single cigarettes that can be hidden, or during school give their packs to market owners nearby or to café owners inside the school. Nevertheless, students said that consequences of smoking at school are usually minor (e.g. not being allowed to use physical education equipment). School officials reported that they did not feel they had much power to control youth smoking. Several educators attributed schools' lack of influence on youth smoking to recent school reform legislation that prohibits harsher punishments or enforcement of student smoking bans off campus.
Anti-smoking messages are undercut by the hypocrisy youth note in parents and professionals who smoke. As two youths stated: ‘While adults are telling us not to smoke, their cigarette smoke comes out of their mouth’, and ‘If it were something terribly bad they [teachers] would not be smoking’. Adults also ask adolescents to buy cigarettes for them: ‘On the one hand, you send us to buy cigarettes for you; on the other hand, you tell us not to smoke’. Many of the students identified more with their teachers, with whom they shared educational achievement, than with their parents, who typically had less than an eighth grade education. Youth also identified ‘the government’ as an authority that gives mixed messages. One of the female students reflected, ‘If it is so bad, why does the government allow them to be produced and sold?’
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODSFINDINGSDISCUSSIONREFERENCES |
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Various features of small-town Turkish society are relevant to prospects for reducing tobacco use by youth. These include: the omnipresence of cigarettes in religious celebrations, social events and hospitality rituals; a general lack of concern about the relationship of tobacco to health; the prioritization of deference to older relatives over health considerations as a rationale for not smoking; smoking as a symbol of passage to adulthood; the interwoven triad of coffee houses, smoking and male identity; smoking as a sign of modernity or form of resistance by young women; the changing role of social teas as a context for women's tobacco uptake rather than non-use; and the potential for school teachers and other professionals to undermine tobacco control and prevention.
Continuing high rates of smoking uptake by Turkish youth are fostered by inconsistency in tobacco control messages in school, family and other social environments. Educators and other professionals are particularly implicated in the mixed messages given to youth about tobacco. Research on the relation between tobacco use and education has emphasized factors such as the role of school-based health education and skills programs, the relationship of academic achievement and social stress to use, and schools as environments in which youth are influenced by their peers (US Department of Health and Human Services, 1994; Currie et al., 2004). The reports of adolescents in our study highlight also the relevance of teachers as role models, an issue less apparent in the literature (Samdal et al., 2000; Poulsen et al., 2002) and in various reviews, not mentioned (Tyas and Pederson, 1998; Turner et al., 2004). Students recognize that smoking is common among the educated elite, particularly teachers and medical professionals. This is not merely a perception, since as many as 43% of physicians, 51% of teachers, 64% of journalists and 27% of politicians (in Ankara) smoke (Bilir, 1997). Most parents in Dursunbey have little more than an elementary school education, and high school students appear to look for role models more to their college-educated teachers than to their parents. Prevention of tobacco uptake by youth is unlikely to make good progress without addressing adults' use, particularly that of key role models in society.
Smoking by young women is a special point of concern. Smoking rates among female professionals illustrate trends in women's smoking in Turkey. Traditionally in the Middle East and many Islamic countries, smoking has been seen as an inappropriate, immoral behavior for females (Dagli, 1999). Turkish women's attitudes toward smoking appear to be rapidly changing, as evidenced by a 1996 study that found 48% of women in Istanbul to be smokers (Dagli, 1999). For Turkish women, themes of liberalization, Western modernism and expanded opportunity are increasingly expressed through smoking behaviors (Hammond and Purcell, 1999). In towns of Dursunbey's size, informal and traditional relationships are still in effect compared with larger cities, and traditional pressures against non-professional women smoking are more easily asserted in small towns. The protective influence of Turkish tradition on young women is disappearing and smoking among young women is likely to rise dramatically in the coming years.
Although recent legislation in Turkey is important for tobacco control efforts, enforcement appears minimal. Smoking is normative in Turkish culture to such a degree that programs face substantial challenges. Reducing youth smoking will require lengthy, comprehensive, multi-faceted, national and local programs. In addition to setting prevention and cessation as goals, these programs should seek to de-normalize tobacco use in family, work, and social settings. This study's findings suggest that a useful emphasis is teacher education, smoking bans (and their consistent enforcement) in schools and at school-related functions, and cessation programs for schools and teachers. It may be productive to employ significant social contexts, e.g. social teas and coffee houses, as possible sites for educational outreach and commitment to smoke-free environments.
The greatest opponent to Turkish tobacco control is the deeply ingrained social norm that supports tobacco use, as exemplified by a school counselor:
Everyone should have a bad habit. Otherwise life is so boring. You should balance bad and good habits. If you don't drink and smoke, why do you live? Everybody will have to die. While we are living, we should enjoy the pleasures of life.
Changing such norms requires a committed, multifaceted approach. Turkey and other countries that have not been home to extensive tobacco control efforts will benefit from programs and policies targeting students, schools, and teachers within comprehensive campaigns to reduce tobacco use (Wold et al., 2004). As demonstrated by countries where smoking prevalence has dropped significantly, this is a decades-long, multi-generational project that is worth doing.
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ACKNOWLEDGEMENTS |
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This work was supported by a grant from Research for International Tobacco Control (RITC) at the International Development Research Centre, Ottawa, Canada.
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