"It’s not like I’m going to do these things forever. I mean, I’m in college and everyone says it’s the time to let go. If I don’t do all these things now, when will I? Now’s the time to party hard with friends, stay up late, smoke and drink, and just enjoy myself. But it’s not like something I do all the time so it’s really not like a big deal. I mean, I’m sure I won’t be smoking when I’m done with college."
—Blake, eighteen-year-old male
The quote above from this college freshman echoes prevalent ideas on college campuses about smoking. Tobacco, like alcohol, is a substance that “everyone” seemed to use, especially at parties. Few students on the campuses where I worked saw themselves as “real” smokers. They were party smokers, that is, people who mostly smoked socially. That’s why so many students referred to their occasional smoking almost as an afterthought, and talked about it as “no big deal.”
Social smoking is common among young adults, particularly those who are in college. Social smokers tend to be lighter smokers who do not smoke on a daily basis. Their smoking is more related to the context in which they find themselves. In fact, it’s an umbrella term that can refer to different patterns. On the college campus, the term “social smoker” most commonly refers to a person who smokes with friends at parties when consuming alcohol. I resist assigning a number of cigarettes to define social smoking at parties, as it really depends on how much drinking is going on and who the individual is hanging out with on a particular night. Other patterns of social smoking also exist. A person on a break from work may smoke because his or her coworkers do, or a person who rarely smokes may have a cigarette with a troubled friend who is smoking as a way of bonding. Social smoking can also describe people who smoke a majority of their cigarettes in social contexts, but may also smoke alone when under stress. Indeed, some research has shown that more than half of college students who smoke fit this broad characterization of social smoker.
Recent years have seen a burgeoning epidemiological and psychological literature on social smoking, which is also referred to as light, low-level, and intermittent smoking. These terms are commonly defined in relation to the number of cigarettes smoked. Relatively few qualitative studies have been conducted to explore these patterns of consumption. At a time when just about everyone knows that smoking is bad for you, why are some college students starting to smoke once they arrive on campus? How, when, and where does social smoking occur? Despite an extant literature on smoking, there are lacunae in our understanding of the behavior. I argue that we must understand more about the meaning of social and low-level smoking to youth, the social contexts that facilitate uptake and those that limit use, and the social utilities of the behavior. Little is known about how smoking serves as a consumption event that facilitates social interaction, how smoking is used as a resource for negotiating identities, and how smoking serves as a signal for communicating emotive states. While much emphasis has been placed on the measurement of how much and how often young adults use cigarettes, less is known about what cigarettes say about who you are and who you are not. Thus, one of the aims of this book is to draw on interview data with social and low-level smokers in order to shed light on these increasingly common patterns of behavior.
Listening to the voices of young adults, I closely examine how smoking fits into their everyday lives and consider the extent to which college life actually fosters and sustains this behavior. In unpacking some of the complex reasons underlying smoking today, I challenge some simplistic but long-standing assessments of the behavior—for example, that most women smoke to control their weight.
Despite their smoking, most students I spoke with were confident that they were “not really smokers” and that their play time with cigarettes would be short-lived. As Blake points out in the opening quote, it was something one did in college, but certainly not after that. However, as students neared graduation, many of those who smoked expressed various degrees of ambivalence or reluctance to quit. Quit plans seemed to move farther into a distant ambiguous future, something that might be reconsidered at the next life milestone, such as getting a real job or starting a family.
While this book is largely focused on the college campus, I also consider what happens after graduation. Many grads today are stepping into an uncertain future, where the prospect of finding a good job in a timely manner is unlikely. Their twenties may be characterized by multiple moves (in and out of their parents’ and friends’ homes) and compounded by multiple stressors, not the least of which is supporting oneself in a time of high unemployment and low wages. Moving into adulthood is now an elongated process, as markers of “settling down,” like marriage, edge upward toward one’s late twenties, if that. For those who have come to depend on the comfort of cigarettes during their college years, this array of life stressors may make cutting back or quitting more difficult, despite their intentions and understandings of the harms of tobacco.
Added to this picture is the powerful tobacco industry, which has focused much of its multibillion-dollar campaigns on young adults— the youngest legal targets of its products. Slim, light, and additive-free cigarettes are marketed to young people who may think they are engaging in harm reduction through the promise of a “healthier” cigarette. Emerging products in the marketplace, like e-cigarettes, carry with them the lure of vaping (distinct from smoking), ostensibly without the harmful effects. Taking these myriad factors into account, one begins to recognize how social smoking is a behavior that may continue well beyond the college years.
My analysis draws on a social ecology of health model, which postulates that in order to understand the meaning of health behavior in context, we need to critically examine multiple levels of influence, such as the individual, the social network, the community, and global systems. Applied to the study of smoking among young adults, the social ecological perspective prompts us to look beyond psychosocial models that privilege individual behavior to consider how social, cultural, and political-economic environments affect youth behavior and how youth behavior, in turn, may influence the environment. Moving from the micro (interpersonal) to the macro (community/societal) level with a focus on reciprocal and bidirectional interaction, the social ecological model offers a productive frame for the discussion of behaviors and environments of risk that have an impact on young adults’ health.
To date, although much research among college students has focused on singular behaviors (e.g., drinking, smoking, pharmaceutical use), qualitative studies point to the co-occurrence and interaction of these behaviors (e.g., smoking and drinking). The term “syndemic” has been used to refer to two or more epidemics (i.e., notable increases in the rate of specific diseases in a population) interacting synergistically and contributing, as a result of their interaction, to the excess burden of disease in a population. Coexisting behaviors like smoking and drinking need to be recognized as closely linked and potential independent threats to health, which need to be studied in context rather than in isolation. Recognition of the existence of syndemics suggests the need for a biosocial reconception of co-substance use and the adoption of holistic approaches that link micro-level behaviors to macro-level social and economic factors.
Shifts in Smoking in the United States
While the past forty years have seen significant declines in adult smoking (from 42 percent in 1965 to 20 percent in 2010), this is not the case among young adults, aged eighteen to twenty-five. Young adults have the highest prevalence of smoking of all other age groups, with approximately 35 percent reporting that they currently smoke. Analyses by race/ethnicity show that white youth have the highest prevalence overall (39 percent) followed by Hispanics (27 percent) and blacks (23 percent). Among women, white youth have the highest prevalence of smoking (37 percent) compared to other females (Hispanics 21 percent; blacks 21 percent).
I should clarify that the prevalence of smoking among young adults is highest among those who do not attend college. The focus in this book is on college-going youth, who actually represent a majority of young people in the United States today. In 2012, about two-thirds of high school graduates were enrolled in colleges or universities, and the majority of these students attended four-year institutions. Thus, it would seem that an in-depth understanding of smoking patterns on college campuses is warranted.
For many years, a widespread assumption in the public health field was that over 90 percent of those who became smokers would begin their habit before they reached age eighteen. The period of maximum vulnerability to initiation was considered to be during the middle or high school years. Recently the conventional wisdom about when youth start smoking has been challenged by findings that as many as
20 percent of smokers start smoking after age eighteen, a figure that represents a substantial increase from earlier years. Nationwide surveys reveal that it is increasingly common for college students to begin smoking after they arrive on campus, mostly in their freshman year. Over 30 percent of college students report that they smoked at least once in the past year, 25 percent report that they smoked at least one time in the previous month, and 12 percent smoke cigarettes daily.
Some research has concluded that smoking behaviors acquired in older adolescence and early adulthood are more likely to persist through later life. There is evidence to suggest that more than half of those who smoke at low levels in their freshman year will still be smoking when they are seniors. And for those who began smoking prior to college, more than one-quarter become regular smokers during the college years. For some of these students, what began as social or occasional smoking will convert to daily smoking. Clearly, an established pattern of smoking on a daily basis will make it more difficult to quit.
By all accounts, young adulthood is a pivotal time in the development of smoking behavior. Smoking patterns among college students are much more fluid than those of adults, whose smoking behaviors tend to be already established. In fact, studies suggest that “the number of individuals aged 18 and 19 years in the early stages of smoking initiation may be more than double that of established smokers aged 18 years.” Those who once detested smoking may take it up in college, those who smoke in social contexts may increase or decrease their use, and party smokers who once swore that they were somehow immune to addiction may become dependent smokers with little interest in quitting.
Scientific understanding of how one becomes a smoker has changed over time. For many years, researchers believed that after a person initiated smoking, the progression to regular or daily use took several years, with established smoking as an endpoint that occurred in the twenties.
During these early years, an individual’s smoking behavior was typically characterized as intermittent or light (i.e., the person smoked occasionally and at a low level, five cigarettes or fewer per day), a pattern that was seen as a temporary and transitional developmental stage while his or her smoking was becoming established. Eventually, the smokers would feel that they required steady and frequent dosing of nicotine, at which point they could be characterized as dependent on nicotine, or addicted smokers.
While this was the dominant characterization of a smoker for many years, by the late 1980s there was a growing recognition that not all smokers fit this pattern. Saul Shiffman, a professor of psychology and pharmaceutical science known for his research on addiction, identified a pattern among adult smokers whom he labeled “chippers.” These smokers inhaled and absorbed nicotine from cigarettes (typically about five or fewer per day) but did not smoke enough to maintain steady-state nicotine levels, nor did they experience many (if any) withdrawal symptoms when they did not smoke. Over time, these low-level smokers did not increase the number of cigarettes they smoked and they showed few signs of dependence.
Increasingly, tobacco researchers have recognized that divergent patterns of smoking uptake exist, with some individuals remaining low-level smokers rather than following neatly along a trajectory of increased cigarette consumption. In fact, in the United States today over a third of adult smokers do not smoke every day, and the proportion of non-daily or occasional smokers appears to be growing. This is a very sharp contrast from twenty-five years ago, when the average smoker consumed thirty-two cigarettes a day, over a pack and a half.
Smokers today smoke an average of thirteen cigarettes per day. And among many college students who smoke, the amount smoked per day is much less.
What accounts for these downward shifts in cigarette consumption? Several reasons seem plausible in the general population. First and foremost, environmental restrictions—smoke-free legislation—have limited the spaces where people can smoke. Half of the U.S. population lives in areas where smoking is banned in workplaces, bars, and restaurants. More than 70 percent of Americans, including about half of current smokers, do not allow smoking in their homes. Rather than being able to light up a cigarette wherever they wish, smokers need to find appropriate places, not only where it is legal for them to smoke but also where they will not offend others. Smoking has been increasingly stigmatized, and even when someone is smoking in a legal space—like outdoors—nonsmokers are often quick to show their annoyance. Restrictions on smoking are increasing on college campuses as well, and many colleges nationwide have enacted total smoking bans, meaning no smoking in campus buildings or outside.
A second reason for the downward shift in cigarette consumption is cost. Taxation on cigarettes, which varies across states, has resulted in increased cost, which can serve as a factor limiting the number of cigarettes one smokes as well as one’s brand choice. Numerous studies have shown that young adults are particularly sensitive to cost.
A third factor contributing to lower levels of smoking is a growing awareness of the harm of tobacco and secondhand smoke. To mitigate harm, many people are adopting harm-reduction practices, like cutting back on the number of cigarettes they smoke each day or trying to quit completely.
How Do College Students Describe Their Smoking?
The short answer to this question is that college students view their smoking very differently than public health and psychology researchers who frequently report on their behavior. Most researchers use the term current smoker to classify those who report smoking part or all of a cigarette in the past thirty days. Some years back, I realized that this label was a total mismatch for how students talked about smoking. In interviews with high school girls about their recent smoking experiences, my colleagues and I had asked, “Would you call yourself a smoker now?” Most girls seemed annoyed by this question, and quickly clarified their own behavior with comments like “I smoke, but I’m not a smoker” or “I just smoke when I’m partying.” These comments made it clear that from the girls’ perspective, there was a distinction between those who “really” smoked and their own occasional behavior. Their image of a smoker was someone “who bought cigarettes and really had to have one.”
On a survey we developed for that project, we incorporated the teen-generated descriptors, and found that while 30 percent of the girls reported that they currently smoked (out of 205 girls), over two-thirds of them described themselves as “someone who smokes but is not a smoker” or “someone who just smokes when I’m partying.” When my colleagues and I used similar response categories on a survey of over nine hundred college freshmen at a large midwestern university, over 40 percent of students who reported some level of smoking similarly characterized themselves in ways that reflected the idea that they were not “really smokers.”
Recently, Carla Berg and her colleagues examined the concept of “smoker identity” among college students at fourteen U.S. universities. Specifically, these researchers wanted to understand the extent to which college students who had smoked in the past month would identify themselves as smokers. Of the ten thousand students they surveyed, almost 25 percent reported smoking in the past thirty days. Of those who had smoked on three to five days in the past month, 92 percent did not consider themselves smokers. Of those who had smoked on six to nine days in the past month, 75 percent did not consider themselves smokers. And even among those who had smoked on ten to nineteen days in the past month, 45 percent did not consider themselves smokers. In total, more than half of college students in this large sample did not classify themselves as smokers, regardless of the frequency of their smoking cigarettes. These findings suggest that smoking may be even more common than our current statistics reveal and that it is a poorly understood label that has a different meaning to laypersons than to researchers. It also begs a reexamination of our classification of smoking.
Qualitative research among young adults in Scotland similarly found that those who smoke are reluctant to label themselves smokers. When asked whether they would call themselves smokers, some respondents compared themselves to friends who smoked more than they did and decided that their own level of smoking did not warrant calling themselves smokers. Others explained that even though they smoked almost every day, the number of cigarettes consumed was too low to call themselves smokers. Still others discounted their smoking status, noting that they smoked cigarettes only when they were drinking alcohol or when smoking marijuana, and therefore it did not “really count.” What is interesting to note in this study is that self-descriptors of smoking status were dependent on a number of factors, with youth engaging in comparative reasoning and evaluating their smoking in relation to others in their social network. In doing so, they were not relying on a simple count of how many cigarettes they had smoked to define themselves.
Does Defining Yourself as a Nonsmoker Matter?
The answer to this is complex and multifaceted. Clearly, many of those who start smoking in their freshman year or who enter college having smoked a few times stop after a couple of months. Approximately 70 percent of all people try a cigarette at some point in their life, yet only a third continue smoking to the point of becoming dependent. At present, the differences between those who progress to high levels of smoking and those who experiment with smoking but do not transition to regular use are not well understood. Recent studies have shown, however, that intermittent smoking (i.e., non-daily smoking) among both adults and college students appears to be a stable category over time.
In other words, those who smoke on a non-daily basis tend to do so for many years.
Recent studies have also shown that symptoms of nicotine dependence can develop rapidly after the onset of occasional or intermittent smoking. That is, there is no minimum nicotine dose or duration of use that has been established as necessary for dependence. What this means is that nicotine dependence can begin for some smokers as early as their first few cigarettes. While this may seem surprising, for some students I spoke with, the transition from trying their first cigarette socially to becoming daily low-level smokers (one to two cigarettes a day) took about two months.
It’s not just the possibility of becoming dependent on a substance that needs to be considered. From a biosocial perspective, we need to recognize that dependence may develop in a social context where one receives strong cues to engage in a particular behavior. College students who smoke occasionally and socially can become dependent or “addicted” to smoking at parties while drinking. In other words, the craving they describe—echoed repeatedly in the phrase “when I’m drinking I’ve got to be smoking”—may have as much of a social dimension as a purely biological one. In a similar way, a low-level smoker who smokes only one or two cigarettes a day may feel very addicted to those cigarettes (often smoked at a special time of day, like after a meal). In fact, their addiction to the “after-food cigarette” may be so strong that they can’t imagine not smoking. It is not just the number of cigarettes that a person smokes but also the meaning of each cigarette and the pleasure that he or she derives from it. Importantly, some cessation experts think that smoking just a few cigarettes a day can be even harder to give up than a heavier habit, since each cigarette carries more of a reward.
Another important issue to consider with regard to college students who smoke—but do not consider themselves smokers—is that they may dismiss potential health consequences of tobacco and disregard messages to quit. Take Taylor, for example, whose grandmother had died after a long and painful struggle with emphysema. Despite the fact that she had observed firsthand the effects of long-term tobacco use and had received many warnings from her mom about her “risky genes,” Taylor distanced herself, adopting instead an air of invincibility. “After all,” she told me, “I really don’t smoke very much and I’m sure I’ll quit pretty soon, . . . and I smoke Marlboro Lights, which I think aren’t as bad for you.” Researchers have called this an “optimistic bias,” referring to people’s tendency to view the risks of various behaviors as lower for themselves than for others who engage in similar behaviors.
Some social smokers, like Taylor, opined that their smoking was not a big deal because of the type of cigarette they smoked. Although tobacco industry marketing has tried to lead the public to believe that one can be a “health-conscious smoker” by smoking “light,” “mild,” or “ultra-light” cigarettes—a belief that is held widely by college students—this is a misconception. Light or mild cigarettes are not better for health than regular cigarettes. Studies on the topography of smoking have shown that smokers who choose light cigarettes believing they are a healthier alternative adapt their smoking behavior—inhaling more deeply and frequently—and as a result obtain similar levels of nicotine as with regular cigarettes. Similar misconceptions espoused by college students are that brands like American Spirit are “a healthier choice” because they do not contain additives. In fact, studies have shown that additive-free cigarettes deliver substantial amounts of nicotine and other toxic components of tobacco smoke.
As noted earlier, most social and low-level smokers believe that they will quit long before they experience any harmful effects of tobacco. There is a growing body of evidence, however, to suggest that even social and low-level smokers have difficulty in quitting, despite their desire to do so. And among regular smokers, national survey data have shown that of the more than 50 percent who tried to quit during the previous year, only 6 percent reported successfully doing so. Relapse rates are notoriously high.
It is well established that tobacco use has substantial health risks that begin almost immediately—even in adolescence and young adulthood. Although social or occasional smoking may be thought of by the lay population as less harmful than daily smoking, these patterns are also associated with poor health outcomes. Studies among college students find that even occasional smoking (at least five days in the previous thirty) increased the odds of experiencing shortness of breath and fatigue while doing regular activities.
Compared to those who have never smoked, light and intermittent smokers are at increased risk for cardiovascular disease, lower respiratory tract infection, and compromised reproductive health, among other health conditions. With regard to cardiovascular disease, light and intermittent smoking carries nearly the same risk for heart attack and stroke as daily smoking. With regard to lung cancer, women aged thirty-five to forty-nine who smoke one to four cigarettes per day have five times the risk of developing lung cancer as nonsmokers; men have three times the risk. Over half of those who continue smoking will have a significant decrease in their life span—about thirteen years shorter than their nonsmoking peers. Another important point to consider is that light or intermittent smokers who think of themselves as nonsmokers are less likely than a regular smoker to be advised to quit or be offered cessation assistance from health professionals.