Smoking during adolescence is primarily a social activity,1 with the majority of young people sourcing tobacco via their friends.2 Research has consistently identified peer group influences as a significant factor in the uptake of smoking,3-8,9 in future smoking intentions,10,11 and in the development of nicotine dependence.12
Peer groups may variously be defined as;
- best friendships,
- romantic attachments,
- small social ‘networks’ and
- larger social ‘crowds’.13
Each of these types of peer group may influence the decision to smoke or not smoke.13
Effects of peer smoking on uptake
A review of peer group influences on adolescent smoking, based on longitudinal studies, explored the extent to which peer smoking predicted adolescent smoking.14 Almost all studies reported positive associations between peer smoking at baseline and adolescent smoking at follow-up. The review also highlighted the variation of peer influence on adolescent smoking by socio-demographic characteristics, including gender differences (with girls more strongly influenced by peer smoking than boys), and less clear effects of age group and ethnicity. Social bonds (e.g. with school and family) and individual characteristics such as genetics and personal attributes were also found to moderate peer smoking.14 A longitudinal analysis of US adolescents15 estimated that a 10% increase in the proportion of classmates who smoke would increase the likelihood of smoking by more than 3%, while an increase in smoking rates of 10% among an individual’s close friends will increase the likelihood of smoking by 5%. They concluded that peer effects are significant determinants of smoking, which persist into adulthood.15 Similarly, an analysis of European school data estimated that, on average across countries, a one percentage point increase in the proportion of smoking classmates was associated with an increase of 0.31% to 0.38% in the probability that a ‘typical’ adolescent would smoke, a range that varied between countries.16
The most influential types of peers
One’s closest friends, and peers who are considered ‘popular’, seem to have more influence over smoking behaviour than peers more generally. A meta-analysis of peer influence on adolescent smoking initiation and continued smoking suggested that smoking initiation is positively associated with peers’ smoking when there is high interpersonal closeness.17 The analysis also suggests that both smoking initiation and continuation was positively associated with peers’ smoking when adolescents were from peer groups that emphasised the needs and goals of the group over individual needs. A 2021 systematic review, found that the descriptive norms—that is, observed norms—of close friends’ smoking behaviour consistently predicted initiation of smoking but not escalation, while the smoking behaviour of other social networks, including peers more generally, were less consistent in their influence.18
Smoking behaviour of the most popular students within the school context has been shown to have the ability to either influence or deter smoking uptake for other students. When those who smoke are among the most popular students within the school context, then uptake the following year can increase by up to 18%. Conversely, when those who smoke are among the least popular within the school context, uptake the following year is not statistically significant.19 A 2023 Australian study exploring risk factors associated with tobacco smoking susceptibility among adolescents who had never smoked found that ever use of e-cigarettes, having a close friend who smoked, or associating smoking with popularity, were of greatest risk for smoking initiation. About seven per cent of those who had never smoked in the study perceived those who smoked as more popular, and about one in seven reported having at least one close friend who smoked.20 In a 2025 social network-based intervention for adolescent smoking the results found that targeting students who are well-connected and influential led to the greatest long-term reductions in smoking. These popular students, theoretically, were best positioned to help spread non-smoking norms through their friendship networks.21
Over-estimation of peer smoking prevalence
Research consistently shows that young people tend to overestimate how common smoking is among their peers, as well as among adults, shaping inaccurate social norms about tobacco use.22 Australian research has shown adolescents believe smoking is more prevalent among their peers than it actually is.23 Similar patterns of overestimation of smoking prevalence have been observed internationally, with young people in Hong Kong,24 the US,25,26 and Europe27 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:14 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.7,14,28 The English National Survey29 conducted in 2016 investigated pupils’ perceptions of smoking prevalence within 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, 81% of those who regularly smoked aged 15 thought that half or more of their age group smoked, whereas in reality 6% of boys and 7% of girls aged 15 years smoked regularly at that time.29
Peer pressure
Peer pressure is one aspect of peer socialisation, in which adolescents are influenced by their friends.14 Socialisation is the tendency for individuals’ norms and behaviours to be influenced by the norms and behaviours of one’s group and conforming to them. Selection, on the other hand, refers to the tendency of individuals to seek-out peers with similar norms and behaviours.30 Some commentators have argued that the importance of peer influence has been overestimated, and that the clustering of smoking behaviour within peer groups could be because adolescents seek out friendships with individuals who share similar interests, of which smoking may be just one signifier,31,32,33 (i.e. ‘selection’).14 In a review of peer influence and smoking behaviour,34 the author concluded that the effect of peer pressure as an influence on adolescent health behaviour is not proven, and is in practice very complex to decipher.34 It is important to understand that young people are not a homogeneous group, and that there are distinct peer clusters who smoke and do so for different reasons.34 It is probable that peer influences both interact with and are compounded by a host of other predictive factors:35 selection and socialisation processes can operate independently, but may also have reciprocal effects. Studies have found support for an important role of either and/or both processes, but their relative importance is strongly debated.14 Based on a review of 13 studies, researchers concluded that while both socialisation and selection processes contribute to peer group homogeneity in terms of smoking behaviour, evidence from studies using more advanced research designs suggested the influence of selection was somewhat greater.14
Further, the common perception that ‘peer group pressure’ equates to open coercion is not necessarily the case: most of the evidence indicates that socialisation is mainly a normative process and not one of overt peer pressure.14 Initiating smoking may arise as a response to more subtle influences, such as being a means of facilitating acceptance and bonding, and avoiding exclusion from peer groups.8,13 Qualitative research from Western Australia found that some adolescent experimenters and adolescents who smoked saw trying a cigarette in the spirit of ‘joining in’ or ‘giving it a go’. However, the same research found that young people of Indigenous or lower socio-economic status background were much more likely to describe overt peer pressure or inducement to try smoking.36,37
The changing nature of peer influence
It is likely that the nature of peer influences on smoking changes over time and across social and cultural groupings.34 While some research suggests that peer influences may vary in importance at differing points along the adolescent continuum, with the influence of close friends’ smoking having most impact in earlier adolescence,1 there is evidence suggesting that parental and sibling smoking behaviour may be more important earlier.38 Research among New Zealand high school students found that the influence of smoking by parents and best friends varied with stage of adolescent tobacco smoking, progressively increasing with smoking frequency.39 There is also some evidence that peer influence on smoking behaviour or intentions may vary with adolescents’ previous smoking experience, whereby peer influence to smoke is stronger for adolescents with pre-existing smoking experience.11
Socialising processes that facilitate smoking can also discourage use.14 For example, being ‘cool’ is important to teenagers,40 although what is deemed to be cool also changes across time, peer groups and social contexts. Smoking has traditionally been viewed as one of the badges of ‘coolness’ among teenagers.41 While ‘coolness’ has been identified by young people as one of the reasons why some of their peers smoke,42 research undertaken in Western Australia suggests that this has shifted over time, with those who smoke increasingly regarded as ‘losers’ or ‘trying too hard to be cool’.37 Refusing an offer of cigarettes or declaring that ‘I don’t smoke’ is socially acceptable and normative among many cohorts of young people.37 Among groups with a negative prevailing attitude to smoking, peer influence may deter uptake of smoking.1,13,14 A 2017 New Zealand survey found that one in 10 students reported having encouraged smoking among their peers, while half reported discouraging their peers from smoking, highlighting the positive impact that young people can have on each other.43
A 2023 systematic review of qualitative research exploring how peer influence on adolescent smoking varies according to the tobacco control context, found that social dynamics of adolescent smoking evolve with broader cultural and policy shifts. In contexts with strong tobacco control where smoking had become denormalised, smoking was less socially acceptable, carried social stigma, and adolescents reported fear of negative judgement for smoking. Within the denormalised context smoking was more likely to occur within marginalised peer groups. In contrast, in normalised contexts, smoking continued to function as a tool for social belonging, identity formation, and popularity.44
Loneliness
Loneliness, the absence of social connection, was found in a 2025 German observational study45 to be associated with greater nicotine use among adolescents. The study found that adolescents experiencing loneliness were significantly more likely to engage in the use of e-cigarettes, cigarettes, waterpipe, or any nicotine product compared to their non-lonely peers. The authors put forward two theories to help explain the association: the self-medication hypothesis, suggesting that adolescents experiencing emotional distress such as loneliness may misperceive nicotine use as helpful in relieving negative feelings or improve mood (see Section 9A.3), and the social facilitation theory, proposing that nicotine use may help adolescents gain acceptance and a sense of belonging within peer groups when facing social exclusion.45
5.8.1 Peer-based approaches for prevention
Evidence associating peer influences with adolescent uptake of smoking is often relied upon as part of the rationale for peer-led and peer-based approaches to smoking prevention. More broadly, peer education approaches have also been applied to a range of other health and social behaviours, and have a strong theoretical underpinning as outlined below.
5.8.1.1 Peer education approaches to smoking among young people
The theoretical roots of peer education approaches can be traced to Bandura’s social learning theory, and to social inoculation theory.46 While peer education has been applied across a diverse range of settings and health issues, including smoking, the common elements relate to the ‘tapping into’ and utilisation of the existing social processes among young people to influence their health-related knowledge, attitudes, skills and behaviour.46 Social influence programs may foster social norms that reduce adolescent social motivation to commence smoking,47,48 and peer education strategies can complement and reinforce other health promotion approaches.49
‘Diffusion of innovations’50 is a theory that has been applied in peer education initiatives, and serves as a model for understanding how information, ideas and or behaviours spread throughout a community. Applied to health promotion, diffusion of innovation theory seeks to identify ‘natural and influential’ opinion leaders to endorse and support desired health behaviours.51 In this regard, it not just a matter of targeting any ‘peer’, but rather those who can act as opinion leaders to influence the views, attitudes or behaviour of others because of their already established and credible social standing with others.51,52 Public health researchers have recommended the use of peer-to-peer communication via trusted social media ‘influencers’.53 While social media has mostly been viewed as a vehicle through which risky behaviours are enabled and spread, presenting enormous challenges for public health prevention efforts, many of these same social media attributes also present opportunities for public health practitioners and researchers to harness and shift the community towards healthier behaviours.53
Transtheoretical model is another theory that has been successfully applied in peer to peer education.54 Transtheoretical model is an intentional behaviour change model that focuses on individual decisions and has been used in smoking cessation programs more broadly. Rather than moving directly from smoking to quitting, or not smoking to smoking, this theory follows the understanding that individuals progress gradually through stages of change, and peer role models can be harnessed to help positively influence this progression.54 See Section 7.3.6 for more on Transtheoretical model/Stages of change.
The role of peer educators varies considerably across programs, and may include formal or informal counselling, information provision one-to-one or in a group, participation in interactive activities with peers, staffing of ‘hotlines’ and resource centres,46 modelling of interpersonal skills,55 and fostering of peer mentors.56 Some programs take a deliberately informal approach, seeking to tap into everyday communication within social groups and/or utilise existing peer ‘influencers’ as a vehicle for behaviour change.52
Young people involved in peer education may also serve as viable role models and opinion leaders, and help to project norms of acceptable and unacceptable health-related behaviours.47,52,57
Research in Scotland58 found that older teenagers were adamant about not wanting younger teenagers to start smoking, and it is suggested that peer education approaches may capitalise upon this attitude.
5.8.1.2 Effectiveness of peer education interventions
A 2013 Cochrane review59 examining school-based programs for smoking prevention included, as a secondary objective, an assessment of the relative effectiveness of peer-led compared with adult-led (teacher or researcher) interventions. The review found no significant differences between peer- and adult-led programs at one year or less, except in the case of adult-led interventions that combined social competence and social influences curricula, which showed favourable outcomes. At the longest follow-up, significant effects were observed in favour of adult-led programs overall, particularly those incorporating social competence or combined social competence and social influence components.59
In an earlier meta-analysis of smoking prevention programs, the researchers concluded that peer or social type programs should be continued as part of smoking prevention efforts, but that the overall magnitude of effect can be limited.60 They argued that the impact of such programs may be improved if delivered early in the transition from elementary to middle school, if same-aged peers play a significant role in delivery of the program, and if they are part of a multi-component health program.
A 2015 systematic review and meta-analysis examining the effectiveness of peer-led interventions found lower odds of weekly or monthly smoking compared to those in a control group.61 Schools were considered an appropriate setting for the interventions where peer leaders were able to deliver part or all of the anti-tobacco curriculum. However, there was no clear pattern, from the studies included, of factors associated with impact, e.g. duration of intervention or underlying theory. The authors speculated that peer-led interventions may resonate to a greater extent with young people due to greater perceived credibility of peers than of adults or professionals, in part due to shared social status, cultural background and being embedded within the same social groups and communities. The authors noted however that in two interventions, there were reports of increased rates of smoking. This finding was observed among those with pro-smoking attitudes and who had a substantial proportion of tobacco-using friends. The authors suggested that interventions take into account peer norms and peer influences in young people’s friendship groups and social networks, and targeting preventive messages to different risk groups in order to maximise effectiveness.61
In a meta-analysis of school based drug prevention programs more broadly, those led by peers addressing the social influences of drug use were among the more effective strategies.62
In a brief report on common reasons why some peer education can fail to be effective, a number of reasons were identified, including a lack of clear aims and objectives, inconsistency between the project design and the external environment/constraints, inadequate appreciation of the fact that peer education is a complex and skilled process to manage, and inadequate training and support of peer educators.
The way in which influential and credible peers are selected can also be critical to the success of peer-led approaches. In school-based peer interventions, peer educators are most often self selected and/or selected by school staff, but this can result in peer educators who may not be perceived as influential or credible by the target group.52 The ASSIST intervention is an example of a UK program that sought to overcome this limitation, through the development of a peer nomination process to identify ‘influential students’.52,63 The intervention was evaluated in a randomised controlled trial and involved 10,730 students aged 12–13 years across 59 schools (30 intervention, 29 control). The nomination process resulted in a diverse mix of students being selected as ‘peer supporters’ in the intervention schools; these students were trained to utilise their informal contacts with peers to disseminate smokefree health promotion messages outside the classroom setting.63 While some students and staff expressed doubts about the suitability of some of the students recruited to be peer supporters, the likelihood of students taking up smoking was significantly lower in the intervention schools at the two-year follow-up.52,63
An economic evaluation of the ASSIST program concluded that it was a cost-effective intervention that resulted in a 2.1% reduction in smoking prevalence at the two-year follow-up, and delivered at a modest cost of £32 per student (based on cost of program delivery projected in 2008 pound equivalent, which equated to approximately $72 Australian dollars).64 The authors also projected the economic costs and health promotion impact of extending the intervention to all Year 8 students (based on student numbers in 2007–08) across all UK schools, concluding that this could result in 20,400 fewer adolescents that smoke for a cost of about £38 million (which equated to around $85 million Australian at the 2008 exchange rate).
In other studies, social branding has been used as a novel approach for peer crowd segmentation at events to identify and engage high-risk groups of young people for tobacco prevention and cessation. In this approach, peer crowds are groups of young people who share common interests, values, and lifestyles both within and outside of one’s immediate peer group, for example, those who identify as ‘Hipsters’ or ‘Partiers’. Anti-tobacco messaging is then delivered through opinion leaders who are viewed as influential peer crowd members. Two interventions using this method have been conducted in the US. The first, COMMUNE,65 was an intervention designed to compete with tobacco industry marketing in social venues. It was tailored for the ‘Hipster’ peer crowd with messaging delivered via peer crowd opinion leaders. The second was HAVOC,66 an intervention developed for ‘Partiers’, utilising brand ambassadors and peer crowd opinion leaders. Both interventions were reported as successful in a follow up research paper where 27 key informants involved in the events were interviewed. In seeking to understand how and why the two interventions were effective, researchers reported six main features that participants found valuable;67 fun, interactive social environment; a sense of belonging; subtle, non-judgmental messaging; peer crowd specific; delivery through opinion leaders; and promotion of brand individuality and recognition’. The inclusion of peer crowd opinion leaders in the interventions were seen as valuable for encouraging event attendance and helping to create an exclusive experience for event attendees by using their willingness to engage positively with other peer crowd members and taking a visible role in the intervention.67
In a smaller randomised trial, the prevention strategy Teens Against Tobacco Use was found to have substantial promise.68 Adult advisors recruited and trained high school and middle school students to develop and deliver tobacco prevention presentations to younger students in the school setting. Classrooms receiving the tobacco prevention presentation had significantly lower tobacco susceptibility scores than classrooms not receiving presentations (12% vs 17%, p<0.01), representing a 37% reduction in the odds of tobacco susceptibility.68
5.8.1.3 Peer-based smoking interventions in Australia
Peer-based education in Australia has traditionally been more commonly applied to drug education and sexual health issues than to smoking prevention or cessation. Historically in Australian tobacco control, there have been a few peer-based programs targeting smoking, such as the ‘Hot water kit’ peer education program developed by the Victorian Smoking and Health Program in the early 1990s; these days, issues relating to peer influence are more commonly embedded within broader school-based programs and resources.
Peer influence was also used as a communication approach as part of the Western Australian Smarter than Smoking media project targeting adolescents. The project produced a series of advertisements that sought to tap into the peer influence psyche, with vignettes, for example, featuring young people reflecting on the lack of money or fitness of peers who smoke. Campaign evaluation data collected from a sample of young people aged 14–15 years between 1999 and 2005 found a significant strengthening in young people’s agreement with statements relating to the cost and effects on fitness of smoking.69
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References
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