Introduction
Why do smokers stop smoking? How do motivations to quit vary over time? Do individuals with different demographic and socioeconomic characteristics stop smoking for different reasons? Answers to these questions may facilitate the understanding of the effectiveness of smoking cessation programs, the additional interventions that are required, and the strategies that should be developed to encourage current smokers and key-target subpopulations to stop smoking.
A number of studies, mainly from North America, have been carried out to examine reasons for quitting smoking (Gilpin et al., 1992; Halpern and Warner, 1993; Hymowitz et al., 1997; Grotvedt and Stavem, 2005; McCaul et al., 2006). In the studies using data from retrospective reports of ex-smokers, health reasons, including both smoking-related symptoms (present health) and the desire to avoid future illness (future health), were by far the most frequently mentioned motives reported by successful quitters, followed by social reasons (such as pressure from family or friends, advice from a doctor, setting a good example, concern over the effect of secondhand smoke on others), and, less frequently, economic cost (McCaul et al., 2006). These studies, however, were based on a relatively limited number of participants, only five studies (three from the USA, one from Norway, and one from Italy) having a sample size exceeding 1000 ex-smokers (La Vecchia et al., 1991; Gilpin et al., 1992; Halpern and Warner, 1993; Hymowitz et al., 1997; Grotvedt and Stavem, 2005). In other cross-sectional studies on motives for a (hypothetical) quit attempt of current smokers (McCaul et al., 2006; Baha and Le Faou, 2010; Pisinger et al., 2011) and a few longitudinal studies based on current smokers registered in cessation services (Barnes et al., 1985; McCaul et al., 2006; Young et al., 2010), the reasons for quitting did not necessarily result in successful smoking cessation (Hymowitz et al., 1997; McCaul et al., 2006).
To our knowledge, only three studies have provided data on ex-smokers in Europe (La Vecchia et al., 1991; Grotvedt and Stavem, 2005; Sieminska et al., 2008). A mail-based survey, conducted in Norway on 1715 ex-smokers, showed that the main reason to quit smoking was concern for health (25% for men and women combined), followed by a dislike of addiction (13.3%), improving physical fitness (10.8%), and economic cost (6.3%) (Grotvedt and Stavem, 2005). In a Polish survey based on 385 ex-smokers and 233 current smokers, among former smokers, 52% reported health concerns as the reason for quitting, 37% reported personal health problems, 13% reported quitting on the recommendation of physicians, and 11% reported quitting because of the economic cost (Sieminska et al., 2008). In Italy, an early study showed that, in 1983, ∼50% of ex-smokers reported present health conditions as the main reason for quitting, 30% reported concern for future health, and 1% the cost of cigarettes. In 1986–1987, motivations to quit remained almost constant, but concerns for future health increased to 38% (La Vecchia et al., 1991).
It is important to examine the reasons behind successful smoking abstinence in Italy, a country with an advanced stage of the tobacco epidemic (Gallus et al., 2011a), but with a limited implementation of strategies for smoking cessation (Joossens and Raw, 2011). Well-informed public health interventions to promote smoking cessation should include an understanding of the motivations of successful quitters for quitting cigarette smoking. Thus, the present article, based on a uniquely large dataset of ex-smokers, examines the reasons for quitting smoking in a representative sample of the adult population in Italy.
Methods
We examined data from six Italian face-to-face, computer-assisted personal in-house interview surveys on smoking conducted annually in 2005–2010 by DOXA, the Italian branch of the Gallup International Association (Gallus et al., 2011a, 2011b, 2011c). For each survey, the sample was representative of the general Italian population aged 15 years or older in terms of age, sex, geographic area, and socioeconomic characteristics. The sample size for each survey included more than 3000 participants. The present study includes a combined sample of 3075 ex-smokers.
The six surveys used the same sampling criteria: the participants were selected through a representative multistage sampling of individuals from 152 municipalities in all of the 20 Italian regions. In the municipalities considered, individuals were randomly sampled from electoral rolls, within strata defined by sex and age group. Whenever the selected participants were unavailable, they were replaced by selecting among neighbors (living in the same floor/building/street) within the same sex and age group. Adolescents aged 15–17 years, whose names are not included in the electoral lists, were chosen by means of a ‘quota’ method (by sex and exact age) using the same approach. Statistical weights were used to ensure the representativeness of each sample. For a more detailed description of the sampling methodology, see Gallus et al. (2011b).
Ad-hoc-trained interviewers collected data using a structured questionnaire. Besides general information on the sociodemographic characteristics, data were collected on smoking habits, including smoking status (never/ex-/current smoker) and number of cigarettes smoked per day. Ever smokers were participants who smoked 100 or more cigarettes in their lifetime. Ex-smokers were participants who had quit smoking for a minimum of 1 year. Information on age at stopping smoking was also collected. Ex-smokers were asked to provide the single main reason for why they stopped smoking, yielding an open-ended response. Interviewers then categorized the answers into the following predetermined choices: (a) health reasons (to be interpreted in the Italian version as ‘current health symptom/problem/condition’, i.e. ‘present health’); (b) recommended by the general practitioner/physician; (c) awareness of the harmful effects of smoking (i.e. ‘future health’); (d) smoking ban (at work place, public places, etc.); (e) pregnancy, child birth; (f) economic cost of cigarettes, to save money; (g) imposed by the partner or the family; (h) loss of pleasure or desire to smoke; and (i) other reasons.
The odds ratios (ORs) and corresponding 95% confidence intervals for quitting smoking because of a specific reason versus any other reasons, according to selected characteristics, were calculated using unconditional logistic regression models after adjustment for age, sex, geographic area, education, marital status, number of cigarettes per day, year of quitting smoking, and survey year.
Results
The present analyses are based on a total of 3075 ex-smokers (1936 men and 1139 women), with a mean age of 55.1±16.9 years (57.1±16.4 for men and 51.7±17.1 for women) and a mean abstinence of 13.9±12.2 years (14.8±12.0 for men and 12.5±12.3 for women).
Table 1 shows the percent distribution of ex-smokers according to their main reasons for quitting smoking, overall and by sex. Present health was the most frequently reported reason for smoking cessation (43.2%), followed by future health (31.9%), child birth (6.3%), imposition by the partner/family (4.0%), physician’s recommendation (3.7%), economic cost (3.0%), loss of pleasure (2.8%), and smoking bans (0.5%). Among 499 ex-smokers who quit after the implementation of the comprehensive legislation regulating smoking in public places and all workplaces, which came into force on the 10 January 2005, only 1.1% (five participants) reported the smoking ban as the main reason for quitting. Men more frequently reported present and future health and economic cost as the main reasons for quitting, whereas women more frequently reported child birth, imposition by the partner/family, and loss of pleasure.
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Table 1: Percent distribution of ex-smokers according to the reasons for quitting smoking, overall and by sex (Italy, 2005–2010)
Table 2 shows the ORs of the five most prevalent reasons to quit versus any other reasons according to selected characteristics. On multivariate analysis, compared with men, women less frequently reported present health (OR=0.7), future health (OR=0.7) and economic cost (OR=0.5), and more frequently reported child birth (OR=11.4) and imposition by the partner/family (OR=2.0). The ORs increased linearly with age for present health (OR=4.7 for ≥65 vs. 15–44 years; P<0.001) and decreased with age for future health (OR=0.6; P<0.001), child birth (OR=0.0; P<0.001), imposition by partners/family (OR=0.4; P=0.006), and economic cost (OR=0.3; P=0.004). Compared with northern Italy, individuals from central and southern Italy more frequently reported present health (OR=1.4 for central and 1.2 for southern Italy) as the main reason for quitting. The ORs increased with education for future health (OR=1.5 for high vs. low; P<0.001), and decreased with education for present health (OR=0.8; P<0.001) and cost (OR=0.5; P=0.029). Compared with married ex-smokers, single individuals more frequently reported present health (OR=1.4) and cost (OR=2.2), and less frequently child birth or imposition by partners/family. Widowed and divorced or separated individuals more frequently reported economic cost (OR=3.1 for widowed and 3.7 for divorced/separated). No relationship was evident with the number of cigarettes smoked per day. With respect to smoking duration, a direct trend was observed for present health (OR=1.6 for ≥30 vs. <15 years; P=0.003) and recommendations by physicians (OR=5.8; P<0.001), and an inverse trend for pregnancy or child birth (OR=0.1; P<0.001) and imposition by the partner/family (OR=0.1; P<0.001). The ORs increased with year of quitting for present health (OR=1.8 for ≥2000 vs. <1990; P<0.001), and decreased with year of quitting for future health (OR=0.8; P=0.080) and child birth (OR=0.2; P<0.001). A direct trend was evident according to the survey year for future health (OR=1.3 for 2010 vs. 2005; P=0.002) and for economic cost (OR=2.2; P=0.042), and an inverse trend was found for present health (OR=0.7; P=0.002).
Table 2: Distribution of 3075 ex-smokers in terms of the main reasons for quitting smoking, according to selected characteristics (Italy 2005–2010)
Discussion
This is one of the largest studies worldwide aimed at examining the motivations to quit smoking of ex-smokers, and the largest in Europe.
In this Italian population, almost one out of two male and more than one out of three female ex-smokers reported present health (i.e. current health condition) as their main reason for quitting smoking. As expected, former smokers who quit as a consequence of health problems had characteristics that indicated poor health, being more frequently men, of older age and single, with a relatively low education, and reporting to have smoked for a longer period and a greater number of cigarettes per day. Given the large proportion of former smokers who quit as a consequence of health problems, and presumably smoking-related conditions, the entire group of ex-smokers in Italy represents a population at a high risk of mortality or morbidity for smoking-attributable chronic conditions, including cancers. This explains the systematically high relative risks of cancer for former smokers with a short time since quitting found in some Italian case–control studies analyzing the effect of smoking cessation on the risk of developing cancer (Zambon et al., 2000; Altieri et al., 2002). Therefore, in Italy as well as in other countries where smoking cessation strategies are not well implemented, the poor health of former smokers should be taken into account in the interpretation of findings of smoking cessation on the risk of developing chronic conditions, as the favorable effects of preventive quitting smoking (Peto et al., 2000; Doll et al., 2004; Bosetti et al., 2008) would be substantially underestimated.
The second most frequent reason is awareness of the risks of smoking, being reported by almost one out of three ex-smokers. Surprisingly, antismoking information campaigns implemented in Italy over the last decade, including health warnings on packs of tobacco products, available in Italy since 2003, and community debates because of the implementation of the smoke-free legislation, which came into force in 2005 in Italy (Gallus et al., 2006), did not appear to motivate smokers sufficiently to quit. In fact, the multivariate analysis shows that those quitting before 1990 more frequently quit because of concern over future health than ex-smokers quitting after 2000. More importantly, the proportion of ex-smokers quitting because of concern over future health is similar to that in 1983 and lower than that in 1986–1987 (38%) (La Vecchia et al., 1991). In contrast to our findings, in most previous studies carried out in countries where strategies for smoking cessation are better implemented than in Italy, including the USA (Halpern and Warner, 1993; McCaul et al., 2006) and Norway (Grotvedt and Stavem, 2005), the proportion of ex-smokers who reported to have quit smoking because of concern over future health exceeded that of ex-smokers reporting to have quit for concerns about present health. Given that concern about the health risks associated with smoking can promote self-protective health behaviors, motivating current smokers to abandon the habit (Dijkstra and Brosschot, 2003), it is clear that the dissemination of knowledge of harmful effects of smoking may convince smokers that ‘smoking prevention is better than cure’. Thus, antitobacco mass-media campaigns, whose effectiveness in changing smoking behavior in adults has been shown (Bala et al., 2008), should be further implemented in Italy, as to date, this strategy has been used only sporadically. Moreover, the inclusion of pictorial images on cigarette packs is recommended, as larger warnings with pictures may be significantly more effective in informing smokers than smaller, text-only messages (Hammond, 2011).
Health professionals can play a key role in motivating smokers to quit (Prokhorov et al., 2010), especially as the majority of smokers have inadequate qualitative information on the nature and the severity of the effects of smoking on their health (Ayanian and Cleary, 1999; Weinstein et al., 2004). However, we found that only a small proportion of ex-smokers quit as a consequence of recommendations by physicians. This is in agreement with a previous study, which showed that, in Italy, physicians rarely advise smokers to quit (Ferketich et al., 2008). Therefore, antitobacco strategies should include methods for physicians to assist smokers to quit during any patient–provider encounter, including connecting private physician offices to a country-level quit-line (Bentz et al., 2006), providing smoking cessation training to physicians (Prokhorov et al., 2010), and coverage of pharmacological support for smoking cessation by the National Health Service, which is still not reimbursed in Italy to date (Ferketich et al., 2009; Gallus et al., 2009; Joossens and Raw, 2011).
We found that women are more likely to quit because of family-related factors, including pregnancy or child birth and pressure from the partner or the family, as compared with men. This suggests that smoking cessation programs should focus on providing more information on the effects of secondhand smoke during pregnancy and postpartum, especially for males. Thus, antismoking campaigns to motivate quitting attempts should emphasize the benefit of smoking cessation both for personal health and for the health of others (social concerns) (McCaul et al., 2006).
Despite the evidence that increasing cigarette price/taxation is an effective strategy to promote cessation among current users (Chaloupka et al., 2011), only 3% of quitters stopped primarily because of the economic cost. This proportion is higher than with that reported in the 1990s (La Vecchia et al., 1991), but to our knowledge is the lowest when compared with at least six other studies, allowing for one single response, carried out in North America, Australia, and Norway, where economic cost was cited as the main reason to quit by 6–27% of ex-smokers (Grotvedt and Stavem, 2005; McCaul et al., 2006). This indicates the limited implementation of taxation as an antitobacco strategy in Italy (Joossens and Raw, 2011). A study analyzing data on cigarette sales for three decades in Italy confirmed the effectiveness of an increase in taxation/price as a strategy to reduce smoking prevalence and consumption. In fact, an increase by 10% in the cigarette price resulted in a decrease in total cigarette consumption by 4.3% and a decrease in smoking prevalence by 3% (Gallus et al., 2003). Thus, cigarette prices in Italy are not sufficiently high to reach a high level of efficacy for smoking cessation. Nevertheless, the odds of reporting economic cost as the main motivation to quit were higher in the youngest age group as compared with their older counterparts, and price has a greater impact among young people, who usually have more limited economic resources (Chaloupka et al., 2011).
Only a negligible proportion of quitters (1%) after 2005 reported the smoking ban as the main reason for quitting.
The limitations of our study include those inherent to its cross-sectional design. Moreover, we could not examine the multidimensional aspects of motivations to stop smoking. Although several factors play roles in influencing smoking cessation, our questionnaire allowed the respondents to choose one single reason for quitting smoking (McCaul et al., 2006). This is because we aimed to focus on the most important reason that motivated ex-smokers to stop. Another important limitation was the retrospective nature of the questions included in the survey, which could have led to a recall bias. In fact, respondents may had difficulties in precisely recalling their motives for smoking cessation (McCaul et al., 2006). Therefore, the fact that a few ex-smokers reported quitting mainly because of smoking bans but actually quit smoking before 2005 (i.e. before the smoking ban came into force) indicates that a recall bias may have been present in our dataset. Another limitation of the study is the lack of detailed information on cessation because of present health conditions. Thus, our data did not allow us to differentiate between ex-smokers who quit only because of a few illness symptoms, including decreased lung function, cough, and sore throat, and those who quit because of severe health conditions.
The strengths of this study include the representativeness of the sample of the Italian adult population, the uniquely large dataset and the availability of several covariates, which allowed us to adjust estimates for a number of potential confounders. Another strength was the open-ended assessment of why ex-smokers quit, allowing us to obtain a wide range of possible responses, and also to distinguish concern over present health from future health as the main reason for quitting smoking. In contrast, most previous studies included present and future health together under a generic heading of ‘health reasons’ (McCaul et al., 2006). In fact, these two motivations are conceptually different, ‘present health’ representing a cause for smoking cessation and ‘future health’ representing a preventive choice. Finally, the choice to consider why smokers quit in ex-smokers rather than in current smokers who reported attempts to stop should be considered a strength of the study. In fact, in studies based on current smokers we have no assurance that the reasons given predict future actual quitting (McCaul et al., 2006).
Conclusion
The findings of the present study indicate the current scenario in Italy: (i) smokers mainly quit as a result of tobacco-related health conditions; (ii) only a minority of ex-smokers quit to avoid future illness; (iii) health providers do not adequately persuade smokers to quit or give advice on the harmful effects of smoking; and (iv) cigarette prices are not sufficiently high to discourage people from continuing to smoke. Thus, the implementation of the following tobacco control strategies is urgently required in Italy: (i) antitobacco mass-media campaigns aimed at informing smokers of the harmful effects of smoking and secondhand smoke; (ii) inclusion of pictorial images on cigarette packs; (iii) implementation of programs by physicians to assist smokers to quit, including reimbursement for smoking cessation pharmacological support; and (iv) increase in the real price/taxation of tobacco products.
Acknowledgements
This work was carried out with the support of the Italian Ministry of Health, the Italian League Against Cancer and the Italian Association for Cancer Research (AIRC No. 10068). The Italian Ministry of Health contributed financially towards the costs of data collection. LILT and AIRC grants partially supported research work conducted by the Department of Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri.
Conflicts of interest
There are no conflicts of interest.
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