Failure of at-risk adolescents to quit smoking according to their organization: Focusing in adolescents on probation

Ⅰ. Introduction

Adolescence is the most important transition period in the lives of individuals, as during this period, social conditions have a biological, behavioral, and psychological impact on them (Sawyer et al., 2012). In addition, most people develop unhealthy habits during adolescence, which could affect their lifelong health (Jackson, Henderson, Frank, & Haw, 2012). The OECD defines at-risk adolescents as those who have run away from home, dropped out of school, are suffering from bullying, have committed delinquencies or crimes, or are at risk of depression and suicide. Most of these at-risk adolescents are exposed to the risk of various crimes, as they were raised in challenging environments and experience accidental impulses (Song & Yang, 2021). Previous studies on adolescents who are subject to probation have reported that the smoking rate was as high as 75% for adolescents who did not show up for class, those who dropped out of school, and others who were at-risk, whereas according to data from the Centers for Disease Control and Prevention (CDC) of the United States, at-risk adolescents have been reported to smoke more than students at regular high schools (McFarland et al., 2019; Peters et al., 2005). The issue of at-risk adolescents’ smoking is largely influenced not only by their peer groups and their experiences of delinquency (Gonzalez et al., 2016; Lee, Lee, & Kim, 2019), but also works as a “gateway” through which they are exposed to a more serious problem: drug abuse (Peters et al., 2005). Moreover, those who start smoking at a younger age are more likely to become lifelong smokers, as it has an impact on their level of nicotine dependence. Smoking at an early age also drastically shortens life expectancy (DiFranza et al., 2000) and affects the growth and health of both male and female adolescents (Song & Yang, 2021). It has also been reported that compared to adults, adolescents show a lower rate of making attempts to quit smoking and succeeding (Abrantes et al., 2009; Zhu, Sun, Billings, Choi, & Malrcher, 1999).

Pursuant to the Act on Probation (hereinafter referred to as the “Probation Act”), probation is an advanced system for the prevention of recidivism, not by detaining adolescents who have committed delinquencies or crimes in detention facilities like prisons and juvenile detention centers, but by forcing them to observe requirements through the monitoring and instructions of probation officers, performing mandatory community service, and taking educational training sessions. Adolescents subject to probation should observe the general and special matters ordered by the court. Among them, special matters might be imposed by the court or Probation Review Commission, depending on the characteristics of the individual minor, who is subject to probation. Using these special matters could help provide smoking interventions and behavioral corrections for adolescents subject to probation, particularly through counseling services for smoking cessation, among other national smoking cessation support programs.

Since the revision of the National Health Promotion Act in 1995, the Korean government has been leading diverse initiatives and policies to help people quit smoking (Kim, Yoo, & Kang, 2019). In line with such efforts, school-based smoking prevention and cessation programs have been carried out to lower the smoking rate among adolescents. According to the 2020 online survey on adolescents’ health behaviors, this program contributed to a large extent in lowering the smoking rate of adolescents from 6.7% in 2019 to 4.4% in 2020, while daily smoking also decreased from 3.2% to 2.3% during the same period (Korea Centers for Disease Control and Prevention, 2020).

Previous studies that studied youth smoking according to school and community characteristics report that adolescents who attended schools focused on strong policies related to tobacco use were less likely to smoke than those who did not (Lovato et al., 2010). In addition, adolescents who transferred to alternative schools due to academic or behavioral problems had a relatively high risk of smoking (Sussman, Dent, Severson, Dee, & Flay, 1998). A prior study on the use of tobacco by teenagers entering youth protection facilities in Quebec reported that tobacco use among teenagers using the facility is routine and policies to encourage a smoking cessation environment are needed (Haley at al., 2016), and a prior study on single mothers in Korea introduced individual smoking cessation counseling as the most effective smoking cessation factor (Lee & Lee, 2021). Therefore, we conducted smoking cessation counseling for single mother facilities, child care facilities, and youth institutions corresponding to child and youth protection facilities.

Currently, most youth smoking-related studies are only data on teenagers in school, and there are few studies based on the type of institution in crisis compared to this. Therefore, through various prior studies, data were collected and analyzed by dividing institutions by type, and the failure of adolescents to quit smoking was investigated according to the type of institution.

Ⅱ. Methods

Ⅲ. Results

1. Participants’ general characteristics

Among the 1,437 participants, 63.1% were males. As for the smoking age, 1,100 high school students made up the largest portion (76.5%). The adolescents who drank (56.1%) were more than those who did not. Those who worked out (61.0%), comprised a larger portion compared to those who did not <Table 1>.

<Table 1>

General characteristics according to various institutionsUnit: N(%)

2. Smoking-related characteristics by institutions

As for the smoking-related characteristics by institutions, significant differences were observed for carbon monoxide concentration, average smoking amount, and total number of years smoking. Among the participants, adolescents on probation showed the highest carbon monoxide concentration at 9.07 ppm, and reported the largest average smoking amount at 13.95 cigarettes <Table 2>.

<Table 2>

Smoking-related characteristics according to various institutionsUnit: %

3. Comparison of failure rate by institutions

In the comparison of failure rates by institutions, adolescents on probation showed the highest failure rate for the period of 4 (90.5%), 6 (91.8%), 12 (96.5%), and 24 (100.0%) weeks <Table 3>.

<Table 3>

Smoking cessation failure rate according to various institutionsUnit: N(%)

4. Comparison and analysis of failure rates by the category of institutions (for the period of 4, 6, and 12 weeks)

When compared and analyzed against the adolescents studying at alternative or vocational schools, it was reported that the failure rate of adolescents on probation was higher for 4 (OR=4.86,95% CI=3.02-7.82), 6 (OR=4.74,95% CI=2.87-7.84), and 12 weeks (OR=6.28, 95% CI=3.12-12.65) <Table 4>.

<Table 4>

Failure rate of smoking cessation by various institutions

Ⅳ. Discussion

In this study, the difference in the failure rate of smoking cessation among adolescents in crisis according to the type of institution was found.

Its results showed that compared to adolescents who were not on probation, those on probation reported the highest figures for carbon monoxide concentration in their exhaled breath, daily average smoking amounts, and smoking cessation failure rate. Juveniles subject to probation refer to subjects in the process of probation disposition No. 4 (short-term one-year) and No. 5 (long-term two-year) during juvenile protection trials, which are made based on the size of each case and the presence or absence of reflection of the perpetrator. Therefore, these results are expected to require close communication and support from probation officers that directly affect the smooth return of adolescents to society along with institutional intervention of smoking cessation programs using special compliance with juvenile probation.

As the “Smoking Prevention at School Program” is operated across the nation only at middle and high schools, it becomes difficult for at-risk adolescents, including those who do not go to school or who have run away from home to participate and benefit from the program. Among them, adolescents on probation are much more likely to smoke. As reported by previous studies (Hershberger, Zapolski, & Aalsma, 2016) a positive relationship could work as a buffer in the relationship between crimes and smoking among teenage criminals because when depending on social support, a high level of correlation exists among social support, illegal acts by adolescents, and smoking (Wojciechowski, 2019). Probation monitoring centers are offering diverse programs for adolescents, including social value-based juvenile delinquency treatment and prevention programs (May, Osmond, & Billick, 2014), and team-based approach programs for the improvement of parent-child relationships (Brank, Lane, Turner, Fain, & Sehgal, 2008). However, as the number of adolescents assigned to one probation officer is very large, probation officers are highly likely to be exhausted owing to excessive workloads and responsibilities (White, Aalsma, Holloway, Adams, & Salyers, 2015). For this reason, it is difficult to provide customized guidance to individual adolescents or adopt in-depth approaches for them. Additionally, systematic non-smoking counseling services for adolescents on probation have never existed. Therefore, in this situation, it is almost impossible for adolescents who are subject to probation to use non-smoking training and counseling services provided by the government, unlike those who are not subject to probation.

Taking cognizance of the situation, this study adopted a non-smoking counseling service in which experienced counselors visited probation-related institutions and consistently provided 10 or more customized individual counseling sessions and programs on non-smoking, under the guidance of the juvenile probation officer. A comparison of failure rates between adolescents on probation and those from alternative/vocational schools showed that those from alternative/vocational schools had lower failure rates than adolescents on probation. This result is in line with the context of a previous study on Canadian youth that found that improving the school environment can reduce youth smoking rates (Azagba, & Asbridge, 2013), and a study on youth smoking reduction through school environments targeting alternative high schools across Denmark. As with the results of previous studies, it indicates that it is much more effective to prevent and reduce tobacco use in alternative vocational schools through an intensive anti-smoking policy based on the school environment (Jakobsen et al., 2021). Therefore, it is expected that skilled smoking cessation counselors or experts will be effective in conducting smoking cessation education in advance to create a smoking cessation environment atmosphere and encourage voluntary participation in smoking cessation counseling at school environment-based institutions.

According to previous studies on out of school adolescents’ smoking, these adolescents’ smoking-related morbidity and mortality rates were higher than those of adolescents who were affiliated to schools, as factors that could protect adolescents on probation based on the school environment were non-existent (Desai, Ruiter, Schepers, Reddy, & Mercken, 2019). In this regard, smaller class sizes, lower teacher-to-student ratios, adolescent-tailored curricula, flexible and safe environments, and other factors of alternative/vocational schools that adolescents are affiliated to, all play an important role in building an environment to help adolescents stop smoking (Edgar-Smith & Palmer, 2015). Nevertheless, according to a previous study that compared adolescents at school and those out of school, only 23.4% of the out of school adolescents were given non-smoking education compared to the at-school adolescents (61.9%) (McFarland et al., 2019). As adolescents on probation are also not affiliated with any institution, they are probably exposed to many types of misconduct and delinquencies because they are not appropriately monitored or educated.

The crime analysis data of the Korea Youth Counseling and Welfare Institute and Korean Prosecution Service reported that 90% of juvenile “repeat offenders” who recommitted a crime after probation was imposed on them, committed the second crime within one year (Korea Youth Councelling & Welfare Institute, 2019). In addition, according to previous studies that explored the factors of delinquent behavior among Pakistani and Thai adolescents, it was found that smoking factors were included in the highest order of delinquent behavior difference in both countries (Panezai, Panezai, Wassan, & Saqib, 2019). Therefore, smoking cessation is the most basic gateway to leading a healthy life for not only adolescents subject to probation but also adolescents in crisis, and is a major issue that should be of continued interest. To address this, during the last decade. the Korean government has been implementing numerous initiatives and non-smoking policies, as well as creating diverse endeavors to change public awareness of smoking, including providing aggressive smoking prevention education at schools (Lee & Kim, 2017), creating and managing an environment where adolescents are prohibited from purchasing cigarettes by raising cigarette prices (Min, Seo, & Park, 2018) and expanding non-smoking zones. In addition to such efforts, building a customized support system for adolescents on probation is also required, as they are in the blind spot of the benefits from such programs and policies of the government. This can be done by hiring experienced experts, who can consider the unique characteristics of adolescents on probation. As in the context of previous studies on school participation of adolescents under probation, lack of school participation is related to negative results such as school dropout and delinquency behavior, and school participation and delinquency are highly correlated. Therefore, as in the study (Crumé, Nurius, Kim, & Logan-Greene, 2021), it is urgent to introduce customized smoking cessation support services and individual smoking cessation counseling so that teenagers can function as healthy members of society.

Unlike previous studies conducted only on youth smokers attending school (Vallata, O’Loughlin, Cengelli, & Alla, 2021), this study is meaningful in that it provides data analysis on smoking-related characteristics and factors affecting smoking failure for adolescents in crisis according to institutional type. As a limitation of this study, the results of this study cannot be applied to the entire youth in crisis in Korea as it may lack representation because the study subjects were recruited and conducted as a convenience sample. Therefore, it is necessary to expand the scope and look beyond regional limitations.

Ⅴ. Conclusion

This study sought to identify the current status of smoking cessation failures of crisis adolescents according to the type of institution and to show that the effect of smoking intervention through surrounding supporters and school environment may vary depending on the type of institution in crisis youth. As a result, adolescents belonging to the Ministry of Justice had the highest carbon monoxide level and average smoking amount compared to other adolescents, which explains the school-based environment and the need to introduce visiting smoking cessation support services.

References

• Abrantes, A. M., Lee, C. S., MacPherson, L., Strong, D. R., Borrelli, B., & Brown, R. A. (2009). Health risk behaviors in relation to making a smoking quit attempt among adolescents. Journal of Behavioral Medicine, 32(2), 142-149. [https://doi.org/10.1007/s10865-008-9184-1]
• Azagba, S., & Asbridge, M. (2013). School connectedness and susceptibility to smoking among adolescents in Canada. Nicotine & Tobacco Research, 15(8), 1458-1463. [https://doi.org/10.1093/ntr/nts340]
• Brank, E., Lane, J., Turner, S., Fain, T., & Sehgal, A. (2008). An experimental juvenile probation program: Effects on parent and peer relationships. Crime & Delinquency, 54(2), 193-224. [https://doi.org/10.1177/0011128706296048]
• Crumé, H. J., Nurius, P. S., Kim, B.-K. E., & Logan-Greene, P. (2021). School engagement among youth entering probation. Journal of Youth and Adolescence, 50(6), 1098-1113. [https://doi.org/10.1007/s10964-021-01405-3]
• Desai, R., Ruiter, R. A. C., Schepers, J., Reddy, S. P., & Mercken, L. A. G. (2019). Tackling smoking among out of school youth in South Africa: An analysis of friendship ties. Addictive Behaviors Reports, 10, 100214. [https://doi.org/10.1016/j.abrep.2019.100214]
• DiFranza, J. R., Rigotti, N. A., McNeill, A. D., Ockene, J. K., Savageau, J. A., St Cyr, D., & Coleman, M. (2000). Initial symptoms of nicotine dependence in adolescents. Tobacco Control, 9(3), 313-319. [https://doi.org/10.1136/tc.9.3.313]
• Edgar-Smith, S., & Palmer, R. B. (2015). Building supportive school environments for alternative education youth. Preventing School Failure: Alternative Education for Children and Youth, 59(3), 134-141. [https://doi.org/10.1080/1045988X.2013.865587]
• Gonzalez, J. M. R., Salas-Wright, C. P., Connell, N. M., Jetelina, K. K., Clipper, S. J., & Businelle, M. S. (2016). The long-term effects of school dropout and GED attainment on substance use disorders. Drug and Alcohol Dependence, 158, 60-66. [https://doi.org/10.1016/j.drugalcdep.2015.11.002]
• Haley, N., Lambert, G., Gervais, A., Tremblay, C., Roy, E., & Frappier, J. Y. (2016). Tobacco use among adolescents entering Quebec Youth Protection Centers. Paediatr Child Health, 21(Supplement_5), e60c-e61. [https://doi.org/10.1093/pch/21.supp5.e60c]
• Hershberger, A., Zapolski, T., & Aalsma, M. C. (2016). Social support as a buffer between discrimination and cigarette use in juvenile offenders. Addictive Behaviors, 59, 7-11. [https://doi.org/10.1016/j.addbeh.2016.03.003]
• Jackson, C. A., Henderson, M., Frank, J. W., & Haw, S. J. (2012). An overview of prevention of multiple risk behaviour in adolescence and young adulthood. Journal of Public Health, 34(suppl_1), i31-i40. [https://doi.org/10.1093/pubmed/fdr113]
• Jakobsen, G. S., Danielsen, D., Jensen, M. P., Vinther, J. L., Pisinger, C., Holmberg, T., . . . Andersen, S. (2021). Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools. Tobacco Prevention & Cessation, 7, 42. [https://doi.org/10.18332/tpc/133934]
• Kim, K. K., Yoo, S., & Kang, E. (2019). The relationship between healthy city and health promotion and the directions for a revision of the national health promotion act. Korean Journal of Health Education and Promotion, 36(5), 87-98. [https://doi.org/10.14367/kjhep.2019.36.5.87]
• Korea Centers for Disease Control and Prevention. (2020). Sample design for 2020 Youth Health Behavior Survey. Cheongju: Author.
• Korea Youth Councelling & Welfare Institute. (2019). Institute-2019-youth counseling issue paper (Korean, authors’ translation). Busan: Author.
• Lee, H., & Kim, H. (2017). Systematic review of smoking prevention programs for Korean school-aged children and adolescents. The Journal of Korean Society for School & Community Health Education, 18(2), 27-42.
• Lee, M. J., & Lee, K. S. (2021). Maintenance of smoking cessation in Korean single mothers. BMC Women’s Health, 21(1), 1-11. [https://doi.org/10.1186/s12905-021-01426-x]
• Lee, Y., Lee, K.-S., & Kim, H. (2019). Predictors of abstinence from smoking: A retrospective study of male college students enrolled in a smoking cessation service. International Journal of Environmental Research and Public Health, 16(18), 3363. [https://doi.org/10.3390/ijerph16183363]
• Lovato, C. Y., Zeisser, C., Campbell, H. S., Watts, A. W., Halpin, P., Thompson, M., ... & Brown, K. S. (2010). Adolescent smoking: effect of school and community characteristics. American Journal of Preventive Medicine, 39(6), 507-514. [https://doi.org/10.1016/j.amepre.2010.08.019]
• May, J., Osmond, K., & Billick, S. (2014). Juvenile delinquency treatment and prevention: A literature review. Psychiatric Quarterly, 85(3), 295-301. [https://doi.org/10.1007/s11126-014-9296-4]
• McFarland, J., Hussar, B., Zhang, J., Wang, X., Wang, K., Hein, S., . . . Barmer, A. (2019). The condition of education 2019. National Center for Education Statistics. Retrieved from http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2019144
• Min, G.-M., Seo, Y.-H., & Park, C.-H. (2018). Cigarette price rise induced change in youth smoking rate. Journal of the Korea Academia-Industrial Cooperation Society, 19(12), 451-461. [https://doi.org/10.5762/KAIS.2018.19.12.451]
• Panezai, S., Panezai, H., Wassan, A. A., & Saqib, S. E. (2019). Exploring juveniles’ delinquent behavior and associated factors: A cross-country comparison of Pakistan and Thailand. Journal of Geography and Social Sciences, 1(1), 57-71.
• Peters, R. J., Kelder, S. H., Prokhorov, A. V., Yacoubian, G. S., Markham, C. M., & Essien, E. J. (2005). Cigarette smoking as an alternative to screened drugs: Why juvenile probationers smoke more. Addiction Research & Theory, 13(1), 35-42. [https://doi.org/10.1080/16066350512331328186]
• Sawyer, S. M., Afifi, R. A., Bearinger, L. H., Blakemore, S.-J., Dick, B., Ezeh, A. C., & Patton, G. C. (2012). Adolescence: A foundation for future health. The Lancet, 379(9826), 1630-1640. [https://doi.org/10.1016/S0140-6736(12)60072-5]
• Song, H.-Y., & Yang, S.-J. (2021). Factors associated with smoking behaviors in out-of-School youth: Based on an ecological model. International Journal of Environmental Research and Public Health, 18(12), 6380. [https://doi.org/10.3390/ijerph18126380]
• Sussman, S., Dent, C. W., Severson, H., Dee, B., & Flay, B. R. (1998). Self-initiated quitting among adolescent smokers. Preventive Medicine, 27(5), A19-A28. [https://doi.org/10.1006/pmed.1998.0379]
• Vallata, A., O’Loughlin, J., Cengelli, S., & Alla, F. (2021). Predictors of cigarette smoking cessation in adolescents: A systematic review. Journal of Adolescent Health, 68(4), 649-657. [https://doi.org/10.1016/j.jadohealth.2020.09.025]
• White, L. M., Aalsma, M. C., Holloway, E. D., Adams, E. L., & Salyers, M. P. (2015). Job-related burnout among juvenile probation officers: Implications for mental health stigma and competency. Psychological Services, 12(3), 291-302. [https://doi.org/10.1037/ser0000031]
• Wojciechowski, T. W. (2019). The development of cigarette smoking behavior among juvenile offenders in adolescence and early adulthood: ADHD symptomatology as a risk factor. Journal of Child & Adolescent Substance Abuse, 28(6), 439-451. [https://doi.org/10.1080/1067828X.2020.1782795]
• Zhu, S.-H., Sun, J., Billings, S. C., Choi, W. S., & Malarcher, A. (1999). Predictors of smoking cessation in U.S. adolescents. American Journal of Preventive Medicine, 16(3), 202-207. [https://doi.org/10.1016/S0749-3797(98)00157-3]