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Despite the well-known health risks, smoking is still highly prevalent worldwide. Greece has the highest level of adult smoking rate (40%) across the European Union. We investigated gender and socio-economic differences in daily smoking and smoking cessation among Greek adults. We conducted a cross-sectional survey between October and November 2009 in 434 adults residing in a Greek rural area. Data were collected with the use of the World Health Organization Global Adult Tobacco Survey (WHO GATS) Core Questionnaire. Respondents were classified into smokers (if they had smoked at least 100 cigarettes in their lifetime and continued to smoke) or non-smokers. Overall, 58.1% (n=252) were smokers (58.5% male, n=127 and 57.8% female, n=125); 51.2% (n=222) were younger than 18 years-old when they started smoking. Men tended to start smoking at a younger age, to smoke more cigarettes/day and to have smoked a greater average of cigarettes during the last 5 days. Overall, 82.5% of smokers attempted to stop smoking a year prior to the study, with women having a greater difficulty in quitting smoking. The main source of information on smoking was the mass media (73.5%) and books (53.7%), whereas doctors and other health professionals were the least listed source of relative information (27.7 and 8.1%, respectively). Smoking rates among Greek adults were high, but a considerable number of individuals who smoked, wished to quit and had attempted to do so. Smoking cessation clinics are not perceived as a valuable support in quitting effort.
Smoking is a major preventable cause of disease. Despite the well-known risk to health, smoking is still highly prevalent worldwide. Within the European Union (EU) the proportion of daily smokers among the adult population varies greatly from around 18% in Sweden to 42% in Greece, whereas the average for the EU countries was 32% [
Although the proportion of European adults who smoke has been in steady decrease for more than 20 years for both genders, research evidence stably places Greece at the top among the EU member states in tobacco consumption [
In Greece, there is a slight decrease in tobacco consumption among men but a notable increase among women, which is more evident in stage 3 of the worldwide tobacco epidemic model [
There are outstanding differences in smoking prevalence between men and women worldwide. In countries like Japan and Pakistan there are 4 times as many men smokers as women, whereas in the United States (US), Europe and Canada there are as many women smokers as men [
In order to fight the global tobacco epidemic and safeguard the right of people to the highest standard of health, the World Health Organization (WHO) Framework Convention on Tobacco Control entered into force in February 2005. Since then, it has become one of the most widely embraced treaties in the history of the United Nations with more than 170 countries (Greece ratified the treaty in 2006). It is an evidence-based treaty and WHO’s most important tobacco control tool, which provides legal dimensions for international health cooperation and sets high standards for compliance.
The aim of this study was to investigate differences in daily smoking and smoking cessation among adult residents in a rural area in Greece.
The survey questions were taken from the Global Adult Tobacco Survey (GATS) questionnaire [
The study protocol was reviewed and approved by the local Ethics Committee.
A total of 434 adults residing in a rural area in Northern Greece were evaluated. Data were collected using a quantitative approach. A cross-sectional survey was conducted in the city of Serres in Northern Greece (part of the Hellenic Network of Health Promotion Hospitals [HHPH]) with about 200,916 residents (2001 census) in 22 boroughs. A self-reported GATS questionnaire was distributed to inhabitants of different age, socioeconomic and employment status living in the broader area of the selected county. The sample comprised of 216 (49.8%) female and 218 (50.2%) male participants. There was a 434 out of 500 (86.8%) response rate to the questionnaires.
Information on demographic, socioeconomic characteristics and smoking behaviour was obtained by self-administered questionnaires. For data analysis purposes responders were classified into 2 groups: a) smokers, and, b) non-smokers. The classification was employed by the WHO guidelines [
Three questions assessed readiness to quit smoking; “Do you want to quit smoking now?”, “Have you tried to quit using tobacco within the last 12 months?” and “Considering your last attempt to quit smoking, for how long did you not use tobacco?” following the stages of change model [
Demographic and socioeconomic characteristics included in this analysis were age groups (15-19, 20-24, 25-44, 45-64 and 65+ years), gender (male, female), ethnic groups, education (elementary school, secondary school, university degree and post graduated studies), marital status (married, living with an intimate partner, living alone, divorced, widowed), annual income and employment status (full time employed, part time employed, unemployed, never employed, retired, agricultural occupation).
The questionnaire consisted of 3 sections with 37 questions in total. The first section included 24 questions about smoking behaviour, the use of nicotine products, such as cigarettes, cigars or nicotine patches in the last 5 days and quitting behaviour. The second section contained 6 scaled questions about participant knowledge of smoking-related diseases and second hand smoking-related diseases, smoking prevention and control legislation, smoking cessation attempts, information received and sources of information on risks in health from nicotine. The third section contained 7 demographic questions (age, gender, ethnicity, marital status, educational level, employment status and annual income). To ensure the quality of data collection, a quality control team examined 10% of the questionnaires.
Statistical analyses were performed using the SPSS version 13.0 software package (SPSS Inc., Chicago, USA). Values were expressed as mean ± SD or as percentage. Differences in the independent variables (age, gender, educational level, marital status, ethnic group, annual income and employment status) between groups according to the dependent variables: a) smoking status, and, b) number of cigarettes smoked were analyzed by Student’s t test, Chi-square test and one-way ANOVA. Correlations between the parameters were determined by Pearson r or Spearman Rho correlation analyses. All p values were two-tailed with significance defined as < 0.05.
Among smokers (n = 252, 58.1%), 47.3 % (n = 112) were moderate smokers, usually smoking less than a packet of cigarettes (<20 cigarettes) per day, 38.3% (n = 91) reported smoking 20 to 40 cigarettes/day and 14.3% (n = 34) smoked more than 40 cigarettes/day.
Cigarettes were the most preferred smoke product and more than 90% (n = 231) of responders smoked them, while the consumption of other tobacco products was marginal; only 3.8% (n = 9) of those interviewed smoked rollup cigarettes and 3.2% (n = 8) smoked cigars.
Responders were asked to rate 4 different statements dealing with beliefs about smoking, passive smoking and smoking in public places (Table
Attitudes to Smoking-Related Issues
n | Mean | SD | |
---|---|---|---|
“Do you thing that smoking is dangerous for your health?” | 434 | 4.60 | 0.65 |
“Do you think that cigarette smoke is harmful for the children?” | 434 | 4.73 | 0.53 |
“How dangerous secondhand smoking do you believe is?” | 434 | 4.24 | 0.71 |
“Are you in favor of banning smoking in public places (such as in restaurants, in buses, streetcars, and trains, in schools, on playgrounds, in gyms and sports arenas, in discos)?” | 434 | 3.90 | 1.27 |
1 = totally disagree, 5 = totally agree.
The majority of the participants were in favour of banning smoking in public places. In more detail, almost 90% of the people who had never smoked, as well as 90% of those who had stopped smoking were in favour of such measures compared with 50% of smokers. Current smokers were significantly less likely than non-smokers to believe smoking is harmful to health. A socio-demographic analysis revealed that support for smoking ban in public places is highest among men (73%, n = 158
The main source of information regarding smoking adverse health effects was mass media (73.5%, n = 319) and books (53.7%, n = 233), whereas medical doctors and other health professionals accounted only for 27.7% (n = 120) and 8.1% (n = 35), respectively. These findings reveal that physicians and other health care professionals are the least listed source of relative information suggesting a broader need for more professional information to tackle smoking. Approximately, 17% of the responders discussed the issue with friends or family members and 3.5% used other sources of information.
More than half of the participants in the survey were current smokers [206 (47.5%) smoked daily, whereas 46 (11%) smoked occasionally]. Approximately, one-fifth of the sample (n = 80, 18%) were former smokers and more than one-fifth (n = 100, 23%) had never smoked. One out of 2 were younger than 18 years old when they started smoking (51.2%), whereas only 0.9% started smoking at an age > 30 years.
An equal distribution of smoking prevalence was observed between women (n = 216, 50%) and men. The majority of the participants (n = 229, 53%) were married with children, aged 35-44 years (n = 142, 33%), holding a secondary educational level degree (n = 198, 46%), a full-time job (n = 196, 45%) and an annual income of 10,000-20,000 Euro. The sample was homogenous in terms of ethnicity.
With regards to the number of cigarettes smoked on a daily basis, there were differences in levels of consumption at various ages; 42.5% (n = 108) of responders aged between 20 to 64 years old smoked at least 20 cigarettes/day, whereas younger responders aged between 15-19 and elderly people over 65 years old smoked less than a packet of 20 cigarettes/day (6.4%, n = 15 and 1.1%, n = 5; p ns).
Significant gender differences were found with regard to the age of smoking initiation (mean age = 16.9 ± 3.5 and 18.4 ± 4.9 years for men and women, respectively; p = 0.002), the number of cigarettes smoked/day (22 ± 15 and 16 ± 11 cigarettes/day for men and women, respectively; p = 0.007) and the total number of cigarettes smoked the last 5 days preceding the study (102 ± 80 and 74 ± 56 cigarettes for men and women, respectively; p = 0.009).
No significant correlations were observed between the level of education, employment status/income and smoking behaviour in the study population.
There was a significant association between family status and the average number of cigarettes smoked/day, as well as the average number of cigarettes smoked within the last 5 days. Divorced participants (n = 11) had the highest cigarette consumption/day (34 ± 14) followed by married participants (n = 26; 20 ± 18), whereas single (n = 77) and married participants with children (n = 139) smoked fewer cigarettes (18 ± 12 and 18 ± 14 cigarettes for single and married participants with children, respectively; p = 0.025).
A marginally non-significant (p = 0.054) relationship was found between gender and the “smoking situation” of the responders. A woman was less likely to start smoking, since nearly 40% of women had never smoked (27.3%) or smoked occasionally (12.5%). On the other hand, women had a greater difficulty in quitting smoking compared with men (33.3
Interestingly, when smokers were asked if they wanted to cease smoking ‘within the next 6 months’, 40.8% stated that they wished to do so and 29.3% attempted to do so within a year prior to the study. Both smokers and ex-smokers identified future health issues as being key reasons for stopping followed by financial reasons (46.7%, n = 147 and 28.6%, n = 90, respectively). Quitting smoking for family reasons or due to social pressure were the least listed (3.2%, n = 10 and 6.3%, n = 20, respectively).
Women tended to start smoking at an older age (18.7 and 16.9 years for women and men respectively; p = 0.021) and men tended to smoke more cigarettes/day (22.4 and 16.3 cigarettes for men and women, respectively; p = 0.001). Men were more likely to use other nicotine products at a significantly higher level than women (0.44 and 0.17 for men and women, respectively; p = 0.018).
Finally, men have smoked an average of 105 cigarettes during the last 5 days; 30 more than the average women (p = 0.001).
The present study focused on smoking knowledge, attitudes and behaviour of adults in a Greek rural area. Furthermore, we examined how their knowledge and attitudes could affect their smoking behaviour and smoking cessation activity. Despite the fact that smoking rates within Europe follow a pattern of decline, in Greece smoking rates are high. In order to control the globalization of the tobacco epidemic, WHO adopted the Framework Convention on Tobacco Control, a treaty that entered into force on 27 February 2005, establishing international standards for antismoking measures after its ratification [
Although general smoking bans have proven effective in other European countries, resulting in considerable decreases in smoking rates, it is questionable whether it will have the same effect in Greece. Unfortunately, the smoking-free legislation imposed on 1 July 2009 in Greece has so far proven ineffective and is often violated, especially with regard to bars/clubs/restaurants. Furthermore, good weather conditions, which allow for outdoor entertainment such as open bars, clubs and restaurants, during long periods of the year, undermine the effectiveness of the ban. The finding that only 6.3% of the study participants would consider to stop smoking due to social pressure is indicative of how much smoking is socially accepted in Greece. To some extent, the fact that Greece is a tobacco producing country may explain why smoking is acceptable in many aspects of social life allowing persistence of this behaviour [
In the present study, smoking prevalence was very high (58.1%) and was equally distributed among men and women (58.5 and 57.8%, respectively). Of note, the National Plan for Smoking in Greece in 2008 reported that 46.8% of men and 29% of women smoke [
A representative survey (n = 9,030) conducted in Turkey in 2008 revealed substantially lower percentages of smoking prevalence (31.2 in total; 47.9 for men and 15.2% for women) [
In our study, women had greater difficulty in quitting, in agreement with previous data. In detail, recent meta-analyses of smoking cessation trials have demonstrated lower abstinence rates for women than men, regardless of whether individuals received group or individual counselling [
This study also demonstrated that 94% of the responders were aware of the adverse effects of smoking on health and that 40.8% wished to quit. Despite the fact that 29.3% attempted to quit smoking, their attempts were unsuccessful and only 4% asked for professional help. This is an important finding as there is considerable data that smoking cessation clinics have the highest impact and thus success rates in enabling individuals to quit [
Smoking is highly addictive. Smokers who try to give up may suffer from withdrawal symptoms including dizziness, cough, anxiety, restlessness, difficulty in concentrating and depression [
Another important finding was that a considerable number of responders were ready to quit ‘within the next 6 months’ (40.8%) or had attempted to quit smoking in the previous year (29.3%). From public health and health promoting perspective, these findings represent an expressed need that could be useful in the field of planning and implementing research-based and efficacious smoking cessation interventions [
Our findings should be taken into consideration for future planning of smoking cessation programmes. Smokers’ attitudes and beliefs are paramount in determining likelihood to quit. Educating individuals on the short- and long-term gains of smoking cessation will be beneficial. In this context, several studies have demonstrated an immediate significant reduction in the incidence of heart attacks in countries where smoking bans in public places have been introduced [
Interestingly, women tend to have a greater risk for coronary heart disease compared with men, but equal benefit from quitting [
In the present study, the majority of participants agreed that passive smoking is damaging to health, although smokers were less likely than non-smokers to support this statement. In addition, almost all participants strongly agreed that second hand smoking is harmful for children. Indeed, passive smoking is associated with increased morbidity and mortality in both genders and at all ages globally [
Several other findings have emerged from this study. Of particular interest is the low rating that smokers gave to advice received from doctors. These findings support those outlined by Nagle
This study has several limitations. The small sample size makes it difficult for the findings to be generalised. Future larger studies should be conducted in order to be representative of the total population. Furthermore, this study completely relied on self-report, which is a subjective measurement method to assess smoking status. The presence of objective measurements would have enhanced the validity of these findings. Therefore, results of this study should be interpreted with caution. Finally, cross-sectional surveys, along with all inherent problems of such a study design, provide measurements for the certain period of time and do not provide a cause-effect relationship.
Smoking rates among Greek adults were high, but a considerable number of individuals who smoked wished to quit. Furthermore, the majority of the responders (82.5%) had attempted to quit smoking a year prior to the study. However, among heavy smokers the majority was not ready to stop and also did not perceive smoking cessation clinics as a valuable support.
Overall, 58.1% were smokers (58.5% men and 57.8% women). Over half of the responders were younger than 18 years old when they started smoking. Men tended to start smoking at a younger age and to smoke more cigarettes/day than women. Women had a greater difficulty in quitting smoking compared with men. Because women started smoking later than men, this could have affected the exposure time to the harmful effects of smoking. Further-more, we cannot assess if starting at a later age may influence quit rates.
The main source of information on smoking was the mass media and books, whereas doctors and other health professionals were the least listed source of relative information. There is a need for a greater input from government with close liaison with public health advisors to dedicate greater resources to tackle the high smoking prevalence in Greece. This involves more directed education, genuine enforcement of public smoking bans and enabling easy access to smoking cessation clinics.
This study was conducted independently; no company or institution supported it financially. Some of the authors have given talks, attended conferences and participated in trials and advisory boards sponsored by various pharmaceutical companies. No professional writer was involved in the preparation of this review.
This paper was presented in part in the 17th International Conference on Health Promoting Hospitals on 6-8 May 2009, Crete, Greece.