Smoking during adolescence is primarily a social activity, 1 and research has consistently identified peer group influences as a significant factor in uptake of smoking. 2-7 Peer influence is important in future smoking intentions among adolescent smokers and non-smokers, 8, 9 as well as in the development of nicotine dependence in adolescent smokers. 10 Peer groups may variously be defined as best friendships, romantic attachments, small social ‘networks’ and larger social ‘crowds’. 11 Each of these types of peer group may influence the decision to smoke or not. 11
Individual and population level dynamics play an important role in the strength of peer influence. 12 A meta-analysis of peer influence on adolescent smoking initiation and continued smoking suggests that smoking initiation is positively associated with peers’ smoking when there is high interpersonal closeness. 12 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 review of peer group influences on adolescent smoking based on longitudinal studies explored the extent to which peer smoking predicts adolescent smoking. 13 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 (said to be well established, with girls more strongly influenced by peer smoking than boys; see Section 5.8.1), 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. 13
Peer pressure is one aspect of peer socialisation, in which adolescents are influenced by their friends. 13 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, 14, 15, 16 (i.e. ‘selection’). 13 In a review of peer influence and smoking behaviour, 17 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. 17 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. 17 It is probable that peer influences both interact with and are compounded by a host of other predictive factors: 18 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. 13 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. 13
It is likely that the nature of peer influences on smoking changes over time and across social and cultural groupings. 17 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. 19 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. 20 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. 9
Some features of adolescent social networks may have long-lasting associations with longer term smoking behaviour. 21 A longitudinal analysis of US adolescents 22 estimated that a 10% increase in the proportion of classmates who smoke will 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. 22 Similarly, an analysis of European school data estimated that, on average across countries, a one percentage point increase in the proportion of smoking classmates is associated with an increase of 0.31% to 0.38% in the probability that a ‘typical’ adolescent smokes, a range that varied between countries. 23
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. 13 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. 7, 11 Qualitative research from Western Australia found that some adolescent experimenters and smokers 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. 24, 25
Socialising processes that facilitate smoking can also discourage use. 13 For example, being ‘cool’ is important to teenagers, 26 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. 27 While ‘coolness’ is still identified by young people as one of the reasons why some of their peers smoke, 28 research undertaken in Western Australia suggests that the inverse is increasingly true, with those who smoke often regarded as ‘losers’ or ‘trying too hard to be cool’. 25 Refusing an offer of cigarettes or declaring that ‘I don’t smoke’ is increasingly socially acceptable and normative among many youth cohorts. 25 Among groups with a negative prevailing attitude to smoking, peer influence may deter uptake of smoking. 1, 11, 13
Smoking behaviour of the most popular students within the school context has also 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. 29
British research has found that dating at an earlier age is a predictor for becoming a smoker later, independent of other possible confounding factors. The authors speculate that dating and smoking behaviours may be connected by a desire to appear to be more grown up, 30 which is consistent with tobacco industry advertising linking its products with sex appeal and popularity. 31 Research also suggests that young people who are lesbian, gay, bisexual, transgender or intersex (LGBTI) have a higher risk of taking up smoking. 32, 33 The National Drug Strategy Household Survey for 2016 found daily tobacco smoking to be higher among people who identified as homosexual/bisexual than heterosexual. 34
Qualitative research identified three main motivations for tobacco uptake among the LGBTI community—image building, socialisation and stress. Smoking was used as a tool for building an image of one’s self or to attain a certain persona. In the LGBTI smoking aids socialisation with some fearing loss of friends if they were to quit. Lastly, smoking was reported by the LGBTI community as a coping mechanism for stresses cause by the intersectionality of race, ethnicity and sexuality. 35 As well as this, the LGBTI population has also been specifically targeted in tobacco advertising. 32
Social norms need only to be perceived to influence behaviour: 13 young smokers tend to congregate together, and also to overestimate the extent of smoking in their own age group, giving them a distorted sense of what is normal behaviour. 6, 13, 36
The English National Survey 39 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, 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. 39
5.8.1 Influence of gender
A large number of studies have examined whether boys and girls are similarly affected by the various factors that influence smoking behaviour. In a major review of the literature, the US Surgeon General’s report for 2001 (Women and Smoking) concluded that ‘Most risk factors for smoking initiation appear to be similar among girls and boys’ (p477. 36 ) However, the review did find that girls may be more likely to be influenced by positive images of smoking, perceptions about smoking and weight control, and improvement of mood. There was also some evidence that girls are more likely to smoke than boys out of rebelliousness, rejection of conventional values, lack of religious conviction, poor self-esteem and emotional distress. Dutch research found gender differences in the association between pre-adolescent smoking initiation and emotional or behavioural problems, with relationships between smoking and problem behaviour (attention problems, thought problems and delinquent behaviour) observed in girls, but not in boys. 40
Other research has proposed that boys are more likely to smoke as a result of ‘psychosocial’ factors (such as risk taking, rebelliousness, self-esteem and coping ability), whereas girls tended more to be influenced by ‘environmental’ factors such as parental smoking habits, peer group attitudes and behaviours. 41 A social network analysis of adolescent smoking in Finland, however, found that both adolescent boy and girl smokers were influenced by parental smoking behaviour and tended to select other smokers as friends, while only adolescent girls were influenced to smoke by their peer group. 42 The strength of the relative influence of psychosocial and environmental factors is likely to change during teenage years. 41 It has been found that psychosocial factors are more closely associated with smoking in young teenage girls than in older girls, who are more influenced by attitude variables (including beliefs about smoking), while younger boys are less susceptible to the influences of both psychosocial factors and environmental variables than older boys.
Australian studies have reported that uptake of smoking in adolescent girls is strongly related to a desire to adopt and reinforce their reputation among a specific peer group, 43 and that strength of self-concept in girls (defined as how an individual perceives her physical presentation and appearance to others) is more closely connected with increased likelihood of smoking than in boys. 44 Environmental pressures on adolescent girls to be self-confident, socially aggressive and sexually precocious may lead to cigarette smoking, in an effort to boost physical self-concept. 44
5.8.1.1 Do concerns about body weight influence the uptake of smoking?
The misperception that smoking depresses appetite, hence assisting with weight control, has long been considered a possible enticement for smoking, especially among females. Over many decades the tobacco industry has overtly targeted the female market with brands and imagery connecting cigarettes with a slim and shapely female form. 36, 45, 46
Many studies have investigated the relationship between adolescent smoking and body weight. A review, 47 analysing 55 studies published between 1980 and 2003, concluded there was some evidence that:
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young smokers were more likely to perceive they were overweight
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some adolescents smoked because they thought it would help with weight control
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adolescent smokers were more likely to have engaged in dieting, the evidence being strongest for girls.
Research from Western Australia 25 has shown that young people (both smokers and non-smokers) cite ‘to be thin’ as a reason for smoking. Recent evidence links smoking among young females with body shape concerns and eating disorder symptoms, 48, 49 including extreme dieting (e.g. fasting or use of laxatives or diet pills). 50
There are several US studies linking increased smoking over time with weight issues among young females. For example, research found increases in smoking prevalence during high school among young females to be associated with self-perceptions of overweight, 51 in another study smoking patterns were predicted by the severity of one’s weight concerns, perceived weight status, and BMI percentiles among young females, 52 while a twins study found both underweight and overweight/obesity to be positively associated with the transition from experimentation to regular smoking among females aged 18–29 years. 53
Analyses of data from a large longitudinal US adolescent survey suggest that for females aged 11–23 years, being overweight—based on measured body mass index (BMI) in 1996—was associated with frequent/heavy smoking five years later. 54
Other research links body weight, dietary behaviours and smoking among young males and females. For example, a Canadian study found that girls who perceived themselves to be overweight and boys with higher self-reported BMI at two time points during high school were more likely to be smokers as young adults. 55
Extreme dieting has been linked with current smoking regardless of gender and weight status. 50 The association between smoking and weight control may be becoming more pervasive over time: while some of the extreme dieting behaviours were not associated with smoking in the years 1999–2003, all of the extreme behaviours were associated with smoking from 2005, regardless of gender and weight. 50 While the magnitude of the association between smoking and extreme dieting became smaller among adolescents in later survey years, it remained unchanged among non-overweight girls over that same time period. The authors speculate that this might reflect the stubborn nature of smoking behaviour in this group and therefore that it would be more difficult to implement smoking cessation intervention for female extreme dieters than for other groups. 50 Research examining the association between restrained eating and smoking among young female smokers, found those who attempted to control what they ate—after a being exposed to temptation—were quicker to smoke in order to prevent more food consumption than non-restrainers. 56 This held true even when alternative distractors, such as a computer tablet, were available. 57
In a 2009 Dutch study, depressive symptoms were related to smoking among adolescent boys and girls similarly, but the effect for depression became non-significant for girls when controlling for the effect of weight concerns and dieting. Researchers therefore proposed that smoking prevention programs for girls with depression might be enhanced by challenging the idea of smoking as a diet strategy and incorporating a focus on healthy weight regulation. 58
The relationship between smoking uptake and mental health problems such as depressive symptoms is explored further in Section 5.5.2.
Relevant news and research
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