5.6 Intentions, attitudes and beliefs

Last updated October 2014 

5.6.1 Perceived benefits and disadvantages of smoking

Not surprisingly, having a positive attitude to smoking is associated with a greater likelihood of adopting 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.4–8 This was observed in a 2009 study involving Mexican Americans aged 11 to 13 years, in which it was 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.9

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.2,5,7,8,10 International studies examining reasons for not smoking among varied groups of 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.11,12 Other frequently mentioned motives cited by non-smoking adolescents (including those who had stopped smoking) are 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).12

Results of recent 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).13 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.14 Similarly, in a longitudinal study in the US following students (mean age 14 years at baseline) 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.15

A national survey 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, 65% of students thought that smoking helped people relax, and about 20% thought that smoking made you slimmer, gave you confidence or was not dangerous. Students who had smoked in the previous week were far more likely to regard smoking positively, especially in the younger age groups.16

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.6 The English national survey16 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, 93% of regular smokers aged 15 thought that half or more of their age group were smokers, whereas in reality 16% of boys and 24% of girls aged 15 years smoked regularly.16 Recent 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.17 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.17

Findings from a recent 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.18

Ethnicity and related social contextual factors may influence perceived smoking prevalence. For example, recent 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).19 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.20 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.20

As with adults,21 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.i 22

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 5.8.1.1.

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.23, 24 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.6 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.6 Wakefield et al showed that senior school students 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.23

Young people's attitudes towards smoking are also influenced by the home and social environment. A US study looked at openness to future smoking among non-smoking high school students in Indiana in 2000 and 2004.25 Students were asked if they thought they would smoke a cigarette in the next year, and if they would smoke a cigarette offered by a best friend. Around three-quarters of students were not open to future smoking (an increase from 74% in 2000 to 77% in 2004). The proportion of students exposed to environmental tobacco smoke (ETS) in the home or in a car in 2004 decreased compared with their counterparts in 2000. Gender, grade, race/ethnicity and exposure to anti-tobacco messages did not significantly predict openness to future smoking. However, exposure to ETS either in homes or in cars was a strong predictor for openness to future smoking in both survey years: the higher the exposure to ETS, the more open to future smoking.25 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) (both asked only in 2004).25 Similarly, recentresearch among US Grade 5 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.26

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 7 to 12.27 Participants are asked to indicate the likelihood that they will be smoking in a year. In the 2008 survey, just over three-quarters (76%) of all respondents (around 24 000 students aged 12–17 years) reported that they were 'certain not to smoke', while 15% were 'very unlikely' or 'unlikely' to smoke, 5% 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 86% of those aged 12 years said they were certain not to smoke, this dropped to 68% by ages 16 and 17, suggesting that almost one-third of older students could still be open to experimentation with tobacco.28 The decrease in intention not to smoke with increasing age was greater among female students than males.27

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-fifth (19%) of current smokers reported that they were unlikely/very unlikely to be smoking in a year, while 8% were certain they would not be smoking in 12 months. Over one-quarter of current smokers (28%) were undecided about their intentions to continue smoking, while 46% 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, almost half of current smokers (47%) may be considered susceptible to encouragement to quit.ii 30

Table 5.6.1
Intention to smoke in the next 12 months among current smokers, Australian secondary school children aged 12–17 years, 2008

 

Current smokers*
%

Certain not to smoke

8

Very unlikely/unlikely to smoke

19

Undecided

28

Likely/very likely to smoke

35

Certain to smoke

11

Source: White V and Smith G 200927 Derived from Table 3.12 (p32)

* Defined as having smoked in the past week

5.6.3 Perceived acceptability of smoking

The National Drug Strategy Household Survey (2010) provides the most recent Australian data on community opinions and perceptions of drug use, based on responses from more than 26 000 participants across Australia aged 12 years or older.31 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 combined32 these data indicate that similar proportions of Australians aged 12–17 years (under one-third) cite tobacco (30%) and alcohol (31%) as the leading (direct or indirect) cause of drug deaths in Australia. Recognition of tobacco as the leading cause of drug deaths in Australia was higher among all other age groups (reaching a maximum of 40% among Australians aged 50–59 years).31

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, 14% of those aged 30–49 years) in 2010. As in previous surveys, excessive drinking of alcohol was the form of drug use thought by all age groups to be of greatest community concern.31

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, 44% of young people aged 12–17 years approved of adult alcohol use; this compared with 14% of this age group indicating approval of regular adult tobacco use, around the same proportion approving of the adult use of painkillers/analgesics for non-medical purposes.31

Survey participants were asked to nominate the first drug they think of as associated with a 'drug problem' in Australia. The proportion of people first nominating tobacco dropped significantly between 2007 (2.6%) and 2010 (2.2%)iii. This was also the case for cannabis and alcohol, while the proportion nominating cocaine, hallucinogens and painkillers substantially increased. As in previous survey years, in 2010 illicit drugs (particularly heroin and cannabis) and alcohol were much more likely to be associated with a 'drug problem' than tobacco by all age groups.31

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.33

 

i Adult smokers may also share these misperceptions. Lower emission cigarettes have not been shown to be a less hazardous option. See also Chapter 3, Section 26 and Chapter 10, Section 10.7.6.

ii Whether these young smokers are able to give up smoking so easily is a separate issue. There is evidence that teenage smokers are especially susceptible to addiction, and that they are likely to underestimate how difficult they will find it to quit smoking (see e.g. DiFranza et al 200929).

iii The 2010 survey report does not provide responses by age group for this question.31

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