Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys

Highlights

• We investigated 4 policy triggers for thinking about quitting smoking.

• We examined trends and socioeconomic differences in mentioning triggers.

• Cigarette price was the most common reported trigger to think about quitting.

• All triggers were mentioned more often by low/moderate than high socioeconomic status (SES) smokers.

• SES differences did not change significantly over time for most policy triggers.

Abstract

Introduction

The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

Methods

Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003–2013). France conducted three survey waves (n = 1420–1735), Germany three waves (n = 515–1515), The Netherlands seven waves (n = 1420–1668), Ireland three waves (n = 582–1071), Scotland two waves (n = 461–507), and the rest of the United Kingdom conducted seven survey waves (n = 861–1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

Results

Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

Conclusions

Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Introduction

Despite the implementation of multiple tobacco control policies and smoking cessation interventions in many countries, tobacco use remains the number one preventable cause of death and disease (WHO, 2012). Increasingly, the burden of tobacco use has become concentrated within low socioeconomic status (SES) groups (Giskes et al., 2005, Harper and Lynch, 2007, Hiscock et al., 2012a, Hiscock et al., 2012b, Hosseinpoor et al., 2012), and tobacco use has been found to account for a considerable proportion of the health inequalities as a function of SES. Thus, it is becoming increasingly important to understand what factors trigger quitting among low SES smokers to inform public health policies and programs that could increase quitting among those population groups for whom quitting is considerably more difficult (Hiscock et al., 2012a, Hiscock et al., 2012b).

Research has confirmed the basic theoretical notion that thinking about quitting is an essential prerequisite for attempting to quit (Caleyachetty et al., 2012, Fong et al., 2006). Specific environmental cues can be beneficial to trigger people's intentions to change their behavior, as described for example in the Health Belief Model (Rosenstock, 1974), Reasoned Action Approach (Fishbein and Ajzen, 2010), Social Cognitive Theory (Bandura, 1986), and Protection Motivation Theory (Rogers and Prentice-Dunn, 1997). A policy or change in policy could be such a trigger. For example, the implementation of smoking restrictions in public places can be a trigger for smokers to re-evaluate their smoking behavior (Hammond et al., 2004). If these policy triggers are weaker for low SES smokers in stimulating quitting, such policies may widen SES differences.

Several studies have identified the reasons smokers cite for quitting smoking. The most frequently mentioned reason is concern for one's current as well as future health (Baha and Le Faou, 2010, Gallus et al., 2013, Grotvedt and Stavem, 2005, Kaleta et al., 2012, McCaul et al., 2006, Pisinger et al., 2011, Vangeli and West, 2008). Other reasons include social pressure, children, disliking being addicted, improving physical fitness, and financial costs. Some studies also investigated income or education differences regarding these reasons (Grotvedt and Stavem, 2005, Pisinger et al., 2011, Vangeli and West, 2008). These studies generally conclude that low SES smokers are more likely than high SES smokers to quit smoking because of the costs and because of current health-related reasons. Smokers with high income are more likely to quit smoking because they dislike being addicted.

There have been few studies on income and education differences regarding policy triggers that influence thinking about quitting smoking. One study conducted in England tested whether there existed SES differences in mentioning various triggers for quitting (Vangeli and West, 2008). For smoking restrictions, no SES differences were found; in contrast, warning labels and financial costs were more often mentioned by low SES groups. Another study found that after the implementation of workplace smoking restrictions in France, smoking restrictions were mentioned more frequently by employed than unemployed smokers as motive for wanting to quit, but in general this reason was reported quite rarely (Baha and Le Faou, 2010). However, these studies were conducted at only one measurement point in time and only in one country. Therefore, it is unknown whether mentioning policy triggers for quitting and socioeconomic differences change after the implementation of policies.

The aim of the current study was to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries: France, Germany, The Netherlands, Ireland, Scotland, and the rest of the United Kingdom (UK). These countries have ratified the WHO Framework Convention on Tobacco Control (FCTC) (WHO, 2003). Furthermore, they implemented cigarette price increases, smoking restrictions in public places, reimbursement of cessation medication, and warning labels, although the specific regulations vary.

An overview of the implementation dates of policies in the included countries is shown in Fig. 1. The timing and magnitude of retail cigarette price changes varied between countries (European Commission, 2014). We adjusted the retail cigarette prices for inflation in each country (The World Bank, 2015) and only included adjusted price increases of at least 5% because larger price increases were associated with more smokers reporting to consider quitting in previous research (Guillaumier et al., 2014, Scollo et al., 2013). Smoking restrictions in public places were implemented in all countries, but there were exceptions in some countries (e.g., in Germany smoking restrictions vary between federal states). All countries, except Germany, had at least some level of reimbursement for stop-smoking medication, but in The Netherlands, the reimbursement was introduced in 2011, discontinued in 2012, and reinstated in 2013. Finally, warning labels on cigarette packs were mandatory in the six countries; France implemented textual warning labels in 2003 and pictorial warning labels between 2010 and 2011 and thus changed the health warnings during the current study. Germany and The Netherlands implemented textual warning labels in 2003 and 2002, respectively, and had them throughout the whole study period. Ireland implemented textual warning labels in 2002 and pictorial warning labels in 2013. The UK (including Scotland) implemented textual warning labels in 2003 and pictorial warning labels between 2008 and 2010. The UK thus also changed the health warnings during the current study, but no Scottish data from the time after the implementation were available.

With data from the International Tobacco Control (ITC) Europe Surveys, we examined trends in self-reported triggers for as many as seven yearly waves in some countries. The following research questions were addressed: (1) Do self-reported triggers for thinking about quitting change over time?, (2) Are there education and income differences regarding reporting these triggers?, and (3) Do these education and income differences change over time?