Perceived risks and benefits of smoking: differences among adolescents with different smoking experiences and intentions
Introduction
Tobacco use accounts for over 450,000 total deaths and 170,000 cancer deaths every year in the United States. Over 90% of adult smokers began smoking cigarettes as adolescents [1]. According to the 2001 Youth Risk Behavior Survey, 63.9% of adolescents (grades 9–12) have tried cigarettes, 28.5% are current smokers (smoking at least 1 day a month), and 13.8% are current frequent smokers (smoking at least 20 days in a month) [2]. Given these statistics, it is clear that eliminating smoking rates during the adolescent years is key to reducing incidences of cancer and other smoking-related negative sequelae.
To prevent or reduce adolescents' tobacco use, prevention and intervention programs often attempt to get adolescents to recognize and acknowledge their own vulnerability to smoking-related negative outcomes by conveying information about prevalence rates, risk factors, and risk estimates [3], [4]. Such efforts are based on theoretical models of health and health-related behavior (e.g., Social Cognitive Theory [5]; the Health Belief Model [6]; the Theory of Reasoned Action [7]; the Theory of Planned Behavior [8]; Self-Regulation Theory [9]; and Subjective Culture and Interpersonal Relations Theory [10]), which posit that individuals' perceptions about the consequences of their actions and perceptions of vulnerability to those consequences play a key role in behavior and behavior change.
The majority of studies testing these theories has compared smokers' and nonsmokers' perceptions, and has yielded mixed results. Although some studies find that adolescents who have smoked perceive greater smoking-related risks than those who have not smoked [11], [12], [13], others show smokers perceive less risk [14], [15], [16], [17], [18], [19], [20], [21]; see also Weinstein [22] for a more detailed review.
These studies have been limited in several ways, some of which might contribute to these inconsistent findings. First, many studies have included unconditional assessments of risk (e.g., “What is the chance that you will get lung cancer?”), rather than conditional assessments where the antecedent behavior is specified (e.g., “What is the chance that you will get lung cancer if you smoke a pack of cigarettes each day?” [23], [24], [25]). It is not surprising that studies using these unconditional risk assessments yield a positive relationship between risk judgments and tobacco use since individuals who are smoking are truly more likely to experience a negative outcome than are nonsmokers because they are, by definition, taking more risks. 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 [24], [25].
Second, there are differences in the types of smoking-related risks that have been assessed. Some studies specify the risks such as lung cancer or heart trouble, whereas other studies ask about the chance that something bad will happen or inquire about how harmful smoking is. Further, most studies have primarily focused on perceptions of long-term risks, such as lung cancer or heart attack, rather than more immediate consequences of smoking, such as bronchitis. Since most of the negative consequences attributed to smoking do not present for many years, there is a need to query adolescents about their perceptions of short-term risks and how these perceptions might play a role in adolescents' smoking decisions. Similarly, the study of health risks rather than social risks is predominant in the literature. The inclusion of social outcomes (e.g., getting into trouble) in addition to health-related or physical consequences is critical when assessing an adolescent sample for whom health outcomes are rarely experienced in the short term.
A third problem with the literature is its focus on risks. An emphasis on perceived risk alone may be inadequate to predict or change smoking behavior because risk is only part of the behavioral decision-making equation. What is missing is an understanding of the extent to which adolescents perceive tobacco-related benefits. The decision-making literature has argued that individuals should consider both the risks and benefits (e.g., a cost–benefit model) when making decisions [26], [27], [28], [29]. Researchers who have studied smoking-related benefits have found that smokers perceive more benefits of smoking than do nonsmokers [15], [16], [19], [21]. To fully 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. However, few studies have inquired about smoking-related physical and social benefits, along with or compared to perceived risks, in predicting adolescents' decisions to smoke.
Finally, the role of intentions has been largely omitted from the risk perception literature. Exploring intentions with regards to risk perception and behavior is critical for two reasons: (1) perceived risks and perceived benefits have been shown to be important determinants of behavioral intentions, and (2) research indicates that behavioral intentions are the most important and immediate determinant of behavior [7], [8], [28]. Indeed, adolescents' intentions to use substances have been shown to predict subsequent substance use behavior [8], [30], [31], [32], [33], and a few studies have specifically linked smoking-related perceptions to intentions [15], [19]. As such, adolescents' intentions to smoke may be acting as a key proxy variable to predicting adolescents' decision making concerning smoking.
The current study addresses these limitations by examining differences in perceived smoking-related physical and social risks and benefits between adolescents who have and have not smoked cigarettes. We also examine differences in perceptions between adolescents who do and do not intend to smoke in the near future. We tested five hypotheses in this study. First, adolescents who have smoked will perceive related risks as less likely and benefits as more likely than will adolescents who have not smoked. Second, adolescents who intend on smoking in the near future will have lower chance estimates for smoking-related risks and higher estimates for benefits than will adolescents without such smoking intentions. Third, the amount of smoking experiences an adolescent has had will be negatively correlated with risk chance estimates and positively correlated with benefit chance estimates. Fourth, the strength of adolescents' intention to smoke will be negatively correlated with risk chance estimates and positively correlated with benefit chance estimates. Finally, perceptions of benefits and risks will each have independent relationships with adolescents' behaviors and intentions to smoke.
Section snippets
Participants
Participants were 395 adolescents recruited from the ninth grade classes of two high schools (53.2% females; 46.8% males) and ranged in age from 12 to 15 years (mean = 14.00 years, SD = 0.40 years). Participants were ethnically diverse, with 52.0% of the participants describing themselves as White/non-Hispanic, 20.4% as Asian, 18.5% as Hispanic or Latino, 3.8% as Pacific Islander, 1.9% as African American, 1.3% as American Indian/Alaskan Native, and 2.1% as other. Participants' mothers'
Results
Before conducting our main analyses, we tested for differences in smoking behaviors and intentions between the participants recruited from the two schools. There were no significant differences between the two schools on gender, age, or smoking behavior. However, significant differences were found on ethnicity [X2 = 57.3, (df = 3), P < 0.001] and mother's education [X2 = 19.7, (df = 8), P < 0.05], with one school (school B) having fewer White/non-Hispanics and lower levels of mothers'
Discussion
Using conditional assessments of tobacco-related health and social risks and benefits, this study tested whether adolescents who have smoked or intend on smoking perceive a lower likelihood of experiencing smoking-related risks and greater likelihood estimates of benefits than do their less experienced counterparts. Consistent with our hypotheses and with other studies using conditional risk assessments [14], [15], [16], [17], [18], [19], [20], [21], we found that adolescents who have smoked
Acknowledgements
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), the UCSF Academic Senate Committee on Research, and the Raschen-Tiedenann Fund from the Research Evaluation and Allocation Committee, School of Medicine, UCSF. Additional support for the authors was provided by a grant from the Maternal and Child Health Bureau (MCHB) of the Department of Health and Human
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