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Tobacco control research conceptualises smoking initiation not as a single event, but as a process that occurs through a series of stages.1,2 While there may be variations in the stages individuals pass through, the ages at which they enter a particular stage, and the time spent in each stage, it is generally accepted that one moves from never smoking (pre-contemplation) through to contemplation, trying their first few cigarettes, experimenting with smoking, smoking regularly but infrequently, and then smoking at an established level (daily or almost every day).1Traditional views of smoking initiation hold that the entire process from never to established smoking occurs almost exclusively in adolescence and consequently, preventive tobacco control initiatives have typically ignored young adults.3,4 However, emerging evidence shows that young adulthood (typically defined as 18 to 30-years-old) also represents a vulnerable time for the initiation, development, and establishment of smoking behaviours.2,4-8 For example, a recent US study found that 25% of those who were never smokers before age 18 smoked their first whole cigarette between the ages of 18 and 21 (representing the trying smoking stage of initiation).8 In New Zealand, the consistently high smoking prevalence among New Zealand young adults (eg, 25.4% for 20 to 24-year-olds in 2012/13 compared with 17.6% in the general population)9 coupled with a low and declining smoking prevalence among adolescents9,10 indicates that significant initiation may be occurring after age 17. Recent longitudinal data support this contention, with 7% of never-smoking 18 to 19-year-olds in New Zealand becoming regular smokers over the next four years (representing progression through all stages of smoking initiation after turning 18).7Several possible reasons for young adult smoking initiation (referred to in this article as late-onset smoking) have been put forward in the literature. First, there is the increased risk associated with significant life changes, where transitions to new environments, activities, and peer groups provide opportunities for the adoption of new behaviours such as taking up smoking.2 The psychological and physiological effects of nicotine also provide a mechanism for coping with the stress and anxiety that might come with these transitions.2 Young adults are at risk of taking up smoking as they face a number of these significant and potentially stressful life changes, including transitioning to life outside the parental home, interacting with new peer groups, entering the workforce, establishing identities, and engaging with new activities. At the same time, young adults are earning greater disposable incomes11 and gaining greater access to tobacco (through the ability to legally purchase cigarettes at age 18) and alcohol (including legal purchase and admission to pubs and clubs). Finally, alluring tobacco pack designs and branding offer young adults a label with which to express their personality and identity and may therefore play a role in supporting and maintaining smoking in that age group.12Many theoretical reasons have been put forward to explain late-onset smoking, but few studies have actually examined the phenomenon. Most that have done so have used varying measures of initiation (eg, some used trying a first cigarette,8 while others used established smoking7), were based in North America, and were focused on either quantifying late-onset smoking or determining the predictors of smoking initiation in young adulthood (which include the use of alcohol, boredom, stress, and exposure to smoking by friends and family).4There is, however, one recent qualitative study that provides some insight into the contexts of smoking initiation for young adults in New Zealand.13 The authors of that study found that young adults started smoking somewhat incidentally as a way of participating in social events and interacting with peers on drinking occasions; they did not necessarily make a conscious, considered decision to begin smoking. In this way, drinking alcohol and the associated social context play an important role in the initiation and development of smoking behaviour in young adults.13While qualitative studies provide insight into the social contexts and functions of smoking for young late-onset smokers in New Zealand, no studies have attempted to quantify the smoking- and cessation-related attitudes and behaviours of this group. To this end, the current research used data from the 2013 New Zealand Smoking Monitor (NZSM) to examine the attitudes and behaviours of young adults who became established smokers only after turning 18-years-old. Specifically, this study assessed current smoking behaviour, nicotine dependence, self-efficacy to quit, intentions and attempts to quit, intended use of cessation aids, and social experiences with smoking, with a view to understanding the barriers to successful cessation in young late-onset smokers. Understanding these barriers, which are largely modifiable, is important as they directly inform the design and targeting of tobacco initiatives aimed at reducing the high smoking prevalence among New Zealand young adults.MethodSurvey designData were collected as part of the New Zealand Smoking Monitor (NZSM), which is an on-going fortnightly survey of current smokers and recent quit attempters smoking-related attitudes and behaviours. The NZSM typically contains three sample groups (non quit attempters, recent quit attempters, and serious quit attempters), but for this study the authors temporarily (from July to November 2013) added a fourth sample group: young adult (18 to 28-year-olds) smokers who took up daily smoking (ie, had become established smokers) after age 18. The method for the NZSM has been described elsewhere.14 In brief, the NZSM uses a panel method where respondents can participate in up to six fortnightly interviews. Those who drop out of the survey (due to completing six interviews, being out of contact, or refusing to participate) are replaced by new respondents. A commercial research agency conducts the fieldwork using computer-assisted telephone interviewing (CATI). Although NZSM respondents can participate in up to six interviews, this paper reports on data collected from late-onset respondents first interview only.The New Zealand Health and Disability Ethics Committee has classified the NZSM as a low-risk study; it is therefore exempted from ethics review.15RecruitmentThe fieldwork agency typically recruits respondents for the NZSM from a nationally-representative omnibus survey (non quit attempters and recent quit attempters) or the New Zealand Quitline (serious quit attempters). However, the low prevalence of young late-onset smokers in the New Zealand population necessitated a different recruitment procedure for this sample. Recruitment contractors obtained contact details for potential late-onset respondents using a street intercept method, where recruiters approached young people in public places in various suburbs of six New Zealand cities (Auckland, Hamilton, Wellington, Christchurch, Palmerston North, and Dunedin). Recruiters asked if the person would like to participate in the survey before screening for eligibility.Eligible respondents were aged between 18 and 28 years, had started smoking daily (ie, had become established smokers) after the age of 18 years, and had smoked most days in the last 30 days. We included only established smokers in this study to ensure that respondents had relatively homogeneous smoking behaviour. Those who met the criteria and agreed to participate were later contacted by the fieldwork agency and re-screened for consent and eligibility before participating in the survey interview.QuestionnaireThis study focused on smoking-related behaviours, cessation-related behaviours, and the social context of smoking. To assess smoking-related behaviours, respondents were asked how old they were when they first tried a cigarette (respondents all became established smokers after turning 18-years-old, but could have smoked their first cigarette at any age) and the two questions in the Heavy Smoking Index (HSI):16 number of cigarettes per day (CPD number of cigarettes smoked per day and time to first cigarette after waking. To assess cessation-related behaviours, respondents were asked: whether they had made a quit attempt that lasted 24 hours or longer in the last 3 months (yes/no response); how many, if any, quit attempts lasting 24 hours or longer they had made in the last 12 months (transformed to yes/no responses for analysis); whether they agreed with the statement \u201cI intend to quit in the next 3 months\u201d (5-point agreement scale); how likely it is (out of 100) they would succeed if they tried to quit smoking (used as an indicator of self-efficacy to quit); and their intended use of specific cessation aids (yes/no responses to specific aids). To assess the social context of smoking, respondents were asked to indicate their agreement (5-point agreement scale) with five statements about their smoking-related experiences in the last two weeks.AnalysisAnalyses were conducted using STATA/IC 13.1. Proportions were first calculated to assess the frequency of particular behaviours in the sample. For questions with responses on a 5-point agreement scale, strongly agree and agree responses were combined to indicate overall agreement with particular statements. Respondents who refused to answer a particular question, or said dont know, were excluded from that particular analysis.Logistic regression analyses were then used to examine differences in responses by demographic and smoking-related variables. For the majority of the analyses, the independent variables were age and gender as previous research indicates these factors are important correlates of smoking behaviour.9 Although previous research has also identified ethnicity as an important correlate of smoking behaviour,9 ethnicity could not be examined due to low numbers of M\u0101ori (n = 8), Pacific (n = 9), and Asian (n = 16) respondents in the sample. The dependent variable was the specific smoking-related behaviour, cessation-related behaviour, or experience with smoking. For the analyses investigating intention to quit, nicotine dependence, self-efficacy, and recent quit attempts were included as additional independent variables in order to better understand the predictors of quit intention among young late-onset smokers.Statistically significant (p < .05) results are highlighted in the result tables, but where the odds ratios indicate potentially important non-significant trends, these are Table 1: Smoking-related behaviours among young late-onset smokers\r\n \r\n \r\n \r\n \r\n \r\n Percent\r\n \r\n n\r\n \r\n \r\n \r\n Age at first cigarette\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 13 or under\r\n \r\n 6\r\n \r\n 6\r\n \r\n \r\n \r\n 14-15\r\n \r\n 17\r\n \r\n 19\r\n \r\n \r\n \r\n 16-17\r\n \r\n 23\r\n \r\n 25\r\n \r\n \r\n \r\n 18-19\r\n \r\n 39\r\n \r\n 42\r\n \r\n \r\n \r\n 20-21\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 22-23\r\n \r\n 4\r\n \r\n 4\r\n \r\n \r\n \r\n 24-25\r\n \r\n 2\r\n \r\n 2\r\n \r\n \r\n \r\n 26 or over\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Number of cigarettes smoked per day\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 1-5\r\n \r\n 41\r\n \r\n 45\r\n \r\n \r\n \r\n 6-10\r\n \r\n 42\r\n \r\n 46\r\n \r\n \r\n \r\n 11-20\r\n \r\n 15\r\n \r\n 17\r\n \r\n \r\n \r\n 21-30\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n 31+\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Time to first cigarette after waking\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Within 5 mins\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 6 to 30 mins\r\n \r\n 21\r\n \r\n 23\r\n \r\n \r\n \r\n 31 to 60 mins\r\n \r\n 27\r\n \r\n 30\r\n \r\n \r\n \r\n After 60 mins\r\n \r\n 43\r\n \r\n 48\r\n \r\n \r\n \r\n Nicotine dependence (HSI score)\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Low dependence (0-1)\r\n \r\n 66\r\n \r\n 73\r\n \r\n \r\n \r\n Medium dependence (2-4)\r\n \r\n 33\r\n \r\n 36\r\n \r\n \r\n \r\n High dependence (5-6)\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\nHSI = Heavy Smoking IndexMay not add to 100% exactly due to roundingdiscussed in the text. ResultsRespondentsThe final sample included 111 current smokers (68 males; 103 non-M\u0101ori). Mean age was 22.5 years (SD = 2.6).Smoking-related behavioursRespondents in the current study were restricted to those who had become established smokers only after turning 18; however, they could have tried their first cigarette at any age. More than one-half of respondents (54%) had tried their first cigarette after turning 18, with 18 to 19-years-old being the most common age for first trying a cigarette. The majority (66%) of respondents had low nicotine dependence due to their relatively light smoking levels (83% smoked fewer than ten cigarettes per day) and long delays to their first cigarette after waking (43% smoked their first cigarette more than 60 minutes after waking). There were no differences in self-reported smoking behaviours by age or gender (p > .1 in all cases). Smoking-related behaviours are summarised in Table 1.Cessation-related behavioursRecent quit attemptsRecent quit attempts were common, with 81% of respondents attempting to quit in the last 12 months and 50% attempting to quit in the last three months. The likelihood of making a quit attempt recently did not vary by gender or age (p > .3 in all cases).Intention to quitNearly one-half of respondents (47%) intended to quit in the next 3 months. One-half (50%) reported high self-efficacy to quit (76% or greater chance of succeeding), 46% reported medium self-efficacy (26-74% chance), and 4% reported low self-efficacy (0-25% chance). The only predictor of intention to quit was having made a recent quit attempt (in the past three or 12 months; Table 2).Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Intended use of cessation aidsTo assess intended use of cessation aids, respondents were read a list of possible aids and asked whether or not they would use each one. After reading the list, respondents were also asked if they would try to quit \u201cwithout any support\u201d. Intended use of cessation aids was low (see Table 3), with 73% of respondents saying they intended to quit \u201cwithout any support\u201d. Aside from intending to quit without any support, the most common intended cessation aid was electronic cigarettes (50%), followed by the internet (46%) and nicotine replacement therapy (NRT; 45%).Table 3: Intended use of cessation products or services by gender and age\r\n \r\n \r\n \r\n \r\n \r\n Overall\r\n \r\n Gender\r\n \r\n Age\r\n \r\n \r\n \r\n Female\r\n \r\n Male\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n Without any support\r\n \r\n %\r\n \r\n 73\r\n \r\n 74\r\n \r\n 72\r\n \r\n 86\r\n \r\n 63\r\n \r\n 76\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.12 (0.45,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.27* (0.08,0.92)\r\n \r\n 0.51 (0.13,2.05)\r\n \r\n \r\n \r\n Electronic cigarettes\r\n \r\n %\r\n \r\n 50\r\n \r\n 61\r\n \r\n 42\r\n \r\n 48\r\n \r\n 52\r\n \r\n 46\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 2.16 (0.97,4.84)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.16 (0.46,2.93)\r\n \r\n 0.92 (0.32,2.65)\r\n \r\n \r\n \r\n Internet\r\n \r\n %\r\n \r\n 46\r\n \r\n 48\r\n \r\n 44\r\n \r\n 45\r\n \r\n 43\r\n \r\n 52\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.14 (0.52,2.52)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.92 (0.37,2.33)\r\n \r\n 1.33 (0.46,3.90)\r\n \r\n \r\n \r\n NRT\r\n \r\n %\r\n \r\n 45\r\n \r\n 48\r\n \r\n 43\r\n \r\n 48\r\n \r\n 47\r\n \r\n 38\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.54,2.62)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.95 (0.37,2.44)\r\n \r\n 0.67 (0.23,2.01)\r\n \r\n \r\n \r\n Quitline\r\n \r\n %\r\n \r\n 38\r\n \r\n 33\r\n \r\n 40\r\n \r\n 59\r\n \r\n 35\r\n \r\n 19\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.74 (0.33,1.68)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.38* (0.15,0.96)\r\n \r\n 0.17* (0.05,0.57)\r\n \r\n \r\n \r\n GP or nurse\r\n \r\n %\r\n \r\n 31\r\n \r\n 29\r\n \r\n 32\r\n \r\n 17\r\n \r\n 44\r\n \r\n 23\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.86 (0.37,2.05)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 3.73* (1.22,11.44)\r\n \r\n 1.44 (0.38,5.43)\r\n \r\n \r\n \r\n Mobile app\r\n \r\n %\r\n \r\n 31\r\n \r\n 33\r\n \r\n 30\r\n \r\n 38\r\n \r\n 29\r\n \r\n 28\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.51,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.65 (0.25,1.73)\r\n \r\n 0.64 (0.25,1.73)\r\n \r\n \r\n \r\n Cessation medication\r\n \r\n %\r\n \r\n 28\r\n \r\n 33\r\n \r\n 24\r\n \r\n 21\r\n \r\n 35\r\n \r\n 21\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.51 (0.62,3.70)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.96 (0.66,5.80)\r\n \r\n 0.96 (0.25,3.67)\r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; multiple responses were allowed and therefore results do not add to 100%; NRT = nicotine replacement therapy Intended use of specific cessation aids did not vary by gender, although there were some effects of age (see Table 3). Specifically, 21 to 24-year-olds were less likely than 18 to 20-year-olds to intend to quit without any support, and more likely to intend to go to their GP or nurse. Both groups of older respondents were less likely than 18 to 20-year-olds to intend to use Quitline.Social context of smokingSmoking was closely linked to drinking alcohol, with 85% of respondents agreeing that \u201cin the last two weeks, there has been an occasion where I smoked because I was drinking\u201d. Smoking also appeared to facilitate social interactions for many responde

Summary

Abstract

Aim

To understand the barriers to cessation among young late-onset smokers (young adults who started smoking daily after turning 18). Such information is crucial to the development of interventions aimed at reducing the high smoking prevalence among young adults.

Method

The New Zealand Smoking Monitor is a fortnightly telephone survey of current smokers and recent quitters. This study focused on responses from a group of late-onset smokers aged 18 to 28 years (N = 111), who were temporarily (for 11 fortnights) added to the monitor.

Results

Most respondents had low nicotine dependence and were actively trying to quit (81% had made at least one attempt that lasted 24 hours or longer in the last year). One-half had high self-efficacy to quit and three-quarters did not intend to use cessation aids. Smoking was tightly linked to drinking alcohol and conferred social benefits (eg, 51% agreed smoking helped me to socialise ).

Conclusion

The tendency not to use cessation aids, strong links between smoking and drinking and the social benefits of smoking may act as barriers to successful cessation among young late-onset smokers. Policies and interventions aimed at breaking associations between smoking, drinking, and socialising (eg, smokefree bars) could be effective for this group.

Author Information

Acknowledgements

Correspondence

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Competing Interests

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OLoughlin JL, Dugas EN, OLoughlin EK, Karp I, Sylvestre M-P. Incidence and Determinants of Cigarette Smoking Initiation in Young Adults. J Adolesc Health. 2014;54(1):26-32. Edwards R, Carter K, Peace J, Blakely T. An examination of smoking initiation rates by age: results from a large longitudinal study in New Zealand. Aust N Z J Public Health. 2013;37(6):516-519. doi:10.1111/1753-6405.12105. Bernat DH, Klein EG, Forster JL. Smoking Initiation During Young Adulthood: A Longitudinal Study of a Population-Based Cohort. J Adolesc Health. 2012;51(5):497-502. doi:10.1016/j.jadohealth.2012.02.017. Ministry of Health. Tobacco Use 2012/13: New Zealand Health Survey. Wellington: Ministry of Health; 2014. Action on Smoking and Health. Factsheet: Youth Smoking in New Zealand. http://www.ash.org.nz/wp-content/uploads/2014/08/2013-Youth-smoking-in-New-Zealand.pdf. Accessed October 1, 2014. Muir K, Mullan K, Powell A, Flaxman S, Thompson D, Griffiths M. 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Tobacco control research conceptualises smoking initiation not as a single event, but as a process that occurs through a series of stages.1,2 While there may be variations in the stages individuals pass through, the ages at which they enter a particular stage, and the time spent in each stage, it is generally accepted that one moves from never smoking (pre-contemplation) through to contemplation, trying their first few cigarettes, experimenting with smoking, smoking regularly but infrequently, and then smoking at an established level (daily or almost every day).1Traditional views of smoking initiation hold that the entire process from never to established smoking occurs almost exclusively in adolescence and consequently, preventive tobacco control initiatives have typically ignored young adults.3,4 However, emerging evidence shows that young adulthood (typically defined as 18 to 30-years-old) also represents a vulnerable time for the initiation, development, and establishment of smoking behaviours.2,4-8 For example, a recent US study found that 25% of those who were never smokers before age 18 smoked their first whole cigarette between the ages of 18 and 21 (representing the trying smoking stage of initiation).8 In New Zealand, the consistently high smoking prevalence among New Zealand young adults (eg, 25.4% for 20 to 24-year-olds in 2012/13 compared with 17.6% in the general population)9 coupled with a low and declining smoking prevalence among adolescents9,10 indicates that significant initiation may be occurring after age 17. Recent longitudinal data support this contention, with 7% of never-smoking 18 to 19-year-olds in New Zealand becoming regular smokers over the next four years (representing progression through all stages of smoking initiation after turning 18).7Several possible reasons for young adult smoking initiation (referred to in this article as late-onset smoking) have been put forward in the literature. First, there is the increased risk associated with significant life changes, where transitions to new environments, activities, and peer groups provide opportunities for the adoption of new behaviours such as taking up smoking.2 The psychological and physiological effects of nicotine also provide a mechanism for coping with the stress and anxiety that might come with these transitions.2 Young adults are at risk of taking up smoking as they face a number of these significant and potentially stressful life changes, including transitioning to life outside the parental home, interacting with new peer groups, entering the workforce, establishing identities, and engaging with new activities. At the same time, young adults are earning greater disposable incomes11 and gaining greater access to tobacco (through the ability to legally purchase cigarettes at age 18) and alcohol (including legal purchase and admission to pubs and clubs). Finally, alluring tobacco pack designs and branding offer young adults a label with which to express their personality and identity and may therefore play a role in supporting and maintaining smoking in that age group.12Many theoretical reasons have been put forward to explain late-onset smoking, but few studies have actually examined the phenomenon. Most that have done so have used varying measures of initiation (eg, some used trying a first cigarette,8 while others used established smoking7), were based in North America, and were focused on either quantifying late-onset smoking or determining the predictors of smoking initiation in young adulthood (which include the use of alcohol, boredom, stress, and exposure to smoking by friends and family).4There is, however, one recent qualitative study that provides some insight into the contexts of smoking initiation for young adults in New Zealand.13 The authors of that study found that young adults started smoking somewhat incidentally as a way of participating in social events and interacting with peers on drinking occasions; they did not necessarily make a conscious, considered decision to begin smoking. In this way, drinking alcohol and the associated social context play an important role in the initiation and development of smoking behaviour in young adults.13While qualitative studies provide insight into the social contexts and functions of smoking for young late-onset smokers in New Zealand, no studies have attempted to quantify the smoking- and cessation-related attitudes and behaviours of this group. To this end, the current research used data from the 2013 New Zealand Smoking Monitor (NZSM) to examine the attitudes and behaviours of young adults who became established smokers only after turning 18-years-old. Specifically, this study assessed current smoking behaviour, nicotine dependence, self-efficacy to quit, intentions and attempts to quit, intended use of cessation aids, and social experiences with smoking, with a view to understanding the barriers to successful cessation in young late-onset smokers. Understanding these barriers, which are largely modifiable, is important as they directly inform the design and targeting of tobacco initiatives aimed at reducing the high smoking prevalence among New Zealand young adults.MethodSurvey designData were collected as part of the New Zealand Smoking Monitor (NZSM), which is an on-going fortnightly survey of current smokers and recent quit attempters smoking-related attitudes and behaviours. The NZSM typically contains three sample groups (non quit attempters, recent quit attempters, and serious quit attempters), but for this study the authors temporarily (from July to November 2013) added a fourth sample group: young adult (18 to 28-year-olds) smokers who took up daily smoking (ie, had become established smokers) after age 18. The method for the NZSM has been described elsewhere.14 In brief, the NZSM uses a panel method where respondents can participate in up to six fortnightly interviews. Those who drop out of the survey (due to completing six interviews, being out of contact, or refusing to participate) are replaced by new respondents. A commercial research agency conducts the fieldwork using computer-assisted telephone interviewing (CATI). Although NZSM respondents can participate in up to six interviews, this paper reports on data collected from late-onset respondents first interview only.The New Zealand Health and Disability Ethics Committee has classified the NZSM as a low-risk study; it is therefore exempted from ethics review.15RecruitmentThe fieldwork agency typically recruits respondents for the NZSM from a nationally-representative omnibus survey (non quit attempters and recent quit attempters) or the New Zealand Quitline (serious quit attempters). However, the low prevalence of young late-onset smokers in the New Zealand population necessitated a different recruitment procedure for this sample. Recruitment contractors obtained contact details for potential late-onset respondents using a street intercept method, where recruiters approached young people in public places in various suburbs of six New Zealand cities (Auckland, Hamilton, Wellington, Christchurch, Palmerston North, and Dunedin). Recruiters asked if the person would like to participate in the survey before screening for eligibility.Eligible respondents were aged between 18 and 28 years, had started smoking daily (ie, had become established smokers) after the age of 18 years, and had smoked most days in the last 30 days. We included only established smokers in this study to ensure that respondents had relatively homogeneous smoking behaviour. Those who met the criteria and agreed to participate were later contacted by the fieldwork agency and re-screened for consent and eligibility before participating in the survey interview.QuestionnaireThis study focused on smoking-related behaviours, cessation-related behaviours, and the social context of smoking. To assess smoking-related behaviours, respondents were asked how old they were when they first tried a cigarette (respondents all became established smokers after turning 18-years-old, but could have smoked their first cigarette at any age) and the two questions in the Heavy Smoking Index (HSI):16 number of cigarettes per day (CPD number of cigarettes smoked per day and time to first cigarette after waking. To assess cessation-related behaviours, respondents were asked: whether they had made a quit attempt that lasted 24 hours or longer in the last 3 months (yes/no response); how many, if any, quit attempts lasting 24 hours or longer they had made in the last 12 months (transformed to yes/no responses for analysis); whether they agreed with the statement \u201cI intend to quit in the next 3 months\u201d (5-point agreement scale); how likely it is (out of 100) they would succeed if they tried to quit smoking (used as an indicator of self-efficacy to quit); and their intended use of specific cessation aids (yes/no responses to specific aids). To assess the social context of smoking, respondents were asked to indicate their agreement (5-point agreement scale) with five statements about their smoking-related experiences in the last two weeks.AnalysisAnalyses were conducted using STATA/IC 13.1. Proportions were first calculated to assess the frequency of particular behaviours in the sample. For questions with responses on a 5-point agreement scale, strongly agree and agree responses were combined to indicate overall agreement with particular statements. Respondents who refused to answer a particular question, or said dont know, were excluded from that particular analysis.Logistic regression analyses were then used to examine differences in responses by demographic and smoking-related variables. For the majority of the analyses, the independent variables were age and gender as previous research indicates these factors are important correlates of smoking behaviour.9 Although previous research has also identified ethnicity as an important correlate of smoking behaviour,9 ethnicity could not be examined due to low numbers of M\u0101ori (n = 8), Pacific (n = 9), and Asian (n = 16) respondents in the sample. The dependent variable was the specific smoking-related behaviour, cessation-related behaviour, or experience with smoking. For the analyses investigating intention to quit, nicotine dependence, self-efficacy, and recent quit attempts were included as additional independent variables in order to better understand the predictors of quit intention among young late-onset smokers.Statistically significant (p < .05) results are highlighted in the result tables, but where the odds ratios indicate potentially important non-significant trends, these are Table 1: Smoking-related behaviours among young late-onset smokers\r\n \r\n \r\n \r\n \r\n \r\n Percent\r\n \r\n n\r\n \r\n \r\n \r\n Age at first cigarette\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 13 or under\r\n \r\n 6\r\n \r\n 6\r\n \r\n \r\n \r\n 14-15\r\n \r\n 17\r\n \r\n 19\r\n \r\n \r\n \r\n 16-17\r\n \r\n 23\r\n \r\n 25\r\n \r\n \r\n \r\n 18-19\r\n \r\n 39\r\n \r\n 42\r\n \r\n \r\n \r\n 20-21\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 22-23\r\n \r\n 4\r\n \r\n 4\r\n \r\n \r\n \r\n 24-25\r\n \r\n 2\r\n \r\n 2\r\n \r\n \r\n \r\n 26 or over\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Number of cigarettes smoked per day\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 1-5\r\n \r\n 41\r\n \r\n 45\r\n \r\n \r\n \r\n 6-10\r\n \r\n 42\r\n \r\n 46\r\n \r\n \r\n \r\n 11-20\r\n \r\n 15\r\n \r\n 17\r\n \r\n \r\n \r\n 21-30\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n 31+\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Time to first cigarette after waking\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Within 5 mins\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 6 to 30 mins\r\n \r\n 21\r\n \r\n 23\r\n \r\n \r\n \r\n 31 to 60 mins\r\n \r\n 27\r\n \r\n 30\r\n \r\n \r\n \r\n After 60 mins\r\n \r\n 43\r\n \r\n 48\r\n \r\n \r\n \r\n Nicotine dependence (HSI score)\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Low dependence (0-1)\r\n \r\n 66\r\n \r\n 73\r\n \r\n \r\n \r\n Medium dependence (2-4)\r\n \r\n 33\r\n \r\n 36\r\n \r\n \r\n \r\n High dependence (5-6)\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\nHSI = Heavy Smoking IndexMay not add to 100% exactly due to roundingdiscussed in the text. ResultsRespondentsThe final sample included 111 current smokers (68 males; 103 non-M\u0101ori). Mean age was 22.5 years (SD = 2.6).Smoking-related behavioursRespondents in the current study were restricted to those who had become established smokers only after turning 18; however, they could have tried their first cigarette at any age. More than one-half of respondents (54%) had tried their first cigarette after turning 18, with 18 to 19-years-old being the most common age for first trying a cigarette. The majority (66%) of respondents had low nicotine dependence due to their relatively light smoking levels (83% smoked fewer than ten cigarettes per day) and long delays to their first cigarette after waking (43% smoked their first cigarette more than 60 minutes after waking). There were no differences in self-reported smoking behaviours by age or gender (p > .1 in all cases). Smoking-related behaviours are summarised in Table 1.Cessation-related behavioursRecent quit attemptsRecent quit attempts were common, with 81% of respondents attempting to quit in the last 12 months and 50% attempting to quit in the last three months. The likelihood of making a quit attempt recently did not vary by gender or age (p > .3 in all cases).Intention to quitNearly one-half of respondents (47%) intended to quit in the next 3 months. One-half (50%) reported high self-efficacy to quit (76% or greater chance of succeeding), 46% reported medium self-efficacy (26-74% chance), and 4% reported low self-efficacy (0-25% chance). The only predictor of intention to quit was having made a recent quit attempt (in the past three or 12 months; Table 2).Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Intended use of cessation aidsTo assess intended use of cessation aids, respondents were read a list of possible aids and asked whether or not they would use each one. After reading the list, respondents were also asked if they would try to quit \u201cwithout any support\u201d. Intended use of cessation aids was low (see Table 3), with 73% of respondents saying they intended to quit \u201cwithout any support\u201d. Aside from intending to quit without any support, the most common intended cessation aid was electronic cigarettes (50%), followed by the internet (46%) and nicotine replacement therapy (NRT; 45%).Table 3: Intended use of cessation products or services by gender and age\r\n \r\n \r\n \r\n \r\n \r\n Overall\r\n \r\n Gender\r\n \r\n Age\r\n \r\n \r\n \r\n Female\r\n \r\n Male\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n Without any support\r\n \r\n %\r\n \r\n 73\r\n \r\n 74\r\n \r\n 72\r\n \r\n 86\r\n \r\n 63\r\n \r\n 76\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.12 (0.45,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.27* (0.08,0.92)\r\n \r\n 0.51 (0.13,2.05)\r\n \r\n \r\n \r\n Electronic cigarettes\r\n \r\n %\r\n \r\n 50\r\n \r\n 61\r\n \r\n 42\r\n \r\n 48\r\n \r\n 52\r\n \r\n 46\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 2.16 (0.97,4.84)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.16 (0.46,2.93)\r\n \r\n 0.92 (0.32,2.65)\r\n \r\n \r\n \r\n Internet\r\n \r\n %\r\n \r\n 46\r\n \r\n 48\r\n \r\n 44\r\n \r\n 45\r\n \r\n 43\r\n \r\n 52\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.14 (0.52,2.52)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.92 (0.37,2.33)\r\n \r\n 1.33 (0.46,3.90)\r\n \r\n \r\n \r\n NRT\r\n \r\n %\r\n \r\n 45\r\n \r\n 48\r\n \r\n 43\r\n \r\n 48\r\n \r\n 47\r\n \r\n 38\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.54,2.62)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.95 (0.37,2.44)\r\n \r\n 0.67 (0.23,2.01)\r\n \r\n \r\n \r\n Quitline\r\n \r\n %\r\n \r\n 38\r\n \r\n 33\r\n \r\n 40\r\n \r\n 59\r\n \r\n 35\r\n \r\n 19\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.74 (0.33,1.68)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.38* (0.15,0.96)\r\n \r\n 0.17* (0.05,0.57)\r\n \r\n \r\n \r\n GP or nurse\r\n \r\n %\r\n \r\n 31\r\n \r\n 29\r\n \r\n 32\r\n \r\n 17\r\n \r\n 44\r\n \r\n 23\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.86 (0.37,2.05)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 3.73* (1.22,11.44)\r\n \r\n 1.44 (0.38,5.43)\r\n \r\n \r\n \r\n Mobile app\r\n \r\n %\r\n \r\n 31\r\n \r\n 33\r\n \r\n 30\r\n \r\n 38\r\n \r\n 29\r\n \r\n 28\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.51,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.65 (0.25,1.73)\r\n \r\n 0.64 (0.25,1.73)\r\n \r\n \r\n \r\n Cessation medication\r\n \r\n %\r\n \r\n 28\r\n \r\n 33\r\n \r\n 24\r\n \r\n 21\r\n \r\n 35\r\n \r\n 21\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.51 (0.62,3.70)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.96 (0.66,5.80)\r\n \r\n 0.96 (0.25,3.67)\r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; multiple responses were allowed and therefore results do not add to 100%; NRT = nicotine replacement therapy Intended use of specific cessation aids did not vary by gender, although there were some effects of age (see Table 3). Specifically, 21 to 24-year-olds were less likely than 18 to 20-year-olds to intend to quit without any support, and more likely to intend to go to their GP or nurse. Both groups of older respondents were less likely than 18 to 20-year-olds to intend to use Quitline.Social context of smokingSmoking was closely linked to drinking alcohol, with 85% of respondents agreeing that \u201cin the last two weeks, there has been an occasion where I smoked because I was drinking\u201d. Smoking also appeared to facilitate social interactions for many responde

Summary

Abstract

Aim

To understand the barriers to cessation among young late-onset smokers (young adults who started smoking daily after turning 18). Such information is crucial to the development of interventions aimed at reducing the high smoking prevalence among young adults.

Method

The New Zealand Smoking Monitor is a fortnightly telephone survey of current smokers and recent quitters. This study focused on responses from a group of late-onset smokers aged 18 to 28 years (N = 111), who were temporarily (for 11 fortnights) added to the monitor.

Results

Most respondents had low nicotine dependence and were actively trying to quit (81% had made at least one attempt that lasted 24 hours or longer in the last year). One-half had high self-efficacy to quit and three-quarters did not intend to use cessation aids. Smoking was tightly linked to drinking alcohol and conferred social benefits (eg, 51% agreed smoking helped me to socialise ).

Conclusion

The tendency not to use cessation aids, strong links between smoking and drinking and the social benefits of smoking may act as barriers to successful cessation among young late-onset smokers. Policies and interventions aimed at breaking associations between smoking, drinking, and socialising (eg, smokefree bars) could be effective for this group.

Author Information

Acknowledgements

Correspondence

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Competing Interests

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Tobacco control research conceptualises smoking initiation not as a single event, but as a process that occurs through a series of stages.1,2 While there may be variations in the stages individuals pass through, the ages at which they enter a particular stage, and the time spent in each stage, it is generally accepted that one moves from never smoking (pre-contemplation) through to contemplation, trying their first few cigarettes, experimenting with smoking, smoking regularly but infrequently, and then smoking at an established level (daily or almost every day).1Traditional views of smoking initiation hold that the entire process from never to established smoking occurs almost exclusively in adolescence and consequently, preventive tobacco control initiatives have typically ignored young adults.3,4 However, emerging evidence shows that young adulthood (typically defined as 18 to 30-years-old) also represents a vulnerable time for the initiation, development, and establishment of smoking behaviours.2,4-8 For example, a recent US study found that 25% of those who were never smokers before age 18 smoked their first whole cigarette between the ages of 18 and 21 (representing the trying smoking stage of initiation).8 In New Zealand, the consistently high smoking prevalence among New Zealand young adults (eg, 25.4% for 20 to 24-year-olds in 2012/13 compared with 17.6% in the general population)9 coupled with a low and declining smoking prevalence among adolescents9,10 indicates that significant initiation may be occurring after age 17. Recent longitudinal data support this contention, with 7% of never-smoking 18 to 19-year-olds in New Zealand becoming regular smokers over the next four years (representing progression through all stages of smoking initiation after turning 18).7Several possible reasons for young adult smoking initiation (referred to in this article as late-onset smoking) have been put forward in the literature. First, there is the increased risk associated with significant life changes, where transitions to new environments, activities, and peer groups provide opportunities for the adoption of new behaviours such as taking up smoking.2 The psychological and physiological effects of nicotine also provide a mechanism for coping with the stress and anxiety that might come with these transitions.2 Young adults are at risk of taking up smoking as they face a number of these significant and potentially stressful life changes, including transitioning to life outside the parental home, interacting with new peer groups, entering the workforce, establishing identities, and engaging with new activities. At the same time, young adults are earning greater disposable incomes11 and gaining greater access to tobacco (through the ability to legally purchase cigarettes at age 18) and alcohol (including legal purchase and admission to pubs and clubs). Finally, alluring tobacco pack designs and branding offer young adults a label with which to express their personality and identity and may therefore play a role in supporting and maintaining smoking in that age group.12Many theoretical reasons have been put forward to explain late-onset smoking, but few studies have actually examined the phenomenon. Most that have done so have used varying measures of initiation (eg, some used trying a first cigarette,8 while others used established smoking7), were based in North America, and were focused on either quantifying late-onset smoking or determining the predictors of smoking initiation in young adulthood (which include the use of alcohol, boredom, stress, and exposure to smoking by friends and family).4There is, however, one recent qualitative study that provides some insight into the contexts of smoking initiation for young adults in New Zealand.13 The authors of that study found that young adults started smoking somewhat incidentally as a way of participating in social events and interacting with peers on drinking occasions; they did not necessarily make a conscious, considered decision to begin smoking. In this way, drinking alcohol and the associated social context play an important role in the initiation and development of smoking behaviour in young adults.13While qualitative studies provide insight into the social contexts and functions of smoking for young late-onset smokers in New Zealand, no studies have attempted to quantify the smoking- and cessation-related attitudes and behaviours of this group. To this end, the current research used data from the 2013 New Zealand Smoking Monitor (NZSM) to examine the attitudes and behaviours of young adults who became established smokers only after turning 18-years-old. Specifically, this study assessed current smoking behaviour, nicotine dependence, self-efficacy to quit, intentions and attempts to quit, intended use of cessation aids, and social experiences with smoking, with a view to understanding the barriers to successful cessation in young late-onset smokers. Understanding these barriers, which are largely modifiable, is important as they directly inform the design and targeting of tobacco initiatives aimed at reducing the high smoking prevalence among New Zealand young adults.MethodSurvey designData were collected as part of the New Zealand Smoking Monitor (NZSM), which is an on-going fortnightly survey of current smokers and recent quit attempters smoking-related attitudes and behaviours. The NZSM typically contains three sample groups (non quit attempters, recent quit attempters, and serious quit attempters), but for this study the authors temporarily (from July to November 2013) added a fourth sample group: young adult (18 to 28-year-olds) smokers who took up daily smoking (ie, had become established smokers) after age 18. The method for the NZSM has been described elsewhere.14 In brief, the NZSM uses a panel method where respondents can participate in up to six fortnightly interviews. Those who drop out of the survey (due to completing six interviews, being out of contact, or refusing to participate) are replaced by new respondents. A commercial research agency conducts the fieldwork using computer-assisted telephone interviewing (CATI). Although NZSM respondents can participate in up to six interviews, this paper reports on data collected from late-onset respondents first interview only.The New Zealand Health and Disability Ethics Committee has classified the NZSM as a low-risk study; it is therefore exempted from ethics review.15RecruitmentThe fieldwork agency typically recruits respondents for the NZSM from a nationally-representative omnibus survey (non quit attempters and recent quit attempters) or the New Zealand Quitline (serious quit attempters). However, the low prevalence of young late-onset smokers in the New Zealand population necessitated a different recruitment procedure for this sample. Recruitment contractors obtained contact details for potential late-onset respondents using a street intercept method, where recruiters approached young people in public places in various suburbs of six New Zealand cities (Auckland, Hamilton, Wellington, Christchurch, Palmerston North, and Dunedin). Recruiters asked if the person would like to participate in the survey before screening for eligibility.Eligible respondents were aged between 18 and 28 years, had started smoking daily (ie, had become established smokers) after the age of 18 years, and had smoked most days in the last 30 days. We included only established smokers in this study to ensure that respondents had relatively homogeneous smoking behaviour. Those who met the criteria and agreed to participate were later contacted by the fieldwork agency and re-screened for consent and eligibility before participating in the survey interview.QuestionnaireThis study focused on smoking-related behaviours, cessation-related behaviours, and the social context of smoking. To assess smoking-related behaviours, respondents were asked how old they were when they first tried a cigarette (respondents all became established smokers after turning 18-years-old, but could have smoked their first cigarette at any age) and the two questions in the Heavy Smoking Index (HSI):16 number of cigarettes per day (CPD number of cigarettes smoked per day and time to first cigarette after waking. To assess cessation-related behaviours, respondents were asked: whether they had made a quit attempt that lasted 24 hours or longer in the last 3 months (yes/no response); how many, if any, quit attempts lasting 24 hours or longer they had made in the last 12 months (transformed to yes/no responses for analysis); whether they agreed with the statement \u201cI intend to quit in the next 3 months\u201d (5-point agreement scale); how likely it is (out of 100) they would succeed if they tried to quit smoking (used as an indicator of self-efficacy to quit); and their intended use of specific cessation aids (yes/no responses to specific aids). To assess the social context of smoking, respondents were asked to indicate their agreement (5-point agreement scale) with five statements about their smoking-related experiences in the last two weeks.AnalysisAnalyses were conducted using STATA/IC 13.1. Proportions were first calculated to assess the frequency of particular behaviours in the sample. For questions with responses on a 5-point agreement scale, strongly agree and agree responses were combined to indicate overall agreement with particular statements. Respondents who refused to answer a particular question, or said dont know, were excluded from that particular analysis.Logistic regression analyses were then used to examine differences in responses by demographic and smoking-related variables. For the majority of the analyses, the independent variables were age and gender as previous research indicates these factors are important correlates of smoking behaviour.9 Although previous research has also identified ethnicity as an important correlate of smoking behaviour,9 ethnicity could not be examined due to low numbers of M\u0101ori (n = 8), Pacific (n = 9), and Asian (n = 16) respondents in the sample. The dependent variable was the specific smoking-related behaviour, cessation-related behaviour, or experience with smoking. For the analyses investigating intention to quit, nicotine dependence, self-efficacy, and recent quit attempts were included as additional independent variables in order to better understand the predictors of quit intention among young late-onset smokers.Statistically significant (p < .05) results are highlighted in the result tables, but where the odds ratios indicate potentially important non-significant trends, these are Table 1: Smoking-related behaviours among young late-onset smokers\r\n \r\n \r\n \r\n \r\n \r\n Percent\r\n \r\n n\r\n \r\n \r\n \r\n Age at first cigarette\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 13 or under\r\n \r\n 6\r\n \r\n 6\r\n \r\n \r\n \r\n 14-15\r\n \r\n 17\r\n \r\n 19\r\n \r\n \r\n \r\n 16-17\r\n \r\n 23\r\n \r\n 25\r\n \r\n \r\n \r\n 18-19\r\n \r\n 39\r\n \r\n 42\r\n \r\n \r\n \r\n 20-21\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 22-23\r\n \r\n 4\r\n \r\n 4\r\n \r\n \r\n \r\n 24-25\r\n \r\n 2\r\n \r\n 2\r\n \r\n \r\n \r\n 26 or over\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Number of cigarettes smoked per day\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n 1-5\r\n \r\n 41\r\n \r\n 45\r\n \r\n \r\n \r\n 6-10\r\n \r\n 42\r\n \r\n 46\r\n \r\n \r\n \r\n 11-20\r\n \r\n 15\r\n \r\n 17\r\n \r\n \r\n \r\n 21-30\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n 31+\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\n Time to first cigarette after waking\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Within 5 mins\r\n \r\n 9\r\n \r\n 10\r\n \r\n \r\n \r\n 6 to 30 mins\r\n \r\n 21\r\n \r\n 23\r\n \r\n \r\n \r\n 31 to 60 mins\r\n \r\n 27\r\n \r\n 30\r\n \r\n \r\n \r\n After 60 mins\r\n \r\n 43\r\n \r\n 48\r\n \r\n \r\n \r\n Nicotine dependence (HSI score)\r\n \r\n \r\n \r\n \r\n \r\n \r\n \r\n Low dependence (0-1)\r\n \r\n 66\r\n \r\n 73\r\n \r\n \r\n \r\n Medium dependence (2-4)\r\n \r\n 33\r\n \r\n 36\r\n \r\n \r\n \r\n High dependence (5-6)\r\n \r\n 1\r\n \r\n 1\r\n \r\n \r\n \r\nHSI = Heavy Smoking IndexMay not add to 100% exactly due to roundingdiscussed in the text. ResultsRespondentsThe final sample included 111 current smokers (68 males; 103 non-M\u0101ori). Mean age was 22.5 years (SD = 2.6).Smoking-related behavioursRespondents in the current study were restricted to those who had become established smokers only after turning 18; however, they could have tried their first cigarette at any age. More than one-half of respondents (54%) had tried their first cigarette after turning 18, with 18 to 19-years-old being the most common age for first trying a cigarette. The majority (66%) of respondents had low nicotine dependence due to their relatively light smoking levels (83% smoked fewer than ten cigarettes per day) and long delays to their first cigarette after waking (43% smoked their first cigarette more than 60 minutes after waking). There were no differences in self-reported smoking behaviours by age or gender (p > .1 in all cases). Smoking-related behaviours are summarised in Table 1.Cessation-related behavioursRecent quit attemptsRecent quit attempts were common, with 81% of respondents attempting to quit in the last 12 months and 50% attempting to quit in the last three months. The likelihood of making a quit attempt recently did not vary by gender or age (p > .3 in all cases).Intention to quitNearly one-half of respondents (47%) intended to quit in the next 3 months. One-half (50%) reported high self-efficacy to quit (76% or greater chance of succeeding), 46% reported medium self-efficacy (26-74% chance), and 4% reported low self-efficacy (0-25% chance). The only predictor of intention to quit was having made a recent quit attempt (in the past three or 12 months; Table 2).Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Table 2: Factors associated with intention to quit in the next 3 months\r\n \r\n \r\n \r\n Independent variable\r\n \r\n Variable categories\r\n \r\n \r\n \r\n Gender\r\n \r\n Female\r\n \r\n Male\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 47\r\n \r\n 47\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 0.98 (0.45, 2.12)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Age\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n %\r\n \r\n 40\r\n \r\n 44\r\n \r\n 59\r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n Ref\r\n \r\n 1.19 (0.48, 2.96)\r\n \r\n 2.18 (0.76, 6.30)\r\n \r\n \r\n \r\n Self-efficacy to quit\r\n \r\n Med\r\n \r\n High\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 48\r\n \r\n 45\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.11 (0.51, 2.39)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Nicotine dependence\r\n \r\n Low\r\n \r\n Med\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 51\r\n \r\n 38\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 1.66 (0.72, 3.81)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 3 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 62\r\n \r\n 31\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 3.59* (1.62, 7.98)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\n Quit attempt in last 12 months\r\n \r\n Yes\r\n \r\n No\r\n \r\n \r\n \r\n \r\n \r\n %\r\n \r\n 53\r\n \r\n 20\r\n \r\n \r\n \r\n \r\n \r\n OR (95% CI)\r\n \r\n 4.50* (1.39, 14.58)\r\n \r\n Ref\r\n \r\n \r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; low self-efficacy and high nicotine dependence were not assessed due to a low number of respondents in those categories Intended use of cessation aidsTo assess intended use of cessation aids, respondents were read a list of possible aids and asked whether or not they would use each one. After reading the list, respondents were also asked if they would try to quit \u201cwithout any support\u201d. Intended use of cessation aids was low (see Table 3), with 73% of respondents saying they intended to quit \u201cwithout any support\u201d. Aside from intending to quit without any support, the most common intended cessation aid was electronic cigarettes (50%), followed by the internet (46%) and nicotine replacement therapy (NRT; 45%).Table 3: Intended use of cessation products or services by gender and age\r\n \r\n \r\n \r\n \r\n \r\n Overall\r\n \r\n Gender\r\n \r\n Age\r\n \r\n \r\n \r\n Female\r\n \r\n Male\r\n \r\n 18-20\r\n \r\n 21-24\r\n \r\n 25-28\r\n \r\n \r\n \r\n Without any support\r\n \r\n %\r\n \r\n 73\r\n \r\n 74\r\n \r\n 72\r\n \r\n 86\r\n \r\n 63\r\n \r\n 76\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.12 (0.45,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.27* (0.08,0.92)\r\n \r\n 0.51 (0.13,2.05)\r\n \r\n \r\n \r\n Electronic cigarettes\r\n \r\n %\r\n \r\n 50\r\n \r\n 61\r\n \r\n 42\r\n \r\n 48\r\n \r\n 52\r\n \r\n 46\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 2.16 (0.97,4.84)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.16 (0.46,2.93)\r\n \r\n 0.92 (0.32,2.65)\r\n \r\n \r\n \r\n Internet\r\n \r\n %\r\n \r\n 46\r\n \r\n 48\r\n \r\n 44\r\n \r\n 45\r\n \r\n 43\r\n \r\n 52\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.14 (0.52,2.52)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.92 (0.37,2.33)\r\n \r\n 1.33 (0.46,3.90)\r\n \r\n \r\n \r\n NRT\r\n \r\n %\r\n \r\n 45\r\n \r\n 48\r\n \r\n 43\r\n \r\n 48\r\n \r\n 47\r\n \r\n 38\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.54,2.62)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.95 (0.37,2.44)\r\n \r\n 0.67 (0.23,2.01)\r\n \r\n \r\n \r\n Quitline\r\n \r\n %\r\n \r\n 38\r\n \r\n 33\r\n \r\n 40\r\n \r\n 59\r\n \r\n 35\r\n \r\n 19\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.74 (0.33,1.68)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.38* (0.15,0.96)\r\n \r\n 0.17* (0.05,0.57)\r\n \r\n \r\n \r\n GP or nurse\r\n \r\n %\r\n \r\n 31\r\n \r\n 29\r\n \r\n 32\r\n \r\n 17\r\n \r\n 44\r\n \r\n 23\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 0.86 (0.37,2.05)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 3.73* (1.22,11.44)\r\n \r\n 1.44 (0.38,5.43)\r\n \r\n \r\n \r\n Mobile app\r\n \r\n %\r\n \r\n 31\r\n \r\n 33\r\n \r\n 30\r\n \r\n 38\r\n \r\n 29\r\n \r\n 28\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.19 (0.51,2.78)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 0.65 (0.25,1.73)\r\n \r\n 0.64 (0.25,1.73)\r\n \r\n \r\n \r\n Cessation medication\r\n \r\n %\r\n \r\n 28\r\n \r\n 33\r\n \r\n 24\r\n \r\n 21\r\n \r\n 35\r\n \r\n 21\r\n \r\n \r\n \r\n OR (95%CI)\r\n \r\n \r\n \r\n 1.51 (0.62,3.70)\r\n \r\n Ref\r\n \r\n Ref\r\n \r\n 1.96 (0.66,5.80)\r\n \r\n 0.96 (0.25,3.67)\r\n \r\n \r\n \r\nNote: Significant effects are bolded and marked with an asterisk; multiple responses were allowed and therefore results do not add to 100%; NRT = nicotine replacement therapy Intended use of specific cessation aids did not vary by gender, although there were some effects of age (see Table 3). Specifically, 21 to 24-year-olds were less likely than 18 to 20-year-olds to intend to quit without any support, and more likely to intend to go to their GP or nurse. Both groups of older respondents were less likely than 18 to 20-year-olds to intend to use Quitline.Social context of smokingSmoking was closely linked to drinking alcohol, with 85% of respondents agreeing that \u201cin the last two weeks, there has been an occasion where I smoked because I was drinking\u201d. Smoking also appeared to facilitate social interactions for many responde

Summary

Abstract

Aim

To understand the barriers to cessation among young late-onset smokers (young adults who started smoking daily after turning 18). Such information is crucial to the development of interventions aimed at reducing the high smoking prevalence among young adults.

Method

The New Zealand Smoking Monitor is a fortnightly telephone survey of current smokers and recent quitters. This study focused on responses from a group of late-onset smokers aged 18 to 28 years (N = 111), who were temporarily (for 11 fortnights) added to the monitor.

Results

Most respondents had low nicotine dependence and were actively trying to quit (81% had made at least one attempt that lasted 24 hours or longer in the last year). One-half had high self-efficacy to quit and three-quarters did not intend to use cessation aids. Smoking was tightly linked to drinking alcohol and conferred social benefits (eg, 51% agreed smoking helped me to socialise ).

Conclusion

The tendency not to use cessation aids, strong links between smoking and drinking and the social benefits of smoking may act as barriers to successful cessation among young late-onset smokers. Policies and interventions aimed at breaking associations between smoking, drinking, and socialising (eg, smokefree bars) could be effective for this group.

Author Information

Acknowledgements

Correspondence

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Competing Interests

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