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 the advocacy 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. A 2004 Australian study found that teenagers significantly overestimated the prevalence of smoking both among adults and among other teenagers, and were more likely to overestimate prevalence if they were from a lower socio-economic status (SES) or Indigenous background.2 While the prevalence of smoking was in fact higher among people of lower SES or Indigenous background, this did not seem to fully explain the extent to which young people from these population groups overestimated smoking, hence supporting the hypothesis that smoking remains not just more common but also more normal and acceptable among such priority population groups.2
In a 2006 Australian study, perceived prevalence of smoking was assessed by asking participants how many out of 100 a) classmates in their year level, b) high school students, and c) adults, they thought smoked cigarettes at least once a week. Other normative measures include questions to gauge perceived approval of smoking (by asking students how much they agreed or disagreed with various attributes to describe smokers (e.g. ‘A teenager who smokes cigarettes seems … cool, successful, smart, healthy, athletic, and popular’), and an item relating to perceived approval (extent to which they agreed or disagreed that most high school/their age students ‘think it’s ok to smoke cigarettes once in a while’. The study found that, on average, students thought about 30% of students their age smoked at least once a week (an overestimate), with those exposed to cigarette advertising or display as part of the experimental study estimating a higher proportion of smoking among both high school students and adults, compared to those not exposed.3
In the English National Survey, published in 2017, 81% of regular smokers aged 15 thought that half or more of their age group were smokers, whereas in reality 6% of boys and 7% of girls aged 15 years smoked regularly at that time.4 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.4 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.5 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.6 Similar findings were observed among European university students7 Other research has also highlighted that the perception of social acceptability of smoking has a strong influence on whether adolescents smoke, more so, in this study, than their friends' smoking habits.8
5.24.1 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.9 10 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.11 Overestimation of smoking prevalence was also associated with smoking status (i.e. regular smoking) at the third time point.11
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.2 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.
5.24.2 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.9, 12 10 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.13 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.13 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.14
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.15
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.16 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.17 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.18 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.10, 18 Restrictions or bans on smoking also physically decrease the opportunities for children and young people to be in the presence of smoking.18 The diminishing number of places in which smoking can occur in Australia, and the negative symbolism of the types of areas smokers 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.19 The tobacco industry itself recognises the power of smoking restrictions to denormalise smoking,19 as evidenced in the efforts of tobacco companies around the world to oppose bans and restrictions on smoking in public places.17 See Chapter 15, Section 22.214.171.124 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.20 3 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.21 Tobacco retailer density and proximity has also been shown to be associated with adolescent smoking behaviours.22 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.23 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.24 For more on the effects of plain packaging see Section 11A.9.
Many societal changes and cultural cues subtly signal the declining social acceptability of smoking in the community.19 Examples include the replacement of cigarette lighters as a ‘routine’ fixture of new vehicles, implementation of differential insurance premiums for smokers, exclusion of tobacco in ethical investment portfolios, specification of non-smokers in ‘lonely hearts’ advertisements. Such trends indicate an erosion of smoking as a marker of what is socially ‘cool’.19 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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13. Linkenbach JW and Perkins HW. Most of us are tobacco free: An eight-month social norms campaign reducing youth initiation of smoking in Montana, in The social norms approach to preventing school and college age substance abuse: A handbook for educators, counselors and clinicians. Perkins HW, Editor San Francisco Jossey-Bass; 2003.
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17. Kang H and Cho SI. Cohort effects of tobacco control policy: Evidence to support a tobacco-free norm through smoke-free policy. Tobacco Control, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30554163
18. Smart R and Stoduto G. Interventions by students in friends' alcohol, tobacco, and drug use. Journal of Drug Education, 1997; 27:213-22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9366127
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24. White VM, Guerin N, Williams T, and Wakefield MA. Long-term impact of plain packaging of cigarettes with larger graphic health warnings: Findings from cross-sectional surveys of Australian adolescents between 2011 and 2017. Tobacco Control, 2019; 28(e1):e77-e84. Available from: https://pubmed.ncbi.nlm.nih.gov/31431490/