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Social Science & Medicine 68 (2009) 2206–2214

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Theory driven research designs for explaining behavioural health risk transitions:The case of smoking

Jane Dixon, Cathy Banwell*

National Centre for Epidemiology and Population Health, Australian National University, Building 62, Canberra, ACT 0200, Australia

a r t i c l e i n f o

Article history:Available online 24 April 2009

Keywords:BourdieuSocial contagion and mimesisHealth risk transitionsCigarette consumptionSmoking

* Corresponding author. Tel.: þ61 2 6325 0016.E-mail addresses: Jane.Dixon@anu.edu.au (J. Dixon

(C. Banwell).

0277-9536/$ – see front matter Crown Copyright � 2doi:10.1016/j.socscimed.2009.03.025

a b s t r a c t

Recent social network analyses have suggested that common chronic disease risk factors are moremutable than expected; raising practical considerations for public health interventions. Within thiscontext, it is timely to assess the alternative social science reasoning being offered to explain behaviouralhealth risk transitions. This paper takes up this challenge by critically reviewing the major theoriesapplied to the temporal trends and sub-population variations in affluent country smoking behaviour.Three explanations dominate: a materialist approach; Bourdieu’s distinctive class-based cultures; and,the spread of norms and emotions within social networks. We note conceptual tension when integratedtheories are adopted. We also report on the relative absence of theoretical interrogation for thepersistent adoption of smoking behaviours among present and successive lower socio-economic status(SES) cohorts. While unequal rates of persistence within cohorts has received some attention, theongoing adoption of a non-innovative and health damaging behaviour is not well understood. To thisend, we suggest the incorporation of several underused concepts: namely Bourdieu’s ‘rules of the game’and ‘symbolic violence’ and ‘mimesis’, an aspect of social contagion. We conclude by describing theimplications for social action of the alternative theories, and argue that theory driven research designscould deliver more efficacious evidence for interventions than the post hoc application of theories toexisting data sets.

Crown Copyright � 2009 Published by Elsevier Ltd. All rights reserved.

Introduction

Over the last decade, the focus has shifted within social epide-miology from documenting socio-economic gradients in healthoutcomes to identifying the mechanisms responsible for thepredictable patterning of numerous health risk behaviours. To thisend, social epidemiologists are putting the long-held theories ofsocial stratification, diffusion and social distinction to the task ofunderstanding the spread of health risk behaviours between socialgroups.

One of the earliest examples is the work by Lopez, Collishaw,and Piha (1994) who identified how cigarette smoking spreads infour stages between men and women. Adding socio-economicstatus variables, other researchers have since confirmed this sametrajectory (Mackenbach, 2006; Graham et al., 2006; Friel & Broom,2007). In general, this body of research can be classified as mate-rialist, a perspective which acknowledges that social position isaccompanied by different levels of material advantage in terms of

), Cathy.Banwell@anu.edu.au

009 Published by Elsevier Ltd. All

individual and social group level resources, opportunities andcapabilities.

Recently a suite of studies on a variety of risk and protectivefactors, including smoking, has emerged based on the applicationof social network analysis (Christakis & Fowler, 2007, 2008; Fowler& Christakis, 2008). Using both social network and social diffu-sions theory, researchers using the longitudinal Framingham HeartStudy have obtained a similar result to that of Lopez: namely, therisks of smoking adoption and persistence are more prevalentamong socially marginal groups, especially those with lowereducation levels. Similar findings were reported for variations inthe presence of the behavioural risks for obesity. The conclusionreached for the two studies was that if normative behavioursspread through person-to-person contact then interventions toalter social network dynamics could help to diffuse healthylifestyles.

However while the materialists and the social network theoristsreached similar conclusions about the composition of smokingvulnerable populations, a close reading of their explanations for thespread of smoking behaviour shows the involvement of differentpathways and mechanisms of transmission. As a result of theirtheoretical approach, social network researchers suggest that

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chronic disease risk factors are more mutable than expected fromthe materialist analyses.

Within the context of the application of alternative socialscience reasoning, it is timely to assess the alternatives beingoffered to explain behavioural health risk transitions. This papertakes up this challenge by critically reviewing the major theoriesapplied to the temporal trends and sub-population variations inaffluent country smoking behaviour. Smoking was selected becauseit has received more attention for a longer period of time than otherrisk factors. Three broad ‘schools’ of theory dominate the literature:a materialist approach; Bourdieu’s distinctive class-based cultures;and, the spread of risky norms within social networks.

A social diffusions of risk behaviours perspective is typicallypresent irrespective of the ‘school’ that is used, but we find that theperspective is not always deployed in the same way. Early diffusiontheorists predicted that ‘‘inferiors’’ will follow the lead of ‘‘supe-riors’’ who readily adopt new practices because they are predis-posed to appreciate technical and cultural innovation (Ferrence,2001). In Rogers’ (1995) diffusion of innovation theory, the verticaltransfer of ideas is present but so is a horizontal process of trans-mission. We also note that there is increasing propensity to usemore than one perspective, or an integrated theoretical approach.

In the next section, we describe the application of the threedifferent theoretical approaches to data from affluent, Westerncountries and draw out the conceptual building blocks used in each.We highlight some tensions that arise with the use of integratedframeworks. We proceed to argue that while the theories are beingapplied to the four stages of the smoking epidemic, that what weare calling the fifth stage – the sedimentation of smoking behaviouramong successive low socio-economic status (SES) cohorts – hasnot received enough attention. To this end, we propose threeconcepts that could usefully be deployed to frame future researchdesigns.

Alternative theoretical applications to ‘the smoking epidemic’

Lopez and colleagues’ proposed a four stage model of genderedpatterns of smoking uptake. These stages were elaborated byMackenbach (2006) using European data to include the SES indi-cators, education and income: (1) begins among the most powerfulgroups: men of high socio-economic status (SES) before becomingmore common among all SES groups; (2) once the behaviourbecomes widespread or democratised and normalised, high SESmen followed by middle SES men stop smoking and women’sconsumption peaks; (3) after some years, high SES women’ssmoking decreases, followed by declines for most men and women;and (4) smoking continues among the least powerful, namelyyoung women and men and women of low SES. In commenting onthese variations in smoking, Mackenbach explicitly referred todiffusion theory, and ‘‘the considerable delay between ‘earlyadopters’ and ‘laggards’’’ (p. 36).

Here, we describe alternative explanations for the social varia-tions of the smoking epidemic transition.

The materialist approach

Perhaps best known, the materialist perspective draws on150 years of work beginning with Marx and Engels (1969), Weber,1947, and more recently Bourdieu’s (1984) notion of fields and thesocial reproduction of class. In an important article representingthe early manifestations of an epidemiological materialist posi-tion, Lynch, Kaplan, and Salonen (1997) argued that unhealthybehaviours in adulthood, including smoking, are the result of thesocio-economic conditions of parents, including education, occu-pation, perceptions of their wealth, and the socially patterned

events that take place across the lifecourse. While they observedthat disadvantaged groups had some autonomy in behaviouralchoices, they concluded that health behaviours and dispositions‘‘are moulded over time by the SES conditions imposed at eachstage of the lifecourse’’ (Lynch et al., 1997, p. 817). This propositionis supported by research showing that childhood socio-economiccircumstances and structures of disadvantage ‘‘embed’’ smokinghabits (Graham, Inskip, Francis, & Harman, 2006). Both the Lynchet al., 1997 and Graham et al., 2006 teams invoked differentaspects of Bourdieu’s work to provide rationales for the variableadoption of behaviours by socio-economic groups: but they wereessentially materialist rationales with their emphasis on socio-economic conditions.

Until recently, a blend of diffusion and materialist theory hasbeen useful for predicting social group convergence in smokingbehaviours over seven or eight decades in a range of countries:with an emphasis on the time lag in unequal exposure to thecommercial supply and marketing of cigarettes, mediated by thesocio-economic resources (mainly occupational status, educationand income) of sub-populations. Factors operating at the nationaland regional level such as social, legal and historical contexts havealso been introduced to explain differential levels of exposure andto show the influence of contextual, as opposed to compositional,variables (Chapman, 2007; Powles, 2001; Blakely, Fawcett, Hunt, &Wilson, 2006) which regulate levels of exposure as well as thesystem of socio-economic privilege.

Bourdieu’s distinctive class-based cultures

From the 1970s onwards, those aspects of Bourdieu’s workwhich emphasised cultural resources have added a new dimensionto social epidemiology. Influenced by Veblen’s (1953) theory onconspicuous consumption of the leisure class, and Elias’ (1970)notions of game theory and habitus, Bourdieu (1984) argued thatgroups distinguish themselves symbolically from other groups bydifferentially consuming commodities, a practice with materialconsequences that is transferred and becomes habituated throughsocialisation, schooling and the family. Contrary to an orthodoxmaterialist position, Bourdieu subscribed to the argument thatwhile the practice of consuming follows social status it is notreducible to it.

Arguably the most sophisticated application of sociologicaltheory to smoking behaviours has been undertaken by Pampel andRogers (2004; Pampel, 2005, 2006, 2007). In a series of papers,a mix of diffusion theory, Bourdieu’s theory of social distinctionplus ‘‘processes of social imitation, network ties, and normativechange’’ (the basis of social network theory) (Pampel, 2005, p. 120),has been applied to over 100 years of smoking data from the USGeneral Social Surveys. According to Pampel (2005), current socio-economic status differences (education, parents’ education,parents’ income, gender and colour) in smoking can be explainedby taking an historical overview of the web of connections betweensocial group characteristics and cohort-specific social conditions(which are identified according to the changing fashions or tastesfor cigarette smoking). Pampel’s general argument resonates withthe materialist position in regard to Stages 1–3: distinction theorydescribes higher socio-economic group smoking behaviours, anddiffusion theory accounts for the later adoption of smokingbehaviours by lower socio-economic groups.

Social distinction describes middle class aspirations to bour-geois lifestyles in Western European and American settings. Whencigarettes were a luxury item in the early 20th century, and wereincorporated into the lifestyles of physicians, they providedsymbolic capital to those with existing economic and culturalcapital. Once mass markets were created for cigarette smoking, the

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point of social distinction became lost and socially advantagedgroups were propelled onto other positional commodities andpractices. In the US only 3% of physicians continue to smokecompared to 36% of blue collar workers (Chapman, 2007, p. 200).

Pampel is more successful than the materialists at explainingsuccessive cohort behaviours. He argues that new cohorts inhabitdifferent cultural contexts; contexts that are constantly beingmanufactured by social institutions like medical research and themedia. These social institutions are responsible for diffusing status-based cultural beliefs and tastes (Pampel, 2005, 2007). Importantly,the social institutions address different status groups: the massmedia promote consumption to the mass population and themedical research establishment ‘speaks’ to the educated populationabout behavioural restraint, and the adoption of another innova-tion, the pursuit of health (Pampel, 2005). In this way, theynormalise the fact that distinction does not to follow commodityconsumption but can be achieved through acts of not consumingbecause the exercise of self restraint in a sea of affluence is rare, andconsequently confers high status. On this matter, the Germansociologist Elias (1939) outlined how the modernisation of societiesresulted from behavioural constraint learned through socialisation.He illustrated this by describing the gradual adoption of tablemanners and the rapidly acquired self-control required to safelydrive a motor vehicle (see Sterne, 2003). Smoking cessationperforms the same civilising function.

The spread of norms and emotions within social networks

A growing literature suggests that normative behaviours can beas health damaging as micro-organisms when they spread throughimitation among socially networked individuals. Recent studies ofthis type build on a proud legacy, with Porter (1999) recountinghow medical theories of contagion have been in circulation sinceHippocrates, oscillating between ideas of environment-to-personor person-to-person contagion, or both.

Working within a socio-cultural perspective, Marsden (1998)dates the theory of social contagion to 200 years ago when it wasused to explain a wave of suicides that swept across Europe.According to those who studied this event, ‘‘many of the suicidevictims had come in contact with Johan von Goethe’s tale Thesorrows of young Werther, in which the hero commits suicide’’ (p. 1).

Social contagion has been used to explain negative crowdbehaviour, trends in self-harm, mass hysteria, aggression,consumer behaviour and financial events (Marsden, 1998). Ina colourful example of ‘moral epidemics’, McKay documentednumerous instances where, in nineteenth century England, ‘vulgar’,‘senseless’ and ‘absurd’ words, phrases and behaviours rapidlyspread only to disappear over night. The examples were generallyobserved among London’s poor. ‘‘These are the whimsies of themass – the harmless follies by which they unconsciously endeavourto lighten the load of care which presses upon their existence’’(McKay, 1841, p. 630). McKay’s own turns of phrase resonate withtwo key requisites of social contagion: imitative behaviours andrapid spread of new emotionally charged predispositions to uselanguage and to behave in certain ways. On this basis, contagiontheories can be contrasted with materialist and Bourdieuian theo-ries with their emphasis on sedimentation and the longue duree oflifestyles. For some critics, Bourdieu overplayed links betweencultural capital and parental class and downplayed the influence onlifestyles of social connections (see Adkins, 2003; Erickson, 1996).

Within social contagion theory, the major social actor is thesocial network and not the social class. Social network theory istypically based on the principle of homophily: that people ofsimilar SES characteristics or with shared tastes and behaviours

tend to interact with each (McPherson, Smith-Lovin, & Cook, 2001;Fowler & Christakis, 2008).

In relation to smoking initiation, the concept was revived in1980 by Epstein who reported that 40% of adult smokers were oftenintroduced to smoking in a group setting (Ferrence, 2001, p. 167).Since then, this reasoning has been adopted to explainarea differences in smoking (Dotinga, Schrijvers, Voorham, &Mackenbach, 2005), social status differences in smoking (Christakis& Fowler, 2008), social differences in obesity (Christakis & Fowler,2007), and happiness (Fowler & Christakis, 2008).

In the paper focusing on obesity risk factors, Christakis andFowler proposed social network phenomena among peers andsiblings to be responsible for the rapid spread of obesity. Inparticular, close social ties were argued to be ‘‘relevant to thebiologic and behavorial trait of obesity’’ (Christakis & Fowler, 2007p. 370) because they normalise large body size and possibly triggerphysiologic imitation, so that the bodies of networked brains arestimulated to eat. Network members were described as ‘inducted’into obesity, through contact and friendship or familial ties whichoperate to ‘‘change . an ego’s general perception of the socialnorms regarding the acceptability of obesity’’ (p. 378).

Social influence over norms, concluded the authors, is a keysocio-cultural mechanism for spreading ideas about acceptablebody size and the resulting social patterning of body sizes.Following the article’s publication, Christakis highlighted to themedia ‘‘the importance of a spreading process, a kind of socialcontagion .’’ (Kolata, 2007, p. 4).

As to smoking, Christakis and Fowler (2008) applied networkanalytic methods and longitudinal statistical methods to the cohortand their contacts for whom they had data from 1971 to 2003. Thebehaviours of smoking persistence and cessation were observed insocial networks consisting of both close and distant ties. Groups ofinterconnected people acted in a ‘cascade’, with neighbourhood orSES factors having no influence; although they did report thatpeople with more education were more likely ‘‘to emulate eachother’’ (p. 2256). The researchers proposed the operation of a rangeof bio-psychosocial processes. However, because networks con-sisted of people who lived at a distance, were not exposed tosecond-hand smoke and were not subject to the same localcontextual factors, they concluded that the spread of social normswas probably the key risk factor.

Their work has now gone beyond the spread of norms toemotions. In their analysis of happiness in networks, Fowler andChristakis (2008) note that the data do not allow the identification ofcausal mechanisms for the spread of happiness but they suggest thatemotions are contagious over a longer time period than previouslyrecognised. Their work reaffirms a recurring view within publichealth that conditions with no clinically infectious agents – affect,attitudes, beliefs and behaviours – can be transmitted betweenpersons much like communicable diseases (Porter, 1999).

Explaining smoking persistence

Theories of diffusion commonly suggest that over the long termconvergence between SES groups will occur, and Lopez et al., 1994and Chapman (2007) among others predict that tobacco smokingwill eventually cease to be a major health risk. Our question is at thispoint, why is smoking cessation convergence taking so long? Epi-genetics may in the future provide clues, as might research on familyrole modelling. In reviewing the social science literature we can notfind any one theory which adequately explains smoking persistenceamong lower SES men and women across the last two decades.While levels of education are important because they are linked toknowledge about and attitudes towards the health consequences ofsmoking (Pampel, 2005; Christakis and Fowler, 2008), a range of

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factors including sex, age, perceptions as well as educationalattainment, have been found to independently predict smokingcareers in a range of countries (Nishi et al., 2005; Nobile, Anfosso,Pavia, & Angelillo, 2000; Youssef, Abou-Khatwa, & Fouad, 2003).

Explaining the fourth phase of the smoking epidemic

The fourth phase of the smoking epidemic – sedimentation ofsmoking behaviour risk within the most marginal groups –continues to be evident (Giskes et al., 2005; Harman, Graham,Francis, & Inskip, 2006; Jefferis, Power, Graham, & Manor, 2004;Mackenbach, 2006; Pampel, 2007). We would argue that smokingpersistence among current cohorts of smokers has been bestaddressed to this point through the many theories and definitionsof addiction promulgated over the last few decades (West, 2001;Keane, 2004). At their core are two main understandings: that useof an ‘‘addictive’’ substance will increase over time because thehuman body requires increasing quantities of the substance toachieve the same physiological effect, and that if the substance israpidly withdrawn the body will experience a negative physiolog-ical response. The second is that (increasing) use of this substancewill have in the long term harmful health effects, often accompa-nied by negative social consequences (Keane, 2004). Despite itslegal status, nicotine is considered to rate with drugs such asa heroin in its addictiveness, because tolerance, cravings andwithdrawal symptoms develop rapidly after use commences and itis difficult to give up.

Theories of physical addiction not only underscore individuallevel behaviours but they can clarify social differences in smokingbecause ‘‘poor smokers face further difficulties through higherlevels of addiction to nicotine, through both higher cigaretteconsumption and higher intake of nicotine per cigarette’’ (Bobak,Jha, Nyugen, & Jarvis, 2000, p. 57). This observation offersa compelling case for why smoking resides in disadvantaged groupswell after their health effects are known. Tobacco with its phar-macological properties is difficult to quit: it creates physicaldependence so that users experience feelings of sickness when theyforego their usual consumption.

Social science reasoning complements addiction theories byhighlighting that a strong component of dependence operates ata psychological, social and cultural level as well as the physiologic.When the consumption of commodities provides pleasure and issedimented into a way of life or habitus, they cannot be surren-dered easily. To do so requires giving up pleasure, reschedulingactivities, focussing on long term health rather than immediateproblems, removing oneself from social groups and spaces.Changing habits is hard work, requiring social support, financialcommitment, dedication: all forms of capital less available to thedisadvantaged. Impulsivity and a loss of control trump self-controlwhich as Offer (2001) notes in relation to diet restriction takes timeand effort to develop. Pampel (2007) complements Offer, when heargues that advantaged groups have resources or capital to callupon when they quit smoking, and they also have the economicpower to move easily onto new pleasurable activities. With its twinemphasis on cultural and economic resources, this is a very Bour-dieuian interpretation.

While Bourdieu paid little attention to health, his theoriessuggest several reasons for why less powerful groups do notnecessarily act on available evidence of risk or harm. They maychoose not to participate (a condition he called ‘disinterested’)because they don’t have the resources to compete successfully (forexample, private medical insurance to cover quit smoking treat-ments). Alternatively, they may not know about the health effectsof their behaviours (a condition he called ‘uninterested’) (Bourdieu,1990). It is also possible that they have learned to take an interest in

forms of capital other than economic (e.g. sexual capital as reflectedby a virile and risk-prone masculinity) (Barbeau, Leavy-Sperounis,& Balbach, 2004; Bourdieu, 1990).

However, there are other largely overlooked aspects of his workthat are useful for understanding the sedimentation of ‘dangerousconsumptions’: namely, the setting of rules of the game, accom-panied by the practice of symbolic violence, or the acceptance ofharmful interpretations to the rules of the game. What theseprocesses do is to shape a differential class-based calculus forestimating risk; which in part posits that harmful practices areadopted when they are not perceived as harmful, or when theyappear the least bad of the alternatives.

Rules of the game accompanied by symbolic violence

To explain the consolidation and reproduction of lifestylepractices, Bourdieu (1984) identified rules of the game. These guidethe everyday practices commonly accepted as appropriate fordifferent sub-populations. Controlled by privileged groups (culturalintermediaries) through their influence over the media, educationsystem and public policy, rules of the game interact with a class-based inheritance of a ‘feel for the game’ (a term that is inter-changeable with habitus). Rules of the game provide clues as towhy lower and middle SES groups adopted cigarette smokingbehaviours after cigarettes became more physically and financiallyaccessible, and prior to the health risks being popularly known.Adoption of higher status practices was in part generated bya desire to be accepted or acceptable.

Of relevance to the conscious persistence of injurious practices,Bourdieu described how groups acquire ‘‘a taste for the necessary’’through the application of ‘‘symbolic violence’’. In this process theprivileged impose needs on others through the application ofsymbolic power: language and commodities are mobilised to framesituations as normal or desirable (Bourdieu, 1990). The social actorswho are paramount in the process of subjugating the habitus to therules of the game are also cultural intermediaries. They appear incontemporary public health research promoting cigarettes to thepoor, young, women and Third World (Barbeau et al., 2004; Honjo& Kawachi, 2000; Lambert, Sargent, Glantz, & Ling, 2004; Bobaket al., 2000). The high rates of smoking in urban areas of lowincome countries, for instance, have been attributed to a combina-tion of higher incomes and higher exposure to cigarette promotions(Bobak et al., 2000, p. 50).

The practice of symbolic violence in tandem with rules of thegame is best illustrated in the work of anthropologist Sidney Mintz(1996). He has described how the poor acquired a taste for thecheapest and most accessible forms of calories in the form of sugarydrinks and foods through having to survive the industrial workdayand then continued to seek confections as one of the most acces-sible forms of pleasure.

Opium and tobacco consumption have been described in similarterms: their increasing availability and affordability provided easyaccess to stimulation, stress and pain relief and satisfied a growingtaste for cheap pleasures (Courtwright, 2001).

Clearly however, the Christakis and Fowler (2008) analysis ofsmoking described earlier posits that whole groups of peopleadopt and quit smoking in concert: including those with low SES.Using US National Health Interview Surveys, Pampel (2007) hasanalysed smoking prevalence by education level for race andgender groups, 1976–2005. He found race-gender persistence inlow educational status groups for white and African–Americanmen and women, but sharp declines for low education Hispanicmales and females. We do not know whether the low educationquitters are emulating the behaviours of higher education groupsor one another. Until recently, it has been assumed that it was the

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former pathway. With recent findings about the importance ofsocial networks we would commend more comprehensiveconsideration of the interrelated theories of social contagion andmimesis.

Theories of contagion and mimesis

Our reading of the literature reveals that social contagion viaimitation is a highly nuanced and sometimes unpredictable activitythat can lead to unhealthy as well as healthy behaviours (Helman,2007). Here we are concerned with the imitation of behaviour,thoughts, and emotions which usually requires repeated actions toachieve the desired look, identity and identification, so that differ-ences become similarities (Gebauer and Wulf, 1995, p. 317). Drawingon public health and feminist-post structural accounts, we recognisethat imitation does not always involve copyingexactlyanother personbut can involve adaptations to what is being copied, thereby changingits meaning. The more useful concept to describe the process oftransmission is mimesis, with imitation or the process of copying,reproducing or simulating an object, behaviour or appearance beinga principle component. However, over the centuries the concept ofmimesis has broadened to encompass ‘‘a spectrum of meanings ..including the act of resembling, of presenting the self, and expressionas well as mimicry, imitatio, representation, and non-sensuous simi-larity’’ (Gebauer & Wulf, 1995, p. 1).

Mimesis includes the ability for people to ‘‘double’’ or becomethe other through acting in similar ways (Taussig, 1993, p. 1), butdoubling also can be subverted to mimic, to parody or to pay ironichomage to its object (Huggan, 1998). Adkins (2003) has proposedthat mimesis (mimicry) can involve the rejection of hegemonicnorms, or the rules of the game. Mimesis introduces an emotionaland playful, as well as hazardous, dimension to the everyday livesof the least advantaged. It does not assume that commodities orbehaviours are solely about social positioning; rather they can beused for coping and resilience through defiance or parody. Oncea commodity or behaviour is firmly located in disadvantagedgroups, the advantaged may not want to ‘‘be doubled’’.

The breadth of meaning to mimesis offers new insights intobehaviour change, while posing some conceptual difficultiesbecause the term is employed in subtly different ways. For some,mimesis occurs from individuals’ perceptions that performing thebehaviours of others confers benefits on those practicing them, andis vital to the cultural survival of outsider groups, such as gays orJews (Bell, 1999). In this sense, it is a mode of accommodation, ofadaptation, or assimilation into the environment in which onemoves; and it may involve copying hegemonic norms as in the caseof gender, which becomes embodied through the repetition ofactions (Bell, 1999). In Bourdieu’s work mimesis offers a consciousstrategy for adaptation to hegemonic norms. For these theorists,mimesis is assumed to be part of a rational quest for personalbenefit: new practices and products are adopted when the esti-mates of relative gain outweigh estimates of cost or loss (Rogers,1995; Ferrence, 2001).

In the case of smoking behaviour, it is plausible that adoptingcommon behaviours reflects a desire for acceptance by a sub-grouping rather than acting out behaviours acceptable to the widersociety. For some gender theorists, behaviours are often under-pinned by an ambivalence for what is being copied (Adkins, 2003).In his analysis of the social gradients in obesity, Offer (2001)suggests that overweight people may be more defiant of the soci-etal norms regarding thinness. Those working in the terrain of theculture of opposition also acknowledge acceptance by one’s owngrouping may lead to copying personally or socially destructivebehaviours. Mimesis suggests how ordinary pleasures and behav-iours with publicised ill-health effects – as opposed to capital-

enhancing tastes, positional goods and practices – spread relativelyquickly through sub-populations.

In the 1960s the culture-of-poverty discussions covered analo-gous territory about whether the poor have a self-limiting culturethat discourages the attainment of upper class attributes (seeSwidler, 1986). Mimesis though is not confined to marginalisedgroups. Tattooing, for example, once closely associated with workingclass men is now part of an accessorised body for middle-classgroups following the lead of Hollywood stars. Whether mimesis isoperating as acceptance, parody or defiance is an empirical ques-tion; with Bourdieu observing that ‘‘one is practically never entitledto assume that the different classes expect the same thing from thesame practice’’ (Bourdieu, 1984, p. 211; Ferrence, 2001).

Explaining the fifth phase of the smoking epidemic

With the passage of time, it is becoming clear that there is a fifthstage to the smoking transition: successive low SES group cohortscontinue to adopt the well publicised high risk behaviour ofsmoking. This is amply supported in recent national surveys (AIHW,2008; Pampel, 2005; Blakely et al., 2006). These show that anaverage of almost one in five adult males continue to smoke inOECD countries, but that the prevalence among men and women ofparticular ethnic and educational backgrounds can be as high asone in two and that the gap maybe growing (Pampel, 2007; Blakelyet al., 2006; AIHW, 2008). The persistent patterning of inequalitiesin prevalence comes about despite different countries adoptinga range of interventions to curb smoking initiation and to assistsmoking cessation over the last 40 years.

Very few people have attempted to account for this stage,although we appreciate the plausibility of Graham’s (2006) struc-tures of disadvantage to embed health behaviours across genera-tions in class-based societies like Britain. Even so, additionaltheoretical concepts are required to explain why successive groupsadopt what is now a non-innovation that is widely known to beharmful. In our opinion, the intergenerational transmission ofhabitus, the contents of which are continuously reproducedthrough symbolic violence, combines with with-in status groupdoubling to explain why new cohorts of less advantaged groupsadopt known risk behaviours.

The inter-cohort transfer of smoking can also be attributed inpart by the ambiguous nature of the rules of the game surroundingsmoking. Since the 1970s, government tobacco control policies inmany Western countries have changed the rules of the game,contributing to the ‘‘denormalisation’’ of smoking (Chapman,2007). The legal impediments to easy smoking accessibility andavailability have encouraged a perception among the middleclasses that smoking is socially unacceptable. At the same time,tobacco continues as a legal consumable that is sold in highlylegitimate outlets like supermarkets. Its ambiguous social statuscan be differentially interpreted depending on circumstances. Thecosts and benefits of a practice are different for different classes,because of ‘‘variations in perception and appreciation of theimmediate or deferred profits they are supposed to bring, as invariations in the costs, both economic and cultural and, indeed,bodily (degree of risk and physical effort)’’ (Bourdieu, 1984, p. 212).This point is reflected in analyses of lower SES group smoking(Lawlor, Frankel, Shaw, Ebrahim, & Davey Smith, 2003), and obesitywhere acceptance of the rules of the game regarding the desir-ability of weight loss advantages some groups while disadvantag-ing others. For instance, the class-based strategies used to pursuethe ‘thin’ ethic that pervades fashion and medical images ofsuccessful men and women have unequal health outcomes –wealthy women eat small portions while poorer women smoke(Offer, 2001).

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Implications for social actions and intervention

A decade ago, researchers predicted that while there wouldalways be lags in smoking adoption and cessation by differentsocial groups, the smoking epidemic would finally runs its course(Lopez et al., 1994, p. 245). In the meantime, the stubborn persis-tence of smoking with its health equity dimension has to beaddressed. With growing evidence that health-compromisingideas, emotions and consumption practices are contagious riskfactors, it is timely to investigate how public health might diffusehealthy lifestyles: a point being belatedly recognised by healthauthorities (National Preventative Health Taskforce, 2008, p. 23).

First, there needs to be acknowledgement of the role ofemotions as precursors to action, and in this context Fowler andChristakis’s (2008) study of happiness is welcome. Coveney andBunton (2003) suggest that pleasure and ‘pleasure revenge’through subjugation of desire are important motivating principlesbehind many behaviours. Pleasure and desire they argue ‘‘areinnately undisciplined and undisciplinable. Pleasure and pleasureseeking is thus conceived as the weak link in the chain of commandfrom authoritarian discourses of health governance to docilecompliance for body maintenance’’ (p. 166). For many groups,pleasure is difficult to associate with non-consumption.

Their point is well-recognised by modern corporations whichare leading the way in establishing what some refer to as ‘‘econo-mies of passion’’ (see Amin & Thrift, 2004). Creating markets forservices and products that tap into strongly held emotions hasbecome hugely profitable for what is known as the culturaleconomy sector. Essentially a cultural intermediary sector, it isresponsible for reviving corporate profits by accessing new marketsthrough viral marketing.

Viral marketing relies on social networks to amplify the message(Leskovec, Adamic, & Huberman, 2007). In this way, corporationssidestep the legal impediments to advertising in the mass media.Following epidemiologic discourse, marketers aim to grab theattention of ‘‘susceptible’’ consumers who will become ‘‘infected’’,and ‘‘spread’’ the company message. Network contact with infectedpersons guarantees the rapid spread of a new idea or commodity,much like the spread of Hepatitis C.

Social contagion has traditionally been conceived as the trans-mission of aspects of culture through either close interpersonalcontact or contact-at-a-distance, via reading a book for example. Inmodern times, the mass media make imitation possible in theabsence of interpersonal contact. ‘‘[A]dvertisements reschool themimetic faculty’’ writes Taussig (1993, p. 30). In simple terms,viewers of television advertisements can replicate the appearanceand behaviours of characters by purchasing the advertisedcommodity.

This principle is illustrated by a vignette from Burger King’s chiefmarketing manager, who attributed his company’s reversal offortune to the hamburger chain’s communication with its mainmarket, young men, via Internet ads. As the business pages put it:

Viral is today’s electronic equivalent of old-fashioned word ofmouth. It’s a marketing strategy that involves creating an onlinemessage that’s novel or entertaining enough to promptconsumers to pass it on to others – spreading the message acrossthe Web like a virus at no cost to the advertiser (Howard, 2007).

Cleverly-targeted advertising of commodities based onemotional appeals to virility, freedom and success may encouragegroups to consume goods that bring both immediate rewards andlonger term problems. Some social actors are keen participantsin using marketing intelligence to tap class-based dispositions.(Barbeau et al., 2004, p. 116) reported that RJ Reynolds, one of theworld’s biggest cigarette corporations, noted:

The loyal Marlboro younger adults can be characterised ashaving a ‘working class/present oriented’ mindset . and worryabout their lives today. The younger adults who have switchedfrom the brand have wants and attitudes reflecting an ‘aspira-tional/future oriented’ mindset . [they] plan for theirsuccessful futures . The concept of a working class/presentoriented mindset is fully consistent with lowered levels ofeducation.

If the cultural dissemination of a ‘taste’ for pleasurable, but highrisk, behaviours is taking place daily in the mass media how doespublic health inoculate self-restraint in a context of contagiousconsumerism? Can a health equity strategy incorporate viralmarketing techniques to reach ‘recalcitrant’ at-risk groups? At thesame time, how does public health avoid what has been describedas cultural imperialism: the waging of a moral crusade againstthose who behave in a risk-laden manner (Førde, 1998)?

Instead of the corporate message ‘‘buy my brand, commodity orservice for a good time/pleasure/personal enrichment’’, the publichealth message is far more complex: defy the social and economicrules of the game by rejecting consumption of the new, convenientand positional. This is the challenge: the healthier life urged bypublic health messages requires people to be either abstemious orto consume less or differently in line with medical science, personalresponsibility and a highly considered and long term rather than anopportunistic approach to decision-making. It flies in the face of thebehavioural discounting principle that ‘‘people are bad at compu-tation when making decisions: they put undue weight on recentevents and too little on far-off ones’’ (Dawnay & Shah, 2005). Theprinciple has been shown to apply to drug use including tobacco(Bickel & Marsch, 2001, p. 74).

Although health promotion and education campaigns couldbenefit from the incorporation of viral marketing techniques, theevidence from Stages 4 and 5 of the smoking epidemic shows thatlittle will be gained from avoiding action on the socio-economicconditions of populations and their environments. For many years,investments in education have been identified as defining healthtransition contours (Caldwell & Caldwell, 1991) and this strategycontinues to be advocated as a defence against the spread andpersistence of many unhealthy behaviours, including smoking(Graham et al., 2006).

While social contagion theories have explanatory potential,the utility of social contagion discourse has been questioned.Mackenbach (2006, p. 36) suggests that applying the term ‘epidemic’to smoking can be misleading. ‘‘[It] should not lead one to assumethat this is a largely autonomous development, like the spread ofmicro-organisms through populations. Smoking is a man-madehabit, which has been promoted by some and fought by others.’’ Inother words, there has to be ongoing attention to power relationsand the capacity for some to impose needs on others. This requiresa thorough understanding of the mechanics of culture (Hruschka &Hadley, 2008), especially the way in which culture ‘‘helps to produceasymmetries in the abilities of individuals and social groups to defineand realise their needs’’ (Johnson, 1986/1987, p. 39).

Overall, a multi-faceted understanding of the reasons behindthe consumption choices being made by different sub-populationswould provide a more sophisticated basis for designing strategiesto reduce health inequalities. In the following section, we sketcha theoretical model to guide future research.

Researching health risk transitions

We fully support the evolution of theoretical approaches thatintegrate concepts from different systems of thinking particularlywhen the research aim is to understand transitions of health

J. Dixon, C. Banwell / Social Science & Medicine 68 (2009) 2206–22142212

behaviours between cohorts and across generations. In the main,theories are applied after the data have been collected; which isa resource efficient exercise. However, Pampel, Christakis andFowler have commented in their respective articles that availabledata do not allow for some fundamental understandings aboutpathway directionality or causal mechanisms.

To illustrate the research challenge involved in health risktransitions across generations and within cohorts, we take themajor concepts spelled out in this paper to provide a theoretical buttestable model of the smoking risk transition as it has evolved inWestern countries. With the weight of evidence continuing tosupport socio-economic status as a powerful mediator of smokingbehaviours, we build the model on this social relationshipacknowledging the presence of social networks within socialclasses.

� Stage 1: Smoking originates with elites, or early adopters,before spreading to other SES groups. Key Stage 1 processesinclude: Bourdieu’s theory of social distinction which proposesthat advantaged groups seek to gain capital through embracingmarket innovations; and, the doubling aspect of mimesis bywhich the novel behaviour of smoking spreads rapidly likea contagion between social status groups and within networksonce economic conditions are right. Imitating behaviours ispart of normalisation processes. Cultural intermediaries,employing mass media advertising and professional andcharismatic authorities like physicians and film stars, are crit-ical for establishing cultural contact between different groups.� Stage 2: Smoking is repudiated by early adopter high SES

groups once it is adopted by the mass of the population. Stage 2

RULES OF GAME: Normalisation Den

Upper SESadopt

Upper SESquit

All SESadopt

Upper SES (adopters) qu

Mid SES q

1 2 3

SMOKING TRANS

SOC

IAL

POSI

TIO

NIN

G

Note 1: These stages do not represent equal amounts of time. 2: Dash line represents anticipated changes.

Dis

tinctio

n

Doublin

g

Dis

tin

ctio

n

Doublin

g

AddictionFeel for the game (habitus)

Fig. 1. Social progression of

processes are two-fold and best explained by Bourdieu’s broadwork. As part of their capital conserving and building strategy,elites want to distinguish themselves from the mass to main-tain rule making authority through being identified as morallysuperior. Further, by accurately interpreting and acceptinghealth evidence, upper SES groups enter a virtuous circle ofcontinuous accrual of physical, health, cultural, economic andsocial capital.� Stage 3: Late high SES adopters quit (women) and more

widespread population declines continue into mid and lowerSES groups. The processes include the ongoing operation ofsocial distinction and doubling within networks.� Stage 4: Smoking continues among some low SES groups. The

relevant processes range from symbolic violence reflected inhigher levels of addiction due to greater exposure to cigarettesand a learned stress relief behaviour; and the diffusion ofnorms that are in opposition to the rules of the game amongsocial networks. Here, mimesis is operating as parody anddefiance of upper SES behaviours and rules of the game inwhich smoking is denormalised but still legal. Further, due to‘hyperbolic’ discounting, the poor retain risky commodity usein the face of escalating price (e.g. cigarettes, illegal drugs), andthe economic costs in turn contribute another facet to theirhealth problems. The physiologic and socio-cultural depen-dence on cigarettes ‘‘embeds’’ their use as part of lower SESgroup lifestyles.� Stage 5: As to the sedimentation of smoking in successive low

SES cohorts, Bourdieu’s ‘feel for the game’, passed on inter-generationally as practical dispositions or habitus, togetherwith ‘symbolic violence’ provide a strong rationale. Equally,

ormalisation Ambiguous

Upper SES adopt new pleasures

lateit

uit

Low SES quit

Marginal low SEScontinue

New low SESuptake smoking

4 5

ITION STAGES1

2

Future

dis

tinctio

n

Doubling

Doublin

g

Habitus

Defia

nce

Sym

bolic

Vio

lenc

e

Dis

tinct

ion

the smoking epidemic.

J. Dixon, C. Banwell / Social Science & Medicine 68 (2009) 2206–2214 2213

across-generation distinction may be operating. Culturalintermediaries using traditional and viral marketing tech-niques act as health inequalities vectors by exposing thewealthy to new consumption possibilities and for proposingthat the disadvantaged consume ‘improved’ versions of oldproducts (e.g. ‘lite’ cigarettes). For the next generation smokingcigarettes will be associated with low SES and high SES groupswill continue to reject cigarettes.

This theoretical model, summarised in Fig. 1, highlights how thesocial status consequences of health-related behaviours becomethe social determinants of the unequal health status of successivegenerations. It also illuminates the existence of parallel pathways inseveral of the stages.

To study the staging and dynamics of the model would beresource intensive, requiring a multi-disciplinary team which couldideally tap an existing longitudinal cohort. The team would use thesocial sciences methods of observation, in-depth interviews andnarrative analysis to understand the nuances of complex practiceslike mimesis (Frohlich, Potvin, Chabot, & Corin, 2002). Further, asPampel (2005) has noted it is necessary to account for the relativeinfluence of social network relations and socio-economic relations.

We would propose that the exercise we have conducted withsmoking could well be applied to other social transitions in a rangeof health risk behaviours: including car reliance, risky alcohol useand infant formula. These risks have seen rapid and marked socio-economic shifts in two to three decades (Hinde and Dixon, 2005;Cockerham, 2007; Smith, 2007).

Conclusion

This paper reflects a growing interest in social epidemiology forthe socio-cultural drivers of health risk behaviours, such as theimportance of networks in the dissemination of emotions andhealth-risk practices. Led by Pampel, Christakis and Fowler, werecognise the positive evolution of integrated frameworks, drawingon many of the concepts described above. Their efforts are groundbreaking in their ability to marry population-based quantitativeand epidemiological studies with social science theory. Our briefand by no means comprehensive review of the different theoreticalapproaches highlights that terms and theories can take severalforms. Complicating matters, integrated theories may containconcepts that are in tension, e.g. class-based distinctive behavioursand homophily type behaviours.

While unequal rates of persistence within cohorts has receivedattention, the predictable adoption of a non-innovative and healthdamaging behaviour in successive cohorts is not well understood.We argue for greater attention and clarity to the conceptual under-pinnings of the theories being deployed, plus the additional input oftheoretically driven, observational and in-depth qualitative researchthat explores social science theory in detail. In the meantime, ifauthorities want to counteract sub-population immunity to thespread of health promoting ideas and practices, the cultural,economic and emotional drivers of ‘dangerous consumptions’ mustbe incorporated within disease prevention strategies.

Acknowledgement

We are very appreciative of feedback from Tony Blakely, SarahHinde and the reviewers of this article.

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