5.1 Stages in the uptake of smoking

Last updated: February 2019 
Suggested citation: Wood, L., Greenhalgh, EM., Vittiglia, A & Hanley-Jones, S. 5.1 Stages in the uptake of smoking. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2019. Available from: https://www.tobaccoinaustralia.org.au/chapter-5-uptake/5-1-stages-in-the-uptake-of-smoking

Traditionally, the process of taking up smoking has been conceptualised as a progression through stages, including precontemplation, smoking preparation, trying cigarettes, experimentation, regular smoking, and addiction.1 While these stages serve as useful guiding points in research and prevention efforts, they are a simplistic representation of smoking progression.2 Smoking habits develop differently between adolescents; while some will experiment with tobacco and never increase their use, others will quickly move from experimentation to dependence.3

Research has highlighted the significant heterogeneity in the development of smoking behaviours, and has identified a number of discrete smoking trajectories amongst adolescents.[e.g., 4, 5]  However, different studies have identified varying numbers and patterns of trajectories based on age of onset, steepness of acceleration, and persistence of use, perhaps reflecting the complexity of modelling cigarette use over time.6  

There is some agreement across studies in terms of identifying an early-onset group that is consistently high or quickly accelerating in their smoking, a later-onset group, and light-smoking groups whose tobacco use does not progress.6 The 2012 Surgeon General’s report suggested that the following four trajectories may be one of several ways of conceptualising the different pathways:2

Nonsmokers

Nonsmokers comprise about half of adolescents, and do not have any history of tobacco use.

Early establishers

This group commences smoking at ages 12 or 13, and quickly escalate to daily use. Adolescents whose smoking begins early, rapidly accelerates, and remains persistent are often identified as an “at-risk” group due to familial smoking, psychosocial factors, and mental health problems.6 This group may also be at greatest risk for chronic nicotine dependence.7  

Late establishers

Late establishers begin smoking at 15 or 16 years old and progress to intermittent use in their early 20s, which then declines in their mid-20s. 

Quitters

This group begin smoking very early, before the age of 11; however their tobacco use declines throughout adolescence and young adulthood. 

These patterns of smoking behaviours can vary by gender and ethnicity;2 however, further research is needed to identify factors that can predict and discriminate between trajectories, in order to effectively tailor prevention and intervention programs.8 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.9 Socioeconomic factors, educational attainment, peer influences are all important predictors of youth smoking behaviours,2 as well as whether early, subjective experiences with smoking are positive or negative.10  

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.11 Research published in 2009 concluded that daily smoking in novice adolescent smokers is a risk factor that may be particularly important in the development of nicotine dependence and the progression to sustained smoking,12 while a more recent study found that any past 30-day smoking among adolescents, inclusive of nondaily smoking, was a strong predictor of future smoking behaviour in young adulthood.13 In addition, research on the ‘conversion rate’ from initial experimentation to daily smoking found over two-thirds of people who try one cigarette become, at least temporarily, daily smokers.14  

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References

1. 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

2. US Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2012. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2012/

3. Fuemmeler B, Lee C-T, Ranby KW, Clark T, McClernon FJ, et al. Individual-and community-level correlates of cigarette-smoking trajectories from age 13 to 32 in a US population-based sample. Drug and Alcohol Dependence, 2013; 132(1):301-308. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23499056

4. Bernat DH, Erickson DJ, Widome R, Perry CL, and Forster JL. Adolescent smoking trajectories: results from a population-based cohort study. Journal of Adolescent Health, 2008; 43(4):334–40. Available from: http://www.jahonline.org/article/PIIS1054139X08001572/fulltext

5. Lessov-Schlaggar CN, Hops H, Brigham J, Hudmon KS, Andrews JA, et al. Adolescent smoking trajectories and nicotine dependence. Nicotine & Tobacco Research, 2008; 10(2):341-351. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18236299

6. Chassin L, Curran PJ, Presson CC, Sherman SJ, and Wirth R. Developmental trajectories of cigarette smoking from adolescence to adulthood. NCI Monograph, 2009; 22. Available from: https://cancercontrol.cancer.gov/BRP/tcrb/monographs/20/m20_5.pdf  

7. Dierker L and Mermelstein R. Early emerging nicotine-dependence symptoms: a signal of propensity for chronic smoking behavior in adolescents. The Journal of Pediatrics, 2010; 156(5):818-822. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3021919/

8. Hu M-C, Griesler PC, Schaffran C, Wall MM, and Kandel DB. Trajectories of criteria of nicotine dependence from adolescence to early adulthood. Drug and Alcohol Dependence, 2012; 125(3):283-289. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22513378

9. 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: www.ncbi.nlm.nih.gov/pubmed/21075539

10. 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

11. 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

12. Wileyto P, O'Loughlin J, Lagerlund M, Meshefedjian G, Dugas E, et al. 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

13. Dutra LM and Glantz SA. Thirty-day smoking in adolescence is a strong predictor of smoking in young adulthood. Preventive Medicine, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29366819

14. Birge M, Duffy S, Miler JA, and Hajek P. What proportion of people who try one cigarette become daily smokers? A meta analysis of representative surveys. Nicotine & Tobacco Research, 2017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29126298