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E
Adolescents’ and Young Adults’ Perceptions of Tobacco Use: A Review and Critique of the Current Literature

Bonnie L. Halpern-Felsher

Department of Pediatrics

University of California, San Francisco


Malena E. Ramos

Department of Pediatrics

University of California, San Francisco


Jodi L. Cornell

Department of Pediatrics

University of California, San Francisco1

INTRODUCTION

Explanations of individuals’ engagement in risk behavior, including tobacco use, often make reference to one’s inability to judge risk and belief in one’s invulnerability to harm. Judgments about risk are viewed as a fundamental element of most theoretical models of health behavior, including Social Cognitive Theory (Bandura 1994), the Health Belief Model (Rosenstock 1974), the Theory of Reasoned Action (Fishbein and Ajzen 1975), the Theory of Planned Behavior (Ajzen 1985), Self-Regulation Theory (Kanfer 1970), and Subjective Culture and Interpersonal Relations Theory (Triandis 1977). These theories posit individuals’ perceptions about the consequences of their actions, and perceptions of vulnerability to those consequences play a key role in behavior.

The relationship between risk perceptions and risk behavior has been applied particularly to adolescents, as descriptions of adolescent risk taking almost invariably make reference to adolescents’ beliefs in their own invulnerability to harm. The theoretical basis for the assertion of adolescent invulnerability can be traced to Elkind (Elkind 1967; Elkind 1978), who argued that when young adolescents first enter into formal operations, they become cognitively egocentric. Due to this egocentrism, the adolescent is hypothesized to hold an exaggerated sense of uniqueness and to believe in a “personal fable”—that one is special and in some way immune to the natural laws that pertain to others. The belief in this personal fable is thought to be the origin of adolescents’ tendencies to view themselves as invulnerable to harm, and therefore to engage in behaviors considered risky by others.

1

This research was supported in part by grants awarded to Dr. Halpern-Felsher from the Tobacco-Related Disease Research Program, Office of the President, University of California (#9K-0072 and #14RT-0010).



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Ending the Tobacco Problem: A Blueprint for the Nation E Adolescents’ and Young Adults’ Perceptions of Tobacco Use: A Review and Critique of the Current Literature Bonnie L. Halpern-Felsher Department of Pediatrics University of California, San Francisco Malena E. Ramos Department of Pediatrics University of California, San Francisco Jodi L. Cornell Department of Pediatrics University of California, San Francisco1 INTRODUCTION Explanations of individuals’ engagement in risk behavior, including tobacco use, often make reference to one’s inability to judge risk and belief in one’s invulnerability to harm. Judgments about risk are viewed as a fundamental element of most theoretical models of health behavior, including Social Cognitive Theory (Bandura 1994), the Health Belief Model (Rosenstock 1974), the Theory of Reasoned Action (Fishbein and Ajzen 1975), the Theory of Planned Behavior (Ajzen 1985), Self-Regulation Theory (Kanfer 1970), and Subjective Culture and Interpersonal Relations Theory (Triandis 1977). These theories posit individuals’ perceptions about the consequences of their actions, and perceptions of vulnerability to those consequences play a key role in behavior. The relationship between risk perceptions and risk behavior has been applied particularly to adolescents, as descriptions of adolescent risk taking almost invariably make reference to adolescents’ beliefs in their own invulnerability to harm. The theoretical basis for the assertion of adolescent invulnerability can be traced to Elkind (Elkind 1967; Elkind 1978), who argued that when young adolescents first enter into formal operations, they become cognitively egocentric. Due to this egocentrism, the adolescent is hypothesized to hold an exaggerated sense of uniqueness and to believe in a “personal fable”—that one is special and in some way immune to the natural laws that pertain to others. The belief in this personal fable is thought to be the origin of adolescents’ tendencies to view themselves as invulnerable to harm, and therefore to engage in behaviors considered risky by others. 1 This research was supported in part by grants awarded to Dr. Halpern-Felsher from the Tobacco-Related Disease Research Program, Office of the President, University of California (#9K-0072 and #14RT-0010).

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Ending the Tobacco Problem: A Blueprint for the Nation The concept of adolescent “invulnerability” remains pervasive in both scientific and lay circles, is used to explain adolescents’ decisions to engage in potentially harmful behavior, and is incorporated into many tobacco-related prevention and intervention programs (Weinstein 1983; Weisenberg et al. 1980; see also Reyna and Farley 2006). We turn to a review and critique of the empirical literature on the relationship between risk judgments and adolescent tobacco use. EMPIRICAL TESTS OF THE RISK PERCEPTION AND TOBACCO USE LINK The majority of studies testing the relationship between perceptions of risk and tobacco use have compared perceptions of tobacco-related risks between those who have and have not smoked. Although some studies find that adolescents who have smoked perceive greater smoking-related risks than those who have not smoked, others found that smokers perceive less risk. For example, Halpern-Felsher and colleagues (2004) found that adolescent smokers and those who intend to smoke estimated their chance of experiencing a smoking-related negative outcome as less likely that did nonsmokers and non-intenders. A study by Johnson and colleagues (2002) also revealed that for both high school (aged 16–18 years) and college students (aged 18–22 years), smokers saw their outcome risk as higher than that of nonsmokers. Similar findings in a study conducted by Weinstein and colleagues (2005) concluded that adult smokers underestimated their relative risk compared to other smokers and to nonsmokers. A national survey of 6,369 people (1,245 current smokers) examined beliefs about the risks of smoking. Key questions separated samples of smokers who were asked either about their own risk or about the risk of the average smoker. More than half of current smokers thought that their own risk was only twice as high or less as that of nonsmokers. The data clearly indicate that smokers underestimate the extent to which smoking elevates lung cancer risk above that of nonsmokers (Weinstein et al. 2005). Arnett (2000) found greater optimistic bias among smokers than among nonsmokers for both adolescents and adults. Another set of studies has found that smokers, both adolescents and adults, believe that the health risks of smoking are lower for themselves than for other, same-age smokers (Weinstein 1998; Hansen and Malotte 1986; McCoy et al. 1992), but higher compared to nonsmokers (Arnett 2000). There are six salient problems with the literature base on the relationship between risk perceptions and tobacco use. First, Slovic and colleagues (2001; 2004) have argued that studies on tobacco-related risk perception fail to consider the affective components that surround decision making (e.g., Slovic 2001; Slovic et al. 2004). In brief, the affect heuristic is thought to play a role in decisions in part through its influence on perceptions of risks and benefits. For example, if one feels good about engaging in a particular behavior, one might judge risks to be lower and in turn be more inclined toward engagement. With regard to cigarette smoking, Slovic (2004) extends this argument by stating that adolescents might not be weighing the risks and benefits in their decisions to smoke, but instead are driven by affective impulses such as enjoying the new experience or having fun with friends (Slovic et al. 2004). We discuss more about the affect heuristic later in this appendix. A second problem with the literature base is the lack of consideration of whether smokers have or have not experienced a related positive or negative outcome. Studies focusing on the role of outcome experience in risk judgments have shown that individuals who have personally experienced a negative outcome linked to an event or risk behavior perceive the same or similar outcome as more likely to happen than do individuals without such outcome experience (e.g., Gochman 1997; Greening et al. 1996; Roe-Berning and Straker 1997; Vaughan 1993; Weinstein

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Ending the Tobacco Problem: A Blueprint for the Nation 1989). Evidence also suggests that early experiences with tobacco, especially physical responses to nicotine, may be precursors of later regular cigarette smoking and nicotine dependence (Eissenberg and Balster 2000; Pomerleau et al. 1998). Pomerleau and colleagues’ (1998) work on early experiences with tobacco use reveals that physical reactions to nicotine predict adult smoking status and that people who become highly dependent on cigarettes appear to have more pleasurable sensations, such as a pleasurable rush or buzz and relaxation, at their initial exposure to tobacco than those who do not become regular smokers (Pomerleau et al. 1998). Unpleasant reactions to the first cigarette such as nausea and cough do not seem to protect against subsequent smoking (Pomerleau et al. 1998). Thus, when examining the role of behavioral experience in risk judgments, it is important to also examine the effects of outcome experience either statistically or by limiting the samples to those with or without such outcome experience. It is also critical to understand the extent to which such outcome experiences lead to increased or decreased cigarette use among older adolescents and young adults. Third, most studies have elicited general judgments about the likelihood of a given outcome occurring (e.g., what is the chance that you will get lung cancer?) without making the judgment conditional on a behavioral antecedent. It is not surprising that studies using these unconditional risk assessments yield a positive relationship between risk perception and behavior since individuals who are engaging in a risk behavior are truly more likely to experience a negative outcome than are non-engagers. Similarly, non-engagers rate their risk of experiencing the negative outcome as lower than do engagers because they are not engaging in the risk behavior. Instead, one must use conditional risk assessments in which the behavior or event linked to the outcome is specified (e.g., what is the chance that you will get lung cancer if you smoke?) (Halpern-Felsher et al. 2001; Ronis 1992; Van der Velde and Hooykaas 1996). Conditional risk assessments are more closely related to factors incorporated in models of health behavior and have been better predictors of behavior than unconditional risk assessments (Ronis 1992; Van der Velde and Hooykass 1996). Fourth, although studies have identified factors associated with tobacco use among multiethnic youth (e.g., Gritz et al. 2003), few studies on adolescent risk perception have included demographic variables such as gender, race or ethnicity, or socioeconomic status, and no study has explored whether these variables moderate the risk perception–tobacco use link. It is possible that the level of perceived risk (and benefit) may differ across groups of individuals, possibly as a factor of culture, socioeconomic status, or differences in exposure to behavior-related outcomes, for example. Alternatively, groups of adolescents or young adults might perceive the same level of risk, but these perceptions might have different implications for their smoking, in part due to differences in perceived control, risk-reducing strategies used, or the value placed on the negative outcome (e.g., bad breath or trouble breathing) compared to the value placed on the benefit (e.g., looking cool) of smoking. Fifth, the majority of studies assessing the link between risk perceptions and tobacco use have employed a cross-sectional design. Therefore, the direction of influence between behavioral experiences and risk perceptions is not discernible. Although perceptions of risk are theorized to motivate behavior, it is plausible to suggest that risk perceptions are reflective of behavioral experiences (e.g., Gerrard et al. 1996; Halpern-Felsher et al. 2001). Further, the nature of the relationship is likely to change over time, depending on factors such as experience, which are known to bias judgment (Weinstein and Nicolich 1993). Finally, many studies examining the relationship between risk perceptions and tobacco use have focused on the onset of tobacco use and have thus included younger adolescent samples.

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Ending the Tobacco Problem: A Blueprint for the Nation Few studies have examined the relationship between risk perceptions and behavior in older adolescence or adulthood, nor have studies determined whether such a relationship is predictive of changes in tobacco use over time. A notable exception is the study by Chassin and colleagues (2000), in which less positive beliefs about smoking were found for adolescent abstainers and later onsetters, as well as among adults who never became established regular smokers. Tucker and colleagues (2003) found no relationship between risk perceptions and tobacco use over time. ADOLESCENTS’ UNDERSTANDING OF THE INHERENT RISKS OF TOBACCO USE In addition to examining the extent to which risk perceptions play an important role in one’s decisions to smoke, a number of studies have examined adolescents’ understanding of tobacco-related risks, including an understanding of actual risks, long- versus short-term risks, health versus social consequences, perceived risk for different types of cigarettes, and cumulative risk of tobacco use over time. These studies are reviewed next. Understanding of Actual Tobacco-Related Risks A number of studies have examined whether adolescents and adults understand the actual risk of tobacco use, compared to epidemiological data. Some studies show that smokers either overestimate or underestimate (e.g., Borland 1997; Halpern-Felsher et al. 2004; Kristiansen et al. 1983; Schoenbrun 1997; Viscusi 1990; 1991; 1992; Viscusi et al. 2000; see also Slovic 2001) the risks of smoking. Jamieson and Romer (2001) found that 14–22 year olds vary in their sensitivity to risk associated with smoking mortality compared to other risk behaviors. Their results noted that 70 percent of smokers and 79 percent of nonsmokers overestimated the risk of lung cancer. Although their beliefs about the likelihood of dying from a smoking-related cause were more accurate (34 percent of smokers and 41 percent of nonsmokers overestimated the death rate from smoking), 41 percent of smokers and 27 percent of nonsmokers either underestimated or did not know this rate. Many study participants (26 percent of nonsmokers and 21 percent of smokers) also underestimated years of life lost due to smoking and inaccurately perceived more deaths caused by gunshots, car accidents, alcohol, and other drug use than by smoking cigarettes. Perceived Short- Versus Long-Term Tobacco-Related Risks Historically, studies have focused primarily on long-term health risks such as heart attack and lung cancer. More recently, there has been an emphasis on short-term risks that are more salient to adolescents, such as the smell of cigarettes, the yellowing of teeth, and the possibility of getting into trouble (Gritz et al. 2003; Halpern-Felsher et al. 2004; Prokhorov et al. 2002). There is also good evidence to suggest that there are other aspects of tobacco risks not fully understood by adolescents and young adults. Slovic (e.g. Slovic 1998; 2001; Arnett 2000; Leventhal et al. 1987) argued that although adolescents in general might be aware of the health and long-term risks of smoking, they are much less aware of the addictive nature of smoking. In fact, studies suggest that adolescent smokers might be less worried about the long-term risks of smoking in part because they believe that they can quit smoking easily and at any time (Arnett 2000; Halpern-Felsher et al. 2004; Slovic 1998). We discuss adolescents’ perceptions of addiction in greater depth later in this appendix.

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Ending the Tobacco Problem: A Blueprint for the Nation Perceived Risk Varies by Type of Cigarettes Smoked Despite evidence that “light” cigarettes are not a safe alternative to smoking, adults harbor misperceptions about the health risks associated with smoking light and ultralight cigarettes, with a large proportion of adult smokers believing that such cigarettes deliver less tar and nicotine, produce milder sensations, reduce the health risks associated with smoking, and assist with smoking cessation. Some smokers have switched to “low-yield” cigarettes in an attempt to reduce the health consequences of smoking (Slovic 2001). When smoking lower-yield cigarettes, smokers puff more frequently or more intensely than when smoking higher-yield cigarettes, presumably to obtain their usual specific level of nicotine from each cigarette. In switching from high-yield to low-yield cigarettes, smokers consume more nicotine from a low-yield cigarette than predicted from high-yield cigarettes (Slovic 2001). A study by Shiffman and colleagues (2001) presented results of a survey of more than 2,120 adults aged 18 or over who were daily smokers. Most smokers in the study believed that lights and ultralights were less harsh and delivered less tar and nicotine compared to regular cigarettes. In fact, all three types of smokers (i.e., of regulars, lights, and ultralights) believed that ultralight cigarettes were less hazardous than lights. Although most smokers thought that smoking lights or ultralights was closer in risk to smoking regular cigarettes than to not smoking at all, 8.7 percent thought that light cigarettes were closer in risk to not smoking, while 20.9 percent believed that the risk of ultralight cigarettes was closer to that of not smoking. Among smokers of ultralights, 27.1 percent believed the risk of smoking ultralights was closer to that of not smoking at all than that of smoking regulars; this was also true of 22.1 percent of the smokers of light cigarettes. Data presented by Etter and colleagues (2003) support the findings by Shiffman and colleagues (2001) that the risk of lung cancer was perceived to be lower in smokers of light cigarettes than in smokers of regular cigarettes. In a sample that included 2,000 people aged 18–70 years, 27 percent of participants answered that the risk of lung cancer was lower in smokers of light cigarettes than in smokers of regular cigarettes; 60 percent said that the risk was the same, and 7 percent said that the risk was higher. For ultralight cigarettes, the corresponding figures were 32, 55, and 6 percent, respectively (Etter et al. 2003). In addition, participants thought that one would have to smoke two light cigarettes or four ultralight cigarettes in order to inhale the same amount of nicotine as that from one regular cigarette. Many smokers choose light cigarettes because they think that such cigarettes are safer or less addictive (Etter et al. 2003). A study conducted by Cummings and colleagues (2004) examined the extent to which smokers of Marlboro Lights perceived lower health risks associated with using a low-tar cigarettes and the extent to which they were aware of filter vents in their cigarettes. In a large-sized sample of adult current cigarette smokers (n = 1,046), 68 percent of Marlboro Lights smokers were unaware that the filters on their cigarettes were ventilated. Many Marlboro Lights smokers also expressed the belief that low-tar and filtered cigarettes are safer than full-flavored cigarettes (Cummings et al. 2004). In addition, a substantial minority of participants (one in four) answered that smokers of light cigarettes were at lower risk of developing lung cancer than smokers of regular cigarettes (Cummings et al. 2004). Fewer studies on perceptions of light cigarettes have been conducted with adolescent samples. A notable exception is a study conducted by Kropp and Halpern-Felsher (2004) in which participants perceived that they would be significantly less likely to get lung cancer, have a heart attack, die from a smoking-related disease, get a bad cough, have trouble breathing, and get wrinkles from smoking light cigarettes than from smoking regular cigarettes for the rest of their lives. Furthermore, when participants were asked how long it would take to become addicted to

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Ending the Tobacco Problem: A Blueprint for the Nation the two cigarette types, they thought it would take significantly longer to become addicted to light versus regular cigarettes. In addition, participants also thought that their chances of being able to quit smoking were higher with light cigarettes than with regular cigarettes. They also agreed or strongly agreed that regular cigarettes deliver more tar than light cigarettes and that light cigarettes deliver less nicotine than regular cigarettes. Although some of the adolescents in this study were aware of the health risks and addictive properties associated with light cigarettes, the data clearly showed that 22 percent of the adolescents were uncertain regarding the differences between regular and light cigarettes and between 25 percent and 35 percent of the adolescents thought that health risks were more likely with regular cigarettes use than with light cigarettes. These studies confirm that adults and adolescents, as well as smokers and nonsmokers, harbor misconceptions about so-called light cigarettes. Such perceptions are likely the result, in part, of the tobacco industry’s marketing of light cigarettes as the healthier smoking choice, a safer alternative to cessation, and a first step toward quitting smoking altogether. Understanding of Cumulative Risk Another small set of studies has examined whether adolescents recognize and acknowledge another aspect of tobacco risk: cumulative risk. Cumulative risk is exposure to a hazard occurring repeatedly over time. A study conducted by Slovic (2000) showed that young smokers, as cumulative risk takers, believe they can get away with some amount of smoking before the risks take hold. Many young smokers tend to believe that smoking the “very next cigarette” poses little or no risk to their health or that smoking for only a few years poses negligible risk (Slovic 2000). Denial about the short-term risks of smoking is higher among adolescent smokers compared to nonsmokers (Slovic 2000). Among adults, the light—that is, the occasional smoker—is in general less addicted than are daily smokers of more than five cigarettes per day (Shiffman 1989). The use of tobacco in response to withdrawal symptoms is less of a factor in such tobacco users. Among adults, light or occasional smokers are relatively uncommon (less than 10 percent of adult smokers); they have greater success in smoking cessation than do heavier smokers, although not all light smokers are able to quit (Benowitz 2001). In contrast, many more adolescents than adults are light or occasional smokers. However, light smoking by adolescents is often not a stable pattern; rather, it represents a state in escalation to daily smoking (Benowitz 2001). Successful smoking cessation may also be affected by the motives for smoking behavior (Rose et al. 1996). For example, Pomerleau and colleagues (1978) reported that those who smoked for affect regulation reasons were less likely to quit, and this may also be true for those who report higher levels of perceived addiction as motivating their smoking behavior. Data collected from two surveys (Robert Wood Johnson, [RWJ], and Annenberg School of Communication, [ANN]) found that 69 percent of RWJ and 45 percent of ANN participants rated their own difficulty of quitting as lower than that of other smokers’ (Weinstein et al. 2004). Figures were lower among the adult cohort from these two surveys. ADOLESCENTS AND NICOTINE ADDICTION Understanding adolescents’ perspectives of nicotine addiction is important since more than 90 percent of addicted smokers began smoking during adolescence (Bottorff et al. 2004; Benowitz 2001; Colby et al. 2000; Epstein et al. 2000), making tobacco use and addiction one of

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Ending the Tobacco Problem: A Blueprint for the Nation the greatest public health concerns in the United States and worldwide (Quintero and Davis 2002; Rugkasa et al. 2001). Nicotine dependence (ND) is defined as the compulsive use of cigarettes to achieve pleasurable and other effects and to avoid withdrawal symptoms (Fagerstrom and Schneider 1989; Rojas et al. 1998). This type of dependence consists of both nicotine seeking (compulsive use for positive reinforcement) and avoidance of nicotine withdrawal symptoms (compulsive use for negative reinforcement), such as a strong compulsion to smoke, irritability, and restlessness (Prokhorov et al. 1996). DiFranza, Savageau, Rigotti and colleagues (2002) showed that approximately 20 percent of adolescents (n = 679) reported nicotine dependence symptoms within a month of initiating monthly smoking. Many smokers report that smoking enhances performance and mood (Benowitz 2001). However, the extent to which the enhanced performance and mood after smoking are due to the relief of symptoms of abstinence or to an intrinsic enhancement effect on the brain is unclear (Benowitz 2001). Thus, nicotine dependence has origins that are both psychologic and biologic, both of which are intimately related. Adolescents’ Perceptions of Addiction There are few studies conducted specifically on the topic of children’s, adolescents’, and young adults’ perceptions of nicotine addiction. In a quantitative study of almost 400 adolescents, Halpern-Felsher and colleagues (2004) showed that adolescents who have smoked believe that they are significantly less likely to become addicted than are adolescents who reported no smoking experience. Similar results were found between adolescents who intend to smoke in the near future and adolescents with no intentions to smoke. Rubinstein and colleagues (2003) examined whether and how adolescents discriminate among categories of smokers and how these discriminations engender different smoking-related perceptions. Five hundred fifty 9th graders who reported never smoking tobacco completed a self-administered survey concerning smoking attitudes and beliefs. The results indicated that adolescents discriminated significantly among nonsmokers, casual smokers, smokers, and addicted smokers, based on both frequency of smoking and the number of cigarettes smoked. Addicted smokers were perceived as having the greatest chance of experiencing negative outcomes, followed by smokers, casual smokers, and last, nonsmokers. Finally, adolescents ascribed a far greater chance of quitting smoking to casual smokers than they did to either regular or addicted smokers. Other studies’ use of both structured and unstructured interviews has motivated our need for further understanding of nicotine dependence among this population. Although a wide range of reasons to smoke were cited among various studies, some of the most common values to emerge included mood management, peer influences, addiction, and image maintenance (Bottorff et al. 2004; Moffat and Johnson 2001; Quintero and Davis 2002). For example, a multi-phase qualitative study conducted by Johnson and colleagues (2003) found that social, pleasure, emotional, and empowerment aspects all played a role in adolescents’ perspectives on the need to smoke. Study participants gave explanations such as “needing to smoke” or being “controlled by cigarettes,” while others described using cigarettes to “feel calm” and the need “to connect” with their peers (Johnson et al. 2003). Another qualitative study conducted among children also had emergent themes similar to those found in studies among young adults. Rugkasa and colleagues (2001) conducted 85 focused interviews among children 10–11 years of age. The study data implied that children’s conceptualizations of nicotine addiction are linked to the notion that tobacco consumption is something that symbolically belongs to the world of adults (Porcellato et al. 1999). Whereas adult

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Ending the Tobacco Problem: A Blueprint for the Nation smokers are perceived as dependent on nicotine, child smokers are perceived in terms of social relations, such as “young people smoke to appear ‘cool,’ ‘hard,’ and ‘grown up’” (Rugkasa et al. 2001). Young children’s ideas of addiction were frequently conflated with “getting used to it” or even simply being able to “handle it” as well as “liking” or “enjoying the taste of cigarettes” when referring to experienced child smoking (Rugkasa et al. 2001; Wang et al. 2004). Johnson and colleagues (2003) found that dependence for adolescents extends beyond nicotine and can be defined by tobacco fulfilling emotional needs (i.e., avoiding unpleasant feelings), social needs (i.e. connecting with others), pleasure-seeking needs, and individuality development. Rugaska and colleagues (2001) concluded that youth perceive dependence risks to be associated only with adult smoking because of their view of adults smoking to cope with everyday life while youth thought their smoking for social reasons was safe. Physical responses to first smoking experience, such as relaxation and dizziness, are associated with the development of nicotine dependence (DiFranza et al. 2004). A narrative inquiry conducted by Moffat and Johnson (2001) found three narratives that emerged among adolescent female participants: invincibility, giving, and unanticipated addiction. Two subnarratives that came about were needing to quit and repeating history (Moffat and Johnson 2001). The authors concluded that semantics and identity issues were key to understanding adolescents’ perceptions. Further studies of both qualitative and quantitative design are needed to add to our understanding of children’s and young adults’ perception of nicotine dependence in order to better inform future intervention programs. Adolescents’ Perceptions of Ability to Quit Smoking Belief in the short-term safety of smoking may combine insidiously with a tendency of young smokers to underestimate or be uninformed about the difficulty of stopping smoking (Slovic 1998). A longitudinal survey conducted as part of the University of Michigan’s Monitoring the Future Study found that 85 percent of high school seniors predicted that they probably or definitely would not be smoking in 5 years, as did 32 percent of those who smoked one or more packs of cigarettes per day. In a follow-up study conducted 5 to 6 years later, of those who had smoked at least one pack per day as seniors, only 13 percent had quit and 72 percent still smoked one pack or more per day (Slovic 1998). A study conducted by Weinstein and colleagues (2004) explored what smokers believe about the difficulty of quitting smoking and the nature of addiction. With data collected in two nationwide surveys (n = 361 and n = 788), an overwhelming proportion (96 percent) of both youth and adult smokers agreed with the statement, “The longer you smoke, the harder it is to quit.” Most also agreed that signs of addiction appear very quickly if a teenager starts smoking half a pack of cigarettes a day: 80 percent of youth and 79 percent of adults said that signs appeared in a few months or less. Although respondents did not appear to be reluctant to say that they were addicted, many smokers, especially youth, tended to claim they were less addicted than the average smoker (Weinstein et al. 2004). Jamieson and Romer (2001) found smokers to hold relatively optimistic beliefs about the meaning of tobacco addiction. Although 82 percent agreed that “a chemical in cigarettes makes smoking addictive,” nearly 60 percent of these smokers still said that they believed quitting is either very easy or possible for most people if they really try (Jamieson and Romer 2001). Similar findings were shown by Weinstein and colleagues (2004) when both youth and adult smokers who want to quit greatly overestimate the likelihood that they will succeed in the coming year.

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Ending the Tobacco Problem: A Blueprint for the Nation When asked about their perceptions of the ease of quitting smoking, adolescents with smoking experience believed that they were more likely to quit smoking and would find it easier to quit smoking than did adolescents with no smoking experience (Halpern-Felsher et al. 2004). Quitting intention has been shown to be modestly related to beliefs about the use of “light” and “ultralight” cigarettes (Etter et al. 2003). Smokers of light cigarettes had the greatest interest in quitting, significantly greater than that of ultralight smokers, while regular smokers achieved only an intermediate quit index score that was significantly different from that of light smokers. Light and ultralight smokers who believed their cigarettes were safer, milder, or delivered less tar and nicotine were currently less interested in quitting, but only very slightly so. Interest in quitting was lowest among those who either denied or strongly endorsed the belief that light and ultralight cigarettes were less harsh (Shiffman et al. 2001a). Kropp and Halpern-Felsher (2004) reported that adolescents believed it would be easier to quit smoking light compared to regular cigarettes. Arnett (2000) assessed the optimistic bias in relation to smoking among both adolescents (aged 12–17 years) and adults (aged 30–50 years). A questionnaire about smoking behavior, attitudes, and smoking risk perceptions was completed to address whether the optimistic bias related to smoking risks was greater for adolescents than for adults. Nearly 60 percent of adolescents and 48 percent of adults believed that “I could smoke for a few years and then quit if I want to,” which shows that many adolescent smokers hold an optimistic bias that the addictiveness of smoking that applies to “most people” does not apply to themselves (Arnett 2000). Weinstein and colleagues (2005) found that people who planned to quit judged their absolute risk of lung cancer as higher than did people who did not plan to quit. People who planned to quit also judged their relative risk of lung cancer higher, and among those not planning to quit, 57.3 percent said that their risk was “the same” as or “a little higher” than nonsmokers. People who did not plan to quit were also more likely to believe that genes primarily determine lung cancer. Perceptions of Secondhand Smoke Despite numerous studies on adolescents’ recognition of the medical risks of primary smoke, and conclusive evidence and public health messages concerning the risks of secondhand smoke, there have been surprisingly few investigations of how adolescents perceive the risks associated with exposure to secondhand smoke. Glantz and Jamieson (2000) asked adolescents whether “thousands of nonsmokers die from breathing other people’s smoke” and found that nonsmoking youth endorsed this statement more than youth who have smoked. They also showed that awareness of the effects of secondhand smoke was related to adolescents’ plans to quit smoking. Romer and Jamieson (2001) found that knowledge of the dangers of secondhand smoke was indirectly related to intentions to quit, through its relationship with perceived risk of smoking overall. In their study of elementary, middle, and high school African American students, Kurtz and colleagues (1996) showed that students with smoking experience had less knowledge about and less negative attitudes toward secondhand smoke and they made fewer efforts to prevent exposure to secondhand smoke than did students without smoking experience. Halpern-Felsher and Rubinstein (2005) explored adolescents’ perceptions of secondhand smoke. Recent literature has suggested that adolescents’ perceptions of the effects of secondhand smoke might serve to deter them from smoking. To address this issue, Halpern-Felsher and Rubinstein (2005) examined: (1) how adolescents perceive the risks associated with primary tobacco exposure compared to secondary exposure, (2) whether adolescents’ perceptions of the

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Ending the Tobacco Problem: A Blueprint for the Nation risks from secondhand smoke vary by whether the adolescent has smoked or not, and (3) whether adolescents’ perceived risks of secondhand smoke varies based on who is producing the secondhand smoke. They found that while adolescents perceived the risk from primary smoke to be greater than that from secondhand smoke, they were still aware of the serious risks posed by exposure to secondhand smoke. Adolescents who have smoked were more likely to perceive the risks from exposure to secondhand smoke as lower than did adolescents who had never smoked. According to adolescents, the greatest risks from secondhand smoke are those from exposure to parental smoking, then from exposure to an officemate’s smoke, and then from smoke from a similar-aged friend. The finding that adolescents are acutely aware of the risks from secondhand smoke may provide another method of approaching smoking prevention and cessation among both teens and their parents. In particular, it may be prudent to include the risks from secondhand smoke exposure in antismoking messages as a further means of discouraging smoking. Perceptions of Tobacco-Related Benefits In order to understand how perceived benefits motivate individuals to smoke, compared with how perceived risks deter smoking, one must integrate these lines of research into one coherent theoretical model, which necessitates examining both sets of perceptions. The Decisional Balance Inventory, a construct of the Transtheoretical Model (Prochaska et al. 1992; Prochaska and Velicer 1992), incorporates a weighing of both the benefits (pros) and the risks (cons) in predicting behavior and behavior change. Applied to smoking, the model encompasses three factors: social pros (e.g., kids who smoke have more friends), coping pros (e.g., smoking relieves tension), and cons (e.g., smoking smells). This construct includes a number of social and short-term outcomes rather than relying solely on long-term health outcomes that are less salient to adolescents and young adults. Tobacco use among adolescents may hinge on their perceptions not only of risks (Slovic 2000), but of benefits as well. Using this inventory, Prokhorov and colleagues (2002) found that scores on the smoking pros scale increased and con scores decreased as adolescents’ susceptibility to smoking increased. Similarly, Pallonen and colleagues (1998) showed a positive relationship between perceived smoking benefits and nonsmokers’ likelihood of tobacco onset, whereas the cons of smoking were less predictive of smoking acquisition. Pallonen and colleagues (1998) found that adolescent nonsmokers were more likely to start smoking or to try smoking if they believe smoking is useful in helping one cope. Halpern-Felsher and colleagues (2004) and Goldberg and colleagues (2002) found that participants who have smoked perceived benefits to be more likely to occur, and risks less likely to occur, than did adolescents who have not smoked. The competence enhancement approach has been used in many smoking prevention programs. Epstein and colleagues (2000) conducted a study in which a sample of 1,459 middle and junior high school students self-reported to test whether a deficiency in competence (poor decision-making skills, low personal efficacy) is linked to acquiring beliefs in the perceived benefits of smoking and whether these perceived benefits are then related to subsequent smoking. The authors of the study found that adolescents with deficiencies in personal competence were more likely to believe that smoking offers social benefits such as looking cool, having more friends, and being better liked. Consequently, adolescents holding these beliefs in the 1-year follow-up were more likely to engage in the 2-year follow-up assessment (Epstein et al. 2000).

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Ending the Tobacco Problem: A Blueprint for the Nation Gender Differences in Perceived Benefits Previous studies have found limited gender-specific differences among smokers with regards to perceived benefits of smoking. Although the research is currently limited to adult cohorts, these findings may point to possible gender differences in adolescents as well. Pirie and colleagues (1991) reported that women were more likely than men to be concerned about post-cessation weight gain. Swan and colleagues (1993) found that women identified weight gain as the cause for relapse to smoking and women who were more concerned about post-cessation weight gain were less likely to be motivated to quit smoking (Weekley et al. 1992). Females reported more ND symptoms than males, even though levels of cigarette consumption were similar (O’Loughlin et al. 2003). McKee and colleagues (2005) conducted a study with 93 adult participants and found that females indicated greater likelihood ratings of perceived risk and benefits than males, although the magnitude of these differences was small. Perceived benefits were positively associated with motivation for men and women, although the authors did not find any gender-specific effects for this relationship. There was also no significant interaction between perceived benefits and gender, predicting pretreatment motivation. Women are less likely to acknowledge the health benefits of smoking cessation (Sorensen and Pachacek 1987) and less likely to be motivated to quit to gain health benefits than men (Curry et al. 1997). Similar studies conducted among the adolescent cohort would be valuable in understanding why females have poorer smoking cessation outcomes compared to males (Perkins 2001). Further studies are needed with adolescents to determine if these gender differences exist in younger cohorts. Adolescents’ Reasons for Smoking Qualitative studies have used methodology such as focus groups or one-on-one interviewing to understand the motivations for teen smoking. Vuckovic and colleagues (2003) found that reasons for smoking included to relieve stress and boredom, because parents smoke, to fit in with peers, to decrease appetite, and to increase the high from alcohol and drugs. Similar reasons for teen smoking were cited in Nichter and colleagues (1997 ) study with female adolescents. Other studies suggest that adolescents form perceptions of smoking images, such as nonsmokers being more mature (Lloyd et al. 1997), and adolescents recognize that different types of smoking identities beyond the usual categories of nonsmokers, experimenters, and smokers exist for adolescents (Johnson et al. 2003). Smoking initiation or first-time use of tobacco has specifically been addressed in qualitative studies. Curiosity as a reason to try smoking is a prominent theme in several qualitative studies (Kegler et al. 2000; Plano et al. 2002; Dunn and Johnson 2001), as well as peer influences as wanting to fit in (Gittelshon et al. 2001). Other studies have identified peer and social influences as main reasons that teens continue to smoke after initiation. Kegler and colleagues (2001) discovered that the adolescents’ most recent smoking events were for more social reasons such as peer inclusion and to alleviate boredom. Qualitative studies comment on peers as reinforcers of smoking behavior by expecting smoking within the peer group (Plano et al. 2002; Gittelsohn et al. 2001; Kegler et al. 2000). The Affect Heuristic Risk perception is typically conceptualized as a cognitive construct—that is, an estimate of the likelihood of a negative event happening—rather than as an affective construct (Gerrard et al. 2003). Although it has been found in many studies that the relationships between these percep-

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Ending the Tobacco Problem: A Blueprint for the Nation tions and intentions are more analytical, thoughtful, and planned (Gerrard et al. 2003), it has been argued that the vast majority of risk decisions are motivated by affect rather than by analysis of quantitative statistical facts (Slovic 2003). This is especially relevant to adolescents. Risk feelings are instinctive reactions in which one evaluates risk. Affect is defined as a subtle form of emotion typically defined by positive (like) or negative (dislike) evaluative feelings toward an external stimulus (Slovic 2003). The reliance on affect and emotion that is thought to happen automatically and reactively is called “experiential thinking.” This type of risk analysis is characterized as the affect heuristic and is argued to guide information-processing and judgment (Slovic al. 2004). The reliance of experiential thinking comes from the act of doing something of habit and allows the performance of activities to happen quickly without the need to think through each step. The fields of marketing and advertising have exploited this type of thinking in order to promote positive imagery and affect toward smoking. Affective cues emanating from the social environment are also powerful influences on smoking behavior (Slovic 2003). Examples of this include healthy and beautiful people smoking and enjoying cigarettes among the company of friends. Unfortunately, experiential thinking does not appreciate the cumulative risk of smoking and nicotine addiction (Slovic 2003). It does, however, play a role in how risks and benefits are perceived and evaluated. This, in turn, has an effect on decision-making abilities, especially with regard to smoking. The importance of affect evaluation is considered to be a part of the overall decision-making process. Since adolescence is a pivotal developmental period in which difficult decisions are made that can have lasting consequences, it is imperative to consider risk feelings as they pertain to overall decision-making abilities. An inverse relationship between perceived risk and perceived benefit of an activity was linked to the strength of positive or negative affect associated with that activity (Alhakami and Slovic 1994; Slovic et al. 2004). In the model of affect heuristic as described in Slovic and colleagues (2004), people base their judgments of an activity or a technology not only on what they think about it but also on how they feel about it. If their feelings toward an activity are favorable, they are moved toward judging the risks as low and the benefits as high. In contrast, if their feelings toward it are unfavorable, they tend to judge the opposite—high risk and low benefit (Slovic et al. 2004). Thus, under this model, affect comes prior to, and directs, judgments of risk and benefit (Slovic et al. 2004). Affective thinking is one mode of thinking; the other is the “rational” or analytic. While both need to be considered in the decision-making process, the affective or “experiential” mode is thought to play an active role in motivating risk behaviors. Thus, in Slovic’s (2004) view, affect contributes to the perception of benefits that promotes smoking behavior. SUMMARY Studies have indicated that, in general, adolescents understand that there are risks associated with smoking (Leventhal et al. 1987; Viscusi 1992; Jamieson and Romer 2001; Arnett 2000). However, there has been debate about how adolescents understand the nature of smoking risks and to what extent their understanding or knowledge about these risks either hinders or promotes their decision to smoke. One viewpoint is that smokers are “informed consumers” making rational choices, and not only are people well aware of the risks associated with smoking, including the risks of getting lung cancer and the mortality and life expectancy rates associated with smoking, but smokers are overestimating these risks (Viscussi 1992). This view includes adolescents within a rational learning model as consumers who respond appropriately to information and make trade-offs between the costs and benefits of smoking. Another viewpoint argues that

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Ending the Tobacco Problem: A Blueprint for the Nation such analyses fail to consider vital aspects of risk such as the influence of optimistic bias, cumulative risk, and youth misperception of addiction (Benowitz 2001; Slovic 2001). Thus, it is important to take into account to what extent adolescents are truly aware of the full extent to which smoking is harmful, including the relative risks of smoking versus other risks, their misperceptions of addiction, and how this judgment process motivates their decision-making behavior. The review provided in this appendix suggests that adolescents and young adults are aware of some of the risks involved in tobacco use, especially those consequences most stressed by public health campaigns. That is, they are aware that smoking involves a significant risk of lung cancer, heart attack, and other health outcomes. However, adolescents are not aware of the full extent to which smoking is harmful, including the relative risk of smoking versus other risks such as alcohol use, getting hit by a car, and so on. In addition, they are not as aware of the cumulative risk of tobacco use or the years of life lost due to tobacco use. Importantly, adolescents are less aware and have less of an understanding of the addictive nature of tobacco use. That is in part because they simply do not understand the risks of addiction and the cumulative nature of tobacco risks, and in part because they believe they can quit at any time and therefore avoid addiction. This is particularly important because adolescents believe that they can negate the risks of smoking by altering the amount they smoke, when they smoke (e.g., only on weekends, only every few days), or what they smoke (e.g., “light” versus regular cigarettes). Similarly, they are less likely to believe that the risk of addiction and related health consequences apply to them because they believe they have control over their tobacco use and its consequences. The literature also strongly suggests that adolescents’ decisions to smoke are not just based on a consideration of long-term health risks. Clearly, social risks (e.g., getting into trouble, smelling bad) play an important role in their behavioral decision making. Additionally, perceived benefits are weighed heavily among adolescents, because they are very much aware that smoking can reduce stress and increase concentration. These findings suggest that efforts to prevent or reduce tobacco use among adolescents might be more effective if they not only focus on long-term health risks but address all of adolescents perceptions, and misperceptions, about tobacco use, including the social consequences, benefits, cumulative risk, and addiction.

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