The association of normative perceptions with adolescent smoking intentions

The State of Norm-Based Antismoking Research: Conceptual Frameworks, Research Designs, and Implications for Interventions

This synthesis review examined 189 qualified studies on norms and smoking in terms of conceptual frameworks, types of social norms, research designs, dependent variables, independent variables and covariates, and findings related to norms. Results show that 7.9% were experimental, and the remaining were cross-sectional. By far, the reasoned action approach (RAA) was the most-cited theory, but RAA was not used to guide experimental designs. The social norms approach, norm focus theory, social cognitive theory guided the intervention experiments. Harmful norms were more frequently examined than healthful norms. Pro-smoking norms positively predicted smoking intentions and behaviors, whereas antismoking norms positively predicted antismoking intentions and behaviors. The over-application of RAA in cross-sectional antismoking research has yielded repetitive findings. Norm-based experiments can adopt other theoretical perspectives to offer insights into antismoking interventions. The RAA constructs are still applicable and can be integrated into intervention designs.

A social norms approach intervention to address misperceptions of anti-vaccine conspiracy beliefs amongst UK parents

Anti-vaccine conspiracy beliefs among parents can reduce vaccination intentions. Parents' beliefs in anti-vaccine conspiracy theories are also related to their perceptions of other parents' conspiracy beliefs. Further, research has shown that parents hold misperceptions of anti-vaccine conspiracy belief norms: UK parents over-estimate the anti-vaccine conspiracy beliefs of other parents. The present study tested the effectiveness of a Social Norms Approach intervention, which corrects misperceptions using normative feedback, to reduce UK parents' anti-vaccine conspiracy beliefs and increase vaccination intentions. At baseline, 202 UK parents of young children reported their personal belief in anti-vaccine conspiracy theories, future intentions to vaccinate, and their perceptions of other UK parents' beliefs and intentions. Participants were then randomly assigned to a normative feedback condition (n = 89) or an assessment-only control condition (n = 113). The normative feedback compared participants' personal anti-vaccine conspiracy beliefs and perceptions of other UK parents' beliefs with actual normative belief levels. Parents receiving the normative feedback showed significantly reduced personal belief in anti-vaccine conspiracy beliefs at immediate post-test. As hypothesised, changes in normative perceptions of anti-vaccine conspiracy beliefs mediated the effect of the intervention. The intervention, did not directly increase vaccination intentions, however mediation analysis showed that the normative feedback increased perceptions of other parents' vaccination intentions, which in turn increased personal vaccination intentions. No significant effects remained after a six-week follow-up. The current research demonstrates the potential utility of Social Norms Approach interventions for correcting misperceptions and reducing anti-vaccine conspiracy beliefs among UK parents. Further research could explore utilising a top-up intervention to maintain the efficacy.

Reactions to, and trial intentions for, three dissuasive cigarette designs: a cross-sectional survey of adolescents in Scotland

OBJECTIVES

There has been growing academic and policy interest in opportunities to decrease the appeal of cigarette sticks, such as making them an unattractive colour or requiring them to display a health warning. We therefore explored reactions to, and trial intentions for, three 'dissuasive' cigarette designs among adolescents in Scotland.

METHODS

A cross-sectional survey with 12-17 year olds in Scotland (n=594) was conducted between November 2017 and November 2018. Participants were shown one 'standard' cigarette (imitation cork filter with white paper casing) and three dissuasive cigarettes: (1) a cigarette with the warning 'smoking kills'; (2) a cigarette with the warning 'toxic' and a skull and cross-bones image and (3) a dark green cigarette. Participants rated each cigarette on nine five-point reaction measures (eg, appealing/unappealing or attractive/unattractive). A composite reaction score was computed for each cigarette, which was binary coded (overall negative reactions vs neutral/positive reactions). Participants also indicated whether they would try each cigarette (coded: Yes/No). Demographics, smoking status and smoking susceptibility were also measured.

RESULTS

More participants had negative reactions to the dark green (93% of adolescents), 'smoking kills' (94%) and 'toxic' (96%) cigarettes, compared with the standard cigarette (85%). For all three dissuasive designs, Chi-square tests found that negative reactions were more likely among younger adolescents (vs older adolescents), never-smokers (vs ever smokers) and non-susceptible never-smokers (vs susceptible never-smokers). Most participants indicated that they would not try any of the cigarettes (range: 84%-91%).

CONCLUSION

Dissuasive cigarettes present an opportunity to further reduce the appeal of smoking among adolescents.

Prevalence and predictors of susceptibility and future intention to smoke cigarettes among school-going adolescents in Ibadan, Nigeria

Introduction

the tobacco control interventions targeted at preventing the initiation of tobacco habits are crucial to effective control of tobacco use among adolescents. An understanding of the predictors of smoking susceptibility and future intention to smoke is important in developing effective intervention programmes. This study, therefore, assessed the prevalence and predictors of susceptibility and future intention to smoke cigarettes among school-going adolescents in Ibadan, Nigeria.

Methods

a cross-sectional study among 830 school-going, non-smoking adolescents, who were randomly selected from 18 secondary schools in Ibadan, Nigeria. Using a self-administered, structured questionnaire, information on socio-demography, tobacco attitudes and habits were collected and analyzed using SPSS version 25.

Results

the prevalence of susceptibility and future intention to smoke cigarette were 25.9% and 6.3%, respectively. Predictors of susceptibility were low social-class (aOR:1.68; 95%CI:1.01-2.80); cigarette sale near schools (aOR:2.04; 95%CI:1.16-3.61); poor attitude (aOR:1.93; 95%CI:1.29-2.89); no harm-perception to smoking (aOR:3.55; 95%CI:2.13-5.92), exposure to secondhand smoke (SHS) (aOR:2.31; 95%CI:1.52-3.50) and perceived safety of short-term smoking (aOR:1.59; 95%CI:1.02-2.44). Predictors of future intention to smoke were: ever-tobacco smoking (aOR:2.05; 95%CI:1.003-4.170); cigarette sale near schools (aOR:1.79; 95%CI:1.09-2.94); poor attitude (aOR:1.95; 95%CI:1.31-2.88), no harm perception to smoking (aOR:3.87; 95%CI:2.38-6.31), exposure to SHS (aOR:2.45; 95%CI:1.64-3.67) and perceived safety of short-term smoking (aOR:1.59; 95%CI:1.05-2.44).

Conclusion

a significant proportion of the population had high susceptibility to smoke as well as high future intention to smoke. Sales of cigarettes near schools, poor attitude and poor perception about the harm from smoking and exposure to SHS were important predictors of both susceptibility and future intention to smoke among respondents.

Perceived Social Acceptability and Longitudinal Trends in Adolescent Cigarette Smoking

The current study uses methods from social network analysis to predict longitudinal trends in adolescent cigarette smoking based on perceived social acceptability from friends, in addition to typical measures of peer influence (e.g., self-reported cigarette use of friends). By concurrently investigating the role of perceived social acceptability of smoking and peer influence, the current study offers new insight into the mechanisms through which peers influence adolescent smoking. Two waves of data from five high schools within one US school district (n = 1563) were used. Stochastic actor-based models simultaneously estimated changes in smoking predicted by perceived social acceptability and peer influence. Findings demonstrate that adolescents with higher perceived social acceptability of cigarette use increased cigarette smoking over time. Conversely, support for peer influence on smoking was not found after controlling for the effects of perceived social acceptability. The results suggest that perceived social acceptability regarding cigarette smoking rather than self-report of cigarette use among friends is predictive of future smoking behavior. Consequently, the findings highlight the need for prevention efforts to take into account the multifaceted dynamics between adolescent smoking and friendships. Programs that address peer influence alone, without considering peer mechanisms such as perceived social acceptability, are at risk of ignoring critical avenues for prevention.

Electronic Cigarette Advertising Impacts Adversely on Smoking Behaviour Within a London Student Cohort: A Cross-Sectional Structured Survey

Introduction

In contrast to tobacco smoking, electronic cigarette (“vaping”) advertisement had been approved in the United Kingdom (UK) in January 2013. Currently, there are an estimated 3.2 million UK e-cigarette users. The impact of e-cigarette advertisement on tobacco use has not been studied in detail. We hypothesised that e-cigarette advertisement impacts on conventional smoking behaviour.

Methods

A cross-sectional structured survey assessed the impact of e-cigarette advertising on the perceived social acceptability of cigarette and e-cigarette smoking and on using either cigarettes or e-cigarettes (on a scale of 1 to 5/‘not at all’ to ‘a lot’). The survey was administered between January to March 2015 to London university students, before and after viewing 5 UK adverts including a TV commercial.

Results

Data were collected from 106 participants (22 ± 2 years, 66% male), comprising cigarette smokers (32%), non-smokers (54%) and ex-smokers (14%). This included vapers (16%), non-vapers (77%) and ex-vapers (7%). After viewing the adverts, smokers (2.6 ± 1.0 vs. 3.8 ± 1.1, p = 0.001) and non-smokers (3.2 ± 0.7 vs. 3.7 ± 0.8, p = 0.007) felt smoking was more socially acceptable, compared to before viewing them. Participants were more likely to try both e-cigarettes (1.90 ± 1.03 to 3.09 ± 1.11, p < 0.001) and conventional cigarettes (1.73 ± 0.83 to 2.27 ± 1.13, p < 0.001) after viewing the adverts compared to before. Vapers were less likely to smoke both an e-cigarette, and a conventional cigarette after viewing the adverts.

Conclusion

E-cigarette advertising encourages both e-cigarette and conventional cigarette use in young smokers and non-smokers. The adverts increase the social acceptability of smoking without regarding the importance of public health campaigns that champion smoking cessation.

Electronic supplementary material

The online version of this article (10.1007/s00408-019-00262-z) contains supplementary material, which is available to authorized users.

Tobacco Industry Denormalization Beliefs in Hong Kong Adolescents

BACKGROUND

Tobacco industry denormalization (TID) seeks to expose the industry's misconducts. Research on TID beliefs, meaning negative attitudes toward the tobacco industry (TI), may inform TID programs, but was limited to western populations. We investigated TID beliefs and their association with smoking and sociodemographic characteristics in Hong Kong adolescents.

METHODS

In a school-based cross-sectional survey of 14214 students (mean age 15.0 years, 51.5% boys), TID beliefs were assessed by two questions: (1) whether the TI was respectable and (2) whether the TI tried to get youth to smoke, each with four options from "definitely no" to "definitely yes." Smoking susceptibility and behaviors were also assessed. Sociodemographic characteristics included age, sex, perceived family affluence, highest parental education, numbers of co-residing smokers, and school-level smoking prevalence.

RESULTS

Of all students, 77.6% considered the TI not respectable and 56.6% believed that the TI tried to get youth to smoke. Stronger TID beliefs were inversely associated with smoking susceptibility and behaviors. For example, students considering the TI definitely not respectable (vs. definitely yes) were 56% (95% confidence intervals [CI] = 45% to 66%), 49% (95% CI = 41% to 56%), and 53% (95% CI = 36% to 65%) less likely to be susceptible to smoking (among never-smokers) and be ever- and current smokers, respectively. Of all correlates examined, only younger age and having no co-residing smoker were associated with TID beliefs.

CONCLUSIONS

Substantial proportions of Hong Kong adolescents did not hold TID beliefs, but those who did were less likely to smoke. Our results suggest that TID programs may help reduce adolescent smoking.

IMPLICATIONS

The TI's misconducts and responsibility for the tobacco epidemic were not well known by Hong Kong adolescents. TID beliefs in this population were inversely associated with smoking. These findings suggest that TID programs in local adolescents may be of value. The investigation into the correlates of TID beliefs found that socioeconomic status and school-level smoking prevalence were not associated with TID beliefs. This suggests that local TID programs targeting adolescents in general, for example, mass-media campaigns, may be more appropriate than those targeting particular schools or selected groups of adolescents.

"Technophilia": A new risk factor for electronic cigarette use among early adolescents?

PURPOSE

Develop and validate a scale that measures Technophilia (positive orientation toward new technology) and use it to address orientation toward new technologies to explain e-cigarette trial and adoption, especially in relatively low risk adolescents.

METHODS

Survey data were obtained from students of the three largest cities in Mexico (n = 8123). We developed eight questions involving access, use and pleasure from different electronic media to measure technophilia. Exploratory factor analysis (EFA) was conducted. Linear GEE models were used when regressing technophilia on covariates. When regressing e-cigarette and conventional cigarette trial and use, logistic GEE models were used. Finally, we used multinomial logistic regression to evaluate the associations between technophilia and e-cigarettes as the first tobacco product.

RESULTS

Technophilia were correlated with theoretically-related variables. Unadjusted and adjusted models regressing e-cigarette trial and use indicated that students in the highest quartile for technophilia were more likely to have tried e-cigarettes compared with the lowest quartile (AORQ4 vs Q1 = 1.36, 95% CI 1.14-1.62). Technophilia was not independently associated with current e-cigarette use in adjusted models. Students with higher technophilia were more likely to have first tried e-cigarettes in both crude and adjusted models (AORQ4vQ1 = 1.66, 95% CI 1.20-2.31; AORQ3vQ1 = 1.43, 95% CI 1.02-2.01). Technophilia did not have a statistically significant, independent association with first use of other tobacco products.

CONCLUSION

This study suggests that technophilia is associated with trial of e-cigarettes among youth. The measure we developed appears useful for understanding why some youth are open to trying novel, technologically oriented ways to consume nicotine.

Role of social normative beliefs as a moderating factor in smoking intention among adolescent girls in Korea

In this study, we investigated the relationship between risk-taking tendency and smoking intention as moderated by social normative beliefs among Korean female adolescents. A cross-sectional study was conducted with 274 female adolescents in middle school. Multiple regression and simple slope analyses were employed to test the moderating effects of social normative beliefs regarding smoking on the relationship between risk-taking tendency and smoking intention. Results determined that risk-taking tendency, social normative beliefs regarding smoking, and their interaction were significant factors influencing smoking intention among adolescents. Risk-taking tendency was associated with greater smoking intention among adolescents, with higher than average social normative beliefs regarding smoking. However, risk-taking tendency was not significantly associated with smoking intention for adolescents with lower than average social normative beliefs regarding smoking. In conclusion, social normative beliefs regarding smoking moderated the relationship between risk-taking intention and smoking intention among Korean female adolescents. Unique sociocultural perceptions about smoking behaviors of adolescents need to be reflected in smoking-prevention and -cessation programs.

Assessing demographic differences in decisional balance for smoking prevention and temptations to try smoking among adolescent subgroups

INTRODUCTION

Cigarette smoking initiation remains prevalent in adolescence. Effective prevention methods are needed to dissuade this behavior. Demographic factors are identified as important risk factors in the developmental nature of smoking in adolescence. The current study investigates potential demographic differences for two new trans-theoretical model measures, the Decisional Balance Inventory (pros and cons) for Smoking Prevention and the Temptations to Try Smoking Scale.

METHODS

A sample of 6th grade Rhode Island students from 20 middle schools (N = 4151) who were participating in a longitudinal and computer-delivered intervention for substance abuse prevention was assessed on these measures at baseline. Three MANOVA tests were conducted to assess the impact of race (White vs. Non-White), ethnicity (Hispanic vs. Non-Hispanic) and gender (male vs female).

RESULTS

Significant effects for race and ethnicity were found for Decisional Balance and Temptations to Try Smoking. For race, Whites reported lesser pros (p <.0001) and Non-Whites reported higher cons (p <.0001) and temptations to try smoking (p <.0001). Differences for ethnicity showed that Hispanics were higher on pros (p <.0001) and temptations to try smoking (p <.0001) than Non-Hispanics. Non-Hispanics reported higher cons (p <.0001). Gender differences were noted only for temptations to try smoking, and showed females were higher on this construct than males (p <.0001). The effect sizes were .01 or below.

CONCLUSIONS

The results did not demonstrate a strong association between these demographics and constructs, suggesting that tailored prevention methods based solely on these factors may not dissuade smoking in this group.

Psychosocial Factors Associated With Smoking Intention in Korean Male Middle School Students

This study examined psychosocial factors influencing smoking intention in Korean male middle school students. We used a descriptive cross-sectional design, based on the biopsychosocial model, to analyze data from 309 male adolescents aged 14–16 years in middle school. Of the psychological factors examined, stress and risk-taking tendency were significantly associated with smoking intention. Of the social factors examined, social normative beliefs, close friends’ and siblings’ smoking, and low socioeconomic status were significant factors in smoking intention. The explanatory power of these variables in the predictive model was 23.1%. In conclusion, the unique psychological and social characteristics of adolescents should be reflected in interventions for smoking prevention.

Individual and contextual determinants of perceived peer smoking prevalence among adolescents in six European cities

BACKGROUND

Young people perceiving a high peer smoking prevalence are more likely to initiate smoking. It is unclear which factors contribute to perceived peer smoking prevalence and if these factors vary according to education. This study aimed to assess the determinants of perceived smoking prevalence and assessed its variation at school and country-level.

METHODS

Data of 10,283 14-17-year-old students in 50 secondary schools in six European cities were derived from the 2013 SILNE survey. The outcome was the perceived smoking prevalence score among peers at school (0-10 scale, 10 represented 100% smoking prevalence). Multilevel linear regression models estimated the associations of factors with perceived prevalence score and variance at school and country-levels. Analyses were also stratified by academic achievement of the adolescent and parental education.

RESULTS

Determinants of a higher perceived prevalence score were female sex, ever smoking, having friends who smoke, low academic achievement, low parental educational level, and higher actual prevalence of smoking in the school. The perceived prevalence score was not associated with school policies or with the availability of cigarettes near the school. Determinants were very similar across levels of academic achievement and parental education. Perceived prevalence scores substantially varied between schools and countries: 10% and 11% of total variance was related to schools and countries respectively.

CONCLUSION

Across educational levels, perceptions of peer smoking are strongly determined by both individual characteristics and school and national contexts. Future studies should assess why perceived smoking prevalence varies between schools and countries and identify modifiable factors.

Psychosocial Determinants of Intention to Use Tobacco Among Adolescents in India

Aim

The present study aims to determine the psychosocial factors associated with ‘intention to use tobacco’, because it is influenced by social norms and beliefs about smoking.

Method

A cross-sectional survey on a random sample of 665 individuals, aged 15-20 years, was conducted using a pretested questionnaire. Three logistic regression models were constructed to identify determinants of ‘intention to use tobacco’, with the total sample, with respondents under 18 years old, and with respondents 18 years old and above.

Results

Odds of intention to use tobacco were higher when friends used tobacco products, and perceived no negative effects on health. Parental use of tobacco increased the odds of intention to use tobacco, and a similar effect was observed when a celebrity was followed as a role model. Approval of occasional use of tobacco increased the odds of intention to use tobacco. Communication with parents about harmful effects of tobacco reduced the odds of intention to smoke among respondents younger than 18 years old.

Conclusion

Social factors and perception of risk significantly influenced the intention to use tobacco. Study results are useful in designing interventions for prevention of tobacco use among adolescents.

Do children overestimate the extent of smoking among their peers? A feasibility study of the social norms approach to prevent smoking

Social norms approaches (SNA) are based on the premise that we frequently overestimate risk behaviours among our peers. By conducting campaigns to reduce these misperceptions, SNAs aim to reduce risk behaviours. This study examines the extent to which 12 to 13year old pupils overestimate smoking among their peers and explores the appropriateness of using SNA in secondary schools to prevent smoking uptake.

METHODS

The extent of overestimation of smoking among peers was assessed through an on-line SNA questionnaire in five schools (n=595). Based on questionnaire results, pupils developed SNA campaigns in each school. Qualitative methods of focus groups (7), interviews (7) and observation were used to explore in-depth, from the perspective of staff and pupils, the appropriateness and feasibility of the SNA to prevent smoking uptake in secondary schools.

RESULTS

A quarter of pupils, 25.9% (95% CI 25.6% to 26.1%) believed that most of their peers smoked, however, only 3% (95% CI 2.8% to 3.3%) reported that they actually did; a difference of 22.9% (95% CI 19.1% to 26.6%). Self-reported smoking was not significantly different between schools (X(2)=8.7 p=0.064), however, perceptions of year group smoking was significantly different across schools (X(2)=63.9 p<0.001). Qualitative analysis identified full school engagement, minimal teacher time requirements, pupils' belief in questionnaire results and understanding wider context, as key in optimising implementation.

CONCLUSION

This study shows significant misperception between self-reported and perceived smoking among peers in secondary schools, thus supporting a key premise of social norms theory. Implementing SNAs and studying effects is feasible within secondary schools.

The relationship between secondhand smoke exposure, pro-tobacco social influences, and smoking susceptibility among nonsmoking Zambian adolescents

BACKGROUND

We tested the hypothesis that the extent of secondhand smoke (SHS) exposure among nonsmoking adolescents would be associated with their overall exposure to pro-tobacco social influences.

METHODS

Data were analyzed using descriptive and multivariate methods from the 2011 Zambia Global Youth Tobacco Survey.

RESULTS

The odds of SHS exposure increased with increasing exposure to pro-tobacco advertisements. About 39.5% of the gap in SHS exposure between nonsmokers with low versus high smoking susceptibility was attributable to differences in parental or peer smoking.

CONCLUSIONS

Sustained efforts are needed to denormalize tobacco use in order to reduce youth susceptibility to tobacco use.

Predictors of intention to smoke among junior high school students in Shanghai, China: an empirical test of the information-motivation-behavioral skills (IMB) model

Background

Adolescent smoking is a worldwide problem that is particularly severe in low- and middle-income countries. Many endogenous and environmental factors affect the intention to smoke, so a comprehensive model is needed to understand the significance and relationship of predictors. The study aimed to test the associations among information-motivation-behavioral skills (IMB) model constructs as predictors of intention to smoke in junior high school students in Shanghai, China.

Methods

We conducted a cross-sectional study of 16,500 junior high school students in Shanghai, China. Data on tobacco-related information, motivation, behavioral skills, and behaviors were collected from students. Structural equation model (SEM) was used to assess the IMB model.

Results

The mean age of participants was 13.8 years old (standard deviation = 1.02; range 11–17). The experimental smoking rate among junior high school students was 6.6% and 8.7% of the participants expected that they would be smokers in 5 years. The IMB model provided acceptable fit to the data (comparative fit index = 0.984, root mean square error of approximation = 0.04). Intention to smoke was predicted by behavioral skills (β= 0.670, P < 0.001) and motivation (β= 0.095, P<0.001) among junior high school students.

Conclusion

The IMB model provides a good understanding of the predictors of intention to smoke and it suggests future interventions among junior high school students should focus on improving motivation and behavioral skills.

The role of tobacco promoting and restraining factors in smoking intentions among Ghanaian youth

BACKGROUND

In Western countries, the relationship between smoking intentions and smoking behaviour is well established. However, youth smoking intentions and associated factors in developing countries are largely unexplored and the former may occur for a variety of reasons. We investigated youth smoking intentions in Ghana with regard to several tobacco promoting and restraining factors, including environmental, familial, attitudinal and knowledge measures.

METHODS

A school-based survey of a representative sample of 12-20-year-olds was conducted in 2008 in Ghana (N = 1338, response rate 89.7%).

RESULTS

In a bivariate model, both among ever and never smokers, allowing smoking on school compound, exposure to tobacco advertisement and parental smoking were associated with future intention to smoke. Compared to those who agreed that smoking is harmful to health, smoking is difficult to quit and that tobacco should not be sold to minors, those who disagreed or were not sure were more likely to have an intention to smoke. In the multivariate analyses, these associations persisted, except that the attitude measures concerning the difficulty of quitting smoking once started and tobacco sales ban were no longer significantly associated with smoking intentions.

CONCLUSIONS

These findings underscore the importance of school smoking policy, parental smoking behaviour and knowledge of the harmful effects of tobacco use in determining Ghanaian youths' future smoking intentions. Because current high percentages of smoking intentions may turn into high smoking rates in the future, the introduction of effective tobacco control measures at all levels of society to prevent youth smoking in Ghana may be essential.