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New South Wales smoking and health survey 2009

Research updates

Issue 2, December 2009

This research program measures tobacco-related knowledge, attitudes and behaviour in the NSW community, to identify any shifts in key measures over time. It forms part of the Cancer Institute NSW's evaluation of its tobacco control program, and assists in driving new tobacco control measures.

The research aimes to understand:

1. patterns of tobacco use and the quitting process
2. knowledge and attitudes about the health consequences of smoking
3. community attitudes regarding current or potential tobacco control measures.

This research also reports on changes over time.

Research design

The research involved a telephone survey of adults recruited randomly using List-Assisted Random Digit Dialling (LA-RDD), based on sample lists provided by the NSW Health Survey Program (constituting a change from previous waves, which used the Electronic White Pages). The sample (N=1,627) included quotas to ensure approximately equal sub-samples of smokers (i.e. the primary target audience for most tobacco control interventions) and non-smokers (as members of the general community), and appropriate representation by geographic location.

In 2009, no further quotas were applied. Instead, data were weighted to reflect the age and gender of smokers and non-smokers in the NSW population and to reflect 18.4 per cent smoking prevalence (where questions were relevant to the population as a whole). The questionnaire was adapted from the 2007 cross-sectional and 2008 longitudinal studies, with some additional areas of interest. The fieldwork period was from 24 April to 10 May, 2009.

Smoking status

The increasing proportion of those who have never smoked weekly and for who have never tried smoking at all suggests an important prevention outcome.

Of the total sample, 42 per cent were daily smokers, only 8 per cent smoked less frequently (weekly and less than weekly), and 14 per cent were ex-smokers (i.e. used to smoke at least weekly but currently did not smoke at all). Among those who had never been regular daily or weekly smokers, a significantly greater proportion (68%) had never tried smoking, compared with last wave (48%).

On average, regular smokers reported consuming 15.4 cigarettes or other tobacco products per day, with daily smokers consuming 16.5 per day, and weekly smokers (who do not smoke daily) consuming 2.2 per day - which is comparable with previous waves.

Smoking behaviour

Almost half of all smokers reported smoking more cigarettes on some days than others. On average, 19.6 cigarettes were smoked on the typical 'heavy' day, and the average maximum number smoked in a day was 30.4 cigarettes. These smokers were most likely to 'binge' smoke when they were stressed or in a bad mood, drinking alcohol, in social situations or around other smokers. These same situations were mentioned as key triggers of relapse after a recent quit attempt. Among those who mentioned stress as a relapse trigger, the primary source was work, financial or study-related stress.

Consistent with previous waves, supermarkets accounted for almost half (46%) of respondents' last cigarette purchases, and this tendency was stronger among older smokers. Smokers, as a group, were the most likely to always notice cigarette displays at cash registers (39%). Ex-smokers (rather than non-smokers) were most likely to report never noticing the display, which may be wilful inattention. Almost one in four smokers reported sometimes, often or always buying cigarettes on impulse when they were shopping for something else, which is likely to be an underestimate of this effect. Younger smokers (18-39 years) were more likely than older smokers to notice the displays and, where noticed, to buy cigarettes on impulse.

Quitting smoking

In 2009, a significantly greater proportion of smokers were considering quitting in the next six months (66%), compared with the 2005 baseline (59%) and even since the last wave (61%). Daily smokers were more likely than less frequent smokers (weekly and less than weekly) to be considering quitting (68% vs 57%). Again, when probed further, just under half (46%) of all smokers were 'seriously' thinking of quitting and a fifth were planning to quit within a month.

With regard to quitting salience, two in five smokers reported having thought about quitting at least once a day over the past two weeks, and almost three-quarters had thought about quitting at least once in the last fortnight. Of those who had thought at all about quitting, 43 per cent reported 'very strong' feelings that they should quit now.

Given that most current smokers have made multiple 'unsuccessful' attempts to quit, an emphasis needs to be placed on
remaining quit.

In 2009, quitting within the next 12 months was also seen as slightly more attainable, with a lower mean difficulty rating (6.4 out of 10, vs 6.8 in 2005), and fewer smokers rating the perceived difficulty at the maximum level (21%, vs 29% in 2007). In addition, only 35 per cent of daily smokers think that they definitely or probably will be smoking in 12 months' time, compared with 43 per cent in 2007. Smokers rated their confidence in their ability to quit smoking as 6.3 out of 10, and their ability to remain quit for good as 6.0, on average. Ex-smokers reported very high levels of confidence in their ability to continue to not smoke, with a mean of 9.8 out of 10.

Most current smokers had made multiple quit attempts (3.5, on average), and encouragingly the proportion who had never tried to quit continued to decrease from 24 per cent in 2005 to 18 per cent in 2009. Ex-smokers had made an average of 2.6 quit attempts, prior to quitting successfully, with 28 per cent reporting making no quit attempts prior to this. The average time since a current smoker's last quit attempt was 3.6 years. Among ex-smokers and current smokers, 37 per cent had attempted to (or actually) quit within the last 12 months. Among current smokers who had tried to quit, the median duration of their last quit attempt was five weeks. Over half (57%) of those who had tried to, or actually, quit reported planning their last quit attempt prior to the day they quit, while almost a third reported not planning at all.

Only 10 per cent of the sample had 'high' or 'very high' nicotine dependence, based on the Fagerstrom Test, which was unchanged since 2007. One component of the Fagerstrom measure was how soon after waking one's first cigarette was smoked, with almost a fifth (18%) doing so within five minutes of waking.

Quit motivations and aids

Health reasons remained the most commonly cited motivation for considering (or actually) quitting smoking among smokers and ex-smokers. Yet, in 2009, there were fewer unprompted mentions of health reasons among those not considering quitting and among ex-smokers. The first of these shifts may be the result of some 'non-considerers' moving into the 'considering' category as a result of education regarding health consequences. In addition, smokers currently considering quitting were more likely to mention cost in 2009 (31%, vs 20% in 2005). A new series of prompted questions, added this wave, highlighted health, fitness, cost and family/children-related reasons as key motivators among smokers, whether currently considering quitting or not. Among ex-smokers, 'not enjoying it anymore' was commonly mentioned, whereas cost received fewer prompted mentions. Generally speaking, respondents in households containing children were more likely to mention at least one family/children-related motivation.

In 2009, smokers and ex-smokers were asked to rate their agreement with a number of statements about quitting. Overall, respondents showed high levels of confidence in GPs or other health professionals, with two thirds believing their advice would increase one's chance of quitting compared with quitting on your own. However, opinions were mixed in relation to Nicotine Replacement Therapy (NRT) and prescribed medications, specifically, with high levels of uncertainty regarding their efficacy. Over two thirds agreed that, if you really want to quit, you'll succeed just as well on your own as with help, yet net agreement was lower for the notion that willpower alone was sufficient. Ex-smokers were more likely than smokers to perceive willpower as sufficient, and smokers were more likely than ex-smokers to agree that prescribed medications would increase their chances of quitting successfully.

In 2009, another new set of quitting attitude statements was presented to smokers only. Most smokers felt they knew where to get help to quit smoking (89% agreement). While four in five reported that they 'want to quit smoking and stay quit', three in five reported that they 'know they should quit smoking but don't want to', perhaps suggesting a difference between longterm and short-term goals or expectations.

Increasing use of 'cutting down', switching to 'low tar' cigarettes and consultation with GPs or health professionals warrant closer consideration of the relative efficacy of these methods

When asked to name any particular support services, assistance or methods available to help smokers quit, 59 per cent showed unprompted awareness of Quitline. Compared with previous waves, significantly fewer smokers (40%) showed unprompted awareness of NRT, whereas more smokers mentioned GPs/health professionals or prescription medication (both 16%).

'Cold turkey' remains the most common strategy used on any quit attempt (76%), followed by cutting down the amount smoked (66%), then NRT (44%), and changing to low tar tobacco (36%). With regard to methods used on one's most recent quit attempt, 'cold turkey' was again common (recovering part of the decline observed in 2007). Since last wave, significant increases were observed in cutting down the amount smoked (26% to 52%), as well as changing to low tar products, consulting a GP, health professional or pharmacist, and prescription medication. Some of these shifts may warrant further exploration with regard to the efficacy of these strategies.

Prompted awareness of Quitline among smokers and ex-smokers remained high (93%), although this was a decrease of 2 per cent since last wave. Again, just over one in ten current smokers had called Quitline at some stage. Most people who had heard of Quitline agreed that it can help people prepare to quit and can provide tailored advice. While agreement with both statements decreased in 2009, no decrease was observed among those who had actually called Quitline. Agreement was significantly lower for the notion that people at Quitline are supportive and understanding (46%) although, again, no decrease was observed among prior callers. In addition, prior callers were more likely than non-callers to disagree that Quitline was mainly for people who had tried to quit and failed. In a new question, three in five smokers who were aware of Quitline agreed that it would improve their chances of quitting, compared to quitting on their own. Nevertheless, a quarter were unsure of Quitline's efficacy.

In 2009, just over one in ten current smokers had tried the prescription medication 'Champix' and, of those remaining, 29 per cent reported being 'likely' or 'very likely' to do so when quitting. For two in five smokers, their GP discussed their smoking and advised them to quit on their last visit. In addition, more than three in five were open to seeking advice from their doctor about quitting.

Health effects of smoking

Smokers were more likely to acknowledge the risks associated with smoking, with 81 per cent believing that they definitely or probably will become seriously ill if they continue to smoke. This indicates a trend towards greater personalisation of the health consequences of smoking. In addition, 86 per cent of smokers felt their smoking has definitely or probably already done harm to their body, as do 62 per cent of ex-smokers. The most common illness people were concerned about getting as a result of smoking was lung cancer (56%), followed by emphysema (26%).

Almost half reported that images and health warnings on cigarette packs had no impact on them, yet 31 per cent said the warnings made them think about quitting, and 13 per cent said they made them try to quit.

Attitudes towards smoking

Fewer smokers compared to previous waves (approximately half) felt they smoke when they can, rather than when they want to, which may reflect behavioural or attitudinal adaptation to smoking restrictions. An overwhelming majority of smokers (83%) said that, if they had their time over again, they would never have started smoking. Smokers were more likely to acknowledge feeling 'uncomfortable'; smoking in front of their family than in public places in general. Fewer admitted that they felt 'embarrassed' to be a smoker, compared with the statements above.

Attitudes towards passive smoking

In 2009, respondents were slightly more likely to see passive smoking as harmless, yet the vast majority (83%) still consider it to be harmful (particularly non-smokers). More than three quarters of smokers acknowledged that their smoking affects the health of others around them, including children, indicating a reasonable level of understanding about the impact of passive smoking.

There continued to be near-universal support for smoking restrictions in playgrounds (94%), as well as strong support for smokefree sports stadiums (86%) and, to a lesser extent, beaches (74%). However, support for smokefree beaches had increased since 2006. While non-smokers were generally more supportive of smokefree settings, each statement still received majority support among smokers.

Attitudes towards the retail environment

There was strong community support for legislative action in relation to licensing of tobacco retail outlets (91%), cigarette ingredient disclosure at the point of sale (91%), cigarette displays being out of sight of children (90%), and retailers requiring proof of age for anyone who appears to be under 25 years (81%). As above, while support was strongest among non-smokers, majority support was evident among smokers for all measures.

More than two thirds support a price increase to discourage children and young people from smoking, regardless of whether the statement referred to a $3 increase or left the dollar amount unspecified. Support was stronger among non-smokers, as expected. When smokers were asked about the potential impact of a $3 price increase, 21 per cent thought they would quit, 29 per cent said they would cut down, and 40 per cent thought it would have no impact on their behaviour. Daily smokers were more likely than other smokers to report that the price increase would have an impact on them.

Almost three in five respondents support regulation to ensure tobacco products are sold in generic packaging, although the reasonable level of uncertainty (13%) may reflect a lack of understanding about this measure. Just over a quarter agreed that lighter-coloured packaging indicates that cigarettes are less harmful. Smokers were more aware than non-smokers that lighter colours do not necessarily indicate lower harm.

Conclusions

The increasing proportion of those who have never smoked weekly and for who have never tried smoking at all suggests an important prevention outcome. With an increasing proportion considering quitting and having tried to quit - yet exhibiting a similar nicotine dependence profile - it seems that the suggestion of a 'hard-core group' of committed smokers continues to be unjustified, as more smokers are more amenable to quitting than before. While large numbers of smokers understand the health risks of smoking and want to quit, doing so is still seen as relatively difficult (despite some gains).

Despite the dominance of health motivations, the cost of cigarettes continues to gain importance among those considering quitting, which may be heightened given the current economic climate. The research suggests that immediate calls to action, and appropriate quit resources and support, would be most effective. While 'cold turkey' remains popular, increasing use of 'cutting down', switching to 'low tar' cigarettes and consultation with GPs or health professionals (often involving prescription medication) warrant closer consideration of the relative efficacy of these methods. Awareness and usage of Quitline remains steady, although certain positive perceptions of the service appear to be deteriorating among those who have never called.

Given that most current smokers have made multiple 'unsuccessful' attempts to quit, an emphasis needs to be placed on remaining quit. This could be achieved through increasing self efficacy both through willpower and a smoker's confidence in their ability to quit.

The impulse purchase effect of cigarette displays, and high levels of community support for keeping cigarettes out of sight of children, add weight to moves to restrict point-of-sale displays. Community support was also high for making particular public settings smokefree, as well as various other measures within the retail environment (including licensing, ingredient disclosure, proof-of-age requirements, increased prices and generic packaging).