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Stages of change and other factors in ‘light’ cigarette smokers
Julia Kelbsch1, Christian Meyer1, Hans-Jürgen Rumpf2, Ulrich John1 and Ulfert Hapke1
1 Ernst-Moritz-Arndt University Greifswald, Institute of Epidemiology and Social Medicine, Germany
2 Department of Psychiatry and Psychotherapy, University of Lübeck, Germany
Correspondence: Julia Kelbsch, Dipl.-Psych., University of Greifswald, Institute of Epidemiology and Social Medicine, Walther-Rathenau-Str. 48, D-17487 Greifswald, Germany, tel. +49 3834-86-7719, fax +49 3834-86-7701, Email: kelbsch{at}uni-greifswald.de
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Abstract |
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Background: It has become well known that ‘light’ cigarettes are deceiving in fostering the attitude that they are ‘safer’ or less health damaging than regular cigarettes. The goal of this study is to analyse the smoking of ‘light’ cigarettes according to the progress over the stages of change to stop or reduce smoking. Methods: A sample representing the general population of a northern German region aged 18 to 64 was drawn (T1, N=4075). 1520 smokers of ‘light’ and regular cigarettes were identified by a face-to-face interview and reassessed longitudinally by questionnaire 30 months later (T2, n=913). Results: At baseline smokers of ‘light’ cigarettes, in particular males, were more likely to be contemplators or preparators in terms of smoking cessation. Those who smoked ‘light’ cigarettes were more likely to have made a quit attempt, were more likely to be female, at younger age, never married, higher educated and less nicotine dependent compared to smokers of regular cigarettes. The follow-up data shows that males who smoked ‘light’ before or changed to ‘light’ cigarettes were more likely to contemplate or to prepare quitting, had more often tried a quit attempt and stopped smoking more often. Conclusion: The results suggest that ‘light’ cigarettes especially by males are used for reasons of reducing or quitting smoking. It is concluded that as such they deceive the smoker and potentially hinder the process of reducing or quitting.
Keywords: ‘light’ cigarettes, population based, smoking, stages of change
For public health aspects, there are two crucial points inherent in smoking ‘light’ cigarettes. (1) Nominal tar yields (yield according to the information on the cigarette pack), even if presented in a correct manner, may be misleading. Evidence shows that it does not have any health benefit.1 (2) Misperceptions about health benefits assumed by the ‘light’ smoker may distract her/him away from quit attempts.1,2
In contrast to other ‘light’ products, there is for both Europe and America no mandatory regulation about what is defined as a ‘light’ cigarette.3 In Germany, where 31% of all cigarettes smoked are cigarettes with nominal low yields of tar and nicotine, there is just a voluntary agreement by the tobacco industries to label cigarettes as ‘light’ if they contain 8 mg tar or less.
It follows from the lack of mandatory regulation about the margins for ‘light’ products that the consumer might be confused about what really is a ‘light’ product. There is considerable argument that using the labels ‘light’ or ‘mild’ for cigarettes is misleading. Smokers compensate for less nicotine supply, e.g. by blocking the filter vents, 4 by deeper inhaling or taking more puffs per cigarette.5 Smokers of ‘light’ cigarettes tend to take in a two- to threefold nicotine amount compared to that measured by standardized machine smoking.5,6 One study even found an intake of nicotine eight times higher than machine smoked yields indicate.7
According to representative studies, smokers of ‘light’ cigarettes tended to be more often women, older and higher educated compared to smokers of regular cigarettes.1,7–9 ‘Light’ smokers seem to be less addicted, smoke fewer cigarettes per day and have significantly higher rates of quit attempts.1,7 However, only little evidence exists about the readiness to change and smoking ‘light’ cigarettes.1 One valuable approach to analyse this intentional process is provided by the stages of change as part of the Transtheoretical Model of behaviour change.10 Smokers may be classified into one of three stages depending on their readiness to change smoking behaviour, from precontemplation (not intending to quit at all) to contemplation (intending to quit in the future) on to preparation (intending to quit in the near future).11
In general, ‘light’ cigarettes might be used for two reasons: (1) the feeling that this is more healthy and less damaging; (2) as a way to cut down cigarette consumption or as a step towards quitting.9,12 If smokers use ‘light’ cigarettes to reduce their health risk and as a step towards quitting it might be assumed that they differ from smokers of regular cigarettes in terms of their readiness to change smoking behaviour. Therefore, the purpose of the present longitudinal study is to analyse factors relevant to the intention to smoke ‘light’ cigarettes with special consideration of the stages of change in a representative sample of adults in Germany, a country with a high smoker rate and low public health efforts.
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Methods |
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The data is from a longitudinal general population study as part of the project ‘Transitions in Alcohol Consumption and Smoking’ (TACOS). The design incorporated a baseline (T1) and a 30 month follow-up (T2) assessment, which included all participants identified as current smokers at T1. While T1 had a broader focus on substance use disorders and psychiatric comorbidity, T2 included an in-depth assessment with respect to smoking and at-risk alcohol consumption. A more detailed description of methods of the cross-sectional part of this study is given elsewhere.13,14
Sample
4075 individuals aged 18 to 64 were randomly drawn from the official resident registration office files of the city of Lübeck and 46 adjoining communities representing a northern German region. All individuals with German nationality (to avoid language problems) and not living in institutions were included in the study. The sample was shown to be representative of the age groups in both genders in the population of the study region. The resulting response rates were 70.2% for T1 and 86.1% for T2 with respect to subjects eligible for the respective assessment.
Procedure
The assessments at T1 took place from July 1996 until March 1997. Trained and supervised interviewers conducted a computer-assisted personal interview, mostly at the participants' homes (91.5%; at other places, such as project office or public places on request).15
At T2, self-administered paper–pencil questionnaires were mailed or handed to the participants personally. Multiple contacts by reminder mailings, telephone and personal visits were used to increase response rates in initial non-responders. The mean time interval between T1 and T2 assessments was 30.8 months (SD = 1.43). The study followed the ethical principles of the American Psychological Association.16
Individuals received written information on the study and were informed that they were free to participate and could withdraw from the study at any time.
Assessments
At T1, the fully standardized and computerized Composite International Diagnostic Interview (CIDI)17
in its German version, the Munich Composite International Diagnostic Interview (M-CIDI),18
was used to gather information on smoking behaviour and socio-demographic variables. Questions included the age of onset of smoking, the number of cigarettes smoked per day during the period of peak consumption, whether the individual had ever tried to quit or cut down on smoking, and the number of attempts to quit or to cut down. Furthermore, the M-CIDI provides the DSM-IV nicotine dependence diagnosis. Demographic variables included gender, marital status, having own children, children living in household, school education and income per household. The Fagerström Test of Nicotine Dependence (FTND) was used to assess the severity of dependence.19
The intention to stop smoking was assessed by the stages of change within the interview (precontemplation: not intending to quit in the next six months, contemplation: intending to quit within the next six months; preparation: intending to quit within the next four weeks and having tried a serious quit attempt in the past year).10
The T2 assessments included items on smoking status and number of cigarettes smoked per day taken from the M-CIDI.
Data analysis
Current smokers were defined by smoking at least one cigarette per day within the last four weeks. ‘Light’ or regular smokers were classified according to the question which brand s/he currently preferred to smoke. If the mentioned brand could not be categorized data was excluded from the analysis. Participants with missing values were excluded from the respective analysis. Therefore, the reported total sample sizes differed between analyses.
First, we examined differences between smokers of ‘light’ and regular cigarettes according to demographic factors, characteristics of smoking behaviour and stages of change to stop smoking in the baseline study by univariate analyses which included chi-square and t-tests. For multivariate analyses, we used logistic regression to identify significant predictors of smoking ‘light’ cigarettes by controlling for the other variables. Longitudinally we tested, first, whether cigarette preference at baseline predicted quit attempts or abstinence, and second, whether brand switching at the time interval between T1 and T2 predicted the intention to stop smoking. The data was analysed with SPSS release 10.0.
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Results |
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Of the 1520 current smokers at T1 1467 could be classified as ‘light’ or regular smokers. Of these 19.4% (n=285) used ‘light’ cigarettes. ‘Light’ smokers, were more likely to be female, younger, never married and less likely to live with children compared to regular smokers. Furthermore, ‘light’ smokers were higher educated (table 1). They currently smoked fewer cigarettes and showed a lower FTND score. More of them had tried to quit in the past compared to smokers of regular cigarettes.
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In terms of the stages of change, among male ‘light’ smokers, there were more men in contemplation or preparation stage than among regular smokers, not however among females (table 2).
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Multivariate analysis showed the following significant variables: gender, age, education, children living in household, cigarettes per day (in the last 4 weeks and at the time of highest consumption), age of onset of regular smoking, FTND sum score, attempt to quit or abstain and stages of change (contemplation and preparation stages are taken together as advanced stages of change). These variables were entered into the regression model. Logistic regression with backward-procedure identified five significant predictors of smoking ‘light’ cigarettes. Gender and school education of at least 12 years best predicted smokers of ‘light’ cigarettes. Both females and those with 12 years or more at school were three times as likely to smoke ‘light’ cigarettes compared to males and those with education of nine years or less. According to nicotine dependence analysis, the lower the FTND the more likely the person is consuming ‘light’ cigarettes. The chance of smoking ‘light’ cigarettes is increased by 2% with every cigarette smoked per day at the time of highest consumption. Furthermore, current smokers in an advanced stage of change, were about twice as likely to smoke ‘light’ cigarettes than precontemplators (table 3).
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Of the 913 subjects included in the final data set T2 850 subjects could be classified with respect to cigarette preference (‘light’ or regular cigarette or abstinence) at both assessments. Among these subjects 32.0% (n=189) were smoking ‘light’ cigarettes at T2. Additional analysis of the prevalence of the same subsample at T1 (25.6%, n=159) showed a significant increase of smoking ‘light’ cigarettes between T1 and T2. Figure 1 illustrates cigarette preferences at T1 and T2. It also indicates how many participants switched from ‘light’ to regular and vice versa, stayed with ‘light’, or regular, or quit.
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Within the 30 month follow-up time, males who changed from regular to ‘light’ were more likely to be in the contemplation or preparation stage than males who continued to smoke regulars. This was not true for females (table 4). Among male smokers who smoked ‘light’ at baseline, there were more who abstained from smoking during the 30 month follow-up period (table 5). Within our sample ‘light’ smokers have tried to quit more often. However, when stratifying by gender, differences are not statistically significant, presumably due to little power. Using direct multivariate logistic regression analysis to predict abstinence or quit attempts at follow-up none of the predictors gender, education, CPD, FTND and the smoking of ‘light’ cigarettes at baseline remained significant.
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Discussion |
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This analysis is the first longitudinal examination regarding characteristics of ‘light’ smokers with special consideration of the intention to change smoking behaviour. We found that, at follow-up, significantly more participants smoked ‘light’ cigarettes than 30 months before. The smokers of ‘light’ cigarettes were younger and showed a lower rate of being married or having own children. In terms of smoking behaviour ‘light’ smokers, consistent with prior research,1,2,7,9 consumed a lower number of cigarettes, were less dependent and had more often tried to quit smoking than smokers of regular cigarettes. Furthermore, individuals who contemplated quitting or were preparing to quit were more likely to be ‘light’ smokers. Thus, the use of ‘light’ cigarettes can be interpreted as an attempt to reduce the health risk from smoking.
In terms of gender differences our study showed, consistent with prior research, that more females than males used ‘light’ cigarettes.7,8 However, both groups seem to differ with respect to the intention to quit smoking and the use of ‘light’ cigarettes. As shown by the longitudinal data only male smokers in the advanced stages of change are more likely to switch from regular to ‘light’ cigarettes. The fact that smoking ‘light’ cigarettes at baseline is only a significant predictor of abstinence at follow-up for males may result from gender differences in motives for smoking ‘light’ cigarettes. Males who decided to smoke ‘light’ cigarettes may do so as a way to progress from smoking to abstinence. In contrast, women might prefer to consume ‘light’ cigarettes because products labelled ‘light’ (diet products) might be in general more attractive for females. ‘Light’ cigarettes seem to be more trendy or are assumed to be a less health damaging product. Thus, females are more open to this misleading message spread by the tobacco industry. However, our data showed no association of switching to ‘light’ cigarettes and the intention to quit for females.
Furthermore, our results confirm prior findings that ‘light’ smoker are better educated than smokers of regular cigarettes. The higher ratio of ‘light’ smokers among better educated individuals fits into the evidence which shows that the better educated are orientated to a more healthy lifestyle. They have more knowledge about the risks of smoking, which probably makes them try to minimize the health risk by smoking assumed less harmful cigarettes. Therefore, it is even worse that they are badly deceived about the deterrent nature of the ‘light’ cigarette. Our result supports the funding that there is a subgroup which is aware of the health risks of smoking and wants to do something about it, but with ‘light’ cigarettes they choose the wrong means.
There are limitations to this study. (1) There was no possibility to prove the validity of the brand names designated by the individual. There may have been several smokers who mentioned their favourite brand but omitted a ‘light’ suffix in the brand name. However, this does not seem very probable if it is assumed that those who smoke ‘light’ identify themselves with a distinct, perhaps more health-oriented behaviour. On the other hand, it may be that some smokers mentioned ‘light’ cigarettes in order to signal a less health damaging smoking behaviour. This however seems to be not very probable since in Germany, there is almost no social pressure on smokers. (2) The longitudinal nature of the study led to the attrition of subjects. (3) Our sample proved to be representative just for one area of Germany, not the whole nation.
To conclude, our results showed that ‘light’ cigarettes might be an alternative to progress from smoking to abstinence for males. Females are the major target group for ‘light’ cigarettes and appear to be most affected by the misleading attribute implying a lower health risk. Therefore, the directive of the European Community20 prohibiting labels suggesting that a particular tobacco product is less harmful than others, are an important improvement for tobacco control.
Key points
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Acknowledgments |
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This study is part of the German research network ‘Analytical Epidemiology of Substance Abuse (ANEPSA)’. Factors related to the use and abuse of psychoactive substances are analysed by different research groups in the context of several longitudinal studies. The Research network is funded in the context of the programme ‘Biological and psycho-social factors of drug abuse and dependence’ by the Federal Ministry of Education, Science, Research, and Technology. Data described in this paper is part of the project ‘Transitions in Alcohol Consumption and Smoking (TACOS)’, part 1: ‘Drug Use in the Adult General Population in a Northern German City and Surrounding Communities’, grant no.: 01 EB 9406 and part 3: ‘Stages of change and utilization of care in persons with risk consumption, abuse or dependence of tobacco or alcohol’ grant no.: 01 EB 9801/8; principal investigators: Professor Dr John (University of Greifswald), Professor Dr Dilling (Medical University of Lübeck).
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