This section examines the role of denormalisation in reducing smoking uptake among young people. It outlines how misperceptions about smoking prevalence and social acceptability influence behaviour, and identifies factors that shape these perceptions. The section also examines forces that contribute to the denormalisation of smoking, including social marketing and education, media portrayals, smokefree policies, restrictions on advertising and retail visibility, plain packaging, and broader cultural shifts that signal declining social acceptance of smoking.
Young people in particular are greatly influenced by their sense of what is normal and attractive, which is in turn influenced by the imagery and social meaning attached to different behaviours.1 It has been the exaggerated ‘normalisation’ of smoking that underlies much of advocacy by public health specialists against tobacco depictions in movies and other popular media. ‘Denormalisation of smoking’ is a phrase used in tobacco control to refer essentially to the erosion of community acceptance and tolerance for smoking. While the advertising of tobacco products has declined markedly over the last few decades, and number of places in which smoking is permitted has dwindled, there are still many instances where smoking takes place in the community or is portrayed in media and other aspects of popular culture.
Overestimation of smoking prevalence:
The tendency for young people to overestimate the prevalence of smoking in the population suggests that normative perceptions about smoking may lag behind reality.
Australian research has shown adolescents believe smoking to be more prevalent among their peers than it actually is.2 Similar patterns of overestimation of smoking prevalence have been observed internationally, with young people in Hong Kong,3 the US,4,5 and Europe6 routinely overestimating the proportion of their peers that smoke and peer approval of smoking.
In the English National Survey, published in 2017, 81% of young people who regularly smoked aged 15 thought that half or more of their age group smoked, whereas in reality 6% of boys and 7% of girls aged 15 years smoked regularly at that time.7 While overestimation was high, from 2004 to 2016 the data indicated an upward trend in the proportion of pupils who believed that either none or a few of their peers smoked, and a downward trend in the proportion who believed about half or more of their peers smoke.7 In a Hong Kong study, overestimation of smoking was shown to be predictive of smoking initiation, with those overestimating smoking prevalence among peers more likely to have smoked at the two-year follow-up of the student cohort.3 A 2019 US study found extensive misperceptions about the norms of tobacco use among middle and high school students, with most students believing that their peers approved of and used tobacco more than they actually did. These misperceptions were found across all student backgrounds and school contexts and were independent predictors of personal attitudes and use of tobacco.5 Similar findings were observed among European university students.6
Misperceptions about the extent to which other people engage in or support smoking are strong predictors of smoking initiation and lead to favourable attitudes toward tobacco use. Social norms need only to be perceived to influence behaviour:8 young people who smoke tend to congregate together and it is this that may lead them to overestimate the extent of smoking in their own age group, giving them a distorted sense of what is normal behaviour.8-10
Ethnicity and related social contextual factors may influence perceived smoking prevalence. For example, an analysis of US cross-sectional time series data from a national survey of young people aged 12–17 years found an association between perceived smoking prevalence (assessed with the question ‘Out of every 10 people your age, how many do you think smoke?’) and race/ethnicity, as well as with exposure to social contextual factors (e.g. parental smoking, school factors such as academic performance, and socio-economic status).11 The authors suggest that young people from minority groups are disproportionately exposed to social contextual factors that are correlated with high perceived smoking prevalence.
Approval of smoking:
The National Drug Strategy Household Survey (2022-2023)12 provides Australian data on community opinions and perceptions of drug use, based on responses from almost 21,000 participants across Australia aged 14 years or older. Participants were asked to nominate if they personally approved or disapproved of regular use of each drug by an adult. People aged 14–17 (17.9%) and 18–24 (18.7%) either approved or strongly approved of the regular use of tobacco by an adult.12 A 2023 national survey of smoking and other drug use among secondary school students in England aged 11–15 years found that 17% of respondents considered it ‘OK’ to try smoking to see what it is like, a decline from 23% in 2021.13 When asked whether it was ‘OK’ to smoke once a week, 10% of students reported that this was acceptable. Attitudes varied markedly by age: younger students were less likely to view smoking as acceptable, with 4% of 11-year-olds reporting that it was ‘OK’ to try smoking, compared with 33% of 15-year-olds. Similarly, 5–6% of 11–12-year-olds considered it ‘OK’ to smoke once a week, compared with 17% of 15-year-olds.13
5.19.1 What factors influence perceptions of smoking prevalence?
Factors identified in the literature as contributing to young people’s mis-estimation of smoking prevalence include age (younger more likely to overestimate), sex (female), number of friends who smoke, exposure to levels of smoking in the home, and their own smoking status.14,15 In an interesting prospective study undertaken in The Netherlands, overestimation of smoking prevalence across three time points was predicted by having a predominantly smoking peer group, a best friend who smokes, and by having at least one parent who smokes.16 Overestimation of smoking prevalence was also associated with smoking status (i.e. regular smoking) at the third time point.16
While quantitative studies have tended to empirically examine factors associated with overestimates of smoking prevalence, qualitative research undertaken in Western Australia for the Smarter than Smoking project asked young people to estimate adult and peer smoking relevance and then asked them what they based their estimates on.17 Participants in the focus groups indicated they based their prevalence estimates either on who they knew/mixed with (this included sphere of family contacts), or what they observed around them in the community. Ironically, smoking has in some ways become more visible in the community as a consequence of tightening bans on indoor or on-premise smoking.
5.19.2 What forces are likely to further denormalise smoking?
Smoking prevention efforts are likely to be enhanced and reinforced by strategies that denormalise the way in which smoking is portrayed or occurs in the broader community.
Social marketing and educational campaigns:
Evidence documenting student tendencies to overestimate smoking prevalence supports calls for the inclusion of strategies to redress unrealistic perceptions of smoking prevalence in smoking education aimed at young people.14,15,18 As articulated in a British Medical Association report into the influences of smoking on young people, efforts to denormalise tobacco use should ‘emphasise the fact that smoking is very much a minority pursuit, and that even among smokers, most are ambivalent about their habit.’ (p29.1) The report also suggests that reinforcing this message may be particularly warranted in lower income communities where higher smoking prevalence rates can create false impressions about the normalcy of smoking.1 An evaluated and published example of this was a ‘social norms’ campaign conducted in Montana in 2000–01 targeting 12–17 year olds.19 The campaign was framed around the normative message ‘Most of Us are Tobacco Free’, with post-intervention data indicating that only 10% of teens in the counties exposed to the campaign reported first time cigarette use, compared to 17% of teens in the control areas.19 Interventions to denormalise adolescent misperceptions of smoking prevalence may not be similarly effective with all young people, with a Chinese study finding that a program aimed at correcting perceptions of peer smoking prevalence was less effective among adolescents with higher levels of depressive symptoms.20
A 2018 study from Hong Kong, highlighted the importance of developing effective denormalisation strategies to counter the influence of the tobacco industry on young people. The study found adolescents who held denormalisation beliefs about the tobacco industry, such as viewing tobacco companies as manipulative, deceptive, and harmful, were associated with lower levels of smoking initiation, experimentation, and current smoking among the adolescents. The authors of the study suggest that denormalisation beliefs about the tobacco industry may play a role in reducing smoking initiation among adolescents.21
For more on media campaigns and young people, see Section 5.17, and for more on tobacco education in schools see Section 5.9.3
Portrayal of smoking in movies and other media:
Advocacy efforts to expose and counter the disproportionate portrayal of smoking in movies are another example of an approach to the denormalisation of smoking. Both the over-representation in movies of smoking relative to real-life prevalence, and the juxtaposition of smoking with other desirable attributes or characters, can promulgate a misleadingly positive conception of tobacco use.1 Research suggests that critical thinking about media messages can inhibit normative perceptions that are likely to increase adolescents' interest in tobacco use.22 See Section 5.16 for more on smoking in movies, TV and other popular culture/media.
Bans on smoking and increased smokefree areas:
Implementation of smokefree policies in public places powerfully denormalises smoking and has been shown to contribute considerably to declines in cigarette smoking prevalence.23 The less frequently young people observe smoking occurring in everyday life, the less likely they are to have the view that smoking is both socially acceptable and normal.24 Hence bans on smoking help to reduce the ‘normalcy’ of seeing people smoking, thereby helping to reshape community norms and perceived social acceptability regarding smoking.15,24 Restrictions or bans on smoking also physically decrease the opportunities for children and young people to be in the presence of smoking.24 The diminishing number of places in which smoking can occur in Australia, and the negative symbolism of the types of areas people who smoke often now have to move to in order to smoke (e.g. alleyways, outside office doors, parking lots), means that smoking is no longer an integral and ‘normal’ part of everyday life.25 The tobacco industry itself recognises the power of smoking restrictions to denormalise smoking,25 as evidenced in the efforts of tobacco companies around the world to oppose bans and restrictions on smoking in public places.23 See Section 5.14, and Chapter 15, Section 15.9.3.2 for more information on the effectiveness of smokefree legislation in changing smoking behaviours among young people.
Point-of-sale advertising bans and retail density:
Widespread availability of tobacco from a variety of retail outlets, and the visible display of tobacco products at point-of-sale, have both contributed to deceptive perceptions about the normalcy and acceptability of smoking in the community.1 Exposure to retail cigarette advertising has been linked, for example, in two experimental studies with adolescents to increased perceived smoking prevalence among high school students and adults.2,26 Reducing the perceived acceptability of smoking is one of the arguments made for prohibiting point-of-sale advertising in countries where this still occurs, and for treating tobacco as an ‘under-the-counter’ product.1 Research evaluating the impact of point-of-sale tobacco display bans on smoking-related beliefs and behaviours in Australian adolescents and young adults found that the removal of tobacco displays from retail environments positively contributed to a denormalisation of smoking among young people.27 Tobacco retailer density and proximity has also been shown to be associated with adolescent smoking behaviours.28 Tobacco control advocates have called for limitations to be placed on the number of tobacco retail outlets, particularly around schools. For example, zoning restrictions or licencing schemes may be used to restrict the availability and visibility of cigarettes around young people, further contributing to the denormalisation of smoking.29 For more on point-of-sale bans and retail density see Section 11.9.
Plain packaging and health warnings:
Plain packaging of cigarettes has contributed to denormalisation of smoking by reducing the appeal of cigarette packaging, limiting the marketing and promotion of tobacco products, and increasing the visibility of health warnings. A 2019 research study of the long-term impact of plain packaging, including larger graphic health warnings, among Australian adolescents between 2011 and 2017 confirmed that plain packaging is fulfilling its aim of reducing the attractiveness and appeal of tobacco products to young people.30 For more on the effects of plain packaging see Section 11A.9.
Other:
Many societal changes and cultural cues subtly signal the declining social acceptability of smoking in the community.25 Examples include the replacement of cigarette lighters as a ‘routine’ fixture of new vehicles, implementation of differential insurance premiums for people who smoke, exclusion of tobacco in ethical investment portfolios, specification of non-smoking in ‘lonely hearts’ advertisements. Such trends indicate an erosion of smoking as a marker of what is socially ‘cool’.25 These changes may be less overt in their effect than the conventional core planks of tobacco control (taxation, policy, advertising bans, etc.), but collectively they contribute to the cultural denormalisation of smoking.
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References
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