the first experience people have with smoking cigarettes in the initial stage of becoming a smoker is typically unpleasant. The smoker usually feels nauseated. One respondent told Hughes (2003: 148) that she really did not like her first cigarette, describing it as “foul.” This raises a crucial question: If the first experience is unpleasant, why do people continue? Hughes’s answer is that people learn how to smoke by having other individuals interpret the experience for them and tell them how to distinguish the desired sensations from the undesirable. Specifically, they are taught how to inhale properly and pull the smoke into their lungs. One woman in the Hughes (2003: 149) study reported on what it was like being a smoker when she first started: “it was quite exciting. I thought I’d grown up! It was something new. And it is a skill that you have to learn to do it properly so that people don’t say, ‘she’s not inhaling properly, she’s not smoking.’ You have to learn how to do it.” Hughes explains that, initially, smoking is a social activity carried out with other people. It typically has its origins in adolescent peer groups, in which teens imitate adult or older teen behavior (de la Haye et al. 2019). Teens smoke to “connect with,” “fit in,” and “impress” their friends. Joy Johnson and her colleagues (Haines, Poland, and Johnson 2009; Johnson et al. 2003) studied teen smoking in Canada and found that adolescents are more socially than physically dependent on cigarettes in the beginning.
The social setting, namely relaxing with peers, caused smoking more than wanting to inhale tobacco smoke. Often the teen did not smoke when friends were not around. But when friends were present, new smokers used cigarettes primarily to connect with them socially, project an image of being “cool,” and express solidarity. Three teenagers in the Johnson et al. (2003: 1484–6) study analyzed smoking in their peer groups this way:
Like it [smoking] is a social aspect of their life that they have become dependent on, as much as the nicotine, you know. I think almost the social setting of it is something that is somewhat addictive itself. (17-year-old female)
People don’t really have to smoke, but they do it anyways to like fit in, or whatever, and they smoke to put out an image to people. (17-year-old male)
It’s more what you will do to fit in, not what you will do to smoke, because you may not actually want to smoke. (16-year-old male)
Reports such as these support Hughes’s (2003) contention that the beginning stage of becoming a smoker is principally a social experience. Not only are the techniques learned within peer groups, but the act of smoking is used to promote social relationships, reinforce personal bonds, and express group affiliation. Soon the adolescent smokers also learn to recognize the effect of nicotine on their emotions. Smoking helped them feel calm and reduced anxiety; it could also ease depression, sadness, fear, loneliness, and anger. Some novice smokers found they could like the taste and others felt smoking was a sign of transition to an adult identity. While many adolescents likely try smoking at some point in growing up, the majority do not continue. For those that do, however, they enter the second stage of smoking described by Hughes, that of continued smoking. Here the beginning smoker starts smoking more frequently as part of a consistent pattern of behavior. These smokers continue to use cigarettes to socialize, but also for other reasons like relaxation, pleasure, alleviating stress, or helping their concentration. They also smoke when they are alone, instead of just when they are with other people. They begin recognizing themselves as smokers and find they have a growing sense of dependence on the addictive qualities of nicotine as they move into the third stage of regular smoker in which smoking becomes a lifestyle habit that leads to the fourth stage of addicted smoking in which the smoker has to smoke a cigarette just to feel “normal.” As one addicted smoker (Johnson et al. 2003: 1488) put it: “It’s gone beyond maybe wanting it or enjoying it, but at this point, your body is addicted to it, and no matter what, you couldn’t get through the day without either thinking about it or feeling you need a cigarette” (19-year-old female).
The causal chain leading to a smoking-related disease in this scenario would look like the following: social interaction among peers leads to smoking that, when continued over time, results in regular smoking and addiction to cigarettes having a high probability of eventually producing health problems. While perhaps not all smokers begin smoking with someone else’s assistance, it appears that almost all do. Moreover, even when smoking is self-taught, the novice smoker confirms the practice in the company of other smokers (Haines et al. 2009). Growing up in a household where one or both parents smoke, having a spouse who smokes, and regularly socializing with smokers are other social situations promoting smoking. In practically all cases, smoking is behavior initially acquired in the company of other people (de la Haye et al. 2019; Thomeer et al. 2019). The origin of this causal chain is social. Removing the social element breaks the chain and prevents the disease process from occurring.
Since smoking typically begins in social networks, it is logical that such networks can also curtail its use. This possibility was considered by Nicholas Christakis and James Fowler (2008), who investigated smoking patterns in densely interconnected social networks in the Framingham, Massachusetts, Heart Study. They found that whole clusters of closely connected people had stopped smoking more or less together. This was due to collective pressures from their network, coming mainly from spouses, siblings, other family members, and co-workers who were close friends. As a social and therefore shared behavior, Christakis and Fowler determined that smokers were more likely to quit when they ran out of people with whom they could easily smoke. They concluded “that decisions to quit smoking are not made solely by isolated individuals, but rather they reflect choices made by groups of people connected to each other both directly and indirectly” (Christakis and Fowler 2008: 2256). Those who remained smokers were pushed to the periphery of the networks as the networks themselves became increasingly separated into smokers and non-smokers. Other research subsequently confirmed the decisiveness of friendship networks in the smoking decisions of a diverse, nationwide sample of adolescents (de la Haye et al. 2019). When it comes to smoking, the social is clearly causal.
A new crisis involving another form of smoking emerged in 2019 in the US as hospitalizations from lung injury and deaths from vaping or smoking e-cigarettes were increasingly reported. E-cigarettes work by heating a liquid that produces an aerosol that is inhaled into the lungs. As this book goes to press over 2,807 people had been hospitalized in all 50 states and the District of Columbia; 68 had died. The common factor was vitamin E acetate in e-cigarettes with tetrahydrocannabinol (THC), which is a derivative of marijuana that produces a “high.” Vitamin E acetate is used to dilute THC oil, thereby requiring less of it and increasing profits. However, when heated, the vitamin burns the lining of the lungs. E-cigarettes were originally developed to help people quit smoking tobacco products but attracted large numbers of adolescents and young adults when “fruit” flavors were introduced. It is this segment of the population in which lung damage from vaping is most prevalent.
Smokers typically have less healthy lifestyles across many related behaviors, such as poorer diets, less regular exercise, and more problem drinking (Burdette et al. 2017; Cockerham 2005; Edwards et al. 2006; Lawrence 2017; Lawrence, Mollborn, and Hummer 2017). This is in addition to the powerful influence of other social variables like class and gender that influence health-related behavioral practices like smoking either positively or negatively. To minimize or deny the causal role of social processes in the onset and continuation of health problems stemming from smoking renders any other explanation far from complete.
The Biomedical Model
The relegation of social factors to a distant supporting role in studies of health and disease causation reflects the pervasiveness of the biomedical model in conceptualizing sickness. The biomedical model is based on the premise that every disease has a specific pathogenic origin whose treatment can best be accomplished by removing or controlling its cause using medical procedures. Often this means administering a drug to alleviate or cure the symptoms. According to Kevin White (2006), this view has become the taken-for-granted way of thinking about sickness in Western society. The result is that sickness has come to be regarded as a straightforward physical event, usually a consequence of
