Strong smoker interest in ‘setting an example to children’ by quitting: national survey data
George Thomson, Department of Public Health, University of Otago, Box 7343 Wellington, New Zealand; e-mail: email@example.com
Objective: To further explore smoker views on reasons to quit.
Methods: As part of the multi-country ITC Project, a national sample of 1,376 New Zealand adult (18+ years) smokers was surveyed in 2007/08. This sample included boosted sampling of Māori, Pacific and Asian New Zealanders.
Results:‘Setting an example to children’ was given as ‘very much’ a reason to quit by 51%, compared to 45% giving personal health concerns. However, the ‘very much’ and ‘somewhat’ responses (combined) were greater for personal health (81%) than ‘setting an example to children’ (74%). Price was the third ranked reason (67%). In a multivariate analysis, women were significantly more likely to state that ‘setting an example to children’ was ‘very much’ or ‘somewhat’ a reason to quit; as were Māori, or Pacific compared to European; and those suffering financial stress.
Conclusion: The relatively high importance of ‘example to children’ as a reason to quit is an unusual finding, and may have arisen as a result of social marketing campaigns encouraging cessation to protect families in New Zealand.
Implications: The policy implications could include a need for a greater emphasis on social reasons (e.g. ‘example to children’), in pack warnings, and in social marketing for smoking cessation.
Smoking by parents, siblings and friends has been recognised as increasing the risk of smoking uptake.1 Other research has associated decreased public and private indoor smoking with decreased risks of starting smoking.2,3 These effects of decreased smoking are consistent with the body of theory about the effect of social context on human behaviour,4 and suggest that decreased example reduces the risk of starting smoking and increases quitting.
The attitudes of smokers towards setting an example to children may have an impact on quitting behaviour, attitudes towards supporting smokefree areas (e.g. smokefree playgrounds),5 and location of smoking behaviour (e.g. smoking out-of-sight of children). There is some evidence that one of the reasons that smokers quit is so as to set an example for children, although this has not been a dominant motive.6–10 In a 1990 survey of San Francisco smokers, Latinos were much more likely than whites to say it was important to quit as an example for children.7 A review of 35 studies conducted before 2001 and that investigated reasons for quitting, found that in nearly all the studies, both smokers and ex-smokers put personal health as the most important reason.6 However, one 2006/07 survey in France found 60% of smokers gave the health effects of secondhand smoke on non-smokers as a reason to quit, 48% gave personal health, 62% the price of cigarettes, and 80% gave setting an example to children.11
In this study we aimed to further explore smoker views on: i) reasons to quit, and ii) on quitting to set an ‘example to children’, by socio-demographic and smoking-related variables.
For the New Zealand arm of the International Tobacco Control Policy Evaluation Survey (ITC Project), smokers were recruited from the New Zealand Health Survey (NZHS) sample of 2006/07.12 The NZHS participants (age 18 and over) were selected by a complex sample design, which included systematic boosted sampling of the Māori, Pacific and Asian populations. Face-to-face interviews were conducted in participants’ homes, with a response rate was 67.9%, resulting in 11,924 interviews.
From the NZHS sample we took smokers who: i) were 18 years or older; ii) had smoked more than 100 cigarettes in their lifetimes; iii) had smoked at least once in the past 30 days; and iv) had agreed to be willing to participate in further research when asked this at the end of the NZHS interview (this was 85.2% of the adult smokers in the NZHS). Out of 2,438 potential respondents who met these criteria, a total of 1,376 completed the NZ ITC Project Wave 1 questionnaire, giving a response rate of 56.4%. But when considering the NZHS response rate and willingness to further participate, then the overall response rate is reduced further to 32.6% (for details see:13).
The computer-assisted telephone survey, between March 2007 and February 2008, was usually three to four months after the NZHS interview. The study protocol was cleared by the Multi-Region Ethics Committee in New Zealand (MEC/06/07/071) and by the Office of Research Ethics, University of Waterloo, Waterloo, Canada (ORE #13547).
We asked the 12 standard ITC Project questions on reasons to quit (see Table 1). The results were weighted to reflect the national population of smokers in New Zealand. The multivariate analysis involved two models: a) using socio-demographic variables (age, gender, ethnicity, socioeconomic deprivation, and financial stress); and b) adding smoking-related beliefs and behaviours (see a previous article using this dataset for more detail on these models).14
Table 1. Reasons for quitting or staying quit among smokers (all results weighted and adjusted for the complex design and ranked by the “yes – very much” response).
|“Setting an example for children?” (n=1376)||26.5||22.7||50.8||1.0 Referent|
|“Concern for personal health?” (n=1376)||19.4||35.9||44.7||0.70 (0.58–0.84) (p<0.001)|
|“The price of cigarettes?” (n=1376)||33.5||28.4||38.1||0.48 (0.40–0.58) (p<0.001)|
|“Concern about effect of cigarette smoke on non-smokers?” (n=1376)||38.6||27.9||33.5||0.23 (0.17–0.30) (p<0.001)|
|“That society disapproves of smoking?” (n=1376)||51.5||26.4||22.1||0.15 (0.12–0.20) (p<0.001)|
|“Smoking restrictions in public places like restaurants, cafes & pubs?” (n=1376)||59.7||20.8||19.5||0.11 (0.08–0.14) (p<0.001)|
|“Smoking restrictions at work?” (n=1376)||66.5||19.5||14.0||0.07 (0.05–0.10) (p<0.001)|
|“Advice from a doctor, dentist or other health professional to quit?” (n=163)||59.0||27.1||13.9||0.20 (0.09–0.42) (p<0.001)|
|“Availability of telephone helpline/quitline/information line?” (n=1376)||65.2||21.7||13.1||0.04 (0.02–0.06) (p<0.001)|
|“Free or lower cost stop smoking medicines?” (n=163)||59.5||27.8||12.7||0.16 (0.06–0.36) (p<0.001)|
|“Advertisements or information about health risks of smoking?” (n=163)||62.9||26.2||10.9||0.11 (0.03–0.28) (p<0.001)|
|“Warning labels on cigarette packets?”c (n=163)||67.8||23.0||9.2||0.12 (0.04–0.29) (p<0.001)|
Of the 12 reasons offered for wanting to quit, or staying quit, ‘setting an example to children’ received the highest level of the ‘very much’ response (by 50.8%; 95%CI=47.2–54.3%) see Table 1. Concern for personal health (44.7%, 95%CI=41.2 – 48.2%), the price of cigarettes (38.1%) and concern about effects of cigarette smoke on non-smokers (33.5%) were the next most important reasons. However, when the ‘very much’ and ‘somewhat’ responses were combined, concern for personal health (80.6%) was higher than ‘setting an example to children’ (73.5%) and the price of cigarettes (66.5%). A separate analysis by the total of the ‘very much’ responses for all respondents (n=3,679) also indicated the statistically significant dominance of the ‘example to children’ response (20.8% versus 18.0% for ‘personal health’ and 15.3% for price (data not shown but available on request).
In univariate analysis, the socio-demographic characteristics of respondents, which were significantly associated with the combined ‘very much’ or ‘somewhat’ responses for ‘setting an example to children’ were: i) women compared to men (crude odds ratio (OR)=1.64; 95%CI=1.18 – 2.28); ii) those of Māori and Pacific ethnicity, compared to European (OR=1.51; 95%CI=1.05 – 2.18; OR=2.02; 95%CI=0.99 – 4.13 respectively); and iii) those under one form of financial stress (i.e. not spending on household essentials because of smoking, compared to those who said no to this question (OR=1.61; 95%CI=1.05 – 2.46).
In the multivariate analysis, being a woman remained significant (e.g. adjusted OR (aOR)=1.64; 95%CI=1.16 – 2.31 in the model considering socio-demographic variables). Being Māori or Pacific ethnicity and being under financial stress were still associated with raised odds ratios (for all: aOR>1.2) but these were no longer statistically significant. In the model that also considered smoking beliefs and behaviours, the following were significantly associated with concern about setting an example to children: being a lighter smoker (using a ‘heaviness of smoking’ index: aOR=1.11, 95%CI=1.01 – 1.22); awareness of secondhand smoke (SHS) harm (aOR=1.62; 95%CI=1.20 – 2.17); and SHS protective behaviours by smokers (aOR=1.81; 95%CI=1.40 – 2.35).
This study (along with the French survey, also from the ITC Project), is unusual in finding ‘setting an example to children’ as being more important than smokers’ concern for health, as a strong reason to quit or to stay quit. In the New Zealand case, the importance of this reason was better captured by allowing respondents to consider the ‘very much’ option in the survey question.
The difference from most previous findings may also reflect differences in the nature of the New Zealand smoker sample and tobacco control policy context. For instance, there may have been an influence from the spread of local authority smokefree parks policies, which aim to discourage smoking around children.15 The review by McCaul et al, that found smokers and ex-smokers putting personal health as the most important reason to quit, was of studies that were nearly all were set in North America.6
An alternative view is that the data from the French ITC Project and our study reflects trends that are occurring more widely. We found no comparable data in other studies collected since 2001, so further up-to-date evidence from other countries is needed to investigate this issue.
Since 1998, there have been at least 15 media campaigns in the US, particularly in California, Massachusetts and Colorado, which have highlighted a smoker's responsibility to quit smoking for the sake of their family (see http://apps.nccd.cdc.gov/MCRC/Apps/SearchResult.aspx?Mode=QS). New Zealand smokers of all ethnicities may also have been sensitised to family responsibility and smoking, because of social marketing over the past eight years about quitting for family and whanau (extended family).16–18 The social marketing has included media campaigns featuring ex-smokers who highlight the effects of smoking on their families. A previous smaller survey in New Zealand, in 1992, found social reasons (socially unacceptable, family pressure) for quitting were less important then, compared to personal health and cost.19 Other research has indicated that ‘example to children’ as a quit motive may increase over time.10
Quitting because of cost or financial stress is a common reason given for quitting or the importance of quitting.6,20 Our results indicate that this was the third ranked reason, and highlight the importance of tobacco prices (via high tobacco taxes) in stimulating quitting. Because there was no tobacco tax rise in New Zealand between 2001 and 2008 (apart from annual indexation), and tobacco products appear to have become more affordable in this period,21 this may have decreased the perception of cost as a reason to quit.
Ethnic differences in reasons to quit may be related to the differing role of family and social structures and influences, for ethnic groups. Perez-Stable et al. argue that famialismo (family/collective well-being) may explain Latino/non-Latino differences in reasons to quit.7 The greater likelihood of Māori and Pacific peoples, in seeing the example of smoking to children as a reason to quit, may be related to their greater priority on collective relationships.22
The recognition by policymakers of the danger of smoker examples to children has led to a widening of tobacco control policy actions. These have included explicit warnings to smokers of these effects from their smoking on cigarette packaging warning labels,23 the extension of smokefree outdoor area policies,24 and making schools completely smokefree. The policy implications of our findings could include a need for a greater emphasis on social reasons (e.g. ‘example to children’) in pack warnings, in social marketing campaigns for smoking cessation, and in the information around targeted smoking cessation support for new parents and school teachers.
The finding of ‘setting an example to children’ as a relatively important reason to quit or to stay quit, should be explored in other settings with the same questions, and also with different approaches to collecting data (e.g. unprompted reasons for quitting or staying quit). Data analysis by whether there are children in the interviewee's household would provide further depth. Gender,25 and ethnic differences in quitting motivation (as opposed to behaviour), may also be an area for further exploration, considering the limited research in the area and the importance of addressing disparities in smoking prevalence. Survey findings such as these may also be further explained and explored by qualitative research, in order to provide a more in-depth understanding of smokers’ attitudes and reasons for quitting.
The ITC Project (NZ) team thank: the interviewees who kindly contributed their time, and our other project partners (see: http://www.wnmeds.ac.nz/itcproject.html).
The Health Research Council of New Zealand provided funding for the ITC NZ Project and the Smokefree Kids Policy Project.
Although we do not consider it a competing interest, for the sake of full transparency we note that some of the authors have undertaken work for health sector agencies working in tobacco control.