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Journal of Studies on Alcohol and Drugs logoLink to Journal of Studies on Alcohol and Drugs
. 2019 Dec 3;80(6):659–668. doi: 10.15288/jsad.2019.80.659

Adolescent Tobacco Use and Misperceptions of Social Norms Across Schools in the United States

Jessica M Perkins a,*, H Wesley Perkins b,✉, Jordan Jurinsky a, David W Craig b
PMCID: PMC6900997  PMID: 31790356

Abstract

Objective:

This study assesses tobacco use norm misperceptions by distinguishing between perceived and actual peer norms for both tobacco use attitudes and behavior, and examines the association between perceived norms and personal use among U.S. students in Grades 6–12.

Method:

Anonymous self-report surveys were conducted with 28,070 students across 64 schools in 11 U.S. states between 1999 and 2017.

Results:

Although 77% of students said tobacco use is never good, 64% of students thought that most students in their grade believed that use is acceptable. Similarly, although 79% of students reported never using tobacco, 85% of students perceived that most students in their grade typically use tobacco, with 66% thinking that peers use monthly or more often. Substantial norm misperception existed regardless of student and school factors, increasing by grade. Perceiving that most peers thought tobacco use is acceptable was highly predictive of personal attitude, and perceiving tobacco use as the norm among same-grade peers strongly predicted personal tobacco use, even after we adjusted for actual peer use prevalence and other factors. Males’ perception of the male peer norm was a stronger predictor of personal use than was their perception of the female peer norm. Females’ perceptions of sex-specific norms were associated with personal use, each at about the same magnitude.

Conclusions:

Norm misperceptions are pervasive across a diversity of students and schools, whereas perceptions of peer norms about tobacco use are highly associated with personal attitude and use. Results suggest that population-wide interventions correcting these misperceptions may help reduce tobacco use broadly among youth.

Initiation of nicotine consumption is most likely to occur between ages 11 and 17, with about one third starting by age 14 (Wittchen et al., 2008). In 2011–2014, 25% of U.S. secondary school students had used some form of tobacco in the past 30 days (Arrazola et al., 2015). In 2016, approximately 3.9 million were using at least one tobacco product, and 1.8 million reported using two or more tobacco products (Jamal et al., 2017). Using tobacco at a young age increases the chance for long-term dependence and health problems.

Perceptions about tobacco use norms among peers may predict tobacco use among adolescents (Botvin et al., 1992; Castrucci et al., 2002; Duan et al., 2009; Eisenberg & Forster, 2003; Olds & Thombs, 2001; Olds et al., 2005; Otten et al., 2009; Wang et al., 2011). However, perceived descriptive norms about the typical frequency or quantity of use among peers may not match reality. For example, 7th- to 12th-grade students in the United States in 1994 overestimated the number of close friends who smoked 1 cigarette per day (Amialchuk et al., 2019). Data from almost 20 years later show that a majority of 6th- to 12th-grade students across the United States in 2015–2016 still overestimated the prevalence of any cigarette and e-cigarette use in the past 30 days among same-grade peers (Agaku et al., 2019). Similar misperceptions about peer tobacco use have been found among Dutch and UK adolescents (Elsey et al., 2015; Otten et al., 2009).

Thus, actual and perceived norms about tobacco use among adolescents may represent separate constructs that could each potentially affect personal use independently. Most study designs, however, do not yield information about the relative importance of both constructs nor about the extent of norm misperception. Tests of the importance of social norms would be strengthened by comparing the associations of actual and perceived norms with personal tobacco use in a single study. It is also important to adjust for potential confounding of each measure’s association with personal tobacco use by the other measure. In addition, as decades of work in social psychology show that attitudes predict behavior (Ajzen, 2001, 2005; Ajzen & Fishbein, 1977, 1980; Fishbein & Ajzen, 1975), research combining data on perceptions of normative tobacco use acceptability among peers (i.e., perceived injunctive norms) with data on perceptions about normative tobacco use frequency (i.e., perceived descriptive norms) is needed. The extent to which both types of norms may predict tobacco use behavior among adolescents is unclear from prior research (Eisenberg & Forster, 2003; Eisenberg et al., 2014; Long & Valente, 2019; Olds et al., 2005; Riou França et al., 2009; Zaleski & Aloise-Young, 2013).

Furthermore, assessing sex-specific peer norms is also important as youth may look to different peer crowds to inform their own choices. For example, studies on other topics have found that same-sex versus opposite-sex perceived norms may differently impact students (Hummer et al., 2012; Korcuska & Thombs, 2003; LaBrie et al., 2009; Lewis & Neighbors, 2004, 2006, 2007; Lewis et al., 2007; Pedersen & LaBrie, 2008; Perkins & Craig, 2012; Thombs et al., 2005). Moreover, perceived norm effect sizes may differ between male and female students (Amialchuk et al., 2019).

Last, no studies have assessed the extent to which adolescents across different extracurricular and sociodemographic groups misperceive tobacco-related norms among their school-based peers, nor have studies assessed the extent of norm misperception in different school contexts such as in schools with different actual tobacco use prevalence rates or differing socioeconomic constituencies. Yet, if perceived social norms predict personal attitudes/behaviors and misperceived norms exist, then correcting misperceived descriptive and injunctive norms represents a potential intervention point. Establishing the prevalence and extremeness of peer norm misperception about tobacco use within and across student factors is crucial in thinking about intervention development for tobacco use prevention. If substantial norm misperception exists across all groups, then population-based interventions to correct misperceptions and ultimately reduce tobacco use may be cost-effective. In addition, a school-based intervention focusing on positive actual behavioral norms among its youth may be less likely to isolate and stigmatize youth because it is focused on the population’s assets instead of pointing out atrisk students. Moreover, students who had misperceived the norms but who do not use tobacco might be more likely to be vocal about their opinions and to encourage peers not to use, thus creating an overall environment that is more supportive of tobacco nonuse.

To address these knowledge gaps, this study assessed social norms about tobacco use attitudes and behaviors among middle school and high school students across 64 schools in 11 regionally diverse U.S. states. We measured perceived injunctive norms, perceived descriptive norms, actual injunctive norms, and actual descriptive norms among same-grade peers as well as the extent of norm overestimation across student groups and school contexts. We then assessed the association of perceived norms with personal tobacco use attitude and behavior after adjusting for actual norms among same-grade peers as well as other factors.

Method

Study sample and procedure

Cross-sectional, population-based data were collected from students in Grades 6–12 from 1999 to 2017 from 64 schools located in Arizona, Colorado, Idaho, Indiana, Iowa, Maine, Massachusetts, Montana, New Jersey, NewYork, and Washington. School and local public health officials contacted authors of this study about conducting an assessment of student health and well-being at their school. Most schools used an online survey, with a few using a paper version. Students voluntarily responded to the survey in class or in other group settings during school. For the online administration, students in a group session were publicly provided with the same password and URL address to ensure students of their anonymity. However, the password was changed between sessions, preventing students from submitting additional responses later. A monitor was present to provide initial instructions and make sure that students did not interact. The Institutional Review Board of the academic institution hosting the online survey approved the survey content, administration methods, and procedure. Local school officials certified their use of their school’s standard parent/guardian consent procedures.

Descriptive school information was obtained from school officials or from the National Center for Education Statistics. There were 6 parochial/private schools and 58 public schools; 22 were in urban or suburban areas, and 42 were in rural areas. School size ranged from 55 to 1,863 students (M = 606). Fifteen schools had fewer than 200 students, and 14 schools had greater than 1,000. White students represented less than 50% of students in 7 schools, 50%–89% in 30 schools, and 90% or more in 23 schools. (Four schools did not report such data.) Fifteen schools had less than 10% of students eligible for a free or reduced-fee lunch; 21 had 10%–25% receiving free or reduced-fee lunch, and 20 exceeded 25% (with 2 over 50%). (Eight schools did not report data regarding free or reduced-fee lunch.)

The average response rate for all schools in this study was 79%, with a minimum school response above 50% required. The resulting sample of students from each school provided a good representation of the framed population’s basic demographic characteristics. The percentage of female respondents differed in absolute value from the institution’s records, on average, by only 3.3% (SD = 2.8%). Likewise, on average, the absolute value of the difference between the percent representing each grade and the percent registered in that grade was only 3.1% (SD = 3.8%). The analytical sample included 28,070 students (after excluding 97 students in an unknown grade) across 220 same-grade same-school cohorts (i.e., grade cohorts), with an average grade-cohort sample size of 128 students (SD = 96).

Measures

To measure personal attitude, students were asked, “Which statement below about student use of tobacco (including cigarettes, cigars, and chewing tobacco) do you feel best represents your own attitude?” The statements were (a) “Tobacco use is never a good thing to do,” (b) “Occasional tobacco use is ok, but not daily use,” and (c) “Daily tobacco use is ok if that’s what the individual wants to do.” To measure students’ perception of the attitudinal norm among their peers, students were asked, “Which statement below about student use of tobacco (including cigarettes, cigars, and chewing tobacco) do you expect to be the most common attitude among students in general in your grade?” The same response options were provided. Binary variables (use is never a good thing vs. occasional or daily use is acceptable) were also created. Less than 1% of students were missing a response to either of these questions (excluding students in the first seven participating schools who did not receive the attitude questions).

To measure actual attitudinal norms, we calculated the percentage of same-grade, same-school peers who personally thought tobacco use is never good. If it was greater than 50%, then the actual attitudinal norm was classified as disapproval. We also created a trichotomous variable based on 50% or less, 51%–75%, and 76%–100% disapproval.

To measure personal use, students were asked how often they personally use cigarettes, cigars, and chewing tobacco. Response options were “never,” “1–2 times per year,” “once a month,” “twice a month,” “once a week,” “twice a week,” and “daily.” Students were asked to indicate their perception of the most typical frequency of tobacco use among same-grade peers, same-grade male peers, and same-grade female peers (using the same response options). For all sets of responses, binary variables were created representing never versus once per year or more often, and trichotomous variables were created representing never, more than never but use less than once per week (i.e., occasional), and once per week or more often (i.e., regular). Personal use and perceived norm use data were missing for only 2% and 3% of students, respectively.

Measures of actual behavioral norms for same-grade peers, same-grade male peers, and same-grade female peers were created by first calculating the percentage that reported never using tobacco in each reference group, and then categorizing that percentage. If greater than 50%, then the actual behavioral norm was classified as “nonuse.” We also created a trichotomous variable based on grade cohort prevalence of never using tobacco: 50% or less, 51%–75%, and 76%–100%.

To measure norm misperception, we compared whether a student’s perception of peer norms matched actual peer norms for specified reference groups.

Age, grade, and race/ethnicity (White, Black, Hispanic/Latino, Asian, Alaskan Native/American Indian, and other) were collected as well as yes/no responses about participation in sports, school club/student government, theater/ dance/music group, volunteer work, a religious group, and having a part-time job. Academic grade point average was measured on a 4.0 scale (labeled A to F with +/–’s); gender and age information were missing from 1.5% and 0.4% of students, respectively. Missing responses for race/ethnicity, activities, and academic grade point average variables were coded as separate “unknown” categories to retain students for analysis who were not asked these questions in early versions of the survey or who did not respond to these questions in later years.

Analyses

We calculated the prevalence of self-reported attitudes and tobacco use as well as the prevalence of peer norm misperception across student and school characteristics to describe the extent of misperceived norms, and then conducted statistical testing for differences between student categories of the various demographic characteristics (correcting for the inflated chance of a type I error due to the number of significance tests involved). To assess the relationship between perceived norms and personal attitudes or behaviors, we conducted multilevel logistic regression analyses that accounted for the clustering of observations at the grade cohort level, and also adjusted for gender, age, race/ethnicity, student activities, survey year, and state.

We first modeled personally believing that occasional or daily tobacco use is acceptable (vs. never a good thing) as a function of the student’s perceived attitudinal norm for same-grade peers (Model 1a) and then adjusted for the actual peer permissiveness level in the local grade cohort (Model 1b). We then modeled personal tobacco use (once per year or more vs. never) as a function of the student’s perceived behavioral norm about same-grade peers while adjusting for personal attitude (Model 2a) and then additionally adjusted for the actual prevalence level of same-grade peer tobacco use (Model 2b). For Models 1a and 2a, we also tested for differences between males and females by adding an interaction term between gender and perceived norm. Last, we modeled personal use as a function of sex-specific perceived and actual norms among male and female students separately (Model 3).

Results

Actual injunctive and descriptive norms

In 195 of 197 local grade cohorts, most students (>50%) indicated that they did not approve of any tobacco use. The mean prevalence of disapproval across these grade cohorts was 77% (SD = 12 percentage points), with 77% of students overall in these cohorts also disapproving. In the remaining two local grade cohorts, in which opposition was not normative (≤50% disapproval), 61% of students thought that occasional or daily tobacco use is acceptable. Similarly, most students in 211 of 220 grade cohorts reported never using tobacco. The mean prevalence of nonusers across these grade cohorts was 79% (SD = 13 percentage points), and 79% of students overall in these cohorts did not use tobacco. In the remaining nine local grade cohorts in which nonuse was not normative, 53% of students overall reported using tobacco at least one to two times per year.

The majority of students across student subcategories opposed any tobacco use, although statistically significant variation in attitudinal opposition to tobacco use existed (Table 1). Although the prevalence of disapproval declined with increasing grade levels, the norm was still to oppose use in every grade. Similarly, the majority of students in student subcategories reported never using tobacco, although there was statistically significant variation in frequency of tobacco use (Table 1). The prevalence of nonuse declined substantially with increasing grade levels (from 95% to 63%), but here also, the norm was to never use tobacco in every grade. Last, a large majority of students across differing school contexts as well as survey years expressed disapproval of tobacco use and reported never using tobacco (typically more than three quarters of students in each subcategory) (Supplemental Table 1).

Table 1.

Descriptive characteristics of respondents and personal disapproval and nonuse of tobacco among middle school and high school students across 64 schools in the United States

graphic file with name jsad.2019.80.659tbl1.jpg

Variable n % believing that tobacco use is never a good thing n % who never use tobacco
All 26,238 76.7 27,534 78.5
Gender
 Males 13,065 74.5 13,365 76.5
 Females 12,847 79.1 13,486 80.5
Grade level
 6 1,923 93.5 2,194 95.2
 7 2,205 89.3 2,483 91.2
 8 2,016 81.6 2,258 81.9
 9 6,298 79.7 6,420 82.5
 10 5,468 75.3 5,612 78.1
 11 4,637 69.2 4,801 70.3
 12 3,691 64.4 3,766 62.6
Race/ethnicity
 Asian 549 86.5 546 90.7
 American Indian/Alaskan Native 173 70.5 172 75.6
 Black 413 78.5 414 84.3
 Hispanic 857 80.6 857 79.1
 White 6,523 79.0 6,526 82.9
 Other 621 83.1 620 87.6
 Unknowna 17,102 75.2 18,399 76.2
Participates in school sports
 No 10,645 73.4 10,486 76.7
 Yes 14,300 79.2 14,118 80.4
 Unknowna 1,293 77.4 2,930 75.7
Participates in school club or student government
 No 12,809 74.5 12,621 76.8
 Yes 6,981 80.7 6,881 83.7
 Unknowna 6,448 76.9 8,032 76.8
Participates in theater, dance, or music group
 No 17,695 75.9 17,460 78.2
 Yes 4,998 80.2 4,922 82.9
 Unknowna 3,545 75.9 5,152 75.2
Participates in a religious group
 No 18,810 75.8 18,545 78.4
 Yes 3,587 82.7 3,545 83.7
 Unknowna 3,841 75.6 5,444 75.4
Engages in volunteer work
 No 13,416 75.0 13,224 77.9
 Yes 6,374 80.4 6,278 81.9
 Unknowna 6,448 76.9 8,032 76.8
Academic grade point average (out of 4)
 <2.0 951 54.3 947 54.9
 2.0–2.99 3,757 68.8 3,751 70.3
 3.0–3.99 11,138 79.2 11,143 81.6
 4.0 3,177 84.6 3,184 88.0
 Unknowna 7,215 76.6 8,509 77.1
Has a part-time job
 No 15,489 81.0 15,287 83.9
 Yes 6,909 67.8 6,804 68.8
 Unknowna 3,840 75.6 5,443 75.4
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Notes: There was a statistically significant difference in the prevalence of disapproval and in the prevalence of nonuse among subcategories of each characteristic of students according to chi-square tests (p < .05). (These tests adjusted for the increased probability of a type I error due to multiple tests by using the Bonferroni method requiring a p value of <.0025 for each test.)

a

“Unknown” represents students who were not asked this question in early versions of the survey or who did not respond to this question in later years. By including an unknown category, these students were retained for regression analysis and are displayed here to describe the full sample.

Peer norm misperception

Despite their peers’ strong actual attitudinal norm against tobacco use, 64% of students in the 99% of grade cohorts with disapproval as the norm erroneously thought most peers believe occasional or daily tobacco use is acceptable. Likewise, 85% of students in the 95% of grade cohorts in which nonuse was normative erroneously thought that most peers use tobacco at least once or twice during the year. Moreover, 66% of students erroneously believed that peers typically use tobacco monthly or more often.

In these “healthy norm” grade cohorts, although the prevalence rates of norm misperception varied across different groups of students, the majority of students across most student subcategories misperceived peer norms (Table 2). For example, the majority of students misperceived the behavioral norm from seventh grade upward and the attitudinal norm from eighth grade upward, with increasing prevalence and extent of norm misperception across grade levels. Especially notable is the finding that more than 90% of students in Grades 10–12 did not accurately identify the actual behavioral norm of nonuse. Moreover, most of these older students erroneously thought that peers use tobacco weekly or more often.

Table 2.

Prevalence of misperceiving peer norms about tobacco use attitudes and behaviors among middle school and high school students across 64 schools in the United States

graphic file with name jsad.2019.80.659tbl2.jpg

Variable % who erroneously believed that same-grade same-school peers thought that occasional tobacco use or daily tobacco use was acceptablea (injunctive norm misperception) % who erroneously believed that same-grade same-school peers use tobacco occasionally or regularlyb (descriptive norm misperception) Median misperceived frequency of tobacco use
Total 64.0 85.0 2 times per month
Gender
 Male 59.1 82.9 2 times per month
 Female 69.1 87.0 2 times per month
Grade level
 6 17.7 44.5 1–2 times per year
 7 34.4 67.2 1 time per month
 8 52.0 83.8 1 time per month
 9 65.8 88.3 2 times per month
 10 73.5 92.4 1 time per week
 11 76.7 93.9 1 time per week
 12 79.4 94.4 1 time per week
Race/ethnicity
 American Indian/Alaskan Native 57.5 75.6 1 time per week
 Asian 57.3 76.2 1 time per month
 Black 61.6 81.2 1 time per week
 Hispanic 55.1 77.9 2 times per month
 White 64.5 83.1 2 times per month
 Other 54.6 68.3 2 times per month
Participates in school sports
 No 63.9 83.4 1 time per week
 Yes 64.5 85.7 2 times per month
Participates in school club or student government
 No 63.8 83.3 1 time per week
 Yes 68.8 88.0 2 times per month
Participates in theater, dance, or music group
 No 63.7 84.6 2 times per month
 Yes 68.9 86.7 2 times per month
Participates in a religious group
 No 64.2 84.5 2 times per month
 Yes 69.7 88.0 2 times per month
Engages in volunteer work
 No 63.0 83.2 1 time per week
 Yes 70.9 88.5 2 times per month
Academic grade point average (out of 4)
 <2.0 71.0 90.4 2 times per week
 2.0–2.99 67.1 87.8 1 time per week
 3.0–3.99 66.7 85.9 2 times per month
 4.0 63.3 85.0 1 time per month
Has a part-time job
 No 60.6 82.0 2 times per month
 Yes 75.1 92.1 1 time per week
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Notes: There was a statistically significant difference in the percentage of students misperceiving peer injunctive and descriptive norms among subcategories of each characteristic of students according to chi-square tests (p < .05), except for sport categories regarding misperception of the typical attitude about tobacco use. (These tests adjusted for the increased probability of a type I error due to multiple tests by using the Bonferroni method requiring a p value of <.0025 for each test.)

a

Results exclude the 2 local grade cohorts of students in which a permissive attitude to tobacco use was normative (of 197 grade cohorts);

b

results exclude the 9 local grade cohorts of students in which any tobacco use was normative (of 220 grade cohorts).

Extensive misperception of sex-specific behavioral norms was also found in these “healthy norm” cohorts (Supplemental Table 2), with a similar pattern of increasing norm misperception as grade increased. The prevalence of male norm misperception was slightly higher for both male and female students than was the prevalence of female norm misperception. However, in almost all grades, a substantial majority of students overestimated tobacco use norms for both male and female peers. Last, the majority of students in every context (e.g., across levels of actual opposition and nonuse) misperceived peer norms (Supplemental Table 3).

In the nine local grade cohorts in which median use was one to two times per year (thus indicating yearly use as the norm), 83% of students erroneously thought that peers typically use tobacco weekly or daily.

Perceived norm associations with personal attitude and use

Students who perceived that most peers think occasional or daily tobacco use is acceptable were three to seven times more likely to personally believe use is acceptable compared with students who perceived peer opposition to tobacco use to be normative (p < .001) (Table 3). The association between the perceived injunctive norm was not substantially diminished when the strength of the actual injunctive norm (i.e., the prevalence of opposition) in one’s grade cohort was included in the model.

Table 3.

Multilevel multivariate logistic regression coefficients (adjusted odds ratios) for perceived and actual injunctive norms predicting permissive personal attitude about tobacco use among middle school and high school students across the United States (Model 1)

graphic file with name jsad.2019.80.659tbl3.jpg

Variable Model 1a
 Model 1b
AOR [95% CI] AOR [95% CI]
Perceived injunctive norm among
same-grade, same-school students:
 Believed most peers think that . . .
  tobacco use is never a good thing 1.0 – 1.0 –
  occasional tobacco use is acceptable 3.2*** [2.9, 3.5] 3.1*** [2.8, 3.4]
  daily tobacco use is acceptable 7.0*** [6.4, 7.7] 6.7*** [6.1, 7.4]
Strength of actual injunctive norm
among same-grade, same-school students:
 76%–100% of peers reported thinking that
  tobacco use is never a good thing
  (average prevalence of opposition was 86% in 108 grade cohorts) 1.0
 51%–75% of peers reported thinking that
  tobacco use is never a good thing
  (average prevalence of opposition was 65% in 87 grade cohorts) 1.6*** [1.5, 1.8]
 50% or fewer peers reported thinking that
  tobacco use is never a good thing
  (average prevalence of opposition was 42% in 2 grade cohorts) 3.1*** [1.7, 5.6]
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Notes: The model also accounts for the clustering within grade cohort and adjusted for gender, age, race/ethnicity, participation in sports, participation in art/theater/dance, volunteering, participation in a religious group, grade point average category, having a part-time job, survey year, and state. AOR = adjusted odds ratio; CI = confidence interval.

***

p < .001.

Similarly, perceiving that tobacco use is the peer norm was associated with a statistically significant increase in the odds of personally using tobacco (adjusted odds ratio [AOR] for perceiving occasional use as the norm = 2.6, 95% CI [2.2, 3.1], p < .001, and AOR for perceiving regular use as the norm = 3.6, 95% CI [3.0, 4.3], p < .001) (Table 4). These associations were not appreciably diminished when the actual behavioral prevalence level of nonuse in one’s grade cohort was included in the model. There was no interaction effect between gender and perceived norm in either Model 1 or Model 2.

Table 4.

Multilevel multivariate logistic regression coefficients (adjusted odds ratios) for perceived and actual descriptive norms predicting personal tobacco use among middle school and high school students across the United States (Model 2)

graphic file with name jsad.2019.80.659tbl4.jpg

Variable Model 2a
 Model 2b
AOR [95% CI] AOR [95% CI]
Perceived descriptive norm students:
among same-grade, same-school
 Believed most peers never use tobacco 1.0 – 1.0 –
 Believed most peers use tobacco occasionally 2.6*** [2.2, 3.1] 2.6*** [2.1, 3.1]
 Believed most peers use tobacco regularly 3.6*** [3.0, 4.3] 3.5*** [2.9, 4.2]
Strength of actual injunctive norm
among same-grade, same-school students:
 76%–100% of peers reported never using tobacco (average prevalence of nonuse was 87% in 129 grade cohorts) 1.0 –
 51%–75% of peers reported never using tobacco (average prevalence of nonuse was 65% in 82 grade cohorts) 1.7*** [1.5, 1.9]
 50% or less peers reported never using tobacco (average prevalence of nonuse was 47% in 9 grade cohorts) 2.8*** [2.1, 3.6]
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Notes: The model also accounts for the clustering within grade cohort and adjusted for personal attitude about tobacco use, gender, age, race/ethnicity, participation in sports, participation in art/theater/dance, volunteering, participation in a religious group, grade point average category, having a part-time job, survey year, and state. AOR = adjusted odds ratio; CI = confidence interval.

***

p < .001.

Last, estimates from Models 3a and 3b showed that males’ perception of the male peer norm was a stronger predictor of personal use than was their perception of the female peer norm (Table 5). For females, however, the associations between both of the sex-specific perceived norms and personal use were about the same magnitude according to estimates from Models 3c and 3d.

Table 5.

Multilevel multivariate logistic regression coefficients (adjusted odds ratios) for sexspecific perceived norms predicting personal tobacco use among middle school and high school male and female students across the United States (Models 3a–3d)

graphic file with name jsad.2019.80.659tbl5.jpg

AOR [95% CI]
Model 3a (males)
 Perceived descriptive norm among
 same-grade, same-school male students:
  Believed most male peers never use tobacco 1.0 –
  Believed most male peers occasionally use tobacco 3.4*** [2.6, 4.3]
  Believed most male peers regularly use tobacco 5.3*** [4.1, 6.8]
Model 3b (males)
 Perceived descriptive norm among
 same-grade, same-school female students:
  Believed most female peers never use tobacco 1.0 –
  Believed most female peers occasionally use tobacco 1.7*** [1.5, 2.0]
  Believed most female peers regularly use tobacco 2.3*** [2.0, 2.8]
Model 3c (females)
 Perceived descriptive norm among
 same-grade, same-school male students:
  Believed most male peers never use tobacco 1.0 –
  Believed most male peers occasionally use tobacco 2.4*** [1.7, 3.2]
  Believed most male peers regularly use tobacco 3.7*** [2.7, 5.0]
Model 3d (females)
 Perceived descriptive norm among
 same-grade, same-school female students:
  Believed most female peers never use tobacco 1.0 –
  Believed most female peers occasionally use tobacco 2.7*** [2.1, 3.4]
  Believed most female peers regularly use tobacco 3.7*** [2.9, 4.7]
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Notes: The multilevel logistic regression models also account for the clustering within grade cohort and adjusted for personal attitude about tobacco use, actual prevalence of reported tobacco use among sex-specific same-grade peers, age, race/ethnicity, participation in sports, participation in art/theater/dance, volunteering, participation in a religious group, grade point average category, having a part-time job, survey year, and state. AOR = adjusted odds ratio; CI = confidence interval.

***

p < .001.

Discussion

This study distinguished between actual norms and perceived norms about tobacco use among a diversity of middle school and high school students across the United States and assessed the association of both constructs with personal opposition to tobacco use and personal frequency of tobacco use. Despite most students opposing tobacco use and never using tobacco across the large majority of local grade cohorts, two thirds of students erroneously believed that most peers would say that occasional or daily tobacco use is acceptable, and the vast majority of students erroneously believed that most peers use tobacco at least occasionally if not weekly or more often. Extensive injunctive and descriptive norm misperceptions existed across student backgrounds and school contexts. These findings are similar to results from a large body of research on risky behaviors among college students showing that students tend to perceive that unhealthy behaviors are the norm among their peers even though healthy attitudes and behaviors are most often the actual norm (Perkins & Perkins, 2018). Moreover, both male and female norms were largely misperceived by both male and female peers.

In addition, perceived injunctive and descriptive norms were strong correlates of personal approval and use of tobacco even after including multivariate adjustments for the actual prevalence levels of disapproval and nonuse of tobacco as well as other potential confounding factors.

Thus, the association of the perceived attitudinal norm with one’s personal attitude, and the association of the perceived behavioral norm with one’s personal tobacco use frequency, were largely independent of the actual prevalence levels of local grade cohort disapproval and nonuse, and more highly predictive of personal attitude and use than the actual norms in students’ local peer contexts. Previous cross-sectional studies on a variety of topics have also found that perceived attitudinal and behavioral norms are often better predictors of personal attitudes and behaviors than are actual peer norms (Perkins et al., 2005; J. M. Perkins et al., 2010, 2018, 2019).

The current findings build on research that was more limited in scope, which found associations between perceived norms and personal tobacco use but had not accounted for actual norms nor combined data on descriptive and injunctive norms (Arbour-Nicitopoulos et al., 2010; Bertholet et al., 2013; Edwards et al., 2008; Eisenberg & Forster, 2003; Elsey et al., 2015; Linkenbach & Perkins, 2003; Martens et al., 2006; Olds & Thombs, 2001; Olds et al., 2005; Perkins et al., 1999; Pischke et al., 2015; Riou França, et al., 2009). Furthermore, associations were similar for male and female students, although the male perceived norm was stronger for female students than the female perceived norm was for male students. These results are similar to sex-specific norm research on alcohol use (Perkins & Craig, 2012). Taken together, norm misperception may be a major risk factor contributing to personal tobacco use.

The consistency of norm misperception across many types of individuals and contexts highlights a widespread opportunity for population-based interventions to reduce tobacco use initiation and frequency levels via the reduction of peer norm misperceptions related to tobacco use. Interventions could disseminate true norms (e.g., “Most students in your grade at your school never smoke or use other tobacco products” citing local data) via various media portals such as population-wide text messages, websites, closed circuit television, posters, and digital signage in schools. These messages could be combined with training on how to improve media literacy, as research has linked social media consumption to inaccurate norm perceptions (Elmore et al., 2017). School counselors or nurses could also provide personalized normative feedback to students when they have appointments for health-related issues or smoking ban violations.

Faced with real peer norms, students who were contemplating tobacco use initiation may feel less pressure to do so, whereas students who already use tobacco may reduce use (or seek cessation help) as they experience cognitive dissonance through the introduction of actual norm information (Linkenbach & Perkins, 2003). In addition, students who already do not support or use tobacco may be more likely to publicly support other students’ ongoing nonuse of tobacco, thus reducing peer initiation of use. Although this study did not assess e-cigarette use, other research has found that adolescents also overestimate peer e-cigarette use, suggesting similar implications for conducting a social norms–based intervention to reduce e-cigarette use (Agaku et al., 2019).

Future research should examine the importance of norms among close friendship networks because some studies have found associations between perceived friends’ tobacco use and personal tobacco use and intentions (Cooper et al., 2016; Duan et al., 2009; Iannotti et al., 1996; Zaleski & Aloise-Young, 2013). Indeed, people may also misperceive close friends’ behavior (Larimer et al., 2011).

Study limitations

First, this study is subject to the limitations inherent in all studies based on self-reports. However, prevalence of tobacco use as reported here is similar to estimates from other work (Arrazola et al., 2015; Jamal et al., 2017). Moreover, tobacco use would likely never be above 50% in most grade cohorts. In addition, our measure of attitudes demonstrating misperceived norms is not subject to recall error, and there is little incentive to lie on either measure under the anonymous data collection design.

Second, because of study design, causal direction between perceived norms and personal attitudes/behavior cannot be confirmed. However, other studies have demonstrated a causal effect (Bewick et al., 2008; Brooks-Russell et al., 2014; DeJong et al., 2006; Haines & Spear, 1996; Krieger et al., 2017; LaBrie et al., 2008; Larimer et al., 2012; Lewis et al., 2015; Linkenbach & Perkins, 2003; Litt et al., 2015; Mattern & Neighbors, 2004; Neighbors et al., 2004, 2006, 2016; H. W. Perkins et al., 2010; Turner et al., 2008). In addition, an older study on 8th-grade students in the United States found that perceived smoking norms led to personal smoking even after controlling for prior smoking behavior and the actual behavioral norm at the school level (Ellickson et al., 2003).

Third, we cannot generalize these results to all U.S. students. However, a high response rate from the entire population of the schools’ target years and demographically representative samples provide confidence in the representativeness of results for the schools included in this study. Furthermore, we do observe a pervasive pattern of misperceived norms about peer tobacco use across regionally, racially/ethnically, and economically diverse contexts and students representing a variety of demographic groups in this study.

Conclusion

Misperceptions about peer tobacco use attitudes and behavior are pervasive among youth across grade, sex, race/ ethnicity, extracurricular activities, and school context. These widespread incorrect beliefs about peer norms may be harmful given the strong associations between perceptions of peer norms and personal attitudes/use. Practitioners could begin to explore comprehensive ways to promote the awareness of positive actual norms about tobacco use disapproval and nonuse. Researchers should design experiments to assess causality while also testing social norms interventions that correct norm misperceptions, presumably reducing actual use.

Footnotes

Jessica M. Perkins acknowledges salary support from National Institutes of Health Grant K01MH115811.

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