Which reference groups matter for Taiwanese high school adolescent smoking? A card sorting study.

Background: Adolescence represents a pivotal period for the initiation of smoking behaviours. While family, peer and social groups serve as significant reference groups influencing adolescents' decision-making process, there remains a paucity of research that examines how diversified reference groups influence their smoking decisions.

Objective: The objective is to compare normative and informative influences given by different reference groups on adolescents' smoking decision-making.

Design: This study applied reference group theory and used the card sorting technique. Adolescents were presented with 16 cards portraying various reference groups and 27 cards portraying different types of reference group influences. They were asked to construct sentences as smoking-elicited and smoking-inhibited cues and ranked these influences based on their relevance to their smoking decision-making.

Participants: The participants were recruited from four cities in the North, Central, South and East regions of Taiwan. The study sample consisted of 297 Taiwanese 11th graders drawn from high schools, vocational high schools and night schools.

Primary outcome measures: The most influential reference group among smokers, former smokers and never smokers.

Results: Our results of multivariable logistic regression show that for current smokers, having a smoking best friend (aOR=7.58, p<0.01), having a smoking colleague (aOR=3.83, p<0.01) and participating in ceremonial dance performances (aOR=4.62, p<0.01) are more likely to smoke. Peers play an important role in providing smoking-elicited cues for current smokers. Families provided the most smoking-inhibited cues for former and never smokers. Normative influences such as encouraging adolescent smoking provided more cues for adolescents than informative influences such as releasing stress by smoking.

Conclusions: Adolescent smoking behaviour was influenced by peer norms, while former and non-smoking behaviours are associated with family norms. Therefore, tobacco prevention efforts should focus more on family-level interventions to discourage smoking initiation. Smoking cessation programmes for current smokers should address the reduction of peer pressure to smoke. Moreover, schools and community partners should collaborate to develop effective smoking cessation strategies, particularly for high-risk groups such as adolescents who involved in ceremonial dance performance.