The Smoking Puzzle: Information, Risk Perception, and Choice . By Frank A. Sloan, V. Kerry Smith, and Donald H. Taylor Jr. Cambridge, MA; London, UK: Harvard University Press . 2003 . 273 pp. $55 .

How does a smoker understand the risks of smoking? Tobacco use is the leading preventable cause of death in the United States and is responsible for approximately 440,000 deaths annually.1 In 2001, the median prevalence of current smoking in the United States was 23.4%.2 In an era when the harms of smoking to one's personal health are understood by all, including smokers, it is unclear which informational messages will influence smokers to quit. Researchers have evaluated the impact of risk perceptions on the probability of smoking, but the impact of risk perception on smoking cessation and relapse has not been fully examined.

In The Smoking Puzzle, Frank Sloan, V. Kerry Smith, and Donald Taylor, Jr. combine their multidisciplinary expertise in economics, health policy, and aging to address the puzzle of why people smoke. Through a historical perspective, they examine factors that have influenced individual beliefs about risk and choice to smoke. The history of knowledge about the effects of tobacco use in the United States is juxtaposed with the population's smoking rates and government sanctions and policies. Other important topics covered include the history of tobacco regulation in the United States, the impact of the landmark surgeon general's report in 1964 that summarized research on the health hazards of smoking, and the tobacco companies' pugilistic responses and increase in power through expansion of exportation. The authors describe some of the past and current ironies of U.S. smoking policy, such as how some government interventions were designed to reduce smoking while others promoted it (e.g., wartime subsidizing cigarettes for military personnel).

The Smoking Puzzle focuses on older smokers, an important population to examine given the increasing number of older individuals in the United States. Smoking is a risk factor for half of the major causes of death for people 65 and older.3 Smoking cessation, even at age 60 and over, can decrease rates of smoking-induced disease.4 The authors studied a cohort of older smokers who started smoking when these ill effects of smoking were not clear.

After 1964, most adults had come to appreciate the ill effects of smoking. Yet despite the tremendous number of laws and regulatory policies in this era, the effect on tobacco control has been mixed (e.g., lack of funding to enforce laws and regulations). The authors believe that recent government interventions and public antismoking campaigns continue to be based on the premise that people lack sufficient knowledge to make an informed decision. They argue that public messages, especially among older individuals, have a limited impact, and that risk messages must be personalized in terms of morbidity and disability (e.g., like those received after a serious health event). For example, providing probabilities on the odds of dying from smoking-related diseases is less effective in these individuals than are simple messages about how smoking may impact quality of life. However, these conclusions are based on a single study, and the effectiveness of these elderly-targeted risk messages has yet to be assessed.

The book is well written but somewhat disjointed. Missing pieces are cognitive and behavioral theories of smoking and risk; the book would be have been strengthened by including more theory-based work (optimistic bias, dual-process theories) to ground the authors' findings. Compared with Paul Slovic's Smoking: Risk, Perception, and Policy,5 which uses psychological and behavioral theories and research to explain the effects of advertising and policy on smokers, Sloan, Smith, and Taylor do not integrate psychological and behavioral theories and research.

The field of risk perception is at a point in which multidisciplinary perspectives, such as those presented in The Smoking Puzzle, are needed to advance our understanding and effectiveness in order to intervene successfully with smokers. The book offers important information to policy makers, researchers, and clinicians, especially those caring for older smokers. Selected chapters could be quite useful in medical school teaching, especially the rich sections on the history of smoking and tobacco-related policy in the United States. Clinicians, especially general internists, will find the discussion of which smoking cessation messages might work best for their older patients stimulating. Sloan, Smith, and Taylor have helped to place many of the pieces together for older smokers, but The Smoking Puzzle remains, in many ways, unsolved.


  1. Top of page
  2. References
  • 1
    Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2000. MMWR Morb Mortal Wkly Rep. 2002;51: 6425.
  • 2
    Centers for Disease Control and Prevention. Cigarette smoking among adults and changes in prevalence of current and some day smoking—United States, 1996–2001. MMWR Morb Mortal Wkly Rep. 2003;52: 3037.
  • 3
    Rimer BK, Orleans CT, Keintz MK, Cristinzio S, Fleisher L. The older smoker: status, challenges and opportunities for intervention. Chest. 1990;97: 54753.
  • 4
    Burns DM. Cigarette smoking among the elderly: disease consequences and the benefits of cessation. Am J Health Promot. 2000;14: 35761.
  • 5
    Slovic P. Smoking: Risk, Perception and Policy. London: Sage Publications; 2001.