PEDIATRICS Vol. 114 No. 4 October 2004, pp. 1028-1034 (doi:10.1542/peds.2003-0558-L)
Social Smoking Among US College Students
* Tobacco Research and Treatment Center and Division of General Medicine, Massachusetts General Hospital, Harvard Medical School; Boston, Massachusetts
Department of Health and Social Behavior, Harvard School of Public Health, Boston, Massachusetts
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ABSTRACT |
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Objective. Young smokers commonly identify themselves as "social smokers," a pattern of smoking behavior that is poorly understood. We assessed the prevalence and correlates of social smoking among US college students.
Methods. Cross-sectional survey of a random sample of 10 904 students enrolled at 119 nationally representative US colleges in 2001.
Results. A total of 51% of 2401 current (past 30-day) smokers were social smokers. (To assess social smoking, students were asked, "In the past 30 days, do you smoke mainly when you are with people, mainly when you are alone, or do you smoke as often by yourself as with others?" Students who stated that they smoked mainly with others rather than alone or equally by themselves and others were defined as social smokers for this analysis.) Social smoking was independently associated with a lower frequency and intensity of tobacco use, less nicotine dependence, less intention to quit, and fewer recent quit attempts.
Conclusions. Social smoking is a distinct pattern of tobacco use that is common among college students and may represent a stage in the uptake of smoking.
Key Words: tobacco • smoking • young adults • patterns of use
Abbreviations: CAS, College Alcohol Study
Recent trends in tobacco use have focused public health attention on young adults (aged 18–24 years). From 1993 to 2000, the prevalence of smoking by US adults fell in all age groups except young adults.1 Smoking rates increased among the young adults in Monitoring the Future Surveys during the 1990s.2 The prevalence of smoking among college students also increased during the 1990s, although college students smoke at lower rates than their noncollege peers.2–5
Young adults’ pattern of tobacco use, like their prevalence of use, distinguishes them from the general adult population.6 Young adults smoke fewer cigarettes daily and are less likely to smoke every day than the general population of adults.3,7 Tobacco use seems to be in transition during young adulthood as the experimental smoking begun during adolescence matures to established use.7,8 Tobacco industry documents indicate that the industry views young adulthood as a critical time in the progression to established smoking behavior.9–12 To promote this transition, the industry has studied the social context in which young adults use tobacco products and uses this information to craft its marketing strategies.9–12 The tobacco industry reaches out to young adults in their social environments by sponsoring promotional events in bars and clubs and on college campuses.9,11–13 Tobacco industry studies have also identified a group of so-called "social smokers" who smoke mainly in social situations, do not believe that they are addicted to smoking, and are concerned about the social acceptability of their smoking.14
Outside of the tobacco industry, little formal attention has been paid to the context in which young adults use tobacco products. Ling and Glantz10 suggested that such knowledge is a prerequisite for designing effective strategies to discourage tobacco use during the young adult years. Studies of college students reveal that their smoking is strongly associated with alcohol use and attending social events.4,7,15–17 "Social smoking" is a term commonly used by young smokers to define their behavior. A qualitative study found that many college students describe themselves as "social smokers," by which they mean that their tobacco use is more like a social activity or a component of their social activities rather than a regular behavior characterized by nicotine dependence.18 These smokers generally believe that they will not continue to smoke after leaving the social college environment.18
To our knowledge, the pattern of social smoking has not been studied formally, despite its common usage. Little is known about the prevalence of social smoking or about how this pattern of use relates to usual measures of smoking behavior or to the trajectory of the development of nicotine dependence. It is likely that social smokers have lower cigarette consumption, a higher prevalence of occasional (nondaily) smoking, and less nicotine dependence, but this has not been explored. Whether social smoking is associated with quitting intentions and quitting behavior is not known, and it is not clear whether social smoking is a stable or a transient pattern of tobacco use.
This study explored the prevalence of social smoking, the characteristics of social smokers, and the association between social smoking and quitting intentions and behavior among US college students, who compose approximately one third of all young adults in the United States.19 The analysis used data from a large, nationally representative random sample of students who attend 4-year colleges and universities. Our goal was to describe this pattern of tobacco use, to explore its role in the development of nicotine dependence, and to inform future efforts to reduce college students’ smoking.
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METHODS |
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Sample
In 2001, the Harvard School of Public Health College Alcohol Study (CAS) surveyed a random sample of students who were enrolled in 120 4-year US colleges and universities. The schools were part of a group of 140 schools that were selected in 1993 to create a nationally representative sample of accredited 4-year US colleges and universities for the first CAS.20 The attrition of 20 schools in 2001 was primarily a result of institutions’ inability to provide a sample of students within the time constraints of the survey. Each participating school provided a list of 215 randomly selected students from all full-time undergraduate students who were enrolled during the 2000–2001 school year. Details of the sampling methods have been previously described.20,21 One college was excluded from the analysis because its response rate was substantially lower than the others, leaving 119 schools.
The 119 colleges in the sample were located in 38 states and the District of Columbia. Sixty-nine percent of the respondents attended public colleges, and 31% attended private colleges, which approximates the US distribution of full-time 4-year college students (67% attend public, and 33% attend private schools).22 Forty-seven percent of respondents attended large colleges (>10 000 students), 23% attended medium-sized colleges (5001–10 000 students), and 29% attended small colleges (<5000 students). The US national distribution is 37%, 24%, and 40%, respectively.22 Large colleges are overrepresented in the CAS sample because schools were selected with a probability proportional to size. Sixty-nine percent of respondents attended schools in large- or medium-sized cities, compared with 71% of students nationwide.22 Thirteen percent of students attended schools with a religious affiliation, compared with 16% nationwide.22
Questionnaire and Measures
The questionnaire assessed students’ demographic and background characteristics; use of tobacco, alcohol, and other substances; and interests and lifestyle choices.20 Demographic factors assessed were age, gender, ethnicity, year in school, marital status, and highest level of parental education attained (a proxy for socioeconomic status).
For assessing cigarette use, respondents were asked whether they had smoked a cigarette; response options were "never used," "used but not in the past 12 months," "used but not in the past 30 days," or, "used in the past 30 days." Students who reported any cigarette use in the past 30 days were considered to be current users. Cigarette smokers were asked to report the ages at which they first smoked a cigarette and first started smoking regularly and to specify daily cigarette use and frequency of smoking ("On how many of the past 30 days did you smoke cigarettes?").
For assessing social smoking, students were asked, "In the past 30 days, do you smoke mainly when you are with people, mainly when you are alone, or do you smoke as often by yourself as with others?" Students who stated that they smoked mainly with others rather than alone or equally by themselves and others were defined as social smokers for this analysis.
Degree of nicotine dependence was assessed by asking the time to first morning cigarette.23 Quit attempts were measured by asking smokers how many times in the past year they attempted to quit and were successful for 24 hours. Intention to quit smoking was measured with the Stages of Change scale, a validated 5-item measure that assesses intention to quit within the next 30 days or 6 months.24 Smokers were classified into 3 stages: precontemplation (not planning to quit in the next 6 months), contemplation (planning to quit in the next 6 months but not the next 30 days), and preparation (planning to quit in the next 30 days and made a successful 24-hour quit attempt in the past year).
Other items assessed were residence (on-campus vs off-campus), grade point average, an item assessing the importance to a student of participating in 9 activities (athletics, academic work, arts, fraternity or sorority life, parties, religion, community service, political activism, and attending sporting events), and an item assessing the time spent involved in 9 activities (watching television, studying, working for wages, socializing, student organizations, intercollegiate sports, physical activity, volunteer work, and nonacademic computer use).
Mailing and Response Rate
Questionnaires were mailed to 21 055 students in February 2001. Three mailings were sent within 3 weeks: a questionnaire, a reminder postcard, and a second questionnaire. Responses were anonymous. Cash prizes were offered to encourage response. The response rate was 52% (n = 10 904). Response rates ranged from 22% to 86% among the 119 colleges. We conducted several analyses to examine the potential bias introduced by nonresponse. A college’s response rate did not correlate with the college’s smoking rate (Spearman’s rho = .15, P = .10). There was no statistically significant difference in current smoking rates between students who responded before and after the second mailing (24.8% vs 26.0%; P = .19). To help control for any nonresponse bias, college response rate was included as a continuous covariate in all multivariate models.
Analysis
Statistical analyses were conducted using STATA.25 Weights were constructed using direct standardization on the basis of each college’s actual distribution of gender, race (white/nonwhite), and age (<18 years, 18–22 years, >22 years) to correct for differences in sample and known demographic profiles of the schools. A total of 2736 students reported current (past 30-day) cigarette smoking; this analysis focused on the 2401 current smokers who answered the question about social smoking. (The survey instructed that only smokers should answer the subset of questions that included this question. Of the students who met our definition of current smokers [smoking in the past 30 days] but did not answer this subset of questions, 98% were nondaily smokers. It is likely that these occasional smokers simply did not consider themselves "smokers.") We performed univariate analyses to identify student-level and college-level characteristics associated with social smoking and to examine the association between social smoking and 2 outcomes: 1) stage of change (dichotomized into precontemplation vs else) and 2) a 24-hour quit attempt in the past year. We then stratified outcomes by smoking intensity (occasional vs daily). Occasional smoking was defined as smoking on at least 1 but <30 of the past 30 days. Student-level covariates included those listed in "Questionnaire and Measures." Binge drinking was defined as drinking 
5 drinks in a row for men and 4 drinks in a row for women during the previous 2 weeks.20 Current marijuana use was use in the past 30 days. College-level factors were size of enrollment (<5000, 5000–10 000, or >10 000 students), geographic region (West, South, North Central, Northeast), campus location (urban, suburban, small town, or rural), public versus private status, religious affiliation, coeducational versus all-female, competitiveness for admission (based on percentage of applicants accepted), and survey response rate (as a continuous variable).
Student-level and college-level factors that were associated (P < .05) with outcomes in the univariate analysis were included in multiple logistic regression models. We tested a first-level interaction between smoking intensity (occasional vs daily) and social smoking on the basis of stratified analysis and our hypothesis that this factor would modify the effect of social smoking on quitting intentions and quitting behavior. All models adjusted for each school’s survey response rate and student demographic factors (gender, ethnicity, age, and marital status). We used the generalized estimating equations approach to fitting the logistic regression models to account appropriately for clustered outcomes that arose in our sampling scheme.26,27 Adjusted odds ratios with 95% confidence intervals are reported.
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RESULTS |
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Characteristics of the Sample
Among the 10 904 respondents, 64% were female, 74% were white, and 89% were 18 to 24 years of age. By comparison, among full-time undergraduates at the 119 participating schools, 53% were female and 70% were white. In a national sample of US undergraduates, 54% were female, 73% were white, and 89% were aged 18 to 24 years.22
Table 1 presents the demographic characteristics of the sample of current (past 30-day) smokers. Among the 2736 current smokers, 64% were female, 90% were 18 to 24 years of age, and 81% were non-Hispanic white. Respondents were evenly distributed among school years. Only one third of smokers reported smoking every day, and only 8% reported smoking a pack of cigarettes or more per day. Consistent with their low level of tobacco consumption, only 18% of respondents met our criterion for nicotine dependence (<30 minutes to first morning cigarette). Five percent of smokers reported that they had smoked their first cigarette within the past 2 years. Approximately half reported a 24-hour quit attempt in the previous year, but the majority of college smokers were not planning to quit smoking in the next 6 months.
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Characteristics of Social Smokers
Among the current smokers, 51% reported smoking mainly with other people, thereby meeting our definition of social smoking. Table 2 presents the association between student-level characteristics and social smoking. A social smoking pattern was inversely associated with the frequency and intensity of tobacco consumption. Only 19% of daily smokers had a social smoking pattern, compared with 71% of occasional smokers (P < .001). Among daily smokers, social smoking was more often reported by light smokers (<1/2 pack per day) than by heavier smokers. Social smoking was also inversely associated with nicotine dependence (<30 minutes to first morning cigarette). Respondents who began smoking within the past 2 years were more than twice as likely to have a social smoking pattern than respondents who had been smoking for a longer period of time. Social smoking was significantly more common among smokers who spent more time socializing with friends, were binge drinkers, and valued participation in the arts. A social smoking pattern was less common among black smokers than white smokers. No college-level characteristic was significantly associated with social smoking.
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Social Smoking, Stratified by Smoking Intensity
Having demonstrated a strong association between the pattern of social smoking and the frequency of occasional (nondaily) smoking, we sought to understand the characteristics of smokers who were discordant on these factors (Table 3). This includes the 19% of daily smokers who reported a social smoking pattern and the 29% of occasional smokers who did not report a social smoking pattern. We repeated the analysis of factors associated with social smoking, stratifying by smoking intensity (daily smoking vs occasional smoking). Daily smokers with a social smoking pattern differed from daily smokers without a social smoking pattern in being less likely to be nicotine dependent and more likely to spend time socializing with friends. Occasional smokers without a social smoking pattern were more likely than occasional smokers with a social smoking pattern to be male, black, and nicotine dependent. They were also more likely to have smoked their first cigarette >2 years ago.
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Social Smoking and Smoking Cessation
Table 4 presents the adjusted odds ratios describing the association between social smoking and subject characteristics and 1) intention to quit smoking (measured by stage of change) and 2) 24-hour quit attempt in the past year. The multiple logistic regression analyses included an interaction between social smoking and smoking intensity. Among occasional smokers, a social smoking pattern was associated with less readiness to change smoking behavior and a lower likelihood of having made a quit attempt in the past year. By contrast, among daily smokers, a social smoking pattern was not associated with readiness to change smoking behavior or a quit attempt in the past year. Quit attempts in the past year were also associated with less nicotine dependence and a longer smoking history.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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To our knowledge, this is the first study to describe the prevalence and characteristics of social smoking, a widely used but poorly understood term. Using data from a large, nationally representative random sample of US college students, we found that half of current smokers reported a pattern of social smoking, which we defined as smoking more often with others than when alone. We expected social smoking to be inversely related to an individual’s tobacco consumption, because individuals who smoke primarily in social situations have fewer opportunities to smoke than individuals whose smoking pattern is unrelated to their social activity. These hypotheses were confirmed. Social smokers were more likely to be occasional (eg, not daily) smokers or, if daily smokers, to be lighter smokers. We also expected social smoking to be associated with less nicotine dependence, and it was, even after adjusting for the frequency and intensity of tobacco use. Individuals who spent more time each day socializing with friends were more likely to be social smokers, presumably because they had more opportunity to smoke in a social situation. Social smoking was also strongly associated with drinking alcohol, which also occurs in a social context among college students. Our findings are consistent with previous studies demonstrating that college smoking is associated with alcohol use and a lifestyle that values socializing and parties.4,16,17
A social smoking pattern was twice as frequent among recent-onset smokers than among individuals who had smoked for at least 2 years, independent of other factors. However, recent-onset social smokers made up a very small proportion of social smokers in our population; the vast majority of social smokers in this population had been smoking for >2 years. A cross-sectional analysis such as this cannot determine whether social smoking is a stage in progression to established smoking or is a pattern that can be sustained for years. Future studies should assess the natural history of social smoking.
It is curious that social smoking was inversely associated with intention to quit smoking and with having made a recent quit attempt, because social smokers are predominantly light or occasional smokers with little evidence of nicotine dependence. These factors are usually associated with a greater interest in and success with quitting. A qualitative study suggested that social smokers may not perceive themselves as "smokers" who need to quit or are at risk for becoming nicotine dependent or regular smokers.18 College students generally believe that they will quit smoking some time after graduation.18 However, studies of occasional smoking in adolescent and adult populations suggest otherwise.6,7,28–30 Social smokers may also not believe that their smoking habits increase risk for smoking-related disease. To the contrary, there is convincing evidence that no level of cigarette smoking is safe.31,32 We caution that our assessment of a quit attempt used the standard definition of a 24-hour period of intentional nonsmoking. The validity of this measure among smokers who, like most of our respondents, do not smoke every day is not certain. It is possible that this analysis overestimated the number of quit attempts in the past year among nondaily smokers. Future studies are warranted to examine in greater detail how quitting motivations of social smokers differ from other young adult smokers. Similarly, we assessed nicotine dependence using time to morning cigarette, and the validity of this measure among nondaily smokers is uncertain.
Our data indicate that social smoking is less common among black smokers. Other patterns of tobacco use are known to differ between black and white smokers. Black smokers smoke fewer cigarettes and prefer mentholated and higher tar cigarettes.33 However, our data are at odds with tobacco industry data that suggest social smoking is more common among blacks.14 This warrants additional research to determine whether this is a function of differing study definitions or there is a difference in the social context of smoking among black individuals. Our analysis did identify a separate subgroup of occasional smokers who did not smoke in a social pattern. These smokers more often were male and black and had smoked for >2 years. This suggests a stable pattern of occasional tobacco use unrelated to social behavior.
This study has strengths and limitations. Strengths include the large, nationally representative sample of US colleges; selection of a random sample of students at each school; and the large number of respondents. One limitation is the survey response rate, which raises the possibility that respondents differed from students who did not respond. This possibility is reduced by the resemblance of respondent demographic characteristics to the overall enrollment of the 119 colleges and to all US 4-year college students. Furthermore, there was no correlation between a college’s response rate and its smoking rate. Although we can never eliminate the possibility of bias introduced by nonresponse, we attempted to minimize its impact through weighting procedures, which matched respondents’ demographics to the actual demographic distribution of schools from which samples were drawn, and by including college response rate as a covariate in all multivariate analyses. Furthermore, this analysis focused on the subset of respondents who reported past 30-day cigarette smoking, and it is unlikely that the survey response rate compromised the internal validity of relationships observed within the data set. Our analysis was also limited by the fact that 12% of current smokers did not answer the social smoking question. It is likely, therefore, that we underestimated the prevalence of social smoking.
Another limitation is that our definition of social smoking was based on a single question and may not be what all young adults mean when they refer to social smoking. The question does not distinguish between people who are smoking in a bar or party environment and people who are simply in an environment with other people. However, data from a qualitative study support our definition of social smoking.18 Future studies should investigate in greater detail what young adults mean by the term. Third, our assessment of nicotine dependence was based on a single item (time to first morning cigarette). Although this is a standard measure in epidemiologic studies, future research should explore the relationship between social smoking and nicotine dependence with a more comprehensive assessment of nicotine dependence. Fourth, our study examined social smoking only among college students. Future work should examine social smoking among all young adults, including those who do not attend college. Young adults who do not attend college are more likely to smoke daily and smoke more heavily and may be less likely to be social smokers.2
In summary, this study has defined a pattern of tobacco use that, unlike other measures, is based on the context of use. The importance of social influences in smoking initiation and progression are well recognized.6,11,34 Whereas social smoking may be a concept new to public health, the tobacco industry has long recognized the role of social influence and promoted smoking through strategic marketing campaigns that focus on young adult social activities and attempt to make tobacco use an integral part of the young adult social environment.9,11,14 This strategy would be expected to encourage a pattern of social smoking and may have contributed to the high prevalence of social smoking in the college population that we studied. Whether social smoking is as common among young adult smokers who are not in college should be determined in future studies. Public health efforts should be directed to understanding better the natural history of social smoking and its implications for adult tobacco use.
Our findings have implications for the development of interventions to discourage smoking among college students. If half of college smokers smoke primarily in social settings, then removing tobacco from these settings should limit students’ opportunity to smoke and prevent them from making the cognitive link between smoking and social activities. This should discourage social smoking and, potentially, smoking overall in this population. This change might be accomplished by prohibiting smoking broadly on college campuses, including all areas of public buildings, student residences, dining halls, bars, stadiums, and outdoor areas, as the American Cancer Society and American College Health Association recommend.35,36 These organizations also recommend that colleges ban tobacco industry sponsorship of social events on campus. There is evidence that smoke-free housing is associated with decreased cigarette smoking among students who were not regular smokers before entering college.37 At the state and community levels, laws that prohibit smoking in bars and restaurants and ban tobacco industry sponsorship of social events in these locations should also discourage smoking.10
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ACKNOWLEDGMENTS |
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This work was supported by grants from the Robert Wood Johnson Foundation, the Flight Attendant Medical Research Institute, the Massachusetts Department of Public Health, and a Midcareer Investigator Award in Patient-Oriented Research from the National Heart Lung and Blood Institute (K24-HL04440).
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FOOTNOTES |
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Accepted Apr 1, 2004.
Address correspondence to Susan Moran, MD, MSCE, Massachusetts General Hospital, Bulfinch Medical Group, Founders 3, Boston, MA 02114. E-mail: smoran1{at}partners.org
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PEDIATRICS (ISSN 1098-4275). ©2004 by the American Academy of Pediatrics
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H. R. White, B. C. Bray, C. B. Fleming, and R. F. Catalano Transitions into and out of light and intermittent smoking during emerging adulthood Nicotine Tob Res, February 20, 2009; (2009) ntn017v1. [Abstract] [Full Text] [PDF]
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J. P. Pierce, M. M. White, and K. Messer Changing age-specific patterns of cigarette consumption in the United States, 1992-2002: Association with smoke-free homes and state-level tobacco control activity Nicotine Tob Res, February 1, 2009; 11(2): 171 - 177. [Abstract] [Full Text] [PDF]
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M. Nichter, M. Nichter, A. Carkoglu, and the Tobacco Etiology Research Network Reconsidering stress and smoking: a qualitative study among college students Tob. Control, June 1, 2007; 16(3): 211 - 214. [Abstract] [Full Text] [PDF]
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