Chapter 4. Factors Influencing Tobacco Use Among Women
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Chapter 4. Factors Influencing Tobacco Use Among Women Introduction 453 Factors Influencing Initiation of Smoking 453 Overview of Studies Examined 453 Social and Environmental Factors 454 Accessibility of Tobacco Products 454 Pricing of Tobacco Products 454 Advertising and Promotion of Tobacco Products 455 Parental Hostility, Strictness, and Family Conflict 455 Level of Parental Supervision, Involvement, or Attachment 468 Parental Smoking 468 Sibling Smoking 469 Peer Smoking 469 Perceived Norms and Prevalence of Smoking 469 Perceived Peer Attitudes Toward Smoking 470 Strong Attachment to Peers 470 Interaction of Social Influences 470 Personal Characteristics 471 Socioeconomic Status and Parental Education 471 Behavioral Control 471 Sociability 471 Fatalism and External Locus of Control 471 Intelligence, Academic Performance, and Commitment to School 472 Rebelliousness, Risk Taking, and Other Health-Related Behaviors 472 Religiousness 473 Self-Esteem 473 Emotional Distress 473 Coping Styles 474 Perceived Refusal Skills 474 Previous Experimentation with Tobacco and Intention to Smoke 474 Susceptibility to Smoking 474 Expectations of Personal Effects of Smoking 475 Beliefs About Effects on Image and Health 475 Concerns About Weight Control 475 Beliefs About Mood Control and Depression 476 Biological Factors 476 Summary 477 Factors Influencing Maintenance or Cessation of Smoking 477 Overview of the Studies Examined 477 Transitions from Regular Smoking 479 Attempts to Stop Smoking 479 Smoking Cessation 482 Relapse to Smoking 487 Summary 488 Marketing Cigarettes to Women 490 Marketing Techniques 490 Advertising 490 Promotions 491 Sponsorship 492 Product Packaging 492 Historical Antecedents 493 Making Cigarettes Glamorous 494 Recognition of Power of Advertising 497 Links of Fashion to Advertising 497 Influence of Tobacco Marketing on Smoking Initiation Among Females 498 Themes in Tobacco Marketing Targeted to Women 505 Contemporary Cigarette Advertisements and Promotions 509 Sponsorship 511 Provisions of the Master Settlement Agreement 515 Restrictions on Brand Name Sponsorships 515 General Advertising and Marketing Restrictions 515 Restrictions on Outdoor Advertising 515 Marketing on the Internet 516 Marketing of Smokeless Tobacco and Cigars 516 Press Self-Censorship in Relation to Cigarette Advertising 517 International Marketing of Cigarettes to Women 519 Historical Overview 519 Marketing Strategies 520 Media Censorship 524 Bans and Restrictions on Tobacco Advertising and Promotion 524 Protests Against Targeting of Women 526 Summary 526 Conclusions 527 References 528 Women and Smoking Introduction The published work on smoking initiation, main- cultural, and personal factors that influence women’s tenance, and cessation, together with descriptive smoking has been based on the social and psycholog- examinations of the trends and themes of cigarette ical theory of the past several decades, and this marketing, has provided insights into why women re s e a rch has burgeoned in recent years. Because start to smoke and why they continue. Numerous smoking initiation among, maintenance and cessation scholars (e.g., Magnusson 1981; Bandura 1986; Sa- among, and tobacco marketing to women have been dava 1987; Frankenhaeuser 1991; Jessor et al. 1991; studied by investigators using a variety of disciplin- DeKay and Buss 1992) have argued that a thorough ary perspectives and approaches, no single organiz- understanding of any behavior must be based on a ing framework exists for addressing the question of comprehensive analysis of the broad social environ- why women smoke. The research has shown that like ment or cultural milieu surrounding the behavior, the most behaviors, tobacco use or nonuse results from a immediate social situation or context in which the complex mix of influences that range from factors that behavior occurs, the characteristics or disposition of are directly tied to tobacco use (e.g., beliefs about the the person performing the behavior, the behavior consequences of smoking) to those that appear to itself and closely related behaviors, and the inter- have little to do with tobacco use (e.g., parenting action of all these conditions. Research on the social, styles and school characteristics). Factors Influencing Initiation of Smoking Overview of Studies Examined personal. Social influences include the characteristics, beliefs, attitudes, and behaviors of the persons who Nearly all first use of tobacco occurs before high make up the more intimate support system of adoles- school graduation, and because nicotine is addictive, cents, such as family and friends. Cultural influences adolescents who smoke regularly are likely to become include the practices and norms of the broader social adult smokers (U.S. Department of Health and environment of adolescents, such as the community, Human Services [USDHHS] 1994). Research on smok- neighborhood, and school. Personal influences in- ing initiation has, therefore, focused on adolescents clude individual biological characteristics, person- and has been informed by a wealth of behavioral ality traits, affective states, and behavioral skills. For studies. Predictors of use of tobacco and other sub- each type of influence, three levels of influence— stances (Conrad et al. 1992; Hawkins et al. 1992; ultimate, distal, and proximal—have been defined USDHHS 1994) and theories of adolescents’ use of by work in evolutionary biology (Alcock 1989), cogni- such substances (Petraitis et al. 1995) point to a com- tive science (Massaro 1991), and personality theory plex set of interrelated factors. (Marshall 1991). McKinlay and Marceau (2000a,b) Many efforts have been made to provide either a have emphasized the importance of a broad new inte- t h e o retical basis or an integrated framework for gration of approaches and multilevel explanations. examining influences on smoking initiation. As a step The levels of influence affect the nature and strength toward an integrated approach, Petraitis and col- of the type of influence. Ultimate influences are leagues (1995) suggested that factors affecting tobac- broad, exogenous factors that gradually direct per- co use can be classified along two dimensions—type sons toward a behavior but are not strongly pre- of influence and level of influence. These authors sug- dictive. Distal influences are intermediate or indirect gested that three distinct types of influence underlie factors that may be more predictive. Proximal influ- existing theories of tobacco use—social, cultural, and ences, which are the most immediate precursors of a Factors Influencing Tobacco Use 453 Surgeon General’s Report behavior, are most predictive. The study of social, cul- 1994; Forster and Wolfson 1998). In numerous surveys tural, and personal domains among adolescents and conducted since the late 1980s, youth often self- the various levels of influence has undergone consid- reported that their most common source of cigarettes erable theoretical development. This review of smok- was purchase from retail stores (Lynch and Bonnie ing initiation examined more than 100 studies in 1994; USDHHS 1994; Centers for Disease Control and which tobacco use was an outcome variable. Selected Prevention [CDC] 1996a,b; Forster and Wolfson 1998). characteristics and major gender-specific findings of Since the early 1990s, noncommercial or social the longitudinal studies are shown in Table 4.1. sources (other minors, parents, older friends) have The primary dependent variables analyzed in the also been studied (Cummings et al. 1992; CDC 1996b; studies differed greatly, ranging from initiation of Forster et al. 1997). Evidence suggested, however, that smoking to amount smoked. The studies most rele- much of the tobacco provided by minors to other vant to this report were longitudinal investigations minors was initially purchased from commerc i a l that examined gender-specific results related to smok- sources by the adolescent donor (Wolfson et al. 1997). ing initiation among adolescents, including predic- Some of these self-report surveys have found that tors of smoking initiation (Ahlgren et al. 1982; Bruns- adolescent girls may be less likely than boys to report wick and Messeri 1983–84; Skinner et al. 1985; Charl- usually purchasing their own cigarettes (CDC 1996b; ton and Blair 1989; McNeill et al. 1989; Simon et al . Kann et al. 1998). Additionally, results from the Mem- 1995), pathways leading to smoking initiation (Flay et phis Health Project (Robinson and Klesges 1997) al. 1994; Pierce et al. 1996; Pallonen et al. 1998), and indicated that girls were less likely than boys to view predictors of both initiation of and escalation to regu- cigarettes as affordable and easy to obtain. Field re- lar smoking (Chassin et al. 1984, 1986; Santi et al. search concerning minors’ access began in the late 1990–91). A few longitudinal studies addressed only 1980s and has generally concentrated on assessing escalation to regular smoking (Semmer et al. 1987; rates of illegal sales of tobacco to minors from retail Urberg et al. 1991; Hu et al. 1995a). Some cross- stores during compliance checks in which underage sectional studies that compared students who had youth attempt to purchase tobacco products (Di- tried smoking with those who had never tried smok- Franza et al. 1987; USDHHS 1994; Forster and Wolf- ing are also discussed in this text because adolescent son 1998; Forster et al. 1998). Compliance check smokers are usually recent beginners (USDHHS studies in which both girls and boys participated