5.2 Prevention

Described as one of the core aims of tobacco control,¹ the term ‘prevention’ is generally used by the tobacco control field to refer to any interventions or efforts to deter smoking. It includes within its spectrum the following when applied to young people in particular:

Factors that lead to someone trying smoking for the first time may not be the same as those that lead to more regular smoking Thus some of the factors discussed in the following sections of this chapter are highly predictive of a first try (such as having family members (see Section 5.7) or a best friend who smokes (see Section 5.8)), while others play more of a role in facilitating continuation (such as ease of access (see Section 5.11)) or deterring smoking (e.g. an unpleasant first experience, or engagement in physical activity and sports (see Section 5.18)).

5.2.1 Preventing 'just trying it'

Traditionally, smoking strategies aimed at young people have concentrated on keeping young people from trying their first cigarette;² however, some of the drivers of the ‘first try’ are difficult to prevent. Curiosity, for example, is a natural part of growing up and a normal part of the teenage trajectory.³ In two qualitative studies conducted among young Australians, 'curiosity’ was a common reason given for trying smoking. Moreover, among the adolescents interviewed in the Western Australian research undertaken for the Smarter than Smoking project, there was very little perceived risk of trial leading to regular smoking, or becoming addicted, even though the risks of smoking were well known and accepted among this group.³

Qualitative research with young Australian Aboriginal peoples and Torres Strait Islanders in 2015 cited the primary reasons for smoking initiation as stress, the social influence of family and peers, a desire to appear ‘cool’, and boredom.⁴

In the broader field of substance abuse prevention, there is debate about the extent to which interventions and programs should focus on preventing ever or first use of a substance, or whether it is more realistic to acknowledge that some experimentation and use will occur, and the emphasis shifted more to reducing harm and levels of use. Within tobacco control, however, there has typically been considerable resistance to harm minimisation approaches, in part because there is no safe level of use even for adults (which differs from alcohol), and due to concern that harm minimisation programs may lead to increased experimentation among non-users due to perceived weakened social norms.⁵  

5.2.2 Preventing progression to continuation

There is a relative research and intervention void in the published literature relating to experimental smoking and the progression to regular smoking,⁶ with the exception of a 2017 meta-analysis that used data from the Global Health Data Exchange to show that over two-thirds of people who try one cigarette become, at least temporarily, daily smokers.⁷ Some of the factors influencing whether young people continue smoking after trying cigarettes are depicted in Figure 5.2.2, as identified in Western Australian qualitative research with young people aged 13–15 years.³

A number of the factors depicted above present opportunities to ‘intercept’ young people between experimentation and continuation. For instance, predisposing attitudes towards or against smoking are factors that influence continuation, and are amenable to intervention.⁸ Enjoyment of the initial smoking experience also influences continuation and can be amenable to intervention via policies that reduce the palatability of tobacco products such as flavour bans (see Section 5.13.1, Section 10.6.4, and Chapter 12, Section 12.6 and 12.7). The standard adult dichotomy between smoker and non-smoker is somewhat less clear among young people: adolescents’ definitions of what constitutes a smoker and what constitutes smoking often differ from clinical or research definitions.⁹ Intermittent patterns of smoking and lower consumption are more typical in younger smokers.¹⁰ Moreover, qualitative research from Western Australia found that young people who smoke ‘socially’ or intermittently often do not regard themselves as smokers or have any intention of becoming a regular smoker.⁸ There is also some evidence that adolescent cigarette smokers may have more daily variability in their smoking patterns than adults, such as significantly more weekend than weekday smoking.¹¹ These findings have implications for assessing adolescent smoking patterns as well as maximising the effectiveness of young people-centred smoking prevention and cessation initiatives; for example, prevention messages need to avoid oversimplifying young people as either smokers or non-smokers.

5.2.3 Regular smoking and addiction

Research suggests that young people’s ideas and expectations of addiction influence their predisposition and likelihood to smoke.¹² There are marked differences in perceptions of the addictive nature of smoking between adolescents who have smoked or intend to smoke and those who are resolved not to try it.^13,14 Research also suggests that young people's understanding of addiction, including its likelihood, processes, and consequences, is poor.^12,15 Adolescents generally do not recognise or comprehend the addictiveness of smoking for people their age, and tend not to see addiction as a likely outcome of ‘just trying it’ or experimenting.³ Notions of what it takes to become addicted seem primarily based on opinion or observation, rather than ‘known facts’.^3,12 Research with young people who smoke indicates that addiction is an unanticipated consequence.^12,16 Furthermore, young people often believe that they can smoke during adolescence without becoming addicted¹⁷ and that they can easily give up at any time.^14,18,19 Addiction and cessation tend to be viewed by teenagers as issues only for adults who smoke.¹²

 This supports the need therefore to include issues of addiction as part of the prevention remit. Issues of addiction can, for example, be incorporated into school-based programs, information on websites, resources aimed at young people and woven into mass media messages. For further information on young people and addiction, refer to Chapter 6, Section 6.7.

5.2.4 A comprehensive approach to prevention

Under the broader rubric of ‘prevention’ reviews of the literature consistently concur that effective smoking prevention for young people requires a comprehensive multifaceted approach,^20,21 involving a range of well-researched, co-ordinated and complementary strategies that reinforce each other.^22-29 As in tobacco control generally, the impact of each strategy when used or considered in isolation is likely to lead to an underestimate of the impact of several strategies in combination, due no doubt to the importance of synergistic effects.³⁰ One-off or single-focus interventions targeting young people are unlikely to produce lasting effects.^22,31

A comprehensive review of the effectiveness of multi-component community (locally) based interventions in influencing smoking behaviour, including preventing the uptake of smoking in young people, incorporated 25 studies and was published in August 2010.³² The authors concluded that there is some evidence that co-ordinated, widespread, multi-component programs can be successful in influencing smoking behaviour and reducing the uptake of smoking in young people. Community members often play a role in design and implementation of such programs, which may include mass media, school and family-based components. The reviewers also note, however, that the evidence is not robust and contains a number of methodological flaws such as risk of various types of bias, incomplete or selective reporting of outcome data, and unclear comparability between baseline intervention and control characteristics.³²

An earlier review of studies involving effective tobacco prevention strategies among young people³³ similarly found strongest support for multi-component interventions. Specifically, researchers found that the strongest and most sustained impacts were achieved through multi-component, community-based interventions of at least three years duration, especially those involving school-based strategies with supportive parent, media, and community.³³ Identified components of effective tobacco prevention programs included a focus on counteracting social factors that influence tobacco, through for example resistance and assertiveness skills training for young people, and being theory-based, with an emphasis on personal (attitudes and norms), social (e.g. group behaviour), and/or environmental (e.g. communications) level theories.³³

The 2012 report of the Surgeon General focussing on preventing tobacco use among young people found that coordinated, multi-component tobacco control interventions that include mass media campaigns, comprehensive community programs, comprehensive statewide tobacco control programs, price increases, and school-based policies, among other interventions, have proven effective in preventing onset and use of tobacco use among young people.³⁴

In a 2025 systematic review³⁵ and meta-analysis of behaviour-based, non-pharmacological interventions for the prevention of tobacco smoking among school-aged children and adolescents, school-based interventions were associated with a significant reduction in smoking initiation at six months, based on pooled analysis. However, these effects were not sustained at longer follow-up periods (12–36 months). Evidence from individual trials and subgroup analyses suggested that, in some settings—such as Saudi Arabia—peer-led, culturally tailored programs were effective in reducing smoking initiation and improving attitudes towards smoking. The authors conclude that future prevention strategies should adopt more holistic approaches that extend beyond the school setting, including greater engagement with families and communities, the use of digital technologies, and improved implementation strategies to support longer-term impact among young people.³⁵

The timing of prevention approaches in terms of developmental ages and different levels of nicotine dependence is an important consideration in comprehensive interventions.^36,37 For example, the implementation of preventive measures well before an age at which smoking experimentation begins to occur is recommended in order to influence young people’s attitudes towards smoking early.³⁶ In addition, an understanding of changes in the relative influence of factors in adolescent smoking (e.g. a decrease in the importance of peer behaviours, attitudes and norms over time and a rise in the role of psychopharmacological effects of nicotine) has been described as fundamental in improving the prevention of adolescent progression to more advanced stages of smoking.³⁷

Research³³ has described two areas offering potential improvements in adolescent smoking control efforts. One is expanding demonstrably effective educational programs such as evidence-based tobacco prevention curricula and national guidelines, in conjunction with relatively intensive engagement of influential community resources including parents and mass media.³⁰ The other involves enhanced research to evaluate tobacco initiation and cessation interventions, particularly in non-school settings.³³

Identifying best practice evidence-based smoking prevention strategies for young people is hindered to some extent by the fact that only a small proportion of prevention interventions implemented in Australia and overseas have been rigorously evaluated, if they are evaluated at all.³⁸ Guidance for effective prevention thus needs to be drawn both from understanding of the factors influencing uptake, as well as the efficacy of prevention efforts that have been evaluated or bear some evidence of positive effect. Comprehensive reviews recommend further research using methodologically high-quality studies to identify specific crucial components of effective prevention programs, examine their cost-effectiveness and evaluate key factors in the promotion, adoption and implementation of effective programs in schools and communities.^32,36,39

The duration, funding and sustainability of interventions are also important. The imperative for sustained effort and funding has been highlighted in some states in the US, where the initial successes of large-scale and comprehensive campaigns and intense tobacco-control activity of the 1990s has diminished, reflected in the halted decline of teenage smoking.⁴⁰ The efficacy and acceptability of programs targeting young people is also enhanced by their involvement in intervention planning and development,³³ an approach supported by the United Nations’ Convention on the Rights of the Child.⁴¹ In the tobacco-control literature, youth participation in intervention design is not often explicitly discussed, and as noted by Williams and colleagues, there is a lack of controlled studies measuring the impact of youth involvement.²²

Research⁴² describes a ‘tobacco control funnel’ depicting three groups of policies through which adolescent smoking can be prevented and reduced at the population level. As illustrated in Figure 5.2.2, the three avenues are restrictions to denormalise smoking (e.g. through price increases, bans on sales to minors and restrictions on areas where smoking is permitted), education to increase awareness (e.g. at school and through mass media campaigns) and ‘disruption’ to de-glamorise smoking (such as through the use of graphic warning labels, plain packaging and tobacco advertising bans).

Table 5.2.1 below maps some of the key uptake factors identified in this chapter that are amenable to intervention, as identified from the literature.

Test your knowledge

References

1. Action on Smoking and Health. Beyond smoking kills: protecting children, reducing inequalities. London: ASH, 2008. Available from: https://ash.org.uk/uploads/ASH_692.pdf?v=1648144392.

2. Hammond D. Smoking behaviour among young adults: beyond youth prevention. Tobacco Control, 2005; 14(3):181–5. Available from: https://pubmed.ncbi.nlm.nih.gov/15923468/

3. 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

4. Cosh C, Hawkins H, Skaczkowski G, Copley D, and Bowden J. Tobacco use among urban Aboriginal Australian young people: a qualitative study of reasons for smoking, barriers to cessation and motivators for smoking cessation. Australian Journal of Primary Health, 2015; 21:334–41. Available from: https://pubmed.ncbi.nlm.nih.gov/24980459/

5. Hamilton G, Cross D, Resnicow K, and Shaw T. Does harm minimisation lead to greater experimentation? Results from a school smoking intervention trial. Drug and Alcohol Review, 2007; 26(6):605–13. Available from: http://informahealthcare.com/doi/abs/10.1080/09595230701613585

6. Brook JS, Morojele NK, Brook DW, Zhang C, and Whiteman M. Personal, interpersonal, and cultural predictors of stages of cigarette smoking among adolescents in Johannesburg, South Africa. Tobacco Control, 2006; 15(suppl.1):i48–53. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC2563542/

7. 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 and Tobacco Research, 2018; 20(12):1427-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29126298

8. Wood L, Lang A, and Coase P. Smarter than Smoking Qualitative Research. A research report. West Perth, Australia: TNS Social Research, 2005.

9. Lee J and Halpern-Felsher B. What does it take to be a smoker? Adolescents' characterization of different smoker types. Nicotine and Tobacco Research, 2011; 13(11):1106–13. Available from: http://ntr.oxfordjournals.org/content/early/2011/08/17/ntr.ntr169.full?sid=1485b814-0c13-492e-b572-d1798f04cb0d

10. Ling PM and Glantz SA. Tobacco industry research on smoking cessation. Journal of General Internal Medicine, 2004; 19:419. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15109339

11. Bailey S, Jeffery C, Hammer S, Bryson S, Killen D, et al. Assessing teen smoking patterns: the weekend phenomenon. Drug and Alcohol Dependence, 2011; 120(1-3):242–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21885211

12. Wang C, Henley N, and Donovan R. Exploring children's conceptions of smoking addiction. Health Education Research, 2004; 19:626–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15199004

13. Halpern-Felsher B, Biehl M, Kropp R, and Rubinstein M. Perceived risks and benefits of smoking:  differences among adolescents with different smoking experiences and intentions. Preventive Medicine, 2004; 39:559–67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15313096

14. Arnett J. Optimistic bias in adolescent and adult smokers and nonsmokers Addictive Behaviours, 2000; 25:625–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10972456

15. Rugkasa J, Knox B, Sittlington J, Kennedy O, Treacy M, et al. Anxious adults vs. cool children: children's views on smoking and addiction. Social Science and Medicine, 2001; 53:593–602. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11478539

16. Moffat B and Johnson J. Through the haze of cigarettes: teenage girls' stories about cigarette addiction. Qualitative Health Research, 2001; 11:668–81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11554194

17. Kropp R and Halpern-Felsher B. Adolescents' beliefs about the risks involved in smoking 'light' cigarettes. Pediatrics, 2004; (114):e445–51. Available from: https://pubmed.ncbi.nlm.nih.gov/15466070/

18. Weinstein ND. Accuracy of smokers' risk perceptions. Nicotine and Tobacco Research, 1999; 1(suppl.1):S123–30. Available from: http://ntr.oxfordjournals.org/content/1/Suppl_1/S123.abstract

19. Paavola M, Vartiainen E, and Puska P. Smoking cessation between teenage years and adulthood. Health Education Research, 2001; 16:49–57. Available from: https://pubmed.ncbi.nlm.nih.gov/11252283/

20. Grimshaw G and Stanton A. Tobacco cessation interventions for young people. Cochrane Database of Systematic Reviews, 2006; 4:CD003289. Available from: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003289/pdf_fs.html

21. 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.

22. Williams J, Patton G, and Sawyer S. Scope for prevention of tobacco initiation in adolescents. Victoria: Centre for Adolescent Health, 2003.

23. May C. Resistance to peer group pressure: an inadequate basis for alcohol education. Health Education Research, 1993; 8:159–65. Available from: http://her.oxfordjournals.org/content/8/2/159.short

24. Tolan P and Guerra. N, What works in reducing adolescent violence: an empirical review of the field.  Boulder, Colorado: Center for the Study and Prevention of Violence, University of Colorado; 1994.

25. Hwang M, Yeagley K, and Petosa R. A meta-analysis of adolescent psychosocial smoking prevention programs published between 1978 and 1997 in the United States. Health Education and Behavior, 2004; 31:702–19. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15539543

26. Perry C. Reaching youths before they begin. ARHP Clinical Proceedings, 1996; October:20–1.

27. Goldman L and Glantz S. Evaluation of antismoking advertising campaigns. Journal of the American Medical Association, 1998; 279:772–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9508154

28. Flay B. Understanding environmental, situational and intrapersonal risk and protective factors for youth tobacco use: the Theory of Triadic Influence. Nicotine and Tobacco Research, 1999; 1(suppl.1):i111–14. Available from: https://academic.oup.com/ntr/article-abstract/1/Suppl_1/S111/1086300?redirectedFrom=fulltext

29. Sowden A, Arblaster L, and Stead L. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 2003; (1):CD001291. Available from: http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001291/pdf_fs.html

30. 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: https://pubmed.ncbi.nlm.nih.gov/11190114/.

31. Glantz SA and Mandel LL. Since school-based tobacco prevention programs do not work, what should we do? Journal of Adolescent Health, 2005; 36:157–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15737768

32. Carson K, Brinn M, Labiszewski N, Esterman A, Chang A, et al. Community interventions for preventing smoking in young people. Cochrane Database of Systematic Reviews, 2011; (7):CD001291. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001291.pub2/full

33. Walsh R and Tzelepis F. Adolescents and tobacco use: systematic review of qualitative research methodologies and partial synthesis of findings. Substance Use and Misuse, 2007; 42(8):1269–321. Available from: https://pubmed.ncbi.nlm.nih.gov/17674235/

34. U.S. Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: U.S. 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: https://www.ncbi.nlm.nih.gov/books/NBK99237/pdf/Bookshelf_NBK99237.pdf.

35. Alsahli FA, Alruwais NM, Alsultan LS, Abojalid BS, Nughays RO, et al. Interventions for Prevention of Tobacco Smoking in School-Aged Children and Adolescents: A Systematic Review and Meta-Analysis. Cureus, 2025; 17(1):e77008. Available from: https://www.ncbi.nlm.nih.gov/pubmed/39912043

36. Muller-Riemenschneider F, Bockelbrink A, Reinhold T, Rasch A, Greiner W, et al. Long-term effectiveness of behavioural interventions to prevent smoking among children and youth. Tobacco Control, 2008; 17(5):301–2. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/17/5/301

37. Skara S and Sussman S. A review of 25 long-term adolescent tobacco and other drug use prevention program evaluations. Preventive Medicine, 2003; 37(5):451–74. Available from: http://www.sciencedirect.com/science/article/pii/S009174350300166X

38. Eureka Strategic Research, Youth tobacco prevention research project. Undertaken for the Australian Government Department of Health and Ageing.  Canberra: Department of Health and Ageing; 2005. Available from: https://webarchive.nla.gov.au/awa/20061027025016/http://pandora.nla.gov.au/pan/64874/20061027-0000/www.health.gov.au/internet/wcms/publishing.nsf/Content/phd-pub-tobacco-literature-cnt.html.

39. Pentz MA. Effective prevention programs for tobacco use. Nicotine and Tobacco Research, 1999; 1(suppl.1):S99–107. Available from: http://ntr.oxfordjournals.org/content/1/Suppl_1/S99.abstract

40. Thomas R and Perera R. School-based programmes for preventing smoking. Cochrane Database of Systematic Reviews 2006; (3):CD001293. Available from: https://pubmed.ncbi.nlm.nih.gov/16855966/

41. Office of the United Nations High Commissioner of Human Rights. Convention on the rights of the child. Geneva: United Nations, 1989. Available from: http://www.unhchr.ch/html/menu3/b/k2crc.htm.

42. Vardavas C. Key points in preventing tobacco use among adolescents. Tobacco Induced Diseases, 2010; 8(1):1. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2819233/?tool=pubmed