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REVIEW ARTICLE

Psychosocial factors related to adolescentsmoking: a critical review of the literature

Suzanne L Tyas, Linda L Pederson

AbstractObjectiveTo extend the analysis ofpsychosocial risk factors for smoking pre-sented in the United States surgeongenerals 1994 report on smoking andhealth, and to propose a theoretical frameof reference for understanding thedevelopment of smoking.Data sourcesGeneral Science Index,Medline, PsycLIT, Sociofile, Sociological

Abstracts, and Smoking and Health.Holdings of the Addiction Research Foun-dation of Ontario Library as well as theauthors personal files.Study selectionReviewed literature fo-cused on studies that examined theassociation of sociodemographic, envi-ronmental, behavioural, and personalvariables with smoking.Data synthesisAdolescent smoking wasassociated with age, ethnicity, familystructure, parental socioeconomic status,personal income, parental smoking,parental attitudes, sibling smoking, peersmoking, peer attitudes and norms, familyenvironment, attachment to family and

friends, school factors, risk behaviours,lifestyle, stress, depression/distress, self-esteem, attitudes, and health concerns. Itis unclear whether adolescent smoking isrelated to other psychosocial variables.ConclusionsAttempts should be madeto use common definitions of outcome andpredictor variables. Analyses shouldinclude multivariate and bivariate mod-els, with some attempt in the multivariatemodels to test specific hypotheses. Futureresearch should be theory driven andconsider the range of possible factors,such as social, personal, economic,environmental, biological, and physiologi-

cal influences, that may influence smokingbehaviour. The apparent inconsistenciesin relationships between parental socio-economic status and adolescent dispos-able income need to be resolved as doesthe underlying constructs for which socio-economic status is a proxy.(Tobacco Control1998;7:409420)

Keywords: adolescence, smoking initiation,psychosocial factors

IntroductionIn recent years, increasing eVorts have beenmade to reduce the prevalence of tobacco use

and the exposure to environmental tobaccosmoke in both the United States and Canada.These eVorts have been somewhat successful:the prevalence of smoking in the general popu-lation has declined by over 15% in the past 25years.14 The reduction seen in adults, however,has not been noted in adolescents,58

particularly young females.9 10 In addition, thestable rates of the recent past have changed inthe past two years and now indicate a rise in

smoking among young people.11

The argument for smoking preventionamong adolescents is based on the observationthat, if smoking does not start duringadolescence, it is unlikely ever to occur8 and ondata indicating that the probability of cessationamong adults is inversely related to age atinitiation.12 13 Even infrequent experimentalsmoking in adolescence significantly increasesthe risk of adult smoking.14 Once smoking hasbegun, cessation is diYcult and smoking islikely to be a long-term addiction. Forexample, it has been estimated that the mediancessation age, for those born from 1975through 1979 who begin smoking in

adolescence, is 33 years for men and 37 yearsfor women.15 Based on a median initiation ageof 16 to 17 years, the predicted duration ofsmoking is 16 and 20 years for 50% of themales and females respectively. Prevention ofthe onset of adolescent smoking is thus anessential component of eVorts to reduce theoverall prevalence of smoking and its attendantmorbidity and mortality.

Although there are educational programmesavailable with demonstrated eVectiveness inreducing the prevalence of adolescent smokingover the shor t ter m, the longer ter mevaluations are not as encouraging.8 1621 ThediVerences in smoking levels between treatedand control groups appear to dissipate overtime, and disappear completely after six years.Further evaluations of these educational effortsare warranted, with consideration given tomethodological problems inherent in suchstudies (such as potential bias resulting fromlosses to follow up, and possible eVects ofinterventions other than the one beingevaluated). There is, however, also a need tocontinue to examine research on the aetiologyof smoking in young people. Research andtheory must be directed toward understandingwhy some individuals smoke and others donot.

Tobacco Control1998;7:409420 409

Centre on Aging,University ofManitoba, Winnipeg,Manitoba, CanadaS L Tyas

Department ofCommunity Healthand PreventiveMedicine, MorehouseSchool of Medicine,Atlanta, Georgia, USAL L Pederson

Correspondence to:Dr LL Pederson,Department of CommunityHealth and PreventiveMedicine, Morehouse Schoolof Medicine, 720 WestviewDrive, SW, Atlanta, Georgia30310, USA;[email protected]

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Theoretical considerationsSome of the research in adolescent smoking isgrounded in theory, whereas other studies havea more empirical orientation. There are fourtheoretical bases that have been used to explainthe initiation to and the acquisition of smoking.They include the rational approach aspresented by Ajzen and Fishbein,22 sociallearning theory as found in the work ofBandura,23 emphasis on social norms and atti-

tudes as reflected by the research of Jessor andJessor,24 and the developmentally orientedaVective approach of Rosenberg.25 All of theseexplanations have found support in at leastsome studies; there is thus no one clearly supe-rior model that can be used to explain adoles-cent smoking. A complication for programmedesign is that the relevance of diVerent types ofvariables, and possibly theoretical orientations,appears to vary depending on the stage ofacquisition (see review by Flay26).

ObjectiveGiven the above considerations concerningprevalence and incidence of smoking, it

appears timely that a review of the literature beconducted to synthesise and integrate the vastamount of information available on variablesrelated to smoking by adolescents. Theoutcome of this review is to provide the basisfor specific recommendations concerningfuture research, theory, and programmesaimed at reducing adolescent smoking. Thespecific approach that is taken in this review isto extend the analysis of psychosocial risk fac-tors for smoking presented in the United Statessurgeon generals 1994 report,8 and to proposea theoretical f rame of reference f orunderstanding the development of smoking.To meet these objectives, studies thatexamined the association of sociodemo-

graphic, environmental, behavioural, andpersonal variables with adolescent smokingwere reviewed, as well as theory-based researchaimed at understanding the mechanismsunderlying initiation to smoking.

MethodsDATA SOURCES AND STUDY SELECTION

The following literature databases weresearched: General Science Index, Medline,PsycLIT, Sociofile, Sociological Abstracts, andSmoking and Health. Holdings of theAddiction Research Foundation of OntarioLibrary as well as references in the authorspersonal files were also examined. Studies were

selected if they related directly to smoking; rel-evant articles which dealt with the acquisitionof other substance abusing behaviours werereviewed but not summarised in the tables.Only studies published in English or Frenchwere included. The search was confined tostudies published from 1984 to 1996.

METHODOLOGICAL CONSIDERATIONS

The methods used to collect and analyse datamust be examined to reconcile at least some ofthe inconsistencies observed in reportedresults. These methodological issues includediVerences in the measures used and the

definitions of predictors and smokingbehaviours, the study design (that is,cross-sectional or longitudinal), sample sizes,losses to follow up and drop outs, datacollection methods, target populations andresponse rates, age groups included, and theuse of biochemical validation of reportedbehaviour. Some studies reported initiation tosmoking and factors related to it, whereas oth-ers focused on current daily and occasional

smoking, and relevant predictor variables. Fur-thermore, some studies assessed statisticalrelationships using bivariate analyses; in otherreports, the same relationships were examinedwith potential confounders controlled. As aresult, the inconsistencies in reported findingswere not unexpected.

DATA SELECTION AND FRAMEWORK

There were numerous frameworks that couldhave been adopted for this reviewforexample, refs2629. The one chosen was based onthe surgeon generals report8; the onlymodification was that articles examining priorsmoking as a risk factor for subsequent

smoking were grouped with other predictorvariables of substance use in behaviouralfactors, rather than in a separate section. Thecategories were mutually exclusive and exhaus-tive (sociodemographic, environmental, behav-ioural, and personal factors). The variables tobe discussed were listed at the beginning ofeach section. Many of the studies were citedunder more than one category of risk factorsbecause they included a range of variables.

DATA EXTRACTION AND TABULAR PRESENTATION

The research literature was summarised in fourdetailed tables (available from LLB), one foreach of the sections on sociodemographic,environmental, behavioural, and personal

factors. Each table included information on thestudys author(s); date of publication; place inwhich the research was conducted; age(s) ofthe subjects; duration of follow up, if any; sam-ple size, by group if relevant; outcome and pre-dictor variables; results; notes concerning theanalysis, any unusual aspects of the methods,and statements concerning special findings;and other tables under which the study wassummarised. Both statistically significant andnon-significant results were indicated.

The table in this report provides an overallsummary of the evidence for an associationbetween the major variables discussed andadolescent smoking. The major trends in the

studies were noted and overall conclusionsdrawn, with indications of areas in which therewere contradictory or inconsistent findings.The summary of whether a particular variablewas associated, not associated or the presenceof an association was undecided was based onstandard statistical levels of significance(p

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if such an association had not yet beensuYciently investigated to warrant a conclu-sion. Both authors independently reviewed theliterature and came to the same conclusionsregarding the current evidence for anassociation between each factor and adolescentsmoking.

DATA SYNTHESIS

Sociodemographic factorsThe factors summarised included age; gender;ethnicity and acculturation; living arrange-ments, family size and structure; parentalsocioeconomic status (SES); spending money

and employment status; and rural/urbanresidence. In some studies, it was diYcult toseparate these factors because there arecollinear relationships between such variablesas SES, family size, and educational level ofparents. There was also considerable overlapbetween the studies in this section and others,because almost all of the studies in this reviewexamined some sociodemographic variables.

Initiation and prevalence of smoking amongadolescents typically rise with increasing ageand gradefor example, refs3033. Adolescentswho began smoking at a younger age weremore likely to become regular smokers34 andless likely to quit smoking.13

Although historically the prevalence ofsmoking was higher among men than women,8

data collected for the past 10 years haverevealed that the rates of current smoking andinitiation to smoking were approximately equalfor the two groups, at least in North America.For adolescents, however, reported smokingrates among girls were higher than for boys insome studies from the 1980s, with conflictingaccounts in other reports of no genderdiVerences or higher rates among boys. Theresults of the studies initially appear inconsist-ent, but further examination reveals ageographical/cultural pattern of gender

diVerences. Reports of equal or higher levels ofsmoking by females were primarily found instudies with subjects from countries with aWestern cultural orientation: England, NewZealand and the United States,31 3540 ratherthan an Eastern one with higher smokinglevels among males: China, Japan, and SriLanka.4145 Also consistent with this pattern ofEast/West diVerences was a report from theUnited States of a significantly higher risk of

current smoking among Vietnamese boys,whereas the risk was lower among white andHispanic boys than among girls of these sameethnic/racial groups.46 These patterns reflectthe gender diVerences found among adults inthese countries.4749

There were a few exceptions to this patternin the articles summarised. In Canada, asignificantly higher prevalence of smoking inmales (20.5%) than females (18.4%) wasreported,50 whereas the opposite might beexpected. Possible explanations for this incon-sistent result are the studys inclusion of oldersubjects (half of the subjects were aged 18 to24 years), who would be more likely to show

the pattern of slightly higher rates of smokingseen in adult Canadian men,2 or the small gen-der diVerence (odds ratio = 1.13 for males)that only reached statistical significancebecause of the large sample size (n = 8018).One other article reported discrepant results. Astudy of Icelandic adolescents found higherlevels of smoking for adolescent girls,51 asmight be expected, but a study in another Nor-dic country, Finland, found higher smokingrates for boys.52

The reasons for the recent increase in smok-ing rates for girls in the West are diverse andprobably include such factors as focusedadvertising and concerns about weight control.Reasons for smoking are likely to be diVerent

for males and females and have been discussedin Pederson,53 Pederson and Lefcoe,54 Kovaland Pederson,55 and in the section below, onpersonal factors. Despite the potentialdiVerences in mechanisms, however, smokingrates among boys and girls were often similar,with many studies reporting non-significantgender diVerences.

The rates of smoking for North Americanaboriginal peoples are consistently the highestof any ethnic group studiedfor example,refs56 57. It is well documented, however, thatblacks show significantly lower levels ofinitiation and current smoking than whites orHispanicsfor example, refs56 58 59. The

reasons for this diV

erence are not clear,particularly given that many of the variablesassociated with smoking, such as low SES,poverty, dysfunctional f amilies, and low educa-tional aspirations, tend to cluster in someblack geographical areas. Among blacks whodo smoke, the mechanisms may be diVerentfrom those for whites; smoking may serve moreof a social function for white adolescentsbecause they are more strongly influenced bypeer smoking.60 Smoking levels appear to berelatively high among Hispanic youth; theyhave variously been reported as higher than forwhite adolescents (for example, ref58), lower

Summary of the association of psychosocial factors with adolescent smoking

Factors Association No association Undecided

SociodemographicAge xGender xEthnicity/race xAcculturation xFamily structure xParental socioeconomic status xPersonal income xUrban/rural residence x

EnvironmentalParental smoking xParental attitudes xSibling smoking xPeer smoking xPeer attitudes and norms xFamily environment xAttachment to family and friends xAvailability of tobacco x

BehaviouralSchool factors xRisk behaviour xLifestyle x

PersonalStress xCoping xDepression/distress xSelf-esteem xAttitudes to smoking/smokers xKnowledge of health eVects of smoking xPersonal health concerns x

Psychosocial factors related to adolescent smoking 411


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(for example, refs34 56 5962), and higher andlower, depending on the level of acculturation.63

It might be expected that the degree towhich individuals from various ethnicbackgrounds identify with, or have beenassimilated into, mainstream society would berelated to the adoption of certain behaviours,including smoking. In the United States, Lan-drine and colleagues63 found that acculturated

Latinos showed smoking rates similar to thoseof whites; less acculturated Latinos showedsignificantly lower smoking rates similar tothose of blacks and Asians. Vega et al 62 did notfind an eVect of acculturation among Hispanicgroups and Wiecha46 reported an inverse asso-ciation of acculturation and smoking forVietnamese adolescents. The influence ofacculturation is thus not clear; some possibleexplanations for the discrepancies may bediVerences in the smoking rates acrosssubjects countries of origin, analyticdiVerences (acculturation was assessed usingunivariate analyses in Wiecha46), and agediVerences (in the study by Vega et al ,62

subjects were several years younger than thosein either of the other two studies and had rela-tively low levels of smoking).

Variables related to family structure havebeen examined in many studies. Overwhelm-ingly, the evidence leads to the conclusion thatintact, two-parent families are protectiveagainst smokingfor example, refs52 6466. Thisassociation has persisted over the past decadeand across countries.

The eVect of household size on risk of smok-ing is unclear: studies have noted largerfamilies to be associated with lower50 67 orhigher levels52 of smoking, or have reported nosignificant relationship.40 The inconsistent

results might reflect diVerences in whetheranalyses controlled for associated variablessuch as parental income, parental education,and smoking by siblings and other householdmembers. In large households, there is agreater chance that at least one member willsmoke and that there will be a higher numberof smokers; if no household member smokes,then there is no increase in risk associated withhousehold size or, in fact, the additionalnon-smoking models may decrease the risk ofadolescent smoking.

Higher levels of parental socioeconomicvariables, such as education and social class,have often been found to be inversely related tosmoking status in adolescentsfor example,refs40 45 52 68 69. The eVect of SES may explainsome of the inconsistent results for maternaland paternal education. Several studies thathave reported non-significant eVects of paren-tal education on adolescent smoking haveexamined maternal education only30 57 70 orhave found paternal but not maternaleducation to be significant.44 Traditionally,however, paternal education has been astronger determinant of household SES thanmaternal education, whereas maternal educa-tional level has been associated with the healthbehaviours in a household.

The personal income of adolescents hasbeen associated with adolescent smoking:young people with more spending moneyshowed higher levels of smoking38 40 51 71 72

presumably because money is needed for thepurchase of cigarettes. Adequate income maysupersede other protective factors; Blackford,Bailey, and Coutu-Wakulczyk73 found that sub-jects who were working and had their own per-sonal income showed higher cigarette use even

though they came from two-parent families.Relatively few studies included measures of

rural/urban status and the results of these stud-ies were inconsistent. A higher prevalence ofsmoking was associated with residence in arural, tobacco-producing area in the UnitedStates74 and urban residence in Sri Lanka.43

Isohanni and colleagues52 noted increasedsmoking by young people living in urban areas,but decreased smoking by those living in anindustrialised province. Two other reportsfound no significant relationship.40 51

Environmental factorsFactors in the environment that potentially

influence initiation and maintenance ofsmoking by adolescents have been the focus ofmany investigations since early studies demon-strated the importance of peer and parentalsmoking as risk factors.75 The broad categoriesthat have been studied are: smoking amongparents, siblings and peers; attitudes andnorms about smoking (including parentalreactions to smoking by their children); familyenvironment; and attachment to family andfriends. Availability and ease of acquiring ciga-rettes are also environmental factors that canhave an impact on smoking amongadolescents. Interpretation of these studies wascomplicated by inconsistencies in the outcomevariable (smoking status, intentions, initiation,

and attitudes); the diVerent combinations ofpredictor variables; the range of methods andpopulations; and the variety of analyticalapproaches that have been used.

The impact of parental smoking has beenstudied in a wide range of contexts in a largenumber of studies with a variety of outcomes.Approximately twice as many of the reviewedstudies have found a significantly increased riskof adolescent smoking with parentalsmokingfor example, refs52 70 76 77, than havenoted a non-significant association.43 78 79 Stud-ies examining the eVect of paternal and mater-nal smoking separately have reported both tobe significant,36 non-significant,31 80 or each one

significant while the other was not.

81 82

Some ofthe inconsistencies may reflect gender-specificdiVerences: parental smoking may be moreimportant for girls than boys because severalstudies reported a significant eVect only forgirls38 69 83 84 whereas none found the reverse. Itis unclear whether parental smoking has astronger influence when it occurs in the same-gender parent: reports have both supportedand opposed this hypothesis.67 85 A dose-response eVect may also be present, with astronger influence if both parents smoke.41 71

Finally, some reports noted that thesignificance of parental smoking depended on

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the outcome studied. It was significant only forintention to smoke and not for currentsmoking in one study.86 Another study foundpaternal smoking significant for current smok-ing but not for experimental smoking, whereasmaternal smoking was significant for both.32

Parental attitudes toward smoking and, inparticular, toward their own childrenssmoking have been shown to be related to ado-lescent smoking. For example, Newman and

Ward76 found that parental indiVerence to theirchilds smoking increased the likelihood ofsmoking in American 1314 year olds. Similarresults were found by Dusenbury andcolleagues32 for current and experimentalsmoking in the United States and by Wang andcolleagues30 for weekly or daily smoking amongadolescents in China. Botvin et al 31 foundparental attitudes to be related to smoking inBlack students in bivariate but not multivariateanalyses, as did McNeill and colleagues35 forEnglish adolescents starting to smoke. Adultsmoking norms were not related to eithersmoking behaviour or intentions in grade 7inner-city youth (1213 year olds).87

The weight of the summarised studiessupports the influence of sibling smoking onadolescent smokingfor example,refs37 41 45 86 88. Some of the studies reportingnon-significant results did find a significanteVect of sibling smoking before controlling forother variables in multivariate analyses.36 89 Insome studies, the influence of smoking by sib-lings was stronger than that of smoking byparentsfor example, refs31 42 90. Sibling butnot parental smoking was also associated withless negative attitudes towards smoking.91

Given the influence of parental and siblingsmoking, it is not surprising that some adoles-cents attributed their own initiation to smoking

to the fact that one or more of their familymembers smoked.36 73 92

Aspects of the family environment whichhave been examined with regard to adolescentsmoking include parental supervision, attach-ment, support, and parenting style. Theamount of time in self care,93 94 lack ofknowledge about their childrens friends78 andinadequate monitoring77 were associated withincreased smoking, although other studies onparental supervision did not observe asignificant relationship.79 95 96

The most important component of parentalattachment may be attachment to the mother:it has been related to smoking in studies whereattachment to the father was not significant.78 97

A poor relationship between mother and childwas associated with a higher prevalence ofsmoking for boys and girls; a poor father/childrelationship significantly influenced smokingonly for girls.38

Parental attachment and support may inter-act with parental smoking to influence smokingamong adolescents. Parental and other adultsupport was protective against adolescentsmoking mainly at low levels of parentalsmoking.98 Adolescents modelled their parentssmoking status more closely as attachment totheir parents increased.99

An authoritative, positive parenting style hasbeen associated with lower levels of adolescentsmoking.100 101 Some aspects of child rearing,however, may have diVerential eVects for malesand females. Low parental concern increasedthe risk of boys taking up regular smoking84

whereas poor communication with parents andrestrictions on going out raised the prevalenceof smoking in girls.38 A permissive, distractedfamily environment was also related to illicit

drug use in girls.102Findings with regard to peer smoking were

more consistent than those for parental smok-ing. Peers have been variously defined asclassmates, friends, best friends, opposite orsame sex friends, and boyfriends or girlfriends.The influence of best friends has been noted tobe greater than that of other good friendswhich, in turn, was greater than that of peers ofthe same age.103 Regardless of the definitionused, however, peer smoking was consistentlyfound to be related to adolescent smoking ini-tiation, maintenance and intentionsforexample, refs31 77 104 105. Some of the inconsist-ency in the reported influence of parental

smoking on adolescent smoking may reflectwhether peer smoking was also examined,because the eVect of parental smoking maybecome non-significant after controlling forpeer smokingfor example, ref89. It is less theexistence of a causal relationship between peerand individual smoking than the direction ofthat association that has been a matter ofdebate.106 107 It is unclear whether peerinfluence leads to smoking or whetherindividuals who smoke tend to seek out othersmokers.

Peer influence may be modified by groupmembership: smoking by best friends wasfound to be related to adolescent smoking forgroup outsiders but not for group members.108

This result was supported by the observationof Ennett and Bauman106 that social isolateswere more likely to become smokers.

Normative values appear to play a role;diVerent measures of smoking were related topressure to smoke and pressure not tosmoke31 109 110 but not to actual prevalence ofsmoking.32 36 111 In addition, adolescent smok-ers tended to overestimate the prevalence ofsmoking among peers.32 87 109 110 The perceivedprevalence of adult smoking is less clear; onestudy found that adolescent smokersoverestimated smoking among adults110

whereas other studies did not.32 87 Perceivedsmoking by friends, however, was reported to

be a stronger predictor of cigarette use thanfriends actual use.112 Some factors may be dif-ferentially important at diVerent ages. Forexample, Santi et al 90 found that best friendtried smoking was related to smokinginitiation during elementary school and mostof five closest friends tried smoking wasrelated to smoking initiation during highschool.

The extent to which the individual is bondedor attached to peers is perhaps the underlyingmechanism for the influence that peers exerton adolescent behaviour. Various constructsused to describe this phenomenon include



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social support, need for aYliation, social bond-ing, and attachment. Peer attachment has beenreported to raise the risk of adolescentsmoking.78 Peer support had no influence whenfriends were non-smokers, but increasedsmoking when peers smoked and there was lit-tle parental or other adult support.98 Peer indif-ference or approval of smokingfor example,refs43 103 and drug use94 has been associatedwith increased adolescent smoking: Urberg

and colleagues109 observed that smokers do notbelieve that peers encourage smoking, but thatthey do not discourage it.

The observation that peer variables appearimportant across ages and countries probablyindicates something about the way adolescentslearn to function in society. The consistencyand magnitude of the relationships lead toconclusions about the power of social connec-tions for maturation and for the adoption ofbehaviours as well as attitudes and beliefs.

The final variable to be discussed in this sec-tion is the accessibility of tobacco. Tobacco isgenerally available to adolescents. Despite leg-islation that prohibits sales to minors, they are

able to acquire cigarettes and other tobaccoproducts through direct purchasethemselves,113 through older friends and familymembers, or by stealing from parents andother adults who smoke. Although accessibilityis important, it has been shown to be less sothan other reasons cited for smoking.39

Behavioural factorsThere were three major categories of behavioural variables. First were those factorsrelated to school, primarily academic perform-ance and aspirations. A second categorycontained risk-taking or deviant factors such asviolence and gang membership. A final relatedgrouping included lifestyle factors such as diet,

exercise, sleep, and dental care. Behavioursrelated to sexual activity, seatbelt use, andalcohol and other drug use are indicators oflifestyle, but also can be described asrisk-taking.

Smoking status has been found to beconsistently related to school performancefor example, refs81114, and has also been associ-ated with educational aspirations,30 41 and com-mitment to school.105 Those students who dowell in school, have high academic aspirationsand are committed to school are less likely tosmoke than those who do not possess thesecharacteristics. The protective eVect of academic performance, aspirations, and

commitment on adolescent smoking mayreflect beliefs necessary for academic success.A longitudinal study of American 1214 yearolds found that belief in conventional rules wasassociated with lower levels of smoking.99

Risk taking and deviance encompass apattern of problem-prone behaviours thatfrequently tend to coincide. For example,measures of deviance and risk-taking wererelated to tr ying to smoke,104 currentsmoking,115 and to associating with smokingfriends.95 As well, certain risky behaviours suchas having a history of trouble with the police94

and, for some ethnic groups, carrying a

weapon46 were also associated with smoking.Although not all studies have shown thisrelationshipfor example, ref 33, overall resultstended to support this pattern.

Lifestyle behaviours tend to occur togetherin adults, so that individuals who adopt ahealthy lifestyle with regard to one aspect oftheir lives tend to do so in others as well. 116

This pattern also appears to occur inadolescents. For example, problem behaviours

such as smoking and other drug use, sexualactivity, riding with a drinking driver, carryinga weapon, and physical fighting have beenassociated with lower levels of health-enhancing behaviours such as seatbelt use,positive eating behaviour, and adequatesleep.117 Alcohol and other drug use increasedthe risk of smoking among adolescentsforexample, refs38 58 118 whereas participation insports or other physical exercise consistentlyprotected against smokingfor example,refs34 52 119.

Not following a healthy lifestyle can be con-sidered a form of risk taking if the individualhas knowledge of its health implications.

Although this knowledge was not assessed insome of the studies reviewed, it is unlikely thatyoung people are unaware of the health risks ofunprotected sexual activity or the use oftobacco, alcohol, and other drugs. Hence,adoption of behaviours such as these can beconsidered to be r isk taking in mostadolescents. Research results supported theconclusion that these unhealthy practices wererelated to smoking initiation and maintenancein a wide range of settingsfor example,refs35 50 94.

Personal factorsResearch on psychosocial correlates ofsmoking and other drug use, specifically inves-

tigations of personality characteristics, motiva-tional factors such as stress, and personalresources such as coping, has arisen fromattempts to delineate the mechanisms explain-ing initiation to smoking among some popula-tion subgroups defined by their sociodemo-graphic characteristics.120132 These studies aresummarised in this section. Research on smok-ing knowledge and attitudes, sex roles, sociali-sation, and religiosity has also been included inthis section because of their interrelationshipsand their functions as proximal determinantsof smoking.

In addition to the methodological andanalytic issues raised earlier, the problems in

interpretation of the factors in this section werecompounded by the use of concepts that weregiven the same name but measured diVerentconstructs (such as stress: acute or chronic) orthat were given diVerent names but measuredsimilar constructs (for example, competenceand locus of control). In addition, the diVerentcombinations of variables included make it dif-ficult to draw definitive conclusions about anysingle variable. Some overall statements,however, can be made about the influence ofpersonal variables on adolescent smoking.

Stress and associated distress or depressionare important factors in the initiation to smok-

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ing. It has long been recognised that life changeor life stress may have a substantial negativeimpact on emotional wellbeing. It is the unsuc-cessful adjustment to this life change that ispostulated to lead to psychological distress.Indeed, in adult and adolescent samples, stresshas been shown to be positively correlated withlevels of psychological distress.133 134 It has beenrepeatedly demonstrated that stress, measuredin a variety of ways, is associated with initiation

to smoking and with maintenance of thebehaviourfor example, refs135137. For thosestudies that do not include a direct measureof stress, the impact can be implied throughassociations with its outcome depression/distress64 138 139.

The use of smoking for dealing with stress isnot unexpected as nicotine may have directpharmacological eVects that moderatestress.140144 In fact, smoking has been cited as ameans of dealing with stress among youngsmokers145 as well as among adults. Althoughthere is some evidence that drugs in general areused for coping,146148 Wills and ShiVman,133 intheir review of the literature, noted that smok-

ing was consistently reported to be a copingmechanism. The relationship of smoking statusand the availability of other coping strategiesfor dealing with stress has been investigatedwith significant38 and non-significant results.94

Pederson and colleagues149 reported that,although a total coping score was notassociated with ever/never-smoking, problemsolving was higher in never-smokers, and druguse and ventilation of feelings were more likelyto be used as coping strategies in ever-smokers.

Other factors that have been consistentlyassociated with smoking are self-esteem,whether overall or with regard to specific con-texts such as home or schoolfor example,refs101 135 150, adult and scholastic

competence,88 151 locus of controlfor exam-ple, refs66 130 152, socialisation,153 susceptibility topeer influence,84 152 and risk-taking.154 The firstfour factors appear to be protective againstsmoking whereas the last two are risk factors.

Johnson and Gilbert37 evaluated the ability ofseveral other constructs, including state andtrait variables, to distinguish smokers fromnon-smokers. Trait anger and anxiety variablesdiscriminated smokers from non-smokers,implying that more stable characteristics maybe important in adolescent smoking. Forgaysetal 155 also found trait anxiety and anger to besignificantly associated with smoking status.Evans et al 156 found sex role predictive of

smoking frequency. Religiosity was a protectivefactor for females and a risk factor for males inpredicting smoking frequency.95

Not surprisingly, more positive attitudestoward smoking and smokers tended to berelated to an increased likelihood ofsmoking.31 45 91 105 118 157 McNeill et al ,35 how-ever, found that beliefs and opinions aboutsmoking did not predict smoking uptake in thepresence of sociodemographic, environmental,and behavioural factors, and Charlton andBlair83 found the relationship between positiveattitudes to smoking and initiation of smokingto be significant only for females. Attitudes

may not be as important as other factors; Stan-ton and Silva89 did not find an association aftercontrolling for friends smoking. Althoughsome studies have found knowledge about thedetrimental health eVects of smoking to beprotectivefor example, refs36 138, the bulk ofthe literature does not support this position(for example, refs31 35 158).

Finally, personal health concerns appear tomotivate young smokers as well as adults. Eiser

et al,130 for example, found that the importanceof health items was related to smoking status;belief that personal health is damaged bysmoking was protective for initiation tosmoking and for daily smoking.80

Discussion and conclusions

ANALYSIS

Table 1 presents an overall summary of thefindings from this review. The rising interest inthe identification of predictors of adolescentsmoking is demonstrated by the surge at thebeginning of this decade in the number ofthese publications. Some general statementscan be made about many of the associations.

Most of the factors summarised in each sectionof the review have been associated with adoles-cent smoking, as has been shown by otherresearchersfor example, see reviews byUSDHHS8; Flay26; Cohen et al 159; Giovino etal.160 Among the variables, only gender showsno association, at least in recent studies and inWester n societies. The influence of acculturation, urban/rural residence, availabil-ity of tobacco, and coping is unclear and moreresearch is needed to determine their eVect.Although the impact of knowledge of thehealth eVects of tobacco is uncertain, severalstudies appear to demonstrate that this knowl-edge has no eVect; it may become relevant,however, when it is personalised by the indi-

vidual.There are some variables that have not been

considered in this review because of the smallamount of evidence available. These includepolicy-related variables such as price andadvertising,161163 and genetic factors.164 Re-search in these areas oVers promise in thedirection of isolating risk and protectivefactors, but the potential importance of thesevariables has yet to be determined.

As noted previously, it is often diYcult tosynthesise results from the myriad of relevantstudies because of the wide variation inmethods, measures, and analyses. In addition,outcomes have varied across studies and, even

when an outcome is labelled in the same way,the definitions often diVer. Therefore, werecommend that standard definitions beadopted in the futurefor example, ref11. Fur-thermore, for those individuals who haveaccess to some of the data reported here,re-analysis of the data employing thesedefinitions would add immeasurably to thebody of knowledge. It may then be possible todraw definitive conclusions about some of thefactors whose eVects are currently unclear.

It has been suggested that some of theinconsistencies have arisen because of a cohorteVect: changes in the variables that are impor-



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tant for diVerent birth cohorts over time. Giventhe relatively limited time period covered inthis review and the consistency of the resultswith those in the past, however, it is unlikelythat this is a major contributor to the pattern ofresults observed.

Some authors of reviews have felt itnecessary to exclude those investigations whichonly include cross-sectional data. Such studieswere included in this literature review. It is

important to note that, where findings wereconsistent, they were generally found in bothtypes of study designs; where they were not, itdid not appear that the diVerent results couldbe attributed to study design. Hence, theinclusion of all studies, regardless of methods,does not detract from the conclusions reachedbut instead adds credibility to them.

One issue arising from an examination of theliterature concerns the nature of protective andrisk factors. Are protective factors more thansimply an absence or low level of risk factors? Isit possible that some factors function in oneway (as the absence or low level of the factor)and others in an alternate fashion (as the pres-

ence of the factor)? As noted in an earlierreview,165 to develop prevention interventions,it is necessary to understand the functioning ofprotective and risk factors, their relative impor-tance, and how they interact. There may besome readily modifiable risk factors that couldserve as the basis for eVective interventions.One such factor is the concern about healtheVects that are perceived as directly relevantand personal, and that appear to impact onadolescent smoking and uptake as well as onthe smoking behaviour of adults.149 Why this isso, when knowledge about health eVects gener-ally appears to bear little relationship to smok-ing by young people, is an important area forinvestigation. It is not readily apparent why

health knowledge seems to be generallyaccepted as important, but yet does not appearto influence behaviour as expected. Futureinvestigations should address this issue as wellas questions concerning the functioning ofrisk/protective factors.

Although it is often assumed that researchfindings will inevitably be translated into inter-vention programmes, the data may insteadremain within the academic community andf ail to be disseminated to exper ts inprogramme and policy development. There ismaterial available that could be applied to cur-riculum development if the lines of communi-cation were open, comprehensible, and used.

For example, it is well known and generallyaccepted that stress and self-esteem are impor-tant constructs in many areas, among themsubstance use/abuse. Why is this informationthen not routinely used by those individualswho have responsibility for programmedevelopment within the schools? It is alsoaccepted that knowledge of health eVects alonedoes not appear to oVer protection againstsmoking; all of us know, however, that thishealth information needs to be communicatedand so we persist in supporting this approach.Flay26 has suggested that interventions need tobe multifaceted rather than narrowly focused

on only one or two factors. It is clear that inter-ventions also must incorporate researchfindings. It is essential that experts worktogether to ensure that the information istranslated into programmes, the programmesare implemented and evaluated, and the resultsare disseminated widely.

PROPOSED THEORETICAL FRAME OF REFERENCE

Useful information on the process of initiationto smoking has been gathered from empiricalresearch; there is a need, however, fortheory-based research that attempts to synthe-sise the current body of knowledge and to gen-erate information that will lead to anunderstanding of the process. If such informa-tion is forthcoming, it could serve as the basisfor prevention and intervention programmesthat will be more successful over the long termthan those that have been used to date. Giventhe complex nature of smoking and theinfluences aVecting it, it is important toconsider individual, social, biological, physi-ological, environmental, and political variablesin the development of a model of acquisition

(see review by Fisher, Lichtenstein, andHaire-Joshu166).

One such theoretical model has been exam-ined in a recent study. It incorporates stress,coping, and personal resources as constructsfor the explanation of initiation to smoking.55

This model can be used to explain some of thesociodemographic diVerences that have beenconsistently noted in the literature and has, asits basis, empirical information from the litera-ture on smoking among adults, on factorsrelated to initiation and maintenance ofadolescent smoking, and on variablesassociated with initiation to other substanceuse. In this model, we have attempted to

integrate these findings and to address factorswhich are potentially modifiable. Hence,research using such a model may yieldinterventions, based on the complex multifac-eted nature of smoking, that may reduce thelikelihood of smoking.

Smoking probably serves diVerent functionsfor males and females (for a review, seeClayton27). The model outlined allowsin-depth examination of the possiblemechanisms operating at various times in thedevelopment and maintenance of smoking.Preliminary data from our own research55 pro-vide support for this approach and documentdiVerent possible functions of smoking.

One of the most consistent findings in theliterature is that of the social influence of peersand others on adolescent smoking. Modelling,direct pressure, and normative beliefs167 havebeen suggested as mechanisms of influenceand investigated along with the potentialimportance of levels of social interactions, assuggested in the works of Eiser et al 157 andSussman et al .115 Of particular interest isresearch suggesting that initiation to smokingis best modelled as a prevalence-driven behav-iour depending upon the degree to which anadolescent comes in contact with othersdisplaying the behaviour.168 The maintenance

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of smoking, on the other hand, shows a degreeof independence from prevalence.103

Because network data and analysis yieldmethods of measuring and systematising theconcept of social context, as well as provideinformation on the association of social contextvariables with behaviour (see review byBauman and Ennett 107), they may contributeto understanding variability in smoking preva-lence and thus help to determine the salience

of stress-coping mechanisms. Integration ofthis network research with data specified in theconceptual model described above would pro-vide the opportunity to examine personalbehaviour in a social context.

Recommendations+ Attempts should be made to use standard

definitions of outcome and predictorvariables. When available and appropriate,previously validated scales should also beused.

+ Analyses should include multivariate andbivariate models, with some attempt in themultivariate models to test specific

hypotheses based on findings from theliterature and from theory.+ Future research should be theory driven and

consider the range of possible factors, suchas social, personal, economic, environmen-tal, biological, and physiological influences,that may influence smoking behaviour.

+ Research teams should include representa-tives from a broad spectrum of disciplines,particularly educators and programmeproviders, so that the information gatheredis potentially useful in the identification ofhigh risk groups and the design of interven-tions.

+ Investigations focused on determiningwhether protective and risk factors are at

opposite ends of the same dimension, or arequalitatively and functionally diVerent,should be supported.

+ The apparent inconsistencies in relation-ships between parental SES and adolescentdisposable income need to be resolved.Another priority area is clarification of therelevant underlying constructs for whichSES is a proxy. Although it is accepted thateducation, occupation, and income arecomponents of SES, further research isrequired to determine what social and otherfactors operate within various groups toproduce diVerences in smoking behaviour.

This research was made possible in part by Health Canada

through a National Health Research and DevelopmentProgramme (NHRDP) Research Training Award to SuzanneTyas. The constructive comments made by Dr Gene McGradyare appreciated.

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doi: 10.1136/tc.7.4.409

1998 7: 409-420Tob ControlSuzanne L Tyas and Linda L Pedersonsmoking: a critical review of the literaturePsychosocial factors related to adolescent

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