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Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Arch Pediatr Adolesc Med. Author manuscript; available in PMC 2011 January 3.
Published in final edited form as:
PMCID: PMC3013365
NIHMSID: NIHMS256358

Improving measurement of normative beliefs involving smoking among adolescents

Brian A. Primack, M.D., Ed.M.,a,b,* Galen E. Switzer, Ph.D.,a,b,c,d and Madeline A. Dalton, Ph.D.e,f

Abstract

Objective

To identify different components of smoking normative beliefs and determine if each component is independently associated with two clinically relevant measures of smoking in adolescents.

Design

Cross-sectional survey.

Setting

One large suburban high school.

Participants

1211 high school students aged 14–18.

Main outcome measures

Current smoking and susceptibility to smoking.

Results

Nineteen percent (N=216) of students reported current smoking, and 40% (N=379) of the non-smokers were susceptible to smoking. Factor analysis identified three normative beliefs constructs, labeled “perceived prevalence of smoking,” “perceived popularity of smoking among elite/successful elements of society,” and “disapproval of smoking by parents/peers.” On average, students felt that 56% of people in the US smoke cigarettes. Twenty-four percent (24%) believed that wealthy people smoke more than poor people. Multiple logistic regression showed that each of the three constructs was independently associated with current smoking (Adjusted OR = 1.05, 95% CI: 1.02, 1.08; Adjusted OR = 1.12, 95% CI: 1.02, 1.23; Adjusted OR = 0.66, 95% CI: 0.59, 0.75; respectively) even after controlling for covariates. Students’ perceptions of smoking among successful/elite and disapproval by parents/peers were independently associated with susceptibility to future smoking (Adjusted OR = 1.20, 95% CI: 1.11, 1.29; Adjusted OR = 0.87, 95% CI = 0.79, 0.96; respectively).

Conclusions

Adolescents’ normative beliefs about smoking are multidimensional and include at least three distinct components, each of which was independently related to smoking outcomes. These distinct components should be considered in the design and evaluation of programs related to prevention and cessation of adolescent smoking.

Keywords: smoking, tobacco, adolescent, norms, normative beliefs, subjective norms, theory of reasoned action, ecological model, youth, factor analysis, principal components analysis, logistic regression, risk behavior, scale development

INTRODUCTION

Several theoretical models that have been used to successfully predict smoking behavior rely on the concept of normative beliefs as precursors to behavior change. According to the Theory of Planned Behavior,1 positive attitudes and subjective normative beliefs involving smoking lead to intention to smoke, which in turn leads to smoking. According to this theory, subjective normative beliefs are specifically defined as the subject’s impression of the acceptance of the behavior by those close to him/her (such as parents, close friends, and significant others).1, 2 Similarly conceived normative beliefs are also considered important precursors to smoking behavior by Jessor & Jessor’s Problem Behavior Theory3 as well as social learning and social cognitive models.4 Accordingly, the acceptance of smoking by significant others has been shown to predict smoking among various groups of adolescents.59

Others have shown that normative beliefs regarding the “perceived prevalence” of smoking are also useful in predicting smoking. In 2005, Olds et al. showed that among 6594 adolescents both perceived prevalence and perceived approval by peers and siblings independently predicted smoking. Perceived prevalence has also been shown to predict smoking among a large group of Chinese adolescents,10 military recruits,11 and multiple groups of American adolescents.6, 1217

Despite the fact that these two different components of normative beliefs—perceived approval and perceived prevalence—can be useful, some have found that normative beliefs do not predict behaviors as strongly as would be expected. Grube et al., for instance, found in their study of both grade school and college students that subjective smoking normative beliefs were not strong predictors of smoking outcomes, and that normative beliefs could perhaps be measured more completely.14 Tickle et al. similarly found in 2006 that, among the various psychosocial mediators of media effects on smoking behavior, normative beliefs were weak predictors of smoking.18 Others have also found that normative beliefs were not as strong predictors of smoking as they were hypothesized to be.1921

One way of improving measurement of subjective normative beliefs involving smoking may be by further expanding their scope. The social learning approach22 would suggest that individuals would be likely to be affected not only by how common they believe smoking to be among the general population, but also by how relatively common it is among more desirable (e.g., successful or elite) societal elements. A young person who believes that smoking is more common among the wealthy, successful, and privileged may be likely to smoke himself, even if he does not believe it is very common in the general population.

However, to our knowledge no such scale has been published in the literature, and it is not currently known if such an additional construct of normative beliefs is independently associated with smoking-related outcomes, even when controlling for currently accepted measurements of normative beliefs, demographic information, and other predictors of smoking such as parent, sibling, and peer smoking.

The purpose of this study was to determine if each of three measures of smoking normative beliefs—perceived prevalence among the general population, perceived popularity among successful/elite elements of society, and perceived disapproval by friends and family—is independently associated with two clinically relevant measures of smoking in adolescents: current smoking and susceptibility to smoking. Our a priori hypothesis was that each measure of smoking normative beliefs would be independently associated with smoking, even when controlling for covariates.

METHODS

Participants and Setting

The study population for our cross-sectional questionnaire consisted of all students attending a suburban public high school outside of Pittsburgh, Pennsylvania with a total enrollment of 1690. Male and female students were eligible to participate if they were 14–18 years old and were available to take the questionnaire on the regular school day in January 2005 when it was administered. On this date, 79 students were absent and 86 were unavailable because of in-school suspensions, field trips, or appointments with the nurse or guidance counselor; 1525 students were therefore eligible to participate.

Procedures

Approval to administer the study questionnaire was granted by the superintendent of the school district and the Institutional Review Board (IRB) of the University of Pittsburgh. Both the superintendent and IRB agreed to a waiver of parental informed consent, since students would not be asked to place their names or any other unique personal identifiers on the questionnaire. The students were invited to complete the questionnaire during their social studies classes, and those who did so were given a packet of trail mix to show appreciation for their time.

Measures

The questionnaire assessed two clinically relevant dependent variables: current smoking, defined as having smoked at least once in the past 30 days, and susceptibility to smoking, assessed with Pierce’s reliable and valid 3-item scale 23. According to this scale, a person is considered “non-susceptible” (and does not intend to smoke) only if he or she answers “definitely no” to the following 3 items: (1) Do you think that you will smoke a cigarette soon? (2) Do you think you will smoke a cigarette in the next year? (3) If one of your best friends were to offer you a cigarette, would you smoke it?

Eleven items were used to measure smoking normative beliefs. Three of the items were “perceived disapproval” items based on items from the Fishbein-Ajzen-Hansen Questionnaire, developed by the authors of the Theory of Planned Behavior. 1, 2 These items, each measured on a 4-point Likert scale (strongly agree / agree / disagree / strongly disagree), included (1) According to my parents, it is very important for me to not smoke cigarettes; (2) According to my friends, it is very important for me to not smoke cigarettes; and (3) According to most people my age, it is very important for me to not smoke cigarettes. Four of the items measured “perceived prevalence.” These items, based on prior work in this area,10, 12, 15, 17 asked students to estimate what percent of different groups of people (8th grade students, 12th grade students, college students, and adults in the US) had smoked at least one complete cigarette in the past 30 days. Students responded on an 11-point scale, from 0 through 100 in 10-point increments. The final four normative belief items asked students to judge on a 4-point Likert scale (strongly agree / agree / disagree / strongly disagree) whether they believed that specific successful or elite elements of society were likely to be smokers. These items included (1) Most successful business people smoke cigarettes at least once a month; (2) In general, more “cool” people smoke cigarettes than “uncool” people; (3) Wealthy people are more likely to smoke cigarettes than poor people; and (4) My favorite celebrities probably smoke cigarettes at least once a month. All normative belief measures were developed after a comprehensive literature review; honing of the scales based on the input of experts in tobacco control, public health, and adolescent medicine; and focus groups with adolescents. This process has been described previously in more depth.24

Finally, we assessed multiple covariates previously shown to be associated with smoking, including age, race/ethnicity, gender, parental education (as a surrogate for socioeconomic status), parent smoking, sibling smoking, and peer smoking.

Analysis

First we performed a descriptive data analysis of the questionnaire responses, computing means and standard deviations. We then used iterative principal components analysis with varimax rotation to determine the underlying factor structure of the smoking normative belief items. The primary goal of this analysis was to determine if the items representing normative beliefs about smoking seemed to be part of one, or more than one, underlying concept(s). If the analysis revealed several concepts, or factors, this would indicate that “normative beliefs” is not a one-dimensional variable, but one with empirically discernable subcategories. Principal components analysis did indicate three subgroups of items, and items belonging to each particular scale were evaluated for internal reliability using Cronbach’s alpha.

Finally, we performed two multivariate multiple logistic regression analyses. For each of the analyses, the independent (predictor) variables consisted of age, sex, race, socioeconomic status, parental smoking, sibling smoking, peer smoking, and each of the three normative belief constructs. In the first analysis, we used current smoking as the dependent variable. For the second analysis, we used susceptibility to smoking as the dependent variable. In this second analysis, we only included nonsmokers, since Pierce’s construct of “susceptibility to smoking” (our measure of intention to smoke) was developed and validated in this population.

In each model, we included the smoking normative belief scales and all covariates to determine if the scales were independent predictors of the outcomes. Because of the small sample size, Hispanic ethnicity was not included as a covariate. We considered any independent variable or covariate to be statistically significant if it had a relationship with the outcome variable at a level of p<.05. We conducted model diagnostics to ensure that the assumptions of logistic regression were satisfied and that adequate model fit was achieved.

Subjects

Of the 1525 students who were eligible for the study, 1402 (92%) completed the questionnaire. Using specific criteria established before administering the survey, we eliminated any questionnaire if 3 or more responses were deemed to be impossible or extremely improbable (N=44) or if the students admitted to providing dishonest answers (N=147). The final sample size was therefore 1211 (86% of the surveys completed). The mean age of the 1211 respondents was 15.9 years, about half (48%; N=572) were male, and 92% (N=1092) were white.

RESULTS

Nineteen percent (N=216) reported current smoking and 40% (N=379) of the non-smokers (N=995) were classified as susceptible to future smoking. Participants were more likely to be current smokers if they were older, had lower socioeconomic status, or had parents, siblings, or friends who smoke. Non-smokers were more likely to be susceptible to future smoking if they had parents, siblings, or friends who were smokers (Table 1).

Table 1
Respondent Characteristics

Principal components analysis on the 11 normative belief items revealed a clear three factor solution with eigenvalues of 2.9, 1.9, and 1.7, explaining 27%, 17%, and 15% of the variance respectively (Table 2). Thus, we defined three factors as the following: (1) perceived prevalence of smoking, 4 items; (2) popularity of smoking among successful/elite elements of society, 4 items; and (3) approval of smoking by parents/peers, 3 items. The three scales were found to be internally consistent with Cronbach alpha scores of 0.67, 0.67, and 0.82 respectively.

Table 2
Smoking Normative Belief Items—Responses and factor loadings*

Summary data for the independent variables (responses to the smoking normative belief items) are located in Table 2. With regard to perceived prevalence, students felt that on average 56% of people in the US smoke cigarettes at least once each month, along with 53% of college students, 48% of high school seniors, and 30% of eighth graders. As is shown in Figures 1 and and2,2, most respondents felt that more people smoke than actually do (22% for the US population25 and 25% for high school seniors26). Specifically, 93% felt that 30% or more of the US population smokes once each month, and 86% felt that 30% or more of high school seniors smoke once each month (Figures 1 and and22).

Figure 1
Histogram of subjects’ impression of the percent of high school seniors who smoke
Figure 2
Histogram of subjects’ impression of the percent of all Americans who smoke

With regard to the popularity of smoking among successful/elite elements of society, 24% indicated they felt that most successful business people smoke at least once a month, 23% felt that “cool” people smoke more than “uncool” people, 24% believed that wealthy people smoke more than poor people, and 35% felt that their favorite celebrities probably smoke at least once a month.

With regard to disapproval of smoking by parents and peers, the vast majority of students (90%) agreed or strongly agreed that it was important to their parents that they not smoke. Fewer (70%) agreed or strongly agreed it was important to their friend that they not smoke, and fewer still (55%) felt it would be important to most people their age.

In the fully adjusted logistic regression model, “perceived prevalence of smoking,” was independently associated with a higher risk of current smoking (OR=1.05, 95% CI: 1.02, 1.08) but not with susceptibility to smoking (Table 3). Each 10% increase in response to the “perceived prevalence” scale was associated with a 5% increase (OR=1.05) in the odds of smoking.

Table 3
Logistic Regression Analyses

“Popularity among successful/elite elements of society,” was independently associated with an increased likelihood of both current smoking and susceptibility to smoking among the never smokers. Even after controlling for all covariates and the other components of normative beliefs, each 1-point increase in response to this scale was associated with a 12% increase (OR=1.12, 95% CI: 1.02, 1.23) in the odds of being a current smoker. Additionally, each 1-point increase in response to this scale was associated with a 20% increase (OR=1.20, 95% CI: 1.11, 1.29) in the odds of being susceptible to future smoking.

In the fully adjusted model, “disapproval of friends and family” was also significantly associated with current smoking and susceptibility to smoking. A 1-point increase in response to the “disapproval of friends and family” scale was associated with a 34% decrease (OR=0.66, 95% CI: 0.59, 0.75) in the odds of being a current smoker, and a 13% decrease (OR=0.87, 95% CI: 0.79, 0.96) in the odds of being susceptible to future smoking.

DISCUSSION

This study identifies three separate scales measuring different aspects of smoking normative beliefs. Each of the three normative belief measures was independently associated with current smoking, and two of the measures—including our new measure of “perceived prevalence of smoking among successful/elite”—were independently associated with susceptibility to smoking among non-smoking adolescents.

Even after adjusting for peer and family smoking, adolescents were less likely to be current smokers or susceptible to future smoking if they perceived a higher prevalence of parent and/or peer disapproval of smoking. This result is consistent with those who have shown the importance of peer and parental approval in the development of smoking behaviors.68, 14, 27, 28 Adolescents’ perception of the of the particular type of person who is a smoker (e.g., successful vs. nonsuccessful, wealthy vs. nonwealthy) was also significantly associated with both current smoking and susceptibility to smoking among nonsmokers. The perceived prevalence of smoking, which is a more common measure of normative views, was positively associated with being a current smoker. This is also consistent with previous research.,8, 1012, 1517 However, in this sample of adolescents perceived prevalence of smoking was not independently associated with increased susceptibility to future smoking among nonsmokers. This suggests that the early stages of smoking inititiation may be more likely to be influenced by normative views that include some level of value judgement and/or assessment (e.g. how others will feel about my smoking; whether people I admire smoke, etc.) than simply by the notion that many people smoke.

This finding may have important implications for future research and educational interventions. With regard to research, it will be particularly important to determine how, when, and where young people glean their understanding of the prevalence of smoking, especially among specific subgroups. It is likely, for instance, that media portrayals of smoking, which often show smoking in a glamorous and positive light, contribute to false impressions of high smoking prevalence among the elite.23, 2931 Future research may be able to improve our understanding of what specific types of media messages and images are more likely to affect normative beliefs.

With regard to intervention, this finding suggests that we can improve smoking normative beliefs education not only by emphasizing the true prevalence of smoking but also by emphasizing more accurate information regarding the types of individuals who are smokers. In this study, 24% of students incorrectly agreed that most successful business people smoke at least once a month, and 24% incorrectly felt that wealthy people smoke more than poor people. It may therefore be valuable to educate young people that the groups who most commonly smoke are not necessarily the ones they view as successful. It may also be valuable to implement media restrictions and/or media literacy programming, since smoking in media is common among elite and successful media characters.3133

Our study population was drawn from a single large high school and was fairly homogeneous in terms of racial and ethnic makeup, which could limit the generalizability of our findings. However, the baseline values for current smoking are similar to values previously reported from a representative sample of U.S. adolescents.26 Because this was a cross-sectional study, we can determine only association and not causation. Although the Theory of Planned Behavior would suggest that conception of normative beliefs precedes smoking intention and behavior, it is certainly possible that adolescents who begin to smoke subsequently develop different subjective normative beliefs. Longitudinal studies and randomized intervention trials are needed to elucidate both the directionality and causal nature of the associations. Although we relied on self-report rather than biochemical verification of smoking behavior, several studies have demonstrated that self-reported smoking status has acceptable validity.3436

In summary, this study reports the development of a new measure of adolescents’ perception of the popularity of smoking among the successful/elite. It also shows that this new construct of normative beliefs, as well as two established measures of normative beliefs, are all independently associated with current smoking. The constructs that measure peer and family disapproval of smoking and popularity of smoking among elite subgroups were significantly associated with susceptibility to smoking among nonsmokers, which suggests that these normative beliefs may be more instrumental during the early stages of smoking uptake. These findings illustrate that there are distinct components of smoking normative beliefs, which should be considered in both the design and evaluation of programs related to prevention and cessation of adolescent smoking.

ACKNOWLEGEMENTS

We gratefully acknowledge the financial support of the Maurice Falk Foundation and Tobacco-Free Allegheny. Although each of these agencies provided financial support, they were not involved in the design and conduct of the study; the collection, management, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript. Dr. Primack is supported by a Physician Faculty Scholar Award from the Robert Wood Johnson Foundation.

REFERENCES

1. Azjen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980.
2. Hanson MJ. The theory of planned behavior applied to cigarette smoking in African-American, Puerto Rican, and non-Hispanic white teenage females. Nurs Res. 1997 May–Jun;46(3):155–162. [PubMed]
3. Jessor R, Jessor SL. Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. San Diego, CA: Academic Press; 1977.
4. Akers RL, Lee G. A longitudinal test of social learning theory: Adolescent smoking. Journal of Drug Issues. 1996 Spr;26(2):317–343.
5. Collins RL, Ellickson PL. Integrating four theories of adolescent smoking. Substance Use & Misuse. 2004 Jan;39(2):179–209. [PubMed]
6. Flay BR, Hu FB, Richardson J. Psychosocial predictors of different stages of cigarette smoking among high school students. Preventive Medicine. 1998 Sep–Oct;27(5 Pt 3):A9–A18. [PubMed]
7. Kear ME. Psychosocial determinants of cigarette smoking among college students. Journal of Community Health Nursing. 2002;19(4):245–257. [PubMed]
8. Olds RS, Thombs DL, Tomasek JR. Relations between normative beliefs and initiation intentions toward cigarette, alcohol and marijuana. Journal of Adolescent Health. 2005 Jul;37(1):75. [PubMed]
9. Weiss JW, Cen S, Schuster DV, et al. Longitudinal effects of pro-tobacco and anti-tobacco messages on adolescent smoking susceptibility. Nicotine Tob Res. 2006 Jun;8(3):455–465. [PubMed]
10. Lai MK, Ho SY, Lam TH. Perceived peer smoking prevalence and its association with smoking behaviours and intentions in Hong Kong Chinese adolescents. Addiction. 2004 Sep;99(9):1195–1205. [PubMed]
11. Ames GM, Cunradi CB, Moore RS. Alcohol, tobacco, and drug use among young adults prior to entering the military. Prevention Science. 2002 Jun;3(2):135–144. [PubMed]
12. Botvin GJ, Botvin EM, Baker E, Dusenbury L, Goldberg CJ. The false consensus effect: predicting adolescents' tobacco use from normative expectations. Psychological Reports. 1992 Feb;70(1):171–178. [PubMed]
13. Collins LM, Sussman S, Rauch JM, Dent CW, et al. Psychosocial predictors of young adolescent cigarette smoking: A sixteen-month, three-wave longitudinal study. Journal of Applied Social Psychology. 1987 Jun;17(6):554–573.
14. Grube JW, Morgan M, McGree ST. Attitudes and normative beliefs as predictors of smoking intentions and behaviours: a test of three models. British Journal of Social Psychology. 1986 Jun;25(Pt 2):81–93. [PubMed]
15. Perkins H, Wechsler H. Variation in perceived college drinking norms and its impact on alcohol abuse: A nationwide study. Journal of Drug Issues. 1996 Fal;26(4):961–974.
16. Prentice DA, Miller DT. Pluralistic ignorance and alcohol use on campus: Some consequences of misperceiving the social norm. Journal of Personality and Social Psychology. 1993 Feb;64(2):243–256. [PubMed]
17. Sussman S, Dent CW, Mestel-Rauch J, Johnson C, et al. Adolescent nonsmokers, triers, and regular smokers' estimates of cigarette smoking prevalence: When do overestimations occur and by whom? Journal of Applied Social Psychology. 1988 Jun;18(7, Pt 1):537–551.
18. Tickle JJ, Hull JG, Sargent JD, Dalton MA, Heatherton TF. A structural equation model of social influences and exposure to media smoking on adolescent smoking. Basic and Applied Social Psychology. 2006;28(2):117–129.
19. O'Callaghan FV, Callan VJ, Baglioni A. Cigarette use by adolescents: attitude-behavior relationships. Subst Use Misuse. 1999;34(3):455–468. [PubMed]
20. Morrison DM, Golder S, Keller TE, Gillmore MR. The theory of reasoned action as a model of marijuana use: tests of implicit assumptions and applicability to high-risk young women. Psychol Addict Behav. 2002 Sep;16(3):212–224. [PubMed]
21. Bell RM, Ellickson PL, Harrison ER. Do drug prevention effects persist into high school? How project ALERT did with ninth graders. [see comment] Preventive Medicine. 1993 Jul;22(4):463–483. [PubMed]
22. Bandura A. Social learning through imitation. In: Jones M, editor. Nebrasa Symposium on Motivation. Vol 10. Lincoln, NE: University of Nebraska Press; 1962.
23. Pierce JP, Choi WS, Gilpin EA, Farkas AJ, Berry CC. Tobacco industry promotion of cigarettes and adolescent smoking. JAMA. 1998;279(7):511–515. [PubMed]
24. Primack BA, Gold MA, Switzer GE, Hobbs R, Land SR, Fine MJ. Development and validation of a smoking media literacy scale. Arch Pediatr Adolesc Med. 2006;160:369–374. [PMC free article] [PubMed]
25. Centers for Disease Control and Prevention. Cigarette Smoking Among Adults: United States, 2004. MMWR. 2005;54(44):1121–1147. [PubMed]
26. Johnston LD, O'Malley PM, Backman JG, Schulenberg JE. Monitoring the future national results on adolescent drug use: overview of key findings 2005. Ann Arbor, MI: University of Michigan; 2006.
27. Sargent JD, Dalton M. Does parental disapproval of smoking prevent adolescents from becoming established smokers? Pediatrics. 2001 Dec;108(6):1256–1262. [PubMed]
28. Chassin L, et al. Predicting the onset of cigarette smoking in adolescents: A longitudinal study. Journal of Applied Social Psychology. 1984 May–Jun;14(3):224–243.
29. Dalton MA, Sargent JD, Beach ML, et al. Effect of viewing smoking in movies on adolescent smoking initiation: a cohort study. Lancet. 2003 Jul 26;362(9380):281–285. [PubMed]
30. Sargent JD, Beach ML, Adachi-Mejia AM, et al. Exposure to movie smoking: its relation to smoking initiation among US adolescents. Pediatrics. 2005 Nov;116(5):1183–1191. [PubMed]
31. Dozier D, Lauzen M, Day C, Payne S, Tafoya M. Leaders and elites: portrayals of smoking in popular films. Tobacco Control. 2005 February;14(1):7–9. [PMC free article] [PubMed]
32. Hazan AR, Lipton HL, Glantz SA. Popular films do not reflect current tobacco use. Am J Public Health. 1994 Jun;84(6):998–1000. [PubMed]
33. Stockwell TF, Glantz SA. Tobacco use is increasing in popular films. Tob Control. 1997 winter;6(4):282–284. [PMC free article] [PubMed]
34. Dolcini MM, Adler NE, Lee P, Bauman KE. An assessment of the validity of adolescent self-reported smoking using three biological indicators. Nicotine Tob Res. 2003 Aug;5(4):473–483. [PubMed]
35. Mayhew KP, Flay BR, Mott JA. Stages in the development of adolescent smoking. Drug Alcohol Depend. 2000 May 1;59 Suppl 1:S61–S81. [PubMed]
36. Post A, Gilljam H, Rosendahl I, Meurling L, Bremberg S, Galanti MR. Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users. Tob Control. 2005 Apr;14(2):114–117. [PMC free article] [PubMed]