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Quality of daily occupational experience and its relationship with adolescent tobacco smoking
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Content
QUALITY OF DAILY OCCUPATIONAL EXPERIENCE AND ITS
RELATIONSHIP WITH ADOLESCENT TOBACCO SMOKING
by
Wenchun Qu
A Disseration Presented to the
FACULTY OF THE GRAUDATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment o f the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(OCCUPATIONAL SCIENCE)
August 2003
Copyright 2003 Wenchun Qu
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UMI Number: 3133329
Copyright 2003 by
Qu, Wenchun
All rights reserved.
INFORMATION TO USERS
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®
UMI
UMI Microform 3133329
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UNIVERSITY OF SOUTHERN CALIFORNIA
THE GRADUATE SCHOOL
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089-1695
This dissertation, written by
Wenchun Qu
under the direction o f h dissertation committee, and
approved by all its members, has been presented to and
accepted by the Director o f Graduate and Professional
Programs, in partial fulfillment o f the requirements fo r the
degree o f
DOCTOR OF PHILOSOPHY
Director
Date Decem ber 1 7 . 2003
Dissertation Committee
Chair
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DEDICATION
To M om and Dad
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ACKNOWLEGMENTS
It has been a long yet fulfilling journey for me to travel from a physician to an
occupational scientist. Accomplishment of this journey would not have been possible
without the guidance, support, and assistance o f numerous people at the various
stages. My deep gratitude is extended to the following persons.
To Dr. Ruth Zemke, whose inspiration, guidance, and friendship has been the
major driving force to keep me motivated in the exploration o f the experience o f
researching and knowing. Having the opportunity to be mentored b y such a prominent
and knowledgeable occupational scientist has indeed been a special privilege.
To Dr. Ann Neville-Jan, who has always been supportive and has played an
active and important role in the development o f ideas of an occupational science
approach in adolescent smoking research.
To Dr. Jeanne Jackson, who has shared encouragement and friendship and has
opened the door o f occupational science through discussions in and out of the
classroom.
To Dr. M ark Krailo, who has provided constructive advice on the statistical
analysis of this research.
To Dr. Shao-Yao Ying, who has been a friend and advisor in my career
pursuits.
To Dr. Carl Anderson Johnson, for his trust and support.
iii
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To Dr. Ping Sun, for sharing his expertise in adolescent tobacco smoking and
statistical design.
To students who have participated in this study, to the teacher o f the classes,
and to the many friends who have help me make this study work, especially to Yen-ta
Chu, who has harnessed the technology to make this study run as smooth as expected.
Finally, to my family, from where I seek comfort, strength, and
encouragement.
This study was supported by NCI/NIDA grant # P50 CA8475-01 and the
California Tobacco-Related Disease Research Program grant # 7PT-7002.
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TABLE OF CONTENTS
DEDICATION................................................................................... ............................... ii
ACKNOWLEDGMENTS................................................................................................ iii
LIST OF TABLES............................................................................................................vii
LIST OF FIGURES............................................................................................................viii
ABSTRACT........................................................................................................................ix
CHAPTER I. PROBLEM STATEMENT AND ITS SIGNIFICANCE................... 1
Rationale and Significance o f Study .................................................................1
Research D e sig n .................................................................................................. 14
Research Hypotheses............................................................................................ 17
Assumptions ......................................................................................................... 18
Lim itations.............................................................................................................18
CHAPTER II. LITERATURE REVIEW ....................................................................... 19
Current Research Areas of Studies on Adolescent Sm oking......................... 19
The ESM Approach for Studying Internal and External
Experience of Occupation............................................................................20
An Occupational Science Approach of ESM Study on Adolescent
Smoking.......................................................................................................... 26
CHAPTER III. M E T H O D ............................................................................................... 33
Participants ............................................................................................................34
Instruments ........................................................................................................... 37
Research Procedure.............................................................................................. 38
Data A nalysis........................................................................................................40
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CHAPTER IV. RESULTS .............................................................................................45
Demographics .............................................................................................45
Descriptive Statistics.............................................................................................48
Patterns o f Internal D aily Occupational Experience while Smoking............ 64
Peri-Smoking Change o f Quality Internal Occupational Experience............ 73
Internal Occupational Experience in Different Flow States while
Smoking......................................................................................................... 75
CHAPTER V. DISCUSSION......................................................................... ................ 80
External Occupational Experience......................................................................80
Internal Occupational Experience.......................................................................83
Strength and Limitations......................................................................................96
Implications and Future Directions o f R esearch.............................................. 98
REFERENCES................................................................................................................... 105
APPENDIX A. Experience Sample Form (Palm Ille Adopted)................................. 113
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LIST OF TABLES
1. Demography of Participants from Both Schools................................................ 47
2. Time of the Day when Smoking O ccurs............................................................. 49
3. Distribution of Smoking Occasions Across the W eek...................................... 52
4. Distribution o f Number of Smoking Occasions by Location............................54
5. Companionship when Smoking at the Three Most Frequent Locations 58
6. Baseline Comparison of Internal Daily Experience Variables at Smoking
occurrences versus Students Who Never Reported Smoke.................... 65
7. Univariate Comparison of Internal Daily Experience on Smoking
occurrences to Non-Smoking Occasions.................................................. 71
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LIST OF FIGURES
1. Time of the D ay when Smoking Occurred...........................................................50
2. Distribution o f Smoking Occasions in Each Location....................................... 55
3. Number O f Students In Each Location While Smoking....................................56
4. Distribution Smoking Occasions by Companionship......................................... 60
5. Distribution o f Activities during Smoking Occasion......................................... 63
6. Pattern o f Internal Occupational Experience while Smoking
- Composite Scores....................................................................................... 68
7. Pattern o f Internal Occupational Experience while Sm oking...........................70
8. Peri-smoking Trend of Internal Occupational Experience.................................74
9. Quality o f Occupational Experiences in Flow by Smoking S tatus.................76
10. Quality o f Occupational Experiences in Boredom by Smoking Status.......... 77
11. Quality o f Occupational Experiences in Apathy by Smoking Status..............78
12. Quality o f Occupational Experiences in Anxiety by Smoking Status.............79
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ABSTRACT
Tobacco smoking is a major unhealthy occupational behavior among
adolescents in the United States. This study investigated the quality and patterns of
occupational experiences while smoking, the change of occupational experiential
quality over the period of pre-, during, and post-smoking times, and the occupational
experience while smoking in different flow states. One hundred and five students of
the 6th grade from Los Angeles area participated. The Experience Sampling Method
combined with Palm Ille technology was used to collect self-reports. External and
internal experiential variables were collected in real time or in close proximity to the
actual occupational occasions.
Participants mostly smoked in the afternoons of weekdays with friends and
peers. Smoking mostly occurred in bedrooms, public streets, less supervised areas of
school, and garages, while participants were engaged in passive activities. W hile
smoking, internal occupational experience was in entropic states, with significantly
decreased affect, activation, cognitive efficiency, and self-concept. Examination of the
peri-smoking times showed that those entropic states started about 50 minutes before
smoking, worsened while smoking, and recovered to negentropic states about 50
minutes after smoking. Further examination o f internal experiential patterns with a
four-channel flow model showed that the entropic states associated with smoking
occurred m ostly in the state o f apathy. When challenges and skills were both below
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individual average, smoking was associated with significantly lowered affect,
activation, cognitive efficiency, and self-concept.
Those results revealed the occupational risk factors for health in adolescents
who smoked. Smoking was associated with lack o f occupational balance, occupational
deprivation, and occupational alienation. It was proposed that adolescent smoking, as
an alien power, deprived the adolescents o f opportunities to explore goal-oriented,
meaningful, and purposeful occupations. An occupational science approach for
correcting the occupational unbalance and occupational deprivation was suggested.
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Chapter I
THE PROBLEM STATEMENT AND ITS SIGNIFICANCE
The primary goal of the study was to explore the relationship between the
quality of daily occupational experience of youth (6th and 7th graders) and
tobacco smoking. Specifically, this study examined the relationship between
tobacco smoking occurrences and the quality of occupational experiences and/or
the patterns of occupational experiences. Factors of occupational experiential
patterns include: on an external level (1) in what occupation was the individual
engaged, (2) where it occurred, (3) and with whom it occurred; and at an internal
level (1) affect, (2) activation, (3) cognitive efficacy, (4) intrinsic motivation, (5)
and self-concept. The secondary goal for this study was to provide baseline
information for developing an occupational science Lifestyle Redesign Program
as a preventive measure for youth smoking.
Rationale and significance of Study
Occupational science is concerned about occupations and their
relationship to health. Occupation is defined as “chunks of activity within the
on-going stream of human behavior, which are named in the lexicon of the
culture” (Yerxa et al., 1990). Although engagement in certain occupations is
health promoting, not all occupations are healthy. Smoking as an occupation is
associated with negative health effects.
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Smoking among youth is a major health problem in the United States.
Approximately 4800 adolescents appear to be experimenting with cigarettes for
the first time each day, and close to 3000 youth become established smokers
daily (Gilpin, Chioi, & Berry, 1999), one third of whom may die prematurely
(MMWR, 1996). Because 89% of adults who smoke daily begin by the age of 18
years, and cigarette use by people 18 years or younger has been increasing in
recent years, reducing smoking among youth has become a cornerstone of the
US national tobacco control policy (Cummings & Shah, 1995). To discover
ways to prevent adolescent tobacco smoking, it is important to understand the
occupational experiential patterns that contribute to their starting experimenting
and/or their going on to become regular users.
Past studies have generated theoretical models including developmental
perspectives (Kandel & Logan, 1984), problem behavior theory (Jessor & Jessor,
1977), sociological perspectives (Lukoff, 1980), psychological perspectives
(Lemer & Vicary, 1984; Vicary & Lemer, 1986), and peer cluster theory
(Oetting & Beauvais, 1986, 1987). More recent literature has revealed a
movement toward increased examination of psychosocial factors in populations
of different gender, race/ethnicity, socioeconomic status, and geographical
locations where smoking occurs, with an increasing trend of utilizing
longitudinal, multivariate analysis as the methodology of choice, among which
such techniques as path analysis are used more and more frequently (Moncher,
Holden, & Schinke, 1991). This research examined the complex nature of youth
smoking from an occupational experiential perspective by examining the
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interaction of both external and internal occupational risk factors for cigarette
smoking.
Studies on adolescent smoking from psychosocial perspectives had
categorized the risk factors for youth smoking into three categories:
intra-personal, social, or environmental (Unger, 1996). Those factors have been
intensively studied either individually or in groups. Significant correlations are
found in factors of each category.
Intra-personal risk factors for adolescent smoking
Intra-personal risk factors for adolescent smoking include genetic,
demographic characteristics, and personality traits. In studying the contribution
of personal factors, it was found that some people are more sensitive to nicotine
than others (Pomerleau, Collins, Shiffman, & Pomerleau, 1993); the reinforcing
potential of nicotine on mood and performance are greater for this subgroup.
Individual factors, possibly genetic, may underlie individual predispositions to
tobacco use and nicotine addiction. Other studies further indicated that smoking
is more prevalent among boys than girls (Newcomb & Bentler, 1986), Whites
are found to be more likely to experiment with smoking than African-Americans,
Hispanics, or Asians (Williams & Covington, 1997), and the risk of smoking
increases with age in adolescents (Newcomb & Bentler, 1986).
Internal experiential risk factors for adolescent have been intensively
studied, and many groups of psychological attributes have been found to be
associated with smoking. For example, youth with higher stress levels (Bruns &
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Geist, 1984), higher tendency to risk taking/rebelliousness (Cohen, Sattler, Felix,
& Brownell, 1987), more negative appraisals of their abilities and personal
qualities (Santos de Barona & Simpson, 1984), lower levels of self-esteem
(Dielman, Leech, Lorenger, & Horvath, 1984), and lower self-efficacy
(Lawrance & Rubinson, 1986) are at increased risk of smoking.
Social risk factors for adolescent smoking
The attitude and behaviors of the people, especially peers, in the social
network of the adolescents can influence adolescent smoking. Social bonding
theory is better able to account for initiation, while social learning theory is
found to be predictive of maintenance (Jessor, 1987; Krohn, Skinner, Massey, &
Akers, 1984). Adolescents who perceive that smoking is prevalent among their
peers are at higher risk of smoking (Sussman, Dent, Flay, Hansen, & Johnson,
1987). The combination of association with friends who smoke and social
disaffection variables explained 48% of the variance in cigarette smoking among
adolescents (Krohn, Naughton, Skinner, Becker, & Lauer, 1986; Sussman et al.,
1993). On the other hand, peers who are nonsmokers can also discourage
adolescents from smoking. Among youth who identified with high-risk peer
groups, the presence of a close friend who was a nonsmoker decreased the
likelihood that the youth would smoke heavily (Sussman et al., 1993).
Environmental risk factors for adolescent smoking
Environmental factors refer to characteristics of the physical environment
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that encourage or discourage smoking. Those factors include time and space
wherein smoking occurs, family and community environment, and parenting
style. Detailed examination of initial smoking situations or environmental
pressure to smoke situations revealed that these situations usually happen: (1) in
the afternoon; (2) in the subject’s or a friend’s home; (3) with a friend present; (4)
typically when someone offered the subject a cigarette (Friedman, Lichtenstein,
& Biglan, 1985). Peers are also found to be the primary source of cigarettes
(Needle et al., 1986; Payne & Evelyn, 1986).
Family environment plays an important role in youth smoking. Adult
family members’ tobacco use was found to be significant positively correlated
with the teenage family member’s tobacco use (Gfroerer, 1987). Adolescents
with absence of one or both parents, whose parents were divorced or separated,
or who are physically abused by parents have a higher rate of smoking (Grady,
Gersick, Snow, & Kessen, 1986; Payne & Evelyn, 1986; Vicary & Lemer,
1986). Parental characteristics (parental conflict, inconsistency, restrictive
limit-setting, and rejection) were also associated with tobacco use (Vicary &
Lemer, 1986).
Several studies have shown that exposure to pro-tobacco media
advertisements is associated with smoking and positive attitudes toward smoking
(Altman, Levine, Coeytaux, Slade, & Jaffe, 1996; Unger, Johnson, & Rohrbach,
1995). Exposure to anti-smoking advertisements, in contrast, may decrease the
likelihood of adolescent smoking. Adolescents exposed to anti-smoking
advertisements showed stronger negative attitudes toward smokers, rating them
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as immature, unglamorous, and lacking in common sense (Pechmann &
Ratneshwar, 1994).
Risk factors and occupation
Psychological or behavioral studies on smoking mostly focused on
selected variables and examined the association between the variables and
smoking. Current studies show that smoking is positively associated with
various aspects of occupation or with personal, social, and environmental factors
within which occupations occur (Atkins, Klein, & Mosley, 1987).
Health-enhancing occupation, like participation in sports, is found to be
negatively associated with smoking initiation in girls, while participation in
organized social activities is found to be positively associated with smoking
initiation (Swan, Creeser, & Murray, 1990). Borland and Rudolph (1975) studied
the relative predictability of scholastic performance, parental smoking, and
socioeconomic status among 1,814 high school students in Pennsylvania and
found that the strongest correlate to smoking was scholastic performance; those
with the highest grades were found to smoke less than those with the lowest
grades. This study is consistent with Sussman et al. (Sussman et al., 1987) in a
research with Hispanic and Asian adolescents in Southern California. Hundelby
(1985) also found that youth who have outstanding performances across a
variety of activities generally tend to report less smoking.
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The study of risk factors in the context of occupations
Although the reductionistic approach brought about huge amounts of
knowledge of the psychosocial variables with which smoking occurred, it failed
to consider the effects of all the risk factors constantly interacting with each
other with great fluidity. To understand the unhealthy behavior of adolescent
smoking, a more holistic approach is needed to allow for insights into the
time-dependent experience of life from an occupational perspective.
Occupational science provides us with a holistic and systematic way to
study adolescents’ daily occupations, examine the quality of occupational
experience and patterns of occupational experience associated with smoking, and
generate knowledge on the relationship of adolescent smoking and compromised
quality of occupational experience or certain occupational experiential patterns.
Occupational science has been concerned about unhealthy behaviors, such as
gang involvement (Snyder, Clark, Masunaka-Noriega, & Young, 1998) and drug
and alcohol use (Stoffel, Cusatis, Seitz, & Jones, 1992). Little has been done
however in exploring occupational risk factors or the relationship of
occupational experiential patterns with adolescent smoking.
In the study of occupations, it is very important that an emphasis should
be put on the fluidity of occupations, which constantly change in both the
socio-cultural settings and in the mental process. There has been enormous
numbers of past studies that have been conducted on the various risk factors and
their association with tobacco smoking. However, these studies were mostly
conducted either with retrospectively collected information or within laboratory
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settings. There has been little research that investigates the intra-personal
experience, social situation, and environmental facts obtained in close temporal
proximity to adolescent engagement in actual occupations.
Retrospective questionnaires are subject to recall bias and less accurate
(Delfino, Jamner, & Whalen, 2001). Shiffman et al. (1997) examined diary data
on smoking relapse and found that retrospective accounts given an average of 72
days later correlated poorly with the real-time data, with kappas of 0.18 to 0.27
for the four content domains of mood, activity, episode triggers, and abstinence
violation effects studied. Little is known on the internal personal experience,
social settings, or space and time patterns that occur during and around the
occupations. There is sparse knowledge of the pattern of daily occupations,
either occupational, psychological, social, or environmental elements, among the
youth smokers. Studies on occupation with real-time data collection will greatly
facilitate more accurate understanding of the nature of the occupation and its
impact on heath and health behaviors.
The ultimate goal of understanding occupation is to use the knowledge
for improving health. Engagement in occupation was found to be capable of
influencing a person’s well-being (Christiansen, 1991). The success of
occupational therapy intervention depends on our understanding of the physical
settings and mental context whereby the actions take place. Knowledge of
occupational experiential patterns and quality of daily occupational experience
and their association with youth smoking may be essential in the development of
occupational science and therapy interventions. The USC Well Elderly Study
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(Clark et al., 1997) demonstrated that Lifestyle Redesign, a program for
developing and enacting a customized health-promoting pattern of daily life,
significantly improved or maintained the physical, psychological, and social
health of the elderly participants. Given the fact that numerous studies have
found that personal, social, and environmental factors are associated with youth
smoking, most youth smoking prevention programs focus on influencing the
youth’s social environmental settings and psychological states. For future
development of a Lifestyle Redesign Program as a preventive measure for youth
smoking, we must first understand the pattern of their daily social,
psychological, and environmental experience in the context of daily occupations.
To achieve this goal, those factors need to be studied in a continuous manner
throughout the day, with focus on the time points between and after classes,
whereby smoking is most likely to happen.
Measurement of occupational experience with experience sampling method
fESMt
The occupational experience can be measured in two dimensions:
internal occupational experience and external occupational experience. Although
many methodologies have been developed in occupational science, experience
sampling method (ESM) has proved to be practically instrumental in the study of
occupation and occupational experiences amongst the context o f the constant
flow of occupations.
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Experience sampling method was developed by Csikszentmyhalyi (1975)
in an effort to study the intrinsic rewards with which a person engage himself in
an activity with a feeling that was common in all sorts of activities, which was
characterized by great pleasure and a feeling that they were doing something that
is worth doing for its own sake. For this consciousness state he coined the term
“flow”.
The essence of ESM was that the participants make self-reports in the
immediate proximity to the time point when they are prompt to do so. The
prototype of ESM was composed of a pager and a survey in paper and pencil.
When the participants were paged at a random schedule, they filled out a series
of questions and rated a number of items - items of the experience sampling
form (ESF). These items reflect both the external settings and experience, and
the internal experiential patterns. Using the ESM, Csikszentmyhalyi and Larson
(1984) gathered self-reports of the occupational experience of adolescents at 40
to 50 randomly chosen moments in their daily lives. The external components
reflect the social and environmental settings of occupations, such as location,
time, and companionship, while internal components assessed the quality of the
occupational experience, such as emotion, cognition, and will. ESM provides us
with access to the participants’ experience, and allows us to identify and describe
the patterns of daily occupational experience as they are recorded by the
participants at real-time. Because ESM records the internal and external
occupational experiences at the time of occurrence, it reveals previously hidden
facts and enables us to get the details of the subjects’ daily occupational
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experiences. One major advantage of ESM is that it allows us to study the
dynamics of subjective states while a person engages in normal daily
occupations (Famworth, Mostert, Harrison, & Worrell, 1996).
Study of occupation within the frame-work of flow experience
The model of flow facilitates the study of occupational experiences within
the frame-work of quality of occupational experiences. Flow is a construct that
describes optimal experience or enjoyment in everyday activities, and it occurs
only when high challenges from the activity are balanced by skills in the
participant. When a person is engrossed in an activity with high challenges and
high skills, he or she can enjoy the moment and may stretch his or her
capabilities to learn new skills and increase self-esteem and personal complexity
(Csikszentmihalyi, 1988; Csikszentmihalyi & Larson, 1987). Moreover, a person
in flow, experiences a positive affective state, high motivation, high cognitive
efficiency, and high activation (Emerson, 1998).
The original model of flow indicated that, when plotted as a graph on
X-Y axes, the ratio of challenges to skills equals one. This model also indicated
that the experience of flow occurs between the potential for anxiety (high
challenges with low skills) and boredom (low challenges with high skills)
(Csikszentmihalyi, 1988). Although this model addressed the question of
intrinsic motivation, it was seriously flawed because the expected experiences,
such as feeling more alert, more strong, more in control, and more concentrated,
were not predicted. To solve this problem, a new model of flow that they called
the four-channel model was developed (Massimini, Csikszentmihalyi, & Carli,
1987). It was proposed that flow begins when challenges and skills are above
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personal means, and are in balance. When both challenges and skills are below
the mean for a person, as is when opportunities are less than normal and when
personal abilities are underutilized, a person is in a state of apathy. Flow is a
force for growth, because when people get more skillful in what they are doing,
and if the challenge is still low, the person can get bored and the activity is no
longer enjoyable. As a result, people will pursue higher challenges. Similarly,
when challenges reach a high level beyond people’s capacity, they will be in a
state of anxiety and the activity is no longer enjoyable. To solve this problem,
the person will seek better skills. An eight-channel model has also been applied
in some ESM studies. In addition to the states of flow, boredom, apathy, and
anxiety, this model has included the states of arousal (high challenges and
average skills), control (average challenges and high skills), relaxation (low
challenges and average skills), and worry (average challenges and low skills)
(Massimini et al., 1987).
In this study, a four-channel model is used to analyze the flow
experience: (1) Flow: when perceived challenges and skills are above the
personal mean of perceived challenges and skills; (2) Boredom: when perceived
skills are above the personal mean of perceived skills and the challenges are
below the personal mean of challenges; (3) Apathy: when both perceived
challenges and skills are below the personal mean of perceived challenges and
skills; (4) Anxiety: when perceived challenges are above the personal mean of
perceived challenges and skills are below the person mean of skills.
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The ecological nature of this ESM and the flow model, which focuses on
observations of what people do and what happens to them both internally and
externally in their normal lives in real ecological settings, makes ESM and the
flow model useful in the study of occupations. ESM provides a holistic approach
for occupational science studies because it makes it possible to examine the
internal occupational experience patterns within the context of social
environmental settings.
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Research Design
Experience Sampling Form data was collected on all students from
whom parent consent and student consent were obtained from the participating
classes 12 to 15 times a day. The interval between two consecutive ESF entries
ranged between 30 to 70 minutes, with an average of 50 minutes. The reason for
the variation in time periods was that this semi-random schedule was used to
reduce the influence of subject expectancies on the prompt to enter data. An
identifying variable was collected on the status of smoking at the same time the
ESF data was collected so that the quality of daily experience patterns of the
students while smoking could be compared with the pattern of the same students
while not smoking.
Cross-sectional prospective design
Smoking status was collected together with concurrent internal and
external experiential variables. As a baseline comparison, occupational
experiential variables of non-smoking time of those who reported smoking at
least once during the study period and the variables of those who never reported
smoking were examined. Then major examination was to compare the
occupational experiential patterns of smoking time with those at non-smoking
time in the students who reported smoking at least once during the study period.
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Repeated measure design
Although cross-sectional study shows us the correlation and pattern and
components of daily occupational experience with smoking, it is impossible to
tell whether a pattern of daily occupational experience precedes smoking or
smoking precedes the daily occupational experience pattern. Only a repeated
measure study that collects occupational experience data at and around the time
of smoking could reveal the order of precedence in a relationship and disclose a
priori predictors of adolescent smoking. In this repeated measure study, internal
and external occupational experience concurrent with smoking events was
assessed at the time 50 minutes before and 50 minutes after they occurred. The
Experience Sampling Method (Csikszentmihalyi & Larson, 1984) combined
with Palm III technology was used to collect quality of experience variables. The
major advantages of this approach are reduction in the likelihood of recall bias
because of the close or immediate proximity of report on the
psycho-social-environmental states and the time the participants were prompted
to make an entry, and holism in assessing psycho-social-environmental states in
the context of daily occupations. The design enables investigators to determine
the temporality of associations and to observe patterns of change in perceived
patterns of daily experience as well as social-environmental settings and their
correlation with smoking occurrences over time. The signal-to-noise ratio is
enhanced because multiple occupational events or conditions/levels are studied
in each participant and because data can be analyzed within the individual
participant’s cluster of measurements, which controls the variability due to
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between-subject characteristics. Repeated measures, on the other hand, reduce
the variability of the response variables without reducing the magnitude of
association, thereby enhancing both power and precision while allowing smaller
sample sizes (Weiss & Ware, 1996).
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Research Hypotheses
The following research hypotheses were tested in this study:
1. Patterns of environmental settings (in terms of time and place)
will be identified while smoking.
2. Patterns of companionship while smoking will be identified.
3. Smoking occurrences are associated with entropic internal
occupational experiential patterns.
4. The quality of occupational experience at pre- and
post-smoking measurement times is associated with smoking.
5. The quality of occupational experience when smoking is
associated with entropic channels of experience.
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Assumptions
1. Under vigorous encouragement, the report of subjective
experience was honest and truthful.
2. The cohort was stable with a low lost-to-follow up rate.
3. If one smoking occasion did not occur in the time period
immediately after an adjacent smoking occasion, the interval between the
two smoking occurrences was long enough so that there was no carryover
effect from one smoking occasion to another.
Limitations
1. The study was based on a self-report of objective as well as
subjective experiences. Promptness in responding to the beep was
important for accuracy assurance.
2. Since information of personal experiences was investigated, the
students might not be willing to reveal their private life. Confidentiality
needed to be overtly guaranteed to promote honest responses.
3. Because multiple entries were required of the participants,
successful data collection depended on the willing and active
participation of the subjects.
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Chapter II
LITERATURE REVIEW
Current Research Areas of Studies on Adolescent Smoking
From an occupational science perspective, there are two key questions in
discovering how to prevent youth tobacco smoking: what are the quality of
occupational experience, including psychological states, social settings, and
physical environment concurrent and/or in close proximity to the actual
occupation of smoking, and what are the patterns of occupational experience of
the youth during smoking occurrences.
Current studies have revealed certain factors of occupational experience
that are associated with adolescent smoking. The association between
psychological, social, and environmental factors and youth smoking has been
extensive studied. According to the U.S. Department of Health and Human
Services (1994), behavioral factors directly related to cigarette use include
academic achievement, other adolescent behaviors, risk taking and deviant
behaviors, peer groups, participation in athletics and other health-enhancing
behaviors, and behavioral skills. Personal factors in the initiation of smoking
include knowledge of long-term health consequences, functional meanings of
adolescent smoking, subjective expected utility, self-esteem, self-image,
self-efficacy, personality factors, and psychological well-being. However, there
is still not adequate understanding of the social and psychological processes
which lie behind individual behaviors within specific occupational contexts
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(Pavis, Cunningham-Burley, & Amos, 1996; Pomerleau et al., 1993). In other
words, what accounts for youth smoking is not only gender, SES, emotion, or
social settings respectively, but also the peri-smoking context within which all
the factors interact, and the context of a subject’s pattern of daily occupational
experience that forms the foundation of the students’ behavior.
Although individual factors, possibly genetic factors, may play a role in
the individual sensitivity to nicotine, psychosocial and environmental factors
play a larger role in determining youth smoking in most of the youth who are not
biologically more susceptible to nicotine (Pomerleau et al., 1993). Such
observations raise important context sensitive questions, such as what are the
social situations in which young people smoke; What social meaning does
smoking have for them in their specific social situations; What are the emotional,
cognitional, and motivational states in which the youth smoke? There are also
important questions that are not limited to the context of events, but the context
of daily experiences, such as: What are the emotional, cognitive, and
motivational patterns of the youth who are more susceptible to smoke; What are
the patterns of the social activities of the young smokers; and What are the
patterns of time and movement in space of those who tend to smoke?
The ESM Approach for Studying Internal and External Experiences
Human occupation is characterized by its complexity, with social,
psychological, and environmental textures closely woven in an interactive
manner. To dissect and understand human occupation, both subjective feelings
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and objective phenomena should be investigated in the context of occupation as
it is occurring. Three major methodologies of contextual studies on subjective
and objective experiences have been developed. First, time budget studies have
been used to study experience through the way a person uses his or her time
(Robinson, 1977; Szalai, 1977); second, research has measured psychological
reactions to everyday activities and experiences; and third, the experience
sampling method was developed. Time budget studies using time diaries are
highly replicable, and they were later extended to observational investigations of
behavioral settings including time use in the socialization of children (Baker,
1968). Studies based on the first and second methodology provided
understandings on global psychological states in representative populations. The
second methodology focused on the impact of everyday life situations on
psychological states, such as psychopathology and coping (Gurin, Veroff, &
Field, 1960). Occupational scientists have adopted the third methodology as a
holistic approach in studying the relationship between people’s daily
occupational experience and their levels of subjective well-being (Lo & Zemke,
1997).
Although studies based on the first and second methodology have
enriched our understanding on global psychological states in representative
populations in the context of daily experiences of occupation, they had several
shortcomings: First, the data was gathered in a retrospective manner, outside of
the context of the situation, thus permitting distortions and rationalizations. Time
diaries were based on memory and were open to rearrangements of experience,
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and they did not provide direct access to a person’s internal states. Time budget
studies also did not reflect the intensity of the experience nor was it clear about
the link between behavior and psychological states or between time use and
experience (Famworth et al., 1996).
The experience sampling method required participants to carry an
electronic pager and a self-report of Experience Sampling Forms (ESF),
typically for a week. At any random moment, a signal was sent to the pager,
causing it to beep or vibrate. At the time of the signal, participants answered
questions on the ESF about various behavioral and experiential aspects of their
immediate experience. Items on the ESF might vary depending on the
investigator’s goal (Csikszentmihalyi & Larson, 1984). Each ESF typically
contained open-ended items such as ‘As you were beeped what was the main
thing you were doing?”, as well as fixed-alternative items to indicate the
intensity of various emotion and cognitive status.
With the experience sampling method, researchers were allowed access
to the stream of consciousness, such as states of heightened happiness or
self-awareness, extreme concentration experience at work, and personal intent
from moment to moment. The ESM allowed researchers to relate these
regularities to characteristics of the person, of the situation, or of the interaction
between person and the situation (Csikszentmihalyi & Larson, 1987). By doing
so, the patterns in people’s subjective experiences could be related to the social
and environmental conditions of their lives, and the subjective phenomena could
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be as objectively studied as possible without compromising the essential person
meaning of the occupational experience.
To examine the association between the patterns o f daily experience and
youth smoking, two dimensions of personal experience were studied with
experience sampling method. The external dimensions focused on situations that
interacted with and altered how people thought and felt, while the internal
dimension was concerned with the nature and quality of their conscious
experience at the time of participation in the occupation: how the youth thought
and felt (Kubey & Csikszentmihalyi, 1990). The external component as defined
in terms o f where the adolescents were, what they were doing, and whom were
they with at the time of the signals. With information about the occupation, the
subject’s location, time, and companionship, the subject’s social and
environmental settings with reference occupations could be assessed in the
context o f patterns throughout the days (Csikszentmihalyi & Larson, 1984).
The purpose of gathering information about the respondents’ subjective
experience was to ascertain how internal states varied in the natural course of
daily activity. Although internal experiential states and processes were extremely
varied, they have been divided by some psychologists into three main types:
emotion, cognition, and conation or will (Hilgard, 1980). In ESM studies,
however, the internal experiences are studied in five domains: affect, activity,
cognitive efficiency, motivation, and self-concept (Csikszentmihalyi & Larson,
1984).
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Emotion or affect has been defined as referring to the internal condition
of experience as a whole - whether it was basically positive or negative
(Csikszentmihalyi & Larson, 1984). At a basic level, negative emotional stages
generally denoted the conveyance of internal information that the person’s goals
were not being met somehow, therefore creating disorder in experience. Positive
emotions indicated that at least one or more of a person’s short- or long-term
goals was being met. Activation was a measure that was inter-related with affect.
It reflected the level of an individual’s energy, indicated by questions about how
alert, active, strong, and excited he was.
Cognition referred to how attention interacted with the enviromnent, and
transformed otherwise meaningless stimuli into useful information. Conation or
will denotes processes by which people directed their mental and physical
energies and managed to sustain and focus them on goals. Because individuals’
ability to process information fluctuated dramatically throughout the day,
cognitive efficiency was studied in terms of variations in an individual’s
cognitive facilities at different time points throughout the day. Concentration
was the major question cognitive efficiency was concerned: length, depth, and
ease of concentration directly affect cognitive efficiency. Alertness and
self-consciousness were also concerned, but because they were highly correlated
with concentration, they were of secondary importance.
The extent of intrinsic motivation was reflected by how much a person
actually wanted to do whatever he is doing. Rather than answering the question
of free will, ESM study was concerned about the reality of according to the
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individual’s feeling whether he was free or he was constrained in the actions.
Sense of control, freedom, and involvement were also measured as
supplementary measures that reflect intrinsic motivation.
The multiple dimensions of internal occupational experience interacted
with each other and generated two general internal occupational experiential
states: entropy and negentropy. Entropy was a state of disorder that led to loss of
meaning. Entropy was an internal occupational experiential pattern that, due to
the tension as a result of conflicting goals and values structured by instinct and
societal norms, the person lost his capacity to work and generate pleasant
experiences. Entropy was associated with bad moods, passivity, lack of
motivation, and unfocused attention. On the other hand, negentropy was a state
of order. It was an occupational experiential pattern in which one felt whole and
act with clarity, commitment, and enthusiasm. The multiple experiential
dimensions, rather than conflicting themselves as in entropy, functioned together
in synergy. During this state, the individual felt positive towards self and others,
presented high levels of activation and motivation, and showed high levels of
effective concentration. Examination of the state of occupational experience
associated with smoking within the context of daily occupations is very
important because it may reveal not only the experiential pattern of smoking, but
also help us better understand the change of experiential patterns over time.
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An Occupational Science Approach of ESM Study on Adolescent Smoking
Experience sampling method study provides an instrument for studying
youth smoking from an occupational science perspective. The quality of
occupational experience and the occupational experiential patterns in concern
can be based on the model of human subsystems, which is an occupational
science application of general system theory (Clark et al., 1991). According to
the concepts of general system theory, human occupation is the result of a
complex system of interaction, which might be described as a complex of
elements interacting in a functional way (von Bertalanffy, 1975). Based on this
theory, a model of human subsystems was developed to delineate the elements of
human occupation in a functional organization of subsystems and the interaction
between the subsystems as an open system in the environment (Clark et al.,
1991).
Six subsystems were defined that need to be considered when studying
an occupation. First, the physical subsystem was composed of physical matter
and the pattern of neural networks formed as a result of repeated process of
occupation. Physical structures were addressed in relation to the role they played
in the enactment of occupations. The pattern of neural networks was formed in
the process of repeated occupational pattern and functionally governs the
experience of occupation (Zemke, 1996). Smoking as a learned behavior,
generates aversive feelings in those at the experimenting stage or beginning
stage. It takes a median of 2 years for an individual to go through the change
from initiation to regular smoker (Baugh, Hunter, Webber, & Berenson, 1981).
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During this change, we hypothesize that the individual not only goes through
both pharmacological changes that makes him nicotine dependent, but also goes
through the neural network changes through repetition of smoking under certain
social environmental pressure or hints. This neural network governs the person’s
smoking behavior in such a way that certain external occupational experiential
patterns will initiate the process of craving in a subconscious level, and smoking
will bring about pleasant internal experience.
Second, the biological subsystem was defined as the living system
involved in biological adaptation, the biologic urge for competence. It
emphasized the role that sensory integration played in the execution of
occupations, and the exploratory behaviors that resulted from the coupling of the
two. In interpreting smoking, besides the pharmacological effect of nicotine on
the central nervous system, the movement of lighting, the gesture of holding the
cigarette, and the sensation of the cigarette between the figures all together
generates a pattern of movements, which eventually transcends and presents
themselves as a ritual. The biological foundation for a complex and coordinated
movement of lighting, the sharp sense of the fingers on location, texture, and
temperature of the cigarettes, and the proprioceptive feeling of the distance of
the cigarette from the body in space is based on the adaptation, which is driven
by urges of competence. Similar to the formation of neural networks, the
establishment of the biological subsystem is also a result of repetition of the
action of smoking, and in turn, when they are established, it enhances smoking
because of the sensory input generates pleasure and satisfaction.
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Third, information processing subsystem was focused on the cognitive
processes that were employed by human beings to successfully enact
occupations. Items of cognitive process, such as schema, attention, imagination,
and perceptual anticipation, were needed for executing everyday occupations
(Neisser, 1976). A person’s knowledge of the goals and moves, and his/her skill
was also part of this subsystem. Occupational science is concerned about the
effect of smoking on the cognitive efficiency, as well as the impact on a person’s
ability to engage himself on healthy occupations. Our concern is that due to the
initiation of smoking, individuals will lose their capacity to process the often
conflicting goals and values, and reduce their ability to engage in goal-oriented
meaningful and purposeful activities, hence sinking into the situation of
occupational deprivation and occupational alienation. Occupational deprivation
and occupational alienation are two of the occupational risk factors for
occupational health (Wilcock, 1998). Because smoking is learned behavior that
attunes the individuals to smoking under certain circumstances, as time goes by
and the behavior is repeated enough times, the physiological and biological
subsystems would coordinate in a way that smoking becomes an automatic
response to the repeated circumstances and other healthy occupation would lose
the opportunity of being considered as options. As a result, smoking deprives the
individual from possibilities of engaging in healthier goal-oriented occupations.
For the same reason, as the individual would not be able to engage in healthier
occupations, the conflict and crave for smoking and goal and value would
generate disorder in the person, leading to the alienation of the activity of
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smoking from the occupational self. Research at the information processing level
would provide us with the knowledge of behaviors such as smoking and their
association to occupational health.
Fourth, the social cultural subsystem was described as focusing on
perceived social and cultural expectations. Understanding of occupation required
detailed analysis of the socio-cultural context in which it occurred and the social
and occupational role the individual assumed in this context. Smoking initiation
is a product of socio-cultural influence. Peer pressure is considered the major
cause of adolescent smoking (Urberg, Cheng, & Shyu, 1991). The socio-cultural
events of peer selection, peer group admission, and the commonly shared value
and rationales of the peer group are largely responsible for the experiment of the
aversive inhalation at the very beginning. As far as occupational science is
concerned, promoting goal-oriented, meaningful and purposeful activities would
provide adolescents opportunities to explore alternatives for the unhealthy peer
subculture, hence reduce the risk to initiation and maintenance of smoking.
Fifth, the symbolic evaluative subsystem was concerned with the
symbolic systems that were used to appraise the individual’s valuing of the
occupation. Aesthetic, moral, emotional, and economic value systems were parts
of this subsystem, which were employed to appraise the significance of the
occupation. Adolescent smoking is a behavior that is caught in the conflict
between personal goal, health risk awareness, and societal norm. When it comes
to smoking, the peer group value and subculture clashes with the value of the
parents and the society. Students have to find their own rationales to legitimize
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their behavior, be it to be part of the group, or just to look cool. Understanding
the evaluation system of the adolescents associated with smoking will help us
develop and promote occupations that have the potential to promote goal and
meaning oriented value systems, which would intrinsically motivate the
adolescents to explore alternative occupations.
Sixth, the transcendental subsystem was concerned with the sense of
meaning the person ascribed to his or her daily occupations over the course of a
lifetime. Meaning was built upon the framework of personal goal and value, and
was represented in the form of purposefulness. When a behavior met the
personal goal and was acceptable to personal value, then with a sense of
purposefulness, the behavior was meaningful, so was an occupation. Because
smoking is a behavior that emerges from the conflicts of peer subculture,
personal goal, and societal value, the meaning of smoking among adolescents
varies from individual to individual. For some, it could mean independence or a
sense of belonging to peer groups, for others, smoking could mean deviation
from parents’ norm and might serve as a rationale for avoiding smoking.
Working with the adolescents at risk for smoking at the level of transcendent
meaning by promoting awareness of the meaning of this behavior, may help to
improve their chances to make conscious comparisons and explore more
goal-oriented and meaningful occupations.
Studying human occupation as a dynamic system might provide
understanding of the formation of relatively stable patterns of behavior and of
the extensive change that we recognize in human occupation, which can be
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found within the relationships of the organism’s subsystems. Studies o f complex,
dynamic systems suggest that living systems are self-organizing and pattern
forming. Human patterns of occupation also bear this quality (McLaughlin Gray,
Kennedy, & Zemke, 1996). To study the pattern of daily experience and its
implications in youth smoking susceptibility, experience sampling method
provides an ideal tool to assessing all the subsystems and their interaction.
The experiencing sampling method provides occupational science studies
with a good instrument for studying human occupation as a system, because it
collects both internal and external experiences at real time, and vastly increases
the chances for investigators to gain insight into the subsystems at interactions.
Experience sampling method has been most successfully applied to complex
situations such as mental health. Dijkman and De Vries (Dijkman & DeVries,
1987) used it for study of the interaction between anxiety symptoms and the
environment in which they occurred. Barge-Schaapveld et al (Barge-Schaapveld,
Nicolson, van der Hoop, & De Vries, 1995) studied depression and assessed
changes in depressed outpatients' experience of daily activities after 6 weeks of
antidepressant treatment. On the Sickness Impact Profile, treatment responders (n
= 12) improved more than non-responders (n = 9) in the domains of household
chores, leisure and social activities. On ESM measures completed 10 times each
day for 6 days pre- and post-treatment respectively, responders showed greater
increases in time spent in chores and greater decreases in passive leisure time than
non-responders. Responders showed greater increases in positive affect and
greater decreases in negative affect during all activities.
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Experience sampling method has also been used in occupational science
and occupational therapy studies. Jacob (Jacobs, 1994) studied job satisfactions
and its relationship with daily experience patterns, and found those who
experience such moods and attitudes as "alert," "happy," "involved," creative,"
"excited," "productive," "accomplished," "proud," "good," "confident,"
"positive," and "challenged" have better job satisfactions. Famworth (Famworth,
2000) examine the time use, including leisure occupations, o f a sample of young
offenders in Melbourne, Australia. The young offenders reported that they were
engaged in leisure occupations, predominantly passive, 57% o f the times beeped,
and in personal care occupations 21% of the times beeped. Only 10% of the
times beeped did they report being engaged in productive occupations such as
education or employment. The time spent in passive leisure occupations was
30% higher than for the average Australian adolescent. Leaving school and lack
of financial and human resources contributed to the high percentage of
engagement in passive leisure occupations.
In summary, current studies have generated enormous information on
social, psychological, and culture risk factors of adolescent smoking. However,
an occupational science approach on the occupational experiential nature of
adolescent smoking will provide a holistic picture on this complex occupational
behavior, identify the occupational risk factors, generate occupational theories
pertinent to adolescent smoking, and eventually develop new intervention
programs that help reduce adolescent smoking by designing and promoting
meaningful, purposeful, and goal-oriented occupational engagements.
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Chapter III
METHOD
This study, as a collaborate project between the USC Department of
Occupational Science and Occupational Therapy and its Institute of Prevention
Research (IPR) of the Department of Preventive Medicine, was composed of two
major parts: The first study was a longitudinal school-based experimental trial of
smoking prevention strategies in a multicultural, urban population of adolescents
in California. The respondents in this study were 6th -grade students attending the
middle schools participating in the study. A baseline survey was conducted in
the spring semester of 2001 to assess tobacco use and related psychosocial and
cultural variables before the implementation of culturally relevant smoking
prevention programs. Half of the students received smoking prevention
programs, while the other half was treated as control. A follow-up survey was
conducted in the spring semester of 2002 to collect data on smoking status of the
same participants. Participant characteristic was collected by the first study.
Second, semi-randomly selected participants of the above study took part in a
repeated measure study with focus on adolescents’ pattern of daily experience
(both external and internal) and its relationship with the incidence of smoking in
adolescents. This study was carried out in the semester between the baseline and
the follow-up study, i.e. the fall semester of 2001. The study of the pattern of
adolescent daily experience and its relationship with adolescent smoking was
funded by the developmental grant from the Trans-disciplinary Tobacco Use
Research Center (TTURC) of IPR.
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The repeated measure design assessed the internal and external
experiences related to the occupation of smoking during the peri-smoking time
as well as the non-smoking time, so as to determine the temporality of
associations and to observe between- and within-individual patterns of change in
perceived quality of daily experience as well as social-environmental settings
and their correlation with response over time, thereby gaining insight into
adolescent participants’ susceptibility.
Participants
School and class selection
Because both the longitudinal experimental trial and the study of quality
of adolescent daily occupational experience focus on two largest immigrant
ethnic groups to the U.S. (Hispanics and Asians), the sample selection procedure
was designed to select schools with large proportions of Hispanic and Asian
students. Data from the California Board of Education and the Roman Catholic
Archdiocese were used to identify and classify schools as Asian, Latino, or
Multicultural. To be classified as Asian or Latino, a school’s ethnic composition
had to exceed 50% of the respective ethnicity of interest, or it had >35% of the
predominant ethnicity of interest and <25% of the other ethnicity of interest (e.g.,
one school qualified as Asian because its Asian composition was 48% and its
Latino population was 21%). To facilitate longitudinal follow-up o f students, the
sample was limited to middle schools that included grades 6, 7, and 8 (i.e.,
school systems were excluded if their students matriculate from elementary
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school to junior high school between grades 6 and 7). Within each school,
three classes were randomly selected and all the students of the selected classes
were included in the cohort if the students and their parents signed the assent and
consent.
Student recruitment
For baseline and follow-up data collection, all 6th -grade students in the
participating classes of participating schools were invited to participate in the
study. The longitudinal experimental trial includes two components with
different informed consent requirements according to California law and the
university’s Institutional Review Board. The smoking status evaluation portion
of the study required only implied parental consent and active student assent (i.e.,
students could choose to participate if their parents did not provide a written
refusal). The more extensive survey of cultural, psychosocial, and occupational
variables, which contained more sensitive questions, required active written
parental consent (i.e., students could choose to participate only if their parents
provided active written informed consent).
Because part of the longitudinal experimental trial study required active
written consent and part required only implied consent, a two-stage process was
used to obtain parental consent and student assent to participate. Consent forms
were sent home to the parents/guardians of all 6 -grade students of participating
classes in the school. If a parent actively refused the child’s participation (i.e.,
checked “no” on the form and returned it to the school), the child was not
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eligible to participate in any part of the survey. If a parent provided active
written consent for the complete survey (i.e., checked “yes” on the form and
returned it to the school), the child was invited to participate in the complete
study. If a parent did not return the consent form at all, the child was invited to
participate only in the portion of the study that did not require active written
parental consent (e.g., non-sensitive survey questions that were part of the usual
curriculum evaluation, which in California requires only implied parental
consent).
Students were then invited to provide written assent to participate. If the
parent and student provided active written consent/assent, the student
participated in the full survey. If the parent provided only implied consent (i.e.,
did not return the survey) and the student provided assent, the student
participated in the curriculum evaluation only. If the parent and/or student
provided a written refusal, the student did not participate in any phase of the
study.
For quality of daily experience data collection, students of all
participating classes were given two forms: parent consent form and student
assent form. Those students whose parents agreed for them to participate and
they themselves also agreed to participate were included in the study. Because
the quality of daily experience data collection was carried out one semester after
the baseline study, during which transfer of students from other schools or other
classes occurred, there were students in participating classes who didn’t have
baseline data. However, they were still included in our quality of daily
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experience data collection as part of the repeated measure design, but they were
not qualified for the follow-up design.
Instruments
USC Student Survey Summer 2000 for Institution of Prevention
Research was used for baseline and follow-up data collection as part of the
longitudinal experimental trial study. This survey collected data on
demographics, smoking status, health values, people in the child's life (parents,
teachers, friends), acculturation and cultural values, personality and
psychopathology, bullying, tobacco-related media exposure, and physical
activity.
The Experience Sampling Form (ESF) (Csikszentmihalyi & Larson,
1984) collected data on the subject’s internal and external experiences during
normal daily occupations including peri-smoking times. The subject’s location,
time, companion, activities, as well as emotion, cognition, and motivation is
recorded within the context of occupations. To facilitate data collection and
analysis, the ESF was modified in format to fit in the Palm (Appendix A).
Based on data of the same age group as participants in our study,
open-ended questions were transformed into multiple-choice questions. In a
experience sampling study on adolescents, Csikszentmihalyi and Larson (1984)
found that adolescents’ 100% of occupations can be coded into 16 categories,
78.9% of locations can be coded into 16 categories, 100% companionship can be
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coded into 13 categories. Because the maximum capacity for Palm Ille is to hold
up to 16 categories, occupation, location, and companionship were coded into 15,
16, and 13 mutually exclusive categories.
Palm Ille™ (Palm Computing, Inc.) was the means of data collection. An
operating system specifically designed by Thinking Bytes Technology for this
study was provided by the Institute of Preventive Research of USC, and was
installed on all the Palms used in this study. Software installation, beeping
schedule upload into the Palm, and data download from the Palm was
accomplished by connecting the Palm to a PC with a cradle. The minimum
requirements for the PC are: IMB-compatible 486 computer or higher; 20MB or
more available hard disk space; 8MB memory or higher; and Microsoft ®
Windows® 95, Windows® 98, or Windows® NT 4.0.
Research Procedure
For baseline and follow-up data collection, students completed a
160-item paper-and-pencil survey in their classrooms during a single class
period (45-50 minutes). Trained data collectors, who were not previously
acquainted with the students, distributed the surveys. The surveys were
identified only by a code number, not with the students’ names or any other
identifying information. Because the students all attend English-language
schools in which their classes were conducted only in English (California state
law prohibits bilingual education in public schools), a basic level of
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English-language proficiency was assumed and the surveys were provided only
in English. However, students were encouraged to ask the data collectors to
clarify the meanings of any unfamiliar words.
The ESF of 35 questions was collected in-between the baseline and
follow-up data collections, at about the mid-point of the school year. With the
help of new technology, the ESF was not collected in a traditional
pager-and-booklet fashion, but on a more convenient format: a Palm Ille survey.
The Palm Ille ran on the operating system specifically designed by Thinking
Bytes Technology for this study, so that the ESF could be uploaded into the Palm
and the Palm could be programmed to beep according to our semi-random
schedules. Each subject carried this Palm for 5 consecutive days, during which
the Palm beeped for 12-14 times a day between 8:10am and 8:30pm, an average
of 50 minutes apart. Each time the Palm beeped, the student was to turn on the
screen and enter their answers by using the stylus to make their choices for fixed
answer questions. All questions must be answered once the survey was initiated.
Unfinished survey can be continued when the Palm was turned on the next time.
It takes about one and a half minutes to finish all the 35 questions at once, and
the participant can then turn off the Palm until it beeps next time. Data was
downloaded into a computer at the end of the 5-day period.
Before the ESF survey, a one class period (45 minutes) orientation was
given to each class. During this orientation, researchers gave the participants
hands-on experience on Palm use and techniques to enter their answers. All
participants entered a trial survey, which was removed in the data cleaning
39
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process. The survey questions were explained to the students question by
question, and the words in the questionnaire any of the subjects didn’t
understand were explained in easy language. Teachers were also asked to explain
the words in case the participants found some words hard to understand after this
orientation. Confidentiality was guaranteed to the students as a measure of
encouraging honesty. An out-orientation was given at the last day of every round.
Participants filled out a survey on how they felt about this methodology, the
questions, and the reason why they didn’t respond to beeps sometimes. Results
of this survey were reported (Chu, 2002).
Data Analysis
Data collected with ESF was either ordinal or on Likert scale. External
components of daily experience were defined as what occupation the participant
is experiencing, where is it happening, and with whom the participant is when
signaled. As described in the section on instruments, to facilitate data collection
and analysis, occupation was categorized into 15 groups, location into 16, and
companionship into 13 mutually exclusive categories. Internal components of
daily experience included three groups of variables: affect and activation,
defined as the emotional state or mood; cognitive efficacy, defined as the level of
concentration, difficulty in concentration, and self-consciousness; intrinsic
motivation, defined as how much a participant wishes to be doing the current
occupation. All items of internal experience were measured on a seven-point
Likert scale (Appendix A).
40
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For baseline and follow-up data, the following items were collected: age
and gender, generation in the USA, ethnicity, SES, academic performance,
smoking status, acculturation, cultural values, family life, peers, health attitudes,
media exposure, psychopathology, and physical health. Answers to all items are
mutually exclusive categories.
Data cleaning and centralization of the scaled data
The Experience Sampling Form data collected on the Palms was
downloaded into an ASCII file for each student. All the ASCII files were
combined into one ASCII file. Trial surveys were identified by the time stamp.
Those surveys that occurred during the orientation class periods were identified
as trial surveys and removed.
The Likert scale variables were centralized to the means of each variable
for each participant. First, Likert scale variables collected with ESF were either:
1) a continuum from one extreme emotional feeling to the opposite extreme in
the following variables, as from drowsy to alert, sad to happy, irritable to
cheerful, weak to strong, lonely to sociable, ashamed to proud, detached to
involved, closed to open, tense to relaxed, bored to excited, confused to clear,
and competitive to cooperative; or 2) a continuum from lowest grade evaluation
to the highest grade evaluation in the following variables, as level of
concentration, ease to concentrate, feel good about self, control, up to own
expectations, up to other’s expectations, physical pain, perceived skill, perceived
challenge, import to self, important to others, success, wishing doing else, and
41
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importance to overall goal. Because the low end and high end of the scales were
ordered in a random fashion in the ESF, all scores were rearranged so that the
low end and high end follow the above-mentioned order. Second, the mean of
each variable for each participant was computed, and the
centralized-to-the-mean score for each observation was computed by subtracting
the mean from the raw score. The centralized-to-the-mean score will be the score
used in the analysis.
Composite scores for internal occupational experiences were computed
as the sum of contributing variables. Affect was the sum of score of feeling
happy, cheerful, and sociable; activation was the sum of being alert, active,
strong, and excited; cognitive efficiency was composed of the level of
concentration, ease of concentration, and clarity; motivation was the
combination of wishing doing activity, control of action, and level of
involvement; last, self-concept was the sum of the level of feeling good about
self, extent of living up to own expectations, and the degree of satisfaction with
how the participant was doing in the activity.
Descriptive analysis
The external daily occupational experience of smoking was analyzed.
The location, time, and companionship while smoking onsets occur was
assessed. Chi square tests were used to determine the significance level. The
distribution of smoking onsets during the weekdays was also presented.
42
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Cross-sectional analysis
Each participant’ s pattern of occupational experience at the time of
smoking was compared with the pattern at the time when not smoking. To this
end, the following steps were made:
(1) A baseline comparison was made univariately between the
occupational experienctial patterns of not-smoking time of the students who
reported smoking with the pattern of the students who never reported smoking.
Two-sided t-test was adopted in this procedure at the significance level of 0.05.
(2) A comparison between the pattern of daily occupational experience
of smoking time of those who reported smoking with the their pattern when not
smoking was made univariately. Two-sided t-test was adopted in this procedure
at the significance level of 0.05.
Repeated measure analysis
The analysis focused on the repeated measures reported in the ESF by
individual participants. Their responses to questions formed the dependent and
independent variables. The temporal distance between adjacently reported time
periods varied because of the quasi-randomized schedule, which is used to
reduce the influence of subject expectations on ESF survey prompt. The average
interval was 50 minutes. Participants’ reports in each ESF entry reflect the daily
occupational experience perceived at the moment of beeping.
43
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In those who reported smoking, internal occupational experience
variables reported an average of 50 minutes before the smoking occurrences,
those reported while smoking, and those reported an average of 50 minutes after
the smoking occurrences were chosen. Repeated measure ANOVA was used to
analyze the significance level of change. This study is a balanced repeated
measures design with one crossover factor. The internal occupational
experiential variables reported at 110 smoking occurrences were compared with
those reported an average of 50 minutes before and 50 minutes after smoking
occurrences. The ANOVA model for this design was given as
Yij = ju + Si + Tj + E ij
where i = 1, 2, 3,..., 43 and j = 1, 2, 3. Here i denotes the number of participants,
and j denotes the number of time-points analyzed, S, is the random effect of
participant i, T j is the fixed effect of time-points, and Ey is the random error for
time-point j within smoking occasion /. In this model, { Si } and {Ey } are
assumed to be mutually independent, S ,- is assumed to be distributed as N(0, crs ),
and Ey is assumed to be distributed as N(0, ct ). Tukey test was used to examine
the difference between any pair of the three time points. Statistical significance
was attributed to p-values < 0.05. All statistics were carried out with SAS
statistical package Version 8.2 (SAS Institute).
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Chapter IV
RESULTS
One hundred and five grade 6 students from two schools participated in
the study. Each student was prompted for self-report for a total average of 70
times over a period of 5 days. The average response rate was 61%, ranging from
77% on day 1 to 50% on day 5, with an attrition of response daily. In terms of
lag between the prompt and completion of self-report, 57% finished self-report
within 5 minutes, 80% finished within 10 minutes, 88% finished within 15
minutes, and 92% finished within 20 minutes.
Demographics
A total of 105 grade six middle school students (56 from Stevenson
Middle School of Los Angeles, 49 from Foothills Middle School of Arcadia,
both in California) participated in this study. Three thousand twenty three
surveys were reported (1643 by students from Stevenson Middle School and
1380 by students from Foothills Middle School).
Of the 105 participants, demographic information and follow-up data was
collected on 76 students by the IPR staff. In summary, although there were 105
participants in our study, for both schools collectively, we can describe 45
(59.2%) females and 31 (40.8%) males, with a median age of 12 years old
(range: 11-16). Students were allowed to enter one or more than one races that he
or her identified with. Of the 73 students who entered race data, there were 46
45
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latino or Hispanic (63.0%), 23 white (31.5%), 12 Chinese and Chinese American
(16.4%), 4 Black or African American (5.5%), and 1 Korean or Korean
American (1.4%) students (table 1).
Of the 45 students who had race data from Stevenson Middle School, 43
were Latino or Hispanic (95.6%), 8 were white (17.8%), and 2 were black or
African American (4.4%) students. Of the 28 students with race data from
Foothills Middle School, 15 were white (53.6%), 12 were Chinese (42.9%), 3
were Latino or Hispanic (10.7%), and 1 Korean or Korean American (3.6%).
All participants were in the first semester of the 6th grade at the time ESF
data was collected.
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Table 1.
Demography of Participants from Both Schools
Number of Participants Percentage (%)
Gender (N=76)
Female
Male
45
31
59.2
40.8
Age (N=70)
1 1 years of age 6 8.6
12 years of age 53 75.7
13 years of age 10 14.3
16 years of age 1 1.4
Race (N=73)
Latino or Hispanic 46 63.0
White 23 31.5
Chinese or Chinese American 12 16.4
Black or African American 4 5.5
Korean or Korean American 1 1.4
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Descriptive statistics
Out of the 3023 ESF entries, 110 (3.6%) cigarette-smoking occurrences
were reported by 43 (41.0%) students, of which 75 were reported by 26 students
(46.4%) from Stevenson Middle School and 35 by 17 students (34.7%) from
Foothills Middle School. The external occupational experiential patterns in terms
of time, place, companionship, and concurrent activities while smoking and the
quality of internal occupational experience was reported.
Time of smoking occurrences
There were two patterns with regard to the time of the day when smoking
occurred: during the weekdays, it occurred mostly in the afternoons when classes
were over and the students were away from school, concentrating during the
period of 2 pm to 6 pm. In comparison, during the weekends, smoking occurred
in a constant pattern between 9 am and 6 pm. See Table 2 and Figure 3.
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Table 2.
Time of Day when Smoking Occurred
<
Time o f the day
Smoking Occurrences
Weekdays Percentage (%)
Smoking Occurrences
Weekends Percentage (%)
7-8am 1 1.2 1 4.2
8-9am 1 1.2 1 4.2
9 -10am 0 0 3 12.5
10-llam 7 8.1 3 12.5
12-lpm 9 10.5 2 8.3
l-2pm 2 2.3 2 8.3
2-3pm 12 14.0 2 8.3
3-4pm 9 10.5 2 8.3
4-5pm 8 9.3 3 12.5
5-6pm 13 15.1 3 12.5
6-7pm 4 4.7
7-8pm 11 12.8 1 4.2
8-9pm 6 7.0
9 -10pm 2 2.3 1 4.2
10-llpm 1 1.2
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14
12
□ Onsets on weekdays
B Onsets on weekends
m l
7am- 8am- 9am- 10am- 11am- 12pm- 1pm- 2pm- 3pm- 4pm- 5pm- 6pm- 7pm- 8pm- 9pm- 10pm-
8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm
Time of Day
o
Figure 1. Time of Day when Smoking Occurred
There was a close to even distribution of the percentage of ESF entries
while smoking throughout the week, ranging from 1.8% to 4.7%, except for
Tuesday, with 10.3%. However, because Tuesday has one fourth of ESF entries
of the daily average, a greater variance should be considered when we interpret
this number. The distribution of number of students who smoked throughout the
week showed a different pattern, with more students smoking on Tuesday
(20.7%), Wednesday (26.6%), and Friday (22.2%), and with fewer students who
smoked during the weekends (Table 3).
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Table 3.
Distribution of Smoking Occurrences Across the Week
Sun Mon Tue Wed Thu Fri Sat
N of ESF entries 393 154 107 624 805 515 425
Smoking occasions 7 5 11 27 19 24 17
Percentage (%) 1.8 3.3 10.3 4.3 2.4 4.7 4.0
N of students 56 37 29 64 94 72 58
Smoking students 5 4 6 17 13 16 7
Percentage (%) 8.9 10.8 20.7 26.6 13.8 22.2 12.1
o n
to
Location of smoking occurrences
Based on the survey of Csikszentmihalyi and Larson (1984), sixteen
most frequent locations in three categories were surveyed in this study. Of the
three categories, smoking occurred the most at home (41.8%), followed by in
public (35.5%), and the least in school (22.7%). By analyzing the subcategories,
it was shown that smoking occurred the most in the bedroom (15.5%), street
(11.8%), school other (than classroom, cafeteria, or hall) (10.9%), and yard or
garage (9.1%). See Table 4 and Figure 4 for details of location distribution. In
order to avoid the effect of large number of smoking occurrences by a small
number of students, the count of participants by location while smoking was
analyzed. The result showed that the distribution of number of student
participants by location while smoking follows basically the same pattern (see
Figure 5), with the most frequent locations being bedroom (25.6%), school other
(25.6%), and streets (23.3%).
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Table 4.
Distribution of Number of Smoking Occurrences by Location (N=l 10)
Location Where Smoking Occurred Number o f Occurrences Percent
Yard or Garage 10 9.1
Living Room 7 6.4
Home Bedroom 17 15.5
(N=46, 41.8%) Kitchen 8 7.3
Dining Room 1 0.9
Home other 3 2.7
Classroom 3 2.7
School Cafeteria 4 3.6
(N=25, 22.7%) Halls 6 5.5
School Other 12 10.9
Transportation 2 1.8
Friend's House 8 7.3
Public Store or Cafe 1 0.9
(N=39, 35.5%) Street 13 11.8
work 7 6.4
Public Other 8 7.3
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Street
12%
Store or Cafe
1 %
Friend's House
7%
T ransportation
work
6 ° /-
Public Other
7%
School Other
11%
Yard or Garage
9%
Living Room
6%
Public
(35% )
Home
(42% )
School
(23% )
Bedroom
16%
Kitchen
7%
Dining Room
1%
Home other
Classroom3%
Cafeteria 3%
4%
Figure 2. Distribution of Smoking Occasions in Each Location
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56
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Figure 3 . Percentage o f Students Reporting smoking i n Each Location
At frequent smoking locations, the students smoked the most with friends
or peer groups. When the students were smoking in the bedroom, 35.3% of the
time they were smoking with friends or peer groups, and 23.5% of the time they
were smoking alone. When smoking at “school other”, 58.3% of the time they
were smoking with classmates or with opposite-sex friends or groups. When
smoking in public streets, 46.2% of the time they were smoking with friends,
and when friends and peer groups were combined, they were present more than
61.6% of the participants’ smoking time (see Table 5).
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Table 5.
Companionship when Smoking at the Three Most Frequent Locations
Companionship
Bedroom
(percent)
School Other
(percent)
Public Street
(percent)
Classmates 25.0
Same-sex Friends 23.1
Same-sex Group 5.9 7.7
Opposite-sex Group 16.7 23.1
Opposite-sex Friends 17.7 16.7 7.7
Friends and Friends' parents 11.8
Alone 23.5 8.3 15.4
Strangers 5.9 15.4
Siblings 5.9
Parents 8.3
Extended Relatives 5.9
Parents and Siblings 8.3
Boss/Co-worker 11.8
Other Adults 11.8 16.7 7.7
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Distribution of smoking occurrences by companionship
Eighty four percent of the time smoking occurrences occurred with
others, and 16% of the time smoking occurred alone. Of the smoking
occurrences with others, 49% was with classmates, friends, or peer groups, 14%
with family members or relatives, 11% with boss/co-workers, and 26% with
other adults or strangers (see Figure 6). Smoking alone occurred primarily at
home (72% of the time), mostly in yard and garage (29%) and bedroom (24%).
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Other Adults
16%
Classmates
5%
Same-sex Friends
6%
Same-sex Group
4%
Strangers
6%
Boss/Co-worker
9%
Parents and Siblings
2%
Extended Relatives
5%
Other
company
Relatives
Alone
Opposite-sex Group
9%
Opposite-sex Friends
11%
Parents
4% Siblings
1%
Friends and Friends'
parents
6%
Alone
16%
Figure 4. Distribution Smoking Occasions by Companionship
Distribution of other activity while smoking
What else participants were doing while smoking showed how and on
what occupation participants’ psychic energy was spent. For example, was the
participant occupied actively or passively? Was energy spent on productive
work, self-maintenance, or leisure occupations? Another important aspect to
know about activity in relation with smoking is that participants’ data might
reveal that some activities have become a condition that triggers their desire to
smoke. While it is important to know what the primary activity or occupation the
student was doing during smoking, it is also important to know what secondary
activity the students were engaged in, because the secondary activity might
reveal the subconscious choice of things to do and opens a window to the
momentary internal experience.
Of the three basic categories of occupational activity (productive,
maintenance, and leisure), it is not surprising to find that smoking occurrences
were associated mostly with leisure both as primary activity and as secondary
activity. Seventy eight percent of smoking occurrences happened with leisure as
primary occupations, and eighty two percent of smoking occurrences happened
with leisure as secondary occupations. Twelve percent of the smoking
occurrences were associated with maintenance occupations as either primary or
secondary activities. Only ten percent of smoking occurred with productive
occupations as primary and six percent of smoking occurred with productive
secondary activities.
61
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Smoking was found to be associated more with passive activities.
Although it is hard to differentiate occupational activities in a clear-cut manner
into active and passive subcategories, smoking was reported to concur the most
with some clearly identifiable passive activities. For example, 34% of the
smoking occurrences concurred with passive primary activities (including 12%
with thinking, 10% with TV/music, 6% with rest, 5% with reading, and 1% with
transportation) and 35% of the smoking occurrences concurred with passive
secondary activities (including 15% with TV/music, 11% with thinking, 6 %
with rest, 5% with reading, and 3% with transportation) (see Figure 7).
62
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1 6
□ Primary Activity
■ Secondary Activity
Productive
Maitenance
Leisure
Activity
Figure 5. Distribution of Activities during Smoking Occurrences (N=110)
C \
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Patterns of Internal Occupational Experience while Smoking
Baseline comparison
The mean of internal daily occupational experience variables of two
groups were compared, with one group comprised of all activity reports by
students who never smoked cigarettes and the reports made at non-smoking time
of students who had reported smoking. First, univariate analysis showed that all
the variables tested were normally distributed. Second, two-sided student t-tests
at p < 0.05 level were conducted to compare the means of each variable between
the two groups. The result showed no statistically significant difference in any
variables between the two groups (see Table 6).
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Table 6.
Baseline Comparison of Internal Daily Experience Variables at Smoking
Occurrences versus Students Who Never Reported Smoke
ESM items Non-Smoker Smoker T-Statistics P-Value
Concentrate 0.000 -0.009 0.16 0.872
Ease of Concentration 0.000 -0.012 0.17 0.866
Feel Good 0.000 -0.011 0.20 0.838
Control 0.000 -0.015 0.28 0.780
Up to Own Expectations 0.000 -0.017 0.30 0.765
0.000 -0.011 0.17 0.867
Up to Others Expectations
Alert 0.000 0.028 -0.48 0.633
Happy 0.000 0.028 -0.51 0.608
Cheerful 0.000 0.010 -0.19 0.853
Strong 0.000 0.036 -0.66 0.509
Active 0.000 0.032 -0.56 0.576
Sociable 0.000 0.002 -0.03 0.978
Proud 0.000 -0.007 0.14 0.888
Involved 0.000 0.007 -0.12 0.902
Excited 0.000 0.016 -0.27 0.786
Open 0.000 -0.012 0.24 0.814
(continued)
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Table 6 (continued)
Baseline Comparison of Internal Daily Experience Variables at Smoking
Occurrences versus Students Who Never Reported Smoke____________
ESM items Non-Smoker Smoker T-Statistics P-Value
Clear 0.000 0.022 -0.39 0.693
Relaxed 0.000 0.005 -0.09 0.930
Competitive 0.000 -0.004 0.08 0.939
Pain 0.000 -0.034 0.53 0.597
Perceived Challenge 0.000 0.004 -0.05 0.960
Perceived Skill 0.000 -0.019 0.32 0.745
Important to Self 0.000 -0.006 0.08 0.933
Important to Others 0.000 -0.014 0.18 0.857
Succeed 0.000 -0.010 0.17 0.866
Wish Doing Else 0.000 0.000 0.00 0.999
Satisfied How Doing 0.000 0.016 -0.25 0.806
Important to Goals 0.000 -0.010 0.14 0.887
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Patterns of participants’ internal occupational experience during smoking
Comparison was made between the internal experience on smoking
occasions and that on non-smoking occasions o f the students who reported
smoking at least once. To examine the quality o f the internal occupational
experience, variables reflecting the order of consciousness were studied. Two
extremes of the experience were established (entropy and negentropy) and the
students’ internal occupational experience may lie on any point between the two
extremes at any given time. While entropy represents a disorder and chaos of
consciousness, negentropy represents an ordered optimal experience. Entropy is
presented with the following phenomena: bad mood, unfocused attention, lack of
motivation, and passivity. On the other hand, negentropy is presented with
positive feelings of self and others, motivation, a sense of competence, and
effective concentration (Csikszentmihalyi & Larson, 1984).
Data of this study showed a strong pattern of entropy while smoking.
When the students were signaled while they were smoking, they reported
experiencing lower affect (t = 2.01, p < 0.05), lower activation (t = 3.76, p <
0.001), lower cognitive efficiency (t = 2.08, p < 0.05), lower motivation (t =
2.58, p < 0.05), and lower self-concept (t = 2.76, p < 0.01) (see Figure 8).
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Affect Activation
Cognitive
Efficiency Motivation Selfconcept
0.5 v
« -1.5
Figure 6. Pattern of Internal Occupational Experience while Smoking - Composite Scores
(* p < 0.05; ** p < 0.01; *** p < 0.001)
□ Not Smoking
■ Smoking
O s
00
Examination of the items that made up the composite scores and other
variables showed more details of the entropic experience of the students while
smoking (see Figure 9 and Table 7). First, thirteen items showed significant
decreases during smoking. While smoking, these students were less
concentrated, felt less good about themselves, less living up to their own
expectation, were less alert, less happy, less strong, less active, less proud of
themselves, less involved in the activity they were doing, less excited, less clear,
less skillful, and felt that the activity was less important to themselves. Second,
in the opposite direction, they felt significantly more physical pain, and felt it
was easier to concentrate. This pattern of results consistently reflects the entropic
nature of the students’ internal occupational experience while smoking.
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C
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s z
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M smoking
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&
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^ < ? a
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o * P
£
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Items of Internal Daily Experience
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• ? /
. ■ N « 5 s .
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s >
b b ,© £i
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Figure 7. Pattern of Internal Occupational Experience while Smoking (* p < 0.05; ** p < 0.01; *** p < 0.001)
O
Table 7.
Univariate Comparison of Internal Daily Experience on Smoking Occurrences to
Non-Smoking Occasions in Participants Who Reported Smoking At Least Once
ESM items Non-Smoking Smoking t-statistics p-value
Concentrate 0.018 -0.485 2.55 0.012
Ease of Concentration -0.021 0.550 -2.62 0.010
Feel Good 0.016 -0.417 2.48 0.015
Control 0.009 -0.233 1.36 0.176
Up to Own Expectations 0.022 -0.590 2.84 0.005
Up to Others Expectations 0.005 -0.136 0.65 0.650
Alert 0.025 -0.648 3.16 0.002
Happy 0.027 -0.717 3.49 <0.001
Cheerful 0.011 -0.281 1.45 0.151
Strong 0.026 -0.699 3.65 <0.001
Active 0.026 -0.690 3.66 <0.001
Sociable -0.003 0.092 -0.50 0.621
Proud 0.012 -0.307 1.67 0.097
Involved 0.022 -0.587 3.05 0.003
Excited 0.015 -0.399 2.02 0.045
Open -0.002 0.045 -0.26 0.797
(continued)
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Table 7 (continued)
Univariate Comparison of Internal Daily Experience on Smoking Occurrencs to
Non-Smoking Occasions in Participants Who Reported Smoking At Least Once
ESM items Non-Smoking Smoking t-statistics p-value
Clear 0.030 -0.783 4.30 <.001
Relaxed -0.006 0.155 -0.88 0.381
Competitive -0.006 0.148 -0.86 0.391
Pain -0.024 0.639 -2.99 0.003
Perceived Challenge 0.009 -0.234 0.97 0.335
Perceived Skill 0.014 -0.378 1.82 0.071
Important to Self 0.016 -0.432 1.91 0.059
Important to Others -0.004 0.101 -0.47 0.640
Succeed 0.008 -0.224 1.11 0.271
Wish Doing Else -0.007 0.182 -0.86 0.388
Satisfied How Doing 0.010 -0.266 1.23 0.222
Important to Goals 0.012 -0.321 1.34 0.184
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Peri-Smoking Change of Quality Internal Occupational Experience
A pattern of entropy at an average of 50 minutes before smoking was
found. The entropy got worse when smoking, but recovered 50 minutes after
smoking (see Figure 10). Repeated measure ANOVA test showed a significantly
increasing trend from pre-smoking to post-smoking times in concentration,
feeling good about self, living up to own expectations, happiness, strength,
activity level, involvement, clarity, and challenge (p < 0.05). A significant
decreasing trend was found for pain (p < 0.05). Other variables that failed to
show statistical significance, however, also followed the same pattern of change,
such as control, alert, cheerful, proud, excited, and succeed.
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Items of Internal Daily Experience
O pre-smoking H smoking □ post-smoking
Figure 8. Peri-smoking Trend of Internal Occupational Experience (* p < 0.05)
Internal Occupational Experience in Different Flow States while Smoking
In this study, a four-channel model was used to analyze the experience
state: flow, boredom, apathy, and anxiety. Comparisons between the pattern of
occupational experience on smoking occurrences and that of the non-smoking
occurrences in different levels of optimal experience in students who reported
smoking at least once were made with a two-sided t-test. The result showed that
in the state of apathy, all the following occupational experience areas showed
significantly lowered composite scores from the already negative nonsmoking
apathetic territory: affect (p < 0.05), activation (p < 0.01), cognitive efficiency (p
< 0.01), and self-concept (p < 0.001). It was also shown that in the state of flow,
at non-smoking times, activation and motivations were positive; when smoking,
activation and motivation were lowered (p <0.01) into negative scores (Figure
11-14).
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[□not smoking Hsmoking
c
C O
0
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tr
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Affect Activation Cognitive Motivation Self-concept
efficiency
Composite Items of Internal Occupational Experience
Figure 11. Quality of Occupational Experiences at Flow by Smoking Status
(**p<0.01)
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□ not smoking ■ smoking j
Affect Activation Cognitive Motivation Self-concept
efficiency
Composite Items of Internal Occupational Experience
Figure 12. Quality of Occupational Experiences at Boredom by Smoking Status
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□ not smoking IB smoking
Affect Activation Cognitive
efficiency
Motivation Self-concept
Composite Items of Internal Occupational Experience
Figure 13. Quality of Occupational Experiences at Apathy by Smoking Status
(* p < 0.05, ** p < 0.01, *** p < 0.001)
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□ n o t sm oking 1 sm o k in g
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
- 0.2
- 0.4
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-1
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Affect A ctivation C ognitive M otivation Self-concept
efficiency
Composite Items of Internal Occupational Experience
Figure 14. Quality of Occupational Experiences at Anxiety by Smoking Status
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DISCUSSION
From a theoretical perspective, smoking is viewed as one of a class of
functionally equivalent occupations through which adolescents express
themselves, cope with anxiety, and deal with the transition from childhood to
adulthood. The underlying cognitive and personality variables (e.g., low
self-esteem, high anxiety levels, poor decision making skills) predispose
adolescents toward the use of tobacco (lessor, 1982). The result of this study
suggests that there are identifiable patterns of adolescents’ occupational
experience that serve a predisposing role to tobacco smoking. Findings of the
patterns and their roles from an occupational science point of view may lead to
development of occupational science intervention strategies and plans that
alleviate the smoking problem by modification of daily occupation.
External Occupational Experience
Most researchers agree that smoking peer influence plays a strong role in
adolescent smoking (Mosbach & Leventhal, 1988). The peer group members and
their preference of time, location, companionship, and concurrent activities
while smoking makes up a subculture of their own that governs their smoking
behavior. Understanding the social and environmental context within which
smoking occurs is of great importance in understanding the subculture of the
peer groups with regard to tobacco smoking. However, so far little research has
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been conducted on the actual circumstances surrounding smoking in junior high
students.
This study depicted the social and contextual factors that influence
smoking by investigating the actual circumstances surrounding smoking. It was
found that smoking was associated with familiar locations, presence of peers,
and passive activities. Those findings agree with the predictions of peer cluster
theory (Oetting & Beauvais, 1986, 1987; Oetting, Edwards, & Beauvais, 1988).
According to the peer cluster theory, substance use, including drugs,
alcohol, and tobacco use, is always directly linked to peer relationships. Friends,
acquaintances, and siblings provide the substance and teach the young person
how to use them. Peers shape attitudes about the substance, provide the
substance, provide the social contexts, and share ideas and beliefs that become
the rationales for use of the substance. Substances are often used in small groups
at particular times and places, and the groups share the same ideas, values, and
beliefs about the substance. These close and highly influential groups are peer
clusters, and within the peer clusters, the substance plays an important part in
defining the group, shaping its typical behaviors, and maintaining the group
identity and structure.
In the study of companionship on smoking occurrences, we found that
the majority of smoking occurrences were with people outside of the family.
Forty one percent o f the smoking occurred with like-age peers, including
classmates, same-sex friends, opposite-sex friends, same-sex groups,
opposite-sex groups, friends and friends’ parents. Thirty one percent of the
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smoking occurrences occurred with possibly older companions, including
strangers, co-worker/boss, and other adults. There was also 12% of the
occurrences that smoking occurred with siblings, extended relatives, and with
parents. Obviously, smoking occurred mostly in groups, especially with
like-aged peers. According to peer cluster theory, smoking happens in groups
because the social context of groups not only provides a positive attitude towards
smoking, it also provides supporting rationales to legitimize smoking (Oetting &
Beauvais, 1987).
Study on location showed that smoking mostly occurred in bedrooms
(16%), public streets (12%), school other (11%), and yards or garages (9%).
These are usually locations where peers hang together, yet away from parent or
teacher supervision, where the peer clusters enjoy the most freedom o f their
activities. The distribution of smoking occurrences over time also fit in the same
pattern. Smoking occurred sporadically in the morning, and peaked during the
period of 2pm to 6pm. This was the period of time when the students were off
from school and were able to enjoy the most freedom to get together with their
favorite peers, go to their favorite places, and do their favorite activities, and it
would not be surprising that the peer clusters find this time period good for
smoking together.
It is interesting that even though smoking occurred most with peers,
smokers were m ostly involved with passive activities. According to
Csikszentmihalyi and Larson (1984), watching TV and listening to the music are
passive activities because they involve no reciprocal exchange; thinking, rest,
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and transportation are passive activities because they are primarily “idling”,
involving no predefined structure and little physical activity; reading outside of
classes mainly involves brief encounters with magazines and newspapers. In our
data, one third of the smoking occurred with clearly definable passive activities
either as primary or secondary activity. To understand this phenomenon of
smoking during passive activities, internal state of the students at the time of
smoking must be considered. This phenomenon in part was a reflection of the
quality of internal experience at the time of smoking, characterized by lower
affect, motivation, activation, cognitive efficiency, and lower self-concept. This
will be further discussed in the discussion of internal experience.
Peer cluster theory is very helpful in explaining the phenomena of the
external experience while smoking, however, it leaves the question of causation
unanswered: does smoking cause psychosocial problems, or do psychological
and social problems cause smoking? Cross-sectional studies on the external
experience would not be able to answer this question. A detailed investigation of
the internal occupational experience is necessitated and other theoretical
frameworks are needed to explain the relationship between smoking and internal
occupational experience.
Internal occupational experience
One of the purposes of this study was to explore the relationship of
quality of internal daily occupational experience of adolescents to smoking. The
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relationship was studied by examining the difference of internal occupational
experience at the time of smoking versus that at times of not smoking, by
examining the trend of internal occupational experience before, at, and after
smoking occurrences, and by examining the change of internal occupational
experience associated with smoking at different conscious levels of intrinsic
experience.
The internal occupational experience during smoking
The baseline univariate analysis results indicate that there was no
difference in the internal occupational experience during non-smoking activities
between the students who reported smoking at least once and those students who
never reported smoking. However, the comparison between the internal
occupational experience while smoking and that during non-smoking activities
showed a clear pattern of entropic change associated with smoking occurrences
in the students who reported smoking at least once. All tested composite scores
were significantly lowered, including affect, activation, cognitive efficiency,
motivation, and self-concept.
Those findings are consistent with past studies on psychosocial
measurements. First, two related dimensions of emotional state were reported
associated with adolescent smoking: affect and activation. Affect combines the
student’s feelings of happiness, cheerfulness, sociability, and friendliness.
Similar emotional states as perceived at the moment of a diary completion soon
after smoking occurrences were studied by Delflno et al. (2001). It was reported
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that elevated levels of anger, sadness, and anxiety were positively associated
with smoking urge in men. Gilbert (1995) pointed out that women tend to report
negative affect as their primary motivation for smoking. Activation is the
combinations of feelings of strength, excitement, activeness, and alertness.
Delfino et al. (2001) also reported that decreased alertness and increased fatigue
is associated with smoking urge in men. Similarly, Leventhal, Fleming, and
Glynn (1988) found that reported feelings of helplessness were associated with
more rapid movement to a second and third experiment with smoking.
Second, self-concept, or an individual’s qualitative self-evaluation, which
combines feeling good about one’s self, living up to one’s own expectations, and
feeling satisfied with how one is doing, have been negatively associated with
smoking. It was found that young nonsmokers and those with no intention of
smoking in the future had higher self-esteem relative to family, school, and peers
than frequent users or those who intended to use in the future (Young & Werch,
1990). It was also reported that low self-esteem within family or school contexts
was associated with initiation and continuance of smoking (Ahlgren, Norem,
Hochhauser, & Garvin, 1982).
Complementary to past research, this study investigated a more
comprehensive spectrum of internal occupational experience, including domains
that have been barely studied, such as cognitive efficiency, motivation, and
general physical pain while smoking. The fact that the students showed lower
cognitive efficiency and lower motivation for the activity they were engaged in
at the time of smoking helped explain the phenomenon that the students were
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very often engaged in passive activities while smoking. It is not surprising that
the students were more likely to be watching TV, listening to music, or thinking
at the time they smoked. Lack of motivation and cognitive efficiency have been
associated with passive activities and promotion of intrinsic motivation has been
used to modify social behaviors (Wu, 2001). Viewed in the general picture o f the
students’ pattern of occupations while smoking, the lack of motivation and
cognitive efficiency were just part of the entropy governing the particular
occupation at the moment of smoking.
Internal occunational experience at peri-smoking times
Few studies have been conducted to examine the change of internal
occupational experience that occurred before, during, and after smoking. The
result of this study on the trend of internal experience before, at, and after
smoking showed that at an average of 50 minutes before smoking, there was an
entopic change of internal occupational experiences from the personal mean.
This change increased in the same entropic direction to a larger extent at the time
of smoking. At an average of 50 minutes after smoking, the internal occupational
experience turned into a slightly negentropic state. Similar patterns of
experiential change were also found in past studies. Delfino et al (Delfino et al.,
2001) reported increased anger, anxiety, and sadness in men and women, and
fatigue in men 10 to 30 minutes before smoking. Smoking then was followed by
decreased anger levels in men and women and decreased sadness in men 10 to
30 minutes after smoking. They further speculated that smoking had palliative
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effects on sadness in men and on anger in men and women. Our findings in this
repeated measure analysis showed the same direction of changes in a more
comprehensive fashion.
In interpreting this peri-smoking trend change, specifically an
entropy-more entropy-negentropy curve, social learning theory might be helpful.
Social learning theory represents an extension of behavior modification to
situation which involve interpersonal activity. It incorporates the added
explanatory concept of modeling, based on imitation and social reinforcement
(Krohn et al., 1984).
From social learning theory, smoking is seen as a learned behavior.
Initially, smoking starts under conditions of social reinforcement, typically those
from peer pressure. Inhalation at the beginning is unpleasant, but after sufficient
practice, it begins to produce positive reinforcement. Smoking now generalized
to situations other than the one in which it was originally acquired.
In brief, a social learning explanation of smoking proceeds along the
following general lines: The habit is acquired under conditions of social
reinforcement, typically those of peer pressure. Initially the inhalation of smoke
is aversive, but after sufficient practice, habituation (or tolerance) occurs, and the
behavior begins to produce sufficient positive reinforcement in its own right to
be sustained independently of social reinforcement. Smoking now generalizes to
situations other than the one in which it was originally acquired. It is important
to note that from the social learning theory, smoking is seen as a learned
behavior from the onset.
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Discriminations between situations in which smoking is punished
socially and those in which it is either ignored or favorably received are formed,
and various circumstances (both external and internal) begin to control smoking.
Some situations may serve as conditional stimuli (CS’s) that prompt smoking,
which in turn elicit covert responses. These responses, which can be
physiological changes such as discomfort or psychological changes such as
annoyance, increase the likelihood of smoking.
There can be a great number of occurrences of internal occupational
experience that can influence smoking. If smoking is seen, in part, as an
avoidance/escape response to aversive withdrawal states, then, hypothetically, by
a process of stimulus generalization, other entropic states, (for example, anger,
tension, boredom) might also serve as discriminative stimuli for smoking. Also
response generalization may occur, in this case, the smoking ritual may serve as
a temporary escape (coping response) from various aversive situations (that is,
smoking as a general response which provides relief).
One of the weaknesses of the interpretation of the fluctuation of the
quality of occupational experience with social learning theory was that the
individual’s intrinsic motivation and reward was not accounted for in the
initiation of smoking occurrences. Occupational science considers human as
occupational beings. The tendency of occupation seeking is self-rewarding and
health related. In the students who smoked, the entropic state before smoking
clearly presented an undesirable situation that the students would avoid or
escape. Smoking, for some, becomes instmmental in achieving this goal. What
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was showed in our study is that after smoking, the students did emerge from the
entropic state, and entered a more desirable negentropic state.
It is not known, however, to what extent the biological response (i.e. the
response to nicotine), or the occupation seeking response accounted for helping
them emerge from the valley of entropic internal occupational experience. Past
studies have shown that nicotine facilitated conditioned-avoidance behavior as
well as positively reinforced behavior in rats (Stephens, 1977) and that it reduced
social or pain-induced aggression in both animals and humans (Hutchinson &
Emley, 1973), but little was known about the change of internal occupational
experience during the peri-smoking period in the context of time, location,
companionship and activity.
We speculated that all students’ quality of internal occupational
experience fluctuates throughout the days. According to Csikszentmihalyi
(Csikszentmihalyi, 1988), the quality of daily occupational experience is
determined by the balance between perceived challenge and skills. Either there are
too many things or things demanding too much effort, in which case a person
tends to be worried or anxious; or there seems to be nothing to do, in which case a
person tends to feel bored. This is why optimal experience typically occurs in
clearly structured activities in which the level of challenges and skills can be
varied and controlled, such as rituals, games, sports, or artistic performances.
In the students of the 6th grade, their daily life outside of classroom may
have been very fluid and lacked structure. In the afternoons after class the students
were pretty much out of the sight and mind of parents and teachers. Fluid
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decision-making governs their moment-to-moment activities, hence the
fluctuation of the quality of occupational experience. There are highs and lows,
and the each student had some way to cope with the valley. The students who
smoked succeed in getting out of the entropic experiential valley through
engaging themselves in smoking, but that doesn’t necessarily mean that smoking
is the main reason for which this goal was accomplished. Students who never
smoked might achieve this goal through engagement in other occupations.
Because there was a natural fluctuation of the quality of occupational
experiences in the 6th graders, which lasted over an approximately 2-hour span,
the tendency for the students to seek certain activities as a strategy for coping
with this unpleasant period of time of low quality of internal occupational
experience became a crucial cutting point for planning to help them develop
healthier occupations. Past studies have shown that certain activities have the
potential of reducing the risk of smoking initiation. Health-enhancing behaviors,
such as sports involvement, might moderate a high-risk environment
(Rantakallio, 1983). Swan, Creeser, and Murray (Swan et al., 1990) found that
girls were significantly less likely to begin smoking if they were involved in an
organized sport, but were significantly more likely to begin smoking if they
participated in organized social activities. From an occupational science of view,
the guidance of healthy behaviors should take into account the activity in the
context of daily occupation and culture, involving all aspects of daily lives. Few
studies have been conducted in this direction. Cultural sensitive studies of
occupation at the time of entropic states are needed for better understanding of
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the needs of the students and for designing intervention occupational science
intervention programs.
Another interesting finding was that smoking was associated with
significantly increased sense of general physical pain. Speculation on the reason
for pain might support that the pain could be the aversive response of the
adolescents to inhalation, because they were still beginners. It could also be the
effect of a psychological struggle while conducting an activity, in this case,
smoking, which was deviant from their goals and from societal norms, as they
were well aware of. The awareness of deviance from goals was manifested by
the fact that when the students were smoking, the score on the question “Are you
living up to your own expectations?” was significantly lowered, and the
awareness of deviation from societal norms was manifested by the fact that they
tend to smoke in the absence of parents and teachers.
The flow experience and smoking
The examination of the quality of internal occupational experiences at
different levels of flow experience showed that smoking makes significant
differences in the internal occupational experience mostly in an apathy state, and
smoking always makes a entropic change.
Flow experience was first described by Csikszentmihalyi
(Csikszentmihalyi, 1975) as autotelic experience regardless of its context.
Artists, athletes, composers, dancers, scientist, and people from all walks of life,
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when they describe how it feels when they were engaged in an occupation that is
worth doing for its own sake, used terms that were interchangeable in their
minutest details. The unanimity suggests that order in consciousness produces a
very specific experiential state, so desirable that one wishes to replicate it as
often as possible. The state was given the name ‘flow’, a terms used to explain
what the optimal experience felt like.
In our case, of the fluctuations of occupational experiential state, the
students of the 6th grade also go through all levels of experience. Whether or not
the state of experience is flow is determined by a universal precondition,
requiring a balance between the challenges the occupation presents to the person
and the skills the person bring into it. The “challenge” includes any opportunity
for an occupation that humans are able to respond to, such as, the vastness of the
sea, the possibility of rhyming words, concluding a successful business deal, or
winning the friendship of another person; all classic challenges presented in the
occupations in which one is engaged. But any possibility for occupation to
which a skill corresponds can produce a flow experience.
To remain in flow as one’s skills increase, one must increase the
complexity of the occupation, taking on new challenges. This holds just as true
for junior high students who gain new knowledge every day and will not feel
bored only when solving questions of increasingly higher levels of difficulty.
Heraclitus’s dictum about not being able to step into the sam e stream twice holds
especially hue for flow. It is a dynamic process that drives the person to higher
and higher levels of complexity. This higher skill then matches higher challenge,
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and attaining even higher skill to match the higher challenge forces people to
stretch themselves and to improve their abilities (Csikszentmihalyi, 1988).
Because a person’s internal occupational experiential pattern may
fluctuate through a wide range during the day, it was proposed that flow
experience begins only when challenges and skills are above a certain level and
are in balance. In operating this concept, the personal mean for perceived
challenges and perceived skills was used as the starting point above which the
experience should turn positive. Hence four channels representing four states of
experience were determined by Massimini et al. (Massimini et al., 1987): (1)
channel 1 : flow was when both perceived challenges and perceived skills were
above the mean levels for the time o f testing and in balance. In this state, a
person felt more concentrated, more in control, more happy, strong, active,
involved, free, excited, open, clear, motivated, and satisfied; (2) channel 2:
boredom was when perceived skills were above average and perceived
challenges below average. In this state, control was above average but
concentration fell, and the remaining variables were only slightly different from
the mean; (3) channel 4: anxiety is when perceived challenges were above
average and perceived skills were below average. At this state, concentration was
significantly high but control was lower; (4) channel 3: apathy was when both
perceived challenges and perceived skills were below average. This is the lowest
quality experience, and most o f the dimensions o f internal occupational
experience were significantly lower than average in this condition.
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First, these data fitted the flow model very well. For students at
non-smoking times, in flow when challenges and skills were high and balanced,
all occupational experiential items, including affect, activation, cognitive
efficiency, motivation, and self-concept were positive. In boredom, when
challenges were below average but skills were above, their occupational
experiential items were positive in affect, activation, motivation, and
self-concept to an extent that was less than that in the state of flow. One
exception, cognitive efficiency, was negative. For the two states of lower
occupational experiential quality, in apathy and anxiety where skill levels were
below average, all occupational experiential areas, affect, activation, cognitive
efficiency, motivation, and self-concept, were below average.
Second, when examining the effect of smoking on the quality of internal
occupational experience, we found that it was in the state of apathy that smoking
made the most significant changes. When challenges and skills were both below
average, at non-smoking times, all occupational experiential area were below
average. However, when smoking, four of the five areas were significantly
lowered, including affect, activation, cognitive efficiency, and self-concept.
Although no statistical significance was obtained, motivation was lowered by
four times. It would seem appropriate to explore potential behavioral or
attitudinal significance of this state of apathy in more detail in the future.
Third, cross-examination of the result of the analysis of occupational
experiential patterns at times of smoking versus not smoking, the peri-smoking
trend of quality of the internal occupational experience, and the findings of the
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effect in different channels indicated the following: (1) Smoking mostly occurred
at times of lowered quality of internal occupational experience; (2) Smoking was
associated with significantly lowered affect, activation, cognitive efficiency,
motivation, and self-concept; (3) The effect of smoking on the quality of internal
occupational experience is the most strong in the state of apathy. Further
examination of the above conclusions showed that the effect of smoking on
quality of internal occupational experience is mostly accounted for by the state
of apathy.
Although we found significantly lowered quality of internal occupational
experience at the time of smoking, this decrease didn’t always happen. When the
level of challenges and skills were not fluctuating in the same direction, such as
either when challenges were above average and skills were below (which was
the state of boredom) or when the challenges were below average and skills were
above (which was the state of anxiety), changes of the quality of internal
occupational experience were not significant. When challenges and skills were
both at above average levels, two out of the five areas (activation and
motivation) were significantly lowered by smoking. When challenges and skills
were both at below average level, which is the state of apathy, all five areas were
significantly lowered.
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Strength and Limitations
The Experience Sampling Method was demonstrated to be informative in
the study of the occupational experiential patterns in adolescents. For the first
time the study of the occupational experience of the 6th graders in association
with their tobacco smoking was conducted in close temporal proximity to their
actual occupation. Not only did the study cover more comprehensively the
aspects of occupation of the adolescents, ranging from time, space, and
companion, to affect, activation, motivation, and self-concept, the methodology
but also made it possible for the occupational experiential items to be reported
with great accuracy. At one hand, real-time data collection was crucial for
capturing the internal occupational experiences, of which accuracy would be
largely compromised in retrospective data collection. On the other hand, it was
just as important to maintain the accuracy of the external experience by
recording where they were, what they were doing and with whom at the time of
engagement.
Analytic strength of repeated measures at peri-smoking time points
allowed us to better understand the changing trend of the occupational
experiential patterns, which might help us better understand the causal
relationship of smoking and the lowered quality of occupational experiences.
Temporal sequence of occupational experiential events and smoking may
provide important information on causality of smoking. For example, past
studies has showed the association of certain psychological factors with
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smoking, but no causal relation has been established, so that it was unknown
whether smoking caused the change of the psychological factors, or the change
of psychological factors triggered smoking, or some other factors caused both
(Delfino et al., 2001). In this study, it was found that the downward change of
the quality of occupational experience was a prelude to smoking, which might
indicate a causation of smoking in the students who reported smoking during the
study.
Study of the quality of occupational experience in different channels
allowed us to break down occupational experience into different experiential
states (flow, boredom, apathy, and anxiety) and pinpoint the states in which the
most changes were observed. Analysis into the detailed states allowed us to find
that it was when the students were in the state of apathy that smoking made the
most difference, which also contributed the most to the change of quality of
occupational experience during smoking.
This study was intended to examine the association between the quality
of occupational experience and smoking in students of middle school. The study
population we sampled is not representative of all adolescents of 12 years of age
living in the Los Angeles area because we didn’t include those who dropped out
of school. Although we didn’t have the statistics on the smoking rate of those
dropouts at the age of 12, we could expect a higher rate than those staying at
school. It was reported that among kids who had dropped out of school after 8th
or 10th grade, smoking rate was almost three times that of the students who
stayed in school. More interestingly, the initiation rate of dropouts was 4 times
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that of those who stayed in school (Gilleskie & Strumpf, 2000). There might be
complex occupational experiential factors that influenced the behavior of the
dropouts. Their quality and patterns o f occupational experience might be
different from that of the students who stayed.
Implications and Future Directions of Research
The ultimate purpose of this research is to further the understanding of
the adolescent’s occupational experiential patterns and their relationship with
smoking, hence enabling us to design relevant occupational science
interventions. Occupational science on the one hand regards human being as
occupational beings, and on the other hand, occupation as influential to health. In
1962, Mary Reilly proposed “That man, through the use of his hands as
energized by mind and will, can influence the state of his own health” (Reilly,
1962). This theory was further delineated and pragmatized by Ann Wilcock in
1998 (Wilcock, 1998). She proposed that humans have “occupational needs” that
goes beyond the instinctive behaviors of many other animals, and these
occupational needs are related to health. It is human being’s biological and social
drive that engages themselves into the seeking of occupations. In turn,
compromised health situations and unhealthy behavior might result from
occupation deprivation, alienation, or unbalanced utilization of capacities. An
occupational science approach to address the unhealthy behavior of adolescent
smoking would need the therapist to attend to the relationship of the
98
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occupational experiential patterns of the adolescents and the unhealthy behavior
of smoking, to address the occupational needs of the adolescents, and to promote
the balancing and making use of their human capacities.
First, adolescent smoking is an unhealthy behavior from the occupational
perspective. Although the views of health vary greatly, the WHO definition,
which is “a state of complete physical, mental, and social well-being not merely
the absence o f disease or infirmity” (WHO, 1946), has been widely agreed on in
the past half a century. The situation of health must be associated with subjective
feelings of well-being, which according to Wilcock (1998), is represented in
three domains: physical well-being, mental well-being, and social well-being.
Smoking, in this study, has been associated with at least two compromised areas.
In the students who smoked dining our research period, as might be due to
physical as well as psychological reasons, smoking was associated with
significantly increased sense of general physical pain. The long term problems
resulting from smoking on health, ranging from bronchitis to lung cancer, are of
great magnitude. The reduced quality of subjective feeling of mental well-being
was reflected in the entropic change of the quality of internal occupational
experiences that was associated with smoking. Across a wide range of variables
that were reported real-time, significant decrease of the quality of experience
was observed in this study. Smoking and the sense of social well-being is an area
that showed conflicting results. As expected, smoking was associated with
increased feeling of being sociable and open. However, it was also related with
significantly decreased feeling of being involved. Given the loss of physical and
99
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mental well-being, smoking could by no means be considered a healthy behavior
in adolescents.
Second, occupational risk factors can be identified for adolescent
smoking. Wilcock defined occupational imbalance, deprivation, and alienations
as occupational risk factors that may lead to the development of health risk
behaviors (1998). Occupational balance, from an external occupational
experiential point of view, was considered to be approximately equal
involvement in physical, mental, social, and rest occupations, and from an
internal occupational experiential view, considered to be the state when
challenge and skills are on above average level and balanced. Lack of such
balance results in boredom, apathy, or anxiety. According to Kubey and
Csikzentmihalyi (Rubey & Csikszentmihalyi, 1990), in searching the optimal
experience of flow, as human capacities increased, the need to keep more diverse
intellectual capacities required more complex and flexible activity patterns.
These activities were superimposed on and integrated with older activities. In
our case, smoking is repetitive activity, involving practically no challenges and
no skills, and it would be not possible for it to provide flow experiences. This
entropic state was not healthy and would impede on the development of healthy
occupation in adolescents.
Smoking may play an important role in occupation deprivation among
the adolescents who smoked. Occupational deprivation was defined as the
situation whereby a person was kept from “acquiring, using, or enjoying
something” by the influence of external circumstance or external agency
100
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(Wilcock, 1998). In the population we studied, most of the students who smoked
were beginners. During this stage, it was well recognized that peer pressure was
the most primary reason for smoking (Flay, Best, Kersell, & Ryan, 1983).
Considering the subculture environment of smoking occurrences, featuring
concurrent passivity, lack of guidance from adults, and apathetic mind settings, it
is clear to see that smoking, in turn, occupied the students’ time resource and
deprive the students of opportunity to explore other activities. In this sense,
smoking was the direct cause of occupational deprivation and peer pressure was
the indirect cause of occupational deprivation. So, one of the occupational
science approaches of intervention would be to explore with the participant more
meaningful and healthy occupations that would be more intrinsically motivating,
meeting their personal goals, and externally rewarding.
Smoking as an alien power prevented the adolescents from freely
expressing their creativities in the pursuit for occupations that harmoniously
connect themselves to natural fluctuations of quality of occupational experience.
Alienating activities were characterized by the nature that they were “forced
upon individuals by the society ” and as long as “activity is not voluntary ...
man’s own deed becomes an alien power opposed to him, which enslaves him
instead of being controlled by him” (Marx & Engels, 1864). The suppressing
subculture of peers when it comes to smoking made those who were involved in
the culture yet did not want to smoke feel estranged and unwelcome. To trade for
admission into the subculture, adolescents might start to experiment with
smoking, despite the aversive responses the inhalation might trigger and the
101
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consequences of conflict with parents might elicit. None of the earlier effects,
either physical pain or psychological fear was enjoyable. However, they
conducted the act because they had to subdue to the norm, values, and rules of
the smoking peers they happened to be involved with. Hence the creative search
for occupations was suppressed and the students were alienated from their
occupational self. This alienation will only go deeper as the students move to
higher grades and later into colleges, when they will expect greater prevalence of
smoking and stronger peer pressure.
It was clearly demonstrated in our study that smoking was associated
with occupational unbalance, occupational deprivation, and occupational
alienation. A holistic approach of intervention should be an occupational science
approach that tackles the smoking problem by helping the adolescents to
establish healthy occupational behavioral patterns.
Third, an occupational science approach for adolescent smoking
prevention is suggested. As occupational scientists, one of our primary roles is to
improve the understanding of human occupation, so that understanding of human
occupational experience can be furthered in various contexts that occupy the
person physically, mentally, and socio-culturally. The information and
interpretation of this information should then be used for designing occupational
science based approaches, applied by the occupational therapy profession in the
practice of preventing unhealthy situations, correct health-impairing behaviors,
and resuming normal functionality by balancing up occupation, avoiding
occupational deprivation, and correcting occupational alienation. Occupational
102
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science has long traditions of interest in prevention and recent studies has shown
tremendous effects of preventive efforts in the well elderly population by
promoting healthier occupations based on the individual needs and capacities
(Clark et al., 1997). Past studies that used the life-style redesign approach has
shown that occupational science interventions successfully prevented high-risk
inner city adolescents from joining gangs (Snyder et al., 1998). In applying the
life-style redesign program, the study transplanted these individuals into an
environment that not only did not allow for criminal behaviors but also promoted
more healthy alternatives. With opportunities for replacing unhealthy behaviors
with more healthy, safe, productive, and socially acceptable occupations, long
term sustainable results were found. Now that this study has found the
occupational experiential patterns associated with smoking and the occupational
risk factors that expose the adolescents to smoking, it is time to design
intervention programs focusing on the daily occupations of the adolescents,
developing personally tailored meaningful and purposeful activities for those
who has not experimented smoking, providing variable alternative occupations
for smoking at times when they felt it was needed. Since life-style redesign
programs emphasis motivations and doing, the participants will be given
opportunities to benefit from the new life experiences.
This indispensable approach, which starts from large scale research
leading to better understanding of human occupation and to application of the
knowledge that provides occupational therapists with evidence and treatment
mechanisms, was made possible only after occupational science, as an
103
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independent discipline, was established at the University of Southern California
in 1989, and scores of well trained occupational science scholars devoted their
life and passion into this cause. For me, in spite of the differences between the
‘medical model’ and other paradigms of occupational science and therapy, there
is only one common noble cause that we are devoted to, and that is for the better
being of all human beings, whatever approach we take.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Appendix A
The Experience Sampling Form on Palm Ille
— m
use
3. What was the M A IN thing
you ’ •ere doing?
Studying Sports/games
Paid activity TVftmwic
Eating Computer
Personal care ArtAwbbies
Trans port atio Reading
Chores/etc Thinking
Rest other
Socialising
Please select your birthday:
Month: •*
Day: w
Year; v
CUD
4, WHY were you doing this
particular activity?
I had to
I wanted to do it
i had nothing else to do
1. Are you smoking no*?
.5 . What else were you doing?
Studying Sports/games
Paid activity
TVffnusic
Eating Computer
Personal care Artihobbifes
T r a n s p o r t atio Seeding
ChoresAsto Thinking
Rest other
Socializing
i. Where mere you?
Yard or Garag Halls
Living room School other
Bedroom transports!!©
Kitchen friend's house
Dining room Store or Cafe
Home other Street
Classroom Work
Cafeteria Public other
S, How skillful are you in the
activity?
Low-0
1
2
3
4
5
H i ph-6
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7, How welt were you
concentrating?
Not at all—0
1
some what-2
3
quite-4
5
very-*$
( Next->3
11. were you living up to your
own expectations?
Not st a ll-0
some what-2
quite-4
very-
8. Was it hard to concentrate?
Not at all— 0
1
some what* 2
3
quite-4
5
very-6
12. Ware you living up to
expectations of others?
Not at all— 0
1
some whal-2
3
quite-4
5
very-8
S. Did you feel good about
yourself?
N ot at all—0
1
some what-2
w *
quite— 4
5
very-8
( •***•>.)
Questions 13 to 25, Pleas#
describe your M OOD as you
— e beeped:
Continue
10. Were you in control of the
situation?
Not at ail—0
1
some what-2
3
quite-4
5
very-®
( * * • > )
13. were you?
very alert—3
quite alert—2
some alert— 1
neither...... 0
some drowsy-1
quite drow*y-2
v e r v d r o w s v - - 3
(N ex t:>3
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14, Were you?
yety heppy-3
■ q u i t e b a p p y - 2
soma h a p p y - l
neither 0
som e sad —1
q u it e s a d — 2
v e r y s a d — 3
15. Were you?
very irritable-3
quite irritabIe-2
tome irritaW*-1
neither........0
some c h e e r f u l * 1
quite cheerful -2
very cheerful-3
( Next->"5
1«. Were you?
very strong-3
quite strong-2
some strong-1
neither.....0
some weak-1
quite w a a k - 2
very ■week-3
( Next-> >
1?. Were you?
very active--®
quite active-2
some a«itv*-i
neither...... 0
some passive-1
quite pwsive-2
v e r y p a s s iv e - 3
( « * * •> )
18, Were you?
v«rylon«ty-3
quite lomly-2
some lonely-1
neither -0
some soctable-1
quite sociable-?
very sociable-3
QEED
13. W ert you?
very ashamed-3
quite ashamed-2
some ashamed-1
neither....... 0
some proud-1
quite proud-2
vervproud-3
( Next-> }
20. Were you?
veryirwolved-3
quite irwolyed-2
some mvolyed-1
neither 0
some detached-1
quite detached-2
verydatached-3
f Hext-> )
2 1 . Were you?
very excrted-3
quite exeited-2
some excited-1
neither.....-0
some bored-1
quite bored-2
v e r y b o r e d —3
("Next-**)
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
22. Were you'?
very clo**d-3
quite clo*«d-2
son'll etosed-1
neither— 0
so m a o p a rt-1
quit* op«n-2
very open--®
26. Wert you?
very clear— -?
quite d e a r — 2
som e clear-— 1
neither....... 0
some eonfu$«d-1
quite confused?
very confused-®
( H*xt->)
24. Were you?
v*ryt*ns«»®
quite t*f»#--2
some tenae-1
rwlther 0
som a relattad-l
quite retexad-2
very relaxed-?
C E D
25. Were you?
very competitive-?
quite competitive?
some ©ompiiittve-1
neither-----0
some cooperative-1
quite coopertative-2
v e r y c o o p e r a t iv e - ®
( N«xt->)
26. Did you ft*i any overall pain
or discomfort as you were
beeped?
' rvone-------0
1 ______
slight— 2
2 ______
bothersomed________
5 ______
severe- 6________
C Next > )
27. Who «tr* you with?
classmates sibling*
same-sex frie parents
same-sex grou ext relatives
opp-*«x group parent & sibs
opp-sex trtehd bo*s/co-*orf<
fmd* & parett oth«r adult*
atone
strangers
0 * 4 ? )
Ouwtlon* 2® to 25, Pleas*
indicate how you FELT about
your activity:
| continue j
CEEED
26 Challenges of the activity:
116
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
2 0 , Y our skills in th e activity:
U>y-0
t
2
3.....
4
' a.......
g
H i g h . ?
C E ± D
3 3 . Do you wish you h a d b e e n
d o i n g s o m e t h i n g e ls e ?
not it a i l - 0
i
2
3
4
5
«
v e r y m u c h - ?
3 0 . W as this activity
important t o y o u ?
n o t a t a l- 0
t
! ': : : ' : 1 j ':
" ' 3 " " ’
4
6
6
v a r y m u o h -7
C 1 E ± D
3 4 . W e r e y o u s a t is f ie d * 1 1 1 1
h o w y o u w e r e d o i n g ?
n o t a t a l l - 0
t
2
3
4
5
e
v e r y m u c h - ?
f Next-o*)
3 1 , W a s t h is a c tiv ity
im p o r t a n t t o others?
n o t a t a i l - 3
t
2
______ 3
4
5
6
v e r y m u o h - 7 _ _ _ _
CEED
3 5 . H o w im p o r t a n t w a s th is
activity i n r e l a t i o n to y o u r
overall g o a l s ?
n o t at aiMJ
1
2
3
4
5
6
v e r y m u c h - ?
32. Were you succeeding at
• h a t you were d o in g ?
n o t at a l l- 0
1
2
_ _ _ _ _ _ _ _3
4
_ _ _ _ _ _ _ 5
e
v e r y m u c h - ?
GEEE)
Thank you for
ling ouflhe
quesionnatre
T h e lo g p r o g r a m
'» ill n o w g o to s le e p .
117
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Abstract (if available)
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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Qu, Wenchun
(author)
Core Title
Quality of daily occupational experience and its relationship with adolescent tobacco smoking
Degree
Doctor of Philosophy
Degree Program
Occupational Science
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
health sciences, rehabilitation and therapy,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c16-493854
Unique identifier
UC11340234
Identifier
3133329.pdf (filename),usctheses-c16-493854 (legacy record id)
Legacy Identifier
3133329.pdf
Dmrecord
493854
Document Type
Dissertation
Rights
Qu, Wenchun
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
health sciences, rehabilitation and therapy