Poor awareness of the health consequences of smoking.

When addressing tobacco-related health problems, most participants had scarce knowledge of what is harmful in smoking and what the actual consequences of tobacco on health are. Participants were able to express only a reduced number of complications.

The best-known harmful effects of tobacco the participants reported were: respiratory problems, a decrease in the participant’s ability to undertake moderate physical activities and risks of cardiovascular complications.

A few participants reported clear knowledge on the relationship between tobacco and diabetes and in these cases their physician had informed them. Almost half of the smokers recognized that living with diabetes could cause particular health problems and that smoking could worsen them and women, more often than men expressed this concern.

People who did not perceive a relationship between smoking and diabetes were unable to perceive a logical connection between them:

“I didn’t think there was sugar…, what I mean is, there isn’t sugar in cigarettes.”

ID11 woman

Some participants focused on body weakening as a whole (aging), to deny a potential causal relationship between smoking and diabetes. Notably, only men expressed this conception.

“No, I mean apart from having diabetes, I’m not too dilapidated. […] I don’t feel bad from diabetes, every year my kidneys are checked, or my eyes or sensation is checked, my foot sensitivity hasn’t changed, and my eyes haven’t changed, the kidneys have had a bit of tinkering, but well… In eighteen years, I think if I had an 18-year-old car, it would be more run-down than me! (Laughter)”

ID08 man

These participants were likely to dismiss the relationship by arguing that diabetes would develop anyway without smoking, based on examples of family members and friends.

Minimizing the harmful effects of tobacco.

More than half the participants considered that smoking was not a problem since they were not experiencing serious lung problems. They portrayed themselves as being “fairly” fit. In particular, three participants (2 men and 1 woman) considered themselves strong enough to contain and cancel out the potential health problems caused by tobacco.

"The doctor, who operated my heart, told me, that we all have our strong and weak points. One of us might have to stop smoking one might not need to. In the end it depended on our good and bad points. Well … I stopped at that, because it suited me to”

ID22 man

Smoking “the right way” or harm reduction.

Many participants mentioned that the manner in which they smoked significantly reduced the harmful effects of smoking.

Both men and women participants described that they did not smoke many cigarettes a day, or currently less than previously. Some participants of both genders claimed they were not dependent on tobacco, or that they were able to take a temporary break from tobacco smoking.

Another strategy to reduce perceived harm of tobacco was typically expressed by women. They described their way of smoking as “soft”, not or less harmful and not problematic; for example, never smoking in the morning, not smoking the whole cigarette or not inhaling deeply cigarette smoke.

“It’s not as bad as others (people or risky behaviors)”.

Misconceptions on harmful effects of tobacco were reinforced through positive comparisons. This comparison could be made either to other people, or to other risky behaviors perceived as “worse”. While these kinds of comparisons concerned both genders, a higher proportion of men tended to use these comparisons. The analogy was always made to men at higher risk.

"I’m not addicted like my son, well, him, in the morning he’s already at it, I tell him " you’re ridiculous! "

ID05 man

Tobacco smoke and costs.

Participants expressed displeasure or even disgust towards tobacco smoke and smell, based on personal taste. These preferences were more likely to be expressed by women. Smell, smoke and effects of smoke were found to be incompatible with the participant’s conceptions of cleanness or desired personal smell.

Among men, discomfort about the smell or tobacco smoke was most frequently found related to a state of illness and/or respiratory distress and not per se.

Cost of smoking was also mentioned as a motivation to quit smoking but to a lesser extent. Heavy smokers or smokers who were planning to quit smoking particularly expressed this concern.

Concerns about health and the impact on diabetes.

At first participants expressed their concerns in a vague manner, for example by stating that smoking was “not good” or “bad”. However, subjects with these kinds of narratives rarely had a high level of preparedness to change.

Both men and women were more likely to raise concerns about actual tobacco-related health problems if they directly experienced negative impact on their body in everyday life. Men and women were both sensitive to susceptibility to respiratory and cardiovascular disorders caused by tobacco.

With respect to diabetes, men and women did not perceive a need to change their smoking habits due to diabetes if they did not perceive an impact of smoking on their diabetes management.

Only three male participants explained that living with diabetes might motivate them to quit smoking and this motivation was significantly related to negative impacts of diabetes, including erectile dysfunction.

Among women, a general concern about health was raised by the experience of living with several chronic diseases:

"No, no, I think that … It’s bad, very bad … Anyway, with diabetes, we’re already at risk for our veins clogging up, if we add another risk … when there’s already a chance, so no, I get it … […] [I know] very well that, having diseases, like for everyone, our disease, or my diseases, it’s not good, I know that. "

ID14 woman

Women also expressed particular concerns about adverse health problems due to tobacco, such as preserving a feminine voice.

Finally, we noticed that male participants became markedly motivated to quit tobacco if they witnessed harmful effects on others, especially family and friends.

Smoking conflicts with positive self-image.

In the group motivated to reduce or quit smoking, participants thought that smoking conflicted with their values, aspirations or expectations about themselves.

Three female smokers expressed that smoking did not align with their personal values, considering it “stupid”, “ridiculous”, “silly”.

Almost half the participants at some point expressed having a problem with their dependence on tobacco. Dependence was experienced as a lack of liberty and both men and women shared a desire for independence often heard in narratives of a strong motivation to quit smoking.

"I don’t have a great opinion of myself, I try to do my best. What people expect of me at work, I work really well, and I think I’m worth it, owe it to myself, to make this gesture (quit smoking), and … I can’t manage, that’s the thing. It’s hard … No it’s terribly hard, isn’t it. "

ID04 woman

Sport-related metaphors were found among men:

“Just before smoking I think I should justify it because it’s a failure. Yes, smoking a cigarette is a failure for me. I mean I do it, I poison myself and that’s the first thing I tell myself. It’s like someone who scored, a goal, for me, it’s a cigarette I say, look; I ‘let in’ a cigarette. "

ID01 man

Men also mentioned experiencing embarrassment or feeling shame at the idea that smoking damages their image, typically if they were sportsmen.

Smoking prevents meaningful familial, professional or relational engagement.

Smoking was sometimes perceived as conflicting with important plans or desires for social engagement. Participants purposefully chose to reduce, hide or attempt to quit smoking to get involved or to maintain engagement in meaningful relationships. The kind of dialogue was very often related to an actual plan to quit or actual attempt to quit.

Professional activity deters smoking: Participants reported that some work activity dissuades them from smoking, even if smoking is permitted in the workplace.

This was particularly evident in physically active professions, typically among men.

Female-dominated professions, such as a health care provider, particularly seem to influence women to quit smoking to avoid inconveniencing patients.

"[While she was studying nursing:] I thought it was awful, caregivers who bent over you, smelling of tobacco, I said to myself, OK, how about one day, I go back to school and stop smoking."

ID43 woman

Smoking is a barrier to positive engagements with others: About one third of participants of both genders felt uncomfortable about smoking in front of non-smokers. They would delay or stop smoking that then triggered them to realize that their smoking was problematic.

Women tended to pay greater attention to avoiding smoking in front of non-smokers than men. However, certain men showed more concern if smoking increased health problems for their partner, for example an asthmatic partner.

Parenting and Grand-parenting roles: Taking on parenting and grand-parenting roles was critical for smoking attitude. This was mentioned by a large majority of participants as strong motivation to reduce or attempt to quit smoking.

R1: Well maybe if I had a grandson or granddaughter to look after at home from time to time … Well, then I think I would stop entirely "

ID03 woman

This particular motivation to reduce smoking stems also from the desire to preserve their health to benefit from the joy of being (grand-) parents as long as possible.

We could not find a clear gender difference for this motivation, although men more often reported smoking at home in front of their children compared to women.

Social and contextual motivations to reduce or quit smoking.

In this section, we identified discourses that described direct influence or incentive from a relationship(s) to quit smoking.

Take-up challenges: A challenge to quit launched between two male friends was very effective for inducing attempts to quit:

"So for me it’s exactly the opposite, because all my life everyone thought of me as a male fighter, a bull [(his astrological sign)], and you better not tell me “You can’t do it! " If someone says that to me, it provokes me, I rise to the challenge… "

ID10 man

For women, challenges rather come from the broader context of social influences:

"I started to [referring to quitting smoking the first time] because it was a bit of a joke at the office, I was in a large, open space office, and the only smoker … "

ID15 woman

Social support and encouragements to quit smoking: Participants reported that they wanted to reduce or quit smoking especially if their partners or close relations encouraged them to do so.

An effective motivation was to quit with one’s partner, if both partners smoked.

It is notable that a few single or divorced male heavy-smokers pointed out that finding a non-smoking woman was the only convincing way they could imagine to quit smoking.

Close friendships and the broader family also played a role in encouraging stopping smoking.

Smoking is not allowed: About two thirds of the participants noticed in that a public ban on smoking or agreement on smoke-free areas at home, encouraged them to reduce or quit smoking.

Physiological effects of tobacco and nicotine.

Out of twenty-one participants nineteen, both genders, talked about the physiological effects of tobacco on their bodies.

Tobacco dependence: Two thirds of the smoker participants described themselves as dependent on tobacco and dependence was used to explain why they kept smoking.

For example, for the large majority, dependence was used to express a lack of capacity to quit smoking, a state of powerlessness, most frequently experienced by women.

"Even though I don’t smoke a lot, I’m still an addict, since I smoke every day, worse though, I’d really have trouble stopping”

ID41 woman

Heavy smokers reported tobacco withdrawal symptoms when trying to quit smoking.

"If I don’t have a cigarette, I act like a drug addict, I don’t take drugs but I’m addicted, I look in all the drawers, I feel awful, it’s … You can’t imagine how addicted I am "

ID09 woman

« Stopping smoking makes me too nervous »: Some participants experienced increased nervousness after stopping smoking. This behavior might lead to negative social consequences, which deters motivation to quit smoking. Anger behavior was found to be different for men and women.

Men reported aggressiveness if they could not smoke. In some cases, this temperament gave rise to potential expression of violence towards others, including subordinates.

Among women, expression of aggressiveness from tobacco withdrawal was less socially accepted.

Diabetes as a barrier: In our sample a significant part of the participants suggested that diabetes might interfere with attempts to quit smoking.

First, smoking might be perceived as a way to manage glycemia. Smoking was also described as a mean to manage physical suffering caused by diabetes and its complications:

"When you wake up in the morning with a very high diabetes rate, you feel like your head doesn’t belong on your body! Because when my diabetes is high, I feel it in my head, for example, I’m dizzy, and then the only way to get my head back to normal is to smoke. And then have my morning coffee, isn’t it? "

ID08 woman

Female participants in particular expressed that living with diabetes was an additional stressor that prevented them from succeeding to quit smoking.

Yes, I really think, now, I have to stop because I have diabetes as well as a progressive rheumatoid arthritis […] but I’m having trouble, its difficult, so difficult, our diseases take a lot out of us on a daily basis, make physical activities hard, which is bad for diabetics who need to walk. Everything requires effort, there’s continual doubt, checking yourself 6 times a day, in the end it’s trying. For me it gets difficult to bear. So stopping smoking, I know, I saw the doctor again today, but … Even though I know I have to stop, I just can’t do it »

ID19 woman

Weight control after smoking cessation was not described as a barrier to quit smoking, even in the context of diabetes, despite participants knowing the risk of gaining weight and experiencing it after quitting. Participants who felt ready to quit were prepared to accept weight gain and deal with potential impacts on diabetes.

Habits and psychological barriers.

Almost all participants reported that smoking was encompassed in some form of ritual or habits. Participants talked about the difficulties of doing without smoking.

"All day-long and at night, if I wake up at night, I smoke … I smoke a cigarette with my medicine in the morning, between my injections, doing anything and everything, I smoke one. But, it’s, it’s becoming a ritual with everything … Totally useless connections, but it’s like that. "

ID 22 man

Half of participants both men and women mentioned that refraining from smoking after meals, especially after lunch and dinner, was the most difficult part of an attempt to quit or reduce smoking. These specific cigarettes were perceived as the most important and pleasant.

Social barriers: Almost all participants mentioned that quitting smoking was difficult if smoking is entangled in significant relationships. Participants reported difficulties to quit if their partners kept on smoking.

"I tried twenty years ago, and stopped for six months, and I was married, to a woman who smoked, Gauloises too! But then, after 6 months, I went home one day and inhaled the scent of Gauloises, I said to myself, why on earth did I stop, and then just like that started again "

ID08 man

Family members, close friends or colleagues also had an impact on smoking behavior.

Peer relationships were a third social context group, especially difficult to manage for people who tried to quit. Among men, the male peer group was identified as a major cause of smoking relapse among current smokers. The activities associated with smoking were typically masculine such as partying with male friends or joining the army.

Women who attempted to reduce or quit smoking experienced difficulties in avoiding smoking during festive events attended by men and women, especially when drinking alcohol:

"Sometimes, it happens without thinking, usually in a group, where, maybe, we’re drinking, well, I don’t drink much alcohol, but from time to time an aperitif, and I noticed, then, I want to smoke straight away. "

ID04 woman