Associations between the Sense of Coherence and the Motivation to Start and Stop Smoking among Adolescents: ndings from a school-based survey


 Background

The science of behaviour change has advanced considerably in understanding the psychological dimensions that make up individuals’ motivation to change their smoking behaviour. However, there is a lack of studies on the factors associated with the motivational system that prompts smoking initiation and cessation among adolescents. An important psychosocial factor related with smoking in adolescence, which has not yet been investigated in relation to their motivational system, is the Sense of Coherence (SOC). The present study aimed to estimate the extent to which the SOC is associated with the motivation to start and stop smoking among a population of adolescent students.
Methods

A cross-sectional school-based survey was carried out in Midwest Brazil. Participants were high-school students aged between 13 and 19 years who completed self-administered questionnaires. Explanatory variable was the SOC score, measured with Antonovsky’s Orientation to Life Questionnaire (13-item version). Motivation to start and stop smoking were measured with questions based on the Prime Theory of Motivation to address desire to smoke, belief on smoking benefit and intention to future smoking. Logistic regression was used in the statistical analysis, and a Directed Acyclic Graph was used to identify potential confounders.
Results

Participants (n = 2189) were 2073 never-smokers (94.7%) and 116 smokers (5.3%). The mean SOC score was 50.1 (95% CI = 49.6–50.7). About a quarter of the never-smokers were motivated to start smoking, and 14.7% of the smokers were not motivated to quit the habit. For each one-unit increase in the SOC score of never-smokers, the odds of desiring to smoke, believing on smoking benefit, and intending to smoke in the future decreased by 3%, 3% and 5%, respectively. Among smokers, the findings were inconclusive as to whether an association between SOC and motivation to stop smoking was present.
Conclusion

Increasing SOC was associated with decreasing motivation to start smoking among never-smokers. The findings indicate that SOC may play a protective role in the process of smoking initiation among adolescents, offering a potential adjuvant resource of theory-based interventions to prevent adolescent smoking.


Methods
A cross-sectional school-based survey was carried out in Midwest Brazil. Participants were high-school students aged between 13 and 19 years who completed self-administered questionnaires. Explanatory variable was the SOC score, measured with Antonovsky's Orientation to Life Questionnaire (13-item version). Motivation to start and stop smoking were measured with questions based on the Prime Theory of Motivation to address desire to smoke, belief on smoking bene t and intention to future smoking.
Logistic regression was used in the statistical analysis, and a Directed Acyclic Graph was used to identify potential confounders.

Results
Participants (n = 2189) were 2073 never-smokers (94.7%) and 116 smokers (5.3%). The mean SOC score was 50.1 (95% CI = 49.6-50.7). About a quarter of the never-smokers were motivated to start smoking, and 14.7% of the smokers were not motivated to quit the habit. For each one-unit increase in the SOC score of never-smokers, the odds of desiring to smoke, believing on smoking bene t, and intending to smoke in the future decreased by 3%, 3% and 5%, respectively. Among smokers, the ndings were inconclusive as to whether an association between SOC and motivation to stop smoking was present.

Conclusion
Increasing SOC was associated with decreasing motivation to start smoking among never-smokers. The ndings indicate that SOC may play a protective role in the process of smoking initiation among adolescents, offering a potential adjuvant resource of theory-based interventions to prevent adolescent smoking.
Background Page 3/19 The harmful consequences of tobacco on health are ubiquitous, and tobacco use remains one of the leading causes of preventable diseases and premature deaths worldwide [1]. While a substantial decline in tobacco consumption in several countries over the last decades was observed, it is still a serious public health concern [2]. To decrease the burden of tobacco-related disease, strategies that facilitate cessation and prevent smoking uptake early in life are fundamental [2].
Smoked products, specially industrialized combustible cigarettes, are the most common forms of tobacco consumption, which usually begins during the second decade of life [3]. Adolescence is a critical phase that demands special attention to prevent the development of addictive behaviours such as smoking [3]. Adolescent smoking onset is a complex phenomenon involving individual, social, and situational in uences [4].
Age, lower socioeconomic status, and having smokers among family members and friends have been closely related to the onset of adolescent smoking [4][5][6]. Another robust predictor of smoking initiation during adolescence is future intention to smoke [4], which is in turn a fundamental aspect related to the motivation to change smoking behaviours [7,8].
Motivation to change refers to re ective and automatic processes that energise and direct smoking behaviours [7,8]. It is one of the key-domains of the Capability, Opportunity, and Motivation -Behaviour (COM-B) System, a theoretical framework for understanding behaviours and designing behaviour change interventions [8,9]. The COM-B model proposes that behaviour change requires motivation, as well as capability and opportunity to change. Capability encompasses psychological and physical capacity to engage in the behaviour change, and opportunity refers to social and physical external factors that prompt the behaviour [8].
Based on the interrelatedness of the three domains in the COM-B model, both capability and opportunity could in uence motivation, such as if individuals understand the severe negative health consequences of smoking (knowledge), they will be less motivated to start smoking. However, knowledge is only one aspect related to adolescents' psychological capabilities [8].
Another important psychosocial factor that has been associated with smoking among adolescents is their Sense of Coherence (SOC) [10,11]. SOC expresses the capability of individuals to deal with stimuli deriving from their internal and external environments in the course of living [12]. Being the core construct of the salutogenic model of health, the SOC is a global measure of the positioning of individuals or groups in the health-disease dynamic process [12].
High levels of SOC indicate improved ability to comprehend, nd meaning and manage life issues [12]. That is, it re ects the feeling that stressful stimuli are reasonably structured, the demands they pose are worthy of engagement and likely to be overcome through physical and psychological resources that might be available, the so-called generalized resistance resources [12].
By making optimum use of the resources at their disposal, individuals with a high SOC have better health prospects [12]. Such in uence can be achieved through behaviours that favour health, in addition to other decisions that strengthen the structural support of health, such as seeking the company of peers who are adept at constructive and healthy activities [12]. In comparison with those with low SOC, people with high SOC feel more in control of their lives, get better social support and live life with more enjoyment. Also, they face life with more positivity and optimism, have greater self-esteem and deal more effectively with stressors [12].
SOC is associated with a decreased risk of all-cause mortality in the general population [13]. Among adolescents, besides its effect on smoking [10,11], high SOC is connected to improved health-related quality of life, health behaviours, mental health, and family relationships [10].
There is previous evidence of the relationship between motivation and other psychosocial aspects (e.g., self-e cacy in avoiding smoking in various high-risk situations, and decisional balance regarding the pros and cons of smoking) [14]. However, we are unaware of any studies examining the association between adolescents' SOC and their motivation to change smoking behaviour, that is, their motivation to start and to stop smoking. Studying this relationship may favour the design and implementation of antismoking interventions for this population that are theory-based. Knowledge about the factors that can in uence interventions' outcomes is essential to clinicians and working to improve their SOC could bene t interventions as an additional strategy to improve their motivation to prevent smoking initiation or quit the habit.
Guided by the COM-B model, we hypothesized that adolescents' SOC, as part of their psychological capability, may be related to their motivation to change smoking behaviours, so that those with high levels of SOC are less motivated to start smoking, or more motivated to quit if they are smokers. The objective of this study was to estimate the extent to which SOC is associated with motivation to start (MStart) and stop smoking (MStop) among adolescent students.

Study design, participants, and setting
We conducted a cross-sectional school-based survey with high-school students aged 13 to 19 years. Adolescents from all 14 public high schools of the Federal Institute of Education Science and Technology of Goiás, from 13 municipalities in the Midwest region of Brazil, including one of the Brazilian capital cities, Goiânia, were selected as a convenience sample to be part of this survey. The study's response rate was 99.7%. Detailed descriptions about the setting and sample size calculations were reported in a previous publication [15].

Data collection, instrument, and procedures
Data were collected at the beginning or end of the students' regular classes. The research instrument, a self-administered printed questionnaire speci cally designed for this survey, consisted of 67 closed questions concerning an array of sociodemographic, psychosocial, smoking behaviours and other healthrelated factors. The methodological steps of the questionnaire design and testing were previously described [15]. It included original questions and others compiled from previous studies, among which is the SOC questionnaire [12].
Students took approximately 20 minutes to complete the questionnaire. To improve response rate, minimize missing data and prevent information bias, the researcher who collected the data provided information about the study and gave prior instructions to the adolescents, using printed banners, on how to ll out the questionnaire. For example, the banners were used to explain which questions were aimed at smokers and should be left blank by non-smokers, and vice-versa.

Smoking status
The adolescents answered the following yes-or-no questions: (i) 'Have you ever tried smoking cigarettes, even one or two puffs?', (ii) 'Currently, do you smoke cigarettes? (Select yes if you smoked at least one cigarette in the past 30 days)'.
Based on the responses, adolescents were classi ed as (i) never-smokers (negative answers to the two questions), (ii) former smokers (answered yes to the rst but not to the second question), (iii) and smokers (two positive answers). Former smokers were not eligible for the present analysis, therefore a status of a non-smoker in this study refers to adolescents who had never tried smoking.

Motivation to changing the smoking behaviour
We relied on the Prime Theory of Motivation [7] to conceptualize and measure the motivation of adolescents to change their smoking behaviours. This comprehensive theory of motivation poses that the main elements of motivation to change a behaviour include, in addition to beliefs about what to do and what is good or bad, the feelings of desire and the self-conscious intentions to act in a speci c way [7]. Concepts are at the psychological level, and the theory was designed to perform as a pegboard into which other theories can be plugged [7]. The pictorial representation of the Prime Theory was adapted to illustrate our assumption of an association between the adolescents' SOC and their motivational system ( Fig. 1).

Outcome 1: Smokers' motivation to stop smoking
We assessed MStop using the Motivation to Stop Scale (MTSS), a one-item instrument based on Prime Theory that was validated in English [16] and Dutch [17]. For the present study, we have translated and adapted the instrument to the Brazilian Portuguese language [15]. The MTSS scale consists of the following question: 'Which of the following describes you?' Response options are: (i) 'I don't want to stop smoking', (ii) 'I think I should stop smoking but don't really want to', (iii) 'I want to stop smoking but haven't thought about when', (iv) 'I REALLY want to stop smoking but I don't know when I will', (v) 'I want to stop smoking and hope to soon', (vi) 'I REALLY want to stop smoking and intend to in the next 3 months' and (vii) 'I REALLY want to stop smoking and intend to in the next month'. The ordering of the categories indicates an ascending level of MStop: (i) absence of any belief, desire or intention, (ii) belief only, (iii) moderate desire but no intention, (iv) strong desire but no intention, (v) moderate desire and intention, (vi) strong desire and medium-term intention and (vii) strong desire and short-term intention [16,17].
Outcome 2: Non-smokers' motivation to start smoking The measurement of MStart was based on a three-item questionnaire proposed by one of the senior authors of Prime Theory [7] to assess desire, beliefs, and intentions to start smoking: 1) Does the idea of smoking feel good to you? (desire); 2) Do you think the bene ts of smoking for you would make up for the risks? (belief); and 3) Do you plan to try smoking in the next year? (intention). Each question has ve response categories, where 1 indicates strong agreement (De nitely yes) and 5 strong disagreement (De nitely not).
To construct the outcome variable MStart, we rst evaluated the internal consistency of the questions, and it was satisfactory (Cronbach's α = 0.72; 95% CI = 0.70-0.74). Then, we dichotomized the response categories into (0) De nitely not (a strong and rm absence of desire, belief, or intention to smoke) and (1) Probably not + Not sure + Probably + De nitely yes. Subsequently, we computed the combination of the responses to the three questions and created an eight-category level MSS ordinal variable which was ordered from (1) absence of any belief, desire and intention (no MStart) to (8) simultaneous presence of any level of belief, desire, and intention (highest level of MStart) ( Table 1). The categories were ordered according to previous studies that assessed motivation to change smoking behaviours and were based on Prime Theory (7,8,16,17). In addition, we analysed each of the three dimensions of motivation investigated (desire, belief, and intention) as a single ordinal outcome. Table 1 Levels of motivation to start smoking identi ed through the combination of responses to the Prime Theory-based questionnaire.

Levels of Motivation
Combination of responses  [12], which was adapted to the Brazilian context [18]. The scale consists of 13 items on a 7-point Likerttype scale with descriptive endpoints. The total SOC score is obtained by the sum of the 13 items single scores, ranging from 13 to 91, with the higher scores indicating stronger SOC [12]. Before computing the SOC score, some of the items (1, 2, 3, 7 and 10) are recoded in reverse to provide an ascendant measurement to the scale. The scale's Cronbach's Alpha in the present study was 0.79 (95% CI = 0.77-0.80) indicating a good internal consistency.

Background variables
The potential confounders were: 1) Self-reported race/skin colour (o cial categories in Brazil [19]: white, black, brown, yellow (Asian descendants) or indigenous; 2) Sex: (i) male and (ii) female; 3) Age: 13 to 19 years; 4) Socioeconomic status, based on the level of education of the adolescents' mother, with categories ascending from no study (illiterate) to university degree (Table 1); 5) Exposure to smoking parents: (i) yes (at least one of their parents was a smoker) and (ii) no; 6) Exposure to smoking friends: (i) yes (at least one of their friends was a smoker) and (ii) no.

Statistical analysis
We describe our data using absolute and relative frequencies (n; %), mean values and standard deviations (SD). Ordinal Logistic Regression was used to estimate the odds ratio (OR) and 95% con dence intervals (CI) for the associations between SOC and adolescents' motivation to start and stop smoking. We used a Direct Acyclic Graph (DAG) [20,21] (Fig. 2) to guide the selection of variables to be adjusted for in the multivariable models, which were age, sex, mothers' educational level, parents' smoking status, and friends' smoking status. The IBM SPSS (v. 24) software was used in the statistical analyses and the DAG was structured using the DAGitty tool [22].

Results
The study owchart is in Fig. 3, and the sample characteristics are in Table 2. Participants were 2189 adolescent students, of whom 2073 (94.7%) were non-smokers and 116 (5.3%) were smokers. Their mean age was 15.9 years (SD = 1.1), most of them were female (54.8%), non-whites (66.7%), and had mothers with a low level of education (66.2%). Smoking parents were observed in 16.7% of cases and more than half of the participants reported having smoking friends.  (Table 3). Strong desire and medium-term intention 2 1.7 Strong desire and short-term intention 5 4.3 Table 3 shows odds ratio and 95% CI for the association between SOC and motivation to start smoking (MStart). The results showed that, both in the unadjusted and adjusted analyses, the SOC of non-smokers was inversely associated with increasing levels of motivation to start smoking (MStart), the adjusted odds ratio being 0.97 (95%CI = 0.96-0.98). Similarly, in the analyses of the three dimensions of MStart as separate outcomes, the adjusted odds ratio indicated a small inverse association between the nonsmokers' SOC and desire (OR = 0.97; 95%CI = 0.96-0.98), belief (OR = 0.97; 95%CI = 0.96-0.98), and intention (OR = 0.96; 95%CI = 0.95-0.97). Regarding the association between the smokers' SOC and their MStop, the adjusted odds ratio was 0.99 (95%CI = 0.96-1.03) ( Table 4).

Discussion
This study innovates by examining adolescents' motivation to changing their smoking behaviour and its association with SOC, using a theoretical framework of evidence-based behaviour change theories, namely the COM-B System [8] and the Prime Theory of Motivation [7]. SOC was conceptually assessed as part of the psychological capability of adolescents to change their smoking behaviours, and in relation to their motivation to change both in terms of smoking acquisition and cessation.
We found evidence of an association between low levels of SOC among adolescents and their motivation to start smoking, as well as with each of the dimensions of motivation investigated, that is, their desire to smoke, belief about smoking bene ts, and intentions to start smoking. This result is in agreement with previous evidence of the association between SOC and smoking among adolescents [10,11,23].
Although the magnitude of the associations was small, the two variables were associated even when adjusted for factors such as the presence of smoking friends, which has been considered a salient social in uence on a child's susceptibility to smoke [6], especially until middle adolescence [24]. Even through adulthood, having friends who smoke as a social activity persists a major trigger for smoking initiation, and a barrier to cessation [25].
SOC seems to be an important psychosocial factor against motivation to start smoking, along with other external factors that in uence smoking in this age group. It has been suggested that adolescents with high SOC deal better with peer pressure to smoke [26].
Our study corroborates the Global Youth Tobacco Survey, which showed that at least one in three adolescent smokers in all the countries surveyed had desire to quit smoking, in the period between 2012 and 2015 [27]. Likewise, the percentage of adolescents who did not wish to quit smoking in the present study was comparable to those found in adults of other countries [16,17]. Since measures of motivation to change smoking behaviour are especially effective in predicting who initiates the change [28], our ndings point to the need for increasing adolescent students' motivation, to stimulate cessation attempts.
Most of our sample of smokers were not motivated to stop smoking or only believed they should but did not desire or had any intention to quit. Similarly, a previous systematic review [14] based on the Transtheoretical Model [29], which is another theory of behaviour change that has been extensively applied in anti-smoking interventions, showed that most adolescent smokers from middle-to-high income countries had no intention to quit smoking [14]. In the present study based on the Prime Theory, intention to start smoking as a single outcome was inversely associated with SOC, as well as desire and belief as single outcomes.
These ndings suggest that improving adolescents' SOC could be used as an intervention with the function of enabling them to prevent smoking initiation. However, longitudinal or experimental evidence is needed before such conclusion can be drawn. The most important limitation is typical for all crosssectional studies, which is to say that causal inferences are beyond this study design, therefore the associations should be further investigated with a prospective study design. Furthermore, the measurement of the outcome variables was based on the adolescents' self-reports, who could have hidden facts trying to avoid exposures since smoking is a behaviour that their parents and teachers would disapprove of. To mitigate this, anonymity and con dentiality were expressly guaranteed to the students during the recruitment process, and the instrument was anonymous.
The study relied on a large sample of adolescent students, consisting of many non-smokers but few smokers. Among the latter, no association between SOC and MStop was observed. However, given the sample size limitation, this study does not provide evidence for lack of an effect between these two variables. All the IFG high-school adolescents were invited to participate and the survey had a high response rate, therefore, our ndings could be considered as having a good validity and refer to highschool students in public schools of a single Brazilian State.

Conclusion
Page 13 /19 In this study, SOC was inversely associated with the motivation of non-smoking adolescent students to start smoking, indicating that high SOC may play a protective role in the process of smoking initiation.
Thus, our ndings could offer a potentially adjuvant resource of theory-based interventions. Among smokers, the ndings were inconclusive as to whether an association between SOC and motivation to stop smoking was present or not. Future longitudinal research is required to allow the assessment of the interaction effects between SOC and adolescents' motivation to start and stop smoking on their smoking behaviour over time. were collected) (Approval No. 2556510). All the participants signed informed consents. The exemption from obtaining consent from parents or guardians of underage adolescents was approved by the REC.

Consent for publication
Not applicable.

Availability of data and materials
The dataset generated and analysed for the current study is available from the corresponding author on reasonable request. Figure 1 Theoretical framework of the study: Sense of Coherence (SOC) and the Prime Theory motivational system. Source: Adapted [7], with permission.

Figure 2
Directed Acyclic Graph used in the study. Study owchart.

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