Introduction

In spite of a decrease in adult smoking since the dissemination of the
1964 U.S. Surgeon General’s Report on Smoking and Health, there is
discouraging evidence that smoking among teenage boys is remaining
virtually constant and among teenage girls it is actually increasing. It
is apparent that more knowledge is needed concerning the way in
which the psychosocial factors that may contribute to the initiation of
smoking can be applied to the development of effective strategies to
deter the onset of smoking.

It is possible that prevention programs directed at children and
adolescents have generally placed too much confidence in merely
communicating knowledge about the dangers of smoking. Developers
of these programs may assume that such fear arousal will in itself be
sufficient to thwart smoking. In fact, as will be amplified later in this
chapter, by the time children reach junior high school, almost all of
them believe smoking is dangerous. It appears that communications
concerning the dangers of smoking whether delivered from schools,
churches, voluntary agencies, mass media, the family, peers, govern-
mental agencies, industrial organizations, consumer organizations, or
labor unions (individually or collectively) have, indeed, been effective
in persuading children and adolescents that smoking is dangerous.
However, it is also evident that fear of the consequences of smoking
may in itself not be sufficient to discourage a substantial number of
children from beginning to smoke when they approach adolescence.

Some investigators in this field have contended that at an earlier
level of the child’s development, perhaps between the ages of 4 to 9 or
10, the child takes quite literally the dangers of smoking. In fact, it is
often observed at this level of development that children may be
especially worried if they observe a parent or older sibling smoking.
They will admonish them to stop smoking because it “can cause cancer
or a heart attack.” Yet as they approach adolescence, many of these
same children will begin smoking.

Responses from the teenagers themselves suggest that peer pressure
to smoke may be one of the major influences. There is also some
evidence that the smoking parent becomes a model for the child. If
both parents smoke there is a greater likelihood that the child will
begin smoking than if only one parent smokes or if neither parent
smokes. But even if one parent smokes, this may influence the child to
smoke more than if neither parent smokes. Interestingly, if an older
sibling and both parents smoke the child is about four times more
likely to smoke than if there were no smokers in the family.

The influence of the mass media in the initiation of smoking is
somewhat more difficult to establish. Smokers are depicted in films
and television, as well as in cigarette advertising which tends to
portray them in interesting and exciting environments, suggesting
that attractive, desirable people tend to smoke. This would logically be

17-5
expected to influence children and teenagers much as the media and
advertising affect the behavior of adults. Yet, the relationship between
exposure to the mass media and the initiation of smoking is difficult to
isolate from the other concurrent influences to which the child is
exposed. In fact, a variety of psychosocial influences may interact to
influence some children to begin smoking.

Some investigators examining the issue of why fear arousal may
often have such a limited effect on health behavior suggest that much
of the information communicated to children concerning smoking and
its dangers may be too general and not sufficiently personalized. Also,
the suggested harmful effects of smoking in many smoking control
messages violate the concept of “time perspective.” As children grow
older they recognize that people around them who smoke do not die
instantly and that heart attacks or cancer are not a certainty. They
may need to be exposed to evidence that smoking has immediate
physiological effects on the body. Younger adolescents particularly live
in the present and are not preoccupied with the future. Emphasizing
what might happen to them when they are much older may not be an
effective way to persuade many of them to resist the pressures to
begin smoking.

Becoming a smoker may have the immediate value to some
teenagers of being accepted by their peers, feeling more mature
because smoking is an adult behavior forbidden to the child, providing
a level of physiological stimulation and pleasure, and might even serve
the function of an act of defiance to authority figures. The prevention
programs reviewed rarely incorporate such concepts. Rather, they
focus primarily on information relating to the long-term dangers of
smoking.

Furthermore, too few of the prevention programs are evaluated
with sufficient rigor. As a result, in the same sense that there is
insufficient basic behavioral research to link clearly many psychosocial
factors to the initiation of smoking in children and adolescents, it is
difficult to determine if many prevention programs significantly deter
the onset of addictive smoking. Even if a program results in increased
knowledge concerning the long-term dangers of smoking, in the
absence of valid evidence of a direct impact on the incidence of
smoking itself, it is possible that many widely disseminated prevention
programs are, in the long-run, of only questionable value in actually
deterring smoking. All of this suggests many avenues for future
research and prevention programs.

To elaborate on the various points discussed above, the sections
which follow deal with current smoking patterns and beliefs, relevant
conceptual models in developmental and social psychology, typical
psychosocial influences in the smoking decision, critical evaluations of
some current prevention programs, and finally, some recommendations
for future research and prevention programs.

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Current Smoking Patterns and Beliefs

While cigarette smoking in the United States for adults over age 21
has declined, there has been a growth in the amount of smoking among
the pre-adult population, primarily due to a dramatic increase in
smoking among teenage girls (61). But care needs to be exercised when
interpreting the findings of the studies reported since definitions of
such terms as “regular smoker,” “occasional smoker,” “experimental
smoker,” and “nonsmoker,” vary from one study to the next. For
example, four national surveys conducted at 2-year intervals from 1968
through 1974 by the National Clearinghouse for Smoking and Health
(61, 86) define a current regular smoker as one who smokes one or more
cigarettes per week. On the other hand, an antismoking education
study conducted at the University of Illinois (18) defines a current
regular smoker as one who smokes cigarettes just about every day.
Also contributing to the ambiguity of results is the way in which the
categorization of frequency of smoking is dealt with in the analysis of
results. For example, in the four national surveys previously cited,
experimental smokers (those who have smoked at least a few puffs but
less than one hundred cigarettes) were combined with nonsmokers in
the analysis of the data. Experimental smokers are extremely
important and should not be neglected in data analysis since
experimental smoking is obviously the initial step toward confirmed
smoking (42).

In the four surveys (61) conducted by the National Clearinghouse,
approximately 16 percent of the teenage population, aged 12 to 18,
were current regular smokers in 1974. The rate of regular smoking for
the same age group in 1968 was approximately 12 percent. In the first
survey, only about half as many girls as boys regularly smoked, but by
1974 this difference had virtually disappeared. In fact, regular smoking
had slightly decreased for boys from 1970 to 1974, but this decrease
was easily offset by the dramatic rise in smoking by girls.

Relevant to the problem of teenage smoking is the age of initiation
of smoking. A significantly larger percentage of regular smokers aged
12 to 14 were reported among teenagers in 1974 (approximately 12
percent) than in 1968 (approximately 6 percent). This increase in
regular smoking at younger ages suggests that the average age of the
initiation of smoking is decreasing.

Further evidence concerning the age of initiation of smoking is
available from retrospective data reflecting self-estimates of onset of
smoking in the Current Population Surveys of 1955 and 1966 (2). No
analysis of age trends in smoking initiation among males was reported
since the number of male respondents was low, particularly in the 1966
survey. However, the responses from the female respondents, regar-
diess of their current age, suggest a shift in the initiation of smoking to
a younger age. For example, over twice as many females, aged 18 to

17—7
2A, classified themselves as regular smokers by age 15 in 1966 than did
the respondents of the same age group in 1955.

In the national surveys between 1968 and 1974 (61 ) the relationship
between various factors related to socioeconomic status and smoking
were examined. For example, teenagers who are employed outside the
home are twice as likely to smoke as teenagers who are not employed.
Also, educational and vocational aspirations are related to smoking.
Students who plan to go to college are the least likely to smoke. A
study conducted by Borland and Rudolph (9) determined that
socioeconomic status bears some relationship to smoking in high school
students (children in lower socioeconomic levels are more likely to
smoke), but socioeconomic status correlates less with smoking than
parental smoking or poor scholastic performance (although all three
variables are themselves correlated).

The literature fails to address adequately the initiation of pre-adult
smoking. Rather, the emphasis is on “regular” smokers. Nevertheless,
inferences from such data may be helpful in suggesting factors that
are related to the initiation of smoking.

As would be expected, beliefs of teenagers about smoking are
related to whether or not they smoke. Of course, smokers generally
hold more favorable attitudes toward smoking than do nonsmokers (65,
75). Nevertheless, data (59) suggest that even teenage smokers seldom
consider the decision to smoke a wise decision. For example, 77 percent
of smokers believe that it is better not to start smoking than to have to
quit. Over half of the teenage smokers believe that cigarette smoking
becomes harmful after just 1 year of smoking. Eighty-four percent say
it is habit forming, while 68 percent agree that it is a bad habit. Of all
teenagers, 78 percent believe that cigarette smoking can cause lung
cancer and heart disease. Eighty-seven percent of all teenagers and 77
percent of teenage smokers believe that smoking can harm their
health. The vast majority of teenagers consider smoking as habit
forming, but almost two-thirds do not feel that becoming addicted to
smoking is an imminent threat to their health. Experimental smoking
is considered safe.

Fishbein (34) cites evidence from a study conducted for the
American Cancer Society in 1975 which suggests that teenage smoking
is perceived by teenagers as more prevalent than it actually is. Eighty-
three percent of the teenagers in this survey tend to think of other
teenagers as being smokers rather than nonsmokers.

Finally, it should be pointed out that knowledge or beliefs about the
dangers of smoking are often confused with attitudes toward smoking
(10). Attitudes may be much more complex than simple beliefs about
the harmful effects of smoking. Various factors influencing the
complexity of attitudes toward smoking are discussed in the most
recent report of the four national surveys mentioned earlier (61). These
factors include the adverse effects of smoking on the individual’s

17—8
health and on the environment (pollution), the psychological and
sociological benefits of smoking (e.g., “makes you feel good”),
rationalizations that allow smoking, perceptions of reasons for
smoking and for smoking initiation, the negative stereotypes concern-
ing smokers, attitudes toward authority, and control over one’s
destiny.

In essence, when considering both current smoking patterns and
beliefs among children and adolescents, the factors related to smoking
can be categorized in terms of perceived psychosocial benefits versus
actual threats to health. Considering this dichotomy, the suggestion of
the U.S. Public Health Service (61) should not be ignored:

It is futile to continue to tell teenagers that smoking is harmful and
that they shouldn’t do it. They know that it is harmful. Most do not
want to do it. The most effective thing that we can do is to help them
to understand the benefits of smoking as compared with the costs
and dangers so that they will have the facts that they need in order
to make a thoughtful decision as to whether to smoke or not to
smoke (p. 27).

Relevant Conceptual Models in Developmental and Social
Psychology

Understanding the factors involved in the initiation of smoking among
children and adolescents is a complex endeavor demanding the
utilization of diverse conceptualizations. This section will consider four
representative conceptual models in developmental and social psychol-
ogy that would appear to be potentially useful in generating
hypotheses to account for the initiation of smoking among the young
and in providing conceptual bases for prevention programs. These
conceptualizations are Piaget’s Cognitive Development Theory, Erik-
son’s Theory of Psychosocial Development, Bandura’s Social Learning
Theory and McGuire’s Persuasive Communication Model.

The Cognitive Developmental Theory of Piaget (26, 69), one of the
most influential cognitive theories, is concerned with the nature and
origin of knowledge. Piaget’s view of the development of knowledge
would appear to offer some applications to understanding the
informational and decisional aspects of the initiation of smoking in the
developing child.

Piaget views knowledge as developing out of the individual’s
adaptive interaction with the environment through the processes of
assimilation (incorporation of concepts into existing cognitive struc-
tures) and accommodation (modification of cognitive structures).
There are four major stages of intellectual development: (1) sensory-
motor period (birth to 2 years), involving simple perceptual and motor
adjustments to immediate environmental phenomena; (2) preopera-
tional period (2 to 7 years), involving a preconceptual phase (the

17—9
emergence of linguistic skills and symbol construction abilities) and an
intuitive phase (the emergence of more complex thoughts, images, and
classification abilities based on perceptual similarity instead of logical
considerations); (8) concrete operational period (7 to 11 years),
involving reversible intellectual operational ability (utilizing a mental
representation of a series of actions), conservational ability (realizing
that quantity remains invariant despite perceptual transformations), 4
clearly defined concept of class inclusion, and the ability to take the
viewpoint of another; and (4) formal operational period (11 to 15 years)
involving the realization that reality is but one of a set of all
possibilities. Thinking in this last stage is characterized by hypotheti-
eal-deductive reasoning, combinational analysis (consideration of
multiple factors), propositional and rule-governed logic, and a futuris-
tic perspective.

Piaget’s ideas, especially those dealing with developing knowledge
about the physical environment, have been extensively explored,
although the investigation and application of his concepts involving
adaptation to the social environment have only rarely been studied.
The initiation of smoking, apparently an age-related behavior, appears
most often to occur within the context of social interactions.
Additionally, smoking involves an important decisional component
requiring the utilization of cognitive or knowledge structures.

By the time they reach the seventh grade, the vast majority of
children believe smoking is dangerous to one’s health (31). Yet despite
this knowledge, many adolescents, aged 12 to 14, experiment with
smoking, and roughly 4 to 5 percent will smoke regularly (weekly) (62).
This situation suggests that “social adaptation” may override “intellec-
tual adaptation” or knowledge. Knowledge of the dangers of smoking
often motivates a preadolescent to become a crusader against smoking,
while the social pressures occurring during early adolescence may
outweigh the effects of this concrete knowledge. So, the individual who
had been at an earlier age an antismoking crusader may become a
regular smoker or at least an experimental smoker as a teenager. This
conflict between knowledge of the dangers of smoking and smoking
suggests the possibility of observing the development of smoking
within the Piagetian framework.

One contemporary psychoanalytic developmental model of conse-
quence is Erikson’s Theory of Psychosocial Development (24, 25)
involving eight psychosocial crises. These crises are: (1) trust vs.
mistrust (0 to 1 year), (2) autonomy vs. shame and doubt (2 to 3 years),
(3) initiative vs. guilt (4 to 5 years), (4) industry vs. inferiority (6 to 11
years), (5) identity vs. role diffusion (12 to 18 years), (6) intimacy vs.
isolation (young childhood), (7) generativity vs. stagnation (middle
adulthood), and (8) ego integrity vs. despair (later adulthood). of
particular interest with reference to the initiation of smoking are
Erikson’s fourth and fifth psychosocial crises.

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Both the struggle to overcome inferiority and the effort to establish
a self identity have been cited in one form or another by numerous
researchers interested in interpreting the initiation of smoking in
adolescents. For example, Erikson’s “identity-crisis” in adolescence
(being torn between the roles of child and adult) might be an
interesting basis for explaining the apparent influence of peer pressure
in the initiation of smoking, particularly if this notion were explored in
some depth empirically.

A third contribution which has greatly influenced developmental
and social psychology is Bandura’s Social Learning Theory (6).
Bandura’s theory, which is concerned with imitative or modeling
processes, would also seem to be useful in understanding the processes
‘nvolved in the initiation of smoking. Social learning theory emphasizes
the roles played by vicarious, symbolic, and self-regulatory processes in
the acquisition of behavior. Further, this theory suggests the
importance of reciprocal determination or the continuous mutual
interaction between self-generated and environmental determinants in
exploring human behavior. Bandura sees social learning as governed
by four component processes: attention, retention, motor reproduction,
and motivation or incentive.

Smoking appears to be initiated as a result of social influences or,
more particularly, the imitation of models such as peers, media
stereotypes, and significant adults (e.g., parents and teachers) (27).
Considering the nature of smoking, a behavior with possible delayed
aversive consequences and often more immediate social reinforcing
consequences (especially for children and adolescents), it would seem
that investigating smoking within the social learning paradigm would
generate many useful hypotheses concerning the initiation of smoking.
For example, the impact on children of the models of smoking parents
or the impact of smoking adult models depicted in the mass media
could be further explored in the context of social learning.

Communications models which examine information processing hold
some promise for understanding the factors underlying the initiation
of smoking as well as for developing more effective prevention
programs. McGuire’s (53) Communication Persuasion Model, for
example, analyzes the persuasive impact of communications according
to five component processes: attention, comprehension, yielding,
retention, and action.

If the communicator wants the message to be accepted and acted
upon, it is important to remember that individuals exposed to the
message must be paying attention if communication is even to begin.
Comprehension of the contents of the message is equally important.
Yielding to or agreeing with the conclusions advocated in the message
is vital if the communication is to have effects in the desired direction.
Retention, or the maintenance of the induced agreement, is particular-
ly important if the beliefs are to be operative when the individual is

17-11
challenged by exposure to messages countering the accepted belief. By
measuring the individual’s response to such challenges, a useful
evaluation of the impact of the communication on the subject, the
degree of yield to the message, and the amount of resulting behavioral
change or action resulting from the message may be obtained.
McGuire’s model would appear to be useful in both preparing and
evaluating communications related to smoking prevention programs
for children.

One of the most interesting aspects of McGuire’s model is his
“inoculation” approach to attitude change. McGuire suggests that
existing attitudes may be strengthened by inoculating individuals
against counter arguments to which they may be exposed. The
application of this model to the pressures to initiate smoking would
consist of “inoculating” adolescents against the social pressures to
smoke which they may encounter at some future time. For example,
Evans, et al. (32), using this approach in filmed messages, acquaint
adolescents with the nature of the various social pressures to smoke. In
a second film, they are inoculated against these pressures by being
presented coping “strategies” based on information obtained from
adolescents themselves. Further variations of such an inoculation
approach would appear to be a promising means of relating a concept
in social psychology to the deterrence of smoking in children and
adolescents.

Typical Psychosocial Influences on the Smoking Decision

As mentioned earlier, despite extensive educational efforts, the onset
of smoking in school-aged children continues relatively unabated, with
age and grade level at which smoking begins reflecting a downward
trend from high school and junior high schoo! into the elementary
grades (61). This trend has been reported consistently in the literature
(18, 29, 84) and has grown at such an alarming rate that Kelson, et al.
(46) refer to it as “the growing epidemic.” It is generally agreed that
the most effective way to attack the problem would be to influence
children not to initiate smoking (29, 88). Developing strategies of
deterrence is dependent upon identifying those influences that lead
children to begin smoking. While not all influences have been
identified, many of them can be discerned in the literature related to
children and smoking. Predictably, the influences most frequently
cited include the role of the family, pressures from peer groups, formal
education programs, and the effects of messages transmitted through
the mass media. To a lesser extent, studies that explore the influences
of individual differences and environmental factors have been
reported.

17—12
Changing Sex Roles

As mentioned earlier, the disappearance of differences between the
incidence of smoking of boys and girls is quite apparent (61). The
reasons for these differences are not clearly established. Possible
explanations, such as a differential impact of antismoking messages on
the two sexes, have not yet keen empirically demonstrated. Another
possibility is that many social differences between the sexes are
gradually disappearing in the light of the women’s movement. A third
possibility derives from the finding that smoking by teenage girls may
have been perceived as more socially acceptable in 1974 than in 1968.
This may have resulted in more honest self-reports of smoking; so
instead of teenage girls actually smoking more, a more accurate
indication of smoking by girls was being recorded.

Parental Smoking Habits

Parents who smoke clearly influence the smoking behavior of their
children. In families where both parents smoke, 22.2 percent of the
boys and 20.7 percent of the girls are also smokers, compared to 11.3
percent and 7.6 percent where neither parent smokes (61). These
proportions have remained consistent over time. Merki (55) lists
parental smoking habits as a major factor directly related to smoking
by junior and senior high school students. Wohlford (89) uses
identification theory to predict a direct relationship between parent
and child smoking behavior. This relationship appears to be stronger
for boys than for girls, a finding Wohlford attributes to stronger peer
influences relative to smoking for girls. A recent American Cancer
Society study (58) seems to confirm this notion. Borland and Rudolph
(9) indicate that parental smoking is the second best predictor of
smoking behavior in high school students. Palmer (68) reports similar
findings for junior high school students. Edson (28) discusses both
parental modeling and children’s efforts to combat parental smoking
as a result of the School Health Curriculum Project. Evans, et al. (32),
in a smoking-deterrence investigation, incorporate a positive message
for coping with parental smoking models, emphasizing that children
can resist the pressure to imitate parents who smoke. Programs
designed to educate parents who smoke on how they may be
influencing their children to smoke should be considered important
components of prevention programs. Also, research should be encour-
aged to examine the precise effects on the child of the smoking parent.

Parental Acceptance of Children’s Smoking

While parental approval of smoking has been suggested as a
contributing factor in influencing children to smoke, Allegrante, et al.
(3) do not find parental approval to be a signficant factor, confirming
Williams’ (88) earlier conclusion that both smoking and nonsmoking

17—13
junior high students report that their parents disapprove or would
disapprove of their smoking.

Siblings Who Smoke

Although Piper, et al. (70) report no significant relationship between
older siblings and the smoking behavior of the subjects in their
longitudinal study, two major surveys (61, 88) implicate the smoking
behavior of older siblings as a possible influence on younger children.
Twenty-eight to thirty percent of the boys and 25 to 26 percent of the
girls who report regular smoking also have older siblings who smoke. If
an older sibling and both parents smoke, the child is four times as likely
to smoke as a child who has no smoking model in the family (62).
Williams also reports the lowest incidence (4.2 percent) of smoking in
those children who live in a household where neither parent smokes
and where there are older siblings, none of whom smoke.

Rebellion Against Family Authority

While cigarette smoking as a form of rebellion against family and
adult authority has not received much attention in the literature, a
recent survey (42) indicates that smoking among teenage girls may
reflect rebellious, anti-authority behavior.

Peer Pressures

Peer pressure is widely assumed to be a significant causal factor in the
initiation of smoking. The strong influence of peer group pressures is
generally evident in young adolescents (38, 78), but the precise
relationship of such pressure to the initiation of smoking is more
difficult to establish.

In an intensive participant-observation study of ninth-grade stu-
dents with a follow-up 2 years later, Newman (64) reports that peer
pressure and conformity to group status norms were perceived by
subjects to be major factors in smoking. The relationship was not as
strong when the subjects were in the 11th grade, but was significantly
different at both grade levels (63). A survey by Palmer (68) of more
than 3,000 junior high school students finds that the prevailing peer
model to be the single most important variable contributing to the
onset of smoking in this age group.

In a longitudinal study of Canadian school children, Matthews (51)
finds that peer influence was a major factor in the initiation of
smoking in the population surveyed. The influence of peers seems to
come from “best friend” relationships, rather than from large or
diversified group pressure. In a multivariate study of correlative
factors in youthful cigarette smoking, Levitt and Edwards (50) report
that having a best friend or group of friends who smoke appears to be
the best predictor of smoking in children from the 5th through the 12th

17—14
grade. Bynner (13) finds the most important variable in explaining
smoking behavior in English and Welsh schoolboys is the number of
their friends who smoke. Williams (88) reviews a substantial number of
studies which also conclude that pressures from peers and best friends
are important influences to smoke.

In prevention programs, Newman (63) cautions against the utiliza-
tion of nonsmoking student models whose general characteristics
differ from those of the target population. The use of such models may
alienate the target population against the antismoking message. Evans
(27, 31) approaches the peer-pressure problem by presenting strategies
for resisting peer pressure as filmed-sequence roles played by students
selected from the target population.

School Environment

Specific school health education programs are addressed comprehen-
sively in other chapters in this report. The dominant role of the school
in the life of children and adolescents suggests the importance of the
school environment in providing influences guiding the smoking
decisions of children. Two important recommendations specified by the
American Association for Health, Physical Education, and Recreation
(4) are for schools to accept the responsibility for providing smoking
education programs and for teachers and other school personnel to
implement these programs.

The role of teachers, health professionals, and other adult role
models as exemplars for the young is examined by'a number of
researchers (16, 62, 80). It may be important that such adult role
models make positive statements related to their position on smoking.
For example, teenagers perceive teachers as likely to be smokers (42).
Sixty-eight percent of the girls and 67 percent of the boys judge most
teachers to be smokers. A recent American Cancer Society survey (5)
states that only 23 percent of female teachers and 18 percent of male
teachers actually smoke. Such a difference in actual and perceived
smoking behavior indicates a lack of communication in an area that
could be critical in influencing the smoking decision in children and
young adolescents.

Mass Media

In a Task Foree Report on Respiratory Diseases, the National
Institutes of Health (60) states that mass media have been used
extensively in antismoking efforts, but exactly how they influence
behavior is unclear. Ward (87) reports that, in a study designed to
ascertain attitudes toward television commercials and to analyze the
effects of television advertising on adolescents, the television medium
appears to influence the formation of ideas and attitudes, yet does not
“trigger” adolescents to buy a product. Ward’s study indicates that
cigarette ads are perceived by teenagers as hypocritical and are listed

W165
as “least-liked” while antismoking ads are perceived as “straight-
forward” and are liked. The effects of messages in other media, such as
billboards, magazines, and displays need to be more precisely studied.
Mendelsohn (54) concludes that, in general, current mass media efforts
to educate the public concerning health issues are disappointing. It is
possible that because of cognitive and social differences in various
development stages of children and adolescents, mass communications
may not be the most appropriate means to reach children and
adolescents with smoking-deterrence messages. More specifically,
targeted communications might be better presented in selected target
situations.

Individual Characteristics

The notion of being able to identify potential smokers has been an
elusive goal for researchers. There are very few investigations relating
personality variables to teenage smoking. Smith’s (79) review of 35
personality and smoking studies found only four related to teenage
smoking. After a search of the literature related to personality
variables that may influence the initiation of smoking, Williams (88)
concludes that “both the empirical results of previous studies and
discussions of the state of the art of research into personality
correlates suggest that personality will not provide the most fruitful
approach to understanding why children do or do not take up cigarette
smoking” (p. 15). There appears to be some agreement that personality
is more related to the amount smoked than to who will begin to smoke
(17, 52, 85).

Individual differences in smoking are related to variables such as
age-in-grade, achievement in areas important to the. young person,
social involvement, and participation in organized activities. Creswell, -
et al. (18), and Laoye, et al. (48) find that student educational
" expectations are related to their smoking behavior. Creswell, et al. (18)
also find some support for a relationship between above average modal
age and smoking behavior. They find smoking to be perceived as a
compensatory behavior for students who had not achieved success in
more traditional roles. Hasenfus (37) postulates that children and
young people may begin smoking out of a normal curiosity, but soon
come to view smoking as a coping behavior similar to adult usage.
Bergin and Wake (7) state that teenage smoking appears to be
triggered by changes in living habits such as changes in residence,
absence of a parent, or matriculation in a university. No conceptual
framework or organized line of research has systematically guided the
research related to individual characteristics in the initiation of
smoking, and the literature reflects the patchwork quality of the
existing knowledge. ©

17-16
Perceptions of Dangers of Smoking

A recent trend in smoking and health research involves an attempt to
identify and modify perceptions on the part of children and adolescents
of the dangers of smoking. Evans, et al. (29) suggest that fear-based
smoking-deterrence messages to this age group, enumerating the
future costs of smoking—heart disease, lung cancer, and other serious
diseases or death—are often ineffective because most children and
young adolescents are more present- than future-oriented. They find it
difficult to perceive such future dangers as meaningful or even
important. Studies designed to communicate the immediate physiologi-
cal effects of cigarette smoking on healthy young people (35, 77) may
help to make the health dangers more immediate and compelling.
Filmed demonstrations comparing teenage smokers and nonsmokers
by the nicotine in their saliva, the carbon monoxide in their breath, and
their heart function are components of the 3-year longitudinal study
by Evans, et al. (37).

Critical Evaluations of Some Current Prevention Programs

Several reviewers (29, 34, 67) point out the serious limitations that
exist in evaluating research in this area. A lack of common definitions
of smoking behavior, reliance on self-reporting and lack of objective
measures of smoking, attrition rates in long-term studies, inappropri-
ate statistical analyses, biased sampling errors inherent in using
available volunteer populations, and lack of appropriate control groups
are major limitations of the vast majority of the studies reviewed. The
results of such studies must thus be viewed with caution.

Most smoking prevention programs have not been specifically
directed at children and adolescents who logically should be the key
target of such programs. Rather, they have been general public
information campaigns conducted by private and governmental
agencies, such as the American Heart Association, the American
Cancer Society, and the U.S. Public Health Service. Various in-school
educational programs incorporating inf: ormation concerning the health
hazards of smoking into course curricula and special programs with
certain unique features have also been instituted.

Public Information Campaigns

Major criticisms are leveled at many public information smoking-
prevention campaigns. Too often these programs fail to build in
adequate evaluations. Also, they tend to be notional and atheoretical.
Content and persuasive strategies in these campaigns are too often
arbitrarily chosen, based on subjective judgment, rather than being
systematically pretested. Bradshaw (11) reviews 14 public educational
campaigns between 1960 and 1970 involving local communities, schools,
and universities in both the United States and the United Kingdom. He

1\7—17
concludes that the effects of these campaigns on smoking behavior
have been minimal at best with many producing no apparent effect.
The failure to conduct adequate follow-up evaluations and to include
comparison control groups in studies carried out are among other
criticisms made of these campaigns. Recognizing the many limitations
of these campaigns, Bradshaw calls for more systematically developed
communications which can become the basis of widely disseminated
programs to deter young people from acquiring the smoking habit.

Public information campaigns aimed at prevention can also be
criticized for failing to evaluate the program’s impact over extended
periods of time. For example, Fishbein (34), in a recent report to the
Federal Trade Commission, indicates that at the present time we do
not have enough information about the beliefs, attitudes, and
intentions already held by the public with respect to smoking decisions
(i.e., to initiate, reduce, increase, or stop) or information regarding the
degree to which these decisions are under attitudinal or normative
control. Fishbein suggests that this information is necessary in order to
develop communication materials of all kinds that would contain the
most appropriate arguments for affecting a given smoking decision.
Concluding his report, he states that “Although there is much that
could be done immediately to inform the public, much more research is
necessary if one wishes to maximize the likelihood that information
will also influence a smoking decision” (p. vi).

Most critically, public information campaigns directed at prevention
of smoking have been too broadly targeted. They have not reflected
the beliefs, attitudes, and intentions held by what should be the prime
target for prevention programs: children and adolescents. As men-
tioned earlier, such campaigns must take into consideration the specific
developmental level of the child or adolescent. Evans, et al. (31), for
example, find that older adolescents may respond to different smoking
prevention messages than younger adolescents.

School Programs

The majority of school programs are preventive in intent, whether
they are oriented toward exploring generic research issues or are
merely single classroom demonstrations of so called “hands-on”
programs designed to illustrate some specific aspect of smoking.

Unfortunately, the vast majority of such programs possess method-
ological shortcomings, particularly in evaluation designs. Many of the
reports of these programs fail to present the documentation necessary
for the most rudimentary evaluation by the reader. It should be noted,
however, that much of the literature related to children and smoking is
found in publications that may not require or encourage reports which
are carefully detailed and which include rigorous evaluations.

Many of these reports are anecdotal or descriptive in nature or are
offered merely as guidelines for curriculum planning and implementa-

17—18
tion. Such a morass of programs reported so loosely cannot be
compared within any theoretical framework. This leads to frequent
repetition of efforts. It appears that in school smoking-prevention
programs, the “wheel” is regularly reinvented. Since a critical
evaluation of most school programs is thus virtually impossible, at least
some observations concerning current school programs will be
presented and the implications of these observations for planning more
rigorously evaluated programs will be discussed.

In a recent review, Thompson (84) expresses a general cynicism
concerning the effectiveness of school programs. She further states
that multimethod campaigns and youth-to-youth programs are gener-
ally ineffective. Terry and Woodward (82) report that relatively few
teachers are trained as health educators, and Chen and Rakip (15) find
serious problems in teacher implementation of programs on smoking
and health. Teachers themselves often express a lack of confidence in
their ability effectively to implement smoking education programs.
This inability may be reflected in Levitt’s (49) survey of 50,000 Indiana
school children, in which less than 1 percent of the students indicate
receiving information about smoking in school health classes. A
comprehensive program for teacher training, at the preservice and
inservice levels, in evaluating and implementing smoking and health
programs is an area where effective action could be taken based on
present knowledge and research.

One promising trend involves preplanned longitudinal, comprehen-
sive studies in school settings carried out by large institutions (e.g.,
universities) with a strong commitment to evaluation. The pressure to
produce immediate and specific effects on smoking is somewhat
lessened because they are being carried out in the context of long-
range evaluation. Thus the investigator has the opportunity to design
conceptually sound projects based on sophisticated models. Such
studies are also fruitful in producing spinoff studies that test specific
hypotheses, pinpoint effects, and eliminate unworkable approaches.
Stringent preplanned evaluation is an integral part of the best of these
in-school programs. While such long range programs, implemented and
evaluated over substantial periods of time, are both costly and difficult
to manage scientifically and logistically, the data produced may have
important implications for developing systematic theoretical concepts
and in generating new research. Such studies may come closer to
isolating the complex social, physiological, and psychological factors
that underlie the smoking phenomenon. Generally, such programs are
carried out so that the community continues to benefit from the
program after its completion, since it provides pretested and evaluated
materials for incorporation into school curricula.

One of the best known of the longitudinal, comprehensive studies is
the National Clearinghouse for Smoking and Health’s School Health
Curriculum Project (based on the so-called Berkeley model) that has

17—19
been introduced into more than 200 school districts in 28 States. The
curriculum is based on results of empirically tested concepts related to
communicating health knowledge to children, including information
about smoking. It is being implemented in programs from kindergar-
ten through seventh grade at the present time. Evaluation components
of the program are just now beginning to yield results. In the smoking
area, a substantial relationship between enrollment and nonenrollment
in the program and smoking knowledge and behavior has been claimed
(58). However, a careful inspection of the quasi-experimental study on
which that assertion is based reveals only small inconsistent differ-
ences (56). Detailed descriptions of the implementation of this program
are given by Edson (23), Caramanica, et al. (14), and Albino and Davis
(2). (The School Health Curriculum Project is discussed more fully in
another chapter in this report.)

The University of Illinois Antismoking Education Study (19, 20) has
been underway for more than a decade. It has produced several
smoking-measurement instruments that have been used in a number of
smoking studies. These instruments incorporate informational, attitu-
dinal, and self-report behavioral components but have not been
validated against more objective measures of actual smoking.

The Illinois Antismoking Education Study generated several kinds
of studies which address themselves to evaluating various in-school
approaches to control smoking. For example, in one study, Irwin, et al.
(41) examine the relative impact of the regular classroom teacher as a
smoking information communicator compared with teachers especially
trained in health communication. Although they find that the
classroom teacher was at least as effective as the specially trained
teacher, more recent studies (82) do not necessarily support this
conclusion. An intention-to-smoke measure was also developed as a
result of the Illinois study. Using this measure, Laoye, et al. (48) find
that a 2-year projection of smoking could be successfully demon-
strated. Merki, et al. (55) explore smoking behavior of rural high school
students and find that student smoking is related to parental smoking
habits, participation in schoo] group activities, and lower educational
aspirations. From a 9-month participant-observation study, Newman
(63, 64) concludes that both covert and overt smoking are low-status
activities for ninth grade girls and overt smoking is a low-status
activity for boys. (The Illinois study is also described more fully
elsewhere in another chapter in this report.)

In Houston a 3-year longitudinal study reported by Evans, et al. (31)
is being undertaken. It is designed to train junior high school students
to resist the pressures to smoke from peers, the media, and models of
smoking parents. Also involved in this study are interventions that
monitor smoking and those that communicate immediate physiological
effects of smoking. A nicotine-in-saliva measure is employed to
increase the validity of self-reports of smoking. A major purpose of the

17—20
study is to explore the feasibility of incorporating into school health
programs inoculations-against-social-pressures-to-smoke messages in
lieu of the frequently used fear-arousal, impersonal, information-
centered communications. Preliminary results indicate that such
intervention strategies, based on the use of films whose content is
derived from feedback from students themselves, may be effective
with some students in deterring the onset of addicted smoking,
although the final results await the completion of the final years of the
investigation. Also, further replications of this general approach to
thwarting smoking behavior in adolescents, using either films or more
personalized interventions, are being undertaken at Stanford (Cheryl
Perry), the University of Minnesota (C. A. Johnson), Tyler, Texas
(Richard Evans), and elsewhere.

General Comments

Obviously, the psychosocial factors that influence the initiation of
smoking are varied and complex. Aside from a few promising
prevention programs, most of them fail to encompass psychosocial
conceptual frameworks. Obviously, there is also a great need for such
programs to be more carefully planned, controlled, and evaluated.

Fodor, et al. (36) propose that educational programs that deal with
the totality of man as a complex being offer the most promise.
“Smoking education must, in fact, become health education, taking
into consideration the multiplicity of factors related to smoking and
health—physical, mental, and social” (p. 94). Rabinowitz and Zimmerli
(72) recognize the complex, long-range problem:

What seems most crucial for future health education planning.....is
that a ‘one-size-fits-all’ approach is contraindicated to student health
teaching in terms of message content, structure, and perhaps,
classroom delivery. To achieve comparable outcomes it may be
essential that several distinct approaches to smoking education be
explored for social subgroups with demonstrably different back-
grounds of exposure, involvement, and maturation (p. 330).

The best efforts at present appear to possess at least some
conceptual basis, are long-term, multiphasic studies attempting to
establish good baseline data, develop and test specific hypotheses using
carefully controlled methods of investigation, employ objective
measures of smoking to validate self-reports, and include evaluations
of the program through several years of implementation.

The ideal prevention program would follow the example of Sweden
(76) where a 25-year effort has begun whose objective is to make those
born in 1975 a nonsmoking generation. The program began in 1974
with expectant parents and is presently concentrating on withdrawal
clinics and other measures to develop a nonsmoking environment for
those children born in 1975. Educational efforts for adults and children

17—21
and increased governmental control over advertising and marketing of
tobacco products are being implemented, and an all-out effort is being
made to create a nonsmoking generation in a nonsmoking environ-
ment, supported by both governmental efforts and the general public.

Some Recommendations for Future Research and Prevention
Programs

Although recommendations for future research and prevention
programs logically emerged in several earlier sections of this chapter,
some additional recommendations may be in order. Most of the current
research concerning psychosocial determinants of smoking in children
and adolescents tends to be correlational in nature. Because of the
limited amount of variance accounted for, it is difficult to establish a
precise linkage between any given psychosocial influence and the
initiation of smoking. Just as Jessor and Jessor (43) have found with
respect to the use of other drugs, it is likely that an array of social
influences precipitates the onset of smoking. What may be needed now
is the selection of some of these specific influences for particular
attention. For example, the influence of the mass media on smoking
initiation, which currently appears to be uncertain, might be better
understood through a series of small, well-controlled basic investiga-
tions. The results of such investigations should be interpreted within
the context of the broader impact of the mass media on the behavior of
children and adolescents to avoid the criticisms leveled at how the
research concerning violence and television was conducted. Additional-
ly, just as the focus in the area of television or films and behavior has
shifted from exploring how they precipitate antisocial behavior to how
they may encourage prosocial behavior (6), some of these investiga-
tions should also examine how the mass media have perhaps
inadvertently contributed to the child’s decision not to begin smoking,
or to quit before he or she has become a confirmed smoker. Perhaps the
use of mass media to counter prosmoking influences should also be
further explored. A similar approach might be used to explore more
explicitly how to counteract the impact of social pressures in the
initiation of smoking (27, 31).

Lacking in most of the investigations reviewed is an adequate
conceptual base. As discussed earlier, certain types of major conceptual
models in developmental and social psychology have gone virtually
unexplored as a source of hypotheses for research in the area of
smoking in children and adolescents. Many other current conceptual
directions in psychology could well be explored as they relate to
smoking. The theory of cognitive dissonance (33), Fishbein’s belief-
behavior concepts (34), Kohlberg’s theory of moral development (47),
impression formation (82), attribution theory (44, 45), decision-making
in children (12), Jessor and Jessor’s multi-determinant conceptual

17—22
structure of problem behavior (43), and the concept of risk-taking (21)
are all examples of theoretical areas that might generate some testable
hypotheses in this area of smoking.

Still another important area of research would be to explore the
interrelationship of the initiation of smoking in children with other
health behaviors. For example, some provocative studies (8, 40), though
not confirmed by other studies such as O’Donnell’s (66), suggest that
smoking may be a “drug entrance ticket.” Children who begin smoking
are more likely to begin using alcohol and hard narcotics. Certainly, a
careful examination of such types of health-behavioral interrelation-
ships would be a crucial area of research. Likewise, how does smoking
relate to the over-all lifestyle of the developing child? A look at the
“natural development” of the smoker, perhaps even completing a few
studies, such as those the Jessors (43) have done with drug usage,
which examine very small samples of children over time, might
generate a number of significant hypotheses.

However, as is being demonstrated in at least one current
investigation (31), useful intervention programs might already be
developed which may have a better chance of having a long-term
impact on the smoking behavior of adolescents than the largely fear-
arousal, impersonal, information-oriented approaches generally used.
Virtually all investigations in this area report that adolescent smokers
and nonsmokers alike really believe that smoking is potentially
dangerous to one’s health (34). Obviously, this fear does not appear to
be enough to deter the onset of smoking or to be sufficiently successful
in motivating smokers to stop (31). Therefore, other types of emphases
in prevention programs should be developed. Such intervention
programs should apply the method of successive approximation. At
each step of the way, the target population of children or adolescents
should provide input into the content of the intervention within the
context of an appropriate psychosocial, conceptual framework. All
intervention materials should be pretested on the children.

Whatever the content of the intervention program, great care should
be taken to plan and utilize an adequate evaluation methodology.
Failure to incorporate rigorous evaluation procedures emerges as a
significant limitation of virtually all of the intervention programs
reviewed. One particularly troublesome problem in evaluation method-
ology deals with the appropriate criterion for the impact of a program.
Measures of information about smoking, attitudes towards smoking, or
self-reports of smoking may not be adequate indicators of a program’s
impact. Serious questions are raised in contemporary social psychologi-
cal literature (30, 32) concerning the relationship between information
gain and attitude change and behavior. It would be most unfortunate
to conclude that a demonstration of the presence of increased
information about smoking dangers or an attitude change toward
smoking has necessarily had a significant impact on smoking behavior.

17—23
|

Furthermore, as smoking among children and young adolescents is a
taboo and socially unacceptable behavior in many social settings (e.g.,
in schools), self-reports of smoking may be inaccurate.

The majority of the investigations reviewed, whether they are
examinations of psychosocial factors, surveys, smoking informational
campaigns, or in-school educational programs, rely heavily upon self-
report measures of smoking. Investigators (73) in the behavioral
science literature describe the existence of an acquiescience or
interpersonal expectation effect; that is, subjects report what they
believe the experimenter expects whether or not it is a true reflection
of their actual behavior. Dunn (22) questions how much credence can
be given to the introspective reports of smokers. He states: “Factors
such as the need for social approval of opinions and actions, the need to
justify a preference commitment, order of presentation effects, brand
imagery effects, halo effects, and the yea-saying tendency are
collectively more determinative of a report of a smoke-induced sensory
experience than is the sensory experience itself” (p. 98). Although this
statement refers principally to self-reports of motivational factors in
smoking, many of the same points can be applied to questioning the
validity of self-reports of smoking itself.

Obviously, measures of smoking behavior that are more objective
than self-reports of smoking are vital for a valid evaluation of
programmed treatments. One such measure has been reported (28, $1).
This involves the use of a procedure which appears to increase the
validity of self-reports of smoking behavior. A mass spectrometric
analysis of nicotine-in-saliva (39) is used to increase the validity of self-
reports. Films depicting this analysis procedure are shown to students
before they have produced a saliva specimen and before they are
requested to record self-reports of their smoking behavior. This results
in significantly more reports of smoking. Other investigators (74) are
exploring the use of chemical indicators of smoking. However, using
only direct chemical indicators as the major dependent measures may
be too costly or may only be recording recent smoking. For example,
nicotine, because of its “half-life” when measured in the blood, records
smoking for only a very brief period (28). Developing improved
techniques for more direct measurement of smoking is clearly an
important area for future investigations.

Finally, future research and prevention programs should address
themselves to the problem of establishing a truly long-term impact.
Many smoking prevention programs often report optimistic success
rates. The reporting of such success rates should be qualified by the
possibility of the individual beginning to smoke at some later time.
Inferences about the evolution of smoking suggest that by the end of
the ninth grade very few adolescents are confirmed smokers. The
critical level of the onset of confirmed smoking appears to be in high
school (88). Therefore, the true impact of any deterrence-of-smoking

17—24
program with adolescents may not even be measurable until after the
adolescent has entered high school. This problem is not unlike the
backsliding or recidivism encountered in virtually all smoking cessation
programs (71, 83).

Thus, in recommendations for future research and in the develop-
ment and implementation of prevention programs with children and
adolescents, the range of possibilities appears vast. Perhaps with a
focus on the initiation of smoking, much critical new knowledge of the
developing life style of children and adolescents will also emerge.
Surely, smoking must be regarded within the total context of the
individual’s development. Perhaps the real question to be answered is:
why do we knowingly choose to engage in self-destructive behavior
when so much of our energy is directed toward preserving our lives?

17—25
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