1. SRNT Conference, 2013 Copy of abstract submitted Background: Health behaviour models suggest that perceived vulnerability to harm and the balance of perceived risks and benefits guide smoking decisions. Although there is substantial support for this model among adults, results in terms of how adolescents understand smoking risk are inconsistent. This study aimed to develop an understanding of how adolescent daily, weekly, experimental, ex-, and never- smokers perceive smoking risk. Method: 602 adolescents (145 daily, 35 weekly, 35 ex, 130 experimental, 257 never smokers) completed a smoking perceptions survey which included questions related to the perception of health and addiction risk, and the perceived general and immediate harm from smoking, avoidance of health-related thoughts, and 3 subscales from a domain specific measure of risk (DOSPERT) relating to social, recreational, and health and safety risk. Results: Daily smokers differed significantly to all other groups on general risk measures (p<.001 for each). They perceived higher levels of relative risk and were less optimistic about the risks, but they were significantly less likely to perceive general or immediate harm from smoking. They were less likely to avoid health risks than never (p<.001), experimental (p<.001), and ex-smokers (p<.05), whereas weekly smokers only differed significantly from never-smokers (p<.05). Weekly smokers also perceived less general harm from smoking than never (p<.001) and experimental (p<.01) smokers. No smoking status differences were seen in overall levels of domain specific risk-taking (DOSPERT) but significant differences are found for social risk between never and daily smokers (p<.05) and for health and safety risks between never- and ex- (p<.05), weekly (p<.05), and daily (p<.001) smokers. Discussion: These findings suggest that risk is an important factor in adolescent smoking decisions. They challenge the contention that adolescent smokers are not aware of the risks involved with smoking but despite this awareness, regular smokers seem more inclined to take health-related risks and are less concerned about immediate harm from smoking. Further examination of DOSPERT risk assessment in adolescents is recommended.

2. Smoking risk perceptions in Irish adolescents with varied smoking experience Louise Hopper & Dr Michael Gormley Trinity College, Dublin

3. SRNT Conference, 2013 Presentation outline Background How risk impacts the smoking decision Measuring risk Research aims and design Results Conclusions 3

4. SRNT Conference, 2013 4 4 Making the smoking decision Rather than disregarding the relationship between smoking and its associated risks, it has been suggested that: Smokers rationally weigh-up the risks against the benefits of smoking (Viscusi, 1992) Smokers engage in cognitive strategies, such as cognitive avoidance, that help maintain their current behaviour (Gerrard, et al., 1996) Cognitive avoidance of behavioural risk can move from motivated to unmotivated and habitual with increased exposure and experience

5. SRNT Conference, 2013 5 5 Adolescents and Smoking Risk Smokers, especially young smokers, seem to be driven by the affective context of smoking decisions (Slovic, 2001), giving little or no conscious thought to the risks involved Evidence that adolescents display greater risk-taking for affective decisions in comparison to more deliberate ones (Figner, et al., 2009) But, there is also evidence that adolescent smokers are aware of, and freely endorse, the long-term risk consequences of smoking (Brady, et al., 2008; Lewis-Esquerre, et al., 2005)

6. SRNT Conference, 2013 Optimistic Risk Bias Despite this endorsement of long-term smoking risk, adolescents tend to Underestimate short-term smoking risk (Slovic, 1998) In particular addiction risk (Weinstein, 2001) AND perceptions of short-term immediate harm from smoking influences adolescent smoking behaviour to a greater extent than longer-term smoking risk (Romer & Jamieson, 2001)

7. SRNT Conference, 2013 7 7 Measuring Risk Numerical risk estimates Participant estimates risk and this is compared to actuarial or epidemiological risk tables (Schoenbaum, 1997) Often used in adult research But it assumes that people have the ability to be able to assign a numerical value to the risk (Borland, 1997) Inappropriate for adolescent risk studies Comparative risk estimates (Relative Risk) Participants to compare their own risk with that of an average person (Sutton & Bolling, 2003) Avoids issues with numerical risk estimates Allows measurement of bias in the personal risk assessment

8. SRNT Conference, 2013 8 Research Aims Determine how adolescents of varied smoking status perceive smoking-related risk Based on previous research, it was expected that: 1. Adolescent smokers, particularly daily smokers, would show an optimistic risk bias for perceived relative risk of smoking 2. An optimistic bias would also be seen when immediate and general harm of smoking were compared. 3. Cognitive avoidance of health-related risks was expected in smokers but not in non-smokers 4. General attitudes to risk were expected to vary by smoking status

9. SRNT Conference, 2013 Research Design Between Group Dependent Variables Relative to General Risk Relative to Smoker Risk General Harm from Smoking Immediate Harm from Smoking Avoid Thoughts of Health Risks Domain Specific Risk (DOSPERT) Optimistic Bias?

10. SRNT Conference, 2013 Relative Smoking Risk Relative to general (RG) ‘Compared to other people your age how likely do you think you are to …..’ Relative to smoker (RS) ‘Compared with a typical smoker your age how likely do you think you are to ….’ 10 Much less likely A bit less likely About the same A bit more likely Much more likely Get lung cancer in the future( ) Have a heart attack in the future( ) Be hooked on cigarettes in 5 years( )

11. SRNT Conference, 2013 Perceived Harm from Smoking General Harm : responses 1 to 4 (risky) How risky do you think smoking is for your health? How risky do you think smoking every day would be for your health?’ The harmful effects of cigarettes have been exaggerated. Do you ___?’ Immediate Harm: responses 1 to 4 (risky) Imagine someone who starts to smoke a packet of cigarettes a day at age 16. How much do you agree with the following statements about this person? There is usually no risk at all to the person for the first few years Although smoking may eventually harm this person’s health, there is really no harm to him or her from smoking the very next cigarette 11

12. SRNT Conference, 2013 General risk-related items Avoiding health-related thoughts ‘How likely is concern for your health to influence your decision to smoke or not to smoke?’ 1 (very likely) to 7 (very unlikely) General attitudes to risk taking DOSPERT scale (Blais & Weber, 2006) Social, Recreational, and Health & Safety subscales only 12

13. SRNT Conference, 2013 Participant Characteristics Daily (n = 145) Weekly (n = 35) Ex-S (n = 35) Experimental (n 130) Never (n = 257) Mean Age16.86 (0.99) 16.77 (1.00) 16.89 (1.02) 16.58 (1.01) 16.41 (0.92) Age Started Smoking13.17 (2.27) 14.80 (1.58) Age Daily Smoker14.37 (2.14) Cig per Day10.89 (6.24) Cig per Week66.07 (43.48) 9.27 (6.95) Dependence (FTND)3.03 (2.39) 0.26 (0.56) 13 On average: Weekly smokers have made 1.8 quit attempts (SD = 1.23) Daily smokers have made 5.0 quit attempts (SD = 10.57)

14. SRNT Conference, 2013 Results : Relative Risk Daily smokers rate relative risk significantly higher than all other smoking groups (p <.001) No impact of measure => no optimistic bias 14 5 (smoking status) x 2 (measure) Multi-Factorial ANOVA Significant main effect of smoking status, F(4,597) = 57.53, p<.001, ŋ p 2 =.28

15. SRNT Conference, 2013 Results : Relative Health Risk Main effect of smoking status only (p <.001) Daily smokers rate relative risk significantly higher than all other smoking groups (p <.001) No impact of measure => no optimistic bias 15 5 (smoking status) x 2 (measure) Multi-Factorial ANOVA

16. SRNT Conference, 2013 Results : Relative Addiction Risk Main effect of measure (p <.05) For non-smokers only Main effect of smoking status (p <.001) Daily smokers rate relative addiction risk significantly higher than all other smoking groups (p <.001) No impact of measure within the smoking groups => no optimistic bias 16 5 (smoking status) x 2 (measure) Multi-Factorial ANOVA

17. SRNT Conference, 2013 Results : Avoid Health Risk Thoughts Clear distinction between smokers and non-smokers Daily smokers avoid thinking about health-risks to a greater extent than ex-smokers (p <.05), experimental (p <.001) and never smokers (p <.001) Weekly smokers also score higher than experimental and never (p <.05) 17 5 (smoking status) Factorial ANOVA Significant main effect of smoking status, F(4,579) = 28.03, p<.001, ŋ p 2 =.16

18. SRNT Conference, 2013 Results : Perceived Harm Significant main effect of measure (p<.001) Lower estimates were given for immediate harm regardless of smoking status Significant main effect of smoking status (p<.001) Daily and weekly smokers differ significantly from never (p<.001) and experimental (p<.01) smokers. 18 5 (smoking status) x 2 (measure) Multi-Factorial ANOVA

19. SRNT Conference, 2013 Results : DOSPERT Scales 19

20. SRNT Conference, 2013 Summary Results support the idea that risk is an important factor in adolescent smoking, but... Challenge the contention that adolescent smokers are not generally aware of the risks associated with smoking, yet.... Smokers do appear to exhibit an optimistic harm- related bias which illustrates the importance of understanding the context of the risk assessment (i.e. long-term vs. short-term risk) 20

21. SRNT Conference, 2013 Conclusion Adolescent smokers generally avoid health-related thoughts to a greater extent than non-smokers, which suggests that some implicit or habitual cognitive avoidance process is triggered when making a smoking-related decision Future Research Comparison of risk profiles across different age groups in order to determine the developmental nature of the understanding of perceived risk Further examination of the DOSPERT risk assessment measure in adolescents 21

22. SRNT Conference, 2013 References Blais, A.-R., & Weber, E. U. (2006). A Domain-Specific Risk-Taking (DOSPERT) scale for adult populations. Judgment and Decision Making, 1(1), 33-47. Borland, R. (1997). What do people's estimates of smoking related risk mean? Psychology & Health, 12(4), 513-521. Brady, S. S., Song, A. V., & Halpern-Felsher, B. L. (2008). Adolescents report both positive and negative consequences of experimentation with cigarette use. Preventive Medicine: An International Journal Devoted to Practice and Theory, 46(6), 585-590. Figner, B., Mackinlay, R. J., Wilkening, F., & Weber, E. U. (2009). Affective and deliberative processes in risky choice: Age differences in risk taking in the Columbia Card Task. Journal of Experimental Psychology: Learning, Memory, and Cognition, 35(3), 709-730. Gerrard, M., Gibbons, F. X., Benthin, A. C., & Hessling, R. M. (1996). A longitudinal study of the reciprocal nature of risk behaviors and cognitions in adolescents: What you do shapes what you think, and vice versa. Health Psychology, 15(5), 344-354. Lewis-Esquerre, J., Rodrigue, J. R., & Kahler, C. W. (2005). Development and validation of an adolescent smoking consequences questionnaire. Nicotine & Tobacco Research, 7(1), 81-90. Romer, D., & Hennessy, M. (2007). A biosocial-affect model of adolescent sensation seeking: The role of affect evaluation and peer-group influence in adolescent drug use. Prevention Science, 8(2), 89-101. Schoenbaum, M. (1997). Do smokers understand the mortality effects of smoking? Evidence from the health and retirement survey. American Journal of Public Health, 87(5), 755-759. Slovic, P. (1998). Do Adolescent Smokers Know the Risks? Duke Law Journal, 47(6), 1133-1141. Slovic, P. (2001). Cigarette smokers: Rational actors or rational fools? In P. Slovic (Ed.), Smoking: Risk, perception, & policy. (pp. 97-124). Thousand Oaks, CA US: Sage Publications, Inc. Sutton, S., & Bolling, K. D. (2003). Adolescents' perceptions of the risks and prevalence of smoking. Zeitschrift für Gesundheitspsychologie, 11(3), 107-111. Viscusi, W. K. (1992). Smoking: Making the risky decision. New York, NY US: Oxford University Press. Weinstein, N. D. (2001). Smokers' recognition of their vulnerability to harm. In P. Slovic (Ed.), Smoking: Risk, perception, & policy. (pp. 81-96). Thousand Oaks, CA US: Sage Publications, Inc. 22

23. 23 Thank you for your attention Questions Louise Hopper School of Psychology, TCD hopperl@tcd.ie Acknowledgement: This research was funded by a post graduate scholarship from Trinity College Dublin.