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 stress and anxiety, alleviating boredom or relieving depression—increases the likelihood of taking up smoking.4-10 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.11
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.2,5,6,8,9,12 International studies examining reasons for not smoking among adolescents who themselves do not smoke found health-related concerns (such as fear of cancer or addiction, prevention of cancer, and maintaining physical fitness) to be most frequently mentioned.13,14 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).14
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).15 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.16 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.17
A national survey (2021)18 of smoking and other drug use in English secondary school students aged 11–15 years found that although there has been a decline in positive attitudes towards smoking, when asked their beliefs about why people their own age smoke, students who did not themselves smoke most frequently cited ‘To look cool in front of their friends’ (82%), and ‘Their friends pressure them into it’ (73%). When students who smoke were asked the same question the most frequently cited reasons were ‘It helps them cope with stress in their life’ (97%), and ‘It gives them a good feeling’ (95%).18
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 survey18 also investigated pupils’ perceptions of smoking prevalence in their age group. While all respondents overestimated the prevalence of smoking in their peer groups, those who smoked were far more likely to do so. For example, 78% aged 15 who smoked regularly thought that half or more of their age group smoked, and 6% of 15 year olds thought that all students the same age as them smoked, whereas in reality 3% of students aged 15 years smoked regularly at that time.18
Australian research has shown adolescents believe smoking to be more prevalent among their peers than it actually is.19 Similar patterns of overestimation of smoking prevalence have been observed internationally, with young people in Hong Kong,20 the US,21,22 and Europe23 routinely overestimating peer smoking rates and peer approval of smoking. Such misperceptions are strong predictors of smoking initiation and lend to favourable attitudes toward tobacco use. Social norms need only to be perceived to influence behaviour:24 Young people who smoke tend to congregate together and overestimate the extent of smoking in their own age group, giving them a distorted sense of what is normal behaviour.2,7,24
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).25 The authors suggest that young people 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 people who smokes’ risk perceptions related to smoking-induced illness suggesting that those who smoke persistently minimise their personal smoking-related health risks and do not believe that they are as much at risk as others who smoke of becoming addicted or suffering health effects.26 While the review found that apparent under- or overestimation of risk depended on the way risk perceptions were assessed in each study, those who smoked consistently judged the size of smoking-related health risk increases to be smaller and less well established than people who did not smoke when risk was measured non-numerically.26 The 2023-2024 Canadian national survey27 on alcohol and drug use among students in grades 7-12 (12-17 years) found 15% of students believed there was little to no risk of harm from regularly smoking cigarettes. Younger students in grade seven were more likely to believe there was little to no risk of regularly smoking cigarettes (18%), compared to older students (12%) in grade 12.27
As with adults,28 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 cigarettesi.29 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.30 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.31
5.6.2 Future intention to smoke
Assessing an individual’s intention (whether adult or adolescent) to smoke in the future is a useful predictor of smoking behaviour.32,33 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 people who smoke 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.32
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 environmental tobacco smoke, the more open to future smoking.34 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).34 Similarly, research among US Grade five students found that the implicit attitudes towards smoking (assessed using adjectives based on children’s perspectives of those who smoke 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.35
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 12.36 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’, 2% 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.36 The decrease in intention not to smoke with increasing age was the same among female and males students.36
Findings from this survey for future intentions among adolescents who currently smoke (defined as those who had smoked in the past week) are summarised in Table 5.6.1. Almost one-third (32%) of adolescents who had smoked in the past year 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 adolescents who had smoked in the past year (25%) were undecided about their intentions to continue smoking, while 23% of adolescents who had smoked in the past year were likely or certain to be smoking in 12 months. Combining adolescents who were ‘undecided’ about smoking with those who reported they were ‘very unlikely or unlikely’ to be smoking in 12 months, over half of adolescents who had smoked in the past year (57%) may be considered susceptible to encouragement to quit.36
In the 2022/2023 Australian Secondary Students’ Alcohol and Drug Survey, 15% of adolescents who had never smoked were classified as being susceptible to smoking, i.e., when asked about their intention to smoke in the next 12 months, they gave a response other than ‘certain not to be smoking’. Females (20%) were more likely than males to be classified as susceptible (12%) whereas there was no significant difference in smoking susceptibility by age group between 12–15 versus 16–17 year olds.37 Figure 5.6.1 below shows that the proportion of students who had never smoked but were susceptible to smoking was significantly higher in 2022/2023 than 2017 (15% vs. 11%) and was at the same level as that observed in the early 2000s.37
5.6.3 Perceived acceptability of smoking
The National Drug Strategy Household Survey (2022-2023)38 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. 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, the proportion of people who perceive tobacco as the drug that causes the most deaths continues to fall, as does the proportion who perceive tobacco to be the drug of most concern. In 2022-2023, 17.4% of people aged 14 and over thought tobacco caused the most deaths in Australia, a statistically significant change from 18.7% in 2019, and much lower than in 2007 (40.4%).38 Tobacco smoking was reported as the form of drug use of most serious concern for the general community by people aged 15–24 years (11.3%) compared to older age groups.38 Participants were also 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.38
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 2021.39 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.39
i Adults who smoke may also share these misperceptions. Lower emission cigarettes have not been shown to be a less hazardous option. See also Chapter 3, Section 26.
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