Tuesday, August 28, 2007

Youth smoking & risk foresight

Smoking cigarettes usually begins in adolescence. In Australia the average age of smoking initiation is 15.9 years. Although the incidence of youth smoking has decreased dramatically over the last few decades still around 10% of school-kids aged 12-17 smoke . A basic issue for designing possible policies for limiting such use is whether youth understand the implications of the action of initiating the dangerous smoking habit.

In short how do youth use information about the risks of health damages and the damages when they themselves make current cigarette consumption decisions?

For a person aged less than 20, serious health damages are unlikely to occur for 50 years or more so that, using the discounted utility model, considerably less weight may be placed on them than were these damages immediate. Death or disability at an old age may also be regarded as less significant than the same event now because less life is lost at older ages and life itself might be regarded as being worth less when a person is older. The upshot is that it is not necessary to rely on myopia to understand youth smoking. Even at low discount rates it can appear to be rational to smoke at young ages because the discounted value of the costs will be low.

There is also the question of the way risk itself is understood by youth in making smoking decisions. Are risks fully appreciated? In a famous study W. Kip Viscusi (1992) argued that people of all ages – including youth – overestimate the numerical values of health risks associated with cigarette smoking. Moreover, information-based increased perception of these risks did lower the probability of youth initiating smoking so that youth could be understood as making weakly rational choices about smoking based on perceived risks. The perceptions were inaccurate but youth were not being lured into smoking through an under-perception of risks.

Information about smoking risks comes from public health warnings and from implied and explicit health warnings in cigarette advertising. Cigarettes can promote themselves as ‘smooth’ or ‘gentle to the throat’ and so on even apart from legislated health warnings on packaging. Fully one quarter of the claims in cigarette ads from 1926-1989, that were examined by Ringold and Calfee (1989), related to health.

Moreover, public health warnings over the damages of smoking are not only a recent phenomenon. Tate (1989) points out that, even as early as 1893, 14 US states outlawed the sale of cigarettes and at least another 21 states considered prohibition on the basis of claimed bad health consequences! There were also active, organised groups of citizens who opposed smoking. The main issue missed in these early heath concerns was recognition of lung cancer risks – lung cancer was rare before 1930 and not even recognised as a disease until 1923.
Overall however recognition of the health risks of smoking is nothing recent.

There has been an explosion of information on the negative consequences of smoking over recent decades. Evidence of increasing recognition of health risks arose in the 1950s with decreased cigarette use. Viscusi claims that people have taken the negative implications of this information too far. The young he claims overestimate the risks of smoking more than the overall population because they have only been exposed to intense, more recent, information. There is considerable evidence that reduced smoking has occurred because of heightened risk perceptions.

Hence Viscusi argued that measures to limit smoking amount to excessive zealousness. The only case for regulation to Viscusi could stem from third party effects such as passive smoking externalities. The negative message about the health consequences of smoking then has been effective and reduced smoking levels among youth. Those youth who are left initiating smoking are well-informed consumers who have assessed risks and benefits appropriately.

In addition, according to Viscusi, smoking policy should focus on trying to incentivise tobacco companies to produce a safer cigarette rather than engaging in public information campaigns that further emphasise the already-exaggerated risk perceptions of smokers.

The impact of the provocative Viscusi study can scarcely be underestimated given the amount of printer’s ink that has been spent subsequently trying to overturn its conclusions. Strong responses, in particular, have come from psychologists who dispute generally dispute Viscusi’s analysis.

Bad decisions by youth. The psychologist Slovic (2001), for example, has edited a volume whose primary purpose is to critique the proposition that youth are well-informed about the risks of smoking and to propose more activist policies than Viscusi would see as desirable for reducing youth smoking. The study, by emphasising smoking initiation decisions, complements work on policies promoting smoking cessation decisions by older smokers (Sloan et al., 2003)).

The empirical component of the Slovic volume is based on surveys involving interviews with 4,000 persons aged 14+ in 1999 and 2000. Contributors discuss different aspects of these databases.

A major idea is that an affect heuristic is important in understanding people’s decisions regarding the initiation of a risky activity such as smoking. According to this, youth may try a risky activity because their feelings about it, rather than their rational thoughts, are favourable to it. Employing this heuristic they may come to understate the risk of a smoking initiation decision.

Also, in questionnaires designed to elicit risk responsiveness, respondents should be asked how they themselves would be affected by smoking rather than how they believe the general population will be affected. This helps to account for the possible ‘optimism biases’ that arise when individuals assess their own risks.

For the most part the remainder of these notes review arguments by various authors in Slovic (2001).

1. What do young people think they know about smoking? P. Jamieson and D. Romer agree with Viscusi that ‘many’ (they claim around 70%) of young people overestimate the risks of such smoking-induced events as lung cancer but they point out that youth estimates of the risk of dying from a smoking-related cause were much more accurate – only 34% overestimated these risks. Also, they claim, youthful smokers underestimate the impact of smoking on years of life lost which the authors see at about 7 years. But modern research suggests that early authors overstate these losses anyway because smokers are risk-takers who will enjoy shorter life spans because of their greater risk tolerance. Accurate figures on life lost after accounting for such effects are 4.4 years lost life for men and 2.4 years for women (Sloan et al. (2004)) so the Jamieson-Romer argument is unconvincing. The authors are correct however in asserting that young people severely underestimate the difficulty of quitting. Youth also wrongly believe smoking is less dangerous to health than drinking or drugs when asked which produced the most deaths per year. That this is false shows that, in assessing risk relative to other activities rather than as numerical probabilities, youth do understate risk.

2. Risks in starting and stopping smoking. In accord with the ‘affect heuristic’ D. Romer and P. Jamieson find that, while risk perceptions do not drive smoking initiation, feelings about smoking do. Positive feelings about smoking reduced perceived risks to the extent that such risks did not influence smoking initiation. The perceived ease of quitting was the only risk factor involved in the decision to try cigarettes. This suggests that counter-advertising emphasising health risks will not deter trialling cigarettes by youth although an emphasis on depicting the smoking experience in a negative way and on difficulties of quitting might. Commercially-oriented advertising that promotes positive feelings about smoking however will encourage smoking and provides a case for limiting advertising.

As youth continue to smoke and as they sense they are becoming addicted to nicotine their perceptions of risk and of short-term harm increase and their optimism about quitting declines. As they have already started smoking this cannot affect their initiation decision but it does bear on the progression of their addiction. Smokers tend to become more aware of the risks – especially long-term risks - as they continue to smoke and become more concerned with quitting. The policy implication is again that the emphasis on risks should focus on quitting not initiation.

The few adults who initiate smoking behave like youth and disregard even heightened perceptions of risk. As they continue smoking however perceived health risk - particularly immediate risks - provide incentives to quit and hence deter continued smoking. Thus risks might bear on smoking decisions once they are initiated even if they don’t impact on initiation itself. Immediate risks become more pressing as the smoker ages.

3. Smokers recognition of vulnerability to harm. Weinstein revises an earlier paper to examine what it means to comprehend a smoking risk. That one recognises a certain probability of risk numerically does not mean that one accounts for that level of risk in real-life unless probabilities are interpreted as a scientist does. This is particularly so if risks are seen to apply in general or ‘on average’ rather than the person themselves because of ‘optimism biases’.

People do not make decisions on the basis of numerically estimated probabilities so, for example, the extent to which risks are acknowledged by smokers depends on the way risk assessments are assessed.

Many studies confirm that smokers recognise that they face higher risks than non-smokers and, in the great majority of studies, non-smokers and ex-smokers rank these risks more highly than smokers do. Smokers however fallaciously understate the relative risk of smoking compared to risks such as road accidents which suggest that, in this sense, smokers understate the risk of smoking. Moreover, even when the average response is not to show an optimism bias, there are many smokers who do not acknowledge any increase in risk from smoking.

4. Cigarette smokers as rational fools. Slovic defines the affect heuristic formally and uses it to analyse the rationality of smoking decisions. Affect means the specific quality of ‘goodness’ or ‘badness’ experienced as a feeling and which demarcates the positive or negative quality of a stimulus. Reliance on such feelings to make decisions is to use the affect heuristic. Such responses occur rapidly and automatically without much consideration so experience is not integrated with reason.

With respect to evaluating risky prospects people both think about the prospect and have feelings about it. With an affect heuristic there is an inverse relation between perceived risks of an activity and benefits from it so, if people like an activity they judge the adverse risks associated with it to be low. The benefits themselves are evaluated by their affect.

Slovic tested this theory with 3000 smokers about 2000 of whom were’ youth’ under age 23. Of the youth there were 478 smokers. Nearly half of smokers said they thought ‘not at all’ about health issues when they began smoking. Most wanted to try something ‘new and exciting’ and gave no thought as to how long they would smoke. More than half of current smokers think a lot about quitting and most both wish to quit and believe can do so within the next year. According to Slovic, the difficulty is that expected future pain or discomfit is less heavily weighted than current visceral factors such as the craving for a cigarette. Earlier work suggests that 32% of young smokers and 45% of adult smokers believe smoking needs to continue for 5 years or more to cause health damage.

Slovic also criticises the size of the Viscusi risk estimates as exaggerated because he considered only smoking as a way of dying. Adding other causes and then asking for estimates of smoking risks reduces estimates by 50%. The same finding holds with respect to other methods of describing risks and for other measures of harm such as expected longevity reductions. In addition, that many in the surveys stated that they would not choose to initiate smoking again suggests that they did not understand the consequences of their smoking initiation actions. Again, smokers only began to think about smoking risks after they have begun to smoke.

5. Advertising. D. Romer and P. Jamieson extend the work of Slovic to show that advertising by enhancing the positive affective qualities of smoking dampens perceptions of health risks. Counter advertising which emphasises the risks is ineffective because it is imagery and feelings that lead to smoking initiation not perceptions of health risks. What are required instead are unfavorable images of smokers and favourable images of non-smokers. These reduce perceptions of support for smoking among peer networks.

6. Nicotine addiction and youth. Benowitz revises an earlier paper to discuss the factual nature of nicotine addiction. The younger the age that smoking is initiated the more likely are youth to become regular smokers. Those who smoke 3 or more cigarettes face a high probability of becoming regular smokers. Children will often be light smokers but, unlike adult chippers, these consumption patterns are not stable and typically estimate into much higher levels of smoking.

The first cigarette produces discomfit and nausea but with repeated smoking positive effects prevail as tolerance develops. With tolerance develops dependence towards these adverse effects develops and many youth are smoking dependent.

Digression: Work by DiFranza et al. (2003) suggests that it need not only be ‘pleasant effects’ that lead to ongoing use – see also here. Strong averse reactions may also trigger continued use via what is termed the sensitivity model. Thus ‘chippers’ – people who can continue smoking cigarettes at low levels - tend to have low initial aversive effects, those who feel ‘sick or dizzy’ with their first cigarette are seen as more likely to continue on to become regular smokers - dizziness and nausea are independent predictors of dependence symptoms. Increased sensitivity to nicotine as manifested by relaxation, dizziness, or nausea in response to the first exposure to nicotine represents a risk factor for the development of nicotine dependence. This confirms earlier work by Hirschman et al. (1984) which associated dizziness after smoking the first cigarette with progression to a second cigarette whereas coughing was associated with non-progression.

N. Benowitz is concerned with articulating the main factors that lead to smoking initiation. These split into proximal factors (direct effect – such as being offered a cigarette) and other distal factors such as prior advertising exposure, Environmental factors include having friends or parents who smoke or being exposed to positive advertising. Behavioral factors include risk-taking or rebellious behaviour. Personal factors include depression, sensation-seeking or pharmacological responses based on genetics or race. Many of these factors, while being associated with smoking initiation, may not be useable triggers that policy-makers can draw on to reduce youth smoking initiation.

Young people underestimate the addictive nature of tobacco and the risk that they will become addicted hence underestimating the risk that they will incur tobacco-related diseases.

7. Visceral factors. G. Loewenstein views addiction not as a sui generis phenomenon but as one form of a wide range of behaviors. He puts Benowitz’s and Slovic’s findings into theoretical perspective by viewing addiction as a form of behavior controlled by ‘visceral factors’ involving short-term fluctuations in tastes in the form of nicotine cravings. These are ‘interrupts’ that focus attention on a high-priority goal. They are aversive sensations that agents can mitigate by having a cigarette. Although they can dominate current decisions youth will underestimate the impact on their own behaviour of future visceral factors that they will experience in the future. So as with Slovic’s ‘affect heuristic’, it is difficult with smoking to anticipate the force of the cravings one will feel for cigarettes when smoking is initiated. This appreciation begins after one is addicted to nicotine.

Initiation into smoking is therefore promoted by biased expectations about the ability to quit. Immediately experienced cue-conditioned cravings (rather than withdrawal costs) then crowd out all other goals other than mitigating the visceral factor despite the obvious benefits of quitting.

8. Quitting. D. Romer, P. Jamieson and R. Ahern consider paradoxes that create incentives to initiate smoking and to defer quitting. They give this the distinctive name the ‘catch-22’ of smoking although the basic result is evident in literature on self-control. If one believes it is easy to quit smoking one may have no hesitation in starting. However initiating smoking can lead to addiction and difficulties in quitting. This paradox creates problems in designing messages that will both reduce the likelihood of initiating smoking while at the same time motivating current smokers to quit.

There is an exaggerated optimism about the possibilities of quitting particularly among youth. This complements the belief that light or occasional smoking is associated with low risks in encouraging smoking initiation. Once people begin to smoke optimism about the possibility of quitting leads to greater intention to quit. But with continued smoking quitting becomes more difficult as perceived addiction increases. Failed attempts to quit also reduce optimism of the success of quitting.

Anti-smoking messages need to stress the difficulty of quitting to those who are thinking of initiating smoking but at the same time to stress to smokers the benefits of thinking one can quit. A message needs to be framed so different groups interpret it in different ways.

For example the message ‘Each cigarette makes it harder to quit, so don’t start, and if you do smoke, stop now’ has two implications. Here the ease of quitting is seen as greatest when you don’t start but, if you have started, the reframed emphasis is on the progressive difficulty of doing it later rather than now.

9. Final speculative thoughts. The notion that youth correctly appreciate the risks and damages associated with initiating smoking is an almost absurd position. The various arguments in Slovic (2001) confirm this. There is no reason to believe that youth thing in terms of numerically estimated probabilities when the risks of initiating cigarette smoking are assessed. Nor is it immediately clear that youth have the capabilities to assess mortality of disability costs.

My intuition is that youth are rationally myopic in outlook. They understand that a single cigarette or so will have a negligible impact on their future health. They thus try a cigarette to see what it is like and having tries it once innocently repeat the experience. What is being misunderstood here is the addiction potential of cigarette consumption which can lead to long-term health costs.

There are strong arguments for banning all positive cigarette advertising and a case for providing information that seeks to discourage youth from smoking. For the most part such messages should not emphasise the long-term health risks of smoking. The emphasis should be on showing that smoking does not provide positive affect - smokers are not social winners and being a smoker evokes disapproval not respect.

The risks discussed should emphasise the extreme difficulties of quitting and the likelihood that smoking a few cigarettes will lead to regular smoking. Costs emphasised should emphasise current costs of reduced current fitness, unattractive odours and loss of current social acceptability.


J.R. DiFranza, J.A. Savageau, K. Fletcher, J.K. Ockene, A.A. Rigotti, A.D. McNeil, M. Coleman & C. Wood, ‘Recollections and repercussions of the first inhaled cigarette’, Addictive Behaviors, 29, 2, 2004, 1-12.

R.S. Hirschman, H. Leventhal & K. Glynn, ‘Development of smoking behavior: Conceptualization and supportive cross-sectional survey data’, Journal of Applied Social Psychology, 14, 1984, 184-206.

D.J. Ringold & J.E. Calfee, ‘The Informational Content of Cigarette Advertising: 1926-1986’, Journal of Public Policy and Management, 8, 1989, 1-23.

F.A. Sloan, V. Kerry Smith & D.H. Taylor, The Smoking Puzzle: Information, Risk Perception, and Choice, Harvard University Press, Cambridge, 2003.

F. A. Sloan, J. Ostermann, G. Picone, C. Conover & D. H. Taylor, The Price of Smoking, The MIT Press, Cambridge, Mass, 2004.

P. Slovic (ed), Smoking: Risk, Perception & Policy, Sage Publications, California 2001.

C. Tate, ‘In the 1800s antismoking was a burning issue’, Smithsonian, 20, 4, 1989, 107-109.

W. Kip Viscusi, Smoking: Making the Risky Decision, Oxford University Press, Oxford, 1992.

1 comment:

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