The European Journal of Public Health Advance Access originally published online on May 27, 2005
The European Journal of Public Health 2005 15(3):256-261; doi:10.1093/eurpub/cki077
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Smoking |
Determinants of smoking status: cross-sectional data on smoking initiation and cessation
A. Jeanne M. van Loon1, Marja Tijhuis1, Paul G. Surtees2 and Johan Ormel3
1 National Institute of Public Health and the Environment, Bilthoven, The Netherlands
2 Strangeways Research Laboratory, Worts Causeway, Cambridge, UK
3 Department of Psychiatry, University of Groningen, The Netherlands
Correspondence: A.J.M. van Loon, National Institute of Public Health and the Environment, Centre for Prevention and Health Care Research, PO Box 1, 3720 BA Bilthoven, The Netherlands, tel. +31 30 2743210, fax +31 30 2744407, Email: jeanne.van.loon{at}rivm.nl
Received March 21, 2003, accepted January 19, 2004
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Abstract |
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Background: Cigarette smoking is known to increase the risk of chronic disease. Improved understanding of factors that contribute to smoking initiation and cessation may help to underpin strategies that lead to smoking behavior change. Methods: Cross-sectional data obtained from 11 967 men and women, aged 20–65 years, were used to study associations with smoking initiation and smoking cessation within the general population. Information on smoking habits, socio-demographic factors and psychosocial factors were collected through self-administered questionnaires. Multiple logistic regression analyses were undertaken by gender. Results: Adverse childhood experiences and personality characteristics (including extraversion, neuroticism and hostility) were found to be related to smoking initiation. Age, marital status and tobacco-related factors were consistently associated with smoking cessation. Older people, married persons and those who smoked more cigarettes per day had a higher likelihood of quitting, both for men and women. Conclusions: Smoking initiation was found to be associated with adverse childhood events and with measures of personality whereas smoking cessation was associated predominantly with socio-demographic and tobacco use-related factors.
Keywords: smoking initiation, smoking cessation, correlates
As smoking is an acknowledged risk factor for a range of chronic diseases, the development of approaches to reduce tobacco use is very important. Identification of factors associated both with smoking initiation and cessation may help to underpin strategies to aid this process. Social pressure from peers or older siblings has been considered a prime factor for initial experimentation.1 Moreover, smoking has been consistently reported to be a coping behaviour for dealing with stress. Anda et al.2 reported a strong association between smoking and adverse childhood experiences that included abuse (emotional, physical and sexual), parental separation and parental substance abuse. Personal resources such as self-esteem, peer and family support and mastery were also reported to be related to smoking behaviour.3 In addition, smokers have been described as extraverted, somewhat neurotic and tense.4 Socio-economic status (SES) is also associated with smoking initiation.5–7 Factors hypothesized to be associated with smoking initiation are summarized in figure 1.
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The reasons smokers have given for maintaining the habit, once initiated, have been analysed extensively and can be summarized as including pleasure-taste, addiction, habit, anxiety, stimulation, social rewards and cigarette handling.8 The bio-behavioural model of smoking cessation and relapse9 integrates readiness to change with known predictors of smoking outcome (figure 2). Therefore, this model can be used as a theoretical framework on which hypotheses about determinants of smoking cessation can be derived. Measures from at least four domains may either interact with readiness or exert independent influences on the smoking cessation process: demographics and smoking history, biological, intra-personal, and situational (or interpersonal) components.9 To find out which factors have independent influences, it is necessary to study the hypothesized determinants simultaneously.
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In a large-scale prospective cohort study in the Netherlands on psychosocial factors and cancer risk it was possible to study cross-sectionally several hypothesized determinants of smoking status simultaneously, within the general population. Given previous research on smoking initiation and cessation, the following hypotheses will be evaluated:
- Individuals who have experienced more adverse childhood experiences have more often started smoking.
- Those individuals who report themselves as more neurotic, extraverted, hostile or less able to master situations, have more often started smoking.
- Those individuals who report themselves as more neurotic, extraverted, hostile or less able to master situations, have less often quit smoking.
- Individuals who have experienced a stressful life or job strain have less often quit smoking.
- Those individuals who started smoking at younger age and/or smoke more cigarettes per day have less often quit smoking.
Additionally, mediating effects of gender on determinants of smoking were explored, since previous studies have suggested that the determinants of smoking behaviour may vary by sex.10–12
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Subjects
The entire cohort of the Monitoring Project on Chronic Disease Risk Factors (MORGEN project)13 formed the study population for a prospective cohort study on psychosocial factors and cancer risk, which started in 1996. In the MORGEN project, data on health status and prevalence of risk factors were collected from 20–65-year-old men and women (between 1993 through 1997), in an age- and sex-stratified random sample of the general population in the Netherlands (n=50 766). The response rate in the MORGEN project was 45% (n=22 769). All participants of the MORGEN project who gave informed consent for further research (94%) were mailed the Health and Life Experiences Questionnaire (HLEQ), an instrument designed to assess psychosocial factors.14 Because data collection for the MORGEN project took place between 1993 and 1997 and data collection for the HLEQ started in 1996, the MORGEN respondents were approached in stages, starting with respondents from 1993 and 1996. As a consequence, the interval between completing the MORGEN questionnaire and receiving the HLEQ questionnaire was 6 months for about half of the study population and 3 years and 6 months for the other half. A total of 12 023 participants (56%) completed the HLEQ.
Smoking habits and demographic factors
Information on smoking habits and demographic characteristics was obtained in the MORGEN project. Subjects were classified as (persistent) smokers if they reported to smoke one cigarette or more per month, as quitters if they reported to have quit smoking and as never smokers if they reported that they had not smoked during their whole life. Information on the number of cigarettes smoked per day, the age of participants when they began to smoke and the number of years smoking were derived from the general questionnaire. In addition, demographic factors that included sex, age, marital status (unmarried versus married), employment status (with or without a paid job) and socio-economic status (recorded as highest level of education) were available from the MORGEN questionnaire.
Psychosocial factors
Information on adverse childhood experiences, personality characteristics, depressive symptoms, life events and work characteristics was obtained by the Health and Life Experiences Questionnaire (HLEQ) as part of a broader range of assessments. The HLEQ was designed for initial use in the European Prospective Investigation into Cancer and Nutrition (EPIC) study in Norfolk, co-ordinated from Cambridge (UK). A more detailed outline of aspects of the HLEQ assessment approach has been provided elsewhere.14,15
Questions about adverse childhood experiences concerned respondents' first 16 years of life and included: 2 weeks or more in hospital, parental divorce/unemployment, experience of a frightening event, being sent away from home, parental drink or drug abuse, experiencing physical abuse, separation from mother.16 Personality characteristics included mastery, neuroticism, extraversion and hostility. Mastery concerns the extent to which personal life changes are perceived as being under one's own control, in contrast to being fatalistically ruled.17 Neuroticism refers to emotional instability, whilst extraversion is defined as ‘having a lot of friends, taking risks, searching for excitement, being impulsive, not always having control over one's feelings, and not always behaving in a trustworthy way’.18 Hostility refers to hostile thoughts as well as hostile acts.19,20
Depressive symptoms were measured as part of an assessment of depressive disorder diagnostic status of each respondent over their lifetime.15 Analysis in this paper relied on reports by participants of any period of 2 weeks or more in their lives of either sustained depressed mood or loss of interest. Having a stressful life was measured with the question ‘All things considered, how stressful do you believe that your life has been over the past 10 years?’ (not at all stressful, rarely-, moderately-, markedly-, extremely-).
Job demands and job control were based on the job strain model of Karasek,21 with item choice based on scales used in the Whitehall II study.22 A detailed description of the composition of summary scores is reported elsewhere.23
Statistical methods
Associations between demographic or psychosocial characteristics and smoking status were considered for men and women separately. Multiple logistic regression analysis was used to study associations with smoking initiation or cessation. Statistical significance was assessed by analysis of variance and maximum likelihood (P<0.05). Smoking initiation was dichotomized as ever versus never smoking and smoking cessation was dichotomized as ex versus current smoking. All relevant information (see figure 1 and figure 2) was entered in the model simultaneously. SES was based on education and categorized as low (primary school, lower vocational or junior high school), medium (intermediate vocational or senior high school) and high (higher vocational training or university). Seven items of the scale used to measure adverse childhood events were summed for each respondent, comparable with the method used by Anda et al.2
Age, number of adverse childhood events, personality scores, job demand, job control, number of cigarettes per day and age at start smoking were considered as continuous variables. All other variables were dichotomized (yes/no). Statistical analyses were restricted to persons with complete information on sex, age, SES and smoking status (n=11 967; 5310 men and 6657 women), using SAS (Statistical Analyses System), version 6.12.
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Correlates of smoking
The prevalence of current smoking is 32% among men and 34% among women and the prevalence of ex-smoking is 37% among men and 28% among women. The distribution of the factors of interest between categories of smoking is presented in table 1, for men and women separately. Among current smokers more men were unmarried, unemployed or of lower SES. Current smokers reported a higher prevalence of depressive symptoms, a higher proportion considered their life as stressful, and a higher proportion reported separation (of at least 1 year) from their mother before the age of 16. Higher scores for adverse childhood events, extraversion, neuroticism and hostility were reported among current smokers. Among male never, ex- or current smokers, mean scores for job demands, job control or mastery differed little. A comparison of ex- with current smokers showed that current smokers smoked fewer cigarettes per day, and started smoking at a later age than ex-smokers. For women, these findings were comparable, except that there was no association between smoking status and employment status.
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Smoking initiation
In the modelling of smoking initiation, smoking status was dichotomized as ever versus never smoking. Separation from mother during childhood was found to be strongly associated with smoking initiation, especially among men (table 2). The number of other adverse childhood events assessed was not significantly associated with smoking initiation among men, whereas we found a positive association among women. Personality characteristics (higher scores for extraversion, neuroticism and hostility) were also positively related to smoking initiation. Men as well as women with a medium or higher SES had significantly lower odds for smoking initiation compared with men or women with a lower SES.
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Smoking cessation
In the modelling of smoking cessation, smoking status was dichotomized as ex-smoking versus current smoking. Age, marital status and SES were most consistently associated with smoking cessation (table 3). Older people, married persons and people with a medium or high SES have higher odds for quitting, both for men and women. Regarding tobacco-related factors, associations with smoking cessation were less consistent. The number of cigarettes smoked per day was positively associated with smoking cessation in men, whereas the age people started to smoke was inversely related with smoking cessation in women. Regarding psychosocial factors, only depressive symptoms were significantly associated with smoking cessation; loss of interest was inversely associated with smoking cessation among men, whereas sustained depressed mood was inversely related with smoking cessation among women. We found no significant associations between personality characteristics or psychosocial job characteristics and smoking cessation.
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Discussion |
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This study has shown that adverse events in childhood and personality characteristics (extraversion, neuroticism and hostility) are related to smoking initiation. Smoking cessation was found to be associated mainly with socio-demographic characteristics. Associations between tobacco use-related factors and smoking cessation or depressive symptoms and smoking cessation differed between men and women. We found no significant associations between personality pre-dispositions or job-related factors and smoking cessation.
We expected that individuals who had experienced more adverse childhood experiences would have more often started smoking. Our findings on adverse childhood experiences and smoking confirm this hypothesis and they are comparable with findings from Anda et al.2 They reported that adverse childhood experiences were related to early smoking initiation, ever smoking, current smoking and heavy smoking.
Our findings on other determinants of smoking initiation are also comparable with findings from other studies and they confirm our second hypothesis about personality characteristics and smoking initiation. In general, current or former smokers have been found to be more hostile,24–27 more neurotic,4,5,24,28 and to have higher scores for extraversion4,27–29 as compared to non-smokers.
Our third hypothesis considered personality characteristics and depressive symptoms in relation to smoking cessation. Studies on personality characteristics and smoking cessation reported lower scores for hostility27 and extraversion28 among ex-smokers compared with current smokers. Furthermore, depressive symptoms were found to be inversely related with quitting rate among US adolescents.30 In our study, personality characteristics were not significantly related to smoking cessation, whereas depressive symptoms were significantly associated with smoking cessation in men (loss of interest) and women (depressed mood).
In contrast to our expectations, we found no significant associations between measures of job strain and smoking cessation. Other studies on smoking and job characteristics showed inconsistent results. In general, hardly any significant association was found between job demands and smoking status.31–33 In some studies low job control was found to be associated with higher prevalence of current smoking among men.33,34 However, in other studies no significant associations were reported between job control and smoking status.31,32
We hypothesized that individuals who started smoking at a younger age and/or smoke more cigarettes per day have less often quit smoking. In other studies successful smoking cessation has been associated mostly with low prior tobacco consumption.35–40 Whilst smoking less than 10 cigarettes a day has been found to be the strongest predictor of both short-term and longer-term cessation.41 Yet, we found an inverse association between the number of cigarettes smoked per day and smoking cessation among men. Matheny and Weatherman undertook a study on smoking relapse among smokers who had undergone a smoking cessation program and they found that people who smoked a greater number of cigarettes daily and cigarettes with a higher tar content were more likely to be abstinent.42 This is in line with the suggestion of Hughes and Hatsukami that light smokers may have contented themselves with decreased smoking rather than quitting smoking.43 Moreover, Schmid and Gmel found that within the stages of change the likelihood of cessation was moderated by addiction variables: in the case of contemplating smokers, the more cigarettes they smoked daily at baseline, the less likely they were to be former smokers after 8 years of follow-up.44 But for smokers in the preparation phase, who had already made an attempt to quit, the converse holds: the more they smoked at baseline, the more likely they were to be non-smokers 8 years later.
Our prior expectations were that the associations with smoking would vary by sex. In general, only small differences in the associations with either smoking initiation or cessation between men and women were found. However, regarding smoking initiation, we had only information on adverse childhood events and personality characteristics. Other studies have not found different associations between these factors and smoking initiation between men and women.2,27 It seems that effects of social pressure or self-esteem on smoking initiation do vary between men and women. Simons-Morton et al. found that social influence variables (including friends' problem behaviour and direct peer pressure) were independently associated with smoking but only among boys, whereas self-control was independently associated with smoking among girls but not boys.12 Nevertheless, the authors considered the latter as a possible artefact of their stratified analysis.
Finally, our results regarding demographic factors and smoking are comparable with findings from others. Smoking initiation is found to be more prevalent among adolescents attending main school compared with adolescents attending high school.6 In other studies on the determinants of smoking cessation, successful smoking cessation was also found to be associated with older age,35–37 being married38,39 and higher SES.5,7
The response rate for the MORGEN project was 45%. This rate was found to be lower among men and younger persons.45 A small non-response survey among the MORGEN study population conducted in 1993,46 showed that men and those with a lower level of education were possibly under-represented in MORGEN, whereas non-smokers, sportsmen and those with a less-than-good self-reported health were over-represented. For the questionnaire on psychosocial factors, the response rate was 55% and respondents reported higher SES, better subjective health and healthier lifestyle behaviours than non-respondents. These differences in response may affect the prevalence rates of the measures considered. However, differences in prevalence estimates of current smoking did not lead to biased associations between smoking status and SES.45 Therefore, it is not expected that differences in response rates affect associations between demographic or psychosocial factors and smoking habits.
This paper was based upon cross-sectional data from an ongoing prospective cohort study on psychosocial factors and cancer risk in which psychosocial characteristics were measured 0.5 or 3.5 years after measurement of smoking habits and socio-demographic factors. The majority of the investigated potential determinants of smoking status refer to rather stable characteristics (sex, date of birth, level of education, personality) in the investigated age range (20–65 years) or in relation to much earlier events (in childhood), so these factors will precede smoking initiation or cessation. However, classification of participants with regard to job demands and job control was based on current employment whilst the measure of depressed mood may also refer to the period following smoking cessation. We have repeated the analyses after restriction was made to those individuals who received the HLEQ only 6 months after they completed the MORGEN study, with comparable results (not presented).
Unfortunately, in our study no information was available on social pressure and perception of smoking. In addition, there might be other factors important in explaining smoking initiation such as circumstances at home or at school. As a consequence, factors used in our study do not fully explain smoking initiation. Similarly, we assumed that smoking cessation could be explained by demographic factors, smoking history, biological factors, intra-personal and situational factors. Again, not all this information was available. Readiness to change is considered to be the major factor in smoking cessation, though we had no information about peoples' intentions to quit smoking. However, the study of Osler and Prescott suggests that successful quitting among smokers in the pre-contemplation (did not wish or try to quit) and contemplation stages (wished or tried to quit) was determined by the same factors (age, SES, prior tobacco consumption, having a non-smoking spouse).37 Nevertheless, it is recommended to use a longitudinal design in future research, with additional information about social pressure, perception of smoking, circumstances at home (and at school) and readiness to change.
In conclusion, smoking initiation was associated with adverse childhood events and personality predispositions, while smoking cessation was associated mainly with socio-demographic factors and factors related to tobacco use. It seems to be important to pay attention to personality characteristics to prevent people from becoming smokers. Adolescents who have experienced adverse childhood events may run extra risk. When people have crossed the line of smoking initiation, then tobacco-related factors are more important in maintaining the risky habit.
Key points
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Acknowledgments |
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This project was supported by a grant from the Dutch Cancer Society. The Monitoring Project on Risk Factors for Chronic Diseases (MORGEN project) was financially supported by the Ministry of Health, Welfare and Sport of the Netherlands and the National Institute of Public Health and the Environment. The authors would like to thank the epidemiologists and field workers of the Municipal Health Services in Amsterdam, Doetinchem and Maastricht for their important contribution to the data collection for this study. The project steering committee consisted of Dr H.B. Bueno de Mesquita, Dr H.A Smit, Dr W.M.M. Verschuren and Dr J.C. Seidell (project leader). Logistic management was provided by A. Jansen and J. Steenbrink and data management by A. Blokstra, P. Steinberger and A. van Kessel. Use of the questionnaire on lifestyle factors was in part made possible by the financial support received from the Europe against Cancer Program of the Commission of the European Communities in relation to the European Prospective Investigation into Cancer and Nutrition
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