BACKGROUND: Light smoking, consuming a few cigarettes daily, and intermittent, or nondaily, smoking patterns are increasingly common but carry health risks comparable to heavier smoking patterns. Nearly all smokers begin smoking as adolescents, who are at risk for developing these smoking patterns. Previous research suggests that smokers underestimate the risks associated with smoking. The extent to which adolescents perceive light and intermittent smoking as harmful has not been previously assessed.
METHODS: Data from 24 658 US adolescents sampled by the 2012 National Youth Tobacco Survey, a national, school-based, cross-sectional survey, were examined. Cross-tabulations and multivariate ordered probit regression models were constructed to describe correlates of US adolescents’ perception of light and intermittent smoking.
RESULTS: Although most adolescents (88.0%; 95% confidence interval [CI], 87.2% to 88.8%) reported beliefs that a heavier smoking pattern is very harmful, only 64.3% (95% CI; 63.2% to 65.3%) and 33.3% (95% CI; 32.0% to 34.6%) reported that light and intermittent smoking, respectively, are very harmful. Conversely, nearly one-quarter of US adolescents believed intermittent smoking causes little or no harm. Males, younger adolescents, Hispanics, and non-Hispanic blacks were more likely than their peers to view light and intermittent smoking patterns as less harmful. Those who were already light or intermittent smokers, those who used other tobacco products, and those who had a family member who used tobacco were also less likely to view their smoking patterns as harmful.
CONCLUSIONS: Misconceptions about the safety of light and intermittent smoking are widespread among US adolescents. Significant public health attention is needed to redress these misperceptions.
What’s Known on This Subject:
Light and intermittent smoking are harmful, but increasingly common, smoking patterns. It is unknown how adolescents perceive these smoking patterns, and whether these views differ by sociodemographic characteristics, and exposure to and use of tobacco.
What This Study Adds:
US adolescents perceive light and intermittent smoking as significantly less dangerous than heavier smoking. One in 4 adolescents believes intermittent smoking causes little to no harm. Perceptions of relative safety were common among smokers.
Mounting concern exists regarding light and intermittent cigarette smoking,1 tobacco use patterns that have become increasingly common.2–4 Nearly one-fifth of adult smokers5,6 and four-fifths of child smokers3 engage in intermittent or nondaily smoking. Previous research assessing children’s smoking trajectories indicates substantial variability in the onset and progression of their smoking.7 Yet data on light and intermittent smoking in children, particularly as a potential stable pattern of use, remain limited. Of all smoking patterns in children, light and intermittent smoking appear the least stable.8 Yet those who smoke lightly or intermittently are more likely than not to continue to do so over the next half year.8 Until recently, in both children and adults light and intermittent smoking were not viewed as potentially stable patterns of tobacco use8,9 and, as a consequence, remain inadequately studied.1
Existing data on light and intermittent smoking suggest a potentially alarming picture. Light and intermittent smokers may perceive their tobacco use to be less addictive,9–11 although nicotine dependence symptoms appear to form rapidly in intermittent smokers12 and the relationship between consumption and addiction does not follow a clear-cut threshold effect.13 Some light and intermittent smokers do not even consider their use to qualify them as “smokers,” demonstrating an unduly optimistic bias in their assessment of smoking’s associated risks.9–11,14 Also possible are potentially significant misconceptions regarding the safety of light and intermittent smoking. No level of tobacco exposure is safe.15 Health risks from light and intermittent smoking are comparable to heavier smoking patterns,16 the relationship between smoking intensity and cardiovascular disease is notably nonlinear,17,18 and reducing smoking intensity without abstinence has not been found to improve survival.19,20
Understanding views that may lead to these smoking patterns is critical. The perceived harm of different tobacco forms correlates with their use.21 Perception of tobacco influences youths’ behaviors over time. Exposure to pro- and anti-tobacco media22 and perceptions of secondhand smoke,23 for example, alter adolescents’ affinities toward tobacco use. Because 9 out of 10 smokers begin smoking as adolescents,24 understanding adolescents’ perception of light and intermittent smoking may be particularly helpful in assessing which individuals may benefit from targeted public health and clinical interventions. Because, among adults, light and intermittent smokers appear most willing of all smokers to quit,25 preventing and identifying those at high risk for developing and continuing these smoking patterns is of obvious importance.
The US Preventive Services Task Force recommends clinicians provide interventions to prevent initiation of tobacco use among school-aged children and adolescents.26 Nearly a half-billion dollars is spent annually on anti-tobacco advertising.27 Yet whether adolescents nationwide perceive light and intermittent smoking to be less harmful than heavier forms of smoking has not been assessed. To address this, we use a national, school-based survey of US adolescents to describe their perception of light and intermittent smoking, comparing those views with perceptions of heavier smoking patterns. We attempt to characterize this at-risk population by examining correlates of adolescents’ perceptions of light and intermittent smoking, including adolescents’ demographics and use of tobacco products.
Data used are from the 2012 National Youth Tobacco Survey (NYTS), a survey conducted by the Centers for Disease Control and Prevention and designed to provide nationally representative estimates of US middle and high school students’ tobacco-related knowledge, attitudes, and behaviors. Its methodology, approved by the Centers for Disease Control and Prevention’s institutional review board, has been described previously.28 In brief, the NYTS uses a stratified cluster sample designed to oversample minority students; students from sixth to twelfth grade enrolled in a public, secular, or nonsecular private school were eligible to be sampled. Respondents completed a pencil-and-paper, self-administered questionnaire. Participation at the school and student level was voluntary. In 2012, the school participation rate was 80.3% and the student participation rate 91.7%.
Three survey questions assessing individuals’ harm perception of light, intermittent, and heavy smoking patterns were used as ordinal dependent variables. Regarding light smoking, respondents were asked, “How much do you think people harm themselves when they smoke a few cigarettes every day?” For intermittent smoking, respondents were queried, “How much do you think people harm themselves when they smoke cigarettes some days but not every day?” and, about heavy smoking, “How much do you think people harm themselves when they smoke 10 or more cigarettes every day?” To each, respondents could select responses from a 4-point Likert scale: “no harm,” “little harm,” “some harm,” or “a lot of harm.”
Independent variables included students’ demographic information and use of and exposure to tobacco products, because norms and misperceptions may differ along these lines.29 Demographic variables included students’ gender, age, and ethnicity. Individuals’ self-reported recent cigarette use was assessed from the question, “During the past 30 days, on how many days did you smoke cigarettes?” We classified individuals as nonsmokers (ie, responding “0 days”); daily smokers (ie, responding “30 days”); or, for the remainder, intermittent smokers. We subsequently categorized daily smokers as either light smokers (ie, ≤5 cigarettes per day) or heavier smokers (ie, >5 cigarettes per day), based on their responses to the question, “During the past 30 days, on the days you smoked, how many cigarettes did you smoke per day?” This definition, used previously,30 corresponds closely to the harm perception questions, allowing us to ascertain potential misperceptions among those engaged in the studied behaviors.
A variable indicating use of any alternative tobacco products within the past 30 days was included, characterized by any use of: cigars, cigarillos, or little cigars; chewing tobacco, snuff, or dip; pipe tobacco; waterpipe tobacco or hookah; snus (ie, moist snuff); or dissolvable tobacco products. A separate variable indicating e-cigarette use within the past 30 days was also included. Previous research indicates that e-cigarette users perceive e-cigarettes as more harmful than conventional cigarettes,31 although e-cigarette users’ perception of smoking itself has not been previously examined. Whether other individuals in the students’ home used tobacco products (ie, cigarettes; smokeless tobacco, such as chewing tobacco, snuff, dip, or snus; cigars, cigarillos, or little cigars; or any other form of tobacco) was included as well.
Because the NYTS used a stratified, multistage sample design, all analyses were weighted to adjust for nonresponse, the probability of selection, and to match the sample’s sociodemographic characteristics with those of US middle and high school students.28 Standard errors, calculated by Taylor series linearization, account for clustering of responses.32 Using Stata 11.2 (Stata Corp, College Station, TX), cross-tabulations were assessed and ordered probit regression models were constructed. Average marginal effects, which estimate the average change of altering each covariate among the study sample, were reported.
Data from 24 658 individuals were assessed. Although 88.0% of adolescents reported they believed heavy smoking caused “a lot of harm,” only 64.3% and 33.3% believed that light and intermittent smoking, respectively, were similarly harmful (Table 1). Conversely, roughly 5% of adolescents viewed heavy smoking as causing little or no harm. In contrast, ∼10% of adolescents viewed light smoking and one-quarter of adolescents viewed intermittent smoking as similarly unharmful (data not shown).
Perception of harm differed by demographic group and individuals’ tobacco use. Whereas, unadjusted, perceptions of harm did not vary by age, females were consistently more likely than males to perceive each tobacco use pattern assessed as harmful. While 69.2% and 36.2% of females perceived that light and intermittent smoking, respectively, caused a lot of harm, only 59.5% and 30.4% of males did so. Asians also were consistently more likely than other ethnic groups to perceive tobacco as harmful.
Perception of smoking patterns varied dramatically by individuals’ tobacco use habits. Though 67.3% of nonsmokers considered light smoking to cause a lot of harm, just 38.6% of intermittent smokers, 35.2% of light smokers, and 28.5% of heavier smokers did so. Intermittent smoking was perceived as even less harmful. Only 35.2% of nonsmokers believed intermittent smoking caused a lot of harm and, strikingly, only 14.0% of intermittent smokers believed their own tobacco use to be very harmful. These views differed markedly from perceptions of heavy smoking. Regarding heavy smoking, 90.3% of nonsmokers and even 45.0% of heavier smokers thought such behavior was very harmful. Alternative tobacco use and having a family member who used tobacco were also associated with perceiving various cigarette smoking patterns as less harmful.
Results from an ordered probit regression model examining correlates of increased perception of harm from intermittent smoking are shown in Table 2. Females and those of older ages were more likely to perceive intermittent smoking as harmful. Compared with whites, blacks and Hispanics perceived intermittent smoking as less harmful. Differences were noted between smokers and nonsmokers; heavier smokers were, for example, 21.8 percentage points less likely than nonsmokers to view intermittent smoking as very harmful. Use of alternative tobacco products and exposure to a family member’s use of tobacco were associated with perceiving intermittent smoking as harmful, although e-cigarette use was not.
Table 3 displays a similar analysis for light smoking. Females were again more likely to perceive light smoking as harmful. Blacks and Hispanics were less likely than whites to perceive light smoking as harmful, although the magnitude of ethnicity’s influence was, as with intermittent smoking, relatively small; blacks and Hispanics were, respectively, 3.4 and 3.9 percentage points less likely than whites to describe light smoking as very harmful. As with intermittent smoking, perception of increased harm increased with age, with those age 16 years and older more likely to perceive light smoking as dangerous. Perception of decreased harm was more common with greater exposure to and use of tobacco products. Compared with nonsmokers, heavier smokers were, all else equal, 36.7 percentage points less likely to describe light smoking as causing a lot of harm, a greater difference than with intermittent smoking. Intermittent and light smokers were, respectively, 21.2 and 24.5 percentage points less likely to do so. As with intermittent smoking, alternative tobacco use and having a family member who used tobacco were associated with decreased harm perception; e-cigarette use was not.
For comparison, beliefs about heavy smoking are shown in Table 4. Results from a similar model indicate similar results along gender and ethnic lines. Unlike analyses of light and intermittent smoking, though, harm perception of heavy smoking did not vary by age. Differences were again noted between nonsmokers and smokers, with the average heavier smoker 33.8 percentage points less likely than their nonsmoking peers to perceive heavy smoking as causing a lot of harm; intermittent and light smokers were, respectively, 10.4 and 13.5 percentage points more likely to do so. Users of alternative tobacco and those with family member who used tobacco were less likely to view heavy smoking as harmful, although the magnitude of the differences noted was smaller than for light and intermittent smoking.
In this study, we report results from the first study of which we are aware to examine views of light and intermittent smoking among US adolescents. Light and intermittent smoking patterns are harmful16 and increasingly common.2–4 Because harm perception influences the development of smoking patterns,21 understanding who espouses views that light and intermittent smoking are less harmful may prove helpful for public health planning. Although the vast majority of US adolescents agree a heavy smoking pattern is very harmful, far fewer believe light and intermittent smoking are similarly harmful. Although some may be reassured that many adolescents do recognize these smoking patterns are dangerous, we find the discrepancy between these views of significant public health concern. Two out of 3 adolescents believe light smoking is very harmful and only 1 of 3 views intermittent smoking as very harmful. Conversely, roughly one-quarter of US adolescents consider intermittent smoking to cause little or no harm. Together, our findings indicate that, among adolescents nationwide, misperceptions regarding the safety of light and intermittent smoking are widespread, a finding potentially at root of these practices’ increasing prevalence.
Important, however unsurprising, is that those who engaged in light and intermittent smoking were much more likely to espouse views that their own smoking patterns were not particularly harmful. Approximately 1 in 3 light smokers perceived their smoking as causing a lot of harm; roughly 1 in 7 intermittent smokers perceived their smoking pattern as similarly dangerous. That marked differences were noted in adolescents’ views of the comparative dangers of heavy, light, and intermittent smoking patterns is broadly consistent with previous research examining US adolescents’ perceptions of light cigarettes. Such research found that adolescents underestimated the associated health risks and overestimated the ease of cessation associated with light cigarettes,33 findings themselves consistent with research illustrating that smokers underestimate smoking’s risks.14 Related findings have also been reported in college-aged youths, which showed widespread misperceptions of harm caused by both tobacco products and nicotine replacement therapy.34
Our findings suggest that males, younger adolescents, and ethnic minorities appear particularly susceptible to beliefs that light and intermittent smoking are safer. Consistent with previous research,34 females perceived each smoking pattern as more harmful compared with males. Such differing views may in part provide insight as to why smoking susceptibility differs by gender,35 and that the use of potentially reduced exposure products also differs by gender.36 If adolescent boys are somehow uniquely susceptible to altered views, a factor unaccounted for in our analysis may be at root; evidence would suggest a contextual, not biologic, explanation underlies this difference.37 One potential factor, exposure to tobacco advertising, suggests no difference between the genders, however.37
Ethnic differences were also noted, with blacks and Hispanics perceiving all smoking patterns as comparatively less harmful than did their white peers. Previous research suggests that blacks and Hispanics, as well as Asians, are more likely to engage in light and intermittent smoking than whites.38 A recent article examining trends among Latino smokers reported that, over a 15-year period, heavy daily smoking decreased, whereas light and intermittent smoking increased.39 Although one cannot assess here how changing views over time may have influenced these patterns, it may not be unreasonable to speculate that the rise in light and intermittent smoking over time,2 particularly in certain populations,39 may have been brought about by differential views as to those smoking patterns’ comparative safety.
Of note, older adolescents were more likely to perceive light and intermittent smoking as very harmful compared with their younger peers, but they were no more likely to perceive heavy smoking as more harmful. Such a discrepancy not only indicates that perceptions of light and intermittent smoking change with age, but suggests that a knowledge gap exists in which younger adolescents view light and intermittent smoking as distinct, safer entities than do their older peers. Consequently, younger adolescents may be at increased risk for establishing these smoking patterns or progressing to more intense tobacco use. Changing the implicit risk-benefit calculation made by would-be light and intermittent smokers may prove critical; one study of young adult social smokers found that such individuals believed that simply extending smoke-free areas would help curb their habit.40 Future research into how and why these alternative smoking patterns are established, and the role of harm perception in that process, may be critically important to reduce the rise in light and intermittent smoking.
Use of alterative tobacco products as well as having a family member who used tobacco were also associated with perceiving light or intermittent tobacco use patterns as less harmful. Such a finding is consistent with previously described links between alternative tobacco products and cigarette smoking41 and between the use of alternative tobacco products and perception of those products’ harm.31 The associations described here suggest the possibility that exposure to a family member’s tobacco use or the use of alternative tobacco products may, in turn, lead to stable patterns of cigarette use, as others have hypothesized regarding alternative tobacco.42
Some reservation is needed in interpreting our results. Data are cross-sectional; although we are able to depict associations between perceptions of various tobacco smoking patterns’ harm and use of tobacco, we cannot provide an assessment regarding to what extent these views motivate tobacco use or whether these views develop in those already using tobacco. In addition, data rely on adolescents’ self-report, which could be subject to unknown biases. Various socioeconomic influences, including adolescents’ family structure, family income, parental education, and geography, were unavailable in the dataset analyzed, and might have influenced the observed associations. In addition, the survey is school-based and generalizations to US adolescents not attending school may be inappropriate.
Our analysis also has multiple strengths that merit attention. It uses a large, nationally representative sample. It uses statistical techniques, including ordinal probit regression, most appropriate to the data’s natural form, and uses average marginal effects calculated from those models to provide readers with estimates of the relative impact of those estimated associations’ magnitudes. Importantly, we detail the widespread misperception that light and intermittent smoking are safer than heavier smoking patterns, beliefs that may be contributing to their rise as public health threats. In noting the marked discrepancy between adolescent views of the dangers of heavier smoking patterns, compared with light and intermittent smoking, we underscore a potentially important shortcoming of programs designed to educate and deter teenagers from smoking. Given adolescents’ widespread understanding that heavier smoking patterns carry substantial risk, minor changes to programs designed to alter normative beliefs29 incorporating the insights presented here may prove fruitful. We advocate that clinicians engaged in tobacco use anticipatory guidance26 emphasize the risk from all tobacco use to correct potential misconceptions.
We examined US adolescents’ perceptions of light and intermittent smoking and correlates of those views with students’ sociodemographic and tobacco exposure profiles. We report that US adolescents differ markedly in their perceptions of heavy smoking compared with light and intermittent smoking. Light smoking is perceived as less dangerous; nearly 1 in 11 adolescents believes it will cause little or no harm. Intermittent smoking is viewed as even less suspect, with nearly one-quarter of all adolescents reporting nondaily smoking will cause little or no harm. These findings should prompt further investigation and public health attention to redress widespread misconceptions that light and intermittent smoking are a safer alternative.
- Accepted November 13, 2014.
- Address correspondence to Stephen M. Amrock, SM, New York University School of Medicine, 550 First Ave, NBV-8 South 4-11, New York, NY 10016. E-mail:
Mr Amrock conceptualized and designed the study, carried out the statistical analyses, drafted the initial manuscript, and revised the manuscript; Dr Weitzman helped interpret the results and critically reviewed and revised the manuscript; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported partially by grants from the National Institutes of Health, NIH/NIEHS 5 P30 ES000260-49 and NIH/NCI 3 P30 CA016087-33S1. Funded by the National Institutes of Health (NIH).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2015 by the American Academy of Pediatrics