5.24 The profound effects of the denormalisation of smoking

Last updated April 2012 

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 Indeed it is 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 there have been significant declines in the prevalence and advertising of smoking over the last few decades, and a diminishing number of places in which smoking is permitted, there are still many instances where smoking takes place in the community or is portrayed in media and youth culture.

The tendency for young people to often overestimate the prevalence of smoking in the population also suggests that normative perceptions about smoking may lag behind the reality. For example, research undertaken for the Smarter than Smoking project in Western Australia in 2004 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 is 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

Normative beliefs about smoking were deconstructed further in a quantitative experimental study by Wakefield and colleagues3 as part of a broader study into the effects of tobacco point-of-sale advertising on children. Perceived prevalence of smoking was assessed in this study 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

5.24.1 What factors influence perceptions of smoking prevalence?

Factors identified in the literature as contributing to children'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.4,5 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.6 Overestimation of smoking prevalence was also associated with smoking status (i.e. regular smoking) at the third time point.6

Australian research undertaken in 2005 found that young people who smoked or who had tried cigarettes were more likely to overestimate smoking prevalence among both peers and in the broader community. In particular, the study found that females aged 12–24 years who smoked tended to estimate that at least 50% of people their age smoked, and some (school years 7 to 10) smokers thought that between half to three-quarters of adults in Australia smoked.5 In a cross-sectional study undertaken across 64 schools in Hong Kong, overestimation of peer smoking prevalence was commonly observed in male and female students, but was only associated with current and ever smoking in boys.7 In another Hong Kong study, overestimation of smoking was also 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.8

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?

Youth 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. Evidence documenting student tendencies to overestimate smoking prevalence supports calls for the inclusion of strategies to redress unrealistic perceptions of smoking prevalence in youth smoking education.4,5,7 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.9 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.9

Interventions to denormalise adolescent misperceptions of smoking prevalence may not be similarly effective with all young people, with a recent 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.10

Advocacy efforts to expose and counter the disproportionate portrayal of smoking in moviesi are another example of an approach to the denormalisation of smoking. As noted in Section 5.16, 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

More broadly, many of the key strategies in tobacco control can contribute directly or indirectly to further denormalisation of smoking. For instance, a Canadian study found that the more frequently young people observe smoking occurring in a range of settings, the more likely they are to have the view that smoking is both socially acceptable and normal.11 Hence bans on smoking in restaurants and other public places can help to reduce the 'normalcy' of seeing people smoking, thereby helping to reshape community norms and perceived social acceptability regarding smoking.5, 11 Restrictions or bans on smoking also physically decrease the opportunities for children and young people to be in the presence of smoking.11

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.12 Further restrictions emerging in Australia (e.g. bans on smoking at public beaches and in outdoor public venues) would no doubt further increase this denormalisation (see Chapter 15, Section 15.5). The tobacco industry itself recognises the power of smoking restrictions to denormalise smoking,12 as evidenced in the efforts of tobacco companies around the world to oppose bans and restrictions on smoking in public places.

A paper by Chapman and Freeman identifies a number of more subtle societal changes and cultural cues signalling the declining social acceptability of smoking in the community.12 Examples range from 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, and many other examples which indicate an erosion of smoking as a marker of what is socially 'cool'.12 As Chapman and Freeman argue, these changes may be more subtle 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.

Two areas working against the denormalisation of smoking have been the widespread availability of tobacco from a variety of retail outlets, and the visible display of tobacco products at point of sale, both of which can fuel 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.13,3 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

i See, for example, http://smokefreemovies.ucsf.edu/problem/moviessell.html. Tobacco imagery in movies and other media are discussed in Section 5.15.3, and in Chapter 11, Section 11.6.4.

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References

1. Hastings G and Angus K. Forever cool: the influence of smoking imagery on young people. London: British Medical Association, Board of Science, 2008. Available from: http://www.management.stir.ac.uk/about-us/?a=19777

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

3. Wakefield M, Germain D, Durkin S and Henriksen L. An experimental study of effects on schoolchildren of exposure to point-of-sale cigarette advertising and pack displays. Health Education Research 2006;21:338-47. Available from: http://her.oxfordjournals.org/cgi/reprint/21/3/338

4. Reid J, Manske S and Leatherdale S. Factors related to adolescents' estimation of peer smoking prevalence. Health Education Research 2008;23(1):81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17301057

5. 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: http://www.health.gov.au/internet/main/publishing.nsf/Content/phd-pub-tobacco-literature-cnt.htm

6. Otten R, Engels R and Prinstein M. A prospective study of perception in adolescent smoking. Journal of Adolescent Health 2009;44(5):478–84. Available from: http://www.jahonline.org/article/PIIS1054139X08004138/fulltext

7. Lai MK, Ho SY and Lam TH. Perceived peer smoking prevalence and its association with smoking behaviours and intentions in Hong Kong Chinese adolescents. Addiction 2004;99(9):1195-205. Available from: http://dx.doi.org/10.1111/j.1360-0443.2004.00797.x

8. 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

9. 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 Perkins, HW, ed. The social norms approach to preventing school and college age substance abuse: a handbook for educators, counselors and clinicians. San Francisco Jossey-Bass, 2003

10. Sakuma K, Sun P, Unger J and Johnson C. Evaluating depressive symptom interactions on adolescent smoking prevention program mediators: a mediated moderation analysis. Nicotine & Tobacco Research 2010;12(11):1099-107. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20861150

11. 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

12. Chapman S and Freeman B. Markers of the denormalisation of smoking and the tobacco industry. Tobacco Control 2008;17(1):25-31. Available from: http://tobaccocontrol.bmj.com/content/17/1/25.abstract

13. Henriksen L, Schleicher N, Feighery E and Fortmann S. A longitudinal study of exposure to retail cigarette advertising and smoking initiation. Pediatrics 2010;126(2):232-8. Available from: http://pediatrics.aappublications.org/cgi/reprint/peds.2009-3021v1

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