5.1 Stages in the uptake of smoking

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The process of taking up smoking may be conceptualised as a progression through stages in a continuum, during which external influences and individual characteristics interact. These stages may be broadly summarised as:^1,2

Precontemplation

The individual has no positive thoughts about smoking and no desire to start in the near future. He or she is oblivious to, disregards or resists pressure to smoke. Never smokers do not proceed beyond this stage.²

Contemplation and preparation

The individual develops positive beliefs and attitudes about cigarettes, shaped by influences such as family, peer group and the media.

Initiation

The individual tries the first few cigarettes, usually with the example of or encouragement by friends. Smoking can serve to boost self-image and secure the approval of the peer group.

Experimentation

Smoking gradually increases in frequency and is viewed positively, even if its initial physiological effects feel unpleasant. Uncommitted smokers at this stage tend to give up, while others will persist, become adept at smoking, and develop a self-image as a smoker. Being part of a family where others smoke assists with ongoing access to cigarettes.

Regular smoking

Smoking becomes more frequent and less sporadic. Adolescents may regularly smoke on the weekends, at parties, or on the way to and from school. At this stage, most smokers are not smoking daily or consuming many cigarettes. Not all smokers who have reached this stage will proceed to the next.

Established/daily smoking

At this stage the smoker is addicted, and tobacco use is perceived to fulfil a range of psychological and physiological functions.

The process of smoking acquisition usually occurs during adolescence, for some rapidly escalating into dependence, while for others becoming established more gradually.³ Progression to heavier smoking among adolescents is typically unidirectional but often discontinuous, interspersed by periods of not smoking.⁴ In any individual, transit through the pathway outlined above may halt, reverse or recommence, depending on a range of influences,⁵ including biological factors² and whether early, subjective experiences with smoking are positive or negative.⁶

Not all individuals who try smoking become committed smokers, and identifying the causes of different behavioural trajectories is an important theme for further research.³ Qualitative research undertaken in Western Australia found that curiosity was one of the dominant reasons among adolescents for trying smoking, with teenage years marked by curiosity about and experimentation in many life experiences, including smoking.⁷

Recent evidence differentiates some of the psychosocial variables (such as family factors and the influence of role models) influencing adolescent smoking onset compared with the frequency of smoking,⁸ while research has identified daily smoking in novice adolescent smokers as a risk factor that may be particularly important in the development of nicotine dependence and the progression to sustained smoking.⁹

References

1. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General, 1994. Atlanta, Georgia: Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, 1994. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_1994/index.htm

2. Mayhew K, Flay B and Mott J. Stages in the development of adolescent smoking. Drug and Alcohol Dependence 2000;59(suppl.1):i61-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10773438

3. Turner L, Mermelstein R and Flay B. Individual and contextual influences on adolescent smoking. Annals of the New York Academy of Sciences 2004;1021:175–97. Available from: http://www3.interscience.wiley.com/journal/118766022/abstract

4. Wellman RJ, DiFranza JR, Savageau JA and Dussault G. Short term patterns of early smoking acquisition. Tobacco Control 2004;13(3):251. Available from: http://tobaccocontrol.bmj.com/content/13/3/251.full.pdf

5. Charlton A, Moyer C, Gupta P and Hill D. Tobacco Control Fact Sheets. Youth and cigarette smoking. Geneva: UICC and Tobacco Control Resource Centre, 2002 [viewed March 2007]. Available from: http://factsheets.globalink.org/en/youth.shtml

6. Urbán R and Sutfin E. Do early smoking experiences count in development of smoking? Temporal stability and predictive validity of an early smoking experience questionnaire in adolescents. Nicotine & Tobacco Research 2010;12(12):1265–9. Available from: http://ntr.oxfordjournals.org/content/12/12/1265.full

7. Leavy J, Wood L, Rosenberg M and Phillips F. Try and try again - qualitative insights into adolescent smoking experimentation and notions of addiction. Health Promotion Journal of Australia 2010;21(3):208-14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21118068

8. Otten R, van Lier P, Engels A and Rutger C. Disentangling two underlying processes in the initial phase of substance use: onset and frequency of use in adolescent smoking. Addictive Behaviors 2011;36(3):237–40. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21075539

9. Wileyto P, O'Loughlin J, Lagerlund M, Meshefedjian G, Dugas E and Gervais A. Distinguishing risk factors for the onset of cravings, withdrawal symptoms and tolerance in novice adolescent smokers. Tobacco Control 2009;18(5):387–92. Available from: http://tobaccocontrol.bmj.com/content/18/5/387.long