Relation among stage of change, demographic characteristics, smoking history, and nicotine dependence in an adult German population

Abstract

Background

The aim of this study was to provide evidence about the individual intention to quit smoking and accompanying characteristics in a country with a low amount of tobacco control (TC) provisions.

Methods

This study used a random sample of the population aged 18–64 in a German area to make a quantitative estimation of the stages of change to quit smoking among current smokers who had at least one quit attempt (n = 1075).

Results

The rate of those who did not intend to stop smoking (precontemplators) was 76.4%, that of those who intended to quit during the next 6 months (contemplators) was 17.0%, and that of those who intended to quit during the next 4 weeks was 6.6%. The three groups did not differ according to gender or age. Of those who had at least 16 years of education, more were contemplators than were those with fewer years of education. Among those who had somatic complaints or nausea from smoking, who had their first cigarette within 1 h or less after awakening, and who had more quit attempts, more were in the contemplation or preparation stage.

Conclusions

Nicotine dependence may add to contemplating about quitting. The precontemplation rate was substantially higher than in samples from nations or states which show a large amount of TC provisions.

Introduction

A valuable part in the description of the intention to quit smoking is a core construct of the transtheoretical model (TTM) of behavior change [1]: the transition from not planning to quit (precontemplation stage) to intending to quit (contemplation stage), and further on intending to quit in the near future, accompanied by typically having taken some action in the past, e.g., one quit attempt within the past year (preparation stage; [1], [2]). The stages have been replicated in many studies [1], [3], and stage-based interventions have been shown to be effective [4], although the concept of analyzing behavior change by stages has led to considerable debate (e.g., [3]) and aspects of the TTM have been criticized [5], [6], [7], [8], [9], [10]. But all together, evidence for the validity of the TTM with respect to smoking is strong [11]. Stage distributions are well-documented for U.S. populations; however, it has been concluded from the evidence existing so far that more studies are particularly needed for non-U.S. populations [11].

Four studies revealed evidence about the stages according to three criteria: representative sample, at least 1000 smokers included, adult age range included 18–64 year olds (Table 1). Among current smokers, precontemplation rates were rather consistent in three of the samples (36.0 to 42.3%) as were rates of individuals in the contemplation or preparation stage [12], [13]. In California, a somewhat lower precontemplation rate was found than in the other samples. In the countries of all four studies, the proportions of current smokers were 25.7% or lower among the population aged 18 or older at the time when the samples were investigated [14].

With respect to the stages of change, only few data about socioeconomic characteristics exist, and even less is known about the smoking behavior itself, such as the number of cigarettes smoked per day, nicotine dependence, and treatment seeking in smoking populations with respect to the stages of change. The distribution within demographic subgroups of smokers in population samples is shown by only one study. According to three samples that were analyzed, there are slightly higher rates of smokers in the preparation stage among males than females [12]. In one of the three samples, there were slightly more precontemplators among smokers at the age of 45 or above than among younger smokers. Compared to people with 12 years or less of education, individuals with more than 12 years of education showed higher rates of contemplation in all three samples and higher rates of contemplation as well as preparation in two of the samples [12].

In contrast to the results from the United States and Australia, hardly any stage distributions have been published from random population samples in other nations. Among smokers in European countries high rates of precontemplation have been revealed, e.g., 74% in a regional population sample aged 18–70 and 72% in a university member sample (82% students) from Switzerland [15] and 59% in a sample recruited by newspaper advertisements in the Netherlands [16]. The large group of precontemplators was subtyped according to long-term plans to quit or never wanting to quit [17]. A cohort study including a representative adult population sample in Germany revealed that there was no substantial increase over time in the rates of contemplation and preparation rates. Over a 6-month period, 78.4% remained in the same stage of change, 11.7% progressed, and 9.9% regressed at least one stage [18]. One factor which may add to explaining the difference between the United States and Australia on the one hand and European nations on the other may be the degree to which the countries provide efforts of tobacco control (TC). Australia and the United States, in particular California, where the highest rates of smokers in contemplation or preparation stage were revealed, show strong TC activities [19], [20], [21], [22]. The strength of TC activities may be estimated based on legislative regulations of tobacco sales, marketing, and use related to tobacco smoking and health [21], [22], [23], [24], [25], [26].

In Germany, there is only extremely few TC provisions [22], [24], [27], [28], even compared to other European nations. This country is one of the two with the lowest tax on the consumer price for cigarettes (69%; [29]), and it ranks second lowest in the desire to quit smoking and third lowest in quit attempts among the populations [30]. The quit rate in Germany was 35.0% in 1989 and 37.4% in 1995. The rate of current smokers aged 18 or older was estimated to be 31.8% in 1989 and 29.2% in 1995, based on the microcensus carried out in 1989 and 1995. This survey included a sample representative of the German population (n = 67,209 ever smokers aged 18 or older in 1989 and n = 87,440 in 1995; [31]). Current smokers were those individuals who answered “Yes” to the question of whether s/he was currently smoking. In contrast to that, the quit rate in the United States in 1991 was 48.5% [14], and the rate of current smokers aged 18 or older was 24.9% according to the National Health Interview Survey (NHIS) 1991 in Rhode Island and 25.7% according to the NHIS 1991 in the United States [14]. In Australia, the rate of current smokers aged 16 or older in 1995 was 27% in males and 23% in females, and the quit rate was 54% in males and 48% in females [32].

All together, we lack information from well-designed studies using populations which differ in TC provisions and smoker rates from the countries where most of the data have been collected so far. Therefore, the goal of this paper is to provide evidence about the distribution of the stages of change by general demographic characteristics, smoking behavior and history, and nicotine dependence criteria among a random population sample in northern Germany.