Perceptions of friendship, peers and influence on smoking according to socioeconomic status and tobacco control context: A systematic review and meta-ethnography of qualitative research

Abstract

Background The relationship between smoking and interpersonal influences has been well established within the literature. There has been a cultural shift in denormalisation and a reduction in tobacco smoking. Despite this, socioeconomic inequality in smoking has prevailed. This highlights the pressing need to understand health inequalities in relation to adolescents’ smoking attitudes across smoking normalisation and socioeconomic contexts. Methods The search was conducted in July 2019 and updated in March 2022 within 11 databases and secondary sources. Search terms included schools, adolescents, smoking, peers, social norms and qualitative research. Screening was conducted by two researchers independently and in duplicate. Study quality was assessed using the eight-item Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-centre) tool for the appraisal of qualitative studies. Results were synthesised using a meta-narrative lens for meta-ethnography and compared across smoking normalisation contexts. Results Forty one studies were included and five themes were developed, mapping onto the socio ecological model. The social processes by which adolescents take up smoking differed according to a mixture of school type, peer group structure, socioeconomic composition and the smoking culture within the school, as well as the wider cultural context. Data available from smoking denormalised contexts, described changes in social interactions around smoking to cope with its stigmatisation. This was manifested through direct peer influence, whereby more subtle techniques were employed, group belonging whereby smoking was less likely to be seen as a key determinant of group membership and smoking was less commonly reported to be used as a social tool, and popularity and identity construction, whereby smoking was perceived more negatively in a post-legislative context. Conclusions This meta-ethnography is the first study to demonstrate, drawing on international data, that peer processes relating to socioeconomic inequalities in adolescent smoking may undergo changes as norms for smoking within society change. Future research should focus on understanding how differences across school-level socioeconomic contexts manifest once post-legislative norms have been established, to inform the adaptation of interventions.