This document provides an impressive and elaborated risk factors that usually contribute to smoking and often went unrecognizable from a naked eye, with psychological, social and environmental perspective

1. SMOKING: RISK FACTORS AND INTERVENTIONS
1
Risk Factors for Smoking
By the age of 18, more than two-thirds of teenagers have experimented with cigarette
smoking with peak experimentation occurring between 13 and 16 years of age (USDHHS, 1994;
Duncan et al., 1995). Initiation and maintenance of tobacco during adolescence is influenced by
interplay of psychosocial, biological and environmental factors (USDHHS, 1994). A summary of
these factors is presented in the given table
Psychosocial Factors
Sociodemographic
Personal and Interpersonal
Attitudes/ Expectations/Perception
Psychobiological Factors
Positive Reinforcement
Body Weight Control
Addiction
PsychologicalFactors
Affective Regulation
Cognitive Enhancement
EnvironmentalFactors
Socioeconomic Status
Media
Psychosocial Factors
Psychosocial factors are the most widely studied variables that directly and indirectly
affect an individual‟s choice to use tobacco. Given that young people are particularly vulnerable
to psychosocial influences, prevention efforts to reduce smoking, must seriously take these
factors into consideration. These psychosocial factors appear to have the greatest influences on
smoking initiation and maintenance.

2. SMOKING: RISK FACTORS AND INTERVENTIONS
2
Sociodemographic Factors
Age
The specific development stage of adolescents predicts smoking initiation (Alexander et
al., 1983; Coombs et al., 1986). According to the results from the National Youth Tobacco
Survey conducted by the American Legacy Foundation and the Center for Disease Control (ALF,
2001), nearly two-thirds of high school students and one-third of middle school students have
tried a puff or more of a cigarette. First experimentation with smoking generally begins in the
early part of adolescence, during the transition from elementary school to middle school. During
the high school years, rates of smoking onset level off. The peak age group for initiation and
experimentation is age 11 through 15 (Alexander et al., 1983; Coombs, Fawzy, & Gerber, 1986).
Personaland InterpersonalFactors
Risk-Taking
In adolescence, deviant behaviors such as risk-taking and rebelliousness have been
associated with drug abuse, including cigarette smoking (Jessor&Jessor, 1977; Dinn et al., 2004;
Burt et al., 2000). Adolescent tobacco users generally are described as being more rebellious,
risk-taking, impulsive and novelty-seeking than are their non-smoking counterparts (Dinn et al.,
2004; Barefoot et al., 1989; Lipkus et al., 1994; Simons-Morton et al., 1999; Burt et al., 2000). In
addition, Chassin et al. (1989) found that deviance was a significant predictor of cigarette
smoking in high school students. Similarly, Turbin and colleagues (2000) found that deviantprone adolescents were more likely to engage in risky behaviors, including smoking. Explanation
for this relationship are less clear and may include peer affiliations, sensation seeking, or less
concern about negative consequences.

3. SMOKING: RISK FACTORS AND INTERVENTIONS
3
Self- Esteem
The process of identity-formation is central part of adolescent development. An
adolescent‟s sense of self-worth develops during the adolescent period and is influenced largely
by interaction with peers, parents, and teachers. Therefore, behaviors that bring approval from
others are likely to enhance self-esteem and are more likely to be repeated, even if these
behaviors are accompanied by some cost to the individual. Several studies, for instance, have
reported that individuals with low self-esteem are more likely than individuals with high selfesteem to initiate smoking (Young &Werch, 1990; Botvin et al., 1992; Stacy et al., 1992; Conard
et al., 1992).
Self-Efficacy
Self-efficacy is defined as an individual‟s belief in their ability to reach a desired a goal
(Bandura, 1986; Elickson and Hayes, 1990; DeVries et al., 1990). For adolescents, self-efficacy
is an important predictor of smoking initiation (Bandura, 1986). Specifically, the less an
adolescent feels s/he can resist the pressure to smoke, the more likely s/he will be likely to
initiate smoking (Ellickson and Hays, 1990; DeVries et al., 1990). In contrast, higher selfefficacy appears to protect against peer influences to smoke (Conard et al., 1992).
Family
Parental smoking appears to have the strongest influence for white and female
adolescents, especially in the early stages of smoking (Bauman, Foshee, Linzar, & Koch, 1990;
Chassin, Presson, Montello, Sherman, & McGrew, 1990; Sussman, Dent, Flay, Hansen, &
Johnson, 1987). A review of the literature suggests that this influence may also include other
factors, such as parental approval or disapproval of smoking, parental involvement in

4. SMOKING: RISK FACTORS AND INTERVENTIONS
4
adolescent‟s free-time supervision, the style and extent of parental communication o health
related matters and whether or not parents promote academic achievement for their children.
Peers
Smoking initiation seems to be a part of peer associations and peer bonding in
adolescence. Smoking may be a shared behavior that certain groups use to differentiate
themselves from other peers and from adults. Adolescents usually try their first cigarette with
their peers; peers may then provide expectation, reinforcement and opportunities for
continuation. The influence of peers may be particularly strong during the preparatory trying and
experimentation stages; during the regular use and addiction stages, personal and pharmalogical
factors may become more important.
Attitudes/Expectations/Perceptions
Although an adolescent‟s general knowledge of the adverse health consequences of
smoking is a poor predictor of subsequent use, smoking risks that are personalized and
individualized appear to be important. The perceived positive functions of smoking as well as an
expected utility of cigarette use are significant predictors (Leventhal& Cleary, 1980; Perry et al.,
1987; Bauman, Fisher, Bryan, & Chenoweth, 1984). These factors are related to having a
positive social image, bonding with peers, and being “mature”; all are socially relevant for
teenagers.
Other factors that strongly predict future smoking include intentions to smoke and prior
experimentation (Conard et al., 1992). The initial adverse physiological reactions to initial
smoking diminish with repeated tries, and tolerance to nicotine increases. Nicotine dependence is
associated with a shift from social to more personal, individual reasons for smoking. Rebellious
attitude is also the precursor for smoking in adolescence.

5. SMOKING: RISK FACTORS AND INTERVENTIONS
5
Psychobiological Factors
In addition to psychosocial reasons for smoking, adolescents report smoking to obtain its
psychological effects. Specifically, adolescents report smoking to reduce anxiety, to control
appetite and body weight, to regulate mood states, to improve attention, and for nicotine‟s
reinforcing or stimulating actions (Barker et al., 2004). Identification of how these factors
contribute to smoking is important because the more an adolescents views smoking as beneficial,
the more likely s/he is likely to initiate smoking.
Positive reinforcement
Nicotine is a psychomotor stimulant that produces positive subjective sensations of
reward and these effects are likely to contribute to smoking initiation and maintenance (Ikard et
al., 1969; Garrett & Griffiths, 2001). Adult smokers reliably cite the positive stimulating effects
of nicotine as reasons for smoking (USDDHS, 1988; Copeland et al., 1995). Further, many
adolescents who smoke report that smoking brings pleasurable effects (USDDHS, 1988).
Animals‟ models of nicotine exposure have demonstrated stimulating effects of nicotine- actions
that reflect dopaminergic stimulation.
Body Weight Control
Adolescents, especiallyadolescent girls, may be influenced to smoke by their beliefs that
smoking affects appetite and body weight. The belief that smoking cigarette curbs weight gain
and reduces appetite has been prospectively associated with smoking initiation, particularly
among adolescent girls (Austin &Gortmaker, 2001). This expectation is likely based on reports
that adult smokers weight less than non-smokers (Grunberg, 1982; Wack & Rodin, 1982; Fisher

6. SMOKING: RISK FACTORS AND INTERVENTIONS
6
& Gordon, 1985; USDHHS,1988) and that smoking cessation results in weight gain (Grunberg,
1982; USDHHS,1988; Faraday et al., 2003).
Addiction
Dependence
Nicotine dependence is characterized by tolerance, unsuccessful efforts to cut down use,
cravings, and continued used despite knowledge of harmful effects (USDHHS, 1988; DSM-IV,
1994). Many adolescents progress to dependence much quicker than do adults, exhibiting signs
of nicotine dependence in a few days to weeks after initiation, even before they become regular
smokers (Chen & Miller, 1988; Breslau et al., 2001). Other studies shows that girls reported
more symptoms than did boys even though they smoked at the same rate. Individuals who begin
smoking in adolescence are likely to smoke for a greater number of years and to smoke more
heavily as adults. (Ershler et al., 1989; Breslau et al., 1993b; Chen &Millar, 1998).
Withdrawal
Symptoms of nicotine withdrawal include: dysphoria, depressed mood, frustration, anger,
irritability, difficulty concentrating, restlessness, increased appetite, and cravings (USDHHS,
1988; DSM-IV, 1994). Ershler et al., (1989) reported that more than half of adolescents who try
to quit smoking experience such withdrawal symptoms. Adolescents reported that the experience
of these symptoms is one of the primary reasons why quitting smoking is so difficult (Johnson et
al., 1982).in 200, the National Youth Tobacco Survey revealed that among adolescent smokers
more than half wanted to smoke and have tried quitting at least once during the past 12 months
(Johnson et al., 1982; CDC, 2001). Of the more than 60% of adolescents who report wanting to
quit, less than 5% are successful (Burt & Peterson. 1998).

7. SMOKING: RISK FACTORS AND INTERVENTIONS
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Psychological Factors
Affective Regulation
Stress and Anxiety Reduction
Psychosocial stress has been associated with smoking in adolescence. Adolescents
frequently report that they smoke to cope with stress or to manage negative affect (Mates
&Allison, 1992). Koval et al. (2002) evaluated the relationship between stress and smoking
among sixth graders and eighth graders and found that for both males and females, increasing
levels of stress were associated with increasing levels of smoking. Cheetah et al. (2001) reported
that nicotine was anxiolytic (anxiety reducing) at low dosages for adolescent females and at
higher dosages for adolescent males. Together these findings suggest that nicotine‟s actions to
reduce anxiety in adolescence might differ based on gender and the context in which anxiety
occurs.
Observation
Children and adolescents develop their intentions to smoke and their expectations about
smoking prior to every starting. Expectations about the effects of smoking are based largely on
observations of other people who smoke. These observations help to shape perceptions about the
consequences of smoking behavior and influence of observer‟s intent to smoke or not to smoke.
For children and adolescents, role models include parents, elder siblings, relatives, teachers,
peers, media representatives or other inspired figures. Smoking has been initiated sometimes
only as the result of aspiration which may lead to heavy smoking (Owing, 2012).
Cognitive Enhancement
Attentional Regulation

8. SMOKING: RISK FACTORS AND INTERVENTIONS
8
Smokers frequently report smoking to enhance attention. Research with human smokers
suggests that smoking does increase attention (Conners et al., 1996). Further, recent research
suggests that individuals with attention-deficit/hyperactive disorder (ADHD) use nicotine to
enhance attention and/or cognitive performance (Levin et al., 1996). Whereas most adolescents
do not report smoking to increase attention, the preponderance of smoking among attentiondisordered youth suggests that attentionalregulation may play a role in why adolescents maintain
cigarette smoking (Whalen et al., 2003; Flory &Lynam, 2003).
Environmental Risk Factors
Socioeconomic Status
Socioeconomic status is inversely related to smoking behavior such that low SES is
associated with increased smoking behavior (Conard et al., 1992). Conard and his colleagues
reviewed twenty-one prospective studies on the relationship between parental SES and
adolescent smoking. Of these studies, 76% supported the inverse relationship between low SES
and greater smoking rates. While it is possible that difference in exposure to health promoting
resources explain this relationship, another intriguing explanation exists.
Media
When media glamorize smoking, portray smoking as an effective way to reduce stress,
associate tobacco use with sexual activities, make it appear attractive by displaying these themes
on highly influencing public figures including professional athletes, musicians and actors;
adolescents attitude towards smoking are greatly affected. Unfortunately, tobacco use in the
media does not accurately reflects rates of smoking in the general population and generally does
not reveal the health hazards that result from tobacco use. Tobacco use in the television and
movies occurs at much higher rates than do smoking rates among the general population (Hazen

9. SMOKING: RISK FACTORS AND INTERVENTIONS
et al., 1977; Glantz, 2003; 2004; Stockwell & Glantz, 1994). Therefore media creates an
unrealistic representation of smoking behavior for impressionable youth and presents only
positive impression of this deadly behavior.
Advertisements and Promotion
In 1990, cigarette companies spent almost 4 billion dollars on advertising and
promotional activities (Federal Trade Commission, 1992). These ample expenditures made
cigarettes the second most promoted consumer product (after automobiles) in the United States.
The tobacco industry claimsthat the purpose of advertising is to increase brand switiching and to
increase market shares of adult consumers.Yet, the evidence shows that some young people are
recruited to smoking by brand advertising. The assertion is supported by data showing that
adolescents consistently smoke the most heavily advertised brands of cigarettes ( McCarthy &
Gritz, 1984; Baker, Hmel, Flaherty & Trebilco, 1987; DiFranza et al., 1991).
9

10. SMOKING: RISK FACTORS AND INTERVENTIONS
10
Interventions for Smoking Cessation
Interventions to promote cessation can be described as clinical interventions which are
aimed at the individual, self-help movements and public health interventions, which are aimed at
populations.
Clinical interventions: promoting individual change
Clinical interventions often take the form of group or individual treatment programs
based in hospitals or universities requiring regular attendance over a 6- or 12-week period. These
interventions use a combination of approaches that reflect the different disease and social
learning theory models of addiction and are provided for those individuals who seek help.
Aversion therapies
It aims to punish smoking rather than rewarding it. Imaginal aversion techniques have
been used for smokers and encourage the smoker to imagine the negative consequence of
smoking, such as being sick (rather than actually experiencing them). However, imaginal
techniques seem to add nothing to other behavioral treatments (Lichtenstein and Brown 1983).
Rapid smoking is a more successful form of aversion therapy (Danaher 1977) and aims to make
the actual process of smoking unpleasant. Smokers are required to sit in a closed room and take a
puff every six seconds until it becomes so unpleasant they cannot smoke any more. Although
there is some evidence to support rapid smoking as a smoking-cessation technique, it has
obvious side effects, including increased blood carbon monoxide levels and heart rates. Other
aversion therapies include focused smoking, which involves smokers concentrating on all the
negative experiences of smoking, and smoke-holding, which involves smokers holding smoke in
their mouths for a period of time and again thinking about the unpleasant sensations. Smoke-

11. SMOKING: RISK FACTORS AND INTERVENTIONS
11
holding has been shown to be more successful at promoting cessation than focused smoking and
it does not have the side effects of rapid smoking (Walker and Franzini 1985).
Contingency contracting
Contingency contractingprocedures also aim to punish smoking and to reward abstinence.
Smokers are asked to make a contract with a therapist, a friend or partner and to establish a set of
rewards/punishments, which are contingent on their smoking/drinking cessation. For example,
money may be deposited with the therapist and only returned when they have stopped
smoking/drinking for a given period of time. They are therefore rewarding abstinence. Schwartz
(1987) analyzed a series of contingency contracting studies for smoking cessation and concluded
that this procedure seems to be successful in promoting initial cessation but once the contract
was finished, or the money returned, relapse was high. However, whether such changes in
behavior would persist over time is unclear. In addition, this perspective is reminiscent of a more
punitive moral model of addictions.
Cue exposure procedures
It focuses on the environmental factors that have become associated with smoking. For
example, if an individual always smokes when they drink alcohol, alcohol will become a strong
external cue to smoke. Cue exposure techniques gradually expose the individual to different cues
and encourage them to develop coping strategies to deal with them. This procedure aims to
extinguish the response to the cues over time and is opposite to cue avoidance procedures, which
encourage individuals not to go to the places where they may feel the urge to smoke.
Self-management procedures
It uses a variety of behavioral techniques to promote smoking cessation in individuals
and may be carried out under professional guidance. Such procedures involve self-monitoring

12. SMOKING: RISK FACTORS AND INTERVENTIONS
12
(keeping a record of own smoking behavior), becoming aware of the causes of smoking (What
makes me smoke? Where do I smoke?), and becoming aware of the consequences of smoking
(Does it make me feel better? What do I expect from smoking?). However, used on their own,
self-management techniques do not appear to be more successful than other interventions (Hall
et al. 1990).
Multi-perspective cessation clinics
It represents an integration of all the above clinical approaches to smoking cessation and
use a combination of aversion therapies, contingency contracting, cue exposure and selfmanagement. In addition, for smoking cessation this multi-perspective approach often
incorporates disease model-based interventions such as nicotine replacement. Lando (1977)
developed an integrated model of smoking cessation, which has served as a model for
subsequent clinics. Lando‟s model has been evaluated and research suggested a 76 per cent
abstinence rate at 6 months (Lando 1977) and 46 per cent at 12 months (Lando and McGovern
1982), which was higher than the control group‟s abstinence rates. Killen et al. (1984) developed
Lando‟s approach but used smoke-holding rather than rapid smoking, and added nicotine
chewing gum into the program. Their results showed similarly high abstinence rates to the study
by Lando.
Self-help movements
Although clinical and public health interventions have proliferated over the past few
decades, up to 90 per cent of ex-smokers report having stopped without any formal help (Fiore et
al. 1990). Lichtenstein and Glasgow (1992) reviewed the literature on self-help quitting and
reported that success rates tend to be about 10–20 per cent at one-year follow-up and 3–5 percent
for continued cessation. The literature suggests that lighter smokers are more likely to be

13. SMOKING: RISK FACTORS AND INTERVENTIONS
13
successful at self-quitting than heavy smokers and those minimal interventions, such as follow
up telephone calls, can improve this success. Research also suggests that smokers are more likely
to quit if they receive support from their partners and if their partners also stop smoking (Cohen
and Lichtenstein 1990) and that partner support is particularly relevant for women trying to give
up smoking during pregnancy (e.g. Appleton and Pharoah 1998). However, although many exsmokers report that „I did it on my own‟, it is important not to discount their exposure to the
multitude of health education messages received via television, radio or leaflets.
Public Health Interventions: Promoting Cessation in Populations
Public health interventions aim to promote behavior change in populations and have
become increasingly popular over recent years. Such interventions are aimed at all individuals,
not just those who seek help.
Doctor’s advice
Approximately 70 per cent of smokers will visit a doctor at some time each year.
Research suggests that the recommendation from a doctor, who is considered a credible source
of information, can be quite successful in promoting smoking cessation. Research also suggests
that the effectiveness of doctors‟ advice may be increased if they are trained in patient-centered
counseling techniques (Wilson et al. 1988).
School Interventions
In some regions of the world, school interventions are considered as integral part for
smoking cessation. But it has been observed that the positive effects of even the most successful
prevention programs tend to diminish over time (Flay et el., 1989). This has been particularly
noted among school based intervention studies that included little emphasis on booster sessions,
few communitywide activities or few mass media components (Botvin&Botvin, 1992).

14. SMOKING: RISK FACTORS AND INTERVENTIONS
14
The National Cancer Institute convened a panel of experts in 1987 to reach consensus on
the essential elements of school based smoking-prevention programs (USDHHS, 1991). These
included classroom sessions to be delivered at least five times per year in each of two years in
the sixth through eighth grades, emphasis on social factors that influence smoking onset, its short
term consequences and refusal skills. Incorporation of the program into the existing school
curricula, during the transition from elementary school to junior high or middle school and
involvement of students in the presentation and delivery of the program. The intervention also
comprised of encouragement of parental involvement, adequate training of the teachers and
social and cultural acceptance of the program in each community.
Worksite interventions
Over the past decade there has been an increasing interest in developing worksite-based
smoking-cessation interventions. These take the form of either a company adopting a nosmoking policy and/or establishing work-based health promotion programs. In addition, the large
number of people involved presents the opportunity for group motivation and social support.
Furthermore, they may have implications for reducing passive smoking at work, which may be a
risk factor for coronary heart disease (He et al. 1994). In two Australian studies, public service
workers were surveyed following smoking bans in 44 government office buildings about their
attitudes to the ban immediately after the ban and after six months. The results suggested that
although immediately after the ban many smokers felt inconvenient, these attitudes improved at
six months with both smokers and non-smokers recognizing the benefits of the ban. However,
only 2 per cent stopped smoking during this period (Borland et al. 1990).

15. SMOKING: RISK FACTORS AND INTERVENTIONS
15
Community-based programs
Large community-based programs have been established as a means of promoting
smoking cessation within large groups of individuals. Such programs aim to reach those who
would not attend clinics and to use the group motivation and social support in a similar way to
worksite interventions. In the Stanford Five City Project, the experimental groups received
intensive face-to-face instruction on how to stop smoking and in addition were exposed to media
information regarding smoking cessation. The results showed a 13 per cent reduction in smoking
rates compared with the control group (Farquhar et al. 1990). In the North Karelia Project,
individuals in the target community received an intensive educational campaign and were
compared with those in a neighboring community who were not exposed to the campaign. The
results from this program showed a 10 per cent reduction in smoking in men in North Karelia
compared with men in the control region. In addition, the results also showed a 24 per cent
decline in cardiovascular deaths, a rate twice that of the rest of the country (Puska et al. 1985).
Government interventions
An additional means to promote smoking cessation is to encourage governments to
intervene. Such interventions can take several forms
Restricting/banning advertising
According to social learning theory, individual learn to smoke by associating it with
attractive characteristics, such as „It will help me relax‟, „It makes me look sophisticated‟, „It
makes me look sexy‟, „It is risky‟. Advertising aims to access and promote these beliefs in order
to encourage smoking. Implementing a ban/restriction on advertising would remove this source
of beliefs. In the UK, cigarette advertising was banned in 2003.

16. SMOKING: RISK FACTORS AND INTERVENTIONS
16
Increasing the cost
Research indicates a relationship between the cost of cigarettes and their consumption.
Increasing the price of cigarettes could promote smoking cessation and deter the initiation of
these behaviors, particularly among children. According to models of health beliefs, this would
contribute to the perceived costs of the behaviors and the perceived benefits of behavior change.
Banning smoking in public places
Smoking is already restricted to specific places in many countries (e.g. in the UK most
public transport is no smoking). A wider ban on smoking may promote smoking cessation.
According to social learning theory, this would result in the cues to smoking (e.g. restaurants,
bars) becoming eventually disassociated from smoking. However, it is possible that this would
simply result in compensatory smoking in other places as illustrated by some of the research on
worksite no-smoking policies. To date, smoking has been banned in public places in Ireland,
Scotland, several states in the US, much of Italy and banned in England from July 2007.
Banning cigarette smoking
Governments could opt to ban cigarettes completely (although they would forego the
large revenues they currently receive from advertising and sales). Such a move might result in a
reduction in these behaviors. In fact the smoking bans in Ireland and in some states in the USA
have resulted in a range of positive outcomes such as a reduction in smoking per se and even a
decline in patients admitted to hospital for heart attacks.

17. SMOKING: RISK FACTORS AND INTERVENTIONS
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