Socio-environmental and psychosocial predictors of smoking susceptibility among adolescents with contrasting socio-cultural characteristics: a comparative analysis

Smoking is an important modifiable risk factor for non-communicable diseases (NCD) in both high-income countries as well as low- and middle-income countries (LMICs), not least because of its role as a precursor and accessory to other risk behaviours among younger populations [1‐3]. In Northern Ireland, a high-income constituent country of the United Kingdom, it is estimated that current cigarette consumption amongst adolescents aged 11-16 years is 4% [4]. By comparison, in Colombia, an upper-middle income country, data suggests 8.1% of adolescents aged 12-18 years smoke, and in the capital city, Bogotá, estimates place this figure at 13.1% [5].

Smoking susceptibility (the absence of a firm commitment not to smoke) is inherently linked to experimentation which predisposes adolescents to subsequent cigarette smoking [6, 7]. The importance of susceptibility to smoking within the developmental context of adolescence is significant given the role of behavioural intentions in predicting future behaviour [8]. Studies have harnessed smoking susceptibility both as a predictor of future smoking [9, 10] as well as an outcome of various social and behavioural risk factors [11, 12]. As such, there is value in understanding the factors that predict smoking susceptibility due to the implications for the subsequent formation of smoking habits that can extend into adulthood.

Various studies point to the role of social norms (both descriptive and injunctive) in adolescent smoking. Descriptive norms are the perception of what behaviours are performed by others [13]. Injunctive norms correspond to the perceived pressures to conform to a behaviour to avoid social sanctions [14]. The perceived prevalence and perceived acceptability of smoking among peers and family members have been shown to predict adolescent smoking [15‐18].

Studies have also investigated the proximal social factors in family and peer contexts [19, 20], as well as distal (upstream) influences emerging from cultural spheres of influence such as exposure to smoking-related media content [21]. For example, it has been shown that adolescents who report higher levels of exposure to smoking in movies are at a greater risk of commencing smoking [22, 23]. However, the socio-environmental factors conducive to smoking are not universal across all contexts, therefore, it cannot be assumed that smoking intentions are regulated entirely by external factors.

Self-efficacy, the belief an individual holds about their ability to exercise control over their own actions and associated outcomes [24], is well established as a determinant of adolescent smoking [25‐27]. For example, refusal self-efficacy has been shown to predict smoking among adolescent boys in a study of Chinese youth [28]. Further, another study [29] found that self-efficacy mediated the association between smoking behaviour and social influence.

Cognitive constructs, such as perceived behavioural control (PBC) and attitude towards smoking, have also been shown to be associated with adolescent’s intentions to smoke [30]. Furthermore, adolescents knowledge of the potential side effects and perceived benefits of smoking can alter their intentions. For example, adolescent smokers report that they perceive themselves as being less likely to become addicted [31], less likely to suffer negative health-related side effects [32], and perceive greater social benefits of smoking [33].

Personality factors were examined in an earlier study [34] that used the five personality dimensions (or “Big Five”) [35]. It was reported that students who scored higher on the extraversion dimension and lower on the emotional stability dimension were consistently more likely to smoke. This finding was reiterated in another study [36] that found adolescents who exhibited more extraverted behavioural traits were at higher risk of smoking, whereas greater emotional stability was protective.

Research indicates that other psychosocial factors such as emotional well-being [37] and life-satisfaction [38] are also protective factors against adolescent smoking. Conversely, depressive symptoms [39], low self-esteem [40], emotional or behavioural problems [41], low life satisfaction [42], and high levels of anxiety [43] are reported to be predictive of adolescent smoking initiation.

This study adds a cross-cultural perspective to the wealth of existing evidence that already highlights the importance of both socio-environmental and individual-level factors that contribute to smoking among adolescents. Importantly, by providing a direct comparison between settings characterised by distinct socio-cultural and normative characteristics, cross-cultural research offers insight into potential ways of optimising intervention policies and preventative strategies to accommodate the variability of risk factors for smoking across settings. Using data obtained from adolescents in Northern Ireland and Bogotá, Colombia, the objective of this study was to compare and contrast socio-environmental and individual-level factors associated with smoking susceptibility in a high-income setting and upper-middle income setting.

Table 1 shows the socio-demographic characteristics of the student sample. Both samples demonstrate similar socioeconomic characteristics, with the majority of students being categorised in low – middle socioeconomic ranking scales. A smaller proportion of the students in the Bogotá sample live with both parents (55%) when compared to the Northern Ireland sample (80%).

The smoking characteristics of the sample are shown in Table 2. A smaller proportion of students in the Bogotá cohort reported having never smoked (80%) compared to Northern Ireland (85%). A larger proportion of students in Bogotá (43%) were classified as susceptible compared to the Northern Ireland cohort (31%).

The unadjusted odds ratios (OR), odds ratios adjusted for sociodemographic characteristics, and multivariate-adjusted odds ratios are reported in Tables 2, 3, and 4 respectively in the Appendix. Corresponding 95% confidence intervals (CI) and p-values are also reported.

Previous research has shown that a disproportionate number of those aged 15 years and over who smoke (approximately 80%) live in LMICs [64]. This is concerning given the role of initiation during early adolescence as a risk factor for subsequent smoking [65]. This study investigated differences between the socio-environmental and individual-level risk factors for smoking susceptibility in a high-income country (Northern Ireland) and upper-middle income country (Bogotá, Colombia). Findings from logistic regression analyses illustrated differences between the two settings regarding descriptive norms, smoking-related cognitions, and psychosocial traits. In Northern Ireland, adolescents who reported that fewer family members smoked were less likely to be susceptible to smoking. In Bogotá, reporting that fewer friends smoked reduced the odds of being susceptible. Reduced odds of being susceptible to smoking were significantly associated with negative attitudes towards smoking in Northern Ireland, while higher levels of self-efficacy and PBC to quit were associated with reduced odds in Bogotá. When psychosocial traits were examined, higher levels of openness and self-reported wellbeing significantly reduced the odds of being susceptible in Northern Ireland. Conversely, higher levels of extraversion increased the odds of being susceptible in Northern Ireland. In Bogotá, students who did not skip school were less likely to be classified as susceptible to future smoking.

Descriptive and injunctive norms are reported in the literature as risk factors for smoking among adolescents [66‐68]. We did find evidence of a significant association between injunctive norms and smoking susceptibility in both countries after adjusting for sociodemographic factors, however, this relationship was not significant in our final model. In the composite sample, injunctive norms favourable to smoking from important people, father, sister(s), and friends were significant in the final model.

We did find support for the role of descriptive norms in predicting smoking susceptibility in the final model. Students in Bogotá who reported less smoking among friends were less likely to be susceptible. In addition, fewer descriptive smoking norms among family reduced the odds of being susceptible in Northern Ireland. Interestingly, reporting less smoking by a mother increased the odds of being susceptible in Northern Ireland in the final model.

In agreement with other studies pointing to a link between pro-smoking messages in media content and an elevated risk of susceptibility to smoking [69, 70], we found a significant correlation between exposure to smoking-related media content and smoking susceptibility in both countries after adjusting for sociodemographic factors. However, this association was no longer significant in the final model. This is in contrast to another study of LMIC settings which found that adolescents who were exposed to smoking in electronic media were more likely to be smokers [71]. Similar to the results of other studies [72, 73], we found exposure to cigarette advertising in shops was a significant predictor of susceptibility in both countries after adjusting for sociodemographic factors. In the final model, this finding was limited to the composite sample.

Consistent with previous research [74] that showed refusal self-efficacy was protective against smoking initiation, we found a statistically significant association between refusal self-efficacy and smoking susceptibility. Additionally, our results concur with the findings of an earlier study [31] that found students who perceived greater risks associated with smoking were at less risk for future initiation. However, when the data were disaggregated by country in the final model, the association was no longer significant. In line with previous findings [33], we found a statistically significant link between perceived benefits of smoking and susceptibility after adjusting for sociodemographic factors in Northern Ireland. Further, our results confirmed a significant correlation between knowledge of the harmful effects of smoking and susceptibility in Bogotá. However, in the final model, knowledge was not a significant predictor of susceptibility in either country. This echoes the findings from an earlier study [75], but contrasts with others [16] who found that lack of knowledge about the harms of smoking predicted ever-smoking.

Of the Big Five Personality factors, only two (openness and extraversion) significantly predicted the odds of being susceptible in Northern Ireland in the final model. In Northern Ireland, our results show that students who were more receptive to new ideas or experiences and expressed a greater tendency to be curious were less likely to be susceptible. This finding coincides with an earlier study [76] that reported lower levels of openness were associated with intentions to smoke. The current analysis also showed that more extraverted students were at greater risk of being susceptible to smoking, adding to the results of two earlier studies [34, 36].

Self-reported wellbeing was a protective factor against smoking susceptibility in both countries after adjusting for sociodemographic factors, and in Northern Ireland in the final model. While studies have shown that a direct inverse relationship exists between life-satisfaction and smoking behaviour [38, 77], our final model did not demonstrate this in Bogotá. We did, however, find a significant positive association between truancy and susceptibility in Bogotá, reinforcing the findings from previous studies [78, 79].

The results reaffirm that refusal self-efficacy and adolescents’ attitudes towards smoking are important targets for prevention interventions in both LMICs and high-income countries. Interventions directed at younger populations should focus on mitigating pro-smoking social influences such as exposure to tobacco advertising by providing appropriate education about the negative side-effects of smoking and equipping adolescents with the necessary skills to refuse cigarettes. Moreover, the results highlight the differences in risk factors for smoking across the two countries, further emphasising the need for smoking prevention policies to be sensitive to the normative and cultural context within which they are implemented.

In sum, the results of the present study suggest there are differences in socio-environmental and psychosocial correlates of smoking susceptibility in the high-income setting of Northern Ireland and upper-middle income setting of Bogotá. For example, reporting fewer descriptive smoking norms among friends was protective against smoking susceptibility in Bogotá, but not Northern Ireland. Students who reported that their school provided information about smoking were less at risk in Northern Ireland, but not in Bogotá. Greater self-efficacy was significantly associated with a lower risk of smoking in Bogotá, highlighting the importance of self-efficacy as a mitigating factor against socio-environmental influences, such as being offered a cigarette by a friend. Exploration of how group identities that prescribe behavioural norms in each country may provide potential insights into the mechanisms underlying the formation of these behaviours within the intragroup context and the impact this has on an individual’s self-efficacy [86].

We affirm that the cultural, normative and social factors unique to each setting provided a good basis for comparison of risk factors across the socioecological spectrum.