Scottish Government

1. Why do some people become smokers and how can this be prevented?

Key points

• Nicotine is a highly addictive drug, acting on the same parts of the brain as other drugs such as heroin, cocaine and alcohol.
• Addiction to nicotine can develop within weeks or months of starting to smoke. However, many young smokers do not think they are addicted.
• Whilst recognising the health hazards, many young people see some benefits in smoking such as coping with anxiety, controlling weight or creating a positive self-image and identity.
• Many other factors contribute to encouraging young people to start and continue smoking including: parental attitudes and behaviour; friends who smoke; and the availability, cost and perceived attractiveness of cigarettes.
• An effective smoking prevention strategy should both reduce the availability and affordability of cigarettes and other tobacco products and discourage young people from wanting to smoke. It should be informed by young people's views through active consultation.

1.1 If we are to be successful in preventing young people from becoming smokers, we need to understand why they start smoking in the first place and why they continue.

1.2 The single most important factor that turns a beginner into a regular smoker is the addictiveness of the nicotine in tobacco. It is now known that nicotine acts on the same parts of the brain as do other drugs such as heroin, cocaine and alcohol ³ . With repeated use, the brain becomes accustomed to the nicotine. Repeated exposure to the nicotine gradually brings about subtle changes in how certain parts of the brain work. As a result, a state is reached where the smoker finds that he or she needs to smoke to feel comfortable. Many other factors reinforce the purely chemical effect of the nicotine - the associations between smoking and other things, such as being with friends, having a drink or reacting to stressful situations. Even the smell of tobacco itself can produce a strong urge to smoke. In addition, the cigarette is a highly efficient nicotine delivery system. The nicotine from inhaled cigarette smoke is rapidly absorbed and carried to the brain almost as quickly as an intravenous injection of heroin ⁴. The resultant "hit" enhances the drug's addictiveness ³.

1.3 Recent research suggests that addiction to nicotine can develop very quickly - within a few months or sometimes just a few weeks. A study of 12 and 13 year olds in the US found that 40% of new smokers quickly developed signs of addiction - an average of six months in boys but as little as three weeks in girls ⁵. The SALSUS survey of 23,000 Scottish 13 and 15 year olds found that 70% of the regular smokers had already tried but failed to give up ⁶. By their late teens, most regular smokers do not see themselves as addicted to nicotine, with many believing they are still in control and could stop if they wanted to ⁷.

1.4 While nicotine may largely explain why people become and remain regular smokers, it clearly cannot be responsible for the first cigarette. Smoking has to be attractive enough for people to want to start. While most young people know that smoking is a cause of ill-health, the belief remains widespread that it also has its positive side. In a 2004 survey of 11-15 year olds in England, 68% thought it helped people relax if they were nervous and around 20% felt that smokers stayed slimmer than non-smokers, and that it gave people confidence and helped them cope better with life ⁸. For some people, therefore, smoking can seem to offer a solution to certain problems. Smoking can also appear to offer the route to acceptance, by friends or colleagues who already smoke. Or it can be legitimised because it is done by people whom you admire - for example, celebrities, elder siblings or parents. Other positive images in the media, including advertising or smoking in films or TV programmes may reinforce its acceptability. Curiosity may also be a strong incentive- "I want to find out what it's like." Starting to smoke is also much more likely if you live in a community or society where smoking is common and tolerated and cigarettes are readily available. What may influence the potential smoker not to start is the knowledge that 83% of smokers say they regret having started smoking, and would not smoke if they had their time again ⁹.

1.5 If the positive attributes of cigarettes outweigh risks that are seen as minimal, distant or non-existent, trying a first cigarette is highly likely. After the first cigarette, the chances of smoking again are high. In the SALSUS survey, 47% of 13 year olds had tried smoking and 8% were already regular smokers ¹⁰. By 15, 64% had tried smoking at least once and 20% were regular smokers. In a survey of over 2000 15 year olds in the UK, 36% of girls had never smoked, 15% had had one or two cigarettes, 13% between 3 and 9, 11% between 10 and 39 and 24% more than 40 .

1.6 If we are to prevent young people from becoming regular addicted smokers, we need to load the balance against the perceived and actual benefits of smoking and in favour of its perceived and actual costs. Figure 1.1 provides a diagrammatic view of a range of factors thought to contribute to whether or not young people become and remain smokers. It divides these factors into three domains: individuals and their knowledge, attitudes and state of mind; their immediate circle of family and friends; and the wider social and cultural environment in which they live. These domains are highly interactive. For example the individual's attitude to smoking can be shaped by their parents but also influenced by what they see on TV or in magazines. One way of looking at the figure is to see it as the battleground on which the struggle to prevent young people from starting to smoke will be won or lost. Which are the elements that are most amenable to change in favour of smoking prevention in ways that are practical and cost-effective? Table 1 has been adapted from Figure 1.1. It summarises the possible means whereby these factors may make smoking more or less attractive and briefly summarises the evidence for their impact in practice. This evidence will be addressed in succeeding chapters.

1.7 An effective smoking prevention strategy should therefore logically both reduce the availability of cigarettes and other tobacco products and discourage young people from wanting to smoke. In the succeeding chapters we will look in more detail at the relevance of the factors outlined above and at the practical possibilities for modifying them with the aim of preventing smoking.

Figure 1.1 Factors associated with smoking.

Table 1.1 Factors influencing smoking by young people and the potential for intervention.