# Smoking: Risk, Perception, & Policy

Books

### Edited by: Paul Slovic

• Chapters
• Front Matter
• Back Matter
• Subject Index

## Preface

American smokers consume about 500 billion cigarettes every year. More than 400,000 deaths annually are attributed to this consumption, making smoking the single most preventable cause of premature mortality in the United States. According to statistics from the World Health Organization, the picture is similar worldwide, where approximately 4 million people die annually from tobacco use, a figure that is predicted to rise to 10 million by 2030 if current trends continue. The majority of smokers start young, before age 18. In the United States, some 3,000 children and young people begin to smoke each day.

The past decade has witnessed a stream of important new developments in our understanding of cigarette smoking and its harmful consequences. There has been growing appreciation of the health effects of breathing secondhand smoke and of the effects on the fetus when a pregnant woman smokes. Most recently, a study has observed effects of nicotine dependence in 12- and 13-year-olds after only days or weeks of light smoking, a very surprising and disturbing finding (DiFranza et al, 2000). Also in the past decade, release of heretofore confidential documents of the tobacco companies has revealed a long history of attempts to attract young people to cigarettes, promote nicotine dependence, and conceal the risks (Glantz, Slade, Bero, Hanauer, & Barnes, 1996).

Another important change in regard to tobacco use in recent years has been in our understanding of the ways in which the risks of smoking are perceived by young people on the threshold of deciding whether or not to smoke and by adults who do and do not smoke. An influential book by economist Kip Viscusi (1992b) has raised the key question pertaining to youth: “At the time when individuals initiate their smoking activity, do they understand the consequences of their actions and make rational decisions?” (p. 11).

Viscusi's book, titled Smoking: Making the Risky Decision, addressed this question. After examining the responses from a national survey of more than 3,000 persons, he concluded that people greatly overestimate the risks posed by smoking, a finding he attributed to the large volume of information about these risks communicated by the government and the news media.

Viscusi argued that his data support a rational learning model in which consumers respond appropriately to information and make trade-offs between the risks and benefits of smoking. With respect to youth, he asserted that his findings “strongly contradict the models of individuals being lured into smoking at an early age without any cognizance of the risks” (p. 143). He further concluded that young people are so well-informed that there is no justification for informational campaigns designed to boost their awareness. Finally, Viscusi observed that social policies that allow smoking at age 18 “run little risk of exposing uninformed decision makers to the potential hazards of smoking” (p. 149). Viscusi's data and conclusions thus appear to lend support to the defense used by cigarette companies in lawsuits brought against them by diseased smokers: “These people knew the risks and made informed, rational decisions to smoke.”

Viscusi's conclusions did not ring true to me. Several deficiencies in his methodology came immediately to mind. First, the principal question he relied upon asks about risks to smokers in general, not to the respondent as smoker. Weinstein (1987) and other researchers have shown repeatedly that people see themselves as being less at risk from hazards than they see other people, a phenomenon referred to as optimism bias.

Second, Viscusi did not consider the repetitive nature of cigarette smoking and the cumulative nature of its risks. Smoking takes place one cigarette at a time, and it seems likely that smokers perceive little or no risk from smoking individual cigarettes despite acknowledging the cumulative risks as very high. A third problem, related to the second, is Viscusi's failure to assess young people's perceptions of the risks of becoming addicted to smoking and thus smoking more cigarettes than they ever intended to consume.

Prompted by a research paper by Patrick Jamieson, Kathleen Hall Jamieson, Dean of the Annenberg School for Communication at the University of Pennsylvania and director of the Public Policy Center at the Annenberg School, had similar doubts and concerns about the knowledge base of adolescent smokers and presmokers. Seeing a need for the development and communication of better messages regarding the dangers of smoking, Dean Jamieson enlisted Daniel Romer and Patrick Jamieson of the Annenberg School, along with Neil Weinstein and myself, in a research project aimed at improving our understanding of the attitudes, beliefs, feelings, and perceptions of risk that young people and adults associate with smoking. We designed two extensive surveys and conducted them by telephone in 1999 and 2000. More than 4,000 persons ages 14 and older were interviewed. The findings from these new surveys, presented in Chapters 2, 3, 4, 6, 7, and 10, form the core of this book.

In Chapter 2, Patrick Jamieson and Daniel Romer describe the methodology for the two surveys and present demographic profiles and smoking patterns of the respondents. Between ages 14 and 22, reported use of cigarettes increased greatly. Of particular interest is the finding that, across all age categories, respondents in Survey 2 could name only about one or two of the many illnesses that result from smoking.

In Chapter 3, Jamieson and Romer examine risk perceptions of individuals aged 14–22 who participated in Survey 1. They did not find any clear or consistent pattern of risk overestimation, in contrast to Viscusi's earlier conclusions. Although some risks of smoking were recognized, many were not. There was no consistent and realistic sense of the addictive nature of smoking among these respondents, and there was a failure to appreciate how risky smoking is when compared with risks from guns, car accidents, alcohol, and drugs.

In Chapter 4, Romer and Jamieson explore in depth the role of risk perception in initiation of smoking and progression toward regular use of tobacco. Data from Survey 2 indicate that heightened perception of risk does not deter young people in the 14–22 age range from starting or continuing smoking. Perceived health risks were found to play a much greater role for adult smokers. Overall, risk perception played a larger role in decisions to stop smoking than in decisions to start. Adults' decisions to quit appeared to be more sensitive to immediate or short-term risks than were young persons' decisions to quit. Concerns about the risks of secondhand smoke influenced decisions about quitting for both young people and adults.

The analyses in Chapter 4 also confirm the central role of affective feelings in determining risk perception. Among survey respondents, positive images and feelings were associated with lower risk perceptions and increased belief in the ease of quitting. Risk perception did not influence smoking initiation apart from feelings. In other words, the decision to try smoking appeared to be driven primarily by the degree to which feelings toward smoking were favorable.

In Chapter 6, I use data from Survey 2 to define further the importance of feelings identified in the earlier chapters by Romer and Jamieson. I introduce a theoretical framework to guide analyses about the role of affect (e.g., favorable and unfavorable feelings) in determining judgment and decisions. I then use this framework, in concert with the survey data, to argue that smokers' decisions are based upon intuitive affect-based thinking, rather than upon the kind of analytic model of reasoning assumed by Viscusi. The individuals surveyed claimed they were not thinking about how smoking might affect their health when they began to smoke; instead, they were focused on trying something new and exciting. Very few smokers originally expected to be smoking for very long, even those who currently have been smoking for many years. A substantial majority of smokers planned to quit and expected to do so during the coming year, regardless of how many times they had unsuccessfully attempted to quit in the past. A high percentage of adult and youth smokers characterized themselves as addicted to cigarettes. When asked, “If you had it to do over again, would you start smoking?” more than 80% of the smokers said that they would not.

“At the time when individuals initiate their smoking activity, do they understand the consequences of their actions and make rational decisions?” The results presented in Chapter 6 lead me to argue that the answer to this central question of Viscusi's is no. When individuals decide to begin smoking, they rely on their feelings and not on analytic thinking. As a result, they do not understand the consequences of their actions and do not make decisions that are true to their future preferences. Reliance on affective feelings is typically a powerful form of rationality. However, it leads people astray when they make decisions about smoking. Borrowing from Amartya Sen's (1977) critique of economic theory, I thus characterize smokers as “rational fools.”

The importance of affect is further demonstrated in Chapter 7 by Romer and Jamieson, who use data from Survey 2 to examine the influence of cigarette advertising on adolescents' decisions to start smoking. Reported exposure to advertising was found to be linked to the prevalence of two images of smoking: popularity and relaxation. Persons for whom relaxation images were more favorable exhibited lower perceptions of smoking risks. These findings suggest that, by creating favorable imagery and positive affect toward smoking in young people, advertising lays the groundwork for the subsequent initiation of smoking behavior. As these favorable images become shared in peer groups, social support is built for smoking. Exposure to antismoking messages does not seem to be successful in countering the favorable images of smoking cultivated by cigarette advertising and does not prevent the initiation of smoking.

In Chapter 10, Romer, Jamieson, and R. Kirkland Ahern use data from both surveys to demonstrate a paradox that they term the “catch-22 of smoking and quitting.” This paradox results from the incompatible consequences of the belief that one can quit smoking at any time. This optimistic belief motivates smokers to attempt to quit. However, the presumption that it is easy to quit helps young people start smoking, which all too often leads to addiction, which undermines their goal of quitting. Romer and colleagues point out the challenges this belief pattern presents for anyone attempting to design communication programs that will both reduce the likelihood that nonsmokers will start and motivate current smokers to quit.

The remaining chapters place the Annenberg survey results in context and explore their implications for smoking-control policies. In Chapter 1, Jonathan Samet presents a thorough overview of the vast amount of data on the risks of tobacco bacco smoking. He describes the risks to both active and passive smokers—including the fetus, infants, and children—as well as risks to adults.

What is known as optimism bias plays an important role in smokers' risk perceptions, and Neil Weinstein reviews the literature on this topic in Chapter 5. He shows that the apparent underestimation or overestimation of risk depends on how risk perceptions are assessed. There is no consistent pattern in the accuracy of smokers' numerical estimates of risk magnitudes; accuracy with this type of question depends entirely on the health outcome rated (e.g., lung cancer cases versus all deaths due to smoking). Some of these numerical judgments are overestimates and some are underestimates. Responses to other types of risk questions show that smokers do acknowledge that smokers face increased health risks. However, they judge the size of the increase in risks to be smaller and less well established than do nonsmokers. Finally, smokers resist acknowledging the personal relevance of the risks: They tend to believe that, compared with other smokers, they themselves are less at risk of becoming addicted or suffering health effects, and they claim that their own risks are only slightly greater than those of the average person. The accumulated data indicate that, despite public attention to the hazards of smoking, smokers minimize the magnitude of their personal vulnerability.

Cigarettes and other forms of tobacco are addicting. In Chapter 8, Neal L. Benowitz reviews the general aspects of nicotine dependence. He also relates this dependence to the progression of tobacco use among young people. He observes that young people underestimate the addictive nature of tobacco and the risk that they will become addicted, and thus underestimate the risk that they will incur tobacco-related disease. Thus children and teenagers become addicted to nicotine before they are able to appreciate fully the consequences of their behavior.

Benowitz's observations are placed in theoretical perspective by George Loewenstein in Chapter 9. Loewenstein views addiction as an extreme example of a wide range of behaviors that are controlled by “visceral factors” such as hunger, thirst, sexual desire, pain, and, with addiction, craving for a drug. Of particular importance is the fact that people underestimate the impact on their own behavior of visceral factors they will experience in the future. Thus, with smoking, it is difficult if not impossible to anticipate the motivational force of the craving for cigarettes that one will experience once one is addicted to cigarettes. I draw heavily on this visceral account in my analysis of the rationality of smoking decisions in Chapter 6.

The final section of this book looks at the legal and policy implications of what we have learned about smoking attitudes, perceptions, and behaviors. In Chapter 11, Jon D. Hanson and Douglas A. Kysar describe the problem of market manipulation that emerges as a result of nonrational cognitive tendencies among individuals and self-interested economic behavior among tobacco companies. They argue that tobacco firms' marketing, promotional, and public relations efforts have led to countless manipulative strategies to lower consumer risk perceptions and elevate product demand. They further contend that legal regulatory efforts that ignore or discount the effects of market manipulation fail to result in socially desirable levels of tobacco use. They propose that a crucial first step toward effective legal regulation of smoking would be the creation of an “enterprise liability” mechanism that would force cigarette manufacturers to incorporate the health costs of smoking into product prices.

In the final chapter, Richard Bonnie draws on findings from Survey 2 and a 1994 Institute of Medicine report titled Growing Up Tobacco Free (Lynch & Bonnie, 1994) to argue for a youth-centered strategy for preventing tobacco-related disease and death. To be successful, such a strategy must encompass measures for reducing the accessibility of tobacco products to young people and increasing their cost. It must also alter the social factors that encourage consumption. Bonnie reviews a number of actions recommended in the Institute of Medicine Report, such as raising cigarette prices, allowing state and local governments to regulate promotion and advertising of tobacco products, and improving enforcement of restrictions on youth access. He also calls upon the U.S. Congress to enact a specific regulatory statute for tobacco products, as recommended in the Institute of Medicine report.

In summary, the data and arguments presented in this book paint a portrait of cigarette smokers that is far different from the one created by Viscusi in 1992. It is hard to defend the view of the beginning smoker as well-informed and rational. Reliance upon feelings of the moment, rather than understanding and analysis of the risks, leads young people to make decisions that they view later as mistakes. Law and policy should give careful consideration to the implications of this new portrayal.

## Acknowledgments

Patrick Jamieson and Dan Romer gratefully acknowledge support from the Robert Wood Johnson Foundation for the first tobacco survey. Thanks also go to the following persons for their advice and assistance in the design and execution of the surveys: Chris Adasiewicz, Dr. Suzanne Fegley, Dr. Martin Fishbein, Dr. Loretta Jemmott, Dr. Mary McIntosh, and Andy Weiss. In addition, the following staff at the Annenberg School and Public Policy Center are gratefully acknowledged for their help in completing the project: Sharon Black, Josh Gesell, Steve Hocker, Janna Robbins, and Deborah Stinnett. We also thank Judy Selhorst for her careful editing and assistance in finalizing the manuscript.

At Decision Research, statistical analysis for Chapter 6 was performed by C. K. Mertz. Invaluable secretarial assistance with the entire volume manuscript was provided by Leisha Wharfield, Janet Douglas, Janet Kershner, and Mona Bronson.

• ## Appendix A: Survey 1: Youth Perception of Tobacco Risk, Summer 1999

Selection Interview

Hello, my name is ___, calling for Princeton Survey Research. We are conducting a national opinion survey about some important health care issues. May I please speak with an adult age 18 or older who lives in this household?

• First, in order to be sure we are representing the opinions of people in different kinds of households, could you please tell me how many people age 45 or older currently live in this household?

[Record number: 0–98]

99 (Refused)

• How many people between the ages of 23 and 44 now live in this household?

[Record number: 0–98]

99 (Refused)

• How many people between the ages of 14 and 22 now live in this household?

[Record number: 0–98; terminate if 0] 99 (Refused) [Terminate]

• ([If N3 > 1:] Which of these people age 14 to 22 had the most recent birthday?) Is this person a male or female?

• Male
• Female
• (Refused) [Terminate]
• How old is this person?

[Record number: 14–22]

98 (Other) [Terminate]

99 (Refused) [Terminate]

Ask N6-N7 if selected child is 14–15 [N5 = 14–15]:

• May I please speak with the parent or legal guardian of this (Insert age [from N5])-year-old ([N4 = 1:] boy | [N4 = 2:] girl)?
• Yes
• No [Terminate]
• We are conducting this study for a large university interested in health care issues facing young people today. This survey is completely confidential. We would like to interview your (Insert age)-year-old (son | daughter). Would it be possible to talk with (him | her) now for a short interview?
• Yes
• No [Terminate]

Ask N8 if selected child is 16–22 [N5 = 16–22]:

• May I please speak with this (Insert age)-year-old (male | female)?
• Yes
• No [Terminate]

(If new respondent:) Hello, my name is ___, calling for Princeton Survey Research. We are conducting a national opinion survey about some important health care issues. This survey is completely confidential.

• Just to confirm, what is your age?

[Record number: 14–22]

14–15

16–17

18–20

21–22

98 (Other) [Terminate]

99 (Refused) [Terminate]

• As I mentioned before, your responses to this survey will be kept completely confidential. Have you ever smoked a cigarette, even one or two puffs?
• Yes
• No
• (Refused) [Terminate]
• During the past 30 days, have you smoked any cigarettes?
• Yes [Select Smoker]
• No [Select Nonsmoker]
• (Refused) [Terminate]

Main Interview

• Respondent's sex:
• Male
• Female
• On another subject, are you currently in school?
• Yes
• No
• (Refused)

Ask D3 if currently in school [D2 = 1]:

• What grade or level of school are you in? (Do not read responses)
• High school freshman
• High school sophomore
• High school junior
• High school senior
• Technical or vocational school after high school
• Junior college
• Four-year college
• (Refused)

Ask D4 if not currently in school [D2 = 2–9]:

• What is the last grade or level of school you completed? (Do not read responses)
• High school freshman
• High school sophomore
• High school junior
• High school senior
• Technical or vocational school after high school
• Junior college
• Four-year college
• (Refused)

• Now I would like you to think about people who smoke cigarettes. Out of every 100 cigarette smokers, how many do you think will (Insert)?

[Randomize items:]

• get lung cancer because they smoke
• have heart problems, like a heart attack, because they smoke
• die from a smoking-related illness

[Record number: 0–100]

• (Don't know)
• (Refused)
• I just asked you about smokers. Now I would like you to think about nonsmokers. Out of every 100 nonsmokers, how many do you think will get lung cancer?

[Record number: 0–100]

• (Don't know)
• (Refused)
• Some people say that cigarette smoking (Insert). Have you heard this?
• will most likely shorten a person's life
• is dangerous to a person's health
• is bad for a person's health but not dangerous
• is not bad for a person's health
• makes it easier for some people your age to keep their weight down makes it easier for some people your age to relax and have a good time with friends
• Yes
• No
• (Don't know)
• (Refused)
• In your opinion, is (Insert) very risky for a person's health, somewhat risky, only a little risky or not at all risky?
• smoking
• smoking every day
• smoking only once in a while, say at parties or with friends
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)
• Please tell me how much you agree or disagree with the following statements. Here is the (first | next) statement: (Insert) Do you strongly agree, somewhat agree, somewhat disagree or strongly disagree?

[Randomize items:]

• If someone wants to smoke, they should be able to because it is their personal choice.
• The harmful effects of cigarettes have been exaggerated.
• Strongly agree
• Somewhat agree
• Somewhat disagree
• Strongly disagree
• (Don't know)
• (Refused)
• In your opinion, is it true or false that smoking two or more packs of cigarettes a week (Insert), or don't you know enough to say?

[Randomize items:]

• will most likely shorten a person's life
• increases a person's chances of getting lung cancer
• True
• False
• (Don't know)
• (Refused)

[Randomize Q7-Q8:]

Ask Q7 if think smoking increases lung cancer risk [Q6b = 1]:

• On average, how much does smoking two or more packs a week increase a person's chances of getting lung cancer? Would you say smokers are about twice as likely to get lung cancer, five times as likely, 10 to 20 times or 50 times as likely?
• Twice
• Five times
• 10 to 20 times1
• 50 times
• (Don't know)
• (Refused)

Ask Q8 if think smoking shortens life expectancy [Q6a = 1]:

• On average, by how many years does smoking two or more packs a week shorten a person's life? Would you say a few months, one year, five to 10 years or 20 years?
• Few months
• One year
• Five to 10 years2
• 20 years
• (Don't know)
• (Refused)

• For each of the following statements, please tell me if you think it is true or false or if you don't know enough to say.

[Randomize items:]

• Women who smoke while pregnant increase the chances their baby will be born with health problems.3
• Each year thousands of nonsmokers die from breathing other people's smoke.4
• Each year more people die from gunshots and car accidents than die from smoking.5
• True
• False
• (Don't know)
• (Refused)
• On another subject, would you say (Insert) is very risky for a person's health, somewhat risky, only a little risky or not risky at all?

[Randomize items:]

• getting drunk regularly
• smoking marijuana regularly
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)

[No Q11]

• Which of these two statements comes closer to what you think? You can just tell me the letter of the statement. (Read responses 1–2:)
• A—People your age who smoke can damage their lungs by smoking for just a few years.6
• B—People your age cannot damage their lungs from smoking because you have to smoke for many years for that to happen.
• (Don't know)
• (Refused)
• For each of the following statements, please tell me if you think it is true or false or if you don't know enough to say.

[Randomize items:]

• Smoking makes it harder for people your age to participate in athletics.7
• Smoking makes it easier for some people your age to keep their weight down.
• Smoking makes it easier for some people your age to relax and have a good time with friends.
• True
• False
• (Don't know)
• (Refused)
• In your opinion, once someone is smoking two or more packs a week, how easy or hard is it for them to quit and never smoke again? Is it … (Read responses 1–4:)
• A—Very easy, and anyone who wants to can
• B—Hard, but most people can do it if they really try
• C—Very difficult, and most cannot do it
• D—Almost impossible, and only a few will be able to do it
• (Don't know)
• (Refused)
• In your opinion, is it true or false that a chemical in cigarettes makes smoking addictive, or don't you know enough to say?
• True8
• False
• (Don't know)
• (Refused)

[No Q16]

• I would like you to imagine four people your age. Each now smokes two or more packs a week but says they want to quit and will do so sometime in the next five years. Of these four people, how many do you think will actually quit in the next five years?

[Record number: 0–4]

• None
• 19
• 2
• 3
• All 4
• (Don't know)
• (Refused)
• Of all the deaths in one year, do you think more people die from (Insert)?

[Randomize items:]

• A—smoking or from B—not exercising10
• A—smoking or B—abusing alcohol and drugs11
• A
• B
• (Don't know)
• (Refused)
• As I read you the names of some movie actors and actresses, tell me if they smoke in their personal lives, do not smoke in their personal lives or if you don't know enough to say.

[Randomize items:]

• Winona Ryder
• Leonardo DiCaprio
• Sylvester Stallone
• Smoke
• Do not smoke
• (Never heard of person)
• (Don't know if smoke)
• (Refused)

Ask Q19-Q21 if smoked in past month [N10 = 1]:

• Next I have some questions about you and your behavior. Some people say that by smoking you are increasing the chances you will get lung cancer when you are older. Do you agree or disagree, or don't you know enough to say?
• Agree
• Disagree
• (Don't know)
• (Refused)
• Do you think smoking is very risky for your personal health, somewhat risky, not too risky or not at all risky?
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)
• If you decided you wanted to quit smoking and never start again, how easy or hard do you think it would be for you to do? Would it be … (Read responses 1–4:)
• A—Very easy
• B—Hard, but you could do it if you tried
• C—Very difficult, and you might not be able to do it
• D—Almost impossible
• (Don't know)
• (Refused)

• Do your parents or any of the adults you live with smoke?
• Yes
• No
• (Don't know)
• (Refused)

Ask Q23 if parents smoke [Q22 = 1]:

• How would you rate their health? Very good, good, poor or very poor?
• Very good
• Good
• Poor
• Very poor
• (Don't know)
• (Refused)

• Have you ever known someone who (Insert)?
• died of lung cancer or another disease because they smoked
• once smoked but quit and never smoked again
• Yes
• No
• (Don't know)
• (Refused)

[No Q25]

Ask Q26-Q26A if smoked in past month [N10 = 1]:

• How frequently did you smoke cigarettes in the past 30 days? (Read responses 1–5:)
• A—Less than one cigarette a day
• B—One to five a day
• C—A half a pack a day
• D—A pack a day
• E—More than a pack a day
• (Refused)
• What brand of cigarettes do you smoke the most? (Do not read responses)
• Benson & Hedges
• Camel
• Kool
• Marlboro
• Merit
• Newport
• Salem
• Vantage
• Winston
• (Other) [Record verbatim]
• (Don't know)
• (Refused)

Ask Q27 if did not smoke in past month but have smoked [N10 = 2 and N9A = 1]:

• Which of the following best describes you? If you want, you can just tell me the letter. (Read responses 1–4:)
• A—You tried smoking just once or twice.
• B—You smoke occasionally.
• C—You smoke regularly, that is, two or more packs a week.
• D—You used to smoke two or more packs a week but now smoke less.
• (Refused)

Ask Q28 if smoked in past month but less than a half a pack or more a day [Q26 = 1,2,9]:

• Have you ever smoked two or more packs of cigarettes a week?
• Yes
• No
• (Refused)

Ask Q29-Q33 if smoked in past month [N10 = 1]:

• Do you plan to quit smoking?
• No
• (Don't know)
• (Refused)
• About how many times, if any, have you quit smoking?

[Record number: 0–97]

• None
• 1–2
• 3–5
• 6–10
• More than 10
• (Don't know)
• (Refused)
• How long have you smoked? For a few months or less, for about a year, for a few years or for more than a few years?
• Few months or less
• A year
• Few years
• More than a few years
• (Don't know)
• (Refused)
• Do you consider yourself addicted to cigarettes or not?
• Yes
• No
• (Don't know)
• (Refused)
• Which of these statements comes closer to what you think? (Read responses 1–2:)
• A—You might have damaged your health by smoking.
• B—You have not smoked long enough to do damage to your health.
• (Don't know)
• (Refused)

• I have just a few more questions to help us understand the people who took part in our survey. Are you yourself of Hispanic origin or descent, such as Mexican, Puerto Rican, Cuban or some other Spanish background?
• Yes
• No
• (Don't know)
• (Refused)
• What is your race? (If Hispanic [D5 = 1]:) Are you white Hispanic, black Hispanic or some other race? (Else:) Are you white, black, Asian or some other race?
• White
• Black
• Asian
• Other
• (Don't know)
• (Refused)

That completes our survey. Thank you very much for taking time to answer our questions. We really appreciate your time. Have a nice (day | evening).

Notes

1. “Men who smoke increase their risk of death from lung cancer by more than 22 times. … Women who smoke increase their risk of dying from lung cancer by nearly 12 times” (Centers for Disease Control and Prevention, 1996, citing “Cigarette Smoking-Attributable Mortality,” 1993).

2. “On average, smokers die nearly seven years earlier than nonsmokers” (Centers for Disease Control and Prevention, 1996, citing unpublished data from the CDC Office on Smoking and Health, 1994).

3. “Women who use tobacco during pregnancy are more likely to have adverse birth outcomes, including babies with low birth weight, which is linked with an increased risk of infant death” (Centers for Disease Control and Prevention, 2000b).

4. “Annually, exposure to secondhand smoke… causes an estimated 3,000 deaths from lung cancer” (Centers for Disease Control and Prevention, 1996, citing U.S. Environmental Protection Agency, 1992).

5. Smoking kills more people each year than gunshots and car accidents combined (McGinnis & Foege, 1993, as cited in Centers for Disease Control and Prevention, 2000b).

6. “Cross-sectional and longitudinal data show that smoking also adversely affects lung function in children and adolescents” (Centers for Disease Control and Prevention, 1994a, p. 17).

7. “Even among young people trained as endurance runners, smoking appears to compromise physical fitness in levels of both performance and endurance” (Centers for Disease Control and Prevention, 1994a, p. 28).

8. “Tobacco-delivered nicotine can be highly addictive. Each year, nearly 20 million people try to quit smoking in the United States, but only about 3 percent have long-term success” (Centers for Disease Control and Prevention, 1994a, p. 31).

9. “Of daily smokers who think that they will not smoke in five years, nearly 75 percent are still smoking five to six years later” (Centers for Disease Control and Prevention, 2000a).

10. Smoking kills more people each year than lack of exercise (McGinnis & Foege, 1993, as cited in Centers for Disease Control and Prevention, 2000b).

11. Smoking kills more people each year than abuse of alcohol and drugs combined (McGinnis & Foege, 1993, as cited in Centers for Disease Control and Prevention, 2000b).

## Appendix B: Survey 2: Perception of Tobacco Risk, Fall 1999, Age 14–22 Version

Selection Interview

Hello, my name is ___, calling on behalf of the University of Pennsylvania.

We are conducting a national opinion survey about some important health issues. May I please speak with an adult age 18 or older who lives in this household?

• First, in order to be sure we are representing the opinions of people in different kinds of households, could you please tell me how many people age 45 or older currently live in this household?

[Record number: 0–97]

• (Don't know)
• (Refused)
• How many people between the ages of 23 and 44 now live in this household?

[Record number: 0–97]

• (Don't know)
• (Refused)
• How many people between the ages of 14 and 22 now live in this household?

[Record number: 0–97]

• None [Screen out: QN3: No teens age 14–22]
• (Don't know) [Screen out: QN3: No teens age 14–22]
• (Refused) [Screen out: QN3: No teens age 14–22]

IF N1 = 1–97 OR N2 = 1–97 CONTINUE INTERVIEW, ELSE THANK & TERMINATE (S/O NO ONE AGE 23+ INHH)

• ([If (N3 > 0:] Which of the people age 23 or older had the most recent birthday?) Is this person male or female?
• Male
• Female
• (Refused) [Refused Information QN4 = Terminate]
• How old is this person?
• 14–22 [Screen out: QN5: Ineligible Age]
• 23–97
• 98 (Don't know) [DK/Refused Age QN5 = Terminate]
• 99 (Refused) [DK/Refused Age QN5 = Terminate]

Ask N6-N7 if selected child is 14–15 [N5 = 14–15]:

• May I please speak with the parent or legal guardian of this (Insert age [from N5])-year-old ([N4 = 1:] boy | [N4 = 2:] girl)?
• Yes
• No [N6 refused—CB for conversion—if refuse again then terminate]
• We are conducting this study on behalf of the University of Pennsylvania about some important health issues facing young people today. This survey is completely confidential. We would like to interview your (Insert age)-year-old (son | daughter). Would it be possible to talk with (him | her) now for a short interview?
• Yes
• No [N7 refused—CB for conversion—if refuse again then terminate]

Ask N8 if selected child is 16–22 [N5 = 16–22]:

• May I please speak with this (Insert age)-year-old (male | female)?
• Respondent already on phone [Continue with N9]
• Respondent coming to phone
• Schedule callback
• (Refused) [N8 refused—CB for conversion—if refuse again then terminate]

(If new respondent:) Hello, my name is ___, calling on behalf of the University of Pennsylvania. We are conducting a national opinion survey about some important health issues. This survey is completely confidential.

• Just to confirm, what is your age?

[Record number:]

• [Screen out: ineligible age]

CONTINUE INTERVIEW

• (Don't know) [Terminate]
• (Refused) [Terminate]

Main Interview

• Respondent's sex:
• Male
• Female
• On another subject, do you currently attend school either part-time or full-time?
• Yes
• No
• (Refused)

Ask D3 if currently attend school [D2 = 1]:

• What grade or level of school are you in? (Do not read responses)
• High school freshman
• High school sophomore
• High school junior
• High school senior
• High school degree
• One year of technical or vocational school after high school
• Two or more years of technical or vocational school after high school
• One year of college
• Two years of college, no degree
• Two years of junior college, associate's degree
• Three years of college, no degree
• Four-year college degree
• Graduate or professional school after college, no degree
• Graduate or professional school degree
• (Don't know)
• (Refused)

Ask D4 if not currently in school [D2 = 2–9]:

• What is the last grade or level of school you completed? (Do not read responses)
• High school freshman
• High school sophomore
• High school junior
• High school senior
• High school degree
• One year of technical or vocational school after high school
• Two years of technical or vocational school after high school
• One year of college
• Two years of college, no degree
• Two years of junior college, associate's degree
• Three years of college, no degree
• Four-year college degree
• Graduate or professional school after college, no degree
• Graduate or professional school degree
• (Don't know)
• (Refused)

Now on another topic …

[Randomly read-in “smoking” or “cigarette,” CATI identify in the data whether “smoking” or “cigarette” was inserted]

• When you hear the word (smoking | cigarette), what is the first thought or image that comes to mind?

[Record verbatim-coding, do not code this OE]

• How would you describe this image? Is it something very good, somewhat good, somewhat bad, or very bad?
• Very good
• Somewhat good
• (Don't know)
• (Refused)
• Next, please try to form an image in your mind of a person smoking a cigarette. Do you have an image of a person smoking? Tell me about this person. Is the person (Insert)?

[Randomize items:]

• Alone?
• Eating a good meal?
• Drinking?
• Just finishing something satisfying?
• Attractive?
• Sick?
• Relaxed?
• Happy?
• Anxious?
• Popular?
• A celebrity or famous person?
• Yes
• No
• (Don't know)
• (Refused)
• As I mentioned before, your responses to this survey will be kept completely confidential. Have you ever smoked a cigarette, even one or two puffs?
• Yes
• No
• (Don't know)
• (Refused)
• Now I want to ask about the last 30 days. In the last 30 days, have you:
• Smoked cigarettes of any kind? [Assign to smoking version]
• Smoked cigars of any kind?
• Used chewing tobacco of any kind?
• Yes
• No
• (Don't know)
• (Refused)
• Have you ever heard of flavored cigarettes called Bidis (Beedeez)?
• Yes
• No
• (Don't know)
• (Refused)
• [If yes to QS6:] Have you ever tried one?
• Yes
• No
• (Don't know)
• (Refused)
• [If yes to QS7:] Have you smoked one in the past 30 days?
• Yes [Assign to smoking version]
• No
• (Don't know)
• (Refused)
• [If yes to QS7:] How would you compare the experience to smoking regular cigarettes? More enjoyable, less enjoyable or about the same?
• More enjoyable
• Less enjoyable
• (Don't know)
• (Refused)

[Ask QS10 of “smokers” (QS5a = 1 OR QS8 = 1)orthose who have smoked cigars in past 30 days (QS5b = 1)]

• Do you consider yourself a smoker?
• Yes
• No
• (Don't know)
• (Refused)
• DUMMY QUESTION TO CLASSIFY SMOKER/NONSMOKER:
• Smoker (QS5a = 1 OR QS8 = 1 OR QS10 = 1)
• Nonsmoker (everybody else)
• To the best of your knowledge, what, if any, are the illnesses caused by smoking cigarettes? (Probe:) Anything else? (Probe until no further ideas come to mind.)
• Lung cancer
• Emphysema
• Heart disease
• Stroke
• Throat cancer
• Mouth cancer
• Diabetes
• Bronchitis
• Other (specify)
• (Don't know)
• (Refused)
• Now I would like you to imagine 100 cigarette smokers, both men and women, who smoked cigarettes for their entire adult lives. How many of these 100 people do you think will die from lung cancer?

[Record number: 0–100]

• (Don't know)
• (Refused)
• I just asked you about smokers. Now I would like you to imagine 100 nonsmokers, both men and women, who never smoked and don't live with smokers. How many do you think will die from lung cancer?

[Record number: 0–100]

• (Don't know)
• (Refused)
• Now I would like you to think again about 100 people who smoke cigarettes for their entire adult lives. All of these smokers will eventually die of something. Now consider the following 5 possible causes of death: automobile accidents, heart disease, stroke, lung cancer, and all other causes combined. Please tell me how many of the 100 cigarette smokers you think will die from (Insert)? OK. Now, how many of the (Insert remaining number) smokers will die from (Insert)? [Keep a running total to help R get to 100 by item e.] [For item e:] OK, you now have (Number remaining) smokers left. By your estimates, these smokers will die from all other causes not mentioned already. Is that about right? [If R wants to re-estimate earlier numbers, then allow to go back.]

[Randomize items a through c; always ask d then e last]

• automobile accidents
• heart disease
• stroke
• lung cancer
• all other causes combined

[Record number: 0–100]

• (Don't know)
• (Refused)
• In your opinion, [IF SMOKER (QZZ = 1) read “is your smoking,” if NONSMOKER (QZZ = 2) read “if you were a smoker, would your smoking”] (be) very risky for your health, somewhat risky, a little risky or not at all risky for your health?
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)
• In your opinion, would (Insert) be very risky for your health, somewhat risky, a little risky or not at all risky for your health?
• your smoking only once in a while, say at parties or with friends
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)

[No Q4A-Q4B]

• Please imagine how you would feel smoking a cigarette. [IF SMOKER (QZZ = 1) read “Does smoking a cigarette,” IF NONSMOKER (QZZ = 2) read “If you were to smoke a cigarette, would it”] make you feel … (Read list)
• Very good
• Somewhat good
• (Don't know)
• (Refused)
• How tense or relaxed would smoking a cigarette make you feel … (Read)
• Very tense
• Somewhat tense
• Neither tense nor relaxed
• Somewhat relaxed
• Very relaxed
• (Don't know)
• (Refused)
• Thinking about your best friend, does he or she smoke? [If no best friend:] Then think of the person who you would like to have as a best friend.
• Yes
• No
• Can't think of anyone
• (Don't know)
• (Refused)
• Thinking about everyone you have contact with in a typical day, how many would you say currently smoke? More than half, between a half and a quarter, less than one-quarter or just about no one?
• More than half
• Between a half and a quarter
• Less than one-quarter
• (Don't know)
• (Refused)
• Thinking about your friends and the people you spend time with, how many would you say currently smoke? More than half, between a half and a quarter, less than one-quarter, or just about no one?
• More than half
• Between a half and a quarter
• Less than one-quarter
• (Don't know)
• (Refused)

• How (do | would) your friends feel (about your smoking/if you smoked)? (Do | Would) they mostly approve, mostly disapprove, or about the same of both?
• Mostly approve
• About the same of both
• Mostly disapprove
• (Don't care)
• (Don't know)
• (Refused)
• Imagine someone who starts to smoke a pack of cigarettes a day at age 16. How much do you agree with the following statements about this person? The first one is (Insert). Do you strongly agree, somewhat agree, somewhat disagree, or strongly disagree?

[Randomize items:]

• There is usually no risk to the person at all 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.
• If someone wants to smoke, they should be able to because it is their personal choice.
• Strongly agree
• Somewhat agree
• Somewhat disagree
• Strongly disagree
• (Don't know)
• (Refused)

[Randomize order of Q6-Q7, within Q6 randomly ask Q6–1 or Q6–2, same for Q7, randomly ask Q7–1 or Q7–2]

• (Alternative 1). If you smoked a pack of cigarettes a day, how much do you think it would increase your chances of getting lung cancer? Would you say you would be no more likely to get lung cancer than if you did not smoke at all, twice as likely, five times as likely, 10 to 20 times or 50 times as likely?
• No more likely
• Twice as likely
• Five times
• Ten to 20 times
• 50 times
• (Don't know)
• (Refused)
• (Alternative 2). If you smoked a pack of cigarettes a day, how much do you think it would increase your chances of getting lung cancer? Would you say you would be no more likely to get lung cancer than if you did not smoke at all, twice as likely, three times as likely, five times as likely, or 10 or more times as likely?
• No more likely
• Twice as likely
• Three times
• Five times
• Ten or more times
• (Don't know)
• (Refused)
• (Alternative 1). If you smoked a pack of cigarettes a day, how much do you think it would shorten your life? Would you say not at all, by one year, five to 10 years, 15 years, or 20 years or more?
• Not at all
• One year
• Five to 10 years
• 15 years
• 20 years or more
• (Don't know)
• (Refused)
• (Alternative 2). If you smoked a pack of cigarettes a day, how much do you think it would shorten your life? Would you say not at all, by a few months, by one year, two or three years, or five to 10 years?
• Not at all
• A few months
• One year
• Two to three years
• Five to 10 years
• (Don't know)
• (Refused)
• How long, if ever, do you think it takes for smoking to seriously harm the health of a new smoker: A few minutes of smoking, a few weeks of smoking, one year, 5 years, more than 5 years of smoking, or does smoking not affect one's health?
• Does not affect health
• A few minutes of smoking
• A few weeks of smoking
• One year of smoking
• Five years of smoking
• More than five years of smoking
• (Don't know)
• (Refused)
• For each of the following statements, please tell me if you think it is true or false or if you don't know enough to say.

[Randomize items:]

• Each year thousands of nonsmokers of all ages die from breathing other people's smoke.
• Each year more people of all ages die from gunshots and car accidents than die from smoking.
• True
• False
• (Don't know)
• (Refused)
• On another subject, if you (Insert), do you think it would be very risky for your health, somewhat risky, a little risky or not risky at all for your health?

[Randomize items:]

• got drunk regularly
• smoked marijuana regularly
• never wore a seat belt when riding in a car
• ate a lot of foods that are high in fat
• Very risky
• Somewhat risky
• A little risky
• Not at all risky
• (Don't know)
• (Refused)

[No Q11-Q12]

[IF SMOKER (QZZ = 1) read “makes,” if NONSMOKER (QZZ = 2) read “would make”]

• For each of the following statements, please tell me if you think it is true or false or if you don't know enough to say.

[Randomize items:]

• Smoking (would) make(s) it harder for me to participate in athletics.
• Smoking (would) make(s) it easier for me to keep my weight down.
• Smoking (would) make(s) it easier for me to relax and have a good time with friends.
• True
• False
• (Don't know)
• (Refused)
• In your opinion, if you were to smoke a pack of cigarettes a day, how easy would it be for you to quit and never smoke again? (Read responses 1–4:)
• Very easy; you could quit with no trouble
• Hard, but you could do it if you really tried
• Very hard, you don't know that you could do it
• Almost impossible, you doubt that you could do it
• (Don't know)
• (Refused)

[No Q15-Q16]

• I would like you to imagine ten people your age who smoke a pack of cigarettes a day. All ten of these people SAY that they would like to quit in the next five years. How many of them do you think would actually quit permanently in the next five years?

[Record number: 0–10]

• (Don't know)
• (Refused)
• Of all the deaths in one year to people of all ages, do you think more people die from (A) smoking or (B) abusing alcohol and drugs?
• A—Smoking
• B—Abusing alcohol and drugs
• (Don't know)
• (Refused)
• Benson & Hedges
• Camel
• Kool
• Marlboro
• Merit
• Newport
• Salem
• Vantage
• Winston
• (Other) [Record verbatim]
• (VOL) None seen
• (VOL) Don't know
• (VOL) Refused
• Have you been to a bar, pub or microbrewery in the past six months?
• Yes
• No
• (Don't know)
• (Refused)
• [If yes to Q18B:] When you have been to a bar, pub or microbrewery in the past six months, has there been any entertainment sponsored by a cigarette company? [Note: Entertainment includes bands or acts]
• Yes
• No
• (Don't know)
• (Refused)
• For each of the following statements, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree.

[Randomize items:]

• If teenagers want to smoke, they should be able to because it is their personal choice.
• I can control how much of other people's cigarette smoke I am exposed to.
• Teenagers should be able to buy cigarettes if they want to.
• Advertising to discourage people from smoking is a good idea.
• The harmful effects of cigarettes have been exaggerated.
• Strongly agree
• Somewhat agree
• Somewhat disagree
• Strongly disagree
• (Don't know)
• (Refused)
• Some groups are running ads telling people why they shouldn't smoke. In the past month, do you remember hearing or seeing many, some or none of these ads?
• Many
• Some
• None
• (Don't know)
• (Refused)

Ask Q19-Q21 if smoked in past month [QZZ = 1]:

• When you first started to smoke, how much did you think about (Insert)? Did you think about this a lot, a little, or not at all?
• How smoking might affect your health?
• How smoking might affect the health of others around you?
• A lot
• A little
• Not at all
• (Don't know)
• (Refused)

[No Q19A-Q19B]

• How much do you think about the health effects of smoking now?
• A lot
• A little
• Not at all
• (Don't know)
• (Refused)
• Since you started smoking, have you heard of any health risks of smoking that you didn't know about when you started?
• Yes
• No
• (Don't know)
• (Refused)
• When you first started smoking, did you think more about how smoking would affect your future health or about how you were trying something new and exciting?
• Thought about trying something new and exciting
• Other
• (Don't know)
• (Refused)
• When you first started smoking, how long did you think you would continue to smoke? A few days, a few months, less than a year, one to five years, longer than five years or didn't you think about it?
• A few days
• A few months
• Less than a year
• One to five years
• Longer than five years
• (Refused)
• If you had it to do over again, would you start smoking?
• Yes
• No
• (Don't know)
• (Refused)
• Compared to the average smoker, do you think you are more likely to get sick from smoking, less likely to get sick from smoking, or that your chance of getting sick from smoking is about the same as the average smoker?
• More likely
• Less likely
• (Don't know)
• (Refused)
• Compared to the average smoker, do you (Insert)?

[Randomize items:]

• Smoke more cigarettes per week, fewer cigarettes per week, or about the same number?
• Smoke cigarettes with higher tar and nicotine levels, lower tar and nicotine levels, or about the same levels?
• Inhale more when you smoke, inhale less, or inhale about the same amount?
• Think you could quit smoking more easily, less easily, or about as easily?
• Think your lifestyle is more healthy, less healthy, or about the same?
• Think you are more influenced by cigarette ads, less influenced by cigarette ads, or about the same?
• More than the average smoker
• Same as the average smoker
• Less than the average smoker
• (Don't know)
• (Refused)

• [If under 23:] Do your parents or any adults you live with smoke? [If 23 or older:] Do your parents smoke?
• Yes
• No
• Farents no longer living
• (Don't know)
• (Refused)

Ask Q23 if parents smoke [Q22 = 1]:

• How would you rate their health? Very good, good, poor or very poor?
• Very good
• Good
• Foor
• Very poor
• (Don't know)
• (Refused)

• Have you ever known someone who (Insert)?
• died of lung cancer or another disease because they smoked
• really wanted to quit smoking but couldn't
• was a regular smoker who quit and never started again
• Yes
• No
• (Don't know)
• (Refused)

[No Q25]

Ask Q26-Q26F if smoked in past month [QZZ = 1]:

• How frequently did you smoke cigarettes in the past 30 days? Just tell me when I get to the right amount. (Read responses 1–7:)
• Less than one cigarette a day
• One to five a day
• Six to ten a day
• Eleven to fourteen a day
• Fifteen to nineteen a day
• Twenty a day
• More than twenty a day
• (Don't know)
• (Refused)
• What brand of cigarettes do you smoke the most? (Do not read responses)
• Benson & Hedges
• Camel
• Kool
• Marlboro
• Merit
• Newport
• Salem
• Vantage
• Winston
• (Other) [Record verbatim]
• (Don't know)
• (Refused)
• Where do you get most of your cigarettes?
• Vending machines
• Convenience stores like 7–11 or gas stations
• Supermarkets
• On the Internet
• From friends
• From relatives
• Other
• (Don't know)
• (Refused)
• How much does a pack of Marlboro cigarettes cost in your city or town? Are they about $1,$2 to $3,$3 to $4, or more? •$1
• $2 to$3
• $3 to$4
• More
• (Don't know)
• (Refused)
• How much do you spend per week on cigarettes? Just tell me when I get to right amount. $1 or less,$2 to $5,$6 to $12,$13 to $20,$21 to $30, or more than$30.
• $1 or less •$2 to $5 •$6 to $12 •$13 to $20 •$21 to $30 • More than$30
• (Don't know)
• (Refused)
• Suppose the price of cigarettes went up $1 per pack. Would the amount you smoked go down or would it stay the same? • Go down • Stay the same • Other • (Don't know) • (Refused) • For each of the following statements, please tell me if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree. • Smokers should have the right to smoke in public places. • I try to avoid smoking near people who think smoke is harmful. • [If under age 23:] I don't expect to live long enough for smoking to hurt me. • Strongly agree • Somewhat agree • Somewhat disagree • Strongly disagree • (Don't know) • (Refused) Ask Q27 if did not smoke in past month but have smoked [QS5a = 2 and QS4 = 1]: • You said earlier that you had not smoked cigarettes in the past month. Which of the following best describes you? If you want, you can just tell me the letter. (Read responses 1–3:) • A—You have tried smoking but never continued. • B—You smoke occasionally but not in the past month. • C—You used to smoke regularly but now smoke less. • (Don't know) • (Refused) Ask Q28 if smoked in past month but less than 11 cigarettes a day [Q26 = 1,2,3,8,9]: • Have you ever smoked a pack or more of cigarettes a day? • Yes • No • (Don't know) • Refused Ask Q29-Q33 if smoked in past month [QZZ = 1]: • Do you plan to quit smoking? • Yes/(Already have) • No • (Don't know) • (Refused) Ask Q29A if planning to quit [Q29 = 1] • When are you planning to quit? Is it in the next six months, six months to a year, or more than a year from now? • Next 6 months • 6 months to a year • More than a year from now • (Don't know) • (Refused) Ask Q29B if planning to quit in next year [Q29A = 1 or 2] • If we called you again in a year, would you guess you would have successfully quit smoking? • Yes • No • (Don't know) • (Refused) • About how many times, if any, have you tried to quit smoking? [Record number: 0–97] • (Don't know) • (Refused) • How long have you smoked? For a few months or less, for about a year, for one to five years or for more than five years? • Few months or less • About a year • One to five years • More than five years • (Don't know) • (Refused) • Do you consider yourself addicted to cigarettes or not? • Yes, addicted • No, not addicted • (Don't know) • (Refused) [Ask all:] • Imagine that you had smoked a pack of cigarettes each day for ten years. If you were then to quit permanently and not smoke again for the next ten years, would your lungs recover completely, recover somewhat or not recover at all? • Recover completely • Recover somewhat • Not recover at all • (Don't know) • (Refused) • I have just a few more questions to help us understand the people who took part in our survey. Are you yourself of Hispanic origin or descent, such as Mexican, Puerto Rican, Cuban or some other Spanish background? • Yes • No • (Don't know) • (Refused) • What is your race? (If Hispanic [D5 = 1]:) Aside from being Hispanic, do you consider yourself white, black or some other race? (Else:) Are you white, black, Asian or some other race? • White • Black • Asian • Other • (Don't know) • (Refused) • Are you married, living as married, widowed, divorced, separated, or have you never been married? • Married • Living as married • Widowed • Divorced • Separated • Never been married • (Don't know) • (Refused) • With which religious group do you identify? Would you describe yourself as Protestant, Catholic, Jewish, Muslim, some other non-Christian religion, or don't you have a religious preference? • Frotestant • Catholic • Jewish • Muslim • Some other non-Christian religion • No religious preference • Other (SFECIFY) • (Don't know) • (Refused) • Last year, that is in 1998, what was your household's total income before taxes? Just stop me when I get to the right category: (Read categories) • Less than$15,000
• $15,000-$30,000
• $30,001-$40,000
• $40,001-$50,000
• $50,001-$60,000
• $60,001-$75,000
• $75,001-$100,000
• $100,000-$150,000
• Over \$150,000
• (Don't know) (DO NOT READ)
• (Refused)
• Do you live with your parents?
• Yes
• No
• Don't know/Refused

That completes our survey. Thank you very much for taking time to answer our questions. We really appreciate your time. Have a nice (day | evening).

## Appendix C: Causal Modeling Methodology

Several chapters in this volume report on analyses of the Annenberg Tobacco Surveys using causal modeling methodology. This methodology is quite common in the social sciences and is particularly helpful for understanding how responses to surveys are related to one another. One feature of the method is the use of causal diagrams to represent these relationships. In this book, these diagrams are used to summarize how people's beliefs and experiences about cigarettes affect their use of cigarettes. For example, the diagrams in Chapter 7 show the relationships between exposure to cigarette advertising and various effects of the advertising. There are three types of relationships or causal paths in the diagrams. The first type of path is from external factors such as age and advertising to mediators such as the perceived risk of smoking. The second type is from mediators to outcomes (e.g., perceived risk to trying smoking). If perceived risk mediates the effects of age or advertising, then paths between age and advertising to risk will be different from zero, and the path from risk to smoking trial will also be nonzero. There is also a direct path from age to trial that represents effects of age not mediated by perceived risk.

A third type of path relates errors of measurement or other sources of unexplained response in the mediators, outcomes, or measures of these concepts. For example, Figure 7.15 has an error in the risk mediator that corresponds to those parts of risk not explained by the external factors (such as age). There is also error in the two measures of risk that is not explained by the risk.

Causal diagrams are called models because they represent both theory and knowledge about smoking. In Figure 7.15, age is shown as a cause of cigarette trial (not the other way around) because we know that trying to smoke will not affect one's age. This path represents all of the experiences as young people grow older that increase their chances of smoking cigarettes. The goal of the analysis is to identify some of these experiences.

Theories of the effects of cigarette advertising suggest that exposure to ads should encourage young people to try smoking by influencing imagery, feelings, and possibly risk perceptions. If the survey results support this prediction, then the paths in Figure 7.17 between advertising exposure and the mediators of influence (imagery, feelings, and risk perception) will be different from zero. The mediators should also directly affect trial. A statistical procedure that combines factor analysis and regression analysis is used to estimate the strength of the paths between the potential causes and their effects. We used a program called AMOS to estimate these paths (see Arbuckle & Wothke, 1999). The paths we present are standardized (sp) and typically range between plus and minus one. It is possible to follow the paths leading from a cause to its effects and to multiply the path weights along the way to measure the size of the causal relation. For example, if the path weight from A to B is .5 and the weight from B to C is .5, then the relation between A and C is .5 × .5, or .25.

The results of our causal analyses suggest that our models are consistent with the survey data. In addition, the statistical program provides various goodness-of-fit indices that allow one to evaluate the adequacy of a causal model. We present the comparative fit index (CFI) for all models. This index varies between zero and one, with values greater than .90 considered to indicate an adequate fit (Bentler, 1990). Nevertheless, even if a model fits the data and the paths have values that are consistent with theory, the findings do not prove that the causes in the model actually caused the outcomes. They only indicate that the model may be correct.

Whenever possible, we present alternative models to see if other explanations of the results are as consistent with the data as the preferred model. In judging the adequacy of alternative models, we look to measures of fit that take into account the complexity of the model as well as its ability to explain the data. We present two measures of fit: the root mean square error of approximation (RMSEA; Browne & Cudeck, 1993) and the Akaike (1987) information criterion (AIC). Values less than .05 for the RMSEA are considered acceptable, and the lower the value, the better the fit. The AIC only has a lower bound of zero, and values closer to zero indicate better fits.

Daniel Romer
Fatrick Jamieson

## References

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R. Kirkland Ahern is a doctoral student at the University of Pennsylvania's Annenberg School for Communication. Her training and research center on cognitive and social psychological influences on the processing of media messages. Her dissertation research explores how selective attention, selective exposure, and emotional priming affect information search in an interactive media environment.

Neal L. Benowitz is Professor of Medicine and Chief, Division of Clinical Pharmacology and Experimental Therapeutics, University of California, San Francisco. He is trained in internal medicine, clinical pharmacology, and medical toxicology. His research has focused on understanding the effects of nicotine in people, including how nicotine maintains tobacco use and the pharmacology of nicotine addiction.

Richard J. Bonnie is the John S. Battle Professor of Law and Director of the Institute of Law, Psychiatry and Public Policy at the University of Virginia. He is an expert on public health ethics and law. As a member of the Institute of Medicine of the National Academy of Sciences, he played a substantial role in the writing of the 1994 IOM report Growing Up Tobacco Free as well as subsequent IOM reports on tobacco.

Jon D. Hanson is Professor of Law at Harvard University. He teaches courses on tort law, tort theory, corporate law, and “law and behavioralism.” Much of his research focuses on consumer behavior and, more specifically, understanding the interactions and net effects of market, regulatory, and other institutional influences on consumer conduct.

Patrick Jamieson is a doctoral student at the Graduate School of Education at the University of Pennsylvania. His areas of interest include tobacco surveys, adolescent mental health, and media contagion and suicide.

Douglas A. Kysar will be Assistant Professor of Law at Cornell Law School beginning in spring 2001. His writing and research have focused on nontraditional economic approaches to understanding consumerism and their attendant effects on social welfare and environmental health. He graduated magna cum laude from Harvard Law School in 1998 and currently practices corporate law in Boston.

George Loewenstein is Professor of Economics and Psychology at Carnegie Mellon University. His research focuses on applications of psychology to economics, and his specific interests include the impact of emotions on decision making, decision making over time, bargaining and negotiations, law and economics, the psychology of adaptation, the psychology of curiosity, and the psychology and economics of “out of control” behaviors, including addiction.

Daniel Romer is a Senior Researcher in the Annenberg Public Policy Center at the University of Pennsylvania. He studies adolescent risk behavior and the influence of both peers and the media on adolescents. He has published extensively on risks to healthy development and interventions that might avert those outcomes, especially among young people living in high-poverty urban neighborhoods.

Jonathan M. Samet, M.D. M.S., is Professor and Chairman of the Department of Epidemiology of the Johns Hopkins University School of Hygiene and Public Health. He is trained as a clinician in the specialty of internal medicine and in the subspecialty of pulmonary diseases. His research has addressed the effects of inhaled pollutants in the general environment and in the workplace. He has written widely on the health effects of active and passive smoking and has served as consultant editor and senior editor for reports of the U.S. surgeon general on smoking and health.

Paul Slovic is President of Decision Research in Eugene, Oregon, and Professor of Psychology at the University of Oregon. He studies human judgment, decision making, and risk analysis. He and his colleagues worldwide have developed methods to describe risk perceptions and to measure the effects of those perceptions on individuals, industry, and society.

Neil D. Weinstein is Professor of Human Ecology and Psychology at Rutgers–The State University of New Jersey. He has published extensively in the fields of risk perception, risk communication, and health-protective behavior. He is particularly well-known for his research on optimism bias in the assessment of personal risks.