For much of the 20th century, smoking was regarded as a socially learned habit and as a personal choice. It is only in the past decade or so that the fundamental role of nicotine in sustaining smoking behaviour has begun to be more widely accepted. It is now recognised that cigarette smoking is primarily a manifestation of nicotine addiction and that smokers have individually characteristic preferences for their level of nicotine intake. Smokers regulate the way they puff and inhale to achieve their desired nicotine dose.

The link with nicotine addiction does not imply that pharmacological factors drive smoking behaviour in a simple way and to the exclusion of other influences. Social, economic, personal, and political influences all play an important part in determining patterns of smoking prevalence and cessation.

Although drug effects underpin the behaviour, family and wider social influences are often critical in determining who starts smoking, who gives up, and who continues.

Why do people start smoking?
Experimenting with smoking usually occurs in the early teenage years and is driven predominantly by psychosocial motives. For a beginner, smoking a cigarette is a symbolic act conveying messages such as, in the words of the tobacco company Philip Morris, “I am no longer my mother’s child,” and “I am tough.”

Smoking a cigarette for a beginner is a symbolic act of rebellion

Children who are attracted to this adolescent assertion of perceived adulthood or rebelliousness tend to come from backgrounds that favour smoking (for example, with high levels of smoking in parents, siblings, and peers; relatively deprived neighbourhoods; schools where smoking is common). They also tend not to be succeeding according to their own or society’s terms (for example, they have low self esteem, have impaired psychological wellbeing, are overweight, or are poor achievers at school).

The desired image is sufficient for the novice smoker to tolerate the aversion of the first few cigarettes, after which pharmacological factors assume much greater importance.

Again in the words of Philip Morris, “as the force from the psychosocial symbolism subsides, the pharmacological effect takes over to sustain the habit.” Within a year or so of starting to smoke, children inhale the same amount of nicotine per cigarette as adults, experience craving for cigarettes when they cannot smoke, make attempts to quit, and report experiencing the whole range of nicotine withdrawal symptoms.