Distributions of smokers by stage: international comparison and association with smoking prevalence

Characteristics of cigarette smokers seeking treatment for cessation versus reduction

Comparisons were made between cigarette smokers seeking treatment to quit smoking and cigarette smokers seeking treatment to reduce the number of cigarettes they smoke. Potential subjects were recruited from the local metropolitan area by advertisement in the local media. A total of 665 cigarette smokers telephoned our clinic to seek treatment for smoking cessation and 565 cigarette smokers telephoned to seek treatment to gradually reduce the number of cigarettes they smoke but not quit smoking. Potential subjects were instructed to call the clinic to find out additional information about the studies, and while on the telephone they were asked questions pertaining to tobacco use and health status. The results show that the two populations are similar in many respects with the following exceptions: smokers seeking treatment to reduce cigarette use tend to smoke more cigarettes per day, are less motivated to quit, make fewer quit attempts, drink more alcoholic beverages per day, and have more health problems (Ps<.05). These results indicate that cigarette smokers seeking treatment for smoking reduction but not cessation may be more dependent smokers who experience more medical disorders.

Motivating and helping smokers to stop smoking

Smokers try to quit only once every 2 to 3 years and most do not use proven treatments. Repeated, brief, diplomatic advice increases quit rates. Such advice should include a clear request to quit, reinforcing personal risks of smoking and their reversibility, offering solutions to barriers to quitting, and offering treatment. All smokers should be encouraged to use both medications and counseling. Scientifically proven, first-line medications are nicotine gum, inhaler, lozenge, and patch plus the nonnicotine medication bupropion. Proven second-line medications are clonidine, nicotine nasal spray, and nortriptyline. These medications are equally effective and safe and the incidence of dependence is very small. The proven psychosocial therapies are behavioral and supportive therapies. These are as effective as medications and are effective via individual counseling, group, and telephone formats. The writing of this article was supported in part by Senior Scientist Award DA-00450 from the National Institute on Drug Abuse.

Relation among stage of change, demographic characteristics, smoking history, and nicotine dependence in an adult German population

BACKGROUND

The aim of this study was to provide evidence about the individual intention to quit smoking and accompanying characteristics in a country with a low amount of tobacco control (TC) provisions.

METHODS

This study used a random sample of the population aged 18-64 in a German area to make a quantitative estimation of the stages of change to quit smoking among current smokers who had at least one quit attempt (n = 1075).

RESULTS

The rate of those who did not intend to stop smoking (precontemplators) was 76.4%, that of those who intended to quit during the next 6 months (contemplators) was 17.0%, and that of those who intended to quit during the next 4 weeks was 6.6%. The three groups did not differ according to gender or age. Of those who had at least 16 years of education, more were contemplators than were those with fewer years of education. Among those who had somatic complaints or nausea from smoking, who had their first cigarette within 1 h or less after awakening, and who had more quit attempts, more were in the contemplation or preparation stage.

CONCLUSIONS

Nicotine dependence may add to contemplating about quitting. The precontemplation rate was substantially higher than in samples from nations or states which show a large amount of TC provisions.

Intentionally reduced smoking among untreated general population smokers: prevalence, stability, prediction of smoking behaviour change and differences between subjects choosing either reduction or abstinence

AIMS

To compare data from the general population on intentionally reduced smoking and smoking cessation.

DESIGN

Longitudinal observation study.

SETTING

Northern German region.

SUBJECTS

Randomly sampled residents aged 18-64 (T1; n = 4075, response rate 70%). Daily cigarette smokers (n = 1520) were followed up after 30 (T2; n = 913) and 36 months (T3; n = 786).

MEASURES

Self-reported smoking-related and socioeconomic variables. Participants were explicitly asked for reduction attempts (reducing cigarettes per day) and maintenance of reduction, which was defined independently of consumption measures.

FINDINGS

Between T1 and T2, reduction attempts (39%) were more frequent than quit attempts (33%), and according to self-report, reduction was more likely to be maintained for up to 12 months. Smokers maintaining reduction for up to 6 months had reduced their consumption at T3 by 34% compared with T2. Between T1 and T2, the occurrence of both a reduction and a quit attempt was most frequent (22%), followed by subjects exclusively trying to reduce (17%) and subjects exclusively trying to quit (4%). Subjects who exclusively tried to reduce had a significantly increased probability of further reduction attempts at T3 (OR = 4.4, 95% CI 2.0-10.1), while the probability of quit attempts was equal compared with subjects not attempting to reduce or quit (OR = 1.1, 95% CI 0.3-3.2). DSM-IV nicotine dependence was less common in subjects who exclusively tried to reduce. Other smoking-related and socioeconomic variables did not predict whether individuals attempted to reduce or attempted to quit.

CONCLUSIONS

A considerable proportion of general population smokers attempt to reduce, and are able to maintain reduction of, cigarette consumption over time. Reduction attempts did not reduce the probability of a subsequent cessation attempt.

Impact of messages on concomitant use of nicotine replacement therapy and cigarettes: a randomized trial on the Internet

AIMS

To assess the impact of messages recommending the concomitant use of nicotine replacement therapy (NRT) and cigarettes on smokers' intention to quit smoking.

DESIGN

Randomized trial.

SETTING

Internet.

PARTICIPANTS

A total of 2027 people who answered an e-mail sent to 9074 current and former smokers recruited on a smoking cessation website.

INTERVENTION

Participants were divided randomly into four groups, each of which received a unique message (in French) by e-mail. The 'control' message said that nicotine replacement therapy (NRT) attenuates withdrawal symptoms in smokers who want to quit. The 'temporary abstinence' message added that NRT can also be used by current smokers to manage smoke-free situations. The 'reduction' message indicated that NRT can be used by current smokers who do not want to quit but want to smoke fewer cigarettes. The 'side-effects' message discouraged concomitant use of NRT and cigarettes.

MEASUREMENTS

Perceived impact of these messages on motivation to quit smoking.

FINDINGS

The e-mail was answered by 2027 people (25% of 8124 valid addresses). Smokers who received the 'reduction' message were slightly more likely than controls to report that this message increased their motivation to quit (66% versus 60%, P = 0.02). In contrast, smokers who received the 'side-effects' message were less likely than controls to report that this message increased their motivation (45% versus 60%, P < 0.001). The 'temporary abstinence' message had no detectable impact on motivation to quit.

CONCLUSIONS

Among smokers recruited via a smoking cessation website, messages encouraging concomitant use of NRT and cigarettes may have either no effect or a positive effect on motivation to quit smoking.

Distribution of daily smokers by stage of change: Current Population Survey results

BACKGROUND

Population-based national estimates of stage of change among daily smokers are unknown. This study described the proportion of U.S. daily smokers, 18 and older, by stage of change. Selected sociodemographic characteristics were delineated.

METHODS

Cross-sectional data were collected via telephone or face-to-face interview in daily smokers who responded to the Current Population Survey in 1992-1993 (n = 39,706), 1995-1996 (n = 34,865), or 1998-1999 (n = 30,153). Main outcomes included stage of change: (1) Precontemplation-not interested in quitting smoking in next 6 months; (2) Contemplation-interested in quitting smoking in next 6 months but not next 30 days; (3) Preparation-interested in quitting smoking in next 30 days and stopped at least 1 day during past year.

RESULTS

During 1992-1993, 59.1% of respondents were precontemplators, 33.2% contemplators, and 7.7% in preparation stage. This distribution was similar in subsequent surveys (1995-1996; 1998-1999). Gender differences were not apparent. Whites were more likely to be precontemplators. As education and income increased, the percentage in precontemplation decreased. Rural residents were more likely in precontemplation and less frequently in preparation.

CONCLUSIONS

Among daily smokers, little movement in stage of change was apparent in the United States during the 1990s. Tobacco control efforts must receive high priority to address these static patterns.

Skalen zu Kernkonstrukten des Transtheoretischen Modells (TTM) im Verhaltensbereich Tabakkonsum

Zusammenfassung. Es werden deutsche Versionen von englischsprachigen Originalinstrumenten zur Erfassung von Kernkonstrukten des Transtheoretischen Modells (TTM) im Kontext des Tabakrauchens vorgestellt. Im Einzelnen werden der “Processes of Change“ - Fragebogen zur Erfassung von Veränderungsprozessen, der “Decisional Balance“ - Fragebogen zur Erfassung der wahrgenommenen Vor- und Nachteile des Rauchens und der “Self-Efficacy“ - Fragebogen zur Erfassung der wahrgenommenen Versuchung zu rauchen bzw. der wahrgenommenen Sicherheit, auf das Rauchen verzichten zu können, präsentiert. Die Erhebungsinstrumente sind Übersetzungen der Originalinstrumente, die auf ihre Adäquatheit für den deutschen Sprach- und Kulturraum geprüft werden. Daten wurden im Rahmen der Studien “Transitions in Alcohol Consumption and Smoking (TACOS)“ erhoben. Es liegt eine bevölkerungsrepräsentative Stichprobe von 898 AktualraucherInnen und ehemaligen RaucherInnen zugrunde. Die statistischen Analysen zu den Testgütekriterien der deutschsprachigen Instrumente umfassten konfirmatorische Faktorenanalysen, Skalen- und Itemkennwerte, sowie Berechnungen zur Reliabilität und Konstruktvalidität. Im Ergebnis können sehr gute Entsprechungen zwischen den Originalinstrumenten und den deutschsprachigen Versionen belegt werden. Die TTM-Erhebungsinstrumente weisen stabile faktorielle Strukturen auf, sind hoch reliabel und valide. Damit wird ein Beitrag zur internationalen Vergleichbarkeit von Studien zum TTM geleistet.

A self-administered questionnaire to measure dependence on cigarettes: the cigarette dependence scale

A valid measure of dependence on cigarettes is a useful tool for clinicians and researchers. The aim of this study was to develop a new, self-administered measure of cigarette dependence, and to assess its validity. The content of the instrument was generated in qualitative surveys. A long version (114 items) was tested on the internet in 3009 smokers. Subsamples provided retest data after 18 days (n=578), follow-up data after 45 days (n=990) and saliva cotinine (n=105). The study resulted in a 12-item scale labelled the Cigarette Dependence Scale (CDS-12), and in a 5-item version of this scale (CDS-5). Except for tolerance, CDS-12 covers the main components of DSM-IV and ICD-10 definitions of dependence: compulsion, withdrawal symptoms, loss of control, time allocation, neglect of other activities, and persistence despite harm. CDS-5 has similar measurement properties but less comprehensive content. Both scales had a high test-retest reliability (r>or=0.83), and a high internal consistency (Cronbach's alpha>or=0.84). CDS-12 scores were higher in daily smokers than in occasional smokers (+1.3SD units), and were associated with the strength of the urge to smoke during the last quit attempt (R(2)>or=0.25), and with saliva cotinine (R(2)>or=0.17). CDS-12 and CDS-5 scores decreased in daily smokers who switched to occasional smoking at 18-day retest. Dependence scores did not predict smoking abstinence at follow-up. In conclusion, CDS-12 and CDS-5 are reliable measures of cigarette dependence which fulfill several criteria of content validity and construct validity and are sensitive to change over time.

What smokers believe about light and ultralight cigarettes

OBJECTIVES

To assess the knowledge of smokers and ex-smokers about light cigarettes and nicotine yields and their perception of the risk of lung cancer, and to identify the characteristics of smokers of light cigarettes.

METHODS

Mail survey in a population sample of 494 smokers and exsmokers in Geneva, Switzerland, in 1999.

RESULTS

Participants were on average 40 years old, and 49% were men. They estimated that one would have to smoke two light cigarettes or four ultralight cigarettes in order to inhale the same amount of nicotine as that in one regular cigarette. Most participants (60%) answered that the risk of lung cancer was the same, but 27% answered that this risk was lower in smokers of light cigarettes than in smokers of regular cigarettes. The most frequent answer (41% of answers) to an open-ended question on the meaning of the number of milligrams of nicotine printed on cigarette packs was that this number indicated the nicotine content in cigarettes, rather than a machine-determined yield in smoke. In a multivariate model, smoking mild, light, or ultralight (vs regular) cigarettes was associated with females, a lower Fagerström dependence score, an intention to quit smoking, and an intention to decrease cigarette consumption.

CONCLUSIONS

Many smokers choose light cigarettes because they think that such cigarettes are safer or less addictive. The public should be further informed of the meaning and purpose of cigarette labels.

Nicotine replacement to reduce cigarette consumption in smokers who are unwilling to quit: a randomized trial

The objective of this study was to assess whether nicotine replacement therapy, administered in a real-life situation, could reduce cigarette consumption in smokers who were not prepared to quit smoking. Daily smokers of more than 20 cigarettes per day who had no intention to quit smoking in the next 6 months were recruited from the general population and randomly assigned to either a 6-month treatment of nicotine (choice among a 15-mg nicotine patch, a 4-mg nicotine gum, a 10-mg nicotine inhaler, or a combination of these, N = 265), matching placebo products (N = 269), or no intervention (N = 389). Products were sent to participants by mail. Education was limited to a booklet. Of 923 participants, 879 (95%) were followed up after 6 months. Mean baseline consumption was 30 cigarettes per day in all groups. At 6 months, cigarette consumption decreased by a median of 10 cigarettes per day in the nicotine group, 7.5 in the placebo group, and 2.5 among controls ( < 0.04 for all pair-wise comparisons). Smoking cessation rates were low (2%-4%) and did not differ significantly between groups. Quit attempts were less frequent among controls (21%) than among the nicotine (28%, = 0.04) and placebo (27%, = 0.08) subjects. In conclusion, nicotine replacement therapy helped smokers reduce their cigarette consumption and maintain this reduction over 6 months, but a large part of this reduction was attributable to a placebo effect. Nicotine treatment for smoking reduction had no detectable impact on smoking cessation.

Naturalistic changes in the readiness to quit tobacco smoking in a German general population sample

BACKGROUND

This study examines naturalistic changes, i.e., changes that occur without formal interventions, in the motivational readiness to quit tobacco smoking. The transtheoretical model (TTM) with the proposed five stages of change (precontemplation, contemplation, preparation, action, maintenance) is used as the theoretical framework.

METHODS

Data were collected as part of a representative general population study in Germany. A total of 786 individuals was assessed two times, 6 months apart, with respect to stage of change. Latent Transition Analysis (LTA) was employed as a special statistical method to analyze stage movements over time.

RESULTS

The best-fitting model to describe naturalistic stage movements included both forward and backward movements. A high proportion of the sample was in the precontemplation stage across both measurement occasions. There were high rates of stage regressions over the 6-month period.

CONCLUSIONS

In a German representative population of smokers, smoking behavior change toward abstinence does not occur naturally in a substantial amount over the 6-month period without intervention. Differing findings in studies for populations in the United States could be due to methodological differences or differences in tobacco-control conditions.

Assessing 'stage of change' in current and former smokers

AIMS

The concept of 'stage of change' is widely used by researchers and clinicians in the field of smoking cessation. Our aim was to assess the validity of three staging questionnaires and of the concept of 'stage of change' itself.

SETTING AND PARTICIPANTS

Survey on the Internet in 1025 ever smokers, retest after 8 days in 318 people (31%), follow-up after 32 days in 451 people (44%).

MEASUREMENTS

Three measures of 'stage of change'.

FINDINGS

Participants (83-93%) were classified in the same stage by all pairs of questionnaires, and 15% changed stage during an interval of 8 days. Including quit attempts in the 'preparation' stage had a large impact on stage distributions, because 18-24% of smokers who had decided to quit in the next 30 days were downgraded to the 'contemplation' stage as they had not made a quit attempt in the previous year. The 'action' stage included 5-7% of occasional smokers. Quit attempts during the past 7 days and 30 days were better predictors of smoking cessation than quit attempts during the past 12 months. Baseline stage and a continuous measure of intention predicted smoking abstinence at follow-up.

CONCLUSIONS

These results reflect theoretical and methodological problems with the concept of stage of change. 'Stage' covers four different variables: current behaviour, quit attempts, intention to change and time since quitting. These variables are combined in a somewhat haphazard manner, none of them is measured comprehensively, and intention and time are continuous variables categorized by arbitrary cutpoints. Measuring each of these four variables independently may be preferable to using an incomplete mix of these elements.

Gender differences in the psychological determinants of cigarette smoking

AIMS

To compare the distributions of smoking-related variables and the size of associations between these variables in men and women.

DESIGN AND PARTICIPANTS

Mail survey in 2934 daily smokers (1533 women and 1401 men) who volunteered for a smoking cessation trial. Follow-up after 7 months in 2456 people (84%).

SETTING

Community setting (French-speaking part of Switzerland, 1998).

FINDINGS

Women smoked less than men (18 versus 22 cigarettes per day, p < 0.001), had lower confidence in their ability to refrain from smoking, used more frequently the strategy defined as 'coping with the temptation to smoke' and reported more drawbacks of smoking (gender differences ranged between 0.1 and 0.3 standard deviation units on these scales). There was no gender difference in the distribution of smokers by stage of change. At follow-up, smoking cessation rates were similar in men and women (6% versus 5%, p=0.3). Intention to quit, quit attempts in the previous year and a more frequent use of self-change strategies predicted smoking cessation and were associated with tobacco dependence in both sexes. A more frequent use by women of coping strategies suggests that some women are 'self-restrained' smokers who control their smoking permanently. This could explain lower smoking rates in women. The size of associations between smoking-related variables was similar in men and women.

CONCLUSIONS

Even though there were gender differences in the distributions of some smoking-related variables, associations between these variables were similar in men and women. This suggests that smoking behaviour is regulated by similar psychological mechanisms in men and women.

Understanding people who smoke and how they change: a foundation for smoking cessation in primary care, part 1

The purpose of this article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation. This article on smoking cessation will be presented in 2 issues. Part 1 describes the theoretical information known about smoking cessation: why smoking is a powerful behavior, the scientific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, published in 2000. The second section of part 2 is a discussion of clinical assessments and strategies for working with smokers, which is grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their smoking experiences and their pathways to cessation.

The nicotine inhaler: clinical pharmacokinetics and comparison with other nicotine treatments

Nicotine inhaled in smoke is the most rapid form of delivery of the drug. With smoking, arterial boli and high venous blood nicotine concentrations are produced within seconds and minutes, respectively. The potency of nicotine as the primary reinforcement in tobacco addiction is attributed to this rapid rate of delivery. By design, nicotine treatments reduce the rate and extent of drug delivery for weaning from nicotine during smoking cessation. Theoretically, they prevent relapse by reducing withdrawal and craving associated with the abrupt cessation of cigarettes. The nicotine inhaler treats the complexity of smoking through weaning both from the drug and from the sensory/ritual components associated with smoking. The inhaler is 'puffed' but not lit and there is considerable 'puffing' required to achieve slower rising and lower nicotine concentrations. These factors allow it to be used as a nicotine reduction treatment. One inhaler contains 10 mg of nicotine (and 1 mg of menthol) of which 4 mg of nicotine can be extracted and 2mg are systemically available. Shallow or deep 'puffing' results in similar nicotine absorption. Nicotine is delivered mainly to the oral cavity, throat and upper respiratory tract with a minor fraction reaching the lungs. This was confirmed with positron emission tomography and by assessment of arterial concentrations. A single inhaler can be used for one 20-minute period of continuous puffing or periodic use of up to 400 puffs per inhaler. With controlled puffing in laboratory testing, venous plasma nicotine concentrations from a single inhaler puffed 80 times over 20 minutes averaged 8.1 microg/L at 30 minutes. Lower concentrations of 6.4 to 6.9 microg/L have been reported for self-administration under clinical conditions. The time to peak plasma concentrations varies but is always significantly longer than with cigarette delivery. Estimates of nicotine intake from cotinine concentrations were higher than expected (60 to 70% of baseline smoking concentrations). This elevation may be due to the swallowing of nicotine and subsequent first-pass biotransformation to cotinine. In general, venous blood nicotine concentrations are considerably lower than with smoking and are within the range observed for other nicotine reduction therapies. Efficacy trials show consistent superiority of the inhaler over placebo. Despite the 'cigarette-like' appearance of the inhaler and the associated sensory/ritual elements, little treatment dependence or abuse has been reported. This is attributed to the slow rise time and low nicotine blood concentrations. The inhaler is a valuable addition to treatment of tobacco dependence and can be used alone or with other treatments.

Smoking cessation, but not smoking reduction, reduces plasma homocysteine levels

BACKGROUND

Cigarette smoking has been associated with increased plasma homocysteine levels. Although hyperhomocysteinemia may mediate some of the adverse cardiovascular consequences of smoking cigarettes, the effects of smoking cessation and smoking reduction on homocysteine levels have not been evaluated previously.

HYPOTHESIS

The purpose of this study was to determine the effects of smoking cessation and smoking reduction on plasma homocysteine levels.

METHODS

Fifty-one healthy subjects who smoked 35.9 +/- 6.4 cigarettes daily were randomized to continue smoking, reduce smoking to 4-8 cigarettes daily, or to stop smoking. A nicotine inhaler and individualized counseling were provided as aids to smoking cessation.

RESULTS

In subjects who quit smoking, homocysteine levels decreased by 11.6%, from 8.58 +/- 2.31 to 7.53 +/- 2.26 micromol/l (p = 0.013). Significant changes in homocysteine levels were not observed in subjects who reduced smoking or continued to smoke.

CONCLUSION

A "harm reduction" strategy of reducing cigarette use may not be sufficient for reducing the vascular risk associated with smoking cigarettes.

[Can we help our patients to stop smoking?: the experience of the Smoking Cessation Program]

OBJECTIVE

To describe the process and results of the Smoking Cessation Program in order to answer this question: Does the lack of time and resources justify poor involvement of physicians in helping patients to stop smoking?

METHODS

Prospective series of cases that included all smokers (n = 1203) who for any reason attended seven general practices over a period of one year. The behaviour of smokers when the program was offered as well as the workload generated by the implementation of the process are described. Subjects who stopped smoking were those who did not smoke two years after enrolment in a sustained and validated form for least 12 months.

RESULTS

A total of 7.3% of all smokers quit (95% confidence interval [CI]: 5.9-8.9). Enrolment of subjects caused an increase in the consultation time of 23 seconds and decreased from a mean of 30 new smokers per month per practice during the first three months to 12 at the end of the first year. All received advise to stop smoking (mean increase of 3 min and 33 s) but only 17.5% accepted the therapeutic plan during the first year (95% CI: 15.4-19.9) that had a duration of 72:11 min and generated a mean of six programmed appointments a month in each practice. Twenty percent of subjects who participated in the therapeutic plan stopped smoking (95% CI: 14.8-26.1).

CONCLUSIONS

Identification and universal advice to smokers, together with treatment of those who are motivated to quit, achieved important success rates without increasing excessively ordinary work loads.

A comparison of cigarette smokers recruited through the Internet or by mail

OBJECTIVES

To compare smokers recruited by mail or through the Internet.

METHODS

A questionnaire was mailed to 19,352 inhabitants of Switzerland in 1998, in an effort to enroll them in a smoking cessation trial. The same questionnaire was also available on the Internet. Furthermore, we mailed a survey to a representative sample (n = 1000) of the population of Geneva, Switzerland, in 1996. In this study, we compare three groups: 1027 smokers recruited through the Internet, 2961 volunteer trial participants recruited by mail (response rate 16%), and 211 smokers in the representative sample also recruited by mail (response rate 75%).

RESULTS

Smokers self-recruited through the Internet were younger, more educated, more motivated to quit smoking and smoked more cigarettes per day than smokers in the other samples. Compared to trial participants, Internet participants had more negative attitudes towards smoking, higher self-efficacy scores, and were more addicted to tobacco. The strength of associations between smoking-related variables was similar in Internet and trial participants.

CONCLUSION

As expected, the three groups of smokers differed on several characteristics. However, bias in distributions of variables did not imply bias in associations between variables. Thus, Internet recruitment is a potentially useful method for analytical studies that focus on associations between variables.

On quitting smoking: development of two scales measuring the use of self-change strategies in current and former smokers (SCS-CS and SCS-FS)

Smoking-cessation advice may be more effective and acceptable if it is based on strategies used by people who quit smoking on their own. The objective of this study was to identify these self-change strategies and to develop and validate questionnaires measuring the frequency of their use in current and former smokers. Development of questionnaire items was based on qualitative data provided by 120 current and former smokers, and the validation study was conducted by mail in 638 smokers and ex-smokers in Geneva, Switzerland, from 1996 to 1998. We identified 5 distinct and interpretable self-change strategies in current smokers and 5 strategies in former smokers, and measured their frequency of use with a 19-item questionnaire in current smoker (SCS-CS) and with a 17 item questionnaire in former smokers (SCS-FS). Eight items and 2 strategies were common to both current and former smokers. the scales fulfilled criteria of test-retest reliability, and content, construct, and predictive validity. Participants who quit smoking between the baseline survey and the 1-month follow-up had higher baseline scores for all self-change strategies (+0.65 to +1.16 standard deviation units) than participants who remained smokers at follow-up. These scales may be used to describe and understand the processes of smoking cessation and relapse, as well as to produce input data for computer systems which produce individually-tailored smoking cessation advice.

Clusters of precontemplating smokers defined by the perception of the pros, cons, and self-efficacy

Western smoker populations contain high percentages of smokers who are not motivated to quit. In order to develop self-help smoking cessation interventions for these smokers, it is of importance to know whether there are subtypes among this group. In the present study, cluster analysis was used to search for clusters of precontemplating smokers. The clusters were described by three cognitive clustering variables: the pros of quitting, the cons of quitting, and self-efficacy expectations. On the basis of earlier studies, three cluster solutions were tested: the 3-, 4-, and 5-cluster solutions. To cross-validate the findings, data from two independently recruited samples of precontemplating smokers were used. Three clusters, which were found in earlier studies in the United States, were replicated. In the present study these were called Unmotivated Pessimists, Motivated Pessimists, and Disengaged. Two additional clusters were identified, which might be typical for the tolerant Dutch smoking culture: Unmotivated Optimists and Motivated Optimists. It is argued that the replicated types are more nicotine-dependent and resistant to change, and represent the hard core smoker population, and that both optimistic types are less dependent, less resistant smokers who will quit with increasing societal anti-smoking pressure. Longitudinal analyses showed that cluster membership was predictive of increases in intention to quit and quitting activity.

Snowball sampling by mail: application to a survey of smokers in the general population

BACKGROUND

In a series of surveys intended for current and former smokers but sent to a random sample of the general population, we asked never smokers and smokers who did not wish to participate to transmit the questionnaire to any ever smoker they knew. We compared participants who received the questionnaire directly from us (original participants) to participants who received it from an addressee (secondary participants).

METHODS

Questionnaires on smoking were mailed to 3300 residents of Geneva (Switzerland) in 1997, and returned by 1167 people (35%).

RESULTS

The final sample consisted of similar numbers of original participants (n = 578, primary response rate = 18% of total sample, or about 46% of ever smokers) and secondary participants (n = 566). Original participants were 1.7 years older than secondary participants (P = 0.03) and were more likely to be men (50% versus 43%, P = 0.009). Proportions of current smokers, stages of change, confidence in ability to quit smoking, cigarettes per day and attempts to quit smoking were similar in the two groups. Secondary participants had lower self-efficacy scores (-0.30 standard deviation (SD) units, P < 0.03), and they derived more pleasure from smoking (+0.25 SD units, P = 0.04). Among ex-smokers, direct participants were less active than secondary participants in coping with the temptation to smoke (-0.58 SD units, P = 0.002). Associations between smoking-related variables were similar in original and secondary participants.

CONCLUSION

Allowing non-eligible addressees to transmit the questionnaire to someone else doubled the response rate, produced moderate bias on some variables only and had no detectable impact on associations between smoking-related variables.

Short-term impact of a university based smoke free campaign

STUDY OBJECTIVE

The aim of this study was to evaluate the impact of a smoke free programme implemented at the University of Geneva, Switzerland, in 1996. This programme included a prohibition to smoke in university buildings everywhere except in limited areas, and a smoking cessation counselling service.

METHODS

Surveys were conducted before and four months after the programme was implemented, in representative samples of programme participants (n = 833) and university members not exposed to the programme (n = 1023).

RESULTS

In retrospective assessments, participants reported being less bothered by environmental tobacco smoke after programme implementation, but no between group difference was detected in prospective assessments. Relationships between smokers and non-smokers improved moderately in the intervention group and remained unchanged in the comparison group (between group p = 0.001). Proportions of smokers who attempted to quit smoking in the past four months increased from 2.0% to 3.8% in the intervention group and remained unchanged at 3.5% in the comparison group (between group difference: p = 0.048). No impact on smoking prevalence (25%) was detected. The programme was appreciated by university members, although some of its modalities were criticised.

CONCLUSION

A regulation prohibiting smoking everywhere but in limited areas of university buildings was acceptable and reduced the perception of bother by environmental tobacco smoke. It did not, however, influence smoking habits or attitudes toward smoking.

Four beliefs that may impede progress in the treatment of smoking

The validity of four often-cited statements about smoking cessation is reviewed and their misinterpretation is discussed. "Most smokers are interested in quitting" is true; however, more important is the fact that smokers try to quit only once every 3.5 years. Thus motivating attempts to quit and removing barriers to treatment are important. "Most smokers quit on their own" is often interpreted to mean that smokers are not nicotine dependent; however, most dependent alcoholics and drug abusers who quit, do so on their own. This statement is also often interpreted to mean that most smokers do not need therapy, but the same was said about clinical depression in the early 1900s. "Quit rates with treatment are low"; however, most successful interventions for chronic disorders are the result of a series of treatments, not just one treatment. "Medication is effective only when accompanied by psychosocial therapy" is a tenet of treatment for traditional drug abuse; however, medications such as over-the-counter nicotine replacement therapies double quit rates even in the absence of psychosocial therapy.

Self-efficacy, decisional balance and the stages of change for smoking cessation in a German sample

The Transtheoretical Model (TTM) has been shown to be a powerful basis for describing and explaining behavior change and designing effective interventions. Previous research has documented its usefulness in the context of smoking cessation as well as other areas but predominantly in US samples. The goal of this study was to provide further data on the applicability of the TTM and the relationship of some of its core constructs (stage of change, self-efficacy, decisional balance) in a German sample of smokers and ex-smokers. Participants (N = 401) were ever-smokers (age M = 47 years, range 35-65, 62% male) who participated in a health check-up for cardiovascular risk factors at their general practitioner's office. For current smokers, significant differences in the number of quit attempts across the stages of change supported the criterion validity of the staging algorithm; differences in number of cigarettes per day were non-significant. Self-efficacy for non-smoking behavior showed an almost linear increase across the stages of change, with significant differences between pre-action and action stages. The pros for smoking cessation also increased significantly across the stages, mainly due to a significantly lower perception of pros by participants in the Precontemplation stage. As expected, the cons for smoking cessation decreased significantly, being lower in Action and Maintenance than in earlier stages. Although the generalizability of the results for the stage distribution is limited by the selectivity of the sample, the results underline the applicability and replicability of these TTM core constructs for smoking cessation with newly developed instruments in a German sample.

The role of social influence and smoker identity in resistance to smoking cessation 1This research program was supported by the Fonds National de la Recherche Scientifique, Switzerland. We are grateful to Juan Fabra for his help in collecting data

153 secondary school students, all smokers, were either exposed to a strongly anti-smoking message originating from a high status source (persuasive message condition) or not (control condition). A questionnaire then measured a set of variables concerning several aspects of tobacco consumption (i.e., smoker identity, attitude, subjective norm, perceived lack of behavioural control, smoking behaviour, and intention to give up smoking). First, regression analysis shows that the smoker's identity plays a direct and important role in explaining current smoking behaviour and the intention not to smoke, even when other variables are controlled. Second, analyses of variance indicate that smokers with a strong identity as a smoker are defensively motivated when confronting a persuasive attempt - i.e. their perception of friends' support to smoke increases. Finally, partial correlations show that the relationship between smoker identity and intention to give up smoking is mediated by this defensive motivation. Taken together, these results suggest that smoker identity is an important factor in explaining smoker's intention to give up smoking and, when antitobacco campaigns are salient, smoker identity can affect other variables which can reverse antitobacco efforts.

Associations between the stages of change and the pros and cons of smoking in a longitudinal study of Swiss smokers

To develop effective smoking prevention interventions, we need to identify modifiable variables, such as the "pros and cons" of smoking, that predict self-initiated smoking cessation. Our objective was to assess associations between the pros and cons of smoking and the stages of change, both cross-sectionally and longitudinally, in a cohort of smokers. In cross-sectional comparisons, the pros of smoking were 0.19-0.31 standard deviation (SD) higher and the cons 0.79-0.87 SD lower in the precontemplation than in the preparation stage. In follow-up data, progressing from precontemplation to contemplation and from contemplation to preparation was associated with substantial and significant increases in the cons (+0.71 SD and +0.50 SD, respectively). No longitudinal associations were found between changes in pros of smoking and progress through stages. Thus this study added evidence from longitudinal data to published evidence from cross-sectional data about the association between the cons of smoking and the stages of change. Intervention studies are necessary to establish whether this association is causal.

An expert system intervention for smoking cessation

The Pathways to Change system (PTC) is an expert system intervention for smoking cessation. Assessments are performed either by mail or by a telephone interview and each smoker receives a three- to four-page report that provides individualized recommendations matched to the individual's needs and readiness-to-change. The Transtheoretical Model of Change provides the theoretical basis for the expert system. Four different studies have demonstrated the efficacy of this intervention in a general population, with cessation rates of 22 to 26%. Furthermore, the difference between the groups was larger at each follow-up assessment point, indicating that the effects of the treatment increased long after the end of treatment. The studies involved two proactively recruited samples, demonstrating that a large proportion (85.3% and 82.5%) of the population of smokers could be successfully recruited into a smoking cessation program. Expert system interventions have the potential to have an extremely high impact on a total population of smokers.

Age and the role of symptomatology in readiness to quit smoking

To develop effective age-appropriate strategies for smoking cessation, it is important to understand factors associated with readiness to quit smoking. This article presents results from an analysis of the role of symptomatology in the decisions to quit smoking among three age groups (18-34, 35-54, and > or = 55 years) from a larger sample of smokers in a managed-care setting. Two measures of readiness to quit smoking were used: stages of change and intention to stop. Using ordinal logistic regression, we found that smokers in the middle and oldest age groups who had experienced at least three of five symptoms in the previous 2 weeks were more likely to be in higher stages of readiness. Regardless of age, smokers who attributed symptoms to smoking were more motivated to try to quit, whereas those who attributed symptoms to aging were less likely to intend to stop smoking. Findings from this study indicate a symptom-based approach to smoking cessation may be a useful strategy, especially in provider-based interventions.

Stage distributions for five health behaviors in the United States and Australia

BACKGROUND

A key variable for the design of individual and public health interventions is the Stage of Change. The five stages of readiness to change are Precontemplation, Contemplation, Preparation, Action, and Maintenance. The distribution of individuals across the stages of change can provide a valuable tool for designing health interventions.

METHODS

The pattern of distribution across the stages of change for five behavioral risk factors is presented from five independent surveys, two from the United States and three from Australia. The five risk factors are smoking, low fat diet, regular exercise, reducing stress, and losing weight. Identical single-item questionnaire items for staging health behaviors were used in all surveys.

RESULTS

The stage distributions for the five risk factors were similar across the five independent samples. In general, the pattern of stage distributions was stable across health risk factors, gender, country, and sample.

CONCLUSIONS

Single-item survey measures of stage of change that are readily applicable to population studies appear to provide important information about the population characteristics of readiness to change behavioral risk factors. The stability of these distributions suggests that interventions matched by stage may have broad applicability.