A range of socio-demographic, environmental, behavioural and personal indicators predict the likelihood of adopting or rejecting smoking, particularly in early adolescence. Detailed literature reviews have been published in the US Surgeon General's reports of 2000,1 20012 and 2012,3 and in several journal articles (e.g. Conrad,4 Sargent,5 Turner,6 and Moolchan).7
The factors discussed in the following sections are ordered according to the Theory of Triadic Influence, a model for integrating and understanding the interrelated influences on youth uptake of smoking developed by Flay. 6,8,9 This model encompasses the 'big picture' of personal, social and environmental effects on behaviour, dividing them into three separate but interconnected streams:
- Biology and personality (intrinsic factors), covering individual demographic, physiological and psychological factors. These influence self-efficacy, which may be broadly defined as an individual's sense of self, social competence, and self-determination.
- Social context (extrinsic factors), relating to the influence of family and friends through their behaviour and attitudes, resulting in the development of a perception of what constitutes normative behaviour.
- Broader environment, encompassing cultural contexts, the informational environment, and legislative and policy issues that affect the pricing and availability of tobacco. The broader environment influences knowledge, expectations, values and evaluations, leading to particular attitudes and beliefs.
The combined effect of the personal, social and wider environment leads to an individual's intentions and ultimate decision about whether or not to smoke. A decision to smoke leads to trialling the behaviour, and the resulting experience is mediated by each of the three major streams of influence–the personal, the social setting and broader expectations and attitudes8, as illustrated in Figure 5.2.1.
Influences on uptake of smoking
Source: Personal communication to Margaret Winstanley from Dr Lisa Wood, Department of Population Health, University of Western Australia, e-mail 2008
Key characteristics that are influential in adolescent smoking uptake include a combination of age; ever smoking or drinking; and parental, sibling and peer smoking.10 A systematic review of prospective longitudinal studies identified a large number of predictors for cigarette smoking onset among adolescents who had never smoked.11 An increased risk of smoking onset was associated with increased age, lower socioeconomic status, poor academic performance, rebelliousness or thrill seeking, intention to smoke in the future, receptivity to tobacco promotion, having family or friends who smoke and exposure to smoking in films.11 Factors which acted as protective against the onset of smoking were higher self-esteem and high parental supervision.11
Different factors may be expected to have a greater or lesser influence on behaviour at different stages in a person’s life: the determinants of smoking in early adolescence may differ from those that are important in mid- to late-adolescence or early adulthood.12, 13 Similarly, the importance of a range of smoking determinants may vary depending on the stage of onset, such as the development of the intention to smoke compared with nicotine dependence.13 There is some evidence of specificity in the factors predicting smoking among adolescents at different smoking stages (such as never smokers, experimental and regular smokers), with peer smoking and low school connectedness found to be more influential in later stages of smoking than in early stages, and alcohol use thought to be more influential in early stages.14 Other predictors, including depression, delinquency, parental smoking and family connectedness, may not be stage specific, significantly differentiating all smoking stages.14
Similarly, longitudinal research among young people aged 14 years has found the influence of several psychological factors including rebelliousness and thrill seeking to be greater in the transition from ‘never smoking’ to ‘trying smoking’ than in the change from ‘trying’ to ‘monthly’ or ‘daily’ smoking.15 Psychological factors have also been found to be more influential than the social factors of parental and close friend smoking behaviour.15 Note however, that the US Surgeon General concluded that the empirical evidence for stage-specific smoking predictors is weak.16
The extensive influence of psychosocial processes occurring during childhood and adolescence on future life trajectories helps explain the source of problem behaviours and substance use throughout individuals’ lives. Temperament, family experiences and interactions with the broader environment all affect whether adolescents will develop individual characteristics that make them more or less vulnerable to drug use and dependence.17
Australian research examined the predictors of changes in adolescent smoking behaviour across three analytic models based on data from Years 7–10 Australian students tracked through a 12-month longitudinal study.18 Results suggested that for males, the frequency of risk-taking behaviour and a male best friend who was a smoker were effective predictors of smoking behaviour changes, while for females, the key predictor was whether at least one parent was a smoker. The prediction of change in adolescent smoking behaviour was significantly improved in the models that included past smoking behaviour.18
The protective effects of smoking cessation during adolescence were highlighted in analyses from a prospective Australian study undertaken in Victoria examining patterns of adolescent smoking and subsequent nicotine dependence in young adulthood.19 The study followed 1520 secondary students for 10 years from 14–15 years of age through eight waves of data collection, assessing adolescent smoking and quitting patterns in waves one to six. While almost 10% of participants were nicotine dependent in the final wave (aged 24 years), dependence prevalence differed markedly between daily (26.7%) and non-daily adolescent smokers (6.8%).19 Results indicated that daily adolescent smokers who had stopped smoking for at least two study waves (≥12 months), as well as adolescents who quit after non-daily smoking, were not at significantly greater risk of nicotine dependence than students who had never smoked. Nicotine dependence was also predicted by maximum smoking levels, how early daily smoking commenced, a longer duration of smoking (particularly daily smoking) and escalation time (length of time of transition between experimentation and daily smoking).19
Canadian researchers found that key predictors of smoking initiation included poor academic performance, stress and alcohol use. Smoking by parents, siblings and especially friends was associated with a higher risk of both initiation and sustained smoking, as was susceptibility to tobacco advertising.13 Research also indicates that pleasant experiences during early smoking experimentation are an important factor in the transition to regular smoking, playing a potentially greater role than negative experiences.20-22 Also a factor in transition to regular smoking is use of noncigarette tobacco products, hookah, noncigarette combustible tobacco and smokeless tobacco. Research has found that use of any one of these products increases the likelihood of progression to traditional combustible cigarette use one year on.23 There is also evidence electronic cigarettes may play a role in transition to regular smoking among adolescents—see Section 18B.6 for further research.
Relevant news and research
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1. US Department of Health and Human Services. Reducing tobacco use: a report of the Surgeon General. Atlanta, Georgia: 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, 2000. Available from:http://www.cdc.gov/tobacco/sgr/sgr_2000/index.htm
2. US Department of Health and Human Services. Women and smoking: a report of the US Surgeon General. Atlanta, Georgia: 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, 2001. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44303/
3. 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/
4. Conrad K, Flay B and Hill D. Why children start smoking cigarettes: predictors of onset. British Journal of Addiction 1992;87(12):1711–24. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.1992.tb02684.x
5. Sargent J and DiFranza J. Tobacco control for clinicians who treat adolescents. CA A Cancer Journal for Clinicians 2003;53(2):102-23. Available from: http://caonline.amcancersoc.org/cgi/reprint/53/2/102
6. 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: https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1196/annals.1308.023
7. Moolchan E, Ernst M and Henningfield J. A review of tobacco smoking in adolescents: treatment imlications. Journal of the American Academy of Child & Adolescent Psychiatry 2000;39:682-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10846302
8. Flay B. Understanding environmental, situational and intrapersonal risk and protective factors for youth tobacco use: the Theory of Triadic Influence. Nicotine & Tobacco Research 1999;1(suppl.1):i111-14. Available from: https://academic.oup.com/ntr/article-abstract/1/Suppl_1/S111/1086300?redirectedFrom=fulltext
9. Flay B, Petraitis J and Hu F. Psychosocial risk and protective factors for adolescent tobacco use. Nicotine & Tobacco Research 1999;1(suppl.1):i59-65. Available from: https://www.semanticscholar.org/paper/Psychosocial-risk-and-protective-factors-for-use.-Flay-Petraitis/1bf4ff3f2d85c693535e7db376e1d0dfebad6a2f
10. Karp I, Paradis G, Lambert M, Dugas E and O'Loughlin J. A prognostic tool to identify adolescents at high risk of becoming daily smokers. BMC Pediatrics 2011;11:70. Available from: http://www.biomedcentral.com/1471-2431/11/70
11. Wellman RJ, Dugas EN, Dutczak H, O'Loughlin EK, Datta GD, et al. Predictors of the onset of cigarette smoking: A systematic review of longitudinal population-based studies in youth. American Journal of Preventive Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2718002 8
12. Hassandra M, Vlachopoulos S, Kosmidou E, Hatzigeorgiadis A, Goudas M, et al. Predicting students' intention to smoke by theory of planned behaviour variables and parental influences across school grade levels. Psychology & Health, 2011; 26(9):1241–58. Available from: http://www.tandfonline.com/doi/full/10.1080/08870446.2011.605137
13. O'Loughlin J, Karp I, Koulis T, Paradis G, and DiFranza J. Determinants of first puff and daily cigarette smoking in adolescents. American Journal of Epidemiology, 2009; 170(5):585–97. Available from: https://academic.oup.com/aje/article/170/5/585/102821
14. Lloyd-Richardson EE, Papandonatos G, Kazura A, Stanton C, and Niaura R. Differentiating stages of smoking intensity among adolescents: Stage-specific psychological and social influences. Journal of Consulting and Clinical Psychology, 2002; 70(4):998. Available from: http://www.apa.org/pubs/journals/releases/ccp-704998.pdf
15. Bricker JB, Rajan KB, Zalewski M, Ramey M, Peterson AV, et al. Psychological and social risk factors in adolescent smoking transitions: A population-based longitudinal study. Health Psychology, 2009; 28(4):439–47. Available from: https://psycnet.apa.org/record/2009-10284-009
16. US Department of Health and Human Services. How tobacco smoke causes disease: The biology and behavioral basis for smoking-attributable disease: A report of the surgeon general. Atlanta, Georgia: 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, 2010. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/2010/index.htm.
17. Baler R and Volkow N. Addiction as a systems failure: Focus on adolescence and smoking. Journal of the American Academy of Child & Adolescent Psychiatry, 2011; 50(4):329–39. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21421173
18. Mazanov J and Byrne D. Modelling change in adolescent smoking behaviour: Stability of predictors across analytic models. British Journal of Health Psychology, 2008; 13(3):361–79(19). Available from: http://www.ncbi.nlm.nih.gov/pubmed/17535501
19. Van De Ven M, Greenwood P, Engels R, Olsson C, and Patton G. Patterns of adolescent smoking and later nicotine dependence in young adults: A 10-year prospective study. Public Health, 2010; 124(2):65–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20060987
20. Rios-Bedoya C, Pomerleau C, Neuman R, and Pomerleau O. Using mimic models to examine the relationship between current smoking and early smoking experiences. Nicotine & Tobacco Research, 2009; 11(9):1035–41. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19578152
21. Urban R. Early smoking experience in adolescents. Addictive Behaviors, 2010; 35(6):612–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20071101
22. Urban R. Smoking outcome expectancies mediate the association between sensation seeking, peer smoking, and smoking among young adolescents. Nicotine & Tobacco Research, 2010; 12(1):59–68. Available from: http://ntr.oxfordjournals.org/cgi/content/full/12/1/59
23. Watkins S, Glantz SA, and Chaffee BW. Association of noncigarette tobacco product use with future cigarette smoking among youth in the population assessment of tobacco and health (path) study, 2013-2015. JAMA Pediatrics, 2018; 172(2):181–7. Available from: http://dx.doi.org/10.1001/jamapediatrics.2017.4173