5.6.1 Perceived benefits and disadvantages of smoking
Not surprisingly, having a positive attitude toward smoking is associated with a greater likelihood of taking up smoking. 1-4 Believing that smoking will confer benefits, such as enhancing popularity and social bonding, or improving mood—for example by reducing anxiety, alleviating boredom or relieving depression—increases the likelihood of taking up smoking. 4-9 A 2009 study involving Mexican Americans aged 11 to 13 years found that adolescents who held positive outcome expectations about cigarettes (e.g. thinking that smoking would help one feel more comfortable in social situations) and perceived themselves to be lower in the school-based social hierarchy were more likely to experiment with smoking over a 12-month period than peers who had lower positive outcome expectations or peers who had a higher perceived social standing at school. 10
Conversely, believing that smoking offers negative social consequences (such as causing bad breath and smelling bad) and has both short- and long-term effects on health and fitness is associated with a lower risk of smoking. 2, 5, 6, 8, 9, 11 International studies examining reasons for not smoking among adolescent non-smokers found health-related concerns (such as fear of cancer or addiction, prevention of cancer, and maintaining physical fitness) to be most frequently mentioned. 12, 13 Other reasons included aesthetic reasons (e.g. causes bad breath or yellow teeth), no perceived benefit (e.g. there’s no point) and economic reasons (e.g. it’s a waste of money). 13
Research examining smoking outcome expectancies among Hungarian high school students supported four dimensions of ‘core’ expectancies: negative consequences (i.e. long-term health outcomes), positive reinforcement (related to individual sensory satisfaction from smoking), negative reinforcement (related to coping and negative emotion regulation through smoking) and appetite–weight control (expectations that smoking helps to manage appetite and weight). 14 Student smoking status was strongly associated with positive and negative reinforcement, and less strongly with appetite and weight control expectancy.
While attitudes to smoking are strongly associated with the likelihood of uptake, the relationship between adolescent smoking attitudes and actual behaviours is likely to be bidirectional. For example, a longitudinal study in The Netherlands found that while smoking attitudes (perceptions of the extent to which daily smoking is associated with e.g. harm, danger, health, being boring/exciting) among adolescents aged 13–15 years did not consistently predict smoking behaviour over three years, past smoking behaviour had a moderate impact on subsequent attitudes, suggesting that adolescents who started to smoke developed less negative attitudes towards smoking. 15 Similarly, in a longitudinal study in the US following students over two school years, adolescents with personal smoking experience (including all those who had ever tried a cigarette) reported decreasing perceptions of risk and increasing perceptions of benefits associated with smoking over time. 16
A national survey (2016) of smoking and other drug use in English secondary school students aged 11–15 years found that although most pupils were aware of the health effects of smoking, 40% of students thought that smoking helped people relax, and about 10% thought that smoking made you slimmer. Students who had smoked in the previous week were far more likely to regard smoking positively, especially in the younger age groups. 17 Of regular smokers aged 11-15 years, 57% agreed it was safe to smoke once a week. 17
Beliefs among young people that most of their peers smoke and that their peer group will approve if they start smoking are also significantly associated with uptake of smoking. The English national survey 17 also investigated pupils’ perceptions of smoking prevalence in their age group. While all respondents overestimated the prevalence of smoking in their peer groups, smokers were far more likely to do so. For example, 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. 17 Research conducted among primary school students in Hong Kong found that overestimation of peer smoking prevalence at baseline was associated with ever smoking, while overestimation among never smokers predicted smoking initiation within two years. 18 Baseline never smokers who initially overestimated but correctly estimated peer smoking at follow-up had a lower risk of smoking initiation than those with persistent incorrect estimation. 18
Findings from a study analysing 2002 data from one time point of the UK Youth Tobacco Policy Survey (covering a national cross-sectional sample of 11–16 year olds) suggested that perceived peer prevalence, perceptions of the tobacco industry and perceived health risk of smoking influenced the likelihood of future smoking intentions among adolescent smokers. Among never smokers, only perceived sibling approval of smoking had an effect on future smoking intentions. 19
Ethnicity and related social contextual factors may influence perceived smoking prevalence. For example, an analyses 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). 20 The authors suggest that youth from minority groups are disproportionately exposed to social contextual factors that are correlated with high perceived smoking prevalence.
As well as the influence of perceived smoking prevalence on smoking behaviour, there is evidence from a review of studies that have investigated smokers’ risk perceptions related to smoking-induced illness suggesting that smokers persistently minimise their personal smoking-related health risks and do not believe that they are as much at risk as other smokers of becoming addicted or suffering health effects. 21 While the review found that apparent under- or overestimation of risk depended on the way risk perceptions were assessed in each study, smokers consistently judged the size of smoking-related health risk increases to be smaller and less well established than non-smokers when risk was measured non-numerically. 21
As with adults, 22 research has shown that adolescents have misconceptions about the health implications of using ‘light’ (low emission) cigarettes. A study of teenagers in California revealed they thought that light cigarettes were less likely to cause diseases, less addictive, and easier to quit smoking. The authors of this study comment that beliefs of this nature may encourage children to take up smoking and discourage them from quitting, in the misguided belief that light cigarettes offer a safer alternative to standard cigarettes 23 Similarly, research using data from the 2012 National Youth Tobacco Survey of US students found one in four US adolescents hold the misconception that intermittent, nondaily, smoking causes little to no harm and is a safer alternative to daily smoking. In the same way, nearly one in eleven US adolescents believe consuming just a few cigarettes per day would cause little to no harm compared to heavy smoking. Both intermittent smoking and light (consuming a few cigarettes per day) smoking patterns have been shown to carry health risks analogous with heavier smoking patterns. 24 A follow up study looking into harm perceptions of intermittent tobacco product use using data from the 2016 National Youth Tobacco Survey found one in ten adolescents held the misconception that intermittent, nondaily, smoking causes little to no harm. 25 There is also some evidence that the belief that smoking will help with weight reduction is also an influence on uptake, especially among girls. This is discussed further in Section 188.8.131.52.
5.6.2 Future intention to be a smoker or a non-smoker
Assessing an individual’s intention (whether adult or adolescent) to smoke in the future is a useful predictor of smoking behaviour. 26, 27 Individuals who express the conviction that they are not going to take up smoking are much less susceptible to starting smoking than those who have not made any firm decision. 7 Assessing susceptibility in this way may be a stronger predictor of future behaviour than other important factors such as proximity to smokers in the immediate social environment. 7 Researchers showed that senior school students in the US who expressed a firm intention not to be smoking in five years were less likely to be smoking at follow-up, regardless of their level of involvement with smoking at the commencement of the study. 26
Young people’s attitudes towards smoking are also influenced by the home and social environment. A US study found that exposure to secondhand smoke either in homes or in cars was a strong predictor for openness to future smoking: the higher the exposure to ETS, the more open to future smoking. 28 In the same study, adolescents’ openness to future smoking was also strongly associated with perceived benefits (such as having more friends, looking cool, feeling more comfortable in social situations, helping relaxation and keeping weight down) and peer acceptance of smoking (most people of your age think it is OK to smoke). 28 Similarly, research among US Grade five students found that the implicit attitudes towards smoking (assessed using adjectives based on children’s perspectives of smokers such as popular, cool, boring) of children without family members who smoked were significantly less favourable than were the implicit attitudes of the children who had family members who smoked. 29
Data on Australian students’ intentions to smoke are available from the triennial Australian Secondary Students’ Alcohol and Drug Survey, conducted among a nationally representative sample of students in years seven to 12. 30 Participants are asked to indicate the likelihood that they will be smoking in a year. In the 2017 survey, just over three-quarters (79%) of all respondents aged 12–17 years reported that they were ‘certain not to smoke’, while 14% were ‘very unlikely’ or ‘unlikely’ to smoke, 4% were ‘undecided’, 3% reported they were ‘likely’ or ‘very likely’ to smoke, and 1% were ‘certain’ to be smoking in 12 months. Younger students were more likely than older students to report that they did not intend to be smoking in a year: while 91% of those aged 12 years said they were certain not to smoke, this dropped to 67% by age 17, suggesting that almost one-third of older students could still be open to experimentation with tobacco. 30 The decrease in intention not to smoke with increasing age was the same among female and males students. 30
Findings from this survey for future intentions among current smokers (defined as those who had smoked in the past week) are summarised in Table 5.6.1. Almost one-third (32%) of current smokers reported that they were unlikely/very unlikely to be smoking in a year, while 21% were certain they would not be smoking in 12 months. One-quarter of current smokers (25%) were undecided about their intentions to continue smoking, while 23% of current smokers were likely or certain to be smoking in 12 months. Combining the ‘undecided’ smokers with those who reported they were ‘very unlikely or unlikely’ to be smoking in 12 months, over half of current smokers (57%) may be considered susceptible to encouragement to quit. 30
Intention to smoke in the next 12 months among current smokers, Australian secondary school children aged 12–17 years, 2017
Certain not to smoke
Very unlikely/unlikely to smoke
Likely/very likely to smoke
Certain to smoke
Source: Guerin N and White V 2017 30 Derived from Table 3.17 (p47)
* Defined as having smoked in the past week
5.6.3 Perceived acceptability of smoking
The National Drug Strategy Household Survey (2016) provides Australian data on community opinions and perceptions of drug use, based on responses from almost 24,000 participants across Australia aged 12 years or older. While tobacco is the single most preventable cause of ill health and death in Australia, contributing to more drug-related hospitalisations and deaths than alcohol and illicit drug use combined, 33 people aged 18-24 were least likely out of all age groups to nominate tobacco as the drug most perceived to be associated with mortality (16.2%), followed by 25–29 (20.3%) and 12–17 (21.3%) year olds. 34
In contrast, tobacco smoking was reported as the form of drug use of most serious concern for the general community by a larger proportion of people aged 12–17 years (23%) than any other age group (compared with, for example, 7.3% of those aged 50–59 years) in 2016. In previous surveys, excessive drinking of alcohol was the form of drug use thought by all age groups to be of greatest community concern. However, meth/amphetamine has overtaken alcohol, with more than 40% of the general population aged 14 year or older citing meth/amphetamine thought to be of most concern for the general community. 32, 34
Participants were also asked to nominate if they personally approved or disapproved of regular use of each drug by an adult. All age groups gave alcohol a far higher approval rating than tobacco. For example, 38.2% of young people aged 12–17 years approved of adult alcohol use; this compared with 10.6% of this age group indicating approval of regular adult tobacco use. 34
Survey participants were asked to nominate the first drug they think of as associated with a ‘drug problem’ in Australia. The proportion of people aged 12–17 first nominating tobacco was 4.5% in 2016, the highest of all age groups. The overall proportion of people first nominating tobacco dropped significantly between 2007 (2.6%) and 2016 (2.0%). 34, 35 This was also the case for cannabis and alcohol, while the proportion nominating meth/amphetamine substantially increased. As in previous survey years, in 2016 illicit drugs (particularly meth/amphetamine, cannabis and heroin) and alcohol were much more likely to be associated with a ‘drug problem’ than tobacco by all age groups. 32, 34
Adults agree that while tobacco is a topic of concern that should be discussed with children, it is not the most important health-related subject. A Perth-based survey in 2002 showed that although the vast majority of parents (93%) felt that smoking was important, it ranked lower than sun protection, exercise, good nutrition and illegal drugs in order of concern. Only 2% of parents surveyed felt that tobacco was the single most important health issue, compared with 34% who ranked illegal drugs as most important. Most parents (94% of non-smokers and 85% of smokers) strongly agreed with the statement that they did not want their children to take up smoking. 36
1. Tang L, Rissel C, Bauman A, Fay K, Porter S, Dawes A , et al. A longitudinal study of smoking in year 7 and 8 students speaking English or a language other than English at home in Sydney, Australia. Tobacco Control 1998;7(1):35–40. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/7/1/35
2. Tyas S and Pederson L. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tobacco Control 1999;7(4):409–20. Available from: http://tobaccocontrol.bmj.com/cgi/content/full/7/4/409
3. 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
4. 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: https://onlinelibrary.wiley.com/doi/full/10.3322/canjclin.53.2.102
5. US Department of Health and Human Services. Preventing tobacco use among young people: A report of the Surgeon General, 1994. Atlanta, Georgia: Public Health Service, Centers for Disease Control and Prevention, Office on Smoking and Health, 1994. Available from: http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_1994/index.htm.
6. 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/.
7. 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/.
8. Hruba D and Zaloudikova I. Why to smoke? Why not to smoke? Major reasons for children's decisions on whether or not to smoke. Central European Journal of Public Health, 2010; 18(4):202–8. Available from: http://www1.szu.cz/svi/cejph/archiv/full10/2010-4-05-full.pdf
9. Song A, Morrell H, Cornell J, Ramos M, Biehl M, et al. Perceptions of smoking-related risks and benefits as predictors of adolescent smoking initiation. American Journal of Public Health, 2008; 99(3):487–92. Available from: http://ajph.aphapublications.org/cgi/content/full/99/3/487?view=long&pmid=19106420
10. Wilkinson AV, Shete S, Vasudevan V, Prokhorov AV, Bondy ML, et al. Influence of subjective social status on the relationship between positive outcome expectations and experimentation with cigarettes. Journal of Adolescent Health, 2009; 44(4):342–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19306792
11. Mitchell J, Rosenberg M, and Wood L. Adolescents with attitude ... Changes in views about smoking over time. Health Promotion Journal of Australia, 2008; 19(2):109–12. Available from: http://www.unboundmedicine.com/medline/ebm/record/18647123/full_citation/Adolescents_with_attitude_____changes_in_views_about_smoking_over_time_
12. Kulbok P, Rhee H, Botchwey N, Hinton I, Bovbjerg V, et al. Factors influencing adolescents' decision not to smoke. Public Health Nursing, 2008; 25(6):505–15. Available from: http://www.ingentaconnect.com/content/bsc/phn/2008/00000025/00000006/art00004
13. Buller D, Borland R, Woodall W, Hall J, Burris-Woodall P, et al. Understanding factors that influence smoking uptake. Tobacco Control, 2003; 12(suppl. 4):iv16–25. Available from: http://tobaccocontrol.bmj.com/cgi/content/abstract/12/suppl_4/iv16
14. Urban R and Demetrovics Z. Smoking outcome expectancies: A multiple indicator and multiple cause (mimic) model. Addictive Behaviors, 2010; 35(6):632–5. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0306460310000316
15. de Leeuw R, Engels R, Vermulst A, and Scholte R. Do smoking attitudes predict behaviour? A longitudinal study on the bi-directional relations between adolescents' smoking attitudes and behaviours. Addiction, 2008; 103(10):1713–21. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1360-0443.2008.02293.x
16. Morrell H, Song A, and Halpern-Felsher B. Predicting adolescent perceptions of the risks and benefits of cigarette smoking: A longitudinal investigation. Health & Psychology, 2010; 29(6):610–7. Available from: https://psycnet.apa.org/record/2010-21227-001
17. Niblett P. Smoking, drinking and drug use among young people in England - 2016. NHS Digital, England 2017. Available from: https://digital.nhs.uk/data-and-information/publications/statistical/smoking-drinking-and-drug-use-among-young-people-in-england/2016.
18. Wang M, Ho S, Lo W, and Lam T. Overestimation of peer smoking prevalence predicts smoking initiation among primary school students in Hong Kong. Journal of Adolescent Health, 2011; 48(4):418–20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21402274
19. Rideout V, Fuhr U, and Roberts D. Generation m2: Media in the lives of 8- to 18-year olds. Menlo Park, California: Henry J Kaiser Family Foundation, 2010. Available from: http://www.kff.org/entmedia/mh012010pkg.cfm.
20. Davis KC, Nonnemaker JM, Asfaw HA, and Vallone DM. Racial/ethnic differences in perceived smoking prevalence: Evidence from a national survey of teens. International Journal of Environmental Research and Public Health, 2010; 7(12):4152–68. Available from: http://www.mdpi.com/1660-4601/7/12/4152/pdf
21. Weinstein ND. Accuracy of smokers' risk perceptions. Nicotine & Tobacco Research, 1999; 1(suppl.1):S123–30. Available from: http://ntr.oxfordjournals.org/content/1/Suppl_1/S123.abstract
22. Borland R, Yong H-H, King B, Cummings M, Fong G, et al. Use of and beliefs about light cigarettes in four countries: Findings from the international Tobacco control policy evaluation survey. Nicotine & Tobacco Research, 2004; 6:1–11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15799594
23. Kropp R and Halpern-Felsher B. Adolescents' beliefs about the risks involved in smoking 'light' cigarettes. Pediatrics, 2004; (114):e445–51. Available from: http://pediatrics.aappublications.org/cgi/content/full/114/4/e445
24. Amrock SM and Weitzman M. Adolescents' perceptions of light and intermittent smoking in the United States. Pediatrics, 2015; 135(2):246–54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25583910
25. Wang TW, Trivers KF, Marynak KL, O'Brien EK, Persoskie A, et al. Harm perceptions of intermittent Tobacco product use among U.S. Youth, 2016. Journal of Adolescent Health, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29501281
26. Wakefield M, Kloska D, O'Malley P, Johnston L, Chaloupka F, et al. The role of smoking intentions in predicting future smoking among youth: Findings from monitoring the future data. Addiction, 2004; 99:914–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/15200587
27. Choi W, Gilpin E, Farkas A, and Pierce J. Determining the probability of future smoking among adolescents. Addiction, 2001; 96:313–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11182877
28. Ling P, Neilands T, and Glantz S. The effect of support for action against the tobacco industry on smoking among young adults. American Journal of Public Health, 2007; 97(8):1449–56. Available from: http://www.ajph.org/cgi/reprint/97/8/1449
29. Andrews J, Hampson S, Greenwald A, Gordon J, and Widdop C. Using the implicit association test to assess children's implicit attitudes toward smoking. Journal of Applied Social Psychology, 2011; 40(9):2387–406. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3090631/?tool=pubmed
30. Guerin NW, V. ASSAD 2017 statistics & trends: Australian secondary students’ use of Tobacco, alcohol, over-the-counter drugs, and illicit substances. Melbourne: Cancer Council Victoria, 2018. Available from: https://beta.health.gov.au/file/9756/download?token=ApVLPOfY.
31. DiFranza J, Wellman R, Ursprung W, and Sabiston C. The autonomy over smoking scale. Psychology of Addictive Behaviors, 2009; 23(4):656–65. Available from: https://psycnet.apa.org/record/2009-24023-011
32. Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey: Survey report. Drug statistics series no. 25, AIHW cat. no. PHE 145.Canberra: AIHW, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=32212254712&libID=32212254712&tab=2.
33. Fidler JA, Wardle J, Henning Brodersen N, Jarvis MJ, and West R. Vulnerability to smoking after trying a single cigarette can lie dormant for three years or more. Tobacco Control, 2006; 15(3):205–9. Available from: http://tc.bmjjournals.com/cgi/content/abstract/15/3/205
34. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2016: Detailed findings. Drug Statistics series no. 31., AIHW Cat. no. PHE 214.Canberra: AIHW, 2017. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/2016-ndshs-detailed/contents/table-of-contents.
35. Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: Detailed findings. Drug statistics series no. 22. Aihw cat. No. Phe 107. 2. AIHW, 2008. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468195
36. Health Promotion Evaluation Unit, Smarter than smoking parent survey. Perth, Australia: Health Promotion Evaluation Unit; 2007.