1. Why do some people become smokers and how can this be prevented?
- 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.
Factors which may influence uptake of smoking
Potential means of preventing smoking
Evidence for effectiveness of policies or interventions
Knowledge, skills and
Lack of awareness of consequences of smoking. Perception of smoking as a good thing. Low intelligence, poor educational attainment and disengagement from school.
Provide clear information about hazards of smoking and develop skills to resist offers of tobacco and other drugs. A supportive school environment.
See entries on school and media.
Differing reasons for valuing or rejecting smoking e.g. weight control for girls; self-image, peer relationships, impact on reproduction and fitness.
Provide information about smoking and develop attitudes that address gender specific concerns.
As yet, lack of evidence for greater effectiveness of gender specific approaches.
Self image and self-esteem
Dissatisfaction with self and self-image may lead to use of tobacco and other drugs as a means of problem resolution, coping or creating desirable identity or self-image.
Creating conditions at home, in school etc that build self-confidence, create alternatives for positive self-images and identity and develop positive coping skills.
No clear evidence on how to do this reliably
Personality & mental health problems
Conduct disorder, truants, impulsive risk- takers more likely to smoke and use other drugs.
Provide support (and treatment) for young people with these problems.
No evidence as yet that smoking rates can be affected in this way.
Attitudes, beliefs and values,
ethnicity and religion
Presence or absence of positive or negative attitude to smoking.
Sustaining values and beliefs which reject smoking and challenging positive attitudes to smoking.
No clear evidence on how to do this reliably.
Family and home
Whether parents and/or siblings smoke; parents' attitudes to smoking; level of parental monitoring.
Support family unit; encourage effective parenting, inform parents about risks of smoking to their children, enable adults to quit; smoke free policies in the home.
Strong rationale, but as yet, no clear evidence of effectiveness.
Friends and relationships
Whether friends and/or colleagues smoke.
Reduce opportunities for friends and colleagues to smoke together esp ban on smoking in public and work-places.
Early evidence that smoking bans may reduce youth smoking.
Young person's knowledge of potential hazards of smoking.
Provide clear information about hazards of smoking and develop skills to resist offers of tobacco and other drugs.
Mixed results of school-based programmes, mostly little if any impact on rates of smoking or use of other drugs.
School ethos and school policies towards smoking
Build supportive school ambiance; clear no-smoking policies.
Some evidence of lower smoking rates in schools that do this.
Social activities and support
Certain activities may discourage or encourage smoking
Eg sport or hanging around with friends.
Provide healthy, fulfilling activities for young people.
No clear evidence that action in this area can reduce smoking rates.
Social and cultural environment
Price of tobacco
Decision to buy influenced by price
Increase real price
Strong evidence that raising real price reduces consumption.
Availability of tobacco
Affects ease of obtaining cigarettes
Reduce access by various means eg age of purchase and its enforcement;
Moderate evidence that enforcement of proof of age reduces cigarette purchase by young people and may reduce smoking rates.
Influences attractiveness of cigarettes and the social image of smoking.
Prohibit all tobacco advertising, promotion and other marketing devices.
Moderate evidence that banning advertising reduces youth smoking.
Influences perceptions of smoking
Reduce positive images and references to smoking; increase negative references
Strong evidence that some sustained media campaigns have reduced youth smoking.
Social norms and values
Seeing lots of smokers around may increase acceptability and encourage smoking.
Banning smoking in enclosed public places, media campaigns on passive smoking.
Early evidence that banning smoking in enclosed public places reduces youth smoking.
Smoking a cultural norm in disadvantaged areas; smoking seen as a means of coping with multiple problems.
Enabling upward social mobility; banning smoking in enclosed public places; targeting smoking prevention and cessation programmes in disadvantaged areas.
No evidence as yet that addressing social disadvantage per se reduces youth smoking.