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Several empirical studies have shown the attitude of smokers to formulate judgments based on distortion in the risk perception. This alteration is produced by the activation of the optimistic bias characterized by a set of the unrealistic beliefs compared to the outcomes of their behavior. This bias exposes individuals to adopt lifestyles potentially dangerous for their health, underestimate the risks and overestimate the immediate positive effects. This study aimed to analyze the relationship between optimistic bias and smoking habits. In particular, it was hypothesized that smokers develop optimistic illusions, able to facilitate the adoption and the maintenance over time of the unhealthy lifestyles, such as cigarette smoking, and the former smokers could acquire a belief system centered on own responsibility. The samples (n = 633, female = 345, male = 288) composed of smokers (35.7%), ex-smokers (32.2%) and nonsmokers (32.1%). Each participant filled out two questionnaires including The Fagerström test and the motivational questionnaire as well as a set of items measured on a Likert scales to evaluate health beliefs. The results confirmed the presence of the optimistic bias in comparative judgments, and the attitude to overestimate the effectiveness of their preventive behaviors in the smokers. Cognitive bias in risk perception may influence health behaviors in negative way and reinforce cigarette smoking over the time. Future research should be conducted to identify the better strategies to overtake this cognitive bias to improve the quitting rate.
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Int J High Risk Behav Addict. 2015 March; 4(1): e20939. DOI: 10.5812/ijhrba.20939
Published online 2015 March 20. Research Article
Personal Fable: Optimistic Bias in Cigarette Smokers
Marianna Masiero 1,2,*; Claudio Lucchiari 1,2; Gabriella Pravettoni 1,2
1Department of Health Sciences, University of Milan, Milan, Italy
2Applied Research Unit for Cognitive and Psychological Science, European Institute of Oncology, Milan, Italy
*Corresponding author: Marianna Masiero, Department of Health Sciences, University of Milan, P. O. Box: 20123, Milan, Italy. Tel: +39-0250321228, Fax: +39-0250321240, E-mail: Mari-
anna.masiero@guest.unimi.it
Received: June 3, 2014; Revised: September 8, 2014; Accepted: September 15, 2014
Background: Several empirical studies have shown the attitude of smokers to formulate judgments based on distortion in the risk
perception. This alteration is produced by the activation of the optimistic bias characterized by a set of the unrealistic beliefs compared to
the outcomes of their behavior. This bias exposes individuals to adopt lifestyles potentially dangerous for their health, underestimate the
risks and overestimate the immediate positive effects.
Objectives: This study aimed to analyze the relationship between optimistic bias and smoking habits. In particular, it was hypothesized
that smokers develop optimistic illusions, able to facilitate the adoption and the maintenance over time of the unhealthy lifestyles, such
as cigarette smoking, and the former smokers could acquire a belief system centered on own responsibility.
Patients and Methods: The samples (n = 633, female = 345, male = 288) composed of smokers (35.7%), ex-smokers (32.2%) and nonsmokers
(32.1%). Each participant filled out two questionnaires including The Fagerström test and the motivational questionnaire as well as a set of
items measured on a Likert scales to evaluate health beliefs.
Results: The results confirmed the presence of the optimistic bias in comparative judgments, and the attitude to overestimate the
effectiveness of their preventive behaviors in the smokers.
Conclusions: Cognitive bias in risk perception may influence health behaviors in negative way and reinforce cigarette smoking over the
time. Future research should be conducted to identify the better strategies to overtake this cognitive bias to improve the quitting rate.
Keywords:Decision Making; Nicotine Dependence; Bias; Risk
Copyright © 2015, Zahedan University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non-
Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial
usages, provided the original work is properly cited.
1. Background
For a long time, the study of the addictive behavior has
been based on a biological model, which highlighted
the role of brain chemistry and neurological consid-
erations. In this approach, nicotine dependence has
been explained as a consequence of limbic and cortical
structures malfunctioning, that was produced by a do-
paminergic up-regulation. Actually, nicotine alters the
reinforcement signal processing in ventral regions of
the basal ganglia thus determining a brain neuro-adap-
tation to the substance. However, starting by the 1990s a
new cognitive model introduced further perspective on
smoking. These models are essentially based on the study
of risk, since risk dis-perception was considered a major
factor in favoring initiation and maintaining an unsafe
behavior over the time (1, 2).
While previous psychological research had stressed the
role of the motivational factors and impulsiveness (3),
the new paradigm suggested that smokers’ mental mod-
els and their belief system might also be considered to
understand individual behaviors and decision making,
in particular when risks should be weighted on benefits
to follow the best option (e.g. smoking versus nonsmok-
ing) (4).
According to Slovic (5, 6) an individual may take dis-
advantageous decisions not only when affective com-
ponents are purposely manipulated (e.g. in marketing
actions), but also when cognitive distortions and biased
beliefs are present. Actually, research on smokers’ behav-
iors has shown that they tend to underestimate both the
long-term and short-term risks of the tobacco consump-
tion. Consequently, smokers’ judgment tends to be driv-
en by anticipatory feelings elicited by previous experi-
ences and consolidated beliefs (7).
Generally speaking, we may state that risk perception
is the result of an intrasubjective cognitive assessment.
The information processing involves both cognitive and
emotional processes. For this reason the risk perception
cannot be considered a pure logic and objective evalua-
tion. In particular, three different elements should be
taken into consideration to understand health-related
risk assessment including the perceived vulnerability,
the preventive efficacy and unwarranted optimism. The
perceived vulnerability is the degree to which an individ-
ual feels to be personally exposed to health consequences
due to their own behavior. A high level of vulnerability in
smokers is generally associated with a:
Masiero M et al.
Int J High Risk Behav Addict. 2015;4(1):e209392
- high level of motivation to give up smoking (8);
- high probability to be involved in smoking cessation
programs;
- high likelihood to do a real attempt to give up (9)
It has also been observed that cancer patients with high
level of perceived vulnerability generally show a higher
motivation to quit (10), and a better success rate (11). The
preventive efficacy is related to the belief of an individual
to be able to carry out preventive actions (e.g. physical
activity) to obtain health benefits. Individuals with high
levels of preventive efficacy believe that their decisions
(e.g. to stop smoking) will actually preserve their future
health. Smokers motivated to give up generally show
high level of preventive efficacy and perceive higher ben-
efits associated with smoking discontinuation; However,
the former smokers who report to perceive high level of
health benefits often fail to sustain their abstinence over
time (9, 12).
Finally, the unwarranted optimism, also called optimis-
tic bias (13) is a cognitive bias that push people to believe
to be invulnerable to a potential risk’s source (14, 15), al-
lowing them to feel a sense of control over the effects of
their choices. This bias leads people to underestimate
risks when considering themselves, while being more
realistic (or pessimistic) when considering other peo-
ple’s behaviors. The optimist bias entails a "first-person
evaluation" as opposed to a “third-person evaluation”;
for instance, smokers are usually more optimistic about
themselves rather than others. Thus, when they use a
first-person evaluation of smoking-related risks, they are
much more optimistic than when they evaluate others’
risks (e.g. “I can stop when I want” or “Since my grand-
father died 80 years old smoking 20 cigarettes a day, I’ve
got good genes”). This optimistic illusion seems to be the
result of two distinct mental processes (16-19):
-The illusion of control, due to the overestimation of
preventive behavior efficacy (e.g. increased physical ac-
tivity that decreases the perceived need to stop). The il-
lusion of control leads smokers to the false belief that
they will able to stop when they want. In this way, they
categorize smoking as a controllable and removable be-
havior. Only later, after repeated failed quit attempts,
they come to understand to be nicotine-dependent. For
instance, among occasional smokers, namely who smoke
less than a cigarette a day, only 15% think that within 5
years could become a heavy smoker, thus developing a
chronic dependence to nicotine. Moreover, among heavy
smokers, 32% consider that within 5 years they will still be
a smoker, while 68% believe that will interrupt. In reality,
the official statistics show that after 5 years 70% of people
keep on smoking (20).
- The need to preserve a good self-esteem level. Indeed,
one’s self-esteem is generally threatened when a risk is
not avoided. At the opposite, one’s self-esteem increases
when self-efficacy is high (21, 22).
In this way, smokers develop illusory beliefs to justify
their behaviors and reduce the negative feelings associ-
ated to the adoption of a risk choice that could be avoid-
ed. Being able to find arguments in favor of others’ risks
(e.g. a high genetic vulnerability), smokers succeed in
managing the cognitive dissonance due to the mismatch
between risk perception (“smoking may be hazardous”)
and the actual behavior (14). This optimistic thinking is
linked to the memory functioning, since a recurrent be-
havior is more easily accessible, and due to a habitation
effect, they are considered acceptable though being risky.
This implies that, when a person assesses specific levels
of risk (e.g. the likelihood to develop a lung cancer due to
heavy smoking) available memories will guide judgment
instead of an objective assessment (23, 24). Finally, the
optimistic bias may be linked to so-called wishful think-
ing including cognitive distortions produced by desir-
able situation, events, subject and/or object evaluation.
This distortion leads people to consider the occurrence
of an event more likely than another only because it is
more desirable. For instance, smokers may conclude that
smoking is not riskier than other behaviors, just because
this is a wishful consideration.
It is important to note that both adolescent and adult
smokers are generally able to recognize the hazardous
smoking in a long-run perspective and the existence of
smoking-related diseases (e.g. lung cancer, cardiovas-
cular problem and other cancer syndrome) (4, 25).They
show to have an adequate information about these is-
sues; nevertheless, they show ambiguous attitudes to-
wards risk, since they don’t relate their choices to health
and wellbeing.
2. Objectives
The present study aimed to analyze the influence of the
optimism bias and illusionary beliefs that support smok-
ing initiation, consolidation and maintenance over time.
Moreover, this study aimed to evaluate four main hypoth-
eses as follows:
1- Since smoking-related issues are common in the
whole society, in smokers and nonsmokers , we hypoth-
esized that smokers with respect to nonsmokers show an
optimistic bias, being more benevolent when evaluating
first-person risks than third-person ones. At the opposite
nonsmokers and former smokers should be more realis-
tic, showing balanced judgments.
2- We hypothesized that former smokers develop a spe-
cific belief system to support their abstinence. In particu-
lar, we supposed former smokers having higher smok-
ing-related risk perception than smokers. At the same
time, we argued that former smokers feel to modulate
the effects of previous smoking on their health by their
actual behavior.
3- Finally, since risk perception and health-related be-
liefs are modulate by behavioral, psychological and de-
mographic variables, we hypothesized that age, gender,
smoking habits (nicotine dependence) and motivation
to quit should affect the smokers’ cognitive distortions.
Masiero M et al.
3
Int J High Risk Behav Addict. 2015;4(1):e20939
3. Patients and Methods
3.1. Subjects
The sample was recruited in collaboration with the
Interdisciplinary Research Center on Decision (IRIDe)
of the University of Milan. The research was conducted
from January 2013 until June 2013. The sample is made by
633 volunteer participants (Female = 54.5%; Male = 45.5%),
recruited through internet sites. During a telephone con-
tact, all the needed information was delivered and if the
subject agreed to participate in the study, an e-mail with
the study description, the informant consent and a link
to an online questionnaire was sent to him/her. The time
to complete the protocol was about 20 minutes for all
conditions. Subjects had the possibility to contact a re-
searcher by an e-mail or telephone on demand. After the
completion of the procedure, each subject was contacted
for a fast debrief. An opportunistic sampling method was
used. The mean age of the samples was 48.01 years (stan-
dard deviation = 15.203), with an age range of 19-74 years.
The samples were classified into three clusters: smokers
(35.7%), ex-smokers (32.2%), and nonsmokers (32.1%).
3.2. Instruments
Two standardized questionnaires were used:
-The Fagerstrom test for nicotine dependence (FTND)
(26) to assess the dependence level both physiological
and psychologically;
- A motivational questionnaire to evaluate the intention
to give up smoking (27);
To evaluate smoking-related beliefs, we used a set of
Likert scale questions. The Fagerström test for nicotine
dependence is a 6-item self-administered questionnaire.
The scale evaluates three main dimensions including the
average daily amount of cigarette smoked, the nicotine
compulsion, and the general level of dependence. The
total score ranges from a minimum of the 0 points to a
maximum of the 10 points, with the following meanings:
0-2 mild dependence, 3-4 not severe dependence, 5-6
strong dependence, 7-10 very strong dependence.
The motivation to give up smoking (27) consists of four
multiple-choice questions; to each is assigned a score
ranging from 1 to 4. The total score allow to classify smok-
ers into one of four motivational clusters: 4-6 low (not
yet seriously considered to give up smoking); 7-10 middle
(the person evaluated both the benefits of quitting and
the risks of smoking); 11-14 high (there are moments in
which the person is determined to quit smoking); 15-19
very high (the person is ready to give up smoking).
To assess the system of subjects’ beliefs, we collected
a set of 11 assertions (Appendix 1) adapted by previous
works (12, 14). The translation and the cultural adaptation
of items were performed by a panel of expert, including
two psychologists, one counselor expert in tobacco ces-
sation and one professional English to Italian translator.
To study the face validity of items, we asked 20 subjects
(all smokers) to indicate whether the questions were
clear, understandable, and in a logical order. To further
validate our version of the instrument, we collected data
from 20 students of the University of Milan (20 smokers,
20 former smokers, and 20 nonsmokers) in a pilot phase
of the study. We performed a test-retest study, asking
participants to answer to the same items three months
after the first trial, finding a mean test-retest correlation
(Spearman’s Rho) of 0.88 (range, 0.82-0.96).
Subjects were asked to rate themselves according to
each assertion on a 4-point Likert scale. Each item has
been built specifically to describe beliefs and opinions
with respect to smoking-related risks and dependence is-
sues. Consequently, items do not assess the individual’s
knowledge levels, since we wanted to assess biased cog-
nitive processes rather than notions. The first 7 items
contain assertions on risk perception. These items are
semantically constructed to assess the self-oriented (first-
person perspective) risk perception in contrast to a gen-
eral risk perception (third-person perspective). Items 8 to
11 consider smoking-related myths and cognitive strate-
gies used to cope with tobacco-related risks.
4. Results
Data were processed using the (SPSS, IBM, USA) version
20.0. Descriptive statistics were used to analyze sample
characteristics. Most smokers (63%) had a moderate to
high nicotine-dependence level as measured by the Fag-
erström test. At the same time, the 41.7% of smokers re-
ported a high motivation score, and most fall between
high and middle level. Although our sample is quite
heterogeneous, most participants had a strong addic-
tion (mean of daily cigarettes = 20.181, standard deviation
= 12.246) and good motivation to quit. A series of cross
tables were created to find associations between the an-
swers and smoking clusters (smokers, ex-smokers and
nonsmokers). The chi-square test was used to evaluate
statistical differences.
Statistically significant effects were found in items 2, 3,
4, 8, and 11 showing different distributions for the three
clusters. In particular, answering to item 2 many smokers
reported to doubt that the cigarette smoking could be a
possible cause of death, while former and nonsmokers
reported more realistic judgments (X2 = 25.469, df = 6, P =
0.000) with respect to well-known statistics. This result is
particularly important because when the subjective per-
spective (first-person risk evaluation) is substituted by a
general perspective (risk for others), the optimistic bias
disappeared (Figure 1).
Also, answers to item 3 (X2 = 28.240, df = 6 P = 0.000)
and 4 (X2 = 23.436, df = 6, P = 0.001) showed different dis-
tributions. These items refer to the smokers’ confidence
in controlling their behavior. Consequently, we can say
that smokers tend to underestimate the power and the
salience of the nicotine addiction. In the third area, we
analyzed the preventive strategies enacted by respon-
dents to contrast the side-effects of tobacco consump-
Masiero M et al.
Int J High Risk Behav Addict. 2015;4(1):e209394
tion. Different distributions were observed in item 8 (X2
= 23.545, df = 6, P = 0.001) and item 11 (X2 = 13.724, df = 6,
P = 0.033). Smokers compared to nonsmokers trust more
on the power of the physical activity to contrasts the ciga-
rette smoking negative effects. Furthermore, smokers
and ex-smokers seem to underestimate the association
between tobacco consumption and lung cancer (Figure
1). Smokers probably tend to develop this illusory belief
to contrast the mismatch between the pleasure for the
smoking (hedonistic dimension) and the health conse-
quences. Coherently with our second hypothesis, former
smokers probably need to believe that their previous be-
havior won’t have severe consequences on their future
health; otherwise, remaining abstinence could be per-
ceived as useless.
To address our third hypothesis, a similar analysis was
carried out on smokers considering motivational to give
up groups (low, middle, high) as measured by the moti-
vational questionnaire. However, no significant differ-
ence was found in judgments and beliefs among these
groups. The role of gender and age was also evaluated.
A statistical difference was found at the item 7: the male
ex-smokers reported more pessimistic evaluations on the
association between cigarette smoking and lung cancer
than female smokers (X2 = 13.553, df = 3, P = 0.004).
Four categories were considered to examine the effect
of age: 19-40 years; 41-50 years; 51-60 years and 61-75 years.
Answers to the item 2, 4, 6 and 10 showed different dis-
tributions for age categories. More in details, at the item
2 (X2 = 20.380, df = 9, P = 0.016) smokers under 40 and
smokers over 50 tend to underestimate the smoking-re-
lated risks. At the opposite, nonsmokers between 19 and
40 years showed higher awareness (X2 = 17.402 df = 9, P =
0.043) about smoking-related risks.
At item 4, younger smokers (aged between 19 and 40)
reported to underestimate the strength physical depen-
dence more than older smokers (X2 = 20.833, df = 9, P =
0.013). Indeed, they believed that cigarette smoking was
an easily controllable behavior. In the clusters of 51-60
and 61-75 years, an inversion of this trend was observed.
The younger ex-smokers (19-40 years) tended to under-
line their chances of contrasting disease development
due to protective behaviors (X2 = 30.771, df = 9, P = 0.000).
This trend was in accordance to answers to item 10, since
smokers over 60 underestimated the risk to develop the
lung cancer, if they had smoke just for few years (X2 =
29.352, df = 9, P = 0.001). Otherwise, smokers under 60 ad-
mitted this risk. It is interesting to note that the nicotine-
dependence level increased during time (X2 = 39.628, df
= 9, P = 0.000), since smokers in clusters 51-60 and 61-75
years reported higher level of dependence as measure
by the Fageström test. This datum suggests that smokers
with high levels of nicotine-dependence (and then the
number of cigarettes consumed) also reported a heavily
biased smoking-related risk perception.
5. Discussion
In the 2011, the World Health Organization report on
the global tobacco epidemic as stressed that the cigarette
smoking is a first cause of death in the world. Each year,
tobacco consumption kills six millions of people. Many
of these people develop a respiratory or cardiovascular
disease due to smoking; however, few of these individu-
als seem to be aware of this great problem. In 2010, it was
conducted a study in several American hospitals, and it
was discovered that the 47.6% of smokers admitted at the
emergency department for acute respiratory care did not
believe that the real cause was cigarettes smoking (28).
In smokers is strong the tendency to underestimate all
smoking-related risks. The need to defend the self-esteem
induces the addicted subject to develop a series of illusion
and false beliefs to support the choice to keep on smoking.
Item 2."I doubt that I would ever die from smoking even if
I smoked for 30 or 40 years."
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
Smokers
Ex- Smokers
Non-Smokers
Smokers
Ex- Smokers
Non-Smokers
Smokers
Ex- Smokers
Non-Smokers
Smokers
Ex- Smokers
Non-Smokers
Smokers
Ex- Smokers
Non-Smokers
Campletely
agree Slighly
agree Slightly
disagree Completely
disagree Campletely
agree Slighly
agree Slightly
disagree Completely
disagree Campletely
agree Slighly
agree Slightly
disagree Completely
disagree
Campletely
agree Slighly
agree Slightly
disagree Completely
disagree Campletely
agree Slighly
agree Slightly
disagree Completely
disagree
Item 3. "Most people who smoke for a few years become
addicted and can't stop."
120
100
80
60
40
20
0
Item 8. "The physical exercise could cancel the effects of
smoking."
Item 11. "The overall risk of developing cancer depends more
on genes than other things."
Item 4. "I could smoke for a few years and then quit if I
Wanted to."
90
80
70
60
50
40
30
20
10
0
80
70
60
50
40
30
20
10
0
Figure 1. Distribution of Answers at Items 2, 3, 4, 8 and 11
Masiero M et al.
5
Int J High Risk Behav Addict. 2015;4(1):e20939
The aim of this study was to investigate the belief system
in smokers and former smokers with respect to nonsmok-
ers. The theoretical framework we used is based on the con-
cept that the optimistic bias is structured on a set of mental
models (cognitive architecture) used to appraise health-re-
lated risk in different contexts. Confirming our hypotheses,
it emerged that the activation of a cognitive distortion is
produced by an error in evaluating smoking-related risk.
In particular, it was observed that smokers underestimate
the strength of their dependence and related problems. In-
deed, smokers generally consider having the control over
their smoking behavior. In this way, smokers do not iden-
tify themselves as being abusers; however, at the opposite
they believe that their behavior is the result of a hedonistic
(the pleasure of tobacco) and aware evaluation (5, 14).
Our data have also confirmed a higher attitude of younger
smokers to neglect the risk to develop a strong dependence
due to nicotine absorption. Indeed, smokers between 19-40
years old consider the cigarette smoking as a consciously
driven behavior. Only later, after repeated failed quit at-
tempts, they come to understand their dependence to nic-
otine. Indeed, at the item 4 the answers of over 60 smokers
showed that the awareness of their dependence is greater
than in younger smokers. The obtained results from this
study are in agreement with those of the previous studies
(28-31), which have stressed both the experiential dimen-
sion of addiction and the limited capacity of people to ra-
tionally assess future consequences of their behavior (7)
understanding the real complexity of a psychological and
physical dependence to nicotine (5).
Another important result is the attitude of female smok-
ers to underestimate smoking-related risks compared to
males. This could explain the problem of the female smok-
ers to give up smoking and the great risk of a new female
smoking epidemic in some country, such as Italy (32). Previ-
ous research addressed this issue (33), finding associations
between the fear to increase the body weight (aesthetics
issues) and the perceived stress reported during the absti-
nence. This association might lead female smokers to un-
derestimate risks to sustain smoking also in the presence
of long-term negative consequences, preferring short-term
benefits.
Actually, female smokers comparing with male smokers
reported to believe that cigarette smoking has a preven-
tive action against anxiety and depression and this belief is
a serious obstacle to smoking discontinuation. Moreover,
some researchers (34) have observed that females are more
inclined to strain the disadvantages provoked by the smok-
ing cessation, instead of the benefits. This is a salient factor,
because the assessment of benefits and the identification
of potential risks are related both to the give-up motivation
and at the success rate of smoking cessation programs. In-
deed, smokers with high level of motivation to give up are
generally able to interrupt and to maintain the abstinence
over a long time period (35).
Finally, the tendency to overestimate the efficacy of pre-
ventive strategies to contrast the negative effects of ciga-
rettes (e.g. to carry out regular physical exercise, to adopt
a healthy diet, to increase vitamins intakes and so on) was
confirmed. Smokers tend to adopt a series of preventive
behaviors with the belief to decrease risks for their health.
Regarding this issue, it is interesting to compare the beliefs
system of smokers and former smokers. We hypothesized
that also former smokers need such beliefs in order to sus-
tain their abstinence.
A high level of awareness about smoking-related risks
might be considered the first motivational factor to con-
trast the pleasure associated with the cigarette consump-
tion. Actually, they reported strong convictions about the
hazardous effects of smoking. Furthermore, ex-smokers
seem to have developed a considerable trust in the power
of a healthy lifestyle to contrast all the risks associated with
the previous smoking behaviors. In this way, former smok-
ers may sustain their abstinence by believing that now they
elude smoking-related risks thanks to healthier choices.
Otherwise, thinking that the tobacco consumption had
already impacted their health irremediably could weaken
the decision to remain abstinence.
In conclusion, smokers and former smokers showed a
different beliefs system. In particular, ex-smokers tend to
assume the responsibility of their health, overestimate the
impact of their decision, while smokers are more optimis-
tic on their future and on their capacity to monitor health
consequences. This optimistic perspective seems to put on
the subject a "veil of Maya”, which changes how the reality
is seen, leading to harmful behaviors by overshadowing
rational judgments. The unrealistic optimism is an impor-
tant obstacle to interrupt the smokers' attempts, because
it prevents the transition to the full awareness of tobacco
consumption. This lack of awareness hinders the passage
through the spiral of change (36) by developing the neces-
sary motivation to quit.
Unfortunately, contrasting this optimistic distortion is
not an easy task (1): however, developing of a strong indi-
vidual awareness is fundamental to improve the likelihood
of the adaptation of a healthy behavior. We argue that the
comprehension of the cognitive processes of smokers is an
important starting point, since it allows the understand-
ing of the complex nature of smoking to promote tobacco
cessation interventions able to fit with smoker needs. Since
many antismoking interventions are only based on drugs,
behavioral change and nicotine substitution strategies
without considering the cognitive issues, investigate how
smokers thinks about their behaviors and their risks is par-
ticular important. In particular, the use of the electronic
cigarettes that promises to be the next frontier to contrast
tobacco consumption in the near future should be ana-
lyzed within this framework to avoid the substitution of
bad behavior with another one.
In conclusion, our data showed interesting suggestions to
better understand the smoker’s mind. However, this study
has several limitations, in particular, the quantity and the
quality of the sample and the data collection methodology,
which do not allow drawing easy generalizations, since
Masiero M et al.
Int J High Risk Behav Addict. 2015;4(1):e209396
this is a survey study that do not permit variable manipula-
tions. For this reason, we have limited the complexity of the
data analysis to allow a simple and direct reading. However,
we argue that our data suggest future lines of research able
to verify the size effect and generalizability of our results
other than to promote cognitive-based intervention to im-
prove the adoption of healthy lifestyle and increase the ef-
ficacy of antismoking cessation programs.
Authors’ Contributions
Dr. Marianna Masiero, Prof. Claudio Lucchiari and Prof.
Gabriella Pravettoni designed the study and wrote the pro-
tocol. Dr. Marianna Masiero managed the literature search-
es and summaries of previous related works. Prof. Claudio
Lucchiari undertook the statistical analysis, and Dr. Mari-
anna Masiero wrote the first draft of the manuscript. All
authors contributed to and have approved the final manu-
script.
Appendix
Items Used to Evaluate Health Beliefs
Most People Who Smoke all Their Lives Eventually Die From an Illness
Caused by Smoking
Completely agree
Slightly agree
Slightly disagree
Completely disagree
I doubt that I would ever die from smoking even if I smoked for 30 or 40
years
Completely agree
Slightly agree
Slightly disagree
Completely disagree
Most people who smoke for a few years become addicted and can’t stop.
Completely agree
Slightly agree
Slightly disagree
Completely disagree
I could smoke for a few years and then quit if I wanted to
Completely agree
Slightly agree
Slightly disagree
Completely disagree
How likely do you think that cigarette smokers will develop lung cancer?
Very Low
Moderate Discreet
Very High
How many people who have developed lung cancer do you think are cured?
> 25%
< 50%
About 75%
Almost all
Would you say smokers compared to non-smokers have:
The same lung cancer risk
A slightly higher lung cancer risk than
A double lung risk
Ten or more times
The non-smokers lung cancer risk
Physical exercise could undo most of the effects of smoking.
Completely agree
Slightly agree
Slightly disagree
Completely disagree
Vitamins could undo most the effects of smoking.
Completely agree
Slightly agree
Slightly disagree
Completely disagree
There is no risk of getting cancer if you only smoke a few years.
Completely agree
Slightly agree
Slightly disagree
Completely disagree
The overall risk of getting cancer depends more on genes than anything
else
Completely agree
Slightly agree
Slightly disagree
Completely disagree
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... Indeed, many smokers have optimistic biases regarding smoking-related diseases and nicotine addiction [33][34][35]. Nevertheless, smokers who perceive health consequences from smoking are more likely to quit [36,37]. Among the U.S. general population, there is evidence of optimistic bias in relation to risk perceptions of COVID-19 [38], as has been found for influenza [39]. ...
... In our sample, daily smokers were more likely to perceive greater COVID-19 harm for themselves and were less likely to have optimistic bias. This is consistent with other research showing that smoking frequency and risk perception for smoking-related diseases are positively correlated [36]. Indeed, more frequent smokers may have experienced more smoking-related health symptoms. ...
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... Most of the participants (199) smoked 1-2 packs per day and only 16 of them smoked 2-4 packs per day (heavy smokers). It is discussed by many researchers that heavy smokers are more likely to underestimate their true risk of developing lung cancer [55,56]. Therefore, we can assume that most of our participants (non-heavy smokers) had a higher perception of their lung cancer risk. ...
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... The risk of current smoking and smoking susceptibility among junior high school students was more significantly affected by SHS exposure at home. According to the theory of human development, family members have a stronger influence on adolescents aged 13-15 years than on those aged 16-17 years 37 . Junior high school students who are younger are likely to imitate the smoking behaviors of intimate people, especially parents. ...
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Traditionally smoking cessation studies use smoker and nonsmoker categories almost exclusively to represent individuals quitting smoking. This study tested the transtheoretical model of change that posits a series of stages through which smokers move as they successfully change the smoking habit. Ss in precontemplation ( n = 166), contemplation ( n = 794), and preparation ( n = 506) stages of change were compared on smoking history, 10 processes of change, pretest self-efficacy, and decisional balance, as well as 1-mo and 6-mo cessation activity. Results strongly support the stages of change model. All groups were similar on smoking history but differed dramatically on current cessation activity. Stage differences predicted attempts to quit smoking and cessation success at 1- and 6-mo follow-up. Implications for recruitment, intervention, and research are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Women may be at relatively greater risk of smoking-related diseases than men but tend to have less success than men in quitting smoking. The failure of most outcome studies to report results by gender and the lack of statistical power for detecting significant gender differences currently do not allow for many firm conclusions to be drawn about smoking cessation rates in women, but several trends warrant attention and further study. First, the difference in cessation rates for women versus men may be even greater in trials of nicotine replacement therapies (NRT). This suggests that women benefit less from NRT relative to men, although this difference may depend on the particular form of NRT (e.g. inhaler versus gum). On the other hand, some non-NRT medications may reverse the poorer outcome of women, producing quit rates in women comparable with those in men. Gender differences in outcome, as well as overall success rates, with NRT and some of the non-NRT medications appear to be enhanced when treatment includes substantial behavioural counselling. However, while several of the non-NRT medications may be particularly appropriate to consider for treating women trying to quit smoking, adverse effects may limit widespread use of some of these drugs, such as clonidine and naltrexone. Thus, even if the gender differences in outcome with NRT versus non-NRT drugs are confirmed in further research, such findings do not necessarily justify limiting NRT use in women, because such treatment is clearly effective and is likely to be safer and more readily available than non-NRT medications. Nevertheless, study of the mechanisms by which some non-NRT drugs are effective in women may aid our understanding of factors that are more influential in smoking behaviour in women than in men. Secondly, smoking cessation treatment for women must address several other issues that often emerge, and these are most likely to require behavioural counselling that is tailored to these problems. These issues include concern about bodyweight gain, restrictions on medication use in pregnant smokers, variability in mood and withdrawal as a function of menstrual cycle phase, harnessing social support to foster abstinence, and the possibility that smoking-associated environmental cues may be more influential in smoking behaviour in women than men. Greater attention to gender differences in clinical trial outcomes and to addressing concerns of women smokers may aid in the development of substantially improved smoking cessation interventions for women.
Article
The argument that people freely choose to smoke assumes that individuals at the point of initiation of smoking (often in adolescence) hold accurate beliefs about smoking. Smoking beliefs and the presence of known smoking risk factors were assessed in interviews with a sample of 895 urban young people. The respondents greatly overestimated the prevalence of adult and peer smoking, negative attitudes of their peers were greatly underestimated, a large proportion believed that they would be less likely than other people to contract a smoking-related illness if they became smokers, and there was a general lack of understanding of the adverse consequences experienced upon smoking cessation. These misperceptions were more common among youngsters who were smokers, who intended to smoke, or who had friends or family members who smoked. Because misinformation among young people is widespread and those at greatest risk for smoking are the most misinformed, the tobacco industry's argument that the decision to smoke reflects an "informed choice" is without merit. (JAMA 1987;257:3373-3376)
Article
The purpose of the present study was to investigate how optimists process health-related information. Sixty-five young adults (ages 18–35) reported skin cancer-related knowledge and behaviors, and read slides of information on skin and skin cancer. Visual attention to the slides was recorded using eye tracking, and their memory for the information was measured. Additionally, participants’ self-reported skin cancer-relevant behavior was assessed prospectively in the months following the lab component of the study. Results show that individuals low in dispositional optimism or high in health-related optimism paid more attention when they were at high objective risk of developing skin cancer; and individuals high in dispositional optimism or high in health-related optimism were more likely to perform adaptive, health-promoting behaviors. In addition, optimistic beliefs were found not to be related with unrealistic optimism. Dispositional and health-related optimism therefore appear to predict health-related cognition and behavior in distinct ways.
Article
In Study 1, over 200 college students estimated how much their own chance of experiencing 42 events differed from the chances of their classmates. Overall, Ss rated their own chances to be significantly above average for positive events and below average for negative events. Cognitive and motivational considerations led to predictions that degree of desirability, perceived probability, personal experience, perceived controllability, and stereotype salience would influence the amount of optimistic bias evoked by different events. All predictions were supported, although the pattern of effects differed for positive and negative events. Study 2 with 120 female undergraduates from Study 1 tested the idea that people are unrealistically optimistic because they focus on factors that improve their own chances of achieving desirable outcomes and fail to realize that others may have just as many factors in their favor. Ss listed the factors that they thought influenced their own chances of experiencing 8 future events. When such lists were read by a 2nd group of Ss, the amount of unrealistic optimism shown by this 2nd group for the same 8 events decreased significantly, although it was not eliminated. (22 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)