INTRODUCTION
Smoking is the single most preventable cause of death and disease1. As nearly 90% of adult smokers started smoking before the age of 18 years, effective interventions to prevent adolescents from experimenting with cigarettes are needed2,3. Over the past decade, an increasing number of countries have implemented smoke-free policies (SFPs) that prohibit smoking in indoor public places and workplaces4,5. SFPs may result in lower smoking rates among adolescents by reducing the visibility of smoking, limiting the opportunities to smoke, and communicating that smoking is socially unacceptable6-8. In more recent years, several countries have extended SFPs to various outdoor settings, including parks, playgrounds, and sports clubs4,5. The last is of special interest for implementing an outdoor SFP since sports clubs are popular leisuretime settings for many adolescents. For example, in the Netherlands, 60% of adolescents aged 12–19 years participate in organized sports9.
The degree to which adolescents support an outdoor SFP is important to the success of such policy. Research has shown that although SFPs could have important effects in theory, they may also cause reaction and resentment10. Adolescents may perceive smoking restrictions, in schools for example, as a threat to their individual freedom and autonomy10,11. This may result in a boomerang effect by causing adolescents to rebel against SFPs and use tobacco as a means of feeling more independent12,13. On the other hand, if adolescents understand the rationale for an SFP, they may be more likely to obey the policy.
To our knowledge, there have been no studies on adolescents’ support for an outdoor SFP at sports clubs. A number of studies have examined support among adults for outdoor SFPs. These studies were confined to other settings than sports clubs (e.g. parks, playgrounds)14. According to these studies, the majority of adults support the implementation of outdoor SFPs, especially in places that are frequently visited by children14,15 or related to sports (e.g. stadiums)15-17. Furthermore, support for SFPs appears to increase after implementation18,19. That is, people who live in places were smoking is already prohibited, are more likely to support SFPs20.
The aim of this study is to explore adolescents’ perceptions with regard to an outdoor SFP at sports clubs in the Netherlands. More specifically, we aim to gain more in-depth knowledge about their reasons for (non) support and any differences therein between adolescents at sports clubs with versus without an outdoor SFP.
METHODS
Participants
A total of 16 sports clubs were included in the study: eight with and eight without an outdoor SFP. We included soccer, tennis, field hockey, and korfball (a Dutch ball sport similar to netball and basketball) clubs to represent the variety of outdoor sports types in the Netherlands. In addition, we aimed for a representative selection of clubs according to region and corresponding level of urbanity. In total, 64 clubs were asked to participate (25 with and 39 without an outdoor SFP). Main reasons for non-participation were lack of interest, not having enough respondents, and being too busy with other things. Table 1 presents the characteristics of the participating sports clubs.
Table 1
Characteristics of the participating sports clubs
At each sports club we conducted focus group discussions (FGDs) with adolescents (aged 13–18 years). FGDs have the advantage to produce rich data from the interaction between group members. As a result of this interaction, FGDs generate more than the sum of individual inputs. Adolescents participating in FGDs hear the opinions of others, which can encourage them to respond to these ideas or suggest new ideas of their own21,22. Per club, two FGDs were conducted except for five clubs with only one FGD. Boys and girls were separated since FGDs with both sexes may interfere with the group dynamic21. A total of 180 adolescents participated in the study. Table 2 presents the characteristics of the participants.
Table 2
Characteristics of participants
| Number of participants (n=180) | % | With an outdoor SFP (n=89) | % | Without an outdoor SFP (n=91) | % | |
|---|---|---|---|---|---|---|
| Gender | ||||||
| Boy | 72 | 40.0 | 37 | 41.6 | 35 | 38.5 |
| Girl | 108 | 60.0 | 52 | 58.4 | 56 | 61.5 |
| Age (years) | ||||||
| 13 | 9 | 5.0 | 4 | 4.5 | 5 | 5.5 |
| 14 | 35 | 19.4 | 18 | 20.2 | 17 | 18.7 |
| 15 | 61 | 33.9 | 33 | 37.1 | 28 | 30.8 |
| 16 | 44 | 24.4 | 20 | 22.5 | 24 | 26.4 |
| 17 | 23 | 12.8 | 11 | 12.4 | 12 | 13.2 |
| 18 | 8 | 4.4 | 3 | 3.4 | 5 | 5.5 |
| Smoking status* | ||||||
| Smoker | 12 | 6.7 | 2 | 2.3 | 10 | 11.0 |
| Non-smoker | 168 | 93.3 | 87 | 97.8 | 81 | 89.0 |
Procedure
Sports clubs were recruited by Sportief Advies, a Dutch organization that contributes to projects related to sports. Clubs were contacted face-to-face, by phone, e-mail, and/or letter. After selection of the sports clubs, a volunteer of the respective club recruited adolescents for the FGDs. Inclusion criteria of the adolescents were aged 13–19 years and being a member of the participating sports clubs. There were no exclusion criteria.
FGDs were conducted by the first three authors (HHG, RRD, IGO) between May and December 2019. All authors had interviewing experience. The FGDs followed the semi-structured topic guide given in the Supplementary file. The topic guide was not pilot tested but thoroughly reviewed by all authors. Some minor changes were made to the topic guide after the first FGDs, e.g. altering questions that turned out to be suggestive in practice. FGDs lasted approximately 20 minutes (range 12–29) and took place in a quiet room at the participating sports clubs with no other people present. Active informed consent was obtained from all participants. If participants were under the age of 16 years, informed consent from their parents was required. Self-reported questionnaires were filled out beforehand by the participants measuring gender, age, and smoking status. At the start of each FDG, the interviewer introduced her/himself, explained the purpose of the FGD, and informed participants on their right to confidentiality. All participants received a €10 gift voucher for their participation.
Statistical analysis
FGDs were transcribed verbatim and MAXQDA was used to help organize the data for analysis. All identifying information was not included in the transcriptions. Thematic analyses, a qualitative analytic method for identifying, analyzing, and reporting themes within data, was used23. The coding was conducted by two authors (RRD, IGO) and another author (HHG) coded 10 transcripts in parallel. Inconsistencies regarding codes were discussed until consensus was reached. Similar codes were pooled and overarching themes were created. Finally, these themes were classified into ‘reasons for supporting an outdoor SFP at sports clubs’ and ‘considerations against an outdoor SFP at sports clubs’.
RESULTS
Overall, participants generally supported an outdoor SFP at sports clubs. Moreover, according to them, an outdoor SFP should be implemented at all sports clubs. On the other hand, some participants had certain considerations against an outdoor SFP. Below we first discuss participants’ reasons for supporting an outdoor SFP at sports clubs and next participants’ considerations against such policy. Finally, we discuss differences in support between adolescents at sports clubs with versus without an outdoor SFP.
Reasons for supporting an outdoor SFP at sports clubs
Children should not be exposed to smoking
A common reason for participants to support an outdoor SFP was that they highly valued the protection of children from secondhand smoke (SHS). In their responses, participants generally referred to either themselves or to younger children. Furthermore, they argued that an outdoor SFP may strengthen a non-smoking norm and, consequently, reduce the risk of smoking initiation among children. Finally, according to participants, adults need to set a good example with regard to smoking at sports clubs since children are easily influenced by role models such as parents or trainers.
‘If people smoke a lot at sports clubs, children are going to associate smoking with sports clubs. Consequently, they might think that smoking and sports clubs fit together, and start smoking themselves.’ (Tennis, girls, with SFP)
Smoking and sports (clubs) do not fit together
According to participants, smoking and sports (clubs) do not fit together, since the two concepts contradict each other, i.e. smoking is unhealthy while participating in sports is healthy. For this reason, participants perceived an outdoor SFP in the sports setting as ‘normal’. Settings in which people go out (e.g. bars) were called ‘different’ compared to sports clubs, since people visit those places to have fun and these places are less visited by children.
‘It looks a bit strange when people at sports clubs – which is a healthy environment – are smoking.’ (Korfball, girls, with SFP).
Secondhand smoke is undesirable
Participants mentioned that they find it annoying when people smoke next to the field. When participating in sports, they do not want to be confronted with the unpleasant smell of cigarettes. According to participants, smokers should not bother other people with their behavior, since it can damage non-smokers’ health as well.
‘I like it [the outdoor SFP at the sports club], because smoke isn't nice. It smells bad and it's unhealthy. Even when you don't smoke yourself, you breathe in other people's smoke.’ (Korfball, boys, with SFP)
An outdoor SFP may enhance a sports club’s image
According to participants, an outdoor SFP provides sports clubs with a healthy, professional, and sporty image. Consequently, smoke-free sports club may be more likely to gain prestige and to attract new members.
‘We want to be a healthy sports club. You can't get fries here either.’ (Field hockey, girls, without SFP)
An outdoor SFP may contribute to the prevention of smoking
Participants mentioned that an outdoor SFP at sports clubs may contribute to the prevention of smoking in different ways. First, because of the SFP, people may find it less ‘normal’ to smoke at sports clubs and smokers may feel embarrassed or uncomfortable when smoking. Second, an outdoor SFP at sports clubs may be beneficial for smokers as it decreases their opportunities to smoke and increases their awareness of the harmful effects of smoking.
‘I think that when people here it's a smoke-free zone, they'll think about the negative consequences of smoking sooner. And try to quit smoking sooner. Or don't want to smoke at all.’ (Field hockey, boys, with SFP).
Considerations against an outdoor SFP at sports clubs
Smokers need to be taken into account
Some participants argued that smokers should be treated the same way as non-smokers. A number of participants mentioned that they feel sorry for smokers and that people who smoke should not be expelled from the venue. Consequently, a number of participants favored a partial SFP over a comprehensive SFP, by creating designated smoking areas. According to them, such areas have the benefit of being able to smoke while not bothering others.
‘I wouldn't make it completely smoke-free. I would create smoking areas. That way, people who want to smoke can still smoke. I would make it pleasant for everyone.’ (Tennis, girls, without SFP)
The effectiveness of the SFP could be questioned
Some participants questioned the effectiveness of an outdoor SFP at sports clubs. First, due to the SFP, people may seek to smoke elsewhere and gather at the entrance. As a result, smoking is still visible and sometimes even more than before. Second, according to some participants, implementing an outdoor SFP at sports clubs has no to minimal effect since smoking is still allowed in other settings.
‘They will be tempted to smoke somewhere else. I don't think it will have a large effect if it's only prohibited here [at the sports club]. All places need to be smoke-free, that's the only way to be effective.’ (Tennis, boys, with SFP)
Smoking does not bother other people
Some participants mentioned that they do not find it necessary to implement an outdoor SFP at their sports club. The reason for this is that they are not bothered by the smoking behavior of others. In addition, at some sports clubs, there are only a few people who smoke. Therefore, according to participants, implementing an outdoor SFP would not make much of a difference.
‘An outdoor SFP is not necessary if you're not bothered by it (smoking).’ (Korfball, girls, without SFP)
There may be expected problems with compliance and enforcement
A number of participants mentioned that they expect smokers not to comply with the SFP, but to keep smoking their cigarette. Especially at times when there are no children around, e.g. in the evening. In addition, some participants expected difficulties with regard to enforcement.
‘I don't think people will comply with the SFP. They'll keep smoking. I also think that no one is going to say anything about it when someone smokes.’ (Korfball, girls, without SFP)
Differences in support between adolescents at sports clubs with versus without an outdoor SFP
Both participants at sports clubs with versus without an outdoor SFP at their sports clubs showed strong support for such policy. Nevertheless, some differences were found between the two groups. Participants at sports clubs with an outdoor SFP more often expressed positive attitudes to such policy. Moreover, their arguments were more persuasive and convincing. Participants at sports clubs without an outdoor SFP mentioned more considerations against such policy. They expressed more often skeptical attitudes such as foreseeing difficulties with regard to implementation. In addition, they more often favored a partial SFP over a comprehensive SFP.
DISCUSSION
Key findings
This study shows that adolescents generally support an outdoor SFP at sports clubs. Most common reasons for support are that children should not be exposed to smoking and that smoking and sports (clubs) do not fit together. Some adolescents have certain considerations against an outdoor SFP. Support for an outdoor SFP was stronger among adolescents at clubs with an outdoor SFP than among those without such policy.
Interpretation of findings
Levels of support found may be related to adolescents’ perceived effectiveness, i.e. their beliefs concerning whether a policy is capable of achieving a given goal24. As we found that the majority of adolescents expect an outdoor SFP at sports clubs to contribute to the prevention of smoking, support is likely to be high. Similarly, some adolescents question the effectiveness of the SFP, which may explain why they are more reluctant to support the SFP.
A major reason for adolescents to support an outdoor SFP at sports clubs is that children should not be exposed to smoking. This finding is consistent with previous studies that showed that support for SFPs is higher for places associated with children14,15, and implies that support may depend on the degree to which adolescents are aware of the harmful effects of passive smoking on children and of children imitating others’ smoking behavior.
Adolescents’ support for an outdoor SFP is stronger among adolescents at sports clubs with versus without an outdoor SFP. This might be explained by the fact that implementation of an outdoor SFP facilitates a process of de-normalizing smoking, by communicating that smoking is socially unacceptable6-8. In addition, according to the Theory of Cognitive Dissonance, people have an inner drive to hold their attitudes and behavior in harmony with their living situation, and to avoid disharmony (or dissonance)25.
Some adolescents have certain considerations against an outdoor SFP at sports clubs, especially those at clubs without such policy. Among others, those adolescents expect problems with regard to compliance and enforcement. However, two recent qualitative studies on the implementation of an outdoor SFP at sports clubs reported that most people comply to the SFP, and that those who do not are being approached by others most of the time25,26. These findings show that expected negative effects of SFPs do not always reflect actual experiences of SFP implementation27.
Limitations
A number of limitations should be considered when interpreting the results. First, social desirability bias might have occurred. Adolescent may have feared disclosing to the interviewer that they have engaged in socially unacceptable behavior, i.e. smoking. In addition, they may have feared that their responses were going to be communicated to their parents or trainer. However, we found that all participants talked very openly about their smoking status and expressed both positive and negative attitudes towards an outdoor SFP.
A second limitation is that the number of smokers in our sample was low (6.7%). Therefore, this study mostly represents the voice of non-smokers. However, as previous studies reported, adolescents who participate in sports often smoke less. Nevertheless, despite their small number, it would be interesting to include more smokers in the FGDS or to use personal interviews to represent their voice.
Finally, it is not clear whether the sports clubs and participants included in this study are representative for the Netherlands as a whole. Nevertheless, we included a large group of participants that differed with regard to types of sports, regions, sex, and age. We therefore expect that our insights into adolescent’s reasons for (non) support may apply in many other contexts, even though the specific views may vary.
Implications
Our findings imply that sports clubs could be encouraged to implement an outdoor SFP at their venues since adolescents generally support such policy and adverse effects are unlikely to occur. Sports clubs with concerns about a possible lack of support should be informed that adolescents’ support is high once the SFP is implemented. A more general implication is that efforts to implement SFPs in other outdoor locations that are often visited by young people could be encouraged, since adolescents highly agree that children should not be exposed to smoking.
CONCLUSIONS
Adolescents’ strong support advocates for wide implementation of an outdoor SFP at sports clubs. An outdoor SFP protects (young) people from exposure to SHS and contributes to making non-smoking the accepted norm. Once sports clubs have implemented an outdoor SFP, it is generally experienced as ‘normal practice’. This should be communicated to sports clubs without an outdoor SFP as it may encourage them to become smoke-free as well.
