Cognitive Susceptibility to Smoking and Initiation of Smokingduring Childhood: A Longitudinal Study1

Christine Jackson, Ph.D.2

University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7400

Background. The earlier the onset of cigarette smok-ing the greater the risk of addictive smoking. Becausesmoking initiation is occurring at ever younger ages,early onset of smoking is primarily a childhood phe-nomenon. In this study cognitive susceptibility tosmoking was examined as a risk factor for childhoodonset of cigarette smoking. This was the first prospec-tive investigation of cognitive susceptibility to smok-ing as a predictor of smoking initiation by children.

Methods. Three annual surveys were completed by788 children who, at baseline, were in the third or fifthgrade and had never puffed on a cigarette.

Results. At baseline, 51% of children had eithersingle or multiple indicators of susceptibility to smok-ing. Over 2 years, children with single indicators ofsusceptibility were 80% more likely to initiate smok-ing, and children with multiple indicators of suscepti-bility were four times as likely to initiate smoking asnonsusceptible peers. Susceptibility was a strongerpredictor of initiation than all other predictors exam-ined, including exposure to family members andfriends who smoke cigarettes.

Conclusion. Among abstinent children ages 8 to 10years, cognitive susceptibility to smoking was a sig-nificant predictor of whether they initiated smokingprior to adolescence. Reducing children’s susceptibil-ity to smoking could strengthen efforts to preventearly onset of cigarette smoking. © 1998 Academic Press

Key Words: children; cigarette smoking; initiation.

INTRODUCTION

Cigarette smoking is a learned behavior that is gen-erally thought to have several stages: preparation, ini-tiation, experimentation, regular smoking, and addic-

tion [1–3]. Forty percent of adolescents initiate smok-ing by age 14, and progression to regular or dailycigarette smoking peaks at ages 15 to 16 [1]. Efforts toprevent smoking have concentrated on adolescents inmiddle school, and have aimed principally to decreaseexperimental and regular smoking.

The notion that a preparation stage precedes theother stages of smoking was introduced over 15 yearsago [2] and is now recognized widely [1]. Yet the prepa-ration stage of smoking has received relatively littleresearch attention. Recently, Pierce and colleagues[4,5] examined the validity of susceptibility to smokingas a predictor of cigarette smoking by adolescents. Inthese investigations, susceptible adolescents werethose who had never puffed on a cigarette but werecognitively predisposed to do so, as indicated by theirlack of a firm commitment against smoking. Over a4-year period, baseline susceptibility to smoking wasfound to be a stronger predictor of experimentation byadolescents than exposure to smoking by family mem-bers or best friends [4]. This result is noteworthy be-cause exposure to smoking models, particularly bestfriends who smoke, has been described as the strongestpredictor of smoking initiation by adolescents [1]. An-other recent study examined the relationship betweensusceptibility to tobacco use (also defined as the lack ofa firm commitment against use) and participation intobacco promotion campaigns [6]. This study foundthat 46% of all nonsmoking adolescents had partici-pated in a tobacco promotion campaign, and that theodds of susceptibility to tobacco use were significantlygreater among adolescents who had participated insuch campaigns [6].

Recent interest in susceptibility to smoking amongabstinent youth may be a response to the now substan-tial evidence that adolescents’ responsiveness to pre-vention programs diminishes once they have initiatedsmoking. Several evaluations of smoking preventionprograms for adolescents have found that the strongestpredictor of smoking after participation in such pro-grams was having initiated smoking prior to baseline[7–10]. Those studies indicated that for some adoles-cents, initiation of smoking determines progression to

1 This research was supported by the National Institute on DrugAbuse, Grant DA07919.

2 Address correspondence and reprint requests to the Departmentof Health Behavior and Health Education, CB# 7400, Rosenau Hall,Room 300D, School of Public Health, University of North Carolina atChapel Hill, Chapel Hill, NC 27599-7400. Fax: 919.966.2921. E-mail:chris_ jackson@unc.edu.

PREVENTIVE MEDICINE 27, 129–134 (1998)ARTICLE NO. PM970255

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0091-7435/98 $25.00Copyright © 1998 by Academic Press

All rights of reproduction in any form reserved.

regular smoking, and they indicated a need for strate-gies to prevent the transition from the preparation toinitiation stage of smoking. As noted by Pierce et al.[4], smoking prevention programs should either pre-vent youth from becoming susceptible to smoking orprevent susceptible youth from initiating smoking.

Many questions remain regarding susceptibility tosmoking among abstinent youth. Most importantly, nostudies have examined susceptibility to smoking as apredictor of smoking initiation by children. Yet, for tworeasons, the concept of susceptibility probably is morerelevant to children than to adolescents. First, thepreparation phase of smoking begins in childhood, assoon as children can recognize smoking as a discretebehavior and can internalize beliefs and norms regard-ing that behavior. Such fundamental psychologicalprocesses begin in early childhood [11,12]. Second, ini-tiation of smoking prior to adolescence has been iden-tified as one of the strongest predictors of progressionto regular smoking and addiction [1,13–19]. Several in-vestigators have recommended preventing early onsetof smoking as a principal strategy for preventing ado-lescent smoking [11,15,18]. If it were known that sus-ceptibility to smoking predicted initiation of smokingby children, then assessment of susceptibility could aidefforts to prevent initiation during childhood. The pre-sent study measured cognitive susceptibility to smok-ing among children ages 8–10 and tested whether sus-ceptibility to smoking predicted their initiation ofsmoking over a 2-year period. This is the first study toobtain a longitudinal test of susceptibility to smokingas a predictor of smoking initiation in a preadolescentsample.

METHODS

Sample and Procedures

At baseline the sample included 1,470 students (788in third grade; 682 in fifth grade) enrolled in 12 el-ementary schools constituting a county school districtin central North Carolina. Attributes of the baselinesample have been described in detail elsewhere [20]. Ofthese, 913 students completed three surveys adminis-tered in February through March of 1994, 1995, and1996. This 62% retention rate is comparable with thoseof other longitudinal studies of cigarette smoking inschool-based populations [21]. Of the 913 students withcomplete longitudinal data, 125 students (14%) re-ported initiation of smoking at baseline, leaving 788students who had never puffed on a cigarette as of the1994 survey for the present study. This sample was83% white and 51% female.

Of the 557 students lost to follow-up, 100 were lostdue to parental refusal, 125 due to student absentee-ism, 29 due to student refusal, and 227 due to out-

migration (students leaving the school district duringthe study). In addition, between the second and thethird years of data collection the local school board ini-tiated a blanket policy that required active consent forall research studies occurring in the district. Althoughpassive consent was approved by an internal reviewboard and was used in this study for Survey Years 1and 2, active consent was used for Year 3. An addi-tional 76 students whose parents could not be con-tacted prior to Year 3 were lost to follow-up. Analysis ofattrition bias is presented under Results.

All student surveys were administered in the class-room. A tear-off page with each student’s name wasused to deliver surveys to students with parental per-mission. An assent transcript was read to studentsthat informed them that they could chose not to par-ticipate in the survey, that they could skip any ques-tions they did not want to answer, and that they couldstop participating at any time. The survey items wereread aloud by graduate students who were trained tostandardize the pace and modulation of their readingand to standardize their responses to predicted ques-tions from students. Teachers were present in theclassroom during administration, but they stayed attheir desks to protect the confidentiality of student re-sponses.

Measures

Smoking initiation status. Children were coded ashaving initiated smoking if they consistently reportedvalues indicating some level of cigarette smoking (i.e.,smoking ‘‘one or two puffs’’ or more) in response toquestions about lifetime use, most use in 1 day, andgrade at first use. Children who consistently reportedvalues indicating nonuse (i.e., ‘‘never’’ or ‘‘none’’) in re-sponse to these three questions or who were inconsis-tent in reporting smoking behavior were coded as ab-stinent. The present study selected all children whowere abstinent in Year 1 and the analyses comparedchildren who were abstinent through Year 3 with thosewho had initiated smoking by Year 3.

Susceptibility to smoking. Susceptibility was de-fined as the lack of a firm commitment against ciga-rette smoking. Four items were used to measure sus-ceptibility to smoking: (1) Do you think you will besmoking cigarettes 1 year from now? (2) Do you thinkyou will be smoking cigarettes in high school? (3) Doyou think that most kids who are like you start smok-ing cigarettes? and (4) Have you ever almost triedsmoking a cigarette but then decided not to? Theseitems measure intention to smoke in the short or longterm (items 1 and 2), normative expectation aboutsmoking (item 3), and ambivalence about trying smok-ing (item 4). The response options for items (1) to (3)

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were ‘‘definitely not,’’ ‘‘probably not,’’ ‘‘probably yes,’’and ‘‘definitely yes.’’ Replicating the method used byPierce et al. [1] and Altman et al. [6], the ‘‘definitelynot’’ response indicated nonsusceptibility and the‘‘probably not,’’ ‘‘probably yes,’’ and ‘‘definitely yes’’ re-sponses indicated susceptibility. The response optionsfor item (4) were ‘‘no’’ or ‘‘yes,’’ indicating nonsuscepti-bility and susceptibility, respectively. Responses tothese items were summed to obtain total susceptibilityscores that ranged from 0 to 4.

Exposure to smokers. Children were asked to reportthe number of cigarette smokers living at home withthem; responses were coded as none, one smoker, ortwo or more smokers. Children also reported how manyof their three best friends had tried smoking a ciga-rette; responses were coded as none or one or morefriends.

Academic ability. Children’s third and fifth gradeteachers were asked to complete a brief checklist in-strument on which they indicated whether each stu-dent had a high, medium, or low level of academic abil-ity.

Analyses

The x2 test was used to compare participants andnonparticipants for assessment of attrition bias. Hier-archical logistic regression analysis was used to exam-ine the relations between the predictor variables (allmeasured at baseline) and the outcome variable (ini-tiation of smoking by Year 3). The predictor variableswere sex, grade, race, academic ability, exposure tosmokers at home or among best friends, and suscepti-bility to smoking. All predictors were coded as categori-cal variables in the regression model. Sex, grade, race,and academic ability were entered at the first step, andthe significance of exposure to smokers at home, expo-sure to smoking by best friends, and susceptibility tosmoking was examined in the final model.

RESULTS

Attrition Analysis

To determine bias associated with sample attrition,children who were abstinent at baseline and had com-plete longitudinal data (n 4 788) were compared withchildren who were abstinent at baseline but were lostto follow-up (n 4 444) on demographic attributes, ex-posure to smokers, and susceptibility to smoking. Par-ticipants were significantly more likely than nonpar-ticipants to be white (84% vs 77%; x2 4 9.01; P < 0.01),female (53% vs 47%; x2 4 3.88; P < 0.05), and in thefifth grade (47% vs 37%; x2 4 10.30; P < 0.01). Therewere no differences between participants and nonpar-ticipants in exposure to smokers at home, exposure tobest friends who had initiated smoking, or susceptibil-

ity to smoking. While attrition was not random withrespect to demographic factors, it was unrelated to thevariables that were the primary focus of this study.

Susceptibility to Smoking

To gauge the relevance of the susceptibility conceptto smoking initiation by children, the associations be-tween each indicator of susceptibility to smoking andinitiation of smoking were examined. As shown inTable 1, each indicator of susceptibility was associatedsignificantly with smoking initiation. For three of thefour indicators, about 60% of children who gave a sus-ceptible response at baseline had initiated smoking byYear 3, compared with about 30% of children who gavethe nonsusceptible response.

The relationship between total susceptibility andsmoking initiation was also examined. There was astrong inverse association between level of susceptibil-ity and smoking initiation (see Table 2). Among chil-dren with a susceptibility score of 0, 24% had initiatedsmoking by Year 3; among children with susceptibilityscores of 3 or 4, 73 and 80%, respectively, had initiatedsmoking by Year 3. Because 51 cases had susceptibilityscores of 3 or 4, scores greater than or equal to 2 werecombined to form one category for the regression analy-

TABLE 1Indicators of Susceptibility to Smoking in 1994 and the

Proportion of Children Reporting Smoking Initiation by1996

Indicators ofsusceptibility to

cigarette smoking,1994 Response n

Smoking initiationby 1996

% (95% CI)

Do you think you willbe smoking ciga-rettes 1 year fromnow?

Definitely not 733 33.3 (29.8;36.7)

Susceptible 55 60.0* (47.0;72.9)Do you think you will

be smoking ciga-rettes when you arein high school? Definitely not 679 31.2 (27.7;34.4)

Susceptible 109 59.6* (50.3;68.8)Do you think that

most kids who arelike you start smok-ing cigarettes? Definitely not 457 28.7 (24.5;37.8)

Susceptible 331 44.1* (38.7;49.4)Have you ever almost

tried smoking acigarette but thendecide not to? No 685 30.5 (27.0;33.9)

Susceptible 103 66.0* (56.8;75.1)

Note. N 4 788; susceptible responses were probably not, probablyyes, or definitely yes for the first three items, and yes for the fourthitem. CI, confidence interval.

* P < 0.0001.

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sis. As shown in Table 2, 49% (n 4 384), 34% (n 4271), and 17% (n 4 133) of the sample had suscepti-bility scores of 0, 1, or ù2, respectively, and the confi-dence intervals for these levels of susceptibility did notoverlap.

Prediction of Smoking Initiation

Of the 788 children who were abstinent at baseline,277 (35%) had initiated smoking by Year 3. As shownin Table 3, the odds of initiation were significantlyhigher among older children (OR 4 2.04) and amongnonwhites (OR 4 1.83). The odds of initiation did notdiffer by sex or by level of academic ability.

Number of smokers at home was strongly associatedwith children’s initiation of smoking by Year 3.Twenty-seven percent of children with no exposure tosmokers at home had initiated smoking, while 44% ofthose with one smoker at home and 47% of those withtwo or more smokers at home had initiated smoking.Exposure to one or more smokers at home doubled chil-dren’s odds of smoking initiation (see Table 3). Chil-dren who had at least one best friend who had initiatedsmoking did not have significantly increased odds ofsmoking initiation.

Susceptibility to smoking was a strong predictor ofsmoking initiation. Children who gave a susceptibleresponse to just one of the four baseline indicators ofsusceptibility were 80% more likely to have initiatedsmoking by Year 3 than nonsusceptible peers (seeTable 3). Children who reported two or more indicatorsof susceptibility at baseline were 3.7 times more likelyto have initiated smoking by Year 3 than nonsuscep-tible peers. Susceptibility to smoking was a strongerpredictor of smoking initiation than all other predic-tors in the multivariate analysis, including exposure tofamily members and friends who smoke cigarettes.

DISCUSSION

Susceptibility to smoking is defined as the absence ofa firm commitment against smoking. Susceptibility to

smoking is one aspect of the preparation stage of smok-ing and is assumed to indicate a cognitive predisposi-tion to smoke. This is the first study to measure sus-ceptibility to smoking among abstinent children and totest whether susceptibility to smoking predicted initia-tion of smoking prior to adolescence.

In this study, children who had never smoked werecategorized at baseline as having no, single, or multipleindicators of susceptibility to smoking. Fifty-one per-cent of these abstinent children had either single ormultiple indicators of susceptibility to smoking atbaseline. Children with single indicators of susceptibil-ity were 80% more likely than nonsusceptible childrento initiate smoking by the third survey year. Childrenwith multiple indicators of susceptibility were nearlyfour times as likely as nonsusceptible peers to initiatesmoking by the third survey year. Susceptibility tosmoking was a stronger predictor of smoking initiationthan was living with smokers, although the latter vari-able was associated with a twofold increase in the oddsof smoking initiation. Susceptibility to smoking also

TABLE 3Logistic Regression of Smoking Initiation Status in 1996

on Age, Sex, Race, Academic Ability, Exposure to Smokers atHome and among Friends, and Susceptibility to Smokingin 1994

Predictor variables, 1994 n

Smoking Initiation by 1996

% OR (95% CI)

GradeThird 419 27.2 1.00Fifth 369 44.2 2.04*** (1.46;2.86)

SexFemale 417 32.6 1.00Male 371 38.0 1.32 (.96;1.83)

RaceWhite 660 33.3 1.00Nonwhite 128 44.5 1.83* (1.18;2.85)

Academic abilityHigh 303 30.0 1.00Moderate 383 36.3 1.08 (.80;2.36)Low 100 46.0 1.38 (.75;1.55)

Household smokersNone 423 27.2 1.001 195 43.6 2.18** (1.48;3.21)2 or more 156 47.4 2.34** (1.53;3.59)

Friends who smokeNone 668 32.8 1.001 or more 109 49.5 1.25 (.78;1.98)

Susceptibility score0 384 24.0 1.001 265 38.4 1.83** (1.76;1.89)ù2 129 60.9 3.74*** (2.36;5.93)

Note. OR, odds ratios, adjusted for all variables in the model; CI,confidence interval; this analysis excludes 24 participants who hadmissing data on one or more predictors.

* P < 0.01.** P < 0.001.

*** P < 0.0001.

TABLE 2Total Scores on Susceptibility to Smoking in 1994 and

the Proportion of Children Reporting Smoking Initiationby 1996

Total susceptibility tosmoking in 1994 n

Smoking initiationby 1996

% (95% CI)

0 384 24.0 (19.7;28.2)1 271 38.4 (32.6;44.1)2 82 52.4 (41.6;63.2)3 41 73.2 (59.6;86.7)4 10 80.0 (55.2;104.7)

ù2 133 60.9 (52.6;69.1)

Note. N 4 788. CI, confidence interval.

CHRISTINE JACKSON132

was a stronger predictor of smoking initiation than washaving one or more best friends who had initiatedsmoking. In fact, in this sample, best friends’ smokingdid not predict initiation of smoking. These results arenoteworthy because research to date has consistentlyshown that peer and parental smoking most stronglypredict smoking initiation by youth [1]. In sum, theresults demonstrate that children as young as 8 yearsof age vary in susceptibility to smoking, and that sus-ceptibility to smoking is a strong predictor of progres-sion to the initiation stage of smoking.

It is commonly held that most if not all children havea negative attitude about smoking. Indeed, it is likelythat if the present study had asked children to evalu-ate the goodness or badness of smoking, most wouldhave indicated a negative attitude about smoking. It isimportant to note, however, that children can report anegative attitude about smoking and still be cogni-tively predisposed toward (i.e., susceptible to) smoking.This discrepancy could occur because agreeing thatsmoking is bad is a socially desirable response thatmay not be congruent with a child’s actual attitudeabout smoking. Alternatively, children can genuinelybelieve that smoking is ‘‘bad’’ and also believe that de-viant behaviors can have positive results, such as im-proved self-image, better peer acceptance, and atten-tion (albeit, negative attention) from parents. Thus, al-though children are likely to report a negative attitudeabout smoking, the present study demonstrated that alarge proportion of abstinent children are susceptibleto smoking, and that when susceptibility to smoking ishigh, children have substantially increased risk of ini-tiating smoking behavior.

As noted previously, there is now substantial evi-dence that the younger the age at which initiation ofcigarettes occurs, the greater the risk of habitual smok-ing [1,13–19]. Students who initiate smoking prior toparticipation in middle-school prevention programshave been found to be unaffected by such programs[7–10]. Other studies have found that early initiatorswere less likely than older initiators to attempt to quitor to succeed in quit attempts [14] and were more likelythan older initiators to smoke as young adults [16].Preventing early onset of tobacco (and other substance)use has thus become an important focus of preventionresearch. Assessment of susceptibility to smokingcould serve to identify children at increased risk forearly initiation of smoking. Obtaining such informa-tion addresses only part of the problem of child smok-ing, however, because we lack strategies for preventingsusceptible children from initiating smoking. We alsolack strategies for preventing children from becomingsusceptible to smoking. Additional research is neededto identify the factors that increase susceptibility tosmoking among children and to test the efficacy of pro-grams to diminish the harmful consequences of suscep-tibility to smoking.

ACKNOWLEDGMENT

We gratefully acknowledge the participation of the students, par-ents, teachers, principals, and administrators who made this studypossible.

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