5 - HayashiItsuki 2012 TeenageSmokingWhatAre SmokingHealthEffectsP

In: Smoking ISBN: 978-1-61470-643-4
Editor: Itsuki Hayashi © 2012 Nova Science Publishers, Inc.

All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
Chapter V
Teenage Smoking:
What are the Main Issues?
Said Shahtahmasebi*
The Good Life Research Centre Trust, Rangiora. New Zealand
ABSTRACT
Some studies associate teenage smoking with a number of socio-
economic variables whilst others suggest psychological, or demographic
and environmental factors. There is no doubt that the literature on
smoking provides a large amount of information that has led to the
reported relationships and subsequent social and public health policies.
However, very few studies treat teenage smoking as a process outcome
where the decision to smoke is influenced by other process outcomes.
The implications are for understanding the true underlying relationships
Copyright 2012. Nova Science Publishers, Inc.
as opposed to superficial and proxy associations. Superficial and proxy

associations often appear important due to study designs that treat the
outcome as a variable rather than a process outcome. As such, a process
outcome is subject to influence due to the process itself as well as other
processes. For example, given the adverse health effects, an individual’s
decision to smoke may be a social and political statement against the “big
brother” type social and health policies on smoking. A point picked up by
the tobacco industry who financially contributes to various anti-smoking
*
Said Shahtahmasebi: Email: said2@slingshot.co.nz.
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AN: 540256 ; Hayashi, Itsuki.; Smoking : Health Effects, Psychological Aspects and Cessation
Account: rug.main.ehost
84 Said Shahtahmasebi
and charitable programmes. In this context all actors (e.g. individuals,

policy makers, and tobacco industry) are part of the problem. In this
chapter I examine some of the issues behind some of these relationships,
public health and health promotion policies and how they may affect
teenage smoking.
INTRODUCTION
Like suicide research, the literature on smoking is huge, providing
information, sometimes conflicting, on various aspects of smoking, from the
health effects to characterizations of smokers and hence policy advice on
tobacco control. For example, a search of PubMed using the search term
‘smoking’ which was restricted to ‘the last 5 years’ and ‘English’ only
language, yielded 32,716 hits. See [1-15] for a small selection of publications
covering issues of behaviour, media, cessation, asthma, lifestyle, as they may
relate to smoking. Like suicide research we tend to use the literature
selectively rather than assess critically. Furthermore, most health campaigns
lack an integrated evaluation scheme and therefore any evaluation is based on
ad hoc studies after the event. In earlier papers [16,17] I discussed some of the
study design and analysis issues that often lead to incomplete and misleading
results. Thus, it is plausible that the conclusions and recommendations
reported in the literature may appear to be that of the authors(s) own views and
may have very little to do with study results. For example, a cross-sectional
study compared smokers who successfully gave up smoking with unsuccessful
‘quitters’[8]. The study suggested an association between successful quitting
and a range of characteristics including being non-Hispanic White, aged 35
years or older, married or living with a partner, and having at least a college
education. The authors therefore recommended the promotion of smoking
cessation programmes that involves family and other household members to

encourage smoke-free homes. However, in terms of the study conclusions, the
results suggest a case of sample selection bias rather than any statistically
significant “effects” that warrant the recommendations by the authors (see also
Statistical Modelling section).
The literature on health research provides ample evidence of the ill effects
of smoking on the health of the public. From a public health perspective,
smoking creates a heavy burden on the health care system through morbidity
leading to mortality and hence the development of vigorous and aggressive
anti-smoking campaigns. Given that tobacco is not a banned substance, the
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Teenage Smoking: What are the Main Issues? 85
anti-smoking campaigns has heavily relied on prescribing and instructing the

public “not to smoke” by creative provision of information as to how smoking

may lead to ill-health and death, sometimes incorporating shock tactics in the
delivery of information. Indeed some studies recommend more aggressive
advertising and anti-smoking campaigns [18,19]. Health promotion and anti-
smoking campaigns are recurrent events. Repeated creativeness presents some
problems; dealing with the increasing levels of creativeness being the most
obvious one. When using shock tactics to make a point one would be faced
with a major challenge; by the end of the campaign (and over the life time of
previous campaigns) the public may well be used to the shocking images of
blocked arteries, blackened lungs and dysfunctional internal organs due to
smoking. By the same token, we need to ask the question “what are the effects
of negative association on health outcomes?” In other words, when social
averages on expectation, attitudes and behaviour are continually subject to
change and the norms are shifted due to too much exposure do these changes
and shifts create an environment of resilience to be receptive to health care
information?
It is quite rational to assume that given the harm that smoking can cause it
would be only too logical for the public never to smoke. Yet smoking is still
considered one of the biggest burdens on the health care system. So the
problem for the health promotion and public health practitioners has been to
increase the level of creativity. It is not surprising that in recent decades the
anti-smoking campaigns, wittingly or unwittingly appear to instruct or demand
the public to stop smoking. Whilst the words may be informative, however,
the nature of the campaigns are usually top-down often using characterisation
from and thus alienating minorities or other groups in society. Inevitably, such
approaches may have led to the “big brother” effect almost intimidating the
public to stop smoking. Note that the author is not a smoker.
On the other hand tobacco is freely sold in shops, the public are well
aware of the risks and despite all the anti-smoking campaigns, a certain
portion of the public makes a decision to smoke. It is this process of decision
making that has been ignored whilst concentrating on various aspects of
smoking such as characteristics of smokers, advertising and exposure.
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TEMPORAL DEPENDENCIES
Adolescent smoking behaviour is a process the outcome of which may be

to make a decision to smoke, not to smoke or give up smoking. Processes are
by nature dynamic. An important feature of a dynamic process is the change
over time of the process and its parameters. It is essential to adopt designs that
permit studies of temporal dependencies in any social process, the importance
of which can be deduced from broad areas of social science theory. Health
research seems to suggest a large number of variables including psycho-social,
behavioural and environmental and individual factors as correlates of
adolescent smoking behaviour. These conclusions are based on investigations
concerned with how smoking at any point in time is related to one or more
explanatory variables. The implicit assumption is that changes in explanatory
variables will produce commensurate changes in smoking. Apart from
problems of control [16, 17], this assumption may be untenable because of
temporal dependence in the smoking behaviour; smoking may depend not just
upon individual and social and other characteristics at a point in time, it may
depend upon prior smoking behaviour and tendencies. There may, for
example, be inertial tendencies with individuals slow to react to changes in
circumstances, as mentioned in the introduction, perhaps as a result of
exposure, changing social expectations and shifting averages. Another
example is the notion of 'cumulative inertia' in which the tendency to move in
the next time period from the current state to another decreases with the length
of duration in the current state [20, 21]. This concept has been addressed in the
context of human migration where a future move may not only depend on the
current status but also the duration in the current status i.e the length of time
between moves [22]. Factors underlying dependence include increasing social,
economic and community ties with duration in a social state. The theory of
cognitive dissonance, another example, is that individuals align their attitude

to their current social state upgrading the satisfaction with both positive and
negative attributes of their current state and down grading those of possible
alternatives. Current social state may be the results of an individual's decision
e.g. to smoke, give up smoking, to move house, to live alone, or may be due to
transition through life (ageing and self-reported health). In some
circumstances, there may exist a relationship in which the current social state
is directly dependent on the previous social state. For example, the existing
smoking status can constrain the choice of future status in which smoking in
adulthood is highly correlated with adolescent smoking [23, 24]. The first
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issue we need to fully understand is that the ill-health effects of smoking may
manifest years after the incidence of smoking. Furthermore the gradual

physical and biological/physiological changes are internal and hence invisible
to the smoker. Therefore, at the time of ill health it is highly unlikely for
individuals to associate their illness to smoking. Using historical information
on smokers and morbidity and mortality it may be possible to detect a strong
statistical link between smoking and morbidity/mortality. The researches have
established this link statistically and can predict with some certainty the effects
of smoking on the public’s health. The clinicians deal with the consequences
of smoking on a daily basis and therefore can physically see the link between
smoking and morbidity. The practitioners advise people about the ill-health
effects of smoking. However, at an individual level, for the unsuspecting youth
and the general public it may be difficult to visualise a link at the time and
during the period of smoking. Once an individual becomes a smoker the only
perceived effect is how bad the individual felt without it and how good the
individual felt with it. It is not surprising to get an unsympathetic reaction
when trying to explain to an individual who perceives many life-years ahead
of them, that smoking will cause him/her ill-health or even death.
INFORMATION AND ITS COMMUNICATION

An important issue arises which questions our presumptions about
communicating information to the public. One major aspect is deciding on
what constitutes appropriate information; and another is what constitutes the
appropriate dissemination of information. A common perception of the
medical profession is of knowledge and trust. Therefore why should not the
public listen to and act on their advice.
For the most part, the flow of information is considered separately and in
isolation in developing health promotion programmes. What we have forgotten
to take into account is that there are other agents who wish to get the attention
of the public. With the advancement in information technology, competition
became intense to reach not only more people but those previously difficult to
reach. Thus what was once an information superhighway has become part of
an elaborate industry that includes a whole collection of competing media to
provide public access to information e.g. internet, television and the
entertainment industry, radio, newspapers, popular and tabloid magazines,
multi-media, voluntary and government agencies. Therefore there are
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competing forces seeking more of our attention. For example, the effects, if
any, of anti-smoking campaigns may be counteracted by the covert pro-

smoking campaigns through the media and the entertainment industry e.g. see
[6, 7, 13, 25-26].
Although we have not yet achieved man’s long time ambition of
discovering the fountain of youth or creating the magic pill that would fully
restore health, yet through the information industry the expectation that “the
cure” is only around the corner has become the public norm. The public has
become well aware of the advancement in medical science. The idea of the
fountain of youth or the magic pill may well relate to man’s wish to do one’s
heart desire without worrying about responsibility and the consequences. The
important point is that the information superhighway may give the public the
idea that anything can be fixed. In particular, this leads to the presumption that
it may not be long before cancers, heart disease and respiratory problems can
be treated, thus, making smoking safe. In the meantime, transplantation has
become quite routine and therefore a viable option. There is no doubt that the
information superhighway provides a continuous and long exposure to the
same information presented in many different ways.
There are many other agencies and products that are using a whole array
of information technology to attract the attention of the public. The hasty
reporting of research results and the media’s slant and trivialization of claims
and counter claims to the amusement of the public could have eroded public
sensitivity to critical receptiveness of information. We do not know how this
increased insensitivity affects behaviour. For instance, consider the
development of the notion of organ transplant from its early days to it
becoming routine practice. Yet in order for some to live another group must
die. And what do we know of the effects of calls such as “everyone should
become donors” [27] by officials on public expectations and behaviour? Thus,
temporal dependencies may be understood through exposure, feedback,
individual and social behaviour.
EXPOSURE
Most studies of exposure to tobacco appear to concentrate on the effects of
pro smoking in multimedia advertising e.g. see [6, 25, 26, 28]. Very few have
studied the effect of exposure to anti-smoking campaigns [29-31]. However,
exposure does not mean the direct experience of pro or anti-smoking
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messages. Smoking and tobacco receive a lot of attention albeit most or all
negative. The public is constantly, in one way or another, exposed to tobacco

and smoking mainly as a health issue, but also through the entertainment
industry, through anti-smoking campaigning, through anti-smoking policies,
the media’s presumption of news worthiness and public interest, coverage and
public discussion of litigations and lawsuits, and so on.
We do not know the effect of this exposure on the public’s perceptions
and attitudes. However, as argued above, studies of exposure to anti- and pro-
smoking media campaigns suggest an effect on adolescents’ smoking
behaviour. It is, therefore, plausible that continued exposure to tobacco be it
through pro and anti-smoking and messages to quit, or through shocks and
other events may lead to a shifting of norms i.e. what was once extreme and
unacceptable would become average or the norm. It may be argued that these
shifts in norms are time dependent and therefore inevitable. On the other hand,
without exposure the link between shift in norm and time may be extremely
weak.
Indeed, it is not surprising to note that tobacco companies have funded
televised smoking prevention advertising [28]. Interestingly but not
surprisingly, it is noticeable that the authors reported of no beneficial
outcomes for young people from exposure to youth-targeted tobacco company
funded smoking prevention advertising, but exposure to the parent-targeted
advertising may be harmful to youth.
FEEDBACK EFFECTS AND BEHAVIOUR

As mentioned earlier under temporal dependencies, smoking behaviour
may be influenced by smoking itself, this effect can be viewed as internal
feedback, e.g. smoking leads to more smoking and is slightly easier to account
for. In addition to this internal feedback, smoking behaviour may be
influenced by other processes such as social and health. In particular, consider
anti-smoking campaigns. Quite apart from the fact that they keep the smoking
issue in the public domain and hence increasing exposure, there is very little
evidence as to what proportion of the population they reach and which groups
benefit and how this may affect the rest of the population. There may be an
external feedback over and above the intended policy effect of the policy. This
kind of influence from other processes which are external to the process under
investigation, in this case smoking, can be viewed as external feedback. Under
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such an influence, the feedback may be direct or indirect. Direct external

feedback may arise from policies, or schemes such as public health campaigns
which are designed specifically to deal with smoking. Indirect external
feedback may arise from other social, health and economic policies or
schemes.
There are two effects immediately obvious from this external feedback.
The first effect is on itself i.e. the process of providing information to
influence another group’s decision making. To illustrate, consider the pattern
of the anti-smoking campaign to date; schemes with increasing levels of
shock. The second effect is, of course, the long exposure to the increasing
level of creative shock that will attenuate public sensitivity requiring higher
levels of shock to relay the same message or information to such an extent that
the process may actually lead to a negative outcome i.e. increased
prevalence/incidence of smoking [28]. Furthermore, some studies (e.g. see
[26]) suggest a higher perceived exposure to pro smoking messages than
nonsmokers but do not report any differences in perceived exposure to anti-
smoking messages between the groups. Nevertheless, the higher proportion of
smokers noticing pro smoking messages suggests some feedback effect
through their habits.
On the other hand, the literature on anti-smoking does not shed any light
on the feedback effects of successive campaigns on smoking outcome through
(i) its own net effect, (ii) interaction with previous campaigns and (iii) other
parameters associated with smoking such as intentions and resilience. For
example, most anti-smoking campaign messages have been “stop smoking” or
“do not smoke”, however, over recent years in New Zealand, the campaign has
taken a turn to “do not smoke in the car”, “do not smoke where children are
present” and so on. The message together with the imagery broadcasting such
messages for the general public appears to condone smoking. It may be argued
that the campaigns are intended to educate smokers to protect the vulnerable
young and others from passive smoking. Equally, it can be argued that after
decades of sustained anti-smoking campaigns such campaigns would appear to
signal surrender: do smoke, but somewhere else! The question arises, as
mentioned earlier, as to what effect do successive policies and campaigns have
on smoking status? As an example, what are the effects of the anti- passive
smoking campaign on those already developing an intention to quit? And on
those developing an intention to take up smoking?
The continuous and long exposure to information of varied quality may
have led to an erosion of the public’s sensitivity to a critical receptivity of
information and its intended message. Thus, cognitive dissonance (individuals
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align their attitude to their current social state) may be manipulated. The
public receive the information yet they “choose” to interpret it to suit. In some
cases, through the media, the information has been so embedded in the public
mindset that it is only used to explain an unexplainable phenomenon. For
example, there is ample evidence to suggest that only a fraction of suicide
cases have been diagnosed with depression. Yet, the insistence of some
psychiatrists and the media on a direct causal relationship appears to have
helped establish the depression-suicide link in the mind of the public.
Therefore it is not surprising to get contradictory comments by relatives and
friends of the case stating “the case was happy and full of life, was doing well
academically, fully taking part in sport and other activities, being popular with
his/her peers,…, we were not aware of his mental health problems, we did not
think the case was suffering from depression. And so on.” [32]. Similarly,
smokers and non-smokers use information selectively perhaps in justification
of their own choices. Comments collected over the years from smokers
include: “my grandfather was a heavy smoker and lived well into his nineties
…”; “I know someone who never smoked and yet died of lung cancer! So why
should I give up.” “I am fed up of being told what to do”; “I refuse to be
intimidated and being told what to do – that is why I am not giving up”.
Why do people behave in such a way? Surely, if the health outcome under
investigation was suicide then according to the psychiatrists adopting a high
risk (to one’s own health) strategy amounts to some form of mental ill-health
and depression. Given the high proportion of smoking related morbidity and
mortality, the question arises whether smoking should be considered a form of
self-harm.
I am not advocating such a move but merely making a point that when
different issues become territorial to a particular discipline, progress in
understanding that issue slows down considerably. It is plausible that the issue
is being viewed with the same lens with varying degrees in strength by
different researchers from the same discipline, most often with the same
outcome.
Although the effects of smoking on physical health are well understood
e.g researchers have been able to estimate the costs of adolescent smoking to
health care and the economy [33], the relationship between smoking and
psychological symptoms such as social defiance, rebelliousness, self-esteem
and depression is vague. Some studies appear to imply a causal relationship
between smoking (“addiction” to tobacco and fear of giving up) and
comorbidity [34, 35]. Which effect is masking the other? As discussed this
relationship may well be due to temporal dependencies and feedback effects
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i.e. comorbidity may well have been present prior to smoking initiation.
Addiction to tobacco does not explain why people take up smoking in the first
place.
PEOPLE AS UNITS OF EXPERIMENT

Research on smoking is vague about causal relationship between various
individual characteristics and other socio-economic factors and smoking
initiation. In other words what are the pathways leading to individuals making
a choice to take up smoking? Based on the current research we may learn
about the characteristics of smokers and a likelihood of belonging to a smoker
group. Commonly, such factors are used to develop public health and anti-
smoking policies. Frequently and on a regular basis smoking and tobacco
appear in the public domain (media) through these policies. Over and above
tax increases any policy change will help tobacco on the top of the media’s
agenda. For example, in New Zealand the issue of banning smoking from bars,
pubs and restaurants was in the media before it became law, during and after.
Some bar owners defied the law, one was prosecuted. Clearly the actions taken
by individuals and society are not only news worthy but of public interest for
open debate and discussion. On the one hand the individuals claim that society
is interfering with their individual freedom of choice, expression and civil
liberty, whilst, society claims (through its representatives) that it is seeking to
protect its members. But, inevitably, smoking becomes the emphasis and
central issue of the debate. So smoking receives more long-term free exposure.
Another example may be the association of smoking with the lower social
classes, the manual workers and indigenous or minority groups in society. It is
easy to assume a link between low income, education and smoking and
develop policies that are based on education and tax increases. Such policies
are not designed to influence the real and underlying social issues that may be
giving rise to smoking in the first place – in particular, given the amount of
free exposure smoking receives and the “big brother” nature of some of the
public health policies. Previous studies (e.g. see [36]) suggest that low income
groups tend to cut back on other household outgoings such as food to budget
for essentials such as cigarettes. But, bootlegging and illegal cigarette
marketing would help sustain the habit and undermine cessation of smoking
[7].
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There is very little research to evaluate the feedback effect of public

policies on the public’s perception of smoking and a decision not to smoke, to

smoke or to give up smoking. Most public health policies lack an integrated
evaluation programme. Policy evaluation may be designed and follow
subsequently but is often based on a naive comparison of proportions of
smokers who potentially intend to give up, which on their own are of meager
value. An expression of intention to achieve an outcome is not the same as the
outcome, in particular given that other social and environmental processes
never cease. For example, Mclauchlan [37] studied high school students’
intention to take up or continue with a foreign language at year 11, 12 and 13
and his results suggested a wide discrepancy between the number of students
who intended to study a foreign language and those who actually registered for
one.
At face value the tobacco industry has been working on several fronts to
recover lost ground due to smoking related mortality and anti-smoking
campaigns. The first option has been to mount a counter attack on public
tobacco control campaigns [13], the second is to recruit new customers in
particular young adolescents as these type of customers provide longer term
business, and thirdly, to increase the rate of tobacco consumption by the
current customers. Such pathways may be acceptable business strategies in
some other industries. However, given the history and the nature of tobacco,
where the pressure has been growing to eliminate smoking from our list of
human behaviour, any form of business planning would inevitably become
covert to avoid a major public backlash. Indeed, the industry appears to be
involved with and contributes to anti-smoking campaigns and schemes. For
example, involvement with “youth smoking prevention” and funding of
televised anti-smoking campaigns [28], programmes and partnership with the
charitable organizations [11], thus creating an image that is socially more
acceptable. It appears that the result of these social investments may be more
exposure to smoking and another lever to manipulate “cognitive dissonance”.

Biologically our bodies are made up of the same materials and have the
same components; brain, heart, blood vessels, limbs, etc. Although we know
that these similar units react and behave differently and according to our own
individual set of criteria, yet when it comes to policy development we only
expect a one directional result; i.e our expectation for which a policy was
developed i.e a total disregard for the dynamics of human behaviour. That is to
say that we expect a positive effect and if our policy does not yield the
perception of a positive result we then move to the next one and the next and
so on. As mentioned above, by our own actions and by ignoring our cognitive
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faculties we constantly expose ourselves to behaviour whereby we continue to

develop policies to discourage the public from adopting.

It is this lack of attention to the cognitive property of the human mind that
may have led research with a less than convincing understanding of smoking.
A decision to smoke may be the outcome of a long process of exposure to
various social and environmental factors including social and public health
policies. Therefore to understand how individuals assess risk by making a
choice to smoke we need to have observed them for a substantial period of
time and not retrospectively at the time of making the choice.
The literature on smoking suggests that we do not yet know why people,
in particular adolescents choose to smoke. However, it is becoming clear that
smokers are developing resilience to anti-smoking campaigns. Despite the
knowledge of its health hazards and the reasons for the anti-smoking
campaigns, all the restrictions including increasingly becoming social outcasts,
smokers are fighting for their rights – just like any other minority group. The
feedback effect: how much of it may be due to the manipulation of cognitive
dissonance by the various external forces including tobacco companies, social
and health policies, and anti-smoking campaigns?
To change the long and well established image of the smoker as the cool,
rebel and confident person in all aspects of life to a social outcast will lead to a
complex feedback effect. In particular when the annual tax revenue from
tobacco is known but rarely discussed.
In an opportunistically set up focused group, smokers expressed very
strong feelings about being marginalised and politicized whilst at the same
time criticizing politicians and health professionals. Interestingly, the
consequences of their smoking habit did not feature. Although it is not known
if that is how smokers in other parts of the country and the world feel it must
be quite alarming for researchers and policy makers. For one thing it suggests
that the health message has not got through or as mentioned above the
feedback effect of the health campaign has led to an uprising to meet the
challenge to change their way of life.
PERSONAL RESPONSIBILITY
Some authors/practitioners recommend that the public take personal
responsibility for their actions [38] i.e. be a good lad and do not smoke, be
compliant etc, and hence achieve good health. Although some aspects of
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smoking have become illegal such as the sale of tobacco to minors, and
smoking in public places, smoking tobacco is still legal. In theory the decision
to take up smoking is left to the individuals.
Once again such a practice ignores the cognitive properties of the human
experimental units. People with similar characteristics may respond differently
to the same outcome without any other exogenous factors. However, given the
continuous exposure to smoking (albeit all negative and anti-smoking),
environmental and social processes, the media and advertising, and social,
economical and political policies (that promotes free choice and free
expression) it is unreasonable to expect and indeed demand that the public be
good citizens and not to smoke. It is perhaps this partiality that may be
influencing the direction of the feedback effect. Most of the above issues were
discussed in an earlier paper [39] and is summarised in figure 1. The circular
line around the process “society” is merely convenience to distinguish time
periods and does not indicate that it is a closed process. The solid ellipses
symbolize filters, interfaces and unobserved effects which may be process
outcomes in their own right. These processes may, for instance, be the
outcome of implemented policies that were either withdrawn or were based on
incomplete information.
The transparent circles symbolize social processes that are directly
responsible for social changes and may influence the outcome of interest (in
this case smoking) directly or indirectly. It can be visualized that this influence
will be through relationships and interactions with other processes and
unobserved filters/interfaces over time. For example, current images of
smokers taking a deep puff and then exhaling with an expression of profound
satisfaction may be more effective than the old images of cool and confident
hero.
Figure 1. An example of a conceptual model of smoking.
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For the prudent non-smokers who have no intention of smoking the image
will be interpreted as pity and possibly disgust; for the smokers it will be
further support not to give up as it will encourage craving and remind them of
their “need” and dependence; for the non-smoker who may be going through
the process of making a decision such images of satisfaction may be enticing
and a back-up to take up smoking. The irony is that for individuals to get the
satisfaction and calming effect from smoking they must first become smokers!
In the next section I discuss the reason why our current policies may well
be due to our knowledge of smoking behaviour gained from inappropriate
methodologies and analyses. Whilst it is quite a task to incorporate the above
dynamic issues related to making a choice “to smoke” or “not to smoke” it is
possible to adopt a more appropriate research methodology to at least get some
idea as to how results may be subjected to some of the issues raised above.
DOES RESEARCH NECESSARILY EQUATE

TO EVIDENCE?
In earlier papers [16, 17], it was argued that longitudinal data were necessary
to investigate dynamic social behaviour. The author demonstrated the pitfalls
of using cross-sectional analysis of cross-sectional data in relation to teenage
smoking. When using survey type data to investigate the relationship between
smoking and explanatory variables a number of analytical issues must be
addressed. The literature on smoking reports a large number of variables to
be associated with teenage smoking. For example, smoking has been
associated with demographic, social, environmental, economic, emotional and
psychological variables [40-46]. Specifically, smoking behaviour has been
associated with the psycho-social effect of wishing to belong to a peer social
group [47], self-esteem and parental smoking behaviour [48], the

psychological process of risk assessment and risk taking [49-51]. Others
suggest smoking behaviour is likely to be influenced through the family
environment, which affects psychological well-being, adjustment and problem
behaviour, perceived academic performance and school conduct [34, 52], the
subjective effect of smoking e.g. feelings of higher self-esteem and being in
control [48, 53]; a perceived ‘benefit’ effect as utilised in the risk models[49-
50]. How the explanatory variables are related with each other will have an
impact on the final results. This is referred to as multicollinearity (e.g. see [54]
page 105).
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Another major problem with survey type studies is that they do not allow
an assessment of past behaviour (e.g. state dependence) and do not handle

residual heterogeneity due to omitted variables (e.g. personality, the feel good
factor and resilience). Residual heterogeneity results when systematic but
unmeasured characteristics of individuals contribute to the response pattern over
time (e.g. see [55]). In survey studies some individual characteristics are often
omitted from the study because they are either unobserved or difficult to measure.
Omitted characteristics, such as resilience, could lead to spurious relationships
between the observed characteristics and the outcome variable; often leading to
an overestimation of the relationships between the response (in this case,
smoking) and the explanatory variables. In this context, within the literature,
residual heterogeneity due to omitted variables is commonly referred to as hetero-
geneity.
A past behaviour effect exists when the experience of a particular outcome
itself changes the probability of experiencing that event on subsequent
occasions. It is also important to have measures of past behaviour on smoking
and explanatory variables in order to gain some insight into the direction of
causality. For example, Murphy et al [48] reported low self-esteem among the
female group who indicated an intention to smoke. This means that the
assertion that the more confident individuals are more likely to be a smoker
[56] may become untenable, as it is likely that the individuals had lower self-
esteem prior to taking up smoking. It is not surprising that researchers [23,24]
applying a cross-sectional statistical technique to longitudinal data, reported a
high correlation between smoking status in adolescence and in adulthood - as a
cessation will often be accompanied by feelings of unease and anxiety [53,57].
Most studies of teenage smoking have relied on cross-sectional observational
or survey questionnaire data. Although multicollinearity can be addressed with
cross-sectional data, to address the omitted variables and past behaviour
effects, longitudinal data are required. Even with longitudinal studies, cross-
sectional statistical techniques have been used (e.g. see [23,24,58]) or researchers
have employed methods that do not fully utilise the longitudinal nature of data
such as the ability to account for heterogeneity (e.g. see [59,60]).
In the following sections I demonstrate the above issues and their impact
on conclusions in practice through analyses of a set of survey data on
adolescents’ health related behaviour.
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MULTICOLLINEARITY
The first aspect to consider is multicollinearity in data. This is due to the

influence of other variables on the relationship between an outcome and
another variable. For example, when investigating the effect of attitudes
towards healthy living on smoking status, the relationship between attitudes
and age, sex must be taken into account. In addition attitudes are subject to
influence by other social and economic processes. Therefore it is not simply
sufficient to cross smoking with observed attitude and make definitive
conclusions. Table 1 shows a simple bivariate analysis of smoking.
It can be seen that all the variables that were included in the analysis
appear strongly significant. A problem then arises as how to interpret these
significant relationships and even more importantly, which variable(s) should
we concentrate on for policy development? Is it prudent to concentrate on the
apparent relationship of a single variable with smoking to develop anti-
smoking policies? Furthermore, does this result tell us anything about why
adolescents take up smoking?
STATISTICAL MODELLING
On the other hand an appropriate analytical methodology may be designed
where multicollinearity is accounted for with a suitable statistical model. In
this section I demonstrate the effect of the issues discussed earlier in this
chapter on the results even when the analytical methodology is appropriate for
the data at hand.
Table 2 shows the results from statistical modelling of a set of cross-
sectional data obtained from high school students in Yorkshire, UK[16]. In
this case the outcome was simply smoking status of students with two possible
outcomes; smoker or nonsmoker. A logistic model was fitted to data. A
forward iterative process for model selection was adopted. The relationship
between smoking and variables were examined one at a time and the variable
with the smallest p-value was entered in the model. Then the process was
repeated with the remaining variables. Again, the variable with the smallest p-
value is selected to enter the model. Those variables which were not
significant at 5% significance level were excluded from the subsequent round.
The process of elimination continued until there were no variables left
significant at the 5% significance level.
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Table 1. Selected variables from the Health Related Behaviour

Questionnaire thought to be associated with smoking habits

of young people. Bi-variate cross-classification;
N=9230, * p<.05, ** p<0.001, *** p<0.00001
Explanatory variables Smoking

Socio-demographic p
***
1- Age
***
2- Gender
***
3- Which parents live with
***
4- Where live
*
5- Social class (see §3)
Socio-environment
6- Whether smoker -
***
7- Whether drinks
***
8- Whether at least one in family smokes
***
9- Whether relative smokes
***
10- Whether best friend smokes
Socio-psychological
**
11- Self-esteem
***
12- Whether happy with weight
***
13- Whether happy with body shape
14- Whether considers health when choosing food
***
14- Whether have a steady partner
***
15- How feels when meeting opposite sex
***
16- How feels when meeting own sex
***
17- Have a drink when have problem
How much worry about:
***
18- school problems
***
19- money problems
***
20- health problems
***
21- career problems
***
22- problems with friend
***
23- family problem
***
24- the way you look
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Table 2. Standard logistic regression: odds ratios for the model

of smoking prevalence with their appropriate 95% Confidence Limits

after controlling for other factors
Explanatory variables Lower Odds Ratio Upper

Age
12-13 1.00 1.00 1.00
14-15 1.59 1.84 2.13
Sex
male 1.00 1.00 1.00
female 1.68 1.96 2.30
Which parent live with
both parents 1.00 1.00 1.00
mother only 0.92 1.13 1.40
father only 0.92 1.45 2.31
mother and step-father 1.18 1.48 1.84
father and step-mother 0.78 1.31 2.19
foster parents 1.78 3.74 7.87
other 0.79 1.31 2.14
Whether drinks
no 1.00 1.00 1.00
yes 2.19 2.56 3.00
Whether at least one family smokes
no 1.00 1.00 1.00
yes 1.40 1.62 1.89
Best friend smokes
no 1.00 1.00 1.00
yes 12.23 14.16 16.36
Have partner
never had one 1.00 1.00 1.00

not at the moment 1.44 2.02 2.85
yes, few weeks 2.25 3.25 4.71
yes, up to 6 months 3.21 4.77 7.09
yes, up to a year 1.72 2.80 4.53
yes, > 1 year 2.10 3.17 4.78
How feel with opposite sex
very uneasy 1.00 1.00 1.00
a little uneasy 1.01 1.32 1.74
at ease 1.43 1.89 2.49
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Explanatory variables Lower Odds Ratio Upper

Happy with body shape
no 1.00 1.00 1.00
yes 0.69 0.80 0.93
Considers health when choosing
food 1.00 1.00 1.00
never 0.50 0.62 0.77
sometimes 0.38 0.48 0.62
quite often 0.23 0.32 0.43
very often 0.30 0.44 0.63
always
Worry about money problems
never/hardly ever 1.00 1.00 1.00
a little 1.12 1.33 1.58
quite a lot/a lot 1.43 1.71 2.05
Worry about family problems
never/hardly ever 1.00 1.00 1.00
a little 0.97 1.17 1.42
quite a lot/a lot 1.15 1.37 1.62
The first noticeable result is that there are not as many significant
variables; indeed, the number of variables that may be related with smoking is
halved.
Given the above background that our model is appropriate for our data set
i.e an appropriate regression model for our binary response (smoker, non-
smoker) is the logistic regression model; we may proceed to interpret the
results. At face value it is quite easy to conclude that “best friend” has the
largest effect on smoking followed by the variables “have partner”; “how feel
with opposite sex”; “which parent live with”; and the two “worrying”
variables. Results in table 2 also suggest that compared to a reference group

the odds of being a smoker increased for those who claimed their best friend
smokes (OR 14.58, 95% CI 12.63-16.83), for those who claimed to have a
partner (OR 3.41, 95% CI 2.36-4.92), those who claimed to be at ease with the
opposite sex (OR 1.80, 95% CI 1.37 to 2.36), those who claimed to worry a lot
about money problems (OR 1.71, 95% CI 1.43-2.05) and those who claimed to
worry a lot about family problems (OR 1.37, 95% CI 1.15-162). On the other
hand, the odds of being a smoker decreased for those who claimed to be happy
with their body shape (OR 0.75, 95% CI 0.65-0.87) and those who claimed to
consider health often when choosing food (OR 0.50, 95% CI 0.39-0.63).
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Pupils who lived with foster parents appear to have an increased risk of nearly
four times that of pupils who lived with both parents. The result for “which
parent live with” can be explained as past behaviour leading to a selection
bias; it is plausible that smoking may well have started while in care prior to
placement with foster parents [61].
MULTICOLLINEARITY REVISITED
Commonly, researchers identify parameters in relation to a research
question and set about measuring or observing these parameters. It is fairly
easy to identify correlations and interactions between explanatory variables
using exploratory data analysis if the variables have been observed. As
emphasized earlier, a major problem with surveys is that some variables go
unobserved. Often some individual characteristics are omitted from the study
either because they are difficult to measure or can not be measured in a survey.
Omitted variables relate to the issues discussed in the introduction including
personal characteristics such as personality and resilience. Omitted variables
are responsible for spurious relationships between the observed characteristics
and the outcome variable resulting in an overestimation of the relationships
between the response (in this case, smoking) and the explanatory variables,
thus, leading to erroneous results and misconclusions [16,17].
In addition to the issue of the unobserved variables when dealing with
survey type data we have the added problem of dealing with different types of
variables mainly subjective and objective variables. Subjectively measured
variables often rely on the respondent’s own assessment such as self reporting
of health, fitness and emotional variables. Clearly, measurements reported by
the respondents will be influenced by their state of mind, wellbeing and other
personal characteristics at the time of reporting. The problem is that we will

not know the size of this error and its sources. We know that individuals use
different values depending on their life events and experiences, physical and
mental status at the time of the survey, to estimate parameters and self-
reporting. Therefore, the self reported values for the observed parameter
carries a measurement error, i.e. the actual value for the parameter being
measured (e.g. fitness) will be compounded with values from a mixture of the
individual’s emotional, psychological, and overall state of health.
In the case of smoking, a problem arises over the inclusion of subjectively
measured social and emotional factors (arbitrarily headed socio-environmental
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and socio-psychological respectively) in the analysis. Social circumstances

will have an impact on the prevalence of teenage smoking, in part, by affecting

emotional variables e.g. the desire to belong to a peer group [47]. It is highly
plausible that the inclusion of such variables in the model will lead to a
complex correlation and interactions between the explanatory variables on one
hand and between explanatory variables and the error component on the other.
Such relationships in the model will lead to a well known specification error
[16,17] which means the results shown in table 2 can not be taken at face
value! In the absence of longitudinal data, to get an idea of the existence of
complex multicollinearity in our cross-sectional data, we can assess the role of
subjective variables by forcing the direction of causality from objective
variables to the outcome (smoking) [62-64]. Therefore, models were fitted
with and without socio-environment and socio-psychological variables. Firstly
a model of objective variables was constructed based on demographic
variables. Secondly, social variables were introduced to this model, and,
thirdly socio-psychological variables were then added to the second model.
The results of this modelling process are shown in table 3.
Although, the final model in both tables are the same, in this round of
analysis we are initially only interested in the model fitting process. It is
during this process that we will gain more insight into the interrelationship
between the various types of variables. The role different variables play in
smoking can be examined by comparing results from the three models in table
3. The inclusion of socio-environmental factors (model 2) has a major impact
on model 1 (table 3): there are significant changes in parameter estimates of
the variables “gender”, “age”, “which parent live with” - and variables
reflecting social status “where live” and “social class” are no longer significant
and drop out of the model. While some increases in parameter estimates are to
be expected when adding new significant variables to the logistic regression
model, the large decrease in parameter estimates confirms that the effect of the
variables “age” and “which parent live with” have substantially reduced. This
is consistent with socio-environmental variables having an intervening effect
between age, parent(s) and smoking. Similarly, when socio-psychological
variables are added to model 2 (see model 2 to model 3, table 3), a modest
decrease in parameter estimates of demographic and socio-environmental
variables can be noted. This decrease is consistent with socio-psychological
variables having an intervening effect between demographic and socio-
environmental variables and smoking.
For example, it can be seen that change in the parameter estimate variable
“best friend smokes” from model 2 to model 3 (table 3) is over two times its
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standard error. This change is consistent with variable “best friend” having an
intervening effect between smoking and demographic variables. If there is a

‘true’ best friend effect it is too complex to distinguish with cross-sectional
data.
Table 3. Model fitting results for the model of smoking - N=9230
Model 1 Model 2 Model 3

Explanatory variables Parameter Standard Parameter Standard Parameter Standard
estimate error estimate error estimate error
Demographic factors
Age
12-13 0.00 0.00 0.00
14-15 1.06 0.06 0.68 0.07 0.61 0.08
Gender
male 0.00 0.00 0.00
female 0.52 0.06 0.68 0.07 0.67 0.08
Which parent live with
both parents 0.00 0.00 0.00
mother only 0.47 0.08 0.23 0.10 0.12 0.11
father only 0.69 0.18 0.49 0.23 0.37 0.24
mother and step-father 0.80 0.09 0.53 0.11 0.39 0.11
father and step-mother 0.77 0.20 0.44 0.25 0.27 0.26
foster parents 1.63 0.29 1.56 0.37 1.32 0.38
other 0.73 0.19 0.38 0.24 0.28 0.25
Where live
town/city centre 0.00
town/city suburb -0.30 0.13
small town/city centre -0.08 0.11
small town/city sub. -0.26 0.11
in village 0.10 0.10
outside town/village 0.20 0.13
Social class 0.00

high 0.15 0.10
medium 0.25 0.09
low
Socio-environmental factors
Whether drinks
no 0.00 0.00
yes 1.11 0.08 0.94 0.08
Whether at least one family 0.00 0.00
smokes 0.60 0.08 0.47 0.08
no
yes
GRONINGEN
Model 1 Model 2 Model 3

Explanatory variables Parameter Standard Parameter Standard Parameter Standard

estimate error estimate error estimate error
Best friend smokes
no 0.00 0.00
yes 2.81 0.07 2.65 0.07
Socio-psychological factors
Have partner
never had one 0.00
not at the moment 0.70 0.17
yes, few weeks 1.18 0.19
yes, up to 6 months 1.56 0.20
yes, up to a year 1.03 0.25
yes, > 1 year 1.15 0.21
How feel with opposite sex 0.00
very uneasy 0.28 0.14
a little uneasy 0.64 0.14
at ease
Happy with body shape
no 0.00
yes -0.22 0.08
Worry about money 0.00
problems 0.29 0.09
never/hardly ever 0.54 0.09
a little
quite a lot/a lot
Worry about family 0.00
problems 0.16 0.10
never/hardly ever 0.31 0.09
a little
quite a lot/a lot
It is plausible that prior to taking up smoking such pupils may have had a
lower self-esteem, a wish to gain confidence, a desire to belong to a peer group

and possibly lacked social and parental guidance. There is some evidence to
suggest that parental influence indirectly predicts lower levels of smoking[65-
67]. The “best friend” effect may not be straightforward to interpret with these
data because we have no knowledge of the pupil’s previous smoking habits;
they may have been a smoker prior to the friendship. Furthermore, the high
odds ratio for ‘best friend’ may well be inflated due to a pragmatic sampling
strategy. Surveying of all pupils within classrooms in selected schools may
have achieved maximum response, but has added complexities to the data, e.g.
(i) the clustering effect where pupils with similar outcome characteristics tend
GRONINGEN
to form clusters (or social groups), and (ii) the possibility of double counting
where pupils in the same classroom cite each other as best friend (e.g., see
[68]). Cross-sectional analysis of such data will lead to an artificially inflated
effect of ‘best friend” on smoking (e.g., see [69]). Therefore, it is unwise to
interpret “best friend” directly as peer pressure effect. The peers pressure
effect may in fact be masking the intention to smoke and a selection bias as
those whose perceptions and attitudes are not aligned to healthy outcomes may
take up smoking [1] and choose peers with similar standards.
The comparison of the three models and changes in the parameter
estimates and their standard error is discussed in full elsewhere [16,17], in this
section I am merely demonstrating these changes to illustrate the complex
interrelationships in data and how it may affect the final results.
Consider the “worrying” variables (worrying about money problems and
family problems). Taken at face value from table 2 may be interpreted as
worrying leads to smoking; those who worry are more likely to be smokers.
But the change in the estimates from model 2 to 3 suggest possible effects of
the issues discussed in the introduction including past behaviour (not only
previous smoking habits but also worrying about problems), personality and
resilience (worrying), complex multicollinearity, and feedback effect. To
illustrate, consider the following questions:-
Is worrying the result of being a smoker?

Do individuals who are more prone to worry have a tendency to
smoke?
Do individuals who take up smoking do so to counteract worrying?
More importantly is worrying the same in non-smokers than smokers?
Is the need for nicotine in smokers exaggerated when faced with
problems, which is then compounded and confounded with the effects
of worrying?
Is it plausible that the association between worrying and smoking may
be due to exposure to society’s portraying of smoking?
Why do adolescents with similar characteristics when faced with
similar problems some may smoke while others may show resilience
and try to deal with them?
As most pupils have been made aware of the dangers of smoking, these
variables may be a proxy for the underlying effect of attitudes to health and
smoking. The choice of food represents the health consciousness of pupils
GRONINGEN
suggesting that those who attach importance to health related behaviour have a
reduced risk of being a smoker. While the worrying variables serve to

demonstrate the subjective effect of smoking where smoking leads to the
maintenance of smoking [53, 57]. Again without prior information on the
pupils smoking behaviour these results do not constitute evidence for worrying
leading to smoking. This association between smoking and worrying/health
may help explain the prevalence but not incidence of smoking.
LONGITUDINAL MODELLING
Whilst we can not answer the above questions with our data I have
demonstrated a pragmatic method of gauging the effects of omitted variables
on the results mainly due to the issues discussed thus far. To formally account
for omitted variables and change over time we need longitudinal data. For the
longitudinal study, the students who were on their final year and were not
returning to high school subsequently were approached and were invited to
participate in a follow up study. Those who gave their consent were
approached and interviewed two years later using the same interview schedule.
The longitudinal study is reported elsewhere [17]. In this section I briefly
demonstrate the existence of omitted variables and its effects more formally.
There were 625 young people in the longitudinal study. However, there
were 619 cases with valid responses included in the analysis. The same model
as the cross-sectional analysis reported in the above tables was fitted to the
data. The reason for using the same model was more of a convenience for
comparison purposes. In the longitudinal modelling we acknowledge that
fitting the ordinary logistic model will be erroneous due to an association
between the explanatory variables and the structural error. In other words,
conventional statistical models such as regression models subsume the

individual-specific heterogeneity into the structural error term, thus violating
the independence assumption and leading to a well-known specification error
[70,71]. The background to this association was in part discussed above i.e.
due to subjective variables carrying a measurement error, and in part is due to
the nature of longitudinal data. That is, repeated observations on the same
individual form a cluster; cluster i consisting of observations on individual i at
time 1 and time 2 and time 3 and so on refer to the same individual in the same
cluster.
GRONINGEN
In effect individuals are used as their own control and therefore, it

will be inappropriate to treat the data as though they are generated from
independent cases. The conventional regression model could not be applied to
such a data structure.
A more appropriate method is the application of mixture models in which
the error is specified by a “variance component”. In such a model,
heterogeneity is implicitly defined in the equation as a time-constant term
which is separate from the regression error term. The recent interest in the
application of mixture models has led to the inclusion of options for mixture
modelling in most major statistical packages such as SAS and GenStat.
However, we are particularly interested in the method of estimating mixture
models with the specification operationalised by Davies [71-73] and applied
within the social sciences (e.g. see [74,62]). This method of estimation uses
integrated likelihood and takes into account the fact that some individuals will
never (or have a very low probability of) change. The adequacy of a model is
tested formally using analysis of deviance; in other words, to test the
significance of an explanatory variable (e.g. gender), the change in deviance
upon adding that variable to the model is compared to the chi-squared distrib-
ution on the corresponding number of degrees of freedom (e.g. 1 in the case of
gender). SABRE [75] was used for model fitting. For statistical background
and full analysis of the longitudinal study the reader is referred to
Shahtahmasebi and Berridge [17]. The results from the longitudinal modeling
is summarised in table 4.
The results, based on our sample, can be interpreted as: the likelihood of
being a smoker appears to increase with age; with exposure to smoking and
drinking as measured by the variables “at least one family member smokes”,
“best friend smokes” and “drinks”; with emotional dependence as measured by
the variables “happy with weight” and “worry about money” and decreases
with having a healthy attitude as measured by the variable “consider health
when choosing food”.

The variable “worry about money” is only marginally significant and the
remaining variables are non-significant even at the 20% level. Perhaps the
most important aspect of these results is the statistically significant scale
variable ( ) indicating that there is substantial residual heterogeneity due to
omitted variables. The results suggest that ignoring heterogeneity may lead to
underestimation.
GRONINGEN
Table 4. Results from longitudinal analysis using Sabre

without Stayers; N=619, (Deviance=1091.26;

>> much greater than, << much less than)
2
Explanatory Variables Parameter Estimate S. Error p
Gender Male 0.00 1.8 >>0.1
female 0.43 0.32
Age 10.5 <0.025
15 and under 0.00
16 years 0.99 0.39
17 years 0.74 0.28
18 and over 0.86 0.41
At least one family member smokes 7.4 <0.01
yes 0.00
no -0.76 0.28
Drinks 39 <<0.0001
yes 0.00
no -1.99 0.37
Best friend smokes 76 <<0.0001
yes 0.00
no -2.29 0.31
Consider health when choosing food 6.9 <0.05
never 0.00
sometimes -0.72 0.41
always -1.28 0.49
Happy with weight 5.7 <0.025
put on/lose 0.00
happy -0.63 0.27
Have a partner 1.3 >>0.1
yes 0.00
no -0.29 0.26
At ease with opposite sex 2.1 >>0.1
yes 0.00
no -0.59 0.41
Worry about money 5.7 0.05
never 0.00
a little 0.12 0.31
a lot 0.72 0.33
Worry about family problems 2.82 >>0.1
never 0.00
a little 0.42 0.32
a lot 0.47 0.31
Scale ( ) 2.38 0.31
GRONINGEN
DISCUSSION AND CONCLUSION

In this chapter the complexities of dealing with smoking were discussed

and analytically illustrated the consequences of ignoring their effects on
research results and conclusions. There are analytical issues partly influenced
by the dynamics of behaviour and partly by the study design and
measurements that must be included in any study of smoking.
Although longitudinal data provide an additional lever to include
additional complexities in the analysis, longitudinal methods can be limiting –
in the above example there were only two time point observations two years
apart and at the starting point the survey already included smokers.
Furthermore, the analytical procedure only allows the inclusion of a time
constant omitted variables. It is possible to control for time varying omitted
variables using a multi-method approach [76].
For example, based on a review of the literature, Tyas [41] suggested that
smoking is often used as a mechanism to cope with stress. The results reported
here, tables 3 and 4, suggest that worrying about family problems and being at
ease with the opposite sex are no longer significant, and worrying about
money is significant at 10%. The calming effect of smoking as a reason for
smoking is not fully justified even when it is reported by the respondents
themselves. Most of the studies reviewed by Tyas are cross-sectional and do
not provide historical information on smoking. The calming effect of smoking
could well be a feed-back effect rather than a response to stress or worry as a
cessation will often be accompanied by feelings of unease and anxiety [53,57].
As discussed earlier another example may be the use of cross-sectional
approaches, even when the study is longitudinal, to gain insight into the
dynamics of social outcome. For instance, using structural equation modelling,
Flay et al [77] suggested that the “best friend” effect on adolescent initiation
into smoking is a direct effect, whilst the analyses presented in this chapter
suggest that at least some of the variation explained by the “best friend” effect
may well be due to its correlation with the omitted variables.
This ambiguity in interpreting the results is further exacerbated by the
subjective effect of smoking, e.g. feelings of higher self-esteem and being in
control (44,50); a perceived ‘benefit’ effect as utilised in risk models (45,46).
Yet, survey studies often treat a mix of observations (e.g. parental smoking
behaviour and self-esteem, or psychological and environmental measures)
as independent correlates of smoking (i.e., that no other effects are present).
A quick examination of public health (anti-smoking) policies clearly
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demonstrates an approach that ignores the consequences of at least two of the

issues discussed in this chapter; multicollinearity and residual heterogeneity.

A recent television anti-smoking advertisement in New Zealand begins
with an apparently “hip” and “cool” young person announcing that “not
smoking” is as cool as smoking was… followed by more similar messages
from people with a similar outlook. Is this an attempt to turn the tables around
on smoking by using peer pressure to encourage anti-smoking behaviour? The
previous campaigns concentrated on second hand smoking in the household
and cars in particular where children are present implying smoke but do it
away from children and others. The campaign for alcohol consumption control
appears to be based on a similar premise: it is not the drinking it is how we are
drinking.
There would be nothing wrong with these educational messages if human
behaviour was static and not dynamic. In particular, adolescence is considered
to be the crucial period during which attitudes and pattern of behaviour are
formed[78,79]. Such campaigns make no assumptions for the issues discussed
above. There is no mechanism by which to measure the effect of
acknowledging the practice of a social ill in a health promotion campaign, in
particular, when it involves the highly dynamic decision making processes of
adolescents. For example, what proportion of young people who have been
exposed to the recent campaign perceived that the campaign provided them
with the justification that smoking can be cool? And what proportion were
influenced by the message that “smoking is no longer cool” to give up or not
to take up smoking? And what proportion, who were going to be influenced by
the campaign, in whatever way, had their perceptions influenced by different
images of smoking in the media, their experiences and other social and
political issues as discussed in the feedback effect?
The dynamics of human behaviour, as discussed throughout this chapter
also applies to the service providers, decision makers and practitioners, and
pro smoking groups, the tobacco industry and so on. Such campaigns maintain
public exposure to smoking. Tobacco industry invests and relies on feedback.
Such social investments are likely to result in more exposure to smoking and
another lever to manipulate “cognitive dissonance”. Questions to ask may be:
how beneficial or harmful are these exposures? And, is there a significant
difference between the types of exposure in terms of effects on smoking or not
smoking?
There is some evidence to suggest that televised anti-smoking exposure
may lead to positive results [80]. However, these studies have used rates of
calls to the quitline following a televised campaign to falsely conclude the
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“effectiveness” of the televised campaign! Increases in the rate of calls to the

quitline may not be used as a measure of quitting or even intention to quit. One
way of describing effectiveness may be to demonstrate an upward trend in the
number of quitters and a downward trend in smoking initiation that can be
associated to a programme or campaign. These types of studies do not provide
any evidence of whether or not any of the calls to the quitline actually led to
cessation for any period of time. In contrast, it is not surprising that Wakefield
[28] found a negative association between televised tobacco company funded
smoking prevention and behaviour. The confused and chaotic world of
tobacco created as a result of various policies and campaign appear to have
benefited the tobacco companies; the more anti-smoking campaigns the more
public exposure to smoking; the more negative messages; the more public
exposure to smoking; the more public smoking cessations schemes, the more
public exposure to smoking, and so on.
The complexities arise from the notion of freedom of choice, the public’s
own risk assessment against that of the practitioners, and people behaving as
people rather than mechanical units that will do what they are told! The
pressure and influences from various social, environment, and political
processes and schemes on individuals’ own process of decision making which
will exacerbate the complex multicollinearity and receptiveness to
“information” that may not strike a chord with the individuals.
Current health promotion campaigns appear to assume no influence
whatsoever from other processes and concentrate on one parameter at a time.
Due to the dynamics of human behaviour; cognitive dissonance, feedback
effects and the issues discussed in this chapter, the one parameter at a time
campaign will itself become part of the problem. It is noteworthy that the
dynamics of human behaviour will also bound freedom of choice; thus,
freedom of choice becomes a constrained or manipulated choice. Therefore
subsequent studies must take account of this fact that there may be a residual
effect from various anti-smoking campaigns and programmes that may

attenuate as well as complicate the effects of future plans. For example, the
authoritative approach of exposing the public to “part” information may have
created a “big brother” effect to which the public are likely to respond
negatively.
Perhaps the best action would be to review the whole public health and
health promotion system in terms of education and training, practice, service
development and delivery. Public health practitioners must be equipped with
the tools and means to critically review the evidence in relation to the issue at
hand before setting about developing a service. In particular, the development
GRONINGEN
of services that is intended to deliver information and educate. The

practitioners must not assume an effect from their programmes but always
integrate an evaluation of the service for intended effect and negative effects
too.
Given the limitations placed on the tobacco industry including high
taxation, compulsory health warning, advertising ban, sponsorship ban, and so
on, in addition the number of law suits and litigations against the tobacco
companies, the industry still generates large sums of money in tax revenues
and is one of the main contributors to the treasury. By the same token, the
marginalization of smokers e.g. increasing costs of keeping up their habit,
additional financial penalties they have to incur on insurance premiums,
employment and so on, and not to mention the ill health effects – does not
appear to have dissuade a proportion of the public from smoking. Indeed, in a
short focus group of smokers which I conducted recently (the subject of
another study), smokers in this particular group were overwhelming
undeterred and anti-government for all their anti-smoking policies in particular
the most recent one which bans smoking in bars and restaurants. The group
was very angry and rebellious about constantly being told what to do and
every aspect of their lives being controlled (the big brother effect). They were
first and foremost preoccupied with the anti-smoking policies restricting their
choices. In New Zealand alone the tax revenue from the tobacco industry is
estimated in excess of $800 million and the Government spend around only
$28 million each year on cessation programmes (such as the subsidized
nicotine patches and gum programme and the Quitline), health promotion and
enforcement of legislation [81,82]. The question must be asked, time and
again, why an industry that is allegedly contributing to morbidity and
mortality, thus not only costing but also placing a great burden on the
economy, health and social sector is considered a worthy avenue of generating
revenue for the treasury?
ACKNOWLEDGMENTS
The analyses reported briefly in the “Statistical Modelling” section of this
chapter are discussed in full including statistical background in Grenell [83].
GRONINGEN
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Editor: Itsuki Hayashi © 2012 Nova Science Publishers, Inc.

as opposed to superficial and proxy associations. Superficial and proxy

and charitable programmes. In this context all actors (e.g. individuals,

cessation programmes that involves family and other household members to

anti-smoking campaigns has heavily relied on prescribing and instructing the

public “not to smoke” by creative provision of information as to how smoking

Adolescent smoking behaviour is a process the outcome of which may be

cognitive dissonance, another example, is that individuals align their attitude

manifest years after the incidence of smoking. Furthermore the gradual

INFORMATION AND ITS COMMUNICATION

any, of anti-smoking campaigns may be counteracted by the covert pro-

individual and social behaviour.

negative. The public is constantly, in one way or another, exposed to tobacco

FEEDBACK EFFECTS AND BEHAVIOUR

such an influence, the feedback may be direct or indirect. Direct external

PEOPLE AS UNITS OF EXPERIMENT

There is very little research to evaluate the feedback effect of public

policies on the public’s perception of smoking and a decision not to smoke, to

exposure to smoking and another lever to manipulate “cognitive dissonance”.

faculties we constantly expose ourselves to behaviour whereby we continue to

develop policies to discourage the public from adopting.

Figure 1. An example of a conceptual model of smoking.

DOES RESEARCH NECESSARILY EQUATE

group [47], self-esteem and parental smoking behaviour [48], the

an assessment of past behaviour (e.g. state dependence) and do not handle

The first aspect to consider is multicollinearity in data. This is due to the

Table 1. Selected variables from the Health Related Behaviour

Questionnaire thought to be associated with smoking habits

Explanatory variables Smoking

Table 2. Standard logistic regression: odds ratios for the model

of smoking prevalence with their appropriate 95% Confidence Limits

Explanatory variables Lower Odds Ratio Upper

never had one 1.00 1.00 1.00

Explanatory variables Lower Odds Ratio Upper

variables. Results in table 2 also suggest that compared to a reference group

personal characteristics at the time of reporting. The problem is that we will

and socio-psychological respectively) in the analysis. Social circumstances

will have an impact on the prevalence of teenage smoking, in part, by affecting

intervening effect between smoking and demographic variables. If there is a

Table 3. Model fitting results for the model of smoking - N=9230

Model 1 Model 2 Model 3

Social class 0.00

Model 1 Model 2 Model 3

Explanatory variables Parameter Standard Parameter Standard Parameter Standard

lower self-esteem, a wish to gain confidence, a desire to belong to a peer group

Is worrying the result of being a smoker?

reduced risk of being a smoker. While the worrying variables serve to

conventional statistical models such as regression models subsume the

In effect individuals are used as their own control and therefore, it

when choosing food”.

Table 4. Results from longitudinal analysis using Sabre

without Stayers; N=619, (Deviance=1091.26;

DISCUSSION AND CONCLUSION

In this chapter the complexities of dealing with smoking were discussed

demonstrates an approach that ignores the consequences of at least two of the

issues discussed in this chapter; multicollinearity and residual heterogeneity.

“effectiveness” of the televised campaign! Increases in the rate of calls to the

effect from various anti-smoking campaigns and programmes that may

of services that is intended to deliver information and educate. The

Public Health. 2007 Jun 28.

Campaigns, 1967-2006. Am. J. Public Health. 2007 Jun 28.

[21] McGinnis R. (1968). A Stochastic model of social mobility. American

requested not to be. http://news.bbc.co.uk/go/em/-/1/hi/health. 6902519.