Key findings
Almost all respondents reported observing others smoke in at least one public space (mostly at train/bus stations), while 56% reported smoking visibility in at least one private space. Adolescents who had observed others smoke at restaurants, train or bus stations, and leisure/sports facilities had more positive beliefs about smoking than those who had not observed smoking in those spaces, even after controlling for best friends’ and parents’ smoking status and the visibility of smoking in the remaining spaces. Associations were of similar magnitude for both ever smokers and never smokers.
Strengths and limitations
This is the first study that investigated the relationship between the visibility of smoking in different spaces and positive beliefs about smoking. In comparison with other international surveys, such as the ESPAD and HBSC, the SILNE-R survey includes more detailed measurements on the visibility of smoking and thus can be considered an advancement that substantially contributes to the existing literature. Also, the large international sample of European adolescents provides estimates that are more widely generalizable than single-country studies.
Some limitations of the present study should be taken into account. First, the cross-sectional design of this study does not allow inferences about causality. It is conceivable that the visibility of smoking in public spaces influences the positive beliefs that adolescents have about smoking, but it is also possible that adolescents with positive beliefs about smoking are more likely to go to places where people smoke.
Secondly, the self-reported, retrospective nature of the survey may have resulted in recall bias as respondents may have inaccurately recalled whether they had seen people smoke in different locations within the last 6 months. If those adolescents who are more positive about smoking are more likely to recall this information correctly, for example because they are more aware of the smokers in their surroundings, this may account for part of the association.
Thirdly, respondents could not specify in the survey how often they had seen others smoke in a certain location within the last 6 months. It is possible that an increased frequency of exposure to others smokers leads to more positive beliefs about smoking.
Interpretation of the findings
The visibility of smoking in private spaces was relatively low among never smokers, possibly because they are less likely to have friends and parents who smoke (Alves et al.
2016). However, the visibility of smoking was high in public spaces among both never smokers and ever smokers. A possible explanation for the high visibility of smoking in public spaces is that European countries lack smoking bans in most outdoor spaces (Martínez et al.
2014). To our knowledge, while European countries have complete smoking bans inside leisure/sports venues and railway stations, they rarely prohibit smoking outdoors (e.g. at bus stops, open-air train platforms, surroundings of football pitches and sports facilities, playgrounds, and in parks). In addition, train stations and bus stops are typically spaces where people need to wait, which may stimulate smokers to smoke more in those spaces (Shiffman et al.
2002). Our findings underline the importance of extending smoking bans to outdoor spaces, in line with FCTC Article 8 (World Health Organization
2007).
Smoking by others was observed by a large majority (80.7%) of adolescents who had visited a bar or club in the last 6 months and 57.4% of adolescents who had visited a restaurant within the last 6 months. These high percentages are contrary to findings from the 2017 Eurobarometer report, according to which only 18.0% of adults who had visited a bar and 5.7% of adults who had visited a restaurant within the last 6 months, in the same seven countries that were included in our study, reported seeing people smoke inside those establishments (TNS Opinion & Social
2017). There are two possible explanations for the higher visibility reported by our respondents. First, it is possible that adolescents go to different bars/clubs (e.g. teen nightclubs) and restaurants (e.g. fast food joints) compared to adults and that the visibility of smoking is higher in those establishments. Second, our survey did not explicitly distinguish between smoking inside or just outside bars/clubs and restaurants. Smokers who are not allowed to smoke inside a bar, club, or restaurant often relocate their smoking outdoors (Rooke et al.
2013; Kennedy et al.
2012), so it is possible that the high percentages found in our study are a reflection of the visibility of smoking around bars and restaurants rather than inside. This explanation is supported by the finding that 71.5% of Irish adolescents reported seeing others smoke at a bar or club (see Online Resource 1), while Ireland has comprehensive indoor smoking legislation (Joossens and Raw
2017).
We found that the association between positive beliefs and observing others smoke in private spaces was mainly attributable to the smoking status of respondents, friends, and parents, confirming our hypothesis that role models such as peers and parents influence the smoking beliefs of adolescents. Interestingly, we found associations for public spaces after adjusting for friends and parents who smoke, and therefore the role of others in public spaces may not be negligible. While friends and parents may be important role models in the home environment, other role models can be present in public spaces, such as leisure/sports facilities. These role models may include older peers and sports teachers who can influence adolescents’ smoking beliefs and behaviour (Escario and Wilkinson
2018; Poulsen et al.
2002). We also found an association for observing others smoke at train or bus stations. It is possible that even observing strangers smoke in everyday-life contexts where smoking is not expected or socially accepted shapes youth perceptions of smoking (Alesci et al.
2003).
The visibility of smoking in bars was not associated with positive beliefs about smoking. Smoking in bars and clubs is seen as normal, socially acceptable behaviour (Nichter et al.
2010; Rooke et al.
2013), meaning that the visibility of smoking may not further influence the beliefs of youth who go out. However, we found that never going to bars was associated with a lower positive beliefs score. As smoking is strongly associated with going out, there may be a selection effect in which adolescents who are less positive about smoking are less likely to visit bars. However, there could also be a causal influence in that youth who do not go out have never been exposed to a smoking culture that shapes positive beliefs about smoking. Other studies suggested smoking bans in bars, and their direct surroundings can play a role in changing the smoking culture (Hamilton et al.
2007; Ritchie et al.
2010), thus preventing adolescents from developing positive beliefs about smoking in the long run.
The relationships we found between the visibility of smoking and positive beliefs among never smokers were as expected, but we also found substantial associations among ever smokers. This suggests that ever smokers may also be susceptible to the visibility of smoking in public spaces. While more positive beliefs among never smokers can lead to smoking initiation (Song et al.
2009), more positive beliefs among smokers can make it more difficult for them to quit smoking (Kahler et al.
2007), indicating the importance of addressing these beliefs among both never and ever smokers.
Finally, it is important to note that the observed effect sizes were relatively small, suggesting that the visibility of smoking possibly does influence adolescents’ positive beliefs about smoking, but that other factors such as the smoking statuses of the individual, friends and parents, tobacco marketing, TAPS, and tobacco policies may have a greater effect on positive beliefs about smoking. However, reducing the visibility of smoking does affect more than youth beliefs of smoking. A reduced visibility of smoking in public spaces may contribute to a perceived social unacceptability of smoking (Alesci et al.
2003; Albers et al.
2004), which may lead to an increase in voluntary home smoking restrictions (Mons et al.
2013). Ultimately, the denormalization of smoking will have an important societal role in long-term prevention of smoking initiation (Zaleski and Aloise-Young
2013) and smoking cessation (Myers and MacPherson
2008).
Conclusion
Most participants reported observing others smoke in public spaces, especially at train/bus stations, bars/clubs, and restaurants. While positive smoking beliefs in the home environment were explained by the smoking status of friends and parents, observing others smoke in different public spaces was found to be associated with more positive beliefs about smoking. Given the high adolescent-reported visibility of smoking in public spaces and associated positive beliefs about smoking, the implementation of more comprehensive smoking bans in public spaces where minors are present may be needed to prevent adolescents from developing positive beliefs about smoking. This will likely also contribute to the denormalization and prevention of smoking among youth in European countries.