Smoking initiation and maintenance

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110 HEALTH PSYCHOLOGY
tolerance may be a disease model concept but it relies upon some degree of social
learning theory for it to operate. Likewise, people might smoke an increasing number
of cigarettes because they have learned that smoking relieves withdrawal symptoms.
However, whilst this form of association is derived from a social learning perspective
it implicitly uses a disease perspective in that it requires the existence of physical withdrawal symptoms. Therefore, most researchers draw upon both disease and social
learning perspectives. Sometimes, this interaction between the two forms of models
is made explicit and the researchers acknowledge that they believe both sources of
influence are important. However, at times this interaction is only implicit.
THE STAGES OF SUBSTANCE USE
Research into addictive behaviours has defined four stages of substance use: (1)
initiation; (2) maintenance; (3) cessation; and (4) relapse. These four stages will now
be examined in detail for smoking and alcohol use and are illustrated in Figure 5.4.
STAGES 1 AND 2: INITIATING AND MAINTAINING AN
ADDICTIVE BEHAVIOUR
Smoking initiation and maintenance
In 1954, Doll and Hill indicated that smoking was predictive of lung cancer. Fifty years
later, approximately 30 per cent of the adult population still smoke even though most of
Fig. 5-4 The stages of substance use
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SMOKING AND ALCOHOL USE
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them are aware of the related health risks. In fact, research exploring whether smokers
appreciate the risks of smoking in comparison with the risks of murder and traffic
accidents showed that smokers were accurate in their perception of the risks of smoking
and showed similar ratings of risk to both ex-smokers and never smokers (Sutton
1998b). The early health promotion campaigns focused mainly on the determinants of
smoking in adult men, but over recent years there has been an increasing interest in
smoking in children. Most children/adolescents try a puff of a cigarette. It is therefore
difficult to distinguish between actual initiation and maintenance of smoking behaviour.
Accordingly, these stages will be considered together.
Smoking in children
Doll and Peto (1981) reported that people whose smoking is initiated in childhood have
an increased chance of lung cancer compared with those who start smoking later on in
life. This is particularly significant as most adult smokers start the habit in childhood and
very few people start smoking regularly after the age of 19 or 20 (Charlton 1992). Lader
and Matheson (1991) reviewed the data from national surveys between 1982 and 1990
and indicated that smoking behaviour in 11- to 15-year-old school boys – including
those boys who have just tried a cigarette – had fallen from 55 per cent to 44 per cent and
that smoking in school girls of a comparable age had fallen from 51 per cent to 42 per
cent. Although this showed a decrease, it was less than the decrease shown in adult
smoking, and the data showed that in 1990 nearly a half of the school children had at
least tried one cigarette. In fact, many children try their first cigarette whilst at primary
school (Murray et al. 1984; Swan et al. 1991).
Psychological predictors of smoking initiation
In an attempt to understand smoking initiation and maintenance, researchers have
searched for the psychological and social processes that may promote smoking
behaviour. Models of health behaviour such as the health belief model, the protection
motivation theory, the theory of reasoned action and the health action process approach
(see Chapter 2) have been used to examine the cognitive factors that contribute to
smoking initiation (e.g. Sherman et al. 1982; Sutton 1982). Additional cognitions that
predict smoking behaviour include associating smoking with fun and pleasure, smoking
as a means of calming nerves and smoking as being sociable and building confidence,
all of which have been reported by young smokers (Charlton 1984; Charlton and Blair
1989; see also Chapter 11 for a discussion of smoking and stress reduction).
Social predictors of smoking initiation and maintenance
Much research focuses on the individual and takes the individual out of their social
context. Individual cognitions may predict smoking behaviour but they are a product
of the individual’s socialization. Interactions within the individual’s social world help
to create and develop a child’s beliefs and behaviour. In Britain, there have been five
longitudinal studies that have identified elements of the child’s social world that are
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