THESIS BY PUBLICATION A THEORY-BASED SMOKING INTERVENTION FOR CHINESE HIGH SCHOOL STUDENTS: DEVELOPMENT, IMPLEMENTATION, AND EVALUATION Xiang Zhao, B.Sc., M.Ed. Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy School of Psychology and Counselling, Faculty of Health Queensland University of Technology 2018 ABSTRACT Background: With 316 million smokers, China is the world’s largest tobacco consumer. Adolescent smoking rates are increasing among females, and remain at a high level among males. Reducing smoking behaviour and associated cognitions in this transitional period is important to curb smoking in early adulthood. Objective: There were two objectives in this PhD: (i) to explore the psychological mechanisms underlying Chinese adolescents’ smoking behaviour (Study 1); and (ii) to develop, implement, and evaluate a school-based smoking intervention among Chinese adolescents (Study 2). The latter objective was based on the former. Design: Mixed approaches were utilised. Study 1 used semi-structured focus groups based on the Theory of Planned Behaviour (TPB) among high school students. Following the Consensual Qualitative Research (CQR) methods, data were coded into seven domains. Based on the findings in Study 1, a belief-driven smoking programme (“Achieve my healthy future”) was designed, and incorporated life skills training. After the implementation of the programme, smoking behaviour, associated cognitions, and skills were evaluated in a longitudinal design (3 time-points). Study 2 also included a qualitative study of the perceptions of school-based tobacco management among high school students and teaching staff members, using focus groups and interviews. Setting: Two middle schools in Kunming, Yunnan Province, China (February – October 2016). Participants: Thirty 10th graders in Study 1 (50% female and 50% male); 207 10th graders enrolled in Study 2 (106 in the intervention group; 101 in the control group). i Measurements: Two qualitative studies and one quantitative study were included. For the elicitation study (Study 1), focus groups was used. For the qualitative study (Study 2), smoking behaviour, associated cognitions (intention, attitude, subjective norm, perceived behavioural control, willingness, prototype), and life skills (stress coping, decision making, assertiveness, pragmatics, dispositions towards critical thinking) were tested. For the perception study (Study 2), mixed data from focus groups, interviews, and field observations were used. Intervention: Based on the findings of Study 1, a four-session classroom-based intervention was designed. The programme focused on psychological constructs (attitude, subjective norm, perceived behavioural control, and prototype) as well as life skills (stress coping, decision making, assertiveness and pragmatics, and critical thinking). Each session lasted for 40 minutes. Key findings: (i) Study 1 identified seven domains, namely, advantages, disadvantages, approvers, disapprovers, facilitators, barriers, and smoker images. Smoking as a gendered behaviour, smoking as influenced by cultural and environmental contexts, smoking as a strategy to cope with stress, and awareness of the harm of smoking, are highlighted themes across domains. Based on the elicited beliefs, a smoking intervention programme was designed. Study 2 showed that (ii) the pilot intervention based on the TPB curbed the growing pro-smoking attitudes among male students, but not among female students; the intervention also improved skills of pragmatics and critical thinking; (iii) trajectories of smoking behaviour, intention, and willingness all assumed two distinct but constant latent classes, independent of the intervention. In the final study (Study 2), I found that (iv) both students and teaching staff members held a pessimistic attitude towards tobacco control at schools, and that smoking is ubiquitous in social milieus outside of school campuses. ii Conclusion: The TPB is able to encapsulate relevant psychological factors associated with Chinese adolescent smoking, but the pilot intervention based on the extended-TPB framework and life skills training did not change any smoking behaviour or associated cognitions. Environmental influences from the complicated social context might have undermined tobacco management in schools including our pilot intervention in research. Future programmes should be more specific for subgroup members (e. g., regular smokers), as our analysis considering heterogeneities among participants indicated two distinct subgroups among the population. Furthermore, interventions may achieve better success using community approaches rather than individual cognitive methods. This preliminary research project also calls for more attention on smoking among high school students as smoking in this transitional period might lead to heavy smoking in early adulthood. Trial ID: ACTRN12616000224426. Registered on 18 February 2016. KEYWORDS Tobacco smoking, school-based intervention, China, adolescence, high school, beliefs, trajectories, realistic evaluation, Theory of Planned Behaviour (TPB), Prototype/willingness (PW) model, life skills training, elicitation, Consensual Qualitative Research (CQR) iii Table of Contents ABSTRACT ................................................................................................................................ i KEYWORDS ........................................................................................................................... iii Table of Contents ...................................................................................................................... iv List of Thesis Publications and Submitted Manuscripts ........................................................... ix A Refereed Conference Presentation ........................................................................................ ix List of Tables ............................................................................................................................. x List of Figures ........................................................................................................................... xi List of Abbreviations ............................................................................................................... xii Statement of Original Authorship .......................................................................................... xiii Acknowledgements ................................................................................................................. xiv 1. INTRODUCTION AND BACKGROUND ....................................................................... 1 1.1. Background of the study ....................................................................................... 1 1.2. Purpose of the study .............................................................................................. 1 1.3. Study objectives and research questions ............................................................... 2 1.4. Significance of the study ....................................................................................... 3 1.5. Definitions of terms .............................................................................................. 3 2. LITERATURE REVIEW ................................................................................................... 5 2.1. Current status of smoking in China ...................................................................... 5 Prevalence and gender ........................................................................................................ 5 Locality ............................................................................................................................... 7 Knowledge of the harm of smoking ................................................................................. 10 National tobacco control ................................................................................................... 13 2.2. Smoking among Chinese adolescents ................................................................. 14 Prevalence ......................................................................................................................... 14 Crucial age ........................................................................................................................ 15 Current studies .................................................................................................................. 16 2.3. School-based smoking interventions .................................................................. 18 Intervention levels and the scope of this PhD .................................................................. 18 Interventions in China ...................................................................................................... 19 Interventions in the West .................................................................................................. 22 From the West to China .................................................................................................... 23 Life skills training: An established school-based intervention framework ...................... 25 Conclusion ........................................................................................................................ 26 iv 2.4. Smoking as a historical and cultural phenomenon in China ............................... 27 Gendered images .............................................................................................................