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Whether a person quits smoking depends in large part on whether his spouse or friends kick the habit, according to a new study published in the New England Journal of Medicine. Harnessing these social forces may be the key to reaching more smokers and helping them quit, experts say.

"While on its face this may seem obvious, there has long been debate about the process smokers go through when deciding whether and when to quit," said Thomas J. Glynn, PhD, American Cancer Society Director of Cancer Science and Trends and International Cancer Control. "This study provides both data and guidance for how the medical profession and policymakers can aid in promoting and accelerating the reduction of cigarette smoking."

The study, led by researchers from Harvard University and the University of California San Diego, is based on 32-years' worth of data from over 12,000 people who participated in the Framingham Heart Study, a long-term study on heart health. The researchers used a wide range of statistical methods to investigate the relationship between social networks and smoking behavior.

Smoking stigma

The researchers saw major shifts in smoking trends during the study period. Smoking prevalence dropped significantly, from 45% in the 1970s to 13% in 2002. In the 1970s, smokers and non-smokers mixed equally in their social networks; by 2000, smokers were more likely to be on the outskirts of social networks and were more likely to be clustered together.

"If you look back at 1971, smokers and non-smokers alike were at the centers of social networks," said co-author James H. Fowler, PhD, associate professor of political science at the University of California San Diego. "For people running companies and having parties, smoking was irrelevant. But during the '80s and '90s we saw a dramatic shift of smokers to the periphery of the social network. Contrary to what we might have thought in high school, smoking has become a supremely bad strategy for getting popular."

Whether a person quit smoking was largely shaped by social pressures, and people tended to quit smoking in groups. If a spouse quit smoking, the other spouse was 67% less likely to smoke. If a friend quit, a person was 36% less likely to still light up. Siblings who quit made it 25% less likely that their brothers and sisters would still smoke.

The social ramifications of smoking seemed to vary by education level. Less educated individuals were more likely to still smoke, but highly-educated smokers were more likely to be marginalized if they continued to light up. People who were more educated were more likely to influence others, and were also more influenced by others around them not smoking.

"This study tells us that social relationships have a critical impact on our health behaviors and decisions," said Richard J. Hodes, MD, National Institute on Aging director, "and that people are strongly influenced by those in their social sphere." He was not directly involved in the research.

These findings aren't unique to smoking cessation. The researchers' previous work looked at the role social dynamics play in whether someone becomes obese. Understanding and harnessing these social forces may be the answer to tackling other stubborn health problems, like improving screening rates and encouraging people to follow exercise and nutrition guidelines.

Reaching out

The researchers also discovered that over the three decades studied in the report, smokers had become an increasingly marginalized group, a position that may be making it more difficult to get cessation messages to them. In an accompanying editorial, Steven Schroeder, MD, suggests strategies for reaching out to hold-out smokers.

He posits that some smokers may be marginalizing themselves by their own choice and that perhaps what's needed is to find ways to tap into that sort of "rebel" mentality in order to help them quit. Schroeder also suggests that maybe these smokers are simply being pushed to the sidelines by the majority and are becoming increasingly isolated within their own social networks because of socioeconomic and other factors. Either way, he writes, "a further reduction in the burden of smoking will require focusing on people who are socially marginalized and whose social networks may be limited."

"This data shows that smoking is not randomly distributed in the population, but instead appears to occur in pockets of socially-connected individuals," said Kevin Stein, PhD, American Cancer Society Director, Quality of Life Research for the ACS Behavioral Research Center. "Therefore, we need to move beyond programs that focus solely on the individual smoker and develop interventions that can reach small, interconnected groups of smokers. If we are successful, we may be able to influence smoking behaviors in a more efficient and effective way."

The American Cancer Society currently offers programs tailored to both the individual and to the group, though based on this data more could be done to target smokers in isolated social networks.

"We encourage a broad number of smokers to consider quitting through advocacy and policy change," said Glynn. "And we provide a specific service for individuals who have made the decision to quit, the ACS Quitline (1-800-ACS-2345)."

For more information on how you can quit smoking, take a look at our Great American Smokeout program.

"Stranded in the Periphery – The Increasing Marginalization of Smokers." Published in the May 22, 2008 issue of the New England Journal of Medicine. Author: Steven Schroeder, MD.