Articles Gender Differences in Psychosocial Determinants of Adolescent Smoking Serena Clayton
ABSTRACT: Because of the social meaning smoking has acquired and because of different trends in male and female initiation rates, it is reasonable to suspect that dirfrent psychosocial factors predict smoking in teen-age boys and girls. A literature review revealed external pressures such as peer and parental smoking are important f o r both boys and girls though their influence may be moderated diflerentially by age and type of smoking behavior assessed. Some data support the hypothesis that female smoking is associated with se!f-confidence, social experience, and rebellion, whereas male smoking is associated with social insecurity. Overall, group diJferences such as gender and socioeconomic status are welldocumented in terms of smoking prevalence but underexplored in the area of psychosocial predictors. I n this review, gender dvferences have been documented with sufficient frequency to warrant further attention to develop gender specific components of smoking prevention prog-rams. (J Sch Health. 1991:610):115-120)
S
chool-based smoking prevention programs have undergone substantial evolution in the past two decades. The disappointing results of early educational programs that were information-based and stressed long-term health consequences of smoking led to development of psychosocial and life-skills curricula. Of all approaches investigated to date, the most successful appear to be those that point out negative short-term consequences of smoking such as bad breath or impaired athletic ability, raise young people’s awareness of the pressures to smoke, and train them in skills to resist these influences. Research on psychosocial predictors of smoking has contributed to program development by identifying influences such as peer smoking and internal factors such as self-esteem. Nevertheless, the fact that smoking prevalence is declining less rapidly among adolescents than among adults suggests school-based smoking prevention programs can be improved.2 One possibility recently explored by researchers involves development of program components to address gender-specific issues in smoking initiation. This review surveys salient findings in the investigation of gender differences in psychosocial determinants of adolescent smoking. RANGE OF FINDINGS The significance of gender differences in psychosocial predictors of smoking seems self-evident given the importance of gender in shaping everyday activity and experience. Smoking has acquired social meaning beyond that of other health behaviors such as diet or seat-belt use. Several authors have discussed the impact Serena Clayton, MA, UCLA School of Public Health, Division of Behavioral Sciences and Health Education, Dept. of Community Health, Los Angeles, CA 90024. Thispaper wassupported, in part. by the National Cancer Institute (CA 49565) Cancer Education Program for Chronic Disease Prevention. This article was submitted July 9, 1990, and revised and accepted for publication January 14, 1991.
of changing gender roles on smoking behavior and the resulting difference in meaning that smoking has for men and women.’-* Most significantly, though current smoking prevalence is roughly equal among males and females, this situation represents the culmination of very different trends for the two genders. Between 1974-1985, smoking initiation among young men declined from 4 . 8 % to 33.4%, while remaining constant among young women at 34%.’ Some evidence indicates the standard smoking prevention curriculum is more effective with boys than with girls,6 further suggesting that the psychosocial mechanisms leading to smoking may, in fact, be different for the two groups. Because of the concern over rising smoking prevalence among girls, the “female smoker” generally receives special consideration. Yet, within this context, authors5J0who review determinants of female smoking have much to say about associations that hold for females, but little to say about those that are specific to females. For those designing smoking prevention programs in girls’ schools, the former is perhaps adequate. However, the more general question is whether, in the typical mixed gender classroom, some smoking prevention activities should be conducted separately for boys and girls, and if so, how should they differ? Figures 1 and 2 provide an overview of the range of variables investigated in studies that related psychosocial factors to smoking behavior and provide a rough indication of the direction of the findings. Figure 1 presents variables associated with smoking differently for boys and girls. Figure 2 contains those variables whose impact on smoking was the same for males and females, whether significant or nonsignificant. External variables are classified under general headings such as school, parents and siblings, peers and others, and internal variables are classified as psychological traits, states and behavioral skills, attitudes and beliefs regarding smoking, and others. These classifications were made to
Journal of School Health
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identify general trends in any category and to investigate specific findings in some areas.
PEER A N D FAMILY INFLUENCE Girls are sometimes said to be more susceptible than boys to external influences and pressures to smoke. However, with respect to peers, little evidence supports this notion. Figure 2 indicates having friends who smoke has been related consistently to smoking for both genders. Chassin et al” found males and females were more strongly influenced by Deer smoking at different
ages. Their sample included 3,819 6th-1 lth grade students in the midwest, and they defined six levels of smoking, ranging from never smoker (“not even one puff”) to regular smoker (more than one cigarette per week): The -dependent variable was transition to a higher level of smoking during the one-year period of study. This transition was predicted by an increased number of smoking friends for girls at the younger ages and for boys at older ages. These findings suggest elementary teachers should focus peer pressure awareness and skills training on girls, whereas high school teachers should emphasize these aspects for boys. Parental smoking also has been associated con-
Figure 1 Variables Found to Have Dlffersntlal Assoclatlon wRh Smoklng Among Male and Female Adolescents Association between the variable and the outcome are positive for the indicated gender unless a negative association is indicated for one gender and a positive association for the other gender. Internal
External School Getting into trouble: Malelo Low bonds to school: MalelS
Psychological Tralts, States and Behavlonl Skllls
Depressed: Male” External locus of control: Female1z Self-efficacy: Female +/male Refusal skllls: Female + / male Aggresslveness: Male -I5 Impulslvlty: MalelZ Low sense of order: Male1z
hmnts and Slbllngs Parents smoke: Female11-13 Male (increase In smoking)ll Mother smokes: Female*.14 Permissive parental attitude to smoking: Female’’ Low attachment to mother: Females1e Low parental supervision: Femalela Low parental concern: Female1s I
I
I Adolescenf Smoking/nonsmoking Degree of smoking Intentions to smoke Transition to more smoking
peers Havlng friends who smoke: Younger female and older male” High bonds to frlends: Malez5 Friends’ expectations of subject: Female-/male + I 1 Favorable peer attitude to smoking: Female” Involved In social activities: Female1s Having friends of the opposlte gender:
2
Attitudes/Bellets about Smoklng Believe smoklng Is hazardous to health: FernalP Feellng pressure to smoke: Male1S
Other Weight control: Femalez3 Cope with negatlve emotlons: Female’
Other Rellglousness: Female -/ male + l o Having part-tlme job: Nonparticlpation in sports: Female‘3
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sistently with adolescent smoking for both males and lar smoking, parental smoking was related to faster. females. In all studies reviewed, parental smoking was a progression only among males from manual labor significant predictor of smoking for at least one gender. households. Where parental smoking predicts smoking in only one Chassin et al" obtained a somewhat similar result. Also, girls are more gender, it is often in female~.I~-'~ For initial "never smokers," the association between influenced by maternal smoking than are b o y ~ , ~ J ~parental smoking and transition to a higher level was whereas both boys and girls are influenced by parental significant for girls, whereas for those who had initially smoking. I' Two studies found interesting modificatried cigarettes, the relationship was significant only for tions of the relationship between parental and child boys. These two studies suggest parental smoking is smoking. Murray et all3conducted a longitudinal study important in influencing both boys and girls to smoke, in Britain between 1974-1978 on a sample of 4,275 chilout the influence may be different. Parental smoking dren ages 11-12 in 1974. They found parenal smoking seems to influence girls to smoke, whereas for boys, it is associated with smoking only in females from manual only among those who begin to experiment, perhaps as labor households. However, when using the same varia result of other influences, that parental smoking is ables to predict progression from experimental to regurelated to a faster adoption of higher levels of smoking. Figure 2 Variables Found to Have Slmllar Assaelation with Smoking Among Male and Female Adolescents lndicates significant positive association for both male and female adolescents, otherwise not significant for either gender.
External School *Less successful in 'Less interested in schooi'a Attitude to schooP Truancy"
' \\
fsychdog/c81 Trans, Stares, and I \ BOh8V/Od Skills hmnts 8nd Siblings
I
'Parents ~ m o k e 6 . ' ~ , 2 ~ Father smokes" 'Siblings srn0ke*6,2~ 'Low general supportiveness of parents" 'Low parent expectations of subject for success" 'Low parent participation with adolescent" Siblings smoket1 Parent attitude to smoking" Parent Strictness"
/
'Risk-taking6.12 'Low self-esteem" 'Low educational aspirations'
Add8SC8nt Smokinghonsmoking Degree of smoking Intentions to smoke Transition to more smoking
\
AfWudss/Be//efs rbout Smoking
I
Knowledge of smoking hazards' Favorable/unfavorable attitude to smokingIs Perceptions of smoking norms" J
hers 'Having friends who ~ m ~ k e ~ ~ ~ ~ ~ , ~ ~ , ~ ~ 'Best friend smokes6,28 'Greater general supportiveness of peers" 'Low peer expectations of subject for success" Participation in unorganized social activities" Peer attitude to smoking" General supportiveness of peerS" Peer strictness"
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usual picture. Yet, the study notes that the same trends were apparent for male adolescents. Thus, the study does not provide strong evidence for the distinction that it is typically cited to support, namely, that self-confidence and rebellion are associated with smoking in adolescent girls, where social insecurity is associated with smoking in boys. Other evidence, however, suggests this distinction may be correct. Gilchrist et a16 used a sample of 882 sixth grade students whom they classified as high-risk or low-risk, based on whether or not they had experimented with cigarettes. Information was collected on the smoking of parents and best friend, educational aspirations, health knowledge, self-efficacy, risk-taking orientation, number of refusals made in a hypothetical situation of peer pressure to smoke, and effectiveness of these refusals as judged by a rater. Unfortunately, the statistical analyses conducted on these data compared high-risk girls to high-risk boys, rather than comparing each to their low-risk counterparts. Again, because of gender differences in maturation, this comparison is an inappropriate means of assessing smoking-related factors. However, an observational comparison of scores for high-risk and low-risk groups within genders reveals more interesting results. For all variables, the direction and general magnitude of influence was roughly the same with the exception of self-efficacy, number of refusals, and effectiveness of refusal (Figure 3). Girls at higher risk of becoming smokers actually made more refusal statements judged to be more effective and had higher self-efficacy scores than low-risk girls. The opposite relationship was found for boys. The study went on to investigate response of these subjects to a smoking prevention program that stressed health information, problem-solving, and interpersonal skills training. As hypothesized, the program was least effective among high-risk girls as measures by rates of smoking one year later. Further support for the hypothesis that different mechanisms lead boys and girls to initiate smoking is provided by Urberg and Robbins’ study of 103 girls and 52 boys in a white, middle class area.I6 Subjects rated the importance of 15 benefits and 19 costs of smoking.
PSYCHOLOGICAL TRAITS, STATES, A N D BEHAVIORAL SKILLS The most provocative hypothesis frequently mentioned in the literature suggests boys use smoking as a mechanism to cope with social insecurity, whereas girls who smoke are more self-confident, rebellious, socially advanced, and sexually experienced than their nonsmoking peers. Though rebelliousness and sexual experience are consistent with frequent characterizations of adolescent smokers, particularly from the “problem behavior” perspective, this distinction between males and females is interesting because of the extent to which school smoking prevention programs have stressed self-esteem and social skills building. If this characterization is accurate, such programs may not be optimal for teen-age girls. This distinction between the function of smoking for girls and boys is based largely on a study conducted for the American Cancer Society in 1975 by Yankelovich, Skelly, and White, Inc. (YSW), a private opinion survey corporation.‘ YSW interviewed 267 girls and 246 boys ages 13-17 in their homes across the nation. Results include a comparison of male and female smokers, and a comparison of female smokers to female nonsmokers. Female smokers were less likely than male smokers to: 1) feel it is important to be popular with the other gender, 2) feel smoking is a social asset, and 3) feel nervous meeting new people and being in new situations. They are more likely to enjoy parties and dances as a favorite leisure activity. Unfortunately, in the absence of data for non-smokers, this comparison is relatively uninformative and may simply reflect general gender differences of differences in rates of maturation. Data on female smokers and nonsmokers indicate smokers are more likely to enjoy parties, have a boyfriend, have had sexual relations, drink, use marijuana, have been suspended from school, and have run away from home. Smokers are less likely to feel nervous meeting new people, enjoy reading, and feel they are not very good at things. Compared to the common view of smokers as low in self-esteem and as using cigarettes to fit in with peers, or cope with social situations, these results suggest perhaps female smokers do not fit the
Figure 3 Self-Efficacy, Number of Refusals, and Effectiveness of Refusals for High-Risk and Low-Risk Boys and Girls’ Number of refusals
Self-Efficacy 14
12.6 girls
12
Effectiveness of refusals
14
14
12
12
0)
b 8
s
8
10.1
8.9 boys
5.6
5.2
4.3 4
4
4.0 high
low
Risk
118
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boys
low
3.7 high
Risk
March 1991, Vol. 61, No. 3
boys
3.5 low
high Risk
Smoking behavior was not related to ratings of these items, but gender differences in ratings were observed. Girls were more likely to endorse the benefits: 1) smoking shows that you do what you want, 2) girls like boys who smoke, and 3) smoking makes your parents mad. They also were more likely to consider impairment of athletic performance as an important cost of smoking. Furthermore, as number of friends who smoke increased, boys agreed more and girls agreed less that 1) smoking gives you something to do when nervous, and 2) smoking makes you feel part of the gang. The authors concluded girls seem to view smoking as a sign of rebellion or independence, signalling to her parents she is autonomous, while boys conversely see smoking as a coping mechanism in social situations. Several other studies supported the conclusions of the YSW study though the evidence they provide is not strong. In a sample of 229 eighth and 11th grade students in a rural area, smoking was related to depression in males but not in females.” The British longitudinal study” using a sample of 4,275 children ages 11-12 found that feeling pressure to smoke was related to smoking only in males from manual labor households. A 1976 study of 199 female undergraduates at a Catholic college found smokers less careful, less reliable, and more sociable than nonsmokers.” Results from the Edwards Personal Preference Schedule revealed smokers differ from nonsmokers on the following needs: lower on order, higher on autonomy, higher on change, higher on heterosexuality, and higher on deference. With exception of deference, these results seem to support the profile of the autonomous, sociable female smoker. With regard to rebellion, Krohn et all9 investigated the impact of social disaffection and friendship patterns among 1,180 9th-12th grade students. While association with friends who smoke was the strongest predictor of smoking behavior, measures of social disaffection also were significant. Positive attitude toward school, success in school, and participation in extracurricular activities all related inversely to smoking for both boys and girls. However, attachment to mother, degree of parental supervision, and religiousness also related inversely to smoking for females and overall social disaffection explained a greater proportion of the variance for girls. For boys, religiousness related positively to smoking. Conversely, evidence also contradicts the notion of the “self-confident, rebellious teen-age girl smoker.” Among 133 Australian girls in seventh and eighth grade, self-concept scores for smokers were significantly lower for smokers.20 Similarly, in a sample of 1,513 eighth grade students (66% white, 34% African-American) in North Carolina, self-esteem was inversely associated with smoking for both males and females.21An analysis of initial situations in which an adolescent experimented with cigarettes or felt pressure to smoke also revealed few gender differences. Friedman and Lichtenstein*’conducted open-ended interviews with 157 7th-12th grade students regarding their first three initial situations. No significant differences were found between males and females on a number of-social and emotional factors: perceived extent and type pressure to smoke, “asked for” vs. “was offered” a cigarette, type of suggestion made by
friends, response of subject, reaction of friends to acceptance or refusal, reason for refusal (if applicable), and emotional reactions. While it is possible that different psychosocial mechanisms were in operation for males and females that were not uncovered by the scope of questions, it seems likely that if girls entered initial situations with more self-confidence and social experience, their perceptions of pressures to smoke and their emotional reactions would be different from those of boys who were socially insecure. Finally, another potentially important aspect of gender differences in smoking initiation involves motivation for weight control. Gritz, Klesges, and MeyeP provide a comprehensive literature review on the subject, indicating weight control constitutes an important factor in continuing and initiating smoking. Page and Gold2‘ found female college students more likely than males to endorse weight control as a benefit of smoking. Again, while one would intuitively suspect this factor to be more important for girls, investigation of the desire to lose weight as a gender specific predictor of smoking remains an open and potentially important research area.
CONCLUSION This review revealed several areas for further research. Both considerable similarities and a number of possible differences exist in the psychosocial predictors of smoking for male and female adolescents. In the area of peer and parent smoking behavior, it has been demonstrated that associations commonly found in mixed gender samples hold for each gender independently. Whether differences exist in the nature of influence of peer and parent models, or whether the influence proves more pronounced for one gender at certain ages, remain interesting questions for further exploration. Insufficient data exist to confirm the hypothesis that girls who smoke are more self-confident, rebellious, and socially skilled than nonsmokers, whereas boy smokers are more insecure and in need of social coping mechanisms than nonsmokers. However, a number of studies found differences between males and females that point in this general direction. Consequently, it appears the most promising area for investigating gender differences in determinants of smoking involves the realm of psychological traits, states, and behavioral skills such as refusal and interpersonal skills, and differences in perceptions of costs and benefits of smoking. Overall, the research on psychosocial determinants of adolescent smoking suffers greatly from a lack of attention to group differences. Though almost all studies break down prevalence data by groups such as gender, ethnicity, or socioeconomic status, few systematically investigate group differences in psychosocial predictors. Yet, these differences clearly are important if the psychosocial curriculum represents the key to smoking prevention. A program effective among middle class, Caucasian boys is unlikely to have the same effect on recently arrived, Mexican girls. Furthermore, it is difficult to draw conclusions from studies that have addressed gender differences because variations in
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instrumentation, choice, and definition of variables, and data analysis procedures limit comparability of findings. If psychosocial research is to inform the design of school-based smoking prevention programs, a coordinated line of investigation clearly would be more constructive than the scattered body of studies that exists. Returning to the practitioner’s question of whether or not school smoking programs should be designed separately for boys and girls, it is clear that program components addressing peer and parent smoking are important for both genders even if there are subtle differences in the nature of influence. Yet, even the relatively small number of strategies reviewed indicates psychosocial predictors of smoking differ for males and females in several cases (Figure 1). While factual information on health hazards of smoking can be taught to mixed gender classes, discussion groups, role playing, and other awareness and skill building activities may be more productive if girls and boys are separated. Separation of classes into single gender groups is logistically inconvenient, yet no more so than ability groupings commonplace for teaching math and reading. Though no definitive answer exists to the question of how “male” and “female” smoking prevention programs should differ, these findings suggest some possible directions for the design of experimental, genderspecific, program components that would be a productive step in the next generation of smoking prevention research. References 1. US Dept of Health and Human Services. Smoking prevention, cessation, and advocacy activities. Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General, chapter 6. Washington, DC, US Public Health Service; 1989. 2. Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, Davis RM. Trends in cigarette smoking in the United States: Projections to the year u)oo.JAMA. 1989;261:61-65. 3. Biener L. Gender differences in the use of substances for coping. In: Rosalind C, Barnett LB, Biener L, Baruch GK, eds. Gender and Stress. New York, NY: Free Press; 1987. 4. Yankelovich, Skelly, and White Inc. Cigarette Smoking Among Teenagers and Young Women: Summary of Findings. Washington, DC: US Government Printing Office; publication no (NIH) 77-1203, 1977. 5 . Gritz EF. Cigarette smoking by adolescent females: Implications for health and behavior. Women’s Health. 1984;9: 103-115. 6. Gilchrist LD, Schinke SP, Nurius P. Reducing onset of habitual smoking among women. Prev Med. 1989;18:235-248. 7. Elkind AK. The social definition of women’s smoking behaviour. Soc Sci Med. 1985;20:1269-1278. 8. Gritz ER. The female smoker: Research and intervention
targets. In: Cohen J, Cullen JW, Martin LR, eds. Psychosociul Aspects of Cancer. New York, NY: Raven Press; 1982. 9. Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, et al. Trends in cigarette smoking in the United States: The changing influence of gender and race. JAMA. l989;261:41-55. 10. US Public Health Service. The Health Consequences of Smoking for Women: A Report of the Surgeon General. Washington, DC: US Government Printing Office; publication no 0-326-003, 286; 1980. 11. Chassin L, Presson CC, Sherman SJ, Montello D, McGrew J. Changes in peer and parent influence during adolescence: Longitudinal versus cross-sectional perspectives on smoking initiation. Dev Psycho/. 1986;22(3):327-334. 12. Williams AF. Personality and other characteristics associated with cigarette smoking among young teenagers. J Health Soc Behav. 1973;14:374-380. 13. Murray M, Swan AV, Bewley BR. Johnson MRD. The development of smoking during adolescence: The MRC/Derbyshire smoking study. In1 J Epidemiol. 1983;12(2):185-192. 14. Nolte AE, Smith BJ, O’Rourke T. The relative importance of parental attitude and behavior upon youth smoking. J Sch Health. 1983;53(4):265-27 1. IS. Chassin L, Presson CC, Sherman SJ. Cigarette smoking and adolescent psychosocial development. Basic Appl Soc Psychol. 1984;5(4):295-315. 16. Urberg K, Robbins RL. Adolescents’ perceptions of the costs and benefits associated with cigarette smoking: Sex differences and peer influence. J Youth Adolesc. 1981;10(5):353-361. 17. Malkin SA, Allen DL. Differential characteristics of adolescent smokers and nonsmokers. J Fam Pruct. 1980;10(3):437-440. 18. Simon WE, Primavera LH. The personality of the cigarette smoker: Some empirical data. In1 J Addict. 1976;11(1):81-94. 19. Krohn MD, Naughton MJ, Skinner WF, Becker SL, Lauer RM. Social disaffection, friendship patterns and adolescent cigarette use: The Muscatine Study. J Sch Health. 1986;56(4):146-150. 20. Baker C, Cover J. Smoking in adolescent girls: Relation to selfconcept, feedback and self-monitoring. Presented at 1982 annual convention of the American Psychological Association; August 23-27, 1982; Washington, DC. 21. Murphy HT, Price CJ. The influence of self-esteem, parental smoking, and living in a tobacco production region on adolescent smoking behaviors. J Sch Health. 1988;58(10):401-405. 22. Friedman LS, Lichtenstein E. Smoking onset among teens: An empirical analysis of initial situations. Addict Behav. 1985;lO:l-13. 23. Gritz ER, Klesges RC, Meyers AW. The smoking and body weight relationship: Implications for intervention and postcessation weight control. Ann Behav Med. 1989;11(4):144-153. 24. Page RM, Gold RS. Assessing gender differences in college cigarette smoking intenders and nonintenders. J Sch Heulth. 1983;53(9):531-535. 25. Ensminger ME, Brown CH, Kellam SG. Sex differences in antecedents of substance use among adolescents. J SOC Issues. 1982;34(2):25-42. 26. Schoonmaker R. A teenage view of cigarette smoking. Conn Med. 1983;47(11):705-707. 27. McCaul KD, Glasgow R, O’Neil HK, Freeborn V, Rump BS. Predicting adolescent smoking. J Sch Health. 1982;52(8):342-347. 28. Elder JP, Molgaard CS, Gresham L. Predictors of chewing tobacco and cigarette use in a multiethnic public school population. Adolescence. 1988:23:689-702.
Statement of Purpose The lournal of School Health, an official publication of the American School Health Association, publishes material related to health promotion in school settings. Iournal readership includes administrators, educators, nurses, physicians, dentists, dental hygienists, psychologists, counselors, social workers, nutritionists, dietitians, and other health professionals. These individuals work cooperatively with parents and the community to achieve the common goal of providing children and adolescents with the programs, services, and environment necessary to promote health and to improve learning. Contributed manuscriptsare considered for publication in the following categories:general articles, research papers, commentaries,teaching techniques, and health service applications. Primary consideration is given to manuscripts related to the health of children and adolescents, and to the health of employees, in public and private pre-schools and child day care centers, kindergartens, elementary schools, middle level schools, and senior high schools. Manuscripts related to college-age young adults will be considered if the topic has implicationsfor health programs in preschools through grade 12. Relevant international manuscripts also will be considered. Prior to submitting a manuscript, prospective authors should review the most recent ”Guidelinesfor Authors.” The guidelinesare printed periodically in the lournal; copies also may be obtained from the lournal office, P.O. Box 708, Kent, OH 44240.
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ABSTRACT: Because of the social meaning smoking has acquired and because of different trends in male and female initiation rates, it is reasonable to suspect that dirfrent psychosocial factors predict smoking in teen-age boys and girls. A literature review revealed external pressures such as peer and parental smoking are important f o r both boys and girls though their influence may be moderated diflerentially by age and type of smoking behavior assessed. Some data support the hypothesis that female smoking is associated with se!f-confidence, social experience, and rebellion, whereas male smoking is associated with social insecurity. Overall, group diJferences such as gender and socioeconomic status are welldocumented in terms of smoking prevalence but underexplored in the area of psychosocial predictors. I n this review, gender dvferences have been documented with sufficient frequency to warrant further attention to develop gender specific components of smoking prevention prog-rams. (J Sch Health. 1991:610):115-120)
S
chool-based smoking prevention programs have undergone substantial evolution in the past two decades. The disappointing results of early educational programs that were information-based and stressed long-term health consequences of smoking led to development of psychosocial and life-skills curricula. Of all approaches investigated to date, the most successful appear to be those that point out negative short-term consequences of smoking such as bad breath or impaired athletic ability, raise young people’s awareness of the pressures to smoke, and train them in skills to resist these influences. Research on psychosocial predictors of smoking has contributed to program development by identifying influences such as peer smoking and internal factors such as self-esteem. Nevertheless, the fact that smoking prevalence is declining less rapidly among adolescents than among adults suggests school-based smoking prevention programs can be improved.2 One possibility recently explored by researchers involves development of program components to address gender-specific issues in smoking initiation. This review surveys salient findings in the investigation of gender differences in psychosocial determinants of adolescent smoking. RANGE OF FINDINGS The significance of gender differences in psychosocial predictors of smoking seems self-evident given the importance of gender in shaping everyday activity and experience. Smoking has acquired social meaning beyond that of other health behaviors such as diet or seat-belt use. Several authors have discussed the impact Serena Clayton, MA, UCLA School of Public Health, Division of Behavioral Sciences and Health Education, Dept. of Community Health, Los Angeles, CA 90024. Thispaper wassupported, in part. by the National Cancer Institute (CA 49565) Cancer Education Program for Chronic Disease Prevention. This article was submitted July 9, 1990, and revised and accepted for publication January 14, 1991.
of changing gender roles on smoking behavior and the resulting difference in meaning that smoking has for men and women.’-* Most significantly, though current smoking prevalence is roughly equal among males and females, this situation represents the culmination of very different trends for the two genders. Between 1974-1985, smoking initiation among young men declined from 4 . 8 % to 33.4%, while remaining constant among young women at 34%.’ Some evidence indicates the standard smoking prevention curriculum is more effective with boys than with girls,6 further suggesting that the psychosocial mechanisms leading to smoking may, in fact, be different for the two groups. Because of the concern over rising smoking prevalence among girls, the “female smoker” generally receives special consideration. Yet, within this context, authors5J0who review determinants of female smoking have much to say about associations that hold for females, but little to say about those that are specific to females. For those designing smoking prevention programs in girls’ schools, the former is perhaps adequate. However, the more general question is whether, in the typical mixed gender classroom, some smoking prevention activities should be conducted separately for boys and girls, and if so, how should they differ? Figures 1 and 2 provide an overview of the range of variables investigated in studies that related psychosocial factors to smoking behavior and provide a rough indication of the direction of the findings. Figure 1 presents variables associated with smoking differently for boys and girls. Figure 2 contains those variables whose impact on smoking was the same for males and females, whether significant or nonsignificant. External variables are classified under general headings such as school, parents and siblings, peers and others, and internal variables are classified as psychological traits, states and behavioral skills, attitudes and beliefs regarding smoking, and others. These classifications were made to
Journal of School Health
March 1991, Vol. 61, No. 3
115
identify general trends in any category and to investigate specific findings in some areas.
PEER A N D FAMILY INFLUENCE Girls are sometimes said to be more susceptible than boys to external influences and pressures to smoke. However, with respect to peers, little evidence supports this notion. Figure 2 indicates having friends who smoke has been related consistently to smoking for both genders. Chassin et al” found males and females were more strongly influenced by Deer smoking at different
ages. Their sample included 3,819 6th-1 lth grade students in the midwest, and they defined six levels of smoking, ranging from never smoker (“not even one puff”) to regular smoker (more than one cigarette per week): The -dependent variable was transition to a higher level of smoking during the one-year period of study. This transition was predicted by an increased number of smoking friends for girls at the younger ages and for boys at older ages. These findings suggest elementary teachers should focus peer pressure awareness and skills training on girls, whereas high school teachers should emphasize these aspects for boys. Parental smoking also has been associated con-
Figure 1 Variables Found to Have Dlffersntlal Assoclatlon wRh Smoklng Among Male and Female Adolescents Association between the variable and the outcome are positive for the indicated gender unless a negative association is indicated for one gender and a positive association for the other gender. Internal
External School Getting into trouble: Malelo Low bonds to school: MalelS
Psychological Tralts, States and Behavlonl Skllls
Depressed: Male” External locus of control: Female1z Self-efficacy: Female +/male Refusal skllls: Female + / male Aggresslveness: Male -I5 Impulslvlty: MalelZ Low sense of order: Male1z
hmnts and Slbllngs Parents smoke: Female11-13 Male (increase In smoking)ll Mother smokes: Female*.14 Permissive parental attitude to smoking: Female’’ Low attachment to mother: Females1e Low parental supervision: Femalela Low parental concern: Female1s I
I
I Adolescenf Smoking/nonsmoking Degree of smoking Intentions to smoke Transition to more smoking
peers Havlng friends who smoke: Younger female and older male” High bonds to frlends: Malez5 Friends’ expectations of subject: Female-/male + I 1 Favorable peer attitude to smoking: Female” Involved In social activities: Female1s Having friends of the opposlte gender:
2
Attitudes/Bellets about Smoklng Believe smoklng Is hazardous to health: FernalP Feellng pressure to smoke: Male1S
Other Weight control: Femalez3 Cope with negatlve emotlons: Female’
Other Rellglousness: Female -/ male + l o Having part-tlme job: Nonparticlpation in sports: Female‘3
1 16
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sistently with adolescent smoking for both males and lar smoking, parental smoking was related to faster. females. In all studies reviewed, parental smoking was a progression only among males from manual labor significant predictor of smoking for at least one gender. households. Where parental smoking predicts smoking in only one Chassin et al" obtained a somewhat similar result. Also, girls are more gender, it is often in female~.I~-'~ For initial "never smokers," the association between influenced by maternal smoking than are b o y ~ , ~ J ~parental smoking and transition to a higher level was whereas both boys and girls are influenced by parental significant for girls, whereas for those who had initially smoking. I' Two studies found interesting modificatried cigarettes, the relationship was significant only for tions of the relationship between parental and child boys. These two studies suggest parental smoking is smoking. Murray et all3conducted a longitudinal study important in influencing both boys and girls to smoke, in Britain between 1974-1978 on a sample of 4,275 chilout the influence may be different. Parental smoking dren ages 11-12 in 1974. They found parenal smoking seems to influence girls to smoke, whereas for boys, it is associated with smoking only in females from manual only among those who begin to experiment, perhaps as labor households. However, when using the same varia result of other influences, that parental smoking is ables to predict progression from experimental to regurelated to a faster adoption of higher levels of smoking. Figure 2 Variables Found to Have Slmllar Assaelation with Smoking Among Male and Female Adolescents lndicates significant positive association for both male and female adolescents, otherwise not significant for either gender.
External School *Less successful in 'Less interested in schooi'a Attitude to schooP Truancy"
' \\
fsychdog/c81 Trans, Stares, and I \ BOh8V/Od Skills hmnts 8nd Siblings
I
'Parents ~ m o k e 6 . ' ~ , 2 ~ Father smokes" 'Siblings srn0ke*6,2~ 'Low general supportiveness of parents" 'Low parent expectations of subject for success" 'Low parent participation with adolescent" Siblings smoket1 Parent attitude to smoking" Parent Strictness"
/
'Risk-taking6.12 'Low self-esteem" 'Low educational aspirations'
Add8SC8nt Smokinghonsmoking Degree of smoking Intentions to smoke Transition to more smoking
\
AfWudss/Be//efs rbout Smoking
I
Knowledge of smoking hazards' Favorable/unfavorable attitude to smokingIs Perceptions of smoking norms" J
hers 'Having friends who ~ m ~ k e ~ ~ ~ ~ ~ , ~ ~ , ~ ~ 'Best friend smokes6,28 'Greater general supportiveness of peers" 'Low peer expectations of subject for success" Participation in unorganized social activities" Peer attitude to smoking" General supportiveness of peerS" Peer strictness"
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usual picture. Yet, the study notes that the same trends were apparent for male adolescents. Thus, the study does not provide strong evidence for the distinction that it is typically cited to support, namely, that self-confidence and rebellion are associated with smoking in adolescent girls, where social insecurity is associated with smoking in boys. Other evidence, however, suggests this distinction may be correct. Gilchrist et a16 used a sample of 882 sixth grade students whom they classified as high-risk or low-risk, based on whether or not they had experimented with cigarettes. Information was collected on the smoking of parents and best friend, educational aspirations, health knowledge, self-efficacy, risk-taking orientation, number of refusals made in a hypothetical situation of peer pressure to smoke, and effectiveness of these refusals as judged by a rater. Unfortunately, the statistical analyses conducted on these data compared high-risk girls to high-risk boys, rather than comparing each to their low-risk counterparts. Again, because of gender differences in maturation, this comparison is an inappropriate means of assessing smoking-related factors. However, an observational comparison of scores for high-risk and low-risk groups within genders reveals more interesting results. For all variables, the direction and general magnitude of influence was roughly the same with the exception of self-efficacy, number of refusals, and effectiveness of refusal (Figure 3). Girls at higher risk of becoming smokers actually made more refusal statements judged to be more effective and had higher self-efficacy scores than low-risk girls. The opposite relationship was found for boys. The study went on to investigate response of these subjects to a smoking prevention program that stressed health information, problem-solving, and interpersonal skills training. As hypothesized, the program was least effective among high-risk girls as measures by rates of smoking one year later. Further support for the hypothesis that different mechanisms lead boys and girls to initiate smoking is provided by Urberg and Robbins’ study of 103 girls and 52 boys in a white, middle class area.I6 Subjects rated the importance of 15 benefits and 19 costs of smoking.
PSYCHOLOGICAL TRAITS, STATES, A N D BEHAVIORAL SKILLS The most provocative hypothesis frequently mentioned in the literature suggests boys use smoking as a mechanism to cope with social insecurity, whereas girls who smoke are more self-confident, rebellious, socially advanced, and sexually experienced than their nonsmoking peers. Though rebelliousness and sexual experience are consistent with frequent characterizations of adolescent smokers, particularly from the “problem behavior” perspective, this distinction between males and females is interesting because of the extent to which school smoking prevention programs have stressed self-esteem and social skills building. If this characterization is accurate, such programs may not be optimal for teen-age girls. This distinction between the function of smoking for girls and boys is based largely on a study conducted for the American Cancer Society in 1975 by Yankelovich, Skelly, and White, Inc. (YSW), a private opinion survey corporation.‘ YSW interviewed 267 girls and 246 boys ages 13-17 in their homes across the nation. Results include a comparison of male and female smokers, and a comparison of female smokers to female nonsmokers. Female smokers were less likely than male smokers to: 1) feel it is important to be popular with the other gender, 2) feel smoking is a social asset, and 3) feel nervous meeting new people and being in new situations. They are more likely to enjoy parties and dances as a favorite leisure activity. Unfortunately, in the absence of data for non-smokers, this comparison is relatively uninformative and may simply reflect general gender differences of differences in rates of maturation. Data on female smokers and nonsmokers indicate smokers are more likely to enjoy parties, have a boyfriend, have had sexual relations, drink, use marijuana, have been suspended from school, and have run away from home. Smokers are less likely to feel nervous meeting new people, enjoy reading, and feel they are not very good at things. Compared to the common view of smokers as low in self-esteem and as using cigarettes to fit in with peers, or cope with social situations, these results suggest perhaps female smokers do not fit the
Figure 3 Self-Efficacy, Number of Refusals, and Effectiveness of Refusals for High-Risk and Low-Risk Boys and Girls’ Number of refusals
Self-Efficacy 14
12.6 girls
12
Effectiveness of refusals
14
14
12
12
0)
b 8
s
8
10.1
8.9 boys
5.6
5.2
4.3 4
4
4.0 high
low
Risk
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3.7 high
Risk
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boys
3.5 low
high Risk
Smoking behavior was not related to ratings of these items, but gender differences in ratings were observed. Girls were more likely to endorse the benefits: 1) smoking shows that you do what you want, 2) girls like boys who smoke, and 3) smoking makes your parents mad. They also were more likely to consider impairment of athletic performance as an important cost of smoking. Furthermore, as number of friends who smoke increased, boys agreed more and girls agreed less that 1) smoking gives you something to do when nervous, and 2) smoking makes you feel part of the gang. The authors concluded girls seem to view smoking as a sign of rebellion or independence, signalling to her parents she is autonomous, while boys conversely see smoking as a coping mechanism in social situations. Several other studies supported the conclusions of the YSW study though the evidence they provide is not strong. In a sample of 229 eighth and 11th grade students in a rural area, smoking was related to depression in males but not in females.” The British longitudinal study” using a sample of 4,275 children ages 11-12 found that feeling pressure to smoke was related to smoking only in males from manual labor households. A 1976 study of 199 female undergraduates at a Catholic college found smokers less careful, less reliable, and more sociable than nonsmokers.” Results from the Edwards Personal Preference Schedule revealed smokers differ from nonsmokers on the following needs: lower on order, higher on autonomy, higher on change, higher on heterosexuality, and higher on deference. With exception of deference, these results seem to support the profile of the autonomous, sociable female smoker. With regard to rebellion, Krohn et all9 investigated the impact of social disaffection and friendship patterns among 1,180 9th-12th grade students. While association with friends who smoke was the strongest predictor of smoking behavior, measures of social disaffection also were significant. Positive attitude toward school, success in school, and participation in extracurricular activities all related inversely to smoking for both boys and girls. However, attachment to mother, degree of parental supervision, and religiousness also related inversely to smoking for females and overall social disaffection explained a greater proportion of the variance for girls. For boys, religiousness related positively to smoking. Conversely, evidence also contradicts the notion of the “self-confident, rebellious teen-age girl smoker.” Among 133 Australian girls in seventh and eighth grade, self-concept scores for smokers were significantly lower for smokers.20 Similarly, in a sample of 1,513 eighth grade students (66% white, 34% African-American) in North Carolina, self-esteem was inversely associated with smoking for both males and females.21An analysis of initial situations in which an adolescent experimented with cigarettes or felt pressure to smoke also revealed few gender differences. Friedman and Lichtenstein*’conducted open-ended interviews with 157 7th-12th grade students regarding their first three initial situations. No significant differences were found between males and females on a number of-social and emotional factors: perceived extent and type pressure to smoke, “asked for” vs. “was offered” a cigarette, type of suggestion made by
friends, response of subject, reaction of friends to acceptance or refusal, reason for refusal (if applicable), and emotional reactions. While it is possible that different psychosocial mechanisms were in operation for males and females that were not uncovered by the scope of questions, it seems likely that if girls entered initial situations with more self-confidence and social experience, their perceptions of pressures to smoke and their emotional reactions would be different from those of boys who were socially insecure. Finally, another potentially important aspect of gender differences in smoking initiation involves motivation for weight control. Gritz, Klesges, and MeyeP provide a comprehensive literature review on the subject, indicating weight control constitutes an important factor in continuing and initiating smoking. Page and Gold2‘ found female college students more likely than males to endorse weight control as a benefit of smoking. Again, while one would intuitively suspect this factor to be more important for girls, investigation of the desire to lose weight as a gender specific predictor of smoking remains an open and potentially important research area.
CONCLUSION This review revealed several areas for further research. Both considerable similarities and a number of possible differences exist in the psychosocial predictors of smoking for male and female adolescents. In the area of peer and parent smoking behavior, it has been demonstrated that associations commonly found in mixed gender samples hold for each gender independently. Whether differences exist in the nature of influence of peer and parent models, or whether the influence proves more pronounced for one gender at certain ages, remain interesting questions for further exploration. Insufficient data exist to confirm the hypothesis that girls who smoke are more self-confident, rebellious, and socially skilled than nonsmokers, whereas boy smokers are more insecure and in need of social coping mechanisms than nonsmokers. However, a number of studies found differences between males and females that point in this general direction. Consequently, it appears the most promising area for investigating gender differences in determinants of smoking involves the realm of psychological traits, states, and behavioral skills such as refusal and interpersonal skills, and differences in perceptions of costs and benefits of smoking. Overall, the research on psychosocial determinants of adolescent smoking suffers greatly from a lack of attention to group differences. Though almost all studies break down prevalence data by groups such as gender, ethnicity, or socioeconomic status, few systematically investigate group differences in psychosocial predictors. Yet, these differences clearly are important if the psychosocial curriculum represents the key to smoking prevention. A program effective among middle class, Caucasian boys is unlikely to have the same effect on recently arrived, Mexican girls. Furthermore, it is difficult to draw conclusions from studies that have addressed gender differences because variations in
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instrumentation, choice, and definition of variables, and data analysis procedures limit comparability of findings. If psychosocial research is to inform the design of school-based smoking prevention programs, a coordinated line of investigation clearly would be more constructive than the scattered body of studies that exists. Returning to the practitioner’s question of whether or not school smoking programs should be designed separately for boys and girls, it is clear that program components addressing peer and parent smoking are important for both genders even if there are subtle differences in the nature of influence. Yet, even the relatively small number of strategies reviewed indicates psychosocial predictors of smoking differ for males and females in several cases (Figure 1). While factual information on health hazards of smoking can be taught to mixed gender classes, discussion groups, role playing, and other awareness and skill building activities may be more productive if girls and boys are separated. Separation of classes into single gender groups is logistically inconvenient, yet no more so than ability groupings commonplace for teaching math and reading. Though no definitive answer exists to the question of how “male” and “female” smoking prevention programs should differ, these findings suggest some possible directions for the design of experimental, genderspecific, program components that would be a productive step in the next generation of smoking prevention research. References 1. US Dept of Health and Human Services. Smoking prevention, cessation, and advocacy activities. Reducing the Health Consequences of Smoking: 25 Years of Progress: A Report of the Surgeon General, chapter 6. Washington, DC, US Public Health Service; 1989. 2. Pierce JP, Fiore MC, Novotny TE, Hatziandreu EJ, Davis RM. Trends in cigarette smoking in the United States: Projections to the year u)oo.JAMA. 1989;261:61-65. 3. Biener L. Gender differences in the use of substances for coping. In: Rosalind C, Barnett LB, Biener L, Baruch GK, eds. Gender and Stress. New York, NY: Free Press; 1987. 4. Yankelovich, Skelly, and White Inc. Cigarette Smoking Among Teenagers and Young Women: Summary of Findings. Washington, DC: US Government Printing Office; publication no (NIH) 77-1203, 1977. 5 . Gritz EF. Cigarette smoking by adolescent females: Implications for health and behavior. Women’s Health. 1984;9: 103-115. 6. Gilchrist LD, Schinke SP, Nurius P. Reducing onset of habitual smoking among women. Prev Med. 1989;18:235-248. 7. Elkind AK. The social definition of women’s smoking behaviour. Soc Sci Med. 1985;20:1269-1278. 8. Gritz ER. The female smoker: Research and intervention
targets. In: Cohen J, Cullen JW, Martin LR, eds. Psychosociul Aspects of Cancer. New York, NY: Raven Press; 1982. 9. Fiore MC, Novotny TE, Pierce JP, Hatziandreu EJ, et al. Trends in cigarette smoking in the United States: The changing influence of gender and race. JAMA. l989;261:41-55. 10. US Public Health Service. The Health Consequences of Smoking for Women: A Report of the Surgeon General. Washington, DC: US Government Printing Office; publication no 0-326-003, 286; 1980. 11. Chassin L, Presson CC, Sherman SJ, Montello D, McGrew J. Changes in peer and parent influence during adolescence: Longitudinal versus cross-sectional perspectives on smoking initiation. Dev Psycho/. 1986;22(3):327-334. 12. Williams AF. Personality and other characteristics associated with cigarette smoking among young teenagers. J Health Soc Behav. 1973;14:374-380. 13. Murray M, Swan AV, Bewley BR. Johnson MRD. The development of smoking during adolescence: The MRC/Derbyshire smoking study. In1 J Epidemiol. 1983;12(2):185-192. 14. Nolte AE, Smith BJ, O’Rourke T. The relative importance of parental attitude and behavior upon youth smoking. J Sch Health. 1983;53(4):265-27 1. IS. Chassin L, Presson CC, Sherman SJ. Cigarette smoking and adolescent psychosocial development. Basic Appl Soc Psychol. 1984;5(4):295-315. 16. Urberg K, Robbins RL. Adolescents’ perceptions of the costs and benefits associated with cigarette smoking: Sex differences and peer influence. J Youth Adolesc. 1981;10(5):353-361. 17. Malkin SA, Allen DL. Differential characteristics of adolescent smokers and nonsmokers. J Fam Pruct. 1980;10(3):437-440. 18. Simon WE, Primavera LH. The personality of the cigarette smoker: Some empirical data. In1 J Addict. 1976;11(1):81-94. 19. Krohn MD, Naughton MJ, Skinner WF, Becker SL, Lauer RM. Social disaffection, friendship patterns and adolescent cigarette use: The Muscatine Study. J Sch Health. 1986;56(4):146-150. 20. Baker C, Cover J. Smoking in adolescent girls: Relation to selfconcept, feedback and self-monitoring. Presented at 1982 annual convention of the American Psychological Association; August 23-27, 1982; Washington, DC. 21. Murphy HT, Price CJ. The influence of self-esteem, parental smoking, and living in a tobacco production region on adolescent smoking behaviors. J Sch Health. 1988;58(10):401-405. 22. Friedman LS, Lichtenstein E. Smoking onset among teens: An empirical analysis of initial situations. Addict Behav. 1985;lO:l-13. 23. Gritz ER, Klesges RC, Meyers AW. The smoking and body weight relationship: Implications for intervention and postcessation weight control. Ann Behav Med. 1989;11(4):144-153. 24. Page RM, Gold RS. Assessing gender differences in college cigarette smoking intenders and nonintenders. J Sch Heulth. 1983;53(9):531-535. 25. Ensminger ME, Brown CH, Kellam SG. Sex differences in antecedents of substance use among adolescents. J SOC Issues. 1982;34(2):25-42. 26. Schoonmaker R. A teenage view of cigarette smoking. Conn Med. 1983;47(11):705-707. 27. McCaul KD, Glasgow R, O’Neil HK, Freeborn V, Rump BS. Predicting adolescent smoking. J Sch Health. 1982;52(8):342-347. 28. Elder JP, Molgaard CS, Gresham L. Predictors of chewing tobacco and cigarette use in a multiethnic public school population. Adolescence. 1988:23:689-702.
Statement of Purpose The lournal of School Health, an official publication of the American School Health Association, publishes material related to health promotion in school settings. Iournal readership includes administrators, educators, nurses, physicians, dentists, dental hygienists, psychologists, counselors, social workers, nutritionists, dietitians, and other health professionals. These individuals work cooperatively with parents and the community to achieve the common goal of providing children and adolescents with the programs, services, and environment necessary to promote health and to improve learning. Contributed manuscriptsare considered for publication in the following categories:general articles, research papers, commentaries,teaching techniques, and health service applications. Primary consideration is given to manuscripts related to the health of children and adolescents, and to the health of employees, in public and private pre-schools and child day care centers, kindergartens, elementary schools, middle level schools, and senior high schools. Manuscripts related to college-age young adults will be considered if the topic has implicationsfor health programs in preschools through grade 12. Relevant international manuscripts also will be considered. Prior to submitting a manuscript, prospective authors should review the most recent ”Guidelinesfor Authors.” The guidelinesare printed periodically in the lournal; copies also may be obtained from the lournal office, P.O. Box 708, Kent, OH 44240.
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