The act of smoking has been the object of extensive research, especially since the 1950s. It remains difficult, however, to know the historical influences that prompted the early use of tobacco. It is known that smoking developed social significance through tribal ceremonies and customs of the indigenous populations of North America. As industrial societies became established, mass production and corporate marketing took advantage of the stimulative and addictive properties of nicotine. The use of tobacco also took on a new social meanings as it was marketed to fulfill psychosocial needs such as a attaining independence or being part of a "cool" trend. The result was widespread and frequent usage, particularly through the smoking of cigarettes. High consumption has since produced devastating health effects. Although early opponents had to rely primarily on moral and emotional persuasion, epidemiological evidence of tobacco's impact on morbidity and mortality now provides the principal impetus to develop policies to prevent smoking.
The abundance of information that now exists on smoking necessitates the use of various frameworks, theories, and models in order to achieve a comprehensive and coherent perspective. A frame work, such as PRECEDE-PROCEED, helps depict the broad context of smoking and encourages the analysis of a comprehensive range of variables; a theoretical approach facilitates explanations as well as predictions; and modeling enhances visual representation or mathematical relations. Most of the major public health models and theories have been applied to smoking, and the literature contains support for many of these theories. This is partly due to the generality of the theoretical concepts.
Figure 1 is a graph of the prevalence of smoking across age groups in Canada. This graph shows that daily smoking largely begins and expands during the teenage years, and then peaks among young adults before decreasing. The behavior follows a sequence of experimentation, initiation, maintenance, and cessation. While the major behavioral change occurs during the teenage years, many of the predisposing factors develop at an earlier age. Beliefs, attitudes, and values begin to develop very early in life, and these influence later behavioral patterns.
DEVELOPMENT OF BEHAVIOR PATTERNS
Human beings have a long period of infant and child development, which allows children to adapt and acquire coping skills that help them survive in
Figure 1
their environments. Due to the increasingly complex nature of society, the early socialization process needs to build capacities for communication, learning, and making decisions for healthful behavior. The initiation of smoking tends to exist among young people who report having a home environment that includes difficulty communicating with parents, lack of parental understanding, low levels of trust, and a generally unhappy home life. This type of family setting creates conditions conducive to a lifestyle that includes smoking. Such predisposing factors are also evident as social networks expand during the teenage years.
The teenage years are a time of transition. They form a bridge between the relatively sheltered environment of childhood and the roles of adulthood. Teenagers begin to confirm their own identities and emulate adult roles. There is a heightened awareness of role models and a tendency to establish boundaries through experimentation and experiencing new risks. School is obviously an important environment for teenagers and students who smoke at this age are more likely to experience difficulties in the academic setting. They experience lower grades, poor student-teacher interactions, minimal academic aspirations for the future, and often complain of unfair school rules. Teenage smokers also tend to have lower self-esteem—they are more likely to report feelings of unhappiness and loneliness, a lack of confidence, and a sense of being unhealthy.
Young people who smoke generally have a reduced capacity to implement practices that promote advancement at home and at school, and in other important settings. This can affect their ability to maintain a healthy sense of identity that includes belonging, worthiness, and hope for the future. Tobacco advertisements prey on these needs by offering an image of suave independence. The insinuation is that smoking will help an individual to achieve desirable qualities. Data are not readily available to quantify the behavioral impact of this practice. It has been shown, however, that young people are readily able to identify images and brands promoted by the tobacco industry.
Other aspects of the social environment have promoted the acceptability of smoking, such as smoking by role models in the movie industry and the widespread visibility of smoking. Studies indicate that smokers tend to overestimate the prevalence of smoking and underestimate the health hazards. All these processes and conditions are set in place during the early years of socialization, and they contribute toward a predisposition that smoking is acceptable and even desirable. Once individuals are predisposed toward the possibility of smoking, enabling factors facilitate the actual behavior.
ENABLING FACTORS
Two obvious requirements are necessary for someone to smoke: being able to acquire cigarettes and having a setting that is conductive to lighting up. Increased access to a supply of cigarettes is closely related to the expansion of a person's boundaries and social networks. Peer groups create an important source and setting for the uptake and maintenance of smoking. During their midteens, smokers tend to have a larger number of friends and spend a great deal of time with them outside of school activities. Friends and relatives often supply cigarettes to begin smoking, but commercial outlets quickly become the main source. Studies have found that young people do not have difficulty obtaining tobacco, even with recent legislation to prevent the sale of tobacco to minors.
When prices are increased, largely through taxation, additional sources become important. These include roll-your-own tobacco, illegal smuggling, tax-free sales on Indian reservations, and mail order. The inverse relationship between price and consumption may be because smoking is more prevalent among persons with a lower socioeconomic status who have a limited amount of money to spend on tobacco products. However, once smoking has begun there is a tendency toward continuance and an integration of smoking into one's lifestyle. The predisposing and enabling factors develop into patterns that reinforce the behavior, as do the addictive properties of nicotine.
REINFORCING BEHAVIOR PATTERNS
Reinforcing patterns begin with having friends who are smokers. Spending time with such friends provides ample opportunities to reinforce smoking behavior. Patterns develop to have a cigarette during breaks at work, with food and beverages, and during social events such as parties. Strong correlations exist between smoking and the consumption of caffeine, alcohol, and marijuana. These patterns move smokers away from healthy and productive lifestyles. There are thus a host of illness symptoms and premature deaths attributable directly to smoking as well as indirectly to the broader pattern of unhealthful behavior.
In 1999, The World Health Organization reported that "the joint probability of trying smoking, becoming addicted, and dying prematurely is higher than for any other addiction." Although smokers downplay the consequences of smoking, they do recognize that a risk exists, though they find it difficult to quit. Many teenagers believe they will only smoke for a short duration. Others state they can "quit anytime." Unfortunately, a significant number are in for a long struggle, and perhaps a lifetime addiction to tobacco. Most of the decline in the proportion of smokers does not occur until past the age of forty. This is partially related to successful quitters and premature deaths of smokers. More than two out of three adult smokers report a desire to quit smoking. The most common reason for successful quitting is a concern about future health. The influence of these health concerns is enhanced by a continual decline in the proportion of adult smokers subsequent to the publication of the 1964 Surgeon General's report outlining the consequences of smoking. However, during the 1990s there was a slightly upward trend in the proportion of high school students who are smoking. For young people, the subjective meaning of smoking extends beyond the concern about future health consequences.
The principal predisposing and enabling factors for smoking occur during the socialization process. Personal insecurities, problems at home, and difficulties in academic environment are all preyed upon by a tobacco industry driven by profits, and smoking cigarettes and intake of nicotine become entrenched into behavioral patterns that create a high-risk trajectory and bleak outlook for the health of individuals and the population. The underlying causes of smoking are complex and deeply rooted, and the necessary research on smoking continues to expand. Public health advocates recognize the need for comprehensive tobacco control strategies, but also admonish individuals that: If you don't smoke, don't start, and if you do smoke, quit. Social changes and changes in individual behavior are required to achieve a significant reduction in tobacco use.
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