Cancer Institute NSW Monograph
NSW Smokers’ Attitudes and Beliefs
Changes Over Three Years
February 2008
Trish Cotter, Donna Perez, Anita Dessaix, Jennifer Crawford, Julie Denney,
Michael Murphy, James F Bishop
Cancer Institute NSW catalogue number: PM: 2008: 01
National Library of Australia Cataloguing-in-Publication data:
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
SHPN (CI) 070221
ISBN 9781741871487
Keywords: smoking, attitudes, beliefs, New South Wales,
Australia.
Suggested citation:
Cotter T, Perez D, Dessaix A, Crawford J, Denney J, Murphy M,
Bishop JF. NSW Smokers’ Attitudes and Beliefs: Changes Over
Three Years; Sydney: Cancer Institute NSW, February 2008.
Published by the Cancer Institute NSW, February 2008.
Cancer Institute NSW
Level 1, Biomedical Building
Australian Technology Park
EVELEIGH NSW 2015
PO Box 41
Alexandria NSW 1435
Telephone (02) 8374 5600
Facsimile (02) 8374 5700
E–mail information@cancerinstitute.org.au
Homepage www.cancerinstitute.org.au
Copyright © Cancer Institute NSW February 2008.
This work is copyright. It may be reproduced in whole or
part for study or training purposes subject to the inclusion of
acknowledgement of the source. It may not be reproduced
for commercial usage or sale. Reproduction for purposes
other than those indicated above requires written permission
from the Cancer Institute NSW.
Contents
Contents
1
Foreword from the Minister
2
Overview
3
SECTION ONE: QUANTITATIVE RESEARCH SMOKING AND HEALTH SURVEY MARCH 2007 RESULTS
COMPARED TO 2005 AND 2006
9
Executive summary
10
Objectives
14
Research design
15
Conduct of quantitative research
16
Sample characteristics
17
Research findings
20
Smoking behaviour
23
Quitting smoking
26
Health effects of smoking
42
Second-hand smoke
48
Attitudes towards smoking restrictions
53
Attitudes towards point-of-sale displays
59
Conclusions and recommendations
60
SECTION TWO: QUALITATIVE RESEARCH UNDERSTANDING SMOKERS NOVEMBER 2006
61
Executive summary
62
Introduction
65
Detailed findings
67
1
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Foreword from the Minister
T
he Cancer Institute NSW was established four years ago through the Cancer Institute (NSW) Act 2003, as a
direct response to decreasing the cancer burden in our State. The Cancer Institute NSW is Australia’s first
state-wide government supported cancer control agency. It aims to promote the best cancer prevention, early
detection, treatment, research and information.
Smoking is the leading preventable cause of death and disease, including cancer, in NSW. The NSW State Plan sets a
target to reduce smoking rates by 1% each year. The use of social marketing to reinforce the health risks of smoking
to adults, supported by accessible quit smoking services, is considered best practice in effective tobacco control
intervention. The State Plan commits the Cancer Institute NSW to continue its efforts to meet this challenge.
In the NSW Tobacco Action Plan 2005–2009 and the NSW Cancer Plan 2007–2010, it is also noted that the Cancer
Institute NSW has responsibility for the design, development and delivery of social marketing mass-media
campaigns, which educate and motivate people to quit smoking.
The continued decline in smoking prevalence since 2003 is encouraging. The 2.4% decline in 2006 was due to a
number of contributing factors that came together in one year. These include the introduction of graphic health
warnings on cigarette packs (from March 2006), further restrictions on smoking in licensed venues and the quality
and frequency of anti-smoking advertising conducted by the Cancer Institute NSW.
This monograph examines changes in NSW smokers’ attitudes, beliefs and knowledge over the past three years, all
of which has been used to set the direction for future campaign development and success.
The Hon. Verity Firth MP
Minister for Women
Minister for Science and Medical Research
Minister Assisting the Minister for Health (Cancer)
Minister Assisting the Minister for Climate Change, Environment and Water (Environment)
2
Overview
Key findings
Total economic returns of
tobacco control programs
are estimated to exceed
expenditure by at least 50
to one.
■
Almost half of smokers think that quitting smoking is
the factor most likely to improve someone’s health.
■
More than 80% of smokers agreed that smokingrelated deaths are likely to be slow and painful.
■
Health reasons remain the main influence for exsmokers’ quit attempt (57%).
2006. The second was the further restrictions on smoking in
NSW licensed venues.
■
Almost two-thirds of smokers said they were
considering quitting in the next six months.
In the year 2006, two Commonwealth Government-funded
campaigns preceded the Cancer Institute NSW’s media
campaigns, with the effect being approximately 40 weeks of
paid anti-smoking media advertising in NSW for that year.
The Cancer Institute NSW launched the first of its antismoking mass-media campaigns on 18 April, with a campaign
to promote the services provided by the NSW Quitline:
Quitline Services Campaign. This campaign was followed
closely by the first of the Health Warnings Campaign
advertising: Amputation. The Health Warnings Campaign (a
State and Territory collaboration) was designed to provide a
connection between the graphic health warnings on cigarette
packs and the anti-smoking message delivered through
mass media. Mouth Cancer was the second of the Health
Warnings Campaign advertising and was aired July–August
in 2006. The Pubs & Clubs Campaign was aired, as in 2005,
to coincide with the changes in legislation regarding smoking
restrictions in NSW licensed venues, in July. Two campaigns
previously aired in 2005 were repeated in 2006: Excuses
and Parents.
Tobacco is still the largest cause of preventable death and
disease in the NSW community. Smoking increases the risk
of many cancers, with one in five of all cancer deaths in NSW
caused by smoking. It is also responsible for cardiovascular
and respiratory diseases and more than 6,600 deaths in
NSW each year, as well as around 150 NSW public hospital
admissions every day. One in two lifetime smokers will die
from their habit; and a third of those deaths will occur in
middle age. Tobacco affects almost every organ in the body,
but quitting smoking at any time results in substantial
health gains.
The cost to the NSW community as a result of tobacco
smoking in 1998–99 was estimated conservatively at $6.6
billion. However, it has also been estimated that for every
$1 spent on tobacco control programs to date, $2 has been
saved on health care. Total economic returns of tobacco
control programs are estimated to exceed expenditure by at
least 50 to one.
In 2004, the Cancer Institute NSW introduced anti-smoking
campaigns back into the NSW market following a number of
years of absence. The first campaign implemented was the
Lady Killer Campaign. In 2005, this work continued with the
implementation of Excuses, Lung Disease and
Parents Campaigns.
Having established an effective anti-smoking platform in
2005, the Cancer Institute NSW’s objective was to develop a
mass-media strategy to capitalise on two key policy initiatives
being introduced in 2006. The first was the introduction of
new graphic health warnings on cigarette packs from March
The target of the advertising was primarily adult smokers.
The Quitline number was shown at the end of all the
advertisements to encourage a behavioural response among
smokers to quit smoking by calling the Quitline. In NSW in
2006, smokers were the target of 32 weeks of anti-tobacco
television advertising funded by the Cancer Institute NSW.
Planning
The NSW Tobacco Action Plan 2005–2009 sets out activities
undertaken by a range of state-based and national,
government and non-government agencies who work in
partnership toward the same target: improve the health
of the people of NSW and to eliminate or reduce their
exposure to tobacco in all its forms.
3
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Action focuses on six areas of program activity: smoking
cessation; exposure to environmental tobacco smoke;
marketing and the promotion of tobacco products; availability
and supply of tobacco products; capacity building; and
research, monitoring and evaluation. NSW strategies and
activities developed over the life of the plan will include:
new social marketing activities; smoking cessation programs
and services; legislative and regulatory activities; research
The Cancer Institute NSW’s
social marketing program is part
of a comprehensive tobacco
control program that is
implemented throughout NSW.
studies and evaluation programs. As a result, the Cancer
Institute NSW’s social marketing program is part of a
comprehensive tobacco control program that is implemented
throughout NSW.
The Cancer Institute NSW has primary responsibility for the
design, development and delivery of social marketing massmedia campaigns, which educate people in NSW about the
harms of smoking.
Campaigns developed and implemented by the Cancer
Institute NSW consider a series of campaign principles,
reflective of the highly successful 1997 Australian National
Tobacco Campaign, Every Cigarette is Doing you Damage,
which was devised on the premise that reducing the
prevalence of smoking will best be achieved on the basis of
an individual model of the psychology involved. The model
assumes that the day-to-day actions of individuals are largely
explained by the existence of a personal agenda. Items for
action on this personal agenda are ranked for
importance/urgency:
4
1.
For intentions to become actions they have to make it
to, and stay on, today’s agenda.
2.
Behaviours that require action over many days are
difficult and require resources and reinforcement that
are external to the individual.
Development
Taking these principles into consideration, the Cancer
Institute NSW’s anti-smoking campaigns in 2006 focused on
making strong health messages personally relevant to NSW
smokers to limit their self-exempting behaviour. They also
had to deliver a strong memory, message and avenue to quit.
The explicit target audience for Cancer Institute NSW
cessation campaigns was adult smokers, with a blue collar
skew. Mass-media campaigns reinforcing the health risks
of smoking to adults, combined with accessible services,
is considered best practice in effective tobacco-control
initiatives as they deliver the earliest and biggest dividend in
terms of early reduction of tobacco-related harm, as well as
having a positive impact on young people.
When planning which campaigns to develop and implement
in NSW, survey evidence from smokers and ex-smokers
had repeatedly affirmed that personalised concern about
health consequences was the primary motivation ascribed
to smoking cessation. Displaying the certain consequences
of smoking in a realistic execution that personalises and
prioritises quitting, is considered the ‘push’ in a ‘push-pull’
campaign strategy.
To maximise the chance of the intended behavioural
response, smokers needed accessible and reliable services
to help them quit. While each campaign execution would
carry the Quitline number, evidence from research suggested
smokers needed stronger quitting advice, support and
information about the services of the NSW Quitline. A new
and dedicated Quitline Services Campaign was developed by
the Cancer Institute NSW as a stronger ‘pull’.
Media advertising needed to provide a clear pathway to the
cessation service Quitline. The NSW Quitline, overseen
by the Cancer Institute NSW and managed at St. Vincent’s
Hospital Sydney, is a confidential, free of charge, evidencedbased service that provides telephone counselling support in
a non-judgemental way to smokers who want to quit. The
service provides information to smokers about different
strategies for quitting and offers the opportunity to join a
call-back service that can double a smoker’s chances of
quitting successfully.
Previous research also showed that calls to the Quitline spike
when advertising occurs; when advertising ceases, calls drop
away to pre-campaign levels. Therefore, the Cancer Institute
NSW developed a schedule of campaigns in consultation
with the NSW Quitline to allow appropriate rostering for
staffing levels to meet demand that campaign advertising was
likely to create.
A range of research and evaluation methods were put
in place to ensure that campaign results were being
appropriately captured to continuously inform the program.
Campaigns would be able to be assessed through the
following methods:
▪
The Smoking and Health Survey: an annual Cancer
Institute NSW quantitative study of smokers and nonsmokers on a range of tobacco-related topics (reported
in detail in this monograph).
▪
NSW Health Population Health Survey: a representative
survey of the NSW population that monitors changes in
smoking prevalence, smoking status and smoking across
key demographics.
▪
Campaign Tracking: weekly, continuous quantitative
evaluation of smoking cessation campaigns, surveying
smokers and recent quitters. It measures campaign
effectiveness and changes in awareness, attitude,
knowledge and behaviour as a result of communication.
▪
Exploratory research: to provide insights into the current
attitudes of smokers for future campaign and program
development (reported in detail this monograph).
▪
Quitline Call Data: analysis of incoming calls to the NSW
Quitline, relative to campaigns on air. Calls to Quitline
are an indicator of intention to quit.
Screen-shot from Quitline Services
television commercial
Screen-shot from Mouth Cancer
television commercial
Screen-shot from Gangrene
television commercial
5
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Implementation
The Cancer Institute NSW launched the first of its anti-smoking mass-media campaigns for 2006 on 18 April, with a
campaign to promote the services provided by the NSW Quitline: Quitline Services Campaign. The plan was to establish the
‘pull’ (support for quitting) prior to releasing the ‘push’ (motivational health effects) style of advertising.
Campaigns 2006
Quitline Services: April to October –
media strategy.
Health Warnings: May to October –
media strategy.
Description
Six 15 sec ads featuring Quitline
advisors talking about a number of
topics, including: planning to quit,
cravings, Nicotine Replacement
Therapy (NRT), call-backs, previous
attempts and no best way to quit.
Amputation: features an operation to
remove a leg that has gangrene.
Mouth Cancer: features a woman with
visual symptoms of mouth cancer.
6
Aim
Aims to provide smokers with an
insight into Quitline and the range of
services and support available.
Aims to build on the graphic health
warnings on tobacco products and
increase impact when a smoker
purchases a tobacco product.
Change is in the Air (Pubs & Clubs):
June–July.
Features David Callan (an Irish
comedian) talking about smoking
restrictions in NSW Pubs & Clubs.
Aims to increase awareness among the
NSW community of the new changes
to smoking inside licensed venues.
Excuses (Echo 1&2): May–June: re-run
from 2005.
Features a number of scenarios of
excuses smokers use and the health
consequences of not quitting.
Aims to encourage smokers to put
quitting on ‘today’s agenda’ by tackling
the excuses for delaying quitting.
Parents: September: re-run from 2005.
Features a young girl talking to her
father who is in a hospital bed.
Aims to highlight the impact of smoking
on the health of the smoker and also
on the smoker’s relationship with their
loved ones.
Main outcomes
Since 2003, more than 150,000 NSW smokers have quit.
Specifically, over the period from 2005 to 2006 the NSW
Health Survey reported a 2.4% decline in smoking prevalence.
▪
‘Daily’ and ‘occasional’ smoking combined declined from
20.1% in 2005 to 17.7% in 2006.
▪
An overall decline in the prevalence of ‘daily’ smoking
among NSW people aged 16 years and over from
15.8% in 2005 to 13.9% in 2006 – a drop of 1.9
percentage points.
▪
‘Occasional’ smoking declined from 4.3% in 2005 to 3.8%
in 2006.
▪
Fifteen per cent of males are ‘daily’ smokers compared
to 12.9% of females.
Screen-shot from Pubs & Clubs
television commercial
The continued decline in smoking rates over time are
encouraging, as are the increasing Quitline calls. The
combination of quit smoking campaigns and quitting support
campaigns drove 57,046 calls to the Quitline in 2006, double
that of 2005 and nearly triple that of 2004.
This third annual Cancer Institute NSW Smoking and Health
Survey found:
▪
Quitting smoking was perceived to be the factor most
likely to improve someone’s health, nominated by 47% of
respondents, up from 35% in 2005.
▪
Consistent with previous waves, 61% of smokers
indicated that they were considering quitting smoking in
the next six months, and 45% felt they were seriously
thinking of quitting. Overall, 21% of smokers stated they
were planning to quit within the next 30 days compared
with 17% in 2005.
▪
As with previous waves, three-quarters of smokers
believed that they either definitely or probably will
become seriously ill if they continue to smoke. Eightythree per cent of respondents agreed that smokingrelated deaths are likely to be slow and painful, up from
75% in 2005.
▪
Screen-shot from Excuses
television commercial
Screen-shot from Parents
television commercial
Health reasons remain the main influence for exsmokers’ last quit attempt (57% compared to 7% due to
the cost of cigarettes).
7
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Correlation between Quitline calls and media weight
3500
1000
Commonwealth Campaigns
Pubs & Clubs
Parents
Echo
Mouth Cancer
Gangrene
Quitline
Quitline Calls 2006
900
Aggregated NSW TARPs - 16+ years
800
700
3000
2500
600
2000
500
1500
400
300
NSW Quitline calls
Figure 1
1000
200
500
100
0
1/
0
8 1/
15/01 06
/
/
22 01 06
/
29/01 06
/0 /0
5 1/ 6
12/02 06
/
19/02 06
/
26/02 06
/0 /0
5 2/ 6
12/03 06
/
19/03 06
/
26/03 06
/0 /0
2/ 3/06
0
9/ 4/06
16 04 6
/
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/
30/04 06
/0 /0
7 4/ 6
14/05 06
/
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/
28/05 06
/
/0 0
4 5/ 6
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/0 /0
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/
/0 0
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/
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/0 /0
3 8/ 6
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/
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/
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/
/0 0
1/ 9/06
1
8/ 0/06
15 10 6
/
/
1
22 0 06
/
29/10 06
/1 /0
5 0/ 6
12/11 06
/
19/11 06
/
26/11 06
/1 /0
3 1/ 6
10/12 06
/
17/12 06
/
24/12 06
/
31/12 06
/1 /06
2/
06
0
Weeks
A direct correlation between Quitline calls and target audience rating points (TARPs) was observed in 2006. A TARP is
a standard measure of weekly television advertising weight scheduled to reach the target audience. The strength of this
relationship was also impacted by two variables: the introduction of graphic warnings on packs from March 2006 and the
strength of the creative execution in prompting smokers to call the Quitline.
In the sections to follow this overview, we report in detail the findings of three years of smoking and health surveys
(conducted in March of each year). In addition, we report on the qualitative exploratory research conducted at the end of
2006 to gauge the change in smokers’ attitudes after almost a year of strong campaign activity, new pack warning and further
restrictions on smoking in licensed venues.
Trish Cotter
Director, Cancer Prevention (2004–2007)
Cancer Institute NSW
James F Bishop MD MMed MBBS FRACP FRCPA
Chief Cancer Officer
CEO, Cancer Institute NSW
8
SECTION ONE: QUANTITATIVE RESEARCH
SMOKING AND HEALTH SURVEY
MARCH 2007
RESULTS COMPARED TO 2005 AND 2006
Trish Cotter1
Donna Perez1
Jennifer Crawford2
Julie Denney2
James F Bishop1
1
2
Cancer Institute NSW
Eureka Strategic Research, Newtown, NSW
9
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Executive summary
Key findings
Research design
■
Health concerns continue to be the biggest reason to
quit smoking.
■
Sixty-one per cent of smokers are considering
quitting in the next six months.
■
Twenty-one per cent of smokers want to quit in the
next month (up from 17% in 2005).
■
Three-quarters of smokers believe they either
definitely or probably will become seriously ill if they
continue to smoke.
■
Almost three-fi fths (58%) believe that the new
warnings have made an impact on them.
The research involved a telephone survey of adults recruited
from the White Pages. The sample (N=1,630) included
quotas to ensure approximately equal sub-samples of
smokers (being the primary target audience for most tobacco
control interventions) and non-smokers (as members of the
general community). One-fifth of the non-smoker subsample was recruited from households containing at least
one smoker. Quotas were also applied for age, gender and
geographic location, to broadly reflect the NSW population.
Minor changes were made to the questionnaire used in
previous waves, and standard telephone pilot testing was
again conducted. The fieldwork period was from 13 March
to 2 April 2007.
■
Close to nine out of ten non-smokers say they are
bothered by exposure to other people’s smoke in
public places.
■
There is strong support for point-of-sale regulations.
Research context
As part of the Cancer Institute NSW’s evaluation of its
tobacco control program, an independent research company
(Eureka Strategic Research) was commissioned to conduct
research to measure current tobacco-related knowledge,
attitudes and behaviour in the community, and to identify
any shifts in key measures over time. This research program
aimed to understand: (a) patterns of tobacco use and the
quitting process; (b) community knowledge about the health
consequences of smoking, including second-hand smoke;
(c) community knowledge and attitudes regarding smoking
restrictions in public places and licensed premises, and (d)
community attitudes towards point-of-sale displays.
10
Smoking status
Of the total sample, 44% were daily smokers, and just under
a fifth of the sample consisted of ex-smokers (i.e. used to
smoke at least weekly). Among those who had never been
a regular smoker, a significantly greater proportion (48%)
had never tried smoking compared with last wave (41%).
On average, smokers reported consuming 14.6 cigarettes or
other tobacco products a day, with daily smokers consuming
an average of 16 a day, and 1.4 a day for those who smoked
at least once a week, but not daily. This represents a
significant decline in consumption among infrequent smokers
(i.e. weekly but not daily), from 15.1 to 10 cigarettes per
week. The remaining figures are comparable with the
2006 study.
Perceptions of smoking vs. other risks
Respondents were asked which, from a list of possible
causes, was responsible for the most deaths before age 65
in NSW each year. More than half of the sample (55%)
nominated ‘smoking tobacco’. Similarly, out of ‘stopping
smoking’, ‘exercising regularly’, ‘eating a healthier diet’,
‘reducing stress’, or ‘limiting alcohol intake’, just under half
(47%) selected ‘stopping smoking’ as the factor most likely to
improve someone’s health.
Smoking behaviour
Three-fifths (60%) reported they usually smoke tobacco
products that they believed to be mild, light or low tar (the
Australian Competition and Consumer Commission obtained
undertakings from tobacco companies to remove light and
mild descriptors from tobacco products in October 2005).
Again, almost half the sample (45%) of smokers reported
purchasing their last pack of cigarettes from a supermarket.
A significant increase was observed in purchases from
tobacconists (from 12% in 2006 to 17% in 2007), cancelling
out the decrease observed in the previous period.
Quitting smoking
Consistent with previous waves, 61% of smokers indicated
they were considering quitting smoking in the next six
months, and 45% felt that they were ‘seriously thinking of
quitting’. Overall, 21% of smokers stated that they were
planning to quit within a month, representing a significant
increase since 2005 (17%). On average, these smokers
planned to quit in 9.1 days time. Again, health was the most
commonly cited reason for considering (or actually) quitting
smoking, among all smoker and ex-smoker segments.
Smokers continue to believe it would be difficult to quit
smoking. On a scale from 0 to 10, where 0 indicates
‘extremely easy’ and 10 indicates ‘extremely difficult’, the
mean rating was 6.7. More than a quarter of smokers (29%)
rated the difficulty of quitting as 10 out of 10. Most smokers
had attempted to quit multiple times (average number
of quit attempts was 3.6), and the proportion of current
smokers who had never tried to quit continued to decrease
from 24% in 2005 to 19% in 2007. The average duration
since a current smoker’s last quit attempt was 3.5 years,
and the average duration since ex-smokers’ quit was 16.7
years. Among ex-smokers and current smokers, 34% had
attempted to (or actually) quit within the past 12 months.
The Fagerstrom Test for Nicotine Dependence was added
in 2007, with only 10% of the sample scoring as ‘high’ or
‘very high’ on this measure. Additional analysis revealed
that Fagerstrom scores were positively associated with
age. One component of the Fagerstrom measure was how
soon a person smoked their first cigarette of the day, with
almost a fifth (19%) doing so within five minutes of waking.
Other questions were added to the 2007 questionnaire to
enable calculation of ‘Quindex’ scores, measuring strength of
Most of the people aware of
Quitline agreed that it can help
people prepare to quit (82%)
and can provide tailored
advice (76%).
quitting intention or activity, with some differences based on
demographic characteristics.
When asked to name any particular support services,
assistance or methods available to help smokers quit, an
increased proportion (62%) showed unprompted awareness
of Quitline (vs. 55% in 2006). In addition, a significantly
greater proportion mentioned natural/alternative therapies,
and a lower proportion mentioned prescribed medication.
While ‘cold turkey’ remains the most commonly used
strategy for quitting smoking, its prevalence decreased
significantly from 70% to 52% over the last period. Reported
use of other strategies or aids has increased since previous
waves, including nicotine replacement therapy, cutting down
the amount smoked, other self-help materials, calling Quitline
and advice from a GP.
When asked about the extent to which television advertising
had influenced their most recent decision to try to quit, 37%
agreed that it had (and this was particularly the case among
successful quitters). Television advertising was consistently
seen as the primary source of awareness about the Quitline.
Prompted awareness of Quitline increased significantly
among smokers and ex-smokers (from 92% to 95%). Again,
13% of current smokers had called Quitline at some stage,
maintaining the increase observed in the last period (versus
10% in 2005). Among those who had called Quitline, 58%
indicated they would recommend Quitline to someone else.
Most of the people aware of Quitline agreed that it can help
people prepare to quit (82%) and can provide tailored advice
(76%). However, compared with those who had never called
Quitline, prior callers were more likely to disagree with some
of the service statements presented (with two of the three
relevant statements representing what Quitline is meant to
provide). Views remained mixed regarding whether Quitline
is meant for people who have ‘tried and failed’, and its
chances of increasing the likelihood of quitting successfully.
11
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Health effects of smoking
The results suggest that most smokers acknowledge the risks
associated with smoking. Like previous waves of research,
three-quarters of smokers believed they either definitely
or probably will become seriously ill if they continue to
smoke. Most agreed that smoking-related deaths are usually
slow and painful (83%), and this represented a significant
Close to nine out of ten nonsmokers said they are bothered
by exposure to other people’s
smoke in public places.
Environmental tobacco smoke
increase compared with the 2005 results. There is slightly
less awareness that smoking-related deaths often mean that
smokers die many years earlier than they would otherwise
have done, with 30% either disagreeing or indicating that
they were unsure whether smoking-related illnesses often kill
people in middle age.
Close to nine out of ten non-smokers said they were
bothered by exposure to other people’s smoke in public
places. Smokers were less likely to indicate they were
bothered by passive smoking, but even among smokers;
around two-fifths said they were concerned. The main
reason why people said they were bothered by exposure to
other people’s smoke in public places was that they perceived
it to be unpleasant. Since 2006, a greater proportion of the
total, weighted sample indicated that they are bothered by
exposure to environmental tobacco smoke because of its
long-term impact on their health. Despite this, there was
more agreement that passive smoking is fairly harmless,
and slightly fewer appear to be aware of the residual nature
of tobacco smoke compared to the 2006 data. This is
probably because there has been a decreased emphasis
on communications regarding the dangers associated with
environmental tobacco smoke.
For almost a fifth of smokers, however, there is still a
tendency to perceive social smoking as not particularly
harmful. That said, the vast majority recognise that even
social smoking is harmful.
Most smokers were found to be unaware of which substance
in cigarettes is the main thing that causes cancer. In fact,
the proportion who indicated that it was tar has decreased
significantly since 2006 (26% vs. 32%). It is unclear, however,
the extent to which this lack of knowledge is problematic,
given that most smokers recognise that their continued
smoking will make them seriously ill. The shift in results
is likely to be a result of recent advertising from the
Commonwealth, which emphasises the chemicals found
in cigarettes. Similarly, the observed increase with the
statement, ‘It’s the additives put in cigarettes that make
natural tobacco so dangerous to health’ is also likely to be
because of this recent campaign activity.
Reflecting the fact that the health warnings on cigarette
packets changed more than a year ago, overall recall (and
12
accuracy of recall) of the old health warnings decreased in
2007. Prompted awareness of the new warnings was high
(99.6%), although smokers’ ability to recall the text of the
warnings (without prompting) was relatively low. This is
likely to be because the primary impact of the new warnings
is visual. Almost three-fifths (58%) believed the new warnings
had made an impact on them, and more than a third
indicated that these pictorial warnings had made them think
about quitting (36%).
Among households with smokers (and a car), more than half
(53%) report that none of the cars in the household have
been smoked in during the past month. This is a similar
result to the 2005 data. Among those households who
have smoked in the car, more than half believed that their
household would ban smoking in the cars in the future.
Attitudes towards smoking restrictions
There continued to be near universal support for smokefree workplaces, as well as strong support for restrictions
in playgrounds. The community is most likely to support
banning smoking in cars in which children are travelling. Even
so, there is majority agreement that all cars should be smoke
free by law, and the proportion that agreed with this has
increased since 2006 (58% vs. 63%).
Three-quarters of non-smokers and nearly a quarter of
smokers (24%) said they try to avoid situations that are likely
to be smoky. Furthermore, fewer smokers (compared with
2006) reported that they avoid situations where they will be
unable to smoke inside (34%).
Like the previous waves of research, most agreed that a
smoke-free pub and club environment is both safer and more
pleasant. Similarly, most believed that the indoor areas of
most pubs and clubs should be smoke free. The increased
levels of agreement with these statements observed
between 2005 and 2006 have been maintained in the most
recent wave of research. Similar to the 2006 results, around
a third disagreed that any restrictions on smoking should be
introduced gradually, rather than all at once. This represents
an increase from the 2005 data.
Smokers believe that their average number of visits to
pubs, clubs or bars will decrease after the implementation
of indoor smoking restrictions. However, looking at the
community as a whole, on average, it was found that the
current number of visits was 3.2, and the expected number
of visits after the indoor ban was 3.6.
Attitudes towards point-of-sale displays
There was found to be strong support for further point-ofsale regulations, particularly among non-smokers. Specifically,
there was near universal agreement that cigarette health
warnings should be displayed where all tobacco products
are sold, and that information about the ingredients in
cigarettes should also be made available. There was slightly
less support for storing cigarettes out of sight, but still close
to four-fifths who agreed with the relevant statement. As
expected, there was a greater level of support when people
were asked whether they support regulations to ensure
cigarettes are stored out of sight of children.
Conclusions
The results of this research are largely consistent with
previous surveys. Again, the majority of smokers indicated
that they wish to quit, and they perceived themselves to be
at risk of becoming seriously ill if they continued to smoke.
However, most perceived quitting as difficult, and 29% of
smokers’ rated the difficulty of quitting as 10 out of 10. The
There was found to be strong
support for point-of-sale
regulations, particularly among
non-smokers.
results suggest that smokers are more open to the idea of
seeking assistance to quit, with fewer successful quitters
having quit ‘cold turkey’.
The Quitline Services campaign appears to have successfully
increased awareness of, and salience of, the service.
There is still scope to improve smokers’ understanding
of who Quitline is for, and their perceptions of its likely
effectiveness, although this will depend on the extent of
delivery of services.
In general, the use of TV advertising appears to have been
successful in NSW. Among those who have tried to quit
(including those who have been successful), more than a
third indicated that TV advertising influenced their decision
to try to quit.
There continues to be widespread support for smokefree pubs and clubs, and extending smoke-free legislation
into other public spaces and the workplace is likely to be
favourably received. Indeed, smoking restrictions seem to be
having an effect on people’s attitudes and behaviour. A small,
but increasing, proportion said that the smoke-free legislation
is one of the reasons why they are considering quitting
smoking. The results also show that infrequent smokers are
smoking even less frequently, and this may well be due to the
restrictions in pubs and clubs.
The results also suggest that introducing new restrictions
at the point-of-sale are likely to be supported, even among
smokers. The only proposal that received a minority of
opposition from smokers was regulations to store cigarettes
out of sight, although it was supported by the great majority
of the population. Such an initiative is likely to be accepted
cigarettes are stored out of the sight of children.
13
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Objectives
Research context
This section outlines the background to the project, and specifies the research objectives.
Background
The Cancer Institute NSW aims to substantially improve cancer control in NSW and to reduce the prevalence of smoking
in NSW by 1% each year. The NSW Cancer Plan 2007–2010 entails an expanded tobacco control program, including
community education about the consequences
of smoking.
In 2005, prior to commencing the planned communication activities, the Cancer Institute NSW conducted a survey to
establish baseline measures of tobacco-related knowledge, attitudes and behaviour in the community. Since then, research
has been conducted annually. The current research represents the third wave of the study, designed to identify any shifts in
key measures over time, as part of the Cancer Institute NSW’s evaluation of its tobacco control program.
Research objectives
The research objectives and key areas of interest for this third wave were:
•
to understand patterns of tobacco use, quit attempts and barriers to quitting
•
to understand community knowledge about the health consequences of smoking (including second-hand smoke)
•
to understand (in brief) community attitudes regarding:
- new smoking restrictions in pubs and clubs
- smoking in public places
- point-of-sale displays.
The research program undertaken to meet the research objectives and explore these issues of interest is outlined in the
next section.
14
Research design
This section provides details of the research methodology.
Quantitative methodology
Quantitative research was necessary to meet the objectives
outlined in Section Two, in order to provide robust
measurements so that changes over time could be accurately
monitored.
The survey was conducted over the telephone, using
Computer Assisted Telephone Interviewing (CATI).
When analysing responses to questions that were asked
of the full sample (i.e. not just smokers), it was important
to keep in mind that smokers account for roughly half of
the sample, but represent only a minority of the actual
population. Accordingly, where findings relate to the NSW
community as a whole, the responses of smokers and
non-smokers have been weighted relative to their actual
prevalence in the NSW population. This prevalence was
estimated to be 17.7% for current smokers and 82.3% for
non-smokers. In part five of this section, the base statement
for each chart indicates where data have been weighted.
Smoking status: household smoking status
Sample size and source
The total sample for this second wave of research consisted
of 1,630 adults living in NSW. A sample of this size gives a
95% confidence interval of no more than ±2.5% for a stand
alone survey, and ±3.5% for comparison with the previous
wave of research. Households were recruited randomly
from the electronic White Pages.
Smoking status: individual smoking status
The primary objective of the research was to understand the
behaviour, attitudes and knowledge of smokers themselves.
Smokers represent the primary target audience for most
of the communication activities and interventions that aim
to bring about a reduction in smoking prevalence in NSW.
Therefore, it was appropriate to include a significant subsample of smokers, rather than sampling smokers according
to their natural occurrence in the population.
It was expected that the views of non-smokers who live
with smokers were likely to differ from the views of
non-smokers who live with other non-smokers. Therefore,
it was important to ensure that the sub-sample of nonsmokers included a minimum of 20% who live with at least
one smoker.
Additional quotas
In addition, quotas were imposed on age, gender and
geographic location, to broadly reflect the NSW population.
This assisted in achieving a representative sample.
In addition, it was important to incorporate the views
of non-smokers, in order to understand the knowledge,
attitudes and behaviour of the general community. The final
sample included approximately equal sub-samples of smokers
(n=821 currently smoked at least once a month) and nonsmokers (n=809 did not currently smoke at all or smoked
less often than once a month). When comparing the views
of two sub-samples (e.g. smokers vs. non-smokers), one
gains the largest amount of statistical power when the
sub-samples are of the same size. Therefore, it was
advantageous to have approximately equal sub-samples of
smokers and non-smokers. It was also important to have
sufficient smokers in the sample to be able to analyse their
views in a robust fashion.
15
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Conduct of quantitative research
Questionnaire development
The questionnaire was adapted from the one used in previous waves, with some questions added and others removed. The
questionnaire was developed in close consultation with the Cancer Institute NSW to ensure that information needs were
prioritised and appropriately addressed. Key questions were designed to ensure comparability with other important research
conducted within the sector, including NSW Health surveys and National Tobacco Campaign evaluations. All open-ended
questions contained pre-coded response frames.
The questionnaire was designed to be comprehensive, without being too burdensome for respondents. The average
interview length across the sample was 17.1 minutes. Interviews were generally longer for smokers (averaging 20.6 minutes)
than non-smokers (averaging 13.5 minutes).
Pilot testing
Prior to fieldwork commencement, standard telephone pilot testing was conducted to test the questionnaire as a working
document among all key sub-groups.
Fieldwork period and response rate
The fieldwork was conducted between 13 March and 2 April, 2007, so that interviewing was completed at a similar time to
previous waves, to maximise comparability.
The response rate for the survey was 45.1% (53.5% in 2006, 54.3% in 2005).i
Analysis
All 2007 results were compared with the data from the previous wave (2006) to test for statistically significant changes. In
addition, post-hoc analysis was conducted to compare the 2007 results with the baseline data (i.e. 2005), in those instances
where a change that was strategically relevant appeared to have occurred. Any such changes are highlighted throughout the
following sections of the report.
i
The response rate is calculated as the proportion of contacts with a competent person where eligibility to participate was determined (i.e. the respondent
co-operated with the survey). The response rate is calculated as: the number that cooperated / (the number that cooperated + number that refused
to co-operate).
16
Sample characteristics
This sub-section reports on smoking status and other demographic characteristics of the sample.
Smoking status
As with previous waves, ‘smokers’ were defined as people who report that they currently smoke tobacco products at least
once a month. This is the key variable used for comparisons between smokers and non-smokers. However, some of the
questions (where relevant) were asked of those who smoke at all, including less often than once a month. (This is annotated
as ‘smokes at all’ in base sample size statements throughout this report.) The term ‘tobacco products’ was used to
incorporate tailor-made or factory-made cigarettes; roll-your-own cigarettes; cigars; pipes; and any other tobacco products.
As determined by the quotas, the sample consisted of almost equal sub-samples of smokers and non-smokers, as illustrated
in Figure 2 below. The majority of smokers again reported that they smoke at least once a day, representing 44% of the
total sample.
Figure 2
Smoking frequency. (2007) (%)
44
Daily
At least once/week
5
21
49
Less often than once/week (at least once/month)
Not at all
Less often than once/month
Q2.1/2.3: Previous smoking status (2007)
18
17
16
Used to smoke at least once/week
Never once/week, but have tried smoking
Never tried smoking
Can't say if ever tried
0.1
Those who do not currently smoke at least once a week were asked if they had ever smoked at least once a week. As
indicated in the second bar above (labelled Q2.1/2.3: Previous smoking status), just under one fifth of the total sample
reported that they no longer smoke on a weekly basis, but that they used to do so. These ‘ex-smokers’ either currently
smoke on a very infrequent basis or not at all. Overall, 16% of people had never tried smoking at all. Among those who had
never been a ‘regular’ smoker (i.e. never smoked at least weekly), 48% had never even tried smoking. This is a significant
increase since the 41% observed in 2006.
Other demographics
A wide range of demographic characteristics were captured in the survey, although it should be noted that many of these
variables (i.e. age, gender and geographic location) were pre-determined by specified quotas, ensuring a good match with
previous waves.
17
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Gender, age and location
The sample had fairly even gender representation, with a slightly higher proportion of females (54%) than males (46%).
Almost two-thirds of respondents were from the Sydney metropolitan area (62%).
The age profile of the sample is shown in the following chart. As can be seen, there was slightly higher representation among
the younger age categories across the total sample, as specified in the quotas. The first two age brackets are narrower than
the remaining age brackets (that is, seven and five years respectively, compared with 10-year brackets from age 30 onwards).
In addition, smokers were more likely to be younger (up to their 40s) than non-smokers, as shown in the following chart.
Figure 3
Age in years: smokers vs. non-smokers. (2007) (%)
%
30
25
22
18
20
21
19
18
15
11
Non-smoker
Smoker
Total
23
15
17
15
13
10
10
7
11
7
8
9
3
6
4
1 2
0
18–24
25–29
30–39
40–49
50–59
60–69
70–79
80+
Education and employment status
The survey also recorded the highest education level attained by respondents, their current employment status and the
occupation of the household’s main income earner, with the results presented in the following charts. There were some
minor differences in the 2006 and 2007 demographic profiles. For example, there were slightly more TAFE/technical
college graduates in the 2007 sample. There were also some minor changes (±3-6%) in the occupation of the main income
earner, such as an increase in the proportion of associate professionals and a decrease in professionals, and a slight increase
in the proportion who were not employed (including students, home duties, retired etc). It is unlikely these demographic
differences between the two samples had any significant impact on the results.
Figure 4
Highest education level attained. (%)
No formal schooling
0.1
Primary school
1
Junior High School (Years 7 – 10)
23
Senior High School (Years 11– 12)
27
TAFE / Technical College
19
University
18
28
Another tertiary institution
2
Refused
0.2
Don't know
0.2
Figure 5
Annual household income
Employment status. (%)
Working full -time
Working part -time or as a casual
19
Retired
17
Home duties
Main language and ATSI
9
Student
Almost all respondents (91%) spoke English as their main
language at home (92% in 2006, 93% in 2005). Each other
language was reported as the main language spoken at home
by no more than 1% of the sample. Overall, 2.1% of the
sample identified as being Aboriginal or Torres Strait Islander
(ATSI) (2.6% in 2006, 2.3% in 2005).
4
Unemployed or looking for w ork
Figure 6
The median household income range was $60–75K per
annum, compared with $45–60K in 2005 and 2006.
44
4
Other - pensioner / carer
1
Other - self employed
1
Other - not specified
0.1
Refused
0.1
Cant Say/Dont Know
0.1
Children in household
Just under a fifth (19%) of households included at least one
child less than six years of age (compared with 16% in 2006,
and 13% in 2005).
Occupation of main income earner. (%)
Managers & Administrators
12
Professionals
10
Associate Professionals
13
Tradepersons and related workers
12
Advanced clerical and service workers
4
Intermediate/elementary clerical, sales & service workers
13
Intermediate production and tr ansport workers
10
Labourers and related workers
4
Not employed
Refused
22
0.4
19
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Research findings
This section reports on the key findings of the research, including smoking-related perceptions and behaviour, and issues
relating to quitting smoking. This is followed by a discussion of people’s understanding of the health effects of smoking.
The final sub-sections relate to other areas of interest, including people’s attitudes towards second-hand smoke, smoking
restrictions and point-of-sale displays.
Perceptions of smoking vs. other risks
After the screening questions were administered, the survey investigated people’s perceptions regarding the relative impact
of smoking (and quitting smoking) on the health of the general community. When asked to select from a list that also
included road accidents, alcohol misuse, illicit drugs and AIDS, smoking tobacco was again perceived by a majority of
respondents as the factor causing the most deaths before age 65 in NSW each year.i The next most commonly selected
factor was road accidents, as with previous waves, although this was nominated by a third of the number of people who
nominated smoking. This is illustrated in the following chart.
Figure 7
Which causes the most deaths before age 65 in NSW each year? (%, single response)
53
56 55
2005
2006
2007
23 22
19
10 10
13
7
Smoking tobacco
Road accidents
Alcohol misuse
6
7
Illicit drugs
6
4
5
Don’t know
1
2
1
AIDS
Base: 2005: n=1,619; 2006 & 2007: n=1,630 (weighted to smoking prevalence).
Quitting smoking was still perceived to be the factor most likely to improve someone’s health, nominated by 47% of the
sample. While the 2007 data suggest that quitting smoking remains particularly salient in terms of its potential to improve
someone’s health, this figure is significantly lower than in 2006. Quitting smoking was again followed by regular exercise and
eating a healthier diet, as indicated in the following chart (over page). It is important to note that the 2005 data were based
on a slightly different measure – adjusted single response data from a multiple response question – and, as such, cannot be
directly compared with the 2006 and 2007 figures.
i
It is possible that the screening questions about smoking affected the demand characteristics of this and the following question. Given that the 2005, 2006 and
future surveys will all involve the same demand characteristics, it is more interesting to note any differences in this finding over time. Even so, at least 44% of
respondents were unaware that smoking represents the biggest cause of premature deaths in NSW.
20
Figure 8
Which is the most likely to improve someone’s health? (% weighted single response 2005, single response
weighted 2006 and 2007)
51
47
2005
2006
2007
35
25
20
23
21
18 18
11
6
Stopping smoking
Exercising
regularly
Eating a healthier
diet
8
7
Reducing stress
3
3
0.2 1
Limiting alcohol
intake
2
Don't know
Base: 2005: n=1,619; 2006 & 2007: n=1,630 (weighted to smoking prevalence). NB: 2005 data measured as multiple response, adjusted score used.
In 2005 and 2006, there were no significant differences between smokers and non-smokers in terms of the proportion that
selected smoking tobacco or stopping smoking, respectively, for the two questions above. In 2007, however, smokers were
more likely to mention smoking tobacco as the cause of most deaths, and more likely to mention stopping smoking as the
factor most likely to improve someone’s health. All other significant differences between smokers and non-smokers on these
two measures are shown in the charts below. Non-smokers are more likely than smokers to mention alcohol misuse as a
cause of death. In addition, smokers are more likely than non-smokers to mention stress, and less likely to mention exercise
or diet, as the main factor improving someone’s health.
Figure 9
Which causes the most deaths before age 65 in NSW each year? (% single response)
63
Non-smoker
54
Smoker
20
17
13
8
Smoking
tobacco
Road
accidents
Alcohol misuse
7
8
Illicit drugs
5
3
1
Don't know
1
Aids
Base: 2007: n=1,630
21
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Figure 10
Which is most likely to improve someone’s health? (%)
52
45
Non-smoker
24
19
Smoker
19
13
11
7
Stopping
smoking
Exercising
regularly
Eating a
healthier diet
Reducing
stress
3
3
2
Limiting alcohol
intake
2
Don't know
Base: 2007: n=1,630
22
Smoking behaviour
Various aspects of smoking-related behaviour were measured in this study.
Number of cigarettes smoked
Among daily smokers only, the average number of cigarettes or other tobacco products consumed was 16.0 per day
(compared with 16.7 in 2006, 16.4 in 2005, and a consistent median of 15). This was not significantly different from
previous waves.
People who smoke at least once a week, but not every day, report smoking significantly fewer cigarettes per day than daily
smokers (p<0.01), as illustrated below. On average, the 2007 data indicate that weekly (but not daily) smokers are smoking
10.0 cigarettes in a week (or 1.4 in a day). This represents a significant reduction in cigarette consumption among this
segment, from 15.1 cigarettes per week in 2006 (or 2.2 per day) (p<0.05).
Figure 11
Average number of cigarettes (per day) by smoking frequency. (%)
16.7
16.4
1.8
2005
Daily smokers
16.0
2.2
2006
1.4
2007
Weekly (but not daily) smokers
Base: Daily smokers: 2005: n=702, 2006: n=700, 2007: n=710; Weekly (but not daily) smokers:
2005: n=58, 2006: n=61, 2007: n=76. In 2007, base expanded to include number of pipes or cigars.
Looking at the combined figure for all those who smoke at least once a week (including daily smokers), people reported
smoking an average of 14.6 cigarettes per day (vs. 15.5 in 2006, and 15.3 in 2005). These results are not significantly different
from the 2005 and 2006 data. The median was 15 cigarettes per day, which is on par with previous waves.
23
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Duration since quitting
Among those who used to smoke on a weekly basis, but currently smoke on a very infrequent basis or not at all, the average
duration since quitting smoking was 16.7 years, with a median of 15 years, as illustrated below. Of the ex-smokers sampled,
15% had quit up to one year ago (as per previous waves) and 45% had quit up to 10 years ago (44% in 2006, 43% in 2005).
There were no significant differences over time in terms of duration since quitting.
Figure 12
Duration since quitting smoking (years). (%)
15.6
16.7
16.3
15
15
2005
15
2006
Mean
2007
Median
Base: 2005: n=315 (used to smoke at least weekly, but not anymore), 2006: n=323, 2007: n=291.
Mild, light or low-tar tobacco products
Of those who smoke at all, three-fifths believe that the tobacco products that they usually smoke are mild, light or low tar, as
indicated in the chart below. This is consistent with last year’s result. The wording of this question changed slightly in 2006 in
light of legislation banning the use of certain descriptors on cigarette packaging, as respondents had formerly been asked ‘Do
you normally smoke tobacco products labelled ‘mild’, ‘lights’ or ‘low tar’?’.
Figure 13
Do you believe that the tobacco products that you normally smoke are mild, light or low tar? (%)
2007
60
2006
63
2005
61
Yes
24
33
8
32
29
No
Don't know
5
10
Source
Overall, 45% of smokers bought their last tobacco products from a supermarket, which is comparable with previous waves.
Since 2006, there was a significant increase in the proportion of smokers who most recently purchased from tobacconists,
which effectively cancelled out the trend observed in the previous period, as indicated on the following chart.
Figure 14
Last cigarettes/tobacco products bought from... (%)
45
Supermarket
48
49
17
Tobacconist
12
17
13
13
13
Petrol station
8
Convenience store
9
Newsagency
3
3
Takeaway store or milkbar
Don't know / Not bought
Other
Liquor outlet / Bottleshop
2
10
2005
2006
2007
4
4
5
3
2
1
2
2
2
2
1
2
Cigarette vending machine
1
0.3
1
Airport / Duty free store
1
1
1
Internet
0
0
0.1
Base: 2005: n=743; 2006: n=722 – smokes at all AND smokes tailor-made cigarettes at all AND has bought cigarettes at some
stage. In 2007, base changed from “last pack of cigarettes” to “cigarettes or other tobacco products” – 2007: n=834, smokes at all.
25
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Quitting smoking
Consideration status
Smokers were asked whether they were considering quitting smoking in the next six months, and over three-fifths indicated
that they were. When probed further regarding the seriousness of their intentions, 45% of the total sample of smokers (a
majority of those considering quitting) felt that they were ‘seriously thinking of quitting’ and 16% of all smokers felt it was ‘just
a possibility’ at this stage. In addition, 21% of the sample of smokers stated that they were planning to quit within the next 30
days. This means that, in 2007, a significantly greater proportion of all smokers plan to quit within a month, compared with
the baseline measure (17% in 2005, p<0.05).
Figure 15a
Quitting intentions. (2007)
Are you considering quitting smoking in the next six months? (%) 2007
61
33
Yes
No
6
Unsure / Don't know
Seriously thinking of quitting or just a possibility? (%)
45
16
0.5
Seriously thinking of quitting
Quitting just a possibility
Considering quitting (including ‘don’t know’)
Planning to quit within next 30 days? (%)
21
7
16
1
Within 30 days
Maybe w/in 30 days
Not w/in 30 days
Don't know
Base: 2007: n=834 – smokes at all
No other significant differences were found between 2005 and 2006. The findings from previous waves of research are
illustrated in the following charts, for comparison purposes.
26
Figure 15b
Quitting intentions. (2006)
Are you considering quitting smoking in the next six months? (%, 2006)
63
33
Yes
No
4
Unsure / Don't know
Seriously thinking of quitting or just a possibility? (%, 2006)
46
16
1
Seriously thinking of quitting
Quitting just a possibility
Considering quitting (including ‘don’t know’)
Planning to quit in next 30 days? (%, 2006)
20
Figure 15c
6
18
1
Within 30 days
Maybe w/in 30 days
Not w/in 30 days
Don't know
Quitting intentions. (2005)
Are you considering quitting smoking in the next six months? (% 2005)
59
36
Unsure / Don't know
Yes
No
Seriously thinking of quitting or just a possibility? (%)
42
5
16
0.4
Seriously thinking of quitting
Quitting just a possibility
Considering quitting (including ‘don’t know’)
Planning to quit in next 30 days? (%)
17
6
17
1
Within 30 days
Maybe w/in 30 days
Not w/in 30 days
Don't know
Base: 2005 & 2006: n=819 – smokes at all
27
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
In 2007, a new question was addedi for those who plan to quit within 30 days (n=159), measuring the number of days in
which they intend to quit. On average, these smokers planned to quit in 9.1 days’ time (with a median of 6 days).
There were no statistically significant differences over time among current smokers (those who smoke at all) in terms of the
perceived difficulty of quitting. Respondents were asked to rate how difficult they felt it would be to quit smoking within
the next twelve months, using a scale from zero to ten. Most people felt that it would be relatively difficult to quit, with the
mean perceived rating being 6.7 out of 10 (and a median of 7.0), as indicated in the following figure. Furthermore, 29% of
smokers rated the difficulty of quitting at the maximum level of 10 out of 10.
Figure 16
Perceived difficultly in quitting within next 12 months.
Perceived difficulty in quitting within next 12 months
Extremely
easy
(0)
Mean = 6.7
Median = 7
29% of
responses
Extremely
difficult
(10)
Compared with previous waves, there were no statistically significant differences among current smokers (those who smoke
at all) in terms of the number of quit attempts made. Most people had attempted to quit on multiple occasions. Among all
current smokers, the average number of quit attemptsii they had made was 3.6 attempts, with a median of 2.0 attempts (3.6
and 2.0 in 2006; 3.7 and 2.0 in 2005). In 2007, only 19% of current smokers had never tried to quit, which was significantly
lower than 24% in 2005 (p<0.05). This is a continuation of the trend observed between 2005 and 2006 (20%), reflecting a
significant increase in the proportion who had tried to quit at some stage.
Another questioniii measured the duration since a current smoker’s last quit attempt, among those who had tried to quit at
some stage. The mean duration was 3.5 years and the median was one year (consistent with the 2006 data). Looking at exsmokers or those who currently smoke at all, 34% had tried to quit within the last year (33% in 2006, not
significantly different).
Fagerstrom Test for Nicotine Dependence
A new measure was added to the questionnaire in 2007, to identify how soon after waking a daily smoker had their first
cigarette. This question was added to enable calculation of the Fagerstrom Test for Nicotine Dependenceiv, of which it is a
component. The short version of the Fagerstrom measure, based on two key questions, was adopted in this study.v The
other component measure is how many cigarettes are smoked per day. Overall, a fifth of daily smokers reported having their
first cigarette within five minutes of waking, but almost half (48%) only have their first cigarette after at least 30 minutes, as
shown below.
Figure 17
How soon after waking up do you smoke your first cigarette? (%, 2007)
19
Within five mins
32
1
48
6-30 mins
> 30 mins
Unsure
Base: daily smokers: 2007: n=713
i
To enable the calculation of ‘Quindex’ scores (discussed in further detail following).
ii
Including zero quit attempts.
iii
Added to the questionnaire in 2006.
iv
Guide for the management of nicotine dependent inpatients - Summary of evidence (2002). NSW Health. Pages 9-10. http://www.health.nsw.gov.au/pubs/g/pdf/
nicotine_sum.pdf
v
In calculating this short version of the Fagerstrom measure, “30+ minutes” was scored as 0 rather than left as missing data (given that no particular score was
assigned to this response in the instructions). This allowed score calculation for all relevant respondents.
28
The distributions of scores on the Fagerstrom measure, ranging from zero to six, are illustrated in the following chart. The
higher the score, the greater the individual’s nicotine dependence. The findings show that only 10% of daily smokers score as
‘high’ or ‘very high’ in terms of nicotine dependence.
Figure 18
Fagerstrom Test for Nicotine Dependence (short version). (%, 2007)
55
55
Very low (0-2)
21
21
Low (3)
Moderate (4)
14
14
High (5)
8
8
2
2
Very high (6)
Base: daily smokers: 2007: n=704 (n=9 unsure for component questions)
Additional analysis revealed a strong, significant positive correlation (.318) between nicotine dependence and perceived
difficulty of quitting in the next 12 months (p<0.01). Furthermore, a small (yet significant) positive correlation (.135) was
found between nicotine dependence and age (p<0.01). Higher Fagerstrom scores were observed among older age groups
(p<0.01), as indicated in the chart below.
Figure 19
Fagerstrom score by age. (%) 2007
100%
1
5
2
8
9
80%
12
4
4
10
10
8
15
11
14
Very high (6)
Fagerstrom score (% with given rating)
23
60%
15
25
High (5)
24
23
Low (3)
17
13
11
10
40%
11
Very low (2)
Very low (1)
9
11
Moderate (4)
15
Very low (0)
23
16
20%
42
30
27
19
20
40-49
50-59
0%
18-29
30-39
60+
Age (yrs)
Base: Daily smokers: 2007: n=704 (n=9 unsure for component questions) - includes 18-29: n=156; 30-39: n=179; 40-49: n=172; 50-59: n=115; 60+: n=82.
29
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Quindex
Other new measures were added in 2007 to enable calculation of ‘Quindex’ scores (quitting index). One such measure
asked respondents about the likelihood they would be smoking in a year’s time. Among daily smokers, 13% said they
definitely won’t be smoking in a year’s time, and 43% think they will still be smoking (either definitely or probably).
Conversely, 94% of ex-smokers said they definitely won’t be smoking in a year, and less than 2% think they will or might start
smoking again. These results are illustrated in the following chart.
Figure 20
Likelihood of smoking a year from now by current smoking status. (%, 2007)
Daily smoker
Less frequent smoker
Not at all
Definitely will
15
5
28
17
23
17
101 4
36
21
13
25
94
Probably will
Might or might not
Probably will not
Definitely will not
Base: 2007: Smokes at all or ex-smoker (currently ‘not at all’). Daily: n=713; Less frequent: n=121; Not at all: n=256.
Quindex scores are calculated separately for daily/weekly smokers versus those who smoke less than weekly or are exsmokers. The distribution of Quindex scores for each of these sub-samples range from 0 to 10 and 0 to 13, respectively, and
are illustrated in the following two charts. Higher scores indicate greater quitting activity or quitting intention. The findings
show that Quindex scores among daily or weekly smokers are skewed towards the lower end (i.e. lower quitting activity
or intention).
Conversely, Quindex scores among less frequent smokers or ex-smokers are skewed towards the higher end (i.e. greater
quitting activity or intention). The ‘spike’ at 10 points reflects that the majority of this group are ex-smokers (6 points
allocated), and that 94% say they will definitely not be smoking in a year’s time (4 points allocated).
30
Figure 21
‘Quindex’ - Quitting index, daily/weekly smokers. (%, 2007)
100
80
%
60
40
20
16
22
12
13
10
10
9
5
0
0
1
2
3
4
5
6
2
1
7
8
0.1
10
9
Base: 2007: Smokes daily or weekly: n=789
Figure 22
‘Quindex’ - Quitting index, ‘less than weekly’ or ex-smokers. (%, 2007)
%
100
80
75
60
40
20
0
0
0
0
0
0
1
2
3
4
3
1
0.3
5
6
6
7
4
2
8
9
3
2
10
11
12
3
13
Base: 2007: Smokes less than weekly or ex-smokers: n=301
Some significant differences in Quindex scores were observed between demographic groups. Among daily or weekly
smokers, Quindex scores were negatively correlated with age (-.110, p<0.01), indicating that younger regular smokers
reported greater quitting intention or activity than older regular smokers. In addition, people with lower household incomes
(under $60,000pa) were more likely to have the lowest possible Quindex score (i.e. 0) and less likely to have certain higher
scores (7 or 8). Conversely, among infrequent or ex-smokers, Quindex scores were positively correlated with age (.226,
p<0.01), indicating that older infrequent/ex-smokers reported greater quitting intention or activity than younger
infrequent/ex-smokers.
31
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Reasons and influences
Respondents were also asked about their reasons for quitting and key influences pertaining to their decisions.
Firstly, among smokers who were considering quitting within the next six months, health reasons remained the most
prominent reason for thinking about quitting at this time (76%, allowing for multiple responses). This sub-group was
significantly more likely to mention issues relating to the cost of cigarettes or other tobacco products in 2007 (30%) than
2006 (23%) (p<0.05). These results suggest that health concerns clearly continue to play a key role in driving smokers to
consider quitting, following by increasing concern about cost. In addition, smokers considering quitting were slightly (but
significantly) more likely to mention restrictions on smoking in public places (including at work) as a reason for thinking about
quitting (p<0.05). These findings are represented in the following chart.i
Figure 23
Reasons for thinking about quitting – currently considering. (unprompted, multiple, %)
76
77
79
Health reasons
Cost of cigarettes / tobacco
20
Fitness reasons
6
6
Help / encouragement / nagging from family, children,
partner or friends
The effect my smoking has on my family and/or children
Other - Specified
I want to see my kids grow up
I dont enjoy it anymore
Restrictions on smoking in public places
Advertising / public health campaigns
Don't know
Cigarette pack health warnings
Help / encouragement / advice from GP or health professional
2
5
9
23
30
2005
2006
2007
9
8
9
8
9
7
8
5
4
4
4
6
3
3
1
1
1
1
3
1
1
1
1
0.4
1
1
Base: 2005: n=480, 2006: n=513, 2007: n=509; smokes at all AND considering quitting in next six months
i
It is important to note that, when tracking unprompted open-ended questions, it is impossible to control entirely for subtleties in interviewer coding. This caveat
should be kept in mind when interpreting and acting upon statistically significant differences in unprompted responses.
32
More detailed analysis of those who mentioned cost as a reason for currently thinking about quitting revealed some
significant differences based on demographic characteristics. For example, age (those aged 60–69 years were more likely
than average to mention cost, and those aged 25–29 years were less likely to do so) and income (those with incomes under
$60,000 were more likely than average to mention cost and those with incomes above $60,000 were less likely do so).
Potentially related to the pattern observed regarding income, those who were retired were more likely than average to
mention cost, and full-time workers were less likely to do so. There were no significant differences in terms of gender.
Smokers who were not considering quitting within the next six months, but had made prior quit attempts, were asked
about the main influences for their most recent quit attempt (allowing for multiple responses). Health reasons were again
reasonably salient, followed by the cost of cigarettes and the role of one’s family and/or friends. There were no significant
changes since previous reporting periods, although it is worth noting that this is based on a small sub-sample.
Again, people who recalled prior quit attempts typically mentioned fewer reasons or influences compared with those
currently considering quitting.
Figure 24
Influences for last quit attempt – not currently considering. (unprompted, multiple, %)
46
Health reasons
49
55
17
18
14
Cost of cigarettes / tobacco
13
Other - Specified
16
2005
2006
2007
11
13
11
10
Help / encouragement / nagging from family or friends
(combined)
11
The effect my smoking has on my family and / or children
6
14
6
Don't know
Fitness reasons
3
2
3
4
1
Advertising (combined)
3
3
3
Help / encouragement / advice from GP / health professional
2
3
3
I want to see my kids grow up
1
2
1
Restrictions on smoking in public places
1
2
0
Cigarette pack health warnings
0
Base: 2005: n=182; 2006: n=191; 2007: n=193; smokes at all AND not considering quitting in next 6 months AND have tried to quit previously
33
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Among this same group (that is, people not currently considering quitting but with prior quit attempts), when asked which
factor was the single biggest influencei on their last quit attempt, health reasons were again most commonly mentioned,
followed by cost and the role of family and/or friends.
Figure 25
Main influence for last quit attempt – not currently considering. (unprompted, main reason, %)
39
Health reasons
43
Cost of cigarettes / tobacco
13
11
Other - Specified
13
18
2007
12
Help / encouragement / nagging from family or friends (combined)
8
9
The effect my smoking has on my family and / or children
5
6
Don't know
3
Advertising (combined)
2
Fitness reasons
2
3
3
Help / encouragement / advice from GP / health professional
2
3
I want to see my kids grow up
1
2
Restrictions on smoking in public places
2006
1
1
Base: 2006: n=191; 2007: n=193; smokes at all AND not considering quitting in next six months AND have tried to quit previously
Among those respondents who no longer smoke at all (that is, successful quitters), health reasons remain a particularly strong
influence on their decision to quit, as indicated in Figure 26 (allowing for multiple responses). This was followed again by cost
of cigarettes and the role of family and/or friends, as was the case for other segments. The effect of smoking on one’s family
and children was also relatively salient in 2007. It is worth noting that changes are less likely to be observed in this sub-group
over a small number of years, because many ex-smokers gave up smoking several years ago.
i
34
This question about ‘single main influence’ among those not considering quitting was added in 2006.
Figure 26
Influences for last quit attempt – ex-smokers. (unprompted, multiple, %)
68
65
Health reasons
16
16
Other - Specified
18
7
11
Help / encouragement / nagging from family or friends
(combined)
Fitness reasons
Help / encouragement / advice from GP or health
professional
Advertising (combined)
2007
11
The effect my smoking has on my family and / or children
I want to see my kids grow up
2006
15
Cost of cigarettes / tobacco
15
4
3
4
1
3
2
2
3
Don't know
2
1
Restrictions on smoking in public places
1
1
Cigarette pack health warnings
1
Base: 2006: n=277; 2007: n=256 – used to smoke at least once/week, currently not at all
Among those who no longer smoke, the single main influence on their decision to quit continues to be health, as indicated
in Figure 27.
Figure 27
Main influence for last quit attempt – ex-smokers. (unprompted, %, 2005: single response, 2006: main reason)
57
57
Health reasons
60
13
Other - Specified
17
7
8
The effect my smoking has on my family and / or children
2005
2006
2007
5
5
7
Help / encouragement / nagging from family or friends (combined)
10
13
7
6
Cost of cigarettes / tobacco
4
Don't know
3
1
1
Fitness reasons
2
1
2
Help / encouragement / advice from GP or health professional
2
1
1
Advertising (combined)
1
1
I want to see my kids grow up
1
0
1
4
Restrictions on smoking in public places
0
0
0.4
Base: 2005: n=281, 2006: n=277, 2007: n=256; used to smoke at least once/week, currently not at all. Due to fieldwork error, Q3.7b recorded as single response
in 2005.
35
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Influence of television advertising
Since 2006, respondents have been asked about the perceived role of TV advertising in their decision to quit. Among
those who had tried to quit (or had quit successfully) within the past two years, 37% reported when prompted that TV
advertising influenced their decision to try to quit either ‘a great deal’ or ‘to some extent’, as illustrated in the following chart.
As indicated in the previous charts assessing unprompted influences for quitting, there are multiple influences on quitting
behaviour and the content of the advertising e.g. health effects maybe more top-of-mind than the actual mechanism (TV
advertising).
Figure 28
Thinking about the last time you tried to quit smoking, to what (%) extent did any ads you have seen on TV
influence you to quit?
0.4
2007
63
26
10
0.4
0.2
2006
62
26
12
0.4
Not at all
To some extent
A great deal
Unsure
Have not seen any ads
Base: 2006: n=471, 2007: n=499 (Tried to quit, or quit successfully, within the last two years)
The perceived impact of TV advertising was significantly greater among successful quitters than unsuccessful quitters. More
specifically, successful quitters were less likely to say ‘not at all’, and more likely to say ‘to some extent’, compared with
unsuccessful quitters. However, it should be noted that the base for successful quitters is relatively low. This does not
necessarily prove a causal relationship between quitting and exposure to television advertising, because those who are predisposed to quitting may be more likely to be influenced by advertising.
Succ.
quitters
Thinking about the last time you tried to quit smoking, to what (%) extent did any ads you have seen on TV
influence you to quit?
2007
Unsucc.
quitters
Figure 29
2007
47
2006
49
53
5
35
13
66
2006
24
63
Not at all
To some extent
25
A great deal
Unsure
10
12
0
0
0
0
Have not seen any ads
Base: 2006: n=40 successful, n=424 unsuccessful; 2007: n=43 successful, n=450 unsuccessful (tried to quit, or quit successfully, within the past two years).
36
Unprompted awareness of particular aids
Since 2006, this study has explored whether smokers could name any particular support services, assistance or methods that
are available to help smokers quit. The results indicated 62% unprompted awareness of Quitline as a support service for
quitting, which was significantly higher than in 2006 (55%). Again, unprompted awareness of Quitline was significantly higher
among females (68%) than males (55%, p<0.01). Nicotine Replacement Therapy (NRT) remained the second most salient
form of assistance to quit smoking, as illustrated below. In addition, in 2007, a significantly greater proportion mentioned
natural or alternative therapies, and a significantly lower proportion mentioned prescribed medication.
Figure 30
Can you name any particular support services, assistance or methods that (unprompted, multiple, %) are
available to help smokers quit?
62
Quitline
55
48
NRT (gum, patches, lozenges or inhalers)
53
12
Natural or alternative therapy
7
12
12
Don't know
9
9
GP or other health professional / counsellor
7
8
Other
Cold turkey
4
4
Unspecified telephone helpline
4
Prescribed medication (eg Zyban)
3
Recall Quitline no.
3
2
Cut down on amount smoked
0.5
0.5
Change to mild, light or low tar tobacco products
6
6
2006
2007
0.2
0.2
Base: 2006: n=819, 2007: n=834 (smokes at all)
Aids used (prompted)
Smokers who had attempted to, or had successfully, quit, were asked which particular strategies or aids they had used on
their last attempt to quit smoking. Going ‘cold turkey’ continues to be the most common strategy, reportedly used by just
over half of all smokers in the sample who had tried to quit. However, this represents a significant decrease since
2006 (p<0.01).
Almost a third (31%) had used some form of nicotine replacement therapy, which showed a small but significant increase over
the three waves (p<0.05). The significant increase in the proportion of respondents who had cut down on the amount they
smoked as part of their attempt to quit smoking altogether (observed in the last period), was upheld in 2007 (26%, p<0.01).
Respondents also reported significantly increased use of other self-help materials since last wave (5% to 10%, p<0.01),
37
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
continuing the trend observed in 2006. Other aids that show statistically significant increases over the three waves include
use of the Quitline (3% to 6%, p<0.01) and advice from one’s GP (9% to 12%, p<0.05). Figure 34 illustrates these findings.
Figure 31 Aids used when last trying to quit. (prompted, multiple, %)
52
Cold turkey
68
Nicotine replacement therapy
Cut down on the amount you smoked
15
12
12
Advice from your GP
Other how to quit or self-help materials
5
3
Changed to mild, light or low tar tobacco products
The Quitline (telephone helpline)
3
Natural or alternative therapy
Advice from your pharmacist
3
1
Advice from other health professional
3
2
Advice from your dentist
2
2
Other - Specified
Don't know
2005
2006
2007
9
9
5
5
5
5
4
5
5
5
Prescribed medication
None of the above
7
6
6
9
10
29
26
26
25
70
31
1
1
4
4
0
0.1
0
Base: 2005: n=899, 2006: 923, 2007: n=921; smokes at all AND have tried to quit; OR used to smoke at least once/week, currently not at all. NB: “Pharmacist”,
“other health professional” and “dentist” were added to questionnaire in 2006.
Quitline
Prompted awareness of the Quitline (described as ‘a confidential, free telephone information and advice service for people
wanting to quit smoking’) among smokers and ex-smokers had increased significantly, to 95%, compared with the 92%
observed in 2006 and 2005. Again, awareness levels among current smokers and ex-smokers were similar regardless of
whether an individual had tried to quit (95%) or not (94%). In terms of actual use of the Quitline, 13% of current smokers
who had tried to quit, or ex-smokers, had called the Quitline at some stage, upholding the statistically significant increase
since 2005 (10%, p<0.05). The following figure summarises these key findings.
38
Figure 32
Quitline awareness and usage among those who have tried to quit. (%)
2007
82
7
4
6
0.2
2006
80
7
6
6
0.4
2005
83
7
7
3
0.2
Aware, but never called
Have called (not last attempt)
Not aware
Used last quit attempt
Unsure
Base: (a) Smokes at all (regardless of whether tried to quit) OR ex-smoker, 2007: n=1,090. (b) 2005: n=899; 2006: n=923, 2007: n=921 (smokes at all AND tried
to quit; OR used to smoke at least week, currently not at all)
Generally speaking, females remained more likely to be aware of the Quitline (97%) than males (93%) (p<0.01). As in
2006, females were not significantly more likely to have called the Quitline at some stage (15%) than males (11%). Again, no
significant gender differences were found (among those still smoking) in terms of whether they had ever tried to quit and, if
so, whether they used the Quitline during their last attempt.
Those smokers and ex-smokers who indicated that they were aware of the Quitline were asked how they had become
aware of the Quitline. Advertising, particularly television advertising, was consistently seen as the primary source of
awareness about the Quitline, with 78% of this sub-group nominating television advertising as the way that they had found
out about Quitline. Almost a fifth of the sample mention cigarette pack health warnings as how they became aware of
Quitline, which was included as a new response option in 2007. The relevant findings are illustrated in the chart below.
Figure 33
How did you become aware of the Quitline? (%, multiple response)
86
All advertising (combined)
89
89
Television ads
74
22
23
24
Magazine / poster / print / outdoor ads
18
Cigarette pack health warnings
10
10
10
Radio ads
Word of mouth (friends or family)
5
4
Other - Specified
4
5
"Quit" brochures / stop smoking materials
GP / medical professional
Don't know
Internet
78
79
1
2005
2006
2007
7
3
3
5
3
4
5
2
2
1
0.5
0.2
0.3
Base: 2005: n=1,015; 2006: n=1,006; 2007: n=1,027 - smokes at all OR ex-smokers, AND aware of Quitline (includes 0 quit attempts). “Cigarette pack health
warnings” added in 2007. “Other print ads” merged into magazine/print/outdoor category in 2007.
39
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Of those who have called Quitline at some stage, 58% stated that they would recommend Quitline to someone else who
wanted to quit smoking, compared with 69% in 2006 and 61% in 2005, as illustrated below. Based on a small sub-sample of
n=122, this finding is not a statistically significantly difference.
Figure 34
How likely to recommend Quitline to someone wanting to quit? (%)
2007
27
2006
2005
Definitely would
31
25
4
35
34
31
1
31
Probably would
14
7
Unsure
13
17
17
Probably would not
15
Definitely would not
Base: 2005: n=88, 2006: n=121, 2007: n=122; have called the Quitline at some stage.
Since 2006, an additional series of statements have been presented to respondents in the study to explore specific
perceptions of and attitudes towards Quitline. The results are summarised in the following two figures, with the first one
showing the findings for all those aware of Quitline, and the second chart highlighting only the findings for those who have
actually called Quitline at some stage.
Compared with 2006, fewer people agree that Quitline can help people prepare to quit (among all those aware of Quitline).
Nonetheless, the majority (82%) still agree, rather than disagree, with this statement. Respondents concurred with the
notion that Quitline provides tailored advice (76%) and, to a lesser extent, that staff are supportive and understanding (62%),
although a third were unsure about the latter statement. Of those aware, 39% (mistakenly) believed Quitline was meant for
people who have ‘tried and failed’. There were also mixed opinions about Quitline’s potential to increase one’s likelihood of
quitting successfully.
Figure 35
Agreement with statements – Quitline perceptions. (%)
Agreement
mild strong
QL can help people prepare to make a quit attempt
44
2006
QL can provide tailored advice on the best way for
someone to quit smoking
2006
43
30
46
27
53
25
The people at QL are supportive and understanding
22 18
44
2006
21 17
43
QL's mainly for people who've tried to quit before,
but failed
2006
Unsure
52
9%
56
49
7%
14%
52
15%
30
34%
37%
27
21
16
23
12%
28
20
17
24
12%
QL would increase my chances of quitting successfully
15
16
32
22
15%
2006
16
15
32
24
13%
100
80
60
40
20
0
20
40
60
80
100
Disagreement
mild
strong
Base: 2006: n=1,006; 2007: n=1,027 (except last statement – excludes those who currently do not smoke at all - 2006: n=875; 2007: n=795).
40
Figure 36
Agreement with statements – Quitline perceptions. (%) (among those who have called)
Agreement
mild strong
Unsure
QL can help people prepare to make a quit attempt
11 8
2006
QL can provide tailored advice on the best way to quit smoking
31
54
35
2006
12 5 19
59
7 5 18
64
5%
27
43
16 12 17
2006
QL's mainly for people who've tried to quit before, but failed
35
24
2006
33
24
QL would increase my chances of quitting successfully
23
16
2006
23
18
100
80
60
40
20
0%
56
6%
6%
5%
13 11
The people at QL are supportive and understanding
2%
48
50
10%
11 20
21
28
23
0
5%
17
20
30
3%
6%
31
40
60
80
100
Disagreement
strong
mild
Base: 2006: n=121; 2007: n=122 (except last statement – excludes those who currently do not smoke at all - 2006: n=108; 2007: n=110).
Overall, prior callers were significantly more likely than non-callers to disagree with three of these statements: (a) Quitline
can help people prepare to make a quit attempt, (b) Quitline can provide tailored advice on the best way for someone
to quit smoking, and (c) Quitline is mainly for people who have tried to quit before, but failed. The first two statements
represent the type of service that Quitline aims to provide, with the findings suggesting that callers are feeling ‘let down’ in
these two areas. It is also important to note that non-callers have no direct experience with Quitline and were therefore
more likely to be unsure with regard to these statements.
41
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Health effects of smoking
Perceived personal susceptibility to illness
As shown in the following chart, nearly a fifth (19%) felt that they definitely or probably will not become seriously ill if they
continued to smoke. However, consistent with previous years, it was found that three-quarters of smokers acknowledged
that they, personally, were likely to become seriously ill from smoking if they continued. These results suggest that most
smokers do not reject the risks associated with smoking.
Figure 37
Likelihood of your becoming seriously ill from smoking if you continue? (%)
2007
24
2006
22
2005
52
53
21
53
Definitely will
Probably will
6
14
5
7
13
5
7
Don't know
Probably won't
14
6
Definitely won't
Base: 2005 & 2006: n=819; 2007: n=834 – smokes at all
Smoking and health
Respondents were asked about the extent to which they agreed or disagreed with certain statements relating to smoking
issues. All statements were asked of all respondents (i.e. smokers and non-smokers). However, the charts below present
the results for the smoker sub-sample specifically, because it is smokers’ understanding of the health risks of smoking that is of
primary interest.
In 2005, 18% agreed that social smokers are not doing themselves any ‘real harm’. There was a statistically significant
decrease in this proportion in 2006 (15%, p<0.01), suggesting that people were a little less likely to agree that social smoking
is not harmful. The 2007 data showed no change from the 2006 data, but the significant shift from the 2005 results has been
maintained (p<0.05). These results are shown in the chart below.
Figure 38
If you’re only a social smoker, you aren’t doing any real harm to yourself. (%)
Agreement
mild strong
62
2007
2006
65
2005
55
100
80
60
17
9
18
8 7
23
40
20
2%
10
2%
4%
10 8
0
Unsure
20
40
60
80
100
Disagreement
strong
mild
Base: 2005: n=805; 2006: n=807; 2007: n=821 (smokes at least monthly)
42
The following chart shows that, again, the majority agreed that smoking-related deaths are likely to be slow and painful
(83%). These results are not significantly different from those obtained in 2006. However, the increase in agreement with
this statement that was observed between 2005 and 2006 (75% vs. 80%) has been maintained. So, comparing the 2005 and
2007 results, it was found that smokers were more likely to agree that smoking-related deaths are slow and painful (p<0.01).
Figure 39
If people die from a smoking-related illness, it is usually slow and painful. (%)
Agreement
mild strong
2007
5 5
17
2006
4 5
18
2005
6 6
19
100
80
60
40
20
Unsure
7%
66
10%
62
13%
56
0
20
Disagreement
strong
mild
40
60
80
100
Base: 2005: n=805; 2006: n=807; 2007: n=821 (smokes at least monthly)
More than four-fifths of smokers (85%) agreed that ‘it’s the additives put in cigarettes that make natural tobacco so dangerous
to health’. Overall, agreement with this statement has increased compared to the 2006 results (p<0.01). This is likely to be a
result of recent campaign activity by the Commonwealth, which has emphasised the chemicals in cigarettes.
Figure 40
It’s the additives put in cigarettes that make natural tobacco so dangerous to health. (%)
Agreement
mild strong
2007
6 4
16
2006
6 6
18
62
2005
6 6
17
62
100
80
60
40
20
0
Unsure
5%
69
20
40
8%
9%
60
80
100
Disagreement
mild
strong
Base: 2005: n=805; 2006: n=807; 2007: n=821 (smokes at least monthly)
There was relatively poor understanding that smoking-related illnesses often kill people in middle age, with 70% agreeing
with the relevant statement and 30% either disagreeing or indicating that they were unsure. The findings for this statement
(shown in the following chart) are not significantly different from previous results.
43
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Figure 41
Smoking-related illnesses often kill people in middle age. (%)
Agreement
mild strong
Unsure
2007
12
12
25
44
7%
2006
10
12
27
43
8%
2005
11
13
25
100
60
80
40
20
0
20
Disagreement
strong
mild
11%
41
40
60
80
100
Base: 2005: n=805; 2006: n=807; 2007: n=821 (smokes at least monthly)
Understanding of tobacco’s cancer-causing agent
Again, most smokers could not correctly identify which substance in cigarette smoke is the main thing that causes cancer.
When asked to choose from a list of substances, as shown in the following chart, 26% of smokers indicated that tar was the
main cancer-causing substance in cigarette smoke. This represented a significant decrease from the 2006 data, when 32% of
smokers said that they thought tar was the main cancer-causing substance in cigarette smoke. In addition, there were fewer
mentions of carbon monoxide (20% in 2007 vs. 27% in 2006), and a greater proportion indicating it was ammonia that causes
cancer (8% in 2007 vs. 3% in 2006). There was also an increase in the proportion who indicated they did not know (15%
in 2007 vs. 9% in 2006). These results (overall p<0.01) suggest there was greater confusion among smokers about which
substance in cigarette smoke causes cancer. The change in results is probably due largely to the Commonwealth campaign,
which emphasises a range of chemicals that can be found in cigarettes.
Figure 42
Which substance in cigarette smoke is the main thing that causes cancer? (%)
34 32
27
26
22
20
2005
2006
2007
19 20 20
15
12
10 8 10
9
8
3 3
Tar
Carbon
Monoxide
Nicotine
Don't know
Lead
Ammonia
1 0.5 1
None of these
Base: 2005: n=805; 2006: n=807; 2007: n=821 (smokes at least monthly)
In 2007, a fifth of smokers felt it was nicotine that was the main cancer-causing substance in cigarettes. This was consistent
with last year’s result. It is unclear the extent to which this is problematic. Certainly, other results from this study suggest
that most smokers are well aware of the dangers of smoking. It is probably not important for them to understand that tar
44
represents the main cancer-causing agent. Given that some smokers believe that nicotine is the main cancer-causing agent,
it is possible that this may act as a barrier to using nicotine-replacement therapy. However, further investigation on this issue
would be required before any reliable conclusion could be drawn.
Again, non-smokers were more likely than smokers to believe that it was nicotine (28%), and smokers were more likely than
non-smokers to believe that carbon monoxide was the primary cancer-causing agent (20% vs. 12%, overall p<0.01).
Health warnings
Smokers were asked to recall any of the health warnings displayed on cigarette packs. When the survey was conducted
in 2006, the new health warnings had only just been released. At that time, the highest spontaneous recall (including
partial recall) was for the warning regarding smoking during pregnancy (69%). In 2007, recall of the old health warnings had
declined. Indeed, all old warnings were significantly less likely to be recalled in 2007 than in 2006 (p<0.01). With respect to
the old health warnings, the one that was most likely to be spontaneously mentioned was ‘smoking causes lung cancer’ (42%),
followed by ‘smoking when pregnant harms your baby’ (39%). Spontaneous recall of the old health warnings in 2006 and
2007 are shown in the following two charts.
Figure 43
Recall of health warnings on cigarette packs. (%, 2007)
Smoking kills
86
9 5
Your smoking can harm others
44
92
Smoking is addictive
33
94
Accurate recall
Figure 44
77
14
9
Smoking causes heart disease
61
32
7
Smoking when pregnant harms your baby
58
27
14
Smoking causes lung cancer
Partial recall
Not mentioned
Recall of health warnings on cigarette packs. (% 2006)
Smoking when pregnant harms your baby
24
Smoking causes lung cancer
30
Smoking kills
29
Smoking causes heart disease
17
Your smoking can harm others
15
Smoking is addictive
46
31
25
45
8
63
14
69
10
12 1
Accurate recall
75
86
Partial recall
Not mentioned
45
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
In 2006, spontaneous recall of most of the new health warnings was very low (for most, 1-2%). Spontaneous recall of the
‘new’ health warnings was significantly higher in 2007 than 2006 (p<0.01). That said, they are still reasonably low. This
is probably because the new warnings are likely to function primarily on a visual level. Although awareness of the images
themselves may be high, it is likely that recall of the written accompanying message is lower. These results are shown in the
following chart.
Figure 45
Recall of ‘new’ health warnings on cigarette packs. (%, 2007)
Smoking causes mouth and throat cancer
4
Smoking harms unborn babies
5
69
26
77
18
Smoking causes peripheral vascular disease
2 13
85
Smoking clogs your arteries
5 10
86
Smoking causes emphysema
5 9
86
Smoking causes blindness
5 7
88
Dont let children breathe your smoke
2 7
91
Smoking - a leading cause of death
34
94
Smoking doubles your risk of stroke
14
94
Quitting will improve your health
23
95
Tobacco smoke is toxic
12
96
Accurate recall
Partial recall
Not mentioned
Base: 2007: n=834–smokes at all
As can be seen, messages regarding mouth and/or throat cancer, and messages relating to unborn babies, were most
commonly recalled. It is possible that the warning relating to unborn babies may appeal more to smokers if it does not apply
to them, allowing them to reject the risks for them personally, and this may explain why it has higher levels of unprompted
recall. The fact that the warning showing mouth cancer has been used more broadly in campaign activity probably explains
the relatively higher recall of this message.
At this point in the survey, respondents were asked about their exposure to, and perceived personal impact of, pictorial
health warnings on tobacco packaging. At the time of the 2006 survey, the roll-out of these new warnings was fairly limited.
Therefore, in 2006, respondents were told: ‘New health warnings are currently being introduced onto cigarette packs. These
show pictures of the damage done by smoking’ and were explicitly asked (a) whether they had seen the new warnings,
followed by (b) their perceived impact. In 2007, it was significantly more likely that smokers would have been exposed to
these pictorial health warnings. Therefore, respondents in the most recent wave were told: ‘Since last year, health warnings
on cigarettes show pictures’ and were then asked directly about the impact of these warnings, with any unprompted
mentions of not having seen the warnings being recorded within this codeframe. This change should be kept in mind when
comparing the relevant results for 2006 with 2007.
In 2007, exposure to the new picture warnings was near universal, with less than 1% of those who smoke at all reporting
that they had not seen the warnings, compared with 76% in 2006. This suggests that, whatever type of impact the warnings
have on people, this impact has significantly greater ‘reach’ in 2007. When asked about the impact of the warnings, the
46
relative order of responses was similar across both waves. The most common responses were ‘they had no effect on me’
(nominated by more than two-fifths of smokers) and ’they made me think about quitting’ (reported by more than a third
of smokers). In addition, more than a quarter reported that the warnings made them want to hide their cigarette packs or
cover the image, which represents a significant relative increase since 2006.i These findings are illustrated in the chart below.
Figure 46
What effect, if any, have these new warnings had on you? (prompted, multiple, %)
Had no effect on me
10
Made me think about quitting
10
Made me feel I should hide my cigarette packet from view
5
Made me feel embarrassed about smoking
4
Other (specified)
Have not seen new warnings
2
42
36
27
17
2006
9
2007
0.4
76
2006 scores adjusted - proportion of total smoker base. Base: 2006: n=819; 2007: n=834 - smokes at all.
Perceptions of tobacco companies’ responsibilities
There was no change in community attitudes regarding tobacco companies being required to make cigarettes that are less
likely to cause fires, which was supported by 69% of respondents. The breakdown of responses is shown in the
following chart.
Figure 47
Tobacco companies should be required to make cigarettes that are less likely to cause fires. (%)
Agreement
mild strong
13
2007
15
9
17
11 7
15
14
2006
2005
100
11
80
60
40
20
0
Unsure
54
7%
6%
55
55
20
40
12%
60
80
100
Disagreement
strong
mild
Base: 2005: n=1,619; 2006: n=1,630; 2007: n=1,630 (weighted to smoking prevalence)
i
This is after factoring in the change in the base size between 2006 and 2007. That is, the figures are based on anyone who smokes at all. Given the lower
awareness of the pictorial warnings in 2006, this is why the difference between the results is so large.
47
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Second-hand smoke
Smoking bans in the car
Just under half (47%) of those households containing at least one smoker (and having a car) reported people having smoked
inside at least one of their cars in the last month. This represents a significant decrease from the 2006 figure of 53%
(p<0.05), but is similar to the 48% found in 2005. The corresponding figure for households containing no smokers was 2%
(as in 2006 and 2005). Among smoking households where children under six years live, 75% reported children had not
travelled in cars that had been smoked in during the last month (no significant change from 66% in 2006, 72% in 2005).
Respondents who indicated that there was at least one car in their household that had been smoked in during the past
month were asked about their household’s intention to ban smoking inside the car. As shown in the following chart, just over
half felt they would consider banning smoking inside their cars at some stage, which was similar to the 2005 and
2006 findings.
Figure 48
Sometime in the future, I think our household will ban smoking in the cars. (%)
Agreement
mild strong
Unsure
2007
35
9
14
38
4%
2006
34
10
13
38
4%
7
14
31
2005
100
80
60
40
20
0
6%
41
20
40
60
80
100
Disagreement
strong
mild
Base: 2005: n= 470; 2006: n=504; 2007: n=468 (at least one car in household has been smoked in during last month).
Attitudes towards environmental tobacco smoke
Respondents were asked about their attitudes regarding exposure to other people’s smoke in public places, with the
significant attitudinal differences based on smoker status consistent with previous waves, as indicated below. Again, around
half the sample of non-smokers are bothered ‘a great deal’ when exposed to other people’s smoke, and almost nine in ten
non-smokers say they are bothered to some extent. Conversely, it was again found that around three-fifths of the subsample of smokers report not being bothered at all (p<0.01). Even so, around two-fifths of smokers themselves continue to
report being bothered to some extent by other people’s smoke.
48
Figure 49
How do you feel when exposed to other people’s smoke in public places? (%)
(a) Non-smokers
47
2007
19
22
11
0.5
51
2006
21
18
9
0.5
47
2005
Bothered a great deal
2007
8
7
2006
7
7
21
Bothered a fair amount
Bothered a little
(b) Smokers
25
20
Not bothered at all
59
28
12
0.2
Don't know
1
58
0.5
2005
8
7
Bothered a great deal
27
Bothered a fair amount
57
Bothered a little
Not bothered at all
1
Don't know
Base: (a) Non-smokers - 2005: n=814; 2006: n=823; 2007: n=809; (b) Smokers (at least monthly) - 2005: n=805; 2006: n=807; 2007: n=821.
Respondents were asked a prompted question about the reasons for being bothered by other people’s smoke. The findings
show that unpleasantness remains the reason most commonly mentioned across all segments of the sample. In 2007,
unpleasantness was more likely to be mentioned by smokers than non-smokers (p<0.05). Short-term and long-term health
effects are again more likely to be mentioned by non-smokers than smokers (p<0.01). In addition, since 2006, a greater
proportion of the total sample say they are bothered by exposure to environmental tobacco smoke due to long-term health
reasons (increasing from 53% to 57%, weighted to smoking prevalence, p<0.05). These findings are illustrated in the series of
charts on the following page.
49
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Figure 50
What is it about tobacco smoke that bothers you? (%, multiple response – 2007)
74
I find it unpleasant
67
It can have an immediate or short term
effect on my health
24
36
It can have a long term effect on
my health
Smoker
Non-smoker
38
59
2006
68
63
I find it unpleasant
It can have an immediate or short
term effect on my health
20
38
It can have a long term effect on
my health
Smoker
Non-smoker
36
55
2005
74
68
I find it unpleasant
It can have an immediate or short term
effect on my health
It can have a long term effect on
my health
Smoker
19
37
Non-smoker
29
46
Base: People who are bothered to some extent. Smokers (at least monthly) - 2005: n=335, 2006: n=336, 2007: n=324. Non-smokers - 2005: n=702, 2006:
n=743, 2007: n=712.
Those respondents who cited multiple reasons above were then asked to nominate their single main reason. Unpleasantness
remained more likely to be the main reason for being bothered by other people’s smoke among smokers than non-smokers
(overall p<0.01), as shown in the following chart. Overall, health effects were more likely to be mentioned as the main
reason by non-smokers than smokers (p<0.01). In particular, long-term health effects were again more likely to be the main
reason for non-smokers than smokers (overall p<0.01). Immediate or short-term health effects were least likely to be the
main reason across the sample. This pattern of results is not surprising, given that smokers are already voluntarily exposing
themselves to the harmful health effects of tobacco smoke, whereas for non-smokers, the health risk arises through
other people.
50
Figure 51
What is the main thing about tobacco smoke that bothers you? (%, single main response – 2007)
65
I find it unpleasant
46
It can have an immediate or short term
effect on my health
Smoker
10
13
Non-smoker
25
It can have a long term effect on my health
40
2006
60
I find it unpleasant
46
It can have an immediate or short term
effect on my health
Smoker
11
14
Non-smoker
29
It can have a long term effect on my health
2005
61
I find it unpleasant
It can have an immediate or short term
effect on my health
It can have a long term effect on my health
38
Smoker
10
16
Non-smoker
29
46
Base: People who are bothered to some extent. Smokers (at least monthly) - 2005: n=335, 2006: n=336, 2007: n=324. Non-smokers - 2005: n=702,
2006: n=743, 2007: n=712.
Understanding of risks of environmental tobacco smoke
All respondents were asked about the extent to which they agreed or disagreed with certain statements relating to secondhand smoke. Although 84% rejected the statement ‘I believe that passive smoking is fairly harmless’, around 16% still failed
to see the harm associated with passive smoking. This indicates that people are more likely to perceive passive smoking as
harmless compared with 2006 (12%, p<0.01).
51
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Figure 52
I believe that passive smoking is fairly harmless. (%)
Agreement
mild strong
Unsure
74
2007
2%
10 4 10
2006
79
9 46
2%
2005
76
10 5 6
3%
100
80
60
40
20
0
20
40
60
80
100
Disagreement
strong
mild
Base: 2005: n=1,619; 2006: n=1,630; 2007: n=1,630 (weighted to smoking prevalence)
All respondents were also asked about the nature of tobacco smoke. Maintaining the trend observed over last period,
slightly fewer people appeared to be aware of the residual nature of tobacco smoke, with 71% agreeing that ‘tobacco smoke
you can no longer see stays in the air for hours’ (vs. 74% in 2005, p<0.01).
Figure 53
Tobacco smoke you can no longer see stays in the air for hours. (%)
Agreement
mild strong
Unsure
2007
6 9
25
46
14%
2006
5 8
27
44
17%
2005
5 9
54
13%
100
80
60
40
20
20
0
20
40
60
80
100
Disagreement
strong
mild
Base: 2005: n=1,619; 2006: n=1,630; 2007: n=1,630 (weighted to smoking prevalence)
The fact there were reasonable proportions who failed to reject these statements suggests the community’s understanding
of when people can be at risk of exposure to passive smoke is somewhat limited. These results are consistent with a theory
that people often only perceive visible smoke to be potentially harmful.
52
Attitudes towards smoking restrictions
Workplace restrictions
The research assessed people’s attitudes and behaviours relating to smoking restrictions in various types of public places.
There was near universal support (94%) for the notion that workers have the right to a smoke-free workplace, yet this figure
represents a slight drop since 96% in 2006 (p<0.05).
Figure 54
All workers have the right to work in a smoke free environment. (%)
Agreement
mild strong
Unsure
2007
42 7
87
1%
2006
21 6
90
1%
2005
22 5
89
1%
100
80
60
40
20
0
20
40
60
80
100
Disagreement
strong
mild
Base: 2005: n=1,619; 2006: n=1,630; 2007: n=1,630 (weighted to smoking prevalence)
Since 2006, this study has assessed the community’s support for smoking restrictions in a range of additional public
environments. Overall, there remained strong support for full smoking restrictions in playgrounds (90%). As hypothesised,
the level of support was significantly stronger among non-smokers than smokers (p<0.01). The results are presented in the
following two charts.
Figure 55
I support making all playgrounds smokefree by law. (%)
Agreement
mild strong
Don't
know
2007
55 6
84
1%
2006
44 7
84
0%
100
80
60
40
20
0
20
40
60
80
100
Disagreement
strong
mild
Base: 2006 & 2007: n=1,630 (all, weighted to smoking prevalence)
53
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Figure 56
I support making all playgrounds smokefree by law. (%)
Agreement
mild strong
2007
35 6
NS
Smkr
2006
100
80
40
20
1%
87
10 5 9
60
1%
73
33 6
Smkr
1%
86
11 5 9
NS
Don't
know
1%
74
0
20
40
60
80
100
Disagreement
strong
mild
Base: 2006 – Smokers (at least monthly), n=807; Non-smokers: n=823. 2007 – Smokers, n=821, Non-smokers: n=809.
Of the two statements included in 2007 that relate to smoking in cars, the highest level of support (90%) was found for
banning smoking in cars in which children are travelling. This was not significantly different since 2006. Relatively speaking,
less support was shown for making all cars smoke free by law (63%), although this figure had increased significantly since 2006
(58%, p<0.01). These findings are shown on the following chart.
Figure 57
Agreement with statements – smokefree laws in cars. (%)
Agreement
mild strong
Don't
know
Cars in which children are travelling should be
smokefree by law (2007)
445
85
1%
2006
546
83
1%
20 16 12
All cars should be smokefree by law (2007)
23
2006
100 80
60
40
20
17 12
0
20
51
2%
46
2%
40
60
80 100
Disagreement
strong
mild
Base: 2006 & 2007: n=1,630 (all, weighted to smoking prevalence)
54
Licensed premises
In terms of how the possibility of environmental tobacco smoke (ETS) exposure affects people’s behaviour, a majority (66%)
of the sample continue to report that, when going out, they try to avoid situations that are likely to be smoky. Again, this
avoidance behaviour is more common among non-smokers (75%) than smokers (24%, p<0.01). Yet, the fact that almost a
quarter of smokers also try to avoid smoky situations remains significant.
Figure 58
When you go out, do you try to avoid situations that are likely to be smoky? (%)
66
2007
33
69
2006
2005
1
30
64
2
35
Yes
No
1
Don't know
Base: 2005: n=1,619; 2006 & 2007: n=1,630 (weighted to smoking prevalence)
Exploring the behaviour of smokers in more detail, fewer smokers in 2007 (34%) report trying to avoid situations where they
will be unable to smoke inside compared to 2006 (p<0.05), reversing the increasing trend observed over the period from
2005 to 2006, as indicated in the following chart.
Figure 59
When you go out, do you try to avoid situations where you will be unable to smoke inside? (%)
34
2007
65
39
2006
60
34
2005
1
1
64
Yes
No
2
Don't know
Base: 2005 & 2006: n=819; 2007: n=834 – smokes at all.
Among smokers, there was no significant change observed in the proportion of people (57%) who agree that there are so
few places to smoke that they smoke when they can, rather than when they want to.
Figure 60
There are so few places to smoke these days, that I smoke when I can, rather than when I want to. (%)
Agreement
mild strong
2007
27
2006
23
2005
26
100
80
60
Disagreement
strong
mild
40
20
12
Unsure
15
42
3%
15
18
41
4%
14
16
0
5%
40
20
40
60
80
100
Base: 2005 & 2006: n=819; 2007: n=834 – smokes at all.
55
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
At this point in the questionnaire, the following description of the upcoming changes to smoking restrictions in licensed
premises was provided to respondents:
‘As you may be aware, in NSW, smoking indoors in pubs, clubs and all licensed premises is gradually being phased out. All indoor
areas of pubs and clubs will be made smoke free by July 1st, 2007.’
Respondents were asked about the extent to which they agreed or disagreed with certain statements relating to changes to
smoking restrictions in licensed premises. The previous increases in support for smoke-free pubs and clubs (for both health
and amenity reasons) has been maintained in 2007. Hence, the majority of people (86%) felt that going smoke free would
make pubs and clubs safer for them to be in. In addition, the majority (87%) continue to see smoke-free pubs and clubs as
more pleasant for them to be in.
Figure 61
Going smoke free makes pubs and clubs safer for me to be in. (%)
Agreement
mild strong
Unsure
2007
7 5 13
74
2%
2006
7 4 14
74
1%
2005
9 5 13
100
80
60
40
20
0
70
20
40
2%
60
80
100
Disagreement
strong
mild
Figure 62
Going smoke free will make pubs and clubs more pleasant for me to be in. (%)
Agreement
mild strong
2007
6 4 12
76
2006
6 5 11
76
2005
10 5 11
100
80
60
40
20
0
2%
2%
72
20
40
Unsure
2%
60
80
100
Disagreement
strong
mild
Base for both charts: 2005 - n=1,603 – excl. pilots; 2006 & 2007: 1,630 (weighted to smoking prevalence).
56
The previous growth in public desire for all indoor areas of pubs and clubs to be smoke free remains constant in 2007, with
84% of the respondents supporting this statement. It should be noted that the wording of this statement changed slightly
between 2005 and 2006, when the statement used was ‘I support a total ban on indoor smoking in pubs and clubs’.
Figure 63
I believe the indoor areas of all pubs and clubs should be smokefree. (%)
Agreement
mild strong
Unsure
2007
8 7 8
76
1%
2006
9 7 10
75
0%
13
2005
100
80
60
40
7 11
20
0
69
20
40
1%
60
80
100
Disagreement
mild
strong
Base: 2005 - n=1,603 – excludes pilots; 2006 & 2007: 1,630 (weighted to smoking prevalence).
The reduced level of support for the gradual phase-in of smoking restrictions that was observed last period has also been
maintained. This suggests a continued preference for restrictions to be introduced all at once, as illustrated below.
Figure 64
Any restrictions on smoking should be introduced gradually, rather than all at once. (%)
Agreement
mild strong
Unsure
2007
27
7
20
43
2%
2006
29
6
20
43
2%
6
17
22
2005
100
80
60
40
20
0
2%
52
20
40
60
80
100
Disagreement
strong
mild
Base: 2005 - n=1,619; 2006 & 2007: 1,630 (weighted to smoking prevalence).
57
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
The research also examined respondents’ expectations regarding how frequently they would visit pubs and clubs once
smoking is no longer permitted indoors. Compared with their current frequency of visits, 70% expect that there will be
no change in their number of visits to pubs, clubs and bars once smoking is no longer permitted indoors. A quarter of
respondents think they will visit more often, as shown in the chart below.
Figure 65
Expected change in number of visits to pubs and clubs once smoking no longer permitted indoors. (%)
2007
6
2006
6
2005
7
64
Visit less often
Same number of visits
70
25
71
23
29
Visit more often
Base: 2005: n=1,606; 2006: n=1,611; 2007: n=1,609 (excl. “don’t know”), weighted to smoking prevalence.
Analysis by smoking status shows that non-smokers remain more likely than smokers to think that they will visit pubs and
clubs more often after the complete ban (p<0.01). Vice versa, smokers are more likely than non-smokers to expect that
their frequency of visits will decrease after a complete ban (p<0.01). In 2007, non-smokers are still more likely than in 2005
to think that they will visit the same number of times (p<0.01). These results are illustrated in the following chart.
Expected change in number of visits once smoking no longer permitted indoors by smoker status. (%)
Smoker
Figure 66
2007
20
73
7
2006
21
73
6
Non-smoker
2005
69
24
7
2007
2
69
29
2006
2
71
28
2005
2
62
Visit less often
35
Same number of visits
Visit more often
Base: 2005: Non-smokers: n=807; Smokers: n=799; 2006: Non-smokers: n=816; Smokers: n=795; 2007: Non-smokers: n=799; Smokers: n=810.
Before being asked the questions that relate to smoking in licensed premises, respondents were asked to indicate roughly
how many times in a typical month they visit a pub, club or bar. Then, after the questions regarding the smoking restrictions,
respondents were asked to indicate roughly how many times each month they felt that they would be likely to go to licensed
premises once a complete ban on smoking inside had been introduced. Overall, the reported figures suggest that the
average number of monthly visits to pubs and clubs would increase from 3.2 to 3.6 visits (consistent with previous waves).
Again, different patterns were observed for smokers versus non-smokers. On average, smokers reported that their visits
would decrease from 3.6 to 3.0 visits per month. Conversely, non-smokers’ reports suggest that they would increase their
average number of visits from 3.1 to 3.8.
58
Attitudes towards point-of-sale displays
An additional series of statements was added to the 2007 questionnaire to explore community support for various means
of regulating point-of-sale displays. Overall, there was strong support for increased regulations at all places where tobacco
products are sold. This included support for the display of cigarette health warnings (94%), as well as the availability of
information to help people quit smoking (93%) and information regarding cigarette ingredients (93%). The wording of the
statement regarding storing cigarettes out of sight at the point-of-sale was rotated across the sample. That is, around half
of the respondents were presented with the statement ‘I support regulation to ensure that, in shops, cigarettes are stored
‘out of sight’ and, for the remainder, the statement ended ‘out of sight of children’. As hypothesised, support for this type
of regulation was generally higher when the statement was phrased ‘out of sight of children’ (89%) than simply ‘out of sight’
(78%). All of these findings are illustrated on the following chart.
Figure 67
Agreement with statements. (%)
Don’t
know
Agreement
mild strong
I support regulations that ensure cigarette health warnings
are displayed where tobacco products are sold.
3 210
84
0%
I support regulation to ensure that, in shops, cigarettes are
stored out of sight of children.
37 9
81
1%
I support regulation to ensure that, in shops, cigarettes are
stored out of sight.
9 11 19
59
2%
Information to help people quit smoking should be available
where all tobacco products are sold.
3 3 11
82
1%
Information about the ingredients in cigarettes should be
available where all tobacco products are sold.
33 9
83
1%
100
80
60
40
20
0
20
40
60
80
100
Disagreement
strong mild
Base: 2007 - n=827 for ‘out of sight of children’; n=803 for ‘out of sight’; n=1,630 for all others (weighted to smoking prevalence).
For each of these statements about point-of-sale displays, there was significantly stronger support among non-smokers than
smokers (p<0.01). The lowest level of support found among smokers was for storing cigarettes ‘out of sight’ (without making
any reference to children). These differences are summarised in the following chart.
Figure 68
Agreement with statements. (%)
Agreement
mild strong
I support regulations that ensure cigarette health warnings
are displayed where all tobacco products are sold.
I support regulation to ensure that, in shops, cigarettes are
stored out of sight of children.
I support regulation to ensure that, in shops, cigarettes are
stored out of sight.
Information to help people quit smoking should be available
where all tobacco products are sold.
Information about the ingredients in cigarettes should be
available where all tobacco products are sold.
NS
Smkr
22 7
88
9 5 20
66
16 8
NS
Smkr
83
11 9 13
NS
Smkr
24
17
16
0%
1%
1%
0%
67
6 10 20
Don't
know
63
2%
2%
41
NS
Smkr
2310
84
1%
6 4 16
73
NS
Smkr
32 8
86
1%
1%
5 5 15
73
2%
100 80
60
40
20
0
20
40
60
80 100
Disagreement
strong
mild
Base: 2007 - For ‘out of sight of children’, smokers (at least monthly): n=414, NS: n=411; For ‘out of sight’, smokers: n=407, NS: n=398; For all others, smokers:
n=821, NS: n=809.
59
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Conclusions and recommendations
Overall, the pattern of results from this research was similar
to that from previous years. Even so, there have been some
significant shifts in a number of key areas. In this round of
research, there was found to be significantly more people
who had never tried smoking. This suggests that the tobacco
control activities operating in NSW appear to be playing an
important role in preventing the uptake of smoking.
Among those who do not smoke every day, there has been
a significant reduction in the mean number of cigarettes
smoked on a weekly basis. Thus, infrequent smokers are
smoking even less frequently. This is likely to be a result of
the expansion of smoke-free legislation in NSW.
Smoking restrictions appear to be having an effect on
people’s attitudes and behaviour, and the final phases of
implementing the smoke-free legislation in the pub and club
environment is likely to have further positive impact. An
analysis of the main reasons why smokers are considering
quitting shows that smoke-free legislation is having a small,
but significant, impact on smokers’ reasons for
considering quitting.
Of the remaining smokers, still more than 60% indicated they
are considering quitting in next six months, with the number
planning to quit within a month increasing significantly from
17% in 2005 to 21% in 2006. In fact, preparedness to quit
appears to have increased, given that there has been a
significant increase in the proportion planning to quit in the
next month. Like previous waves of research, the majority of
smokers appeared to accept the likelihood of their becoming
seriously ill if they continue to smoke. It is evident that large
numbers of smokers understand the health risks of smoking
and want to quit. This suggests that calls to action and quit
resources and support would seem likely to produce the
greatest effect among this group in the population.
In general, the use of TV advertising appears to have been
successful in NSW. Among those who have tried to quit
(including those who have been successful), more than a third
indicated when prompted that TV advertising influenced
their decision to try to quit. This is expected to be higher
given that there are multiple influences on quitting behaviour
and the content, e.g. health effects may be more top-of-mind
than the actual mechanism (TV advertising).
60
Health reasons have continued to be the biggest reason to
quit. The cost of cigarettes has gained importance, with
almost a third citing this as a reason for considering quitting.
There may be an opportunity to further leverage smokers’
propensity to see cigarettes as too costly.
More successful quitters used aids, self-help materials and
support from the Quitline when they gave up smoking,
suggesting that attitudes towards seeking assistance have
changed. It is possible that the Quitline campaign has
brought about this positive change. Certainly, the Quitline
campaign appears to have successfully increased (particularly
unprompted) awareness of the service, thereby increasing
its salience in the minds of smokers. Many of the other
attitudinal measures suggest there is still potential to improve
smokers’ understanding of who Quitline is for, and their
perceptions of its likely effectiveness.
Awareness of pictorial warnings on cigarette packs was found
to be high. More than half of smokers report that these have
had some effect, suggesting that the pictorial warnings have
made a positive impact since their introduction in
March 2006.
After the introduction of the Excuses campaign, there were
a number of significant improvements in relation to specific
beliefs targeted by campaign. Specifically, in 2006, smokers
were found to be more likely to see smoking as harmful, and
they were more likely to agree that smoking-related illness is
usually slow and painful, than they were in 2005. The 2007
data show that these improvements have remained stable.
Strong support for smoke-free pubs and clubs has been
maintained. The results suggest that there is now greater
acceptance of these restrictions among smokers, who
report being less likely to avoid places where they cannot
smoke. Likewise, there is widespread support for smoking
restrictions in workplaces, playgrounds, and increased
support for banning smoking in all cars.
The results also suggest that introducing new restrictions
at the point-of-sale are likely to be supported, even among
smokers. The only proposal that received any significant
opposition from smokers was regulations to store cigarettes
out of sight. Such an initiative is more likely to be accepted if
cigarettes are stored out of the sight of children.
SECTION TWO: QUALITATIVE RESEARCH
UNDERSTANDING SMOKERS
DECEMBER 2006
Trish Cotter1
Anita Dessaix1
Donna Perez1
Michael Murphy2
1
2
Cancer Institute NSW
Market Access Research and Consulting, South Melbourne, Victoria
61
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Executive summary
Key findings
The legal and cultural smoking environment
■
The social milieu of smoking has changed
substantially in recent years.
▪
■
The combination of graphic warning labels and
their associated advertising, and legislative changes;
have resulted in smokers feeling more outcast than
they have previously been.
The current legislative and cultural environment has
substantially affected smokers in a variety of different
ways, with the most significant change being that
smokers believe they have become more socially outcast
than any time in the past.
▪
There is a perception that the combination of smoking
restrictions and graphic warning labels have granted nonsmokers more permission to complain about smoking
and smokers, and that this has developed into a form of
ostracism and discrimination.
▪
Numerous stories were presented that smokers believed
demonstrated how they were being harshly and unfairly
judged for their smoking.
▪
Consequently, smokers are feeling somewhat browbeaten at the moment. While it was apparent that
this experience has supported some in their resolve
to reduce their smoking, it has also left smokers with a
perception that they are on their own in their quitting
attempts and that there is little support or assistance
available for them in the process.
▪
The sense of pressure that smokers are experiencing
suggests that there is an increasing need for health
authorities and campaign messages to engender
a greater sense of empathy with smokers and the
difficulties that they experience in quitting. This
perceived pressure to quit may be attributed to the
current tobacco control environment, which includes
legislation and advertising.
▪
Creating empathy would be achieved to some extent
through a demonstration of the support and assistance
that is available to smokers in the quitting process.
■
Smokers are asking for a greater degree of empathy
with their situation, and more support and assistance
in the process of quitting.
This research project was exploratory in nature, and
sought to provide insights into NSW smokers that could
be used as the basis for the development of future
campaigns and programs to reduce the incidence of smokingrelated diseases.
The qualitative research approach involved 10 group
discussions with smokers, segmented by age (18–24,
25–34, 35–49 and 50+) and location (Sydney, Parramatta
and Dubbo).
Participants were prompted to talk about a range of
issues related to the way they think and feel about being
a smoker, with a specific focus on today’s legislative and
cultural environment.
The psychosocial role of smoking
▪
▪
▪
62
Smokers commonly talk about smoking as simply
‘just something that I do’. However, their behaviours
demonstrated that it has far more of a pivotal role in
their life than the flippancy suggested by this statement.
That smokers tend to downplay the importance of
smoking in their lives suggests a key communication
objective is to prompt smokers to think about the effects
and consequences of smoking, rather than just smoking
without thinking about it. In line with the sentiment of
the National Tobacco Campaign, this means somehow
prompting smokers to be conscious of each cigarette
they have and the effects of each and every cigarette.
To achieve this end, there may be an opportunity to
create a sense of personal relevance in advertisements
through creating ‘smoker moments’ from the behaviours
that demonstrate the high level of priority smokers
actually place on their smoking.
Quitting and services for smokers
▪
Thoughts about quitting appear to be focused primarily
on attitudes, rather than strategies. While unsuccessful
quit attempts appear to be related to a lack of effective
strategies to assist smokers through the difficulties they
experience in the process.
▪
These findings confirm that a critical factor in
facilitating smokers in quitting would be to assist them
in developing strategies for quitting, and especially in
formulating mechanisms to deal with stress during their
quit attempts.
▪
Stress and the perception of stress is a significant factor
in smoking. People report smoking as a stress relief;
smoking when they are under stress; failing in their quit
attempts when they experience stress and putting off
quit attempts until they are stress free.
▪
The importance of stress as both a prompt to smoke
and a reason not to quit illustrates that assisting smokers
in developing ways to deal with stress without smoking
would be of considerable value in assisting them to quit.
▪
Knowledge and experience of services for smokers, such
as the Quitline and Quit courses, was very low.
▪
There is a need to better inform smokers about the
range of assistance that is available to them in the
quitting process, given misconceptions about the service
among some smokers.
▪
▪
Hence, such communications should aim to
communicate the value that these services offer
to smokers in terms of how they can help and the
difference they can make to quit attempts.
Perceptions of health consequences and related messages
▪
Smokers’ perceptions of health consequences suggest
that messages about the inevitability of disease have
a greater capacity to affect smoker’s thoughts and
intentions about quitting, compared with those that
focus or rely on the risk of disease.
▪
In particular, there appears to be considerable utility in
messages about the inevitability of emphysema.
▪
There appears to be an opportunity for developing
communications that refer to the already experienced
health effects, such as shortness of breath, and
relate these symptoms to more serious long-term
consequences. Such messages would be expected to
have a high degree of salience and relevance, and would
provide an effective prompt to think about smoking
and quitting.
▪
A specific example is that shortness of breath at the
top of stairs could be used as a ‘smoker moment’ that
would create a strong sense of personal relevance in
communication concepts.
▪
The effective communication of health effects
messages is still dependent on smokers developing an
understanding that it is the cigarette they are smoking
now that is the problem, rather than the one that they
may or may not smoke in the future.
▪
These findings also suggest that the ‘Every cigarette
is doing you damage’ message still has some salience.
However, more needs to be done to demonstrate how
this is the case.
▪
Smokers have a limited understanding of the mechanism
by which smoking is associated with a wide range of
diseases. In particular, once diseases are not directly
related to the respiratory or the circulatory system, it is
less obvious how smoking can play a role.
▪
Hence, there is likely to be some value in messages
that are aimed at increasing smokers’ understanding of
how smoking causes diseases. A specific example that
appears to have some utility is messages about the toxic
chemicals in tobacco smoke that spread through the
body and thereby causes cell damage in all organs
and tissues.
However, it is acknowledged that any promotion of this
service needs to be matched by the quality and value of
the actual service that is delivered.
Smoking as an addiction
▪
▪
Perceptions about the notion of addiction suggest that
caution would need to be taken to ensure that any
communications about addiction were not interpreted as
judgemental and accusatory.
Further, the diversity of reactions to the concept of
addiction suggest that any related messages would
benefit from focusing on the behavioural and habitual
aspects of smoking that are indicative of addiction,
rather than the specific fact of addiction. Smokers relate
well and strongly to these kind of behaviours, but not
consistently to the concept of addiction.
63
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Quit advertising
▪
The visual impact of recent advertising associated with
the graphic warning labels has substantially changed
the smoking environment. The consequent sense of
ostracism that smokers are experiencing suggests that
there may be a need for communications to create a
greater sense of empathy with smokers.
▪
Other than the recent warning labels campaigns, the quit
advertisements most commonly mentioned as having an
impact included Parents and Echo.
▪
Other ads mentioned by smaller numbers as having had
some impact included Emphysema (Radio), Bubblewrap,
Hook and various Quitline advertisements.
▪
Responses to the tag line ‘Every cigarette is doing you
damage’ suggest that there is likely to be considerable
value in communications that assist smokers to improve
their understanding of how this is the case
The government and the tobacco industry
▪
64
For messages that focus on criticising the tobacco
industry to achieve any salience, increased knowledge
and understanding of the role and activities of the
industry would be required.
Introduction
Background
Research objectives
The Cancer Institute NSW commissioned Market Access
to conduct qualitative research that contributed to an
understanding of NSW smokers in 2006. This report
documents the background and approach to the research,
and the findings and conclusions from the research.
The overall aim of the research was to provide an
understanding of NSW smokers’ thoughts and feelings about
smoking in 2006, to inform campaign development.
The key issues relevant at the time (Nov 2006) that were
pertinent to the design and approach that was adopted for
the project:
▪
▪
▪
▪
being a smoker in today’s legislative and
cultural environment
▪
the psychosocial role of smoking
▪
the social acceptability of smoking
There was an unprecedented amount of tobacco control
activity, including ongoing communications campaigns,
new graphic health warnings and the phasing out of
smoking in pubs and clubs.
▪
the health consequences of smoking, including loss of life
and quality of life
▪
addiction
The combination of warning labels and communication
campaigns included a strong focus on graphic
health messages.
▪
current interventions, including communication
campaigns, health warnings, price and
smoking restrictions
▪
support services for smokers.
NSW reported a 2.2% decline in smoking prevalence
between 2003 and 2005, with smoking prevalence then
appearing to plateau.
Other factors about smokers and smoking that were directly
relevant to the design and approach for the project included:
▪
To address this aim, the research specifically addressed issues
related to the attitudes, beliefs and knowledge of smokers in
relation to issues such as:
While health is the primary reason for quit attempts,
smokers are not fully aware of the health consequences
of smoking and most underestimate the severity of
smoking-related illness.
▪
Smokers want to quit, but tend to delay quitting by using
self-exempting beliefs about the risks.
▪
Smoking plays an important psychosocial role, which is
likely to be affected by changing rules and social norms.
▪
These changing rules and social norms mean that there
are increased pressures on smokers.
▪
The research was exploratory in nature, and sought to
provide insights into NSW smokers that could be used
as the basis for the development of future campaigns and
programs to reduce the incidence of smoking
related diseases.
Research approach
The research was conducted through a series of 10 group
discussions with 79 smokers. Factors taken into account for
stratifying the groups included age, sex and location. Based
on discussions with the Cancer Institute NSW project team,
the chosen option was to segment the research primarily on
age and to include a specific focus on younger smokers.
The research was conducted in metropolitan Sydney,
including an inner city location and a suburban location
(Parramatta) to provide a cross-section of middle and lower
socio-economic status (SES) smokers, and in a medium-sized,
regional town (Dubbo).
The following recruitment criteria were also included:
▪
Smokers who smoke at least five cigarettes a day (to
exclude people who are only social or
occasional smokers).
▪
Smokers who report that they are thinking about
65
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
quitting in the next twelve months (to exclude those
who are resistant to change).
▪
Group 7: Aged 18–24, including some under 20 and
some over 20, Parramatta.
▪
Smokers from middle and lower SES backgrounds (to
reflect the smoking population).
▪
Group 8: Aged 25–34, including some under 30 and
some over 30, Parramatta.
▪
A mix of men and women in each group.
▪
▪
Based on the selected locations, it was possible to
ensure that at least some of the participants came from
backgrounds other than Australian.
Group 9: Aged 35–49, including some under 40 and
some over 40, Parramatta.
▪
Group 10: Aged 50 years and over, Parramatta.
▪
Exclude smokers working in health promotion, market
research or tobacco industries.
The groups were segmented as per the table below. A mix
of men and women were recruited to each group.
18–24 yrs
25–34 yrs
35–49 yrs
50 yrs +
Outer
Metropolitan
1 group
1 group
1 group
1 group
Inner
Rural
Metropolitan
1 group
1 group
1 group
1 group
1 group
1 group
These age ranges were chosen because they provide
reasonably natural groupings that facilitate the group
discussion process and reflect similarities in life stage
and attitudes to smoking. Hence, the focus of research
structured along these lines allowed an exploration of
the factors that might vary by life stage. In summary, the
following groups were conducted:
66
▪
Group 1: Aged 18–24, including some under 20 and
some over 20, Central Sydney.
▪
Group 2: Aged 25–34, including some under 30 and
some over 30, Central Sydney.
▪
Group 3: Aged 18–24, including some under 20 and
some over 20, Dubbo.
▪
Group 4: Aged 25–34, including some under 30 and
some over 30, Dubbo.
▪
Group 5: Aged 35–49, including some under 40 and
some over 40, Dubbo.
▪
Group 6: Aged 50 years and over, Dubbo.
Recruitment
Recruitment was conducted by a professional recruitment
agency. Participants were paid an incentive according
to current market rates. An appropriate screener was
developed to assist the recruitment processes.
Group facilities
Metropolitan focus groups were conducted in locations that
allowed viewing via one-way mirror. In the rural location
the groups were conducted in a local conference centre. All
research sessions were recorded for the purposes of analysis.
Analysis and Reporting
Recordings of the groups were transcribed and the
transcripts thematically analysed for preparation of this
report. A selection of quotes has been included in the
report for illustrative purposes. The number after each
quote is a reference to the group number. However, it needs
to be noted that the included quotes are for illustration
rather than necessarily reflecting the specific attitudes of and
differences between each demographic group.
Detailed findings
The findings of the research have been presented in
relation to the key areas of discussion, matching the main
research objectives. Analysis of the research focused on
identifying those issues about smoking and characteristics
of smokers that are especially relevant to the current social
and cultural context, and we have not necessarily attempted
to document all of the issues and characteristics that have
been previously documented and where there has been no
obvious recent change.
The findings are presented under the following
main headings:
▪
Psychosocial role of smoking
▪
Social and cultural context of smoking
▪
Quitting and Quit services
▪
Attitudes to addiction
▪
Perceptions of health consequences
▪
Perceptions of recent advertising
▪
Attitudes to government and tobacco industry
▪
Summary of geographic differences
Psychosocial role of smoking
Participants were prompted to discuss what they liked about
smoking and the role that it played in their lives. Commonly,
smoking was described as a habit, simply as ‘something we
do’ rather than something that smokers think about.
“It’s something to do when you’re bored.”
“I don’t light up ‘cos I like it, I just light up ‘cos I do.”
“It’s just something that I do. I know that sounds really strange,
but … I more or less feel like it’s part of getting dressed. You
feel naked if you don’t have a cigarette.”
“Once it becomes a habit, it becomes less things you like about
it, rather than just having to do it. Like, it’s part of your day,
part of your routine.”
However, despite this apparent flippancy, the behaviours
that participants talked about suggest that they do in fact
think about their smoking quite a lot. Descriptions of the
habit of smoking suggested that they planned their days
around smoking, allowing a break for a cigarette at notable
time points across the day, including around work periods,
around transport usage, to fit in with recreation and exercise
regimes, to accommodate family obligations, etc.
Further, participants reported having made choices about
where they went and who they spent their time with to
ensure that they could smoke. This had consequences in
terms of both activities and friendships, and demonstrated
the strength of their link to smoking.
“My decisions are based around smoking. Like, if we’re going
somewhere and there’s say two cars driving, I’ll get in the car
you can smoke in. Or if we’re going somewhere and we’ll sit
somewhere, I’ll be like, ‘Oh, can we sit there, I wanna smoke?’
So, I think you have a lot more options if you didn’t smoke.”
“Yeah, you can miss out on friendships from smoking, but I’d
rather smoke, so …”
“It’s also, like, money ... usually like, for example, if you had your
last $50, you consider you only have $40, ‘cause you allow ten
bucks for a packet of smokes.”
“Yeah, or petrol. Have you got ten bucks? No, I want
cigarettes, forget the car.”
“If I’m invited to a restaurant, I won’t go because you can’t
smoke.”
“You don’t want to go somewhere you can’t smoke. The choice
is not to go there.”
“With my wife’s two sisters, because, like, they’re dead against
it and they hate the smell of it … we’ll have a cigarette and
then we’ll have a shower and get changed and go [to visit
them].”
“We don’t go out as much anymore because there are so
many restrictions and you can’t smoke in restaurants and stuff.
So, we’d much rather be in our own backyard or on our own
balcony because there’s no restrictions there.”
“You do it just because you do it”
67
NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Participants generally accepted the notion of smoking
as providing the punctuation marks in daily life – it was
something to do at the beginning and end of each activity
and provided a pause in the middle if needed.
“Just anywhere, you know, like I’m going to catch a bus, have
a cigarette. I’m going for a walk, have a cigarette. You know,
I’m watching TV, I’ve just had dinner, like you know … we find
associations for everything.”
“I think it just kind of finishes your task … like, it just kind of
completes your task. If you’ve had dinner, you have a cigarette
to complete it.”
“I’ll do this, then I’ll have a cigarette.”
Smoking across age and life stages
Participants were prompted to discuss how smoking had
changed for them. There was acknowledgement from
smokers that the role of smoking in their lives had changes
substantially since they first took it up.
Consistently, they reported taking it up when they were
younger because it was the thing to do among their peer
group. Being a smoker meant being one of the trend-setters,
part of the cool group. It was regarded as adult
and rebellious.
It seemed, though, that circumstances began to change
sometime after people left secondary school. Smoking had
become more intrinsic, a characteristic of the definition
and perception of self, and less something that was done to
achieve an image.
“I wait and I wait and I wait until everyone else goes to bed …
then I have complete and utter quiet, no TV, nothing on, just me
and the coffee and the two smokes. And that’s just my time.”
“It’s something to do, like, sometimes, like … I’d be studying
and, like trying to have a break and like, it’s a good break,
coffee, cigarettes. It’s a nice little ten minute break.”
“It marks the time of your day, you know what I mean? It’s like
a milestone in your day.”
“You reward yourself.”
These findings suggest that a key communication objective
should be to prompt smokers to be conscious of the
effects and consequences of smoking, rather than just
smoking without thinking about it. In line with the
sentiment of the NTC, this means prompting smokers to
be aware of and focused on each cigarette that they have
and of the effects of each and every cigarette. One aspect
of this message could be associated with the behaviours
that demonstrate the high level of priority smokers do
actually place on their smoking.
68
“It’s not [cool] to us, because we’re older.”
“It’s natural now, it’s just a habit.”
“[It changes] probably when you turn eighteen, you don’t have
to hide them anymore … you can buy them yourself, you don’t
have to find someone to buy them for you.”
“It’s not peer pressure anymore, whereas when we first started
smoking everyone was doing it.”
“When I started, when I was young, it was like, you know, sort
of the cool thing to do. But, now I look at myself and … there’s
nothing cool about it … I think I feel like an idiot … anyone
who sees me doing it, you know, I should be smarter than that.”
“It’s almost as soon as you get out of school … you go into
the big world, and people just look down on you … whereas in
school … the kids were like, ‘You smoke’, you know.”
“It started out to be cool, ‘cause everyone else was doing it ...
now it’s … completely changed. You can’t stop now.”
“I don’t think you really notice the change … like, you start
having it to be cool and that, and then before you know it, ‘Oh
I’ve got to have a cigarette otherwise I can’t
perform’.”
would deny the health effects, or at least argue that
these did not apply to them, and they would vehemently
defend their right to continue smoking. On the other
hand, when prompted, they almost all reported that they
wished they had never started and that there was some
kind of magic pill to help them quit.
For some, it was apparent that this change happened soon
after they left secondary school, while some others indicated
that the ‘cool’ phase could continue well into their twenties
and possibly thirties.
The segmentation of the groups highlighted that attitudes
and thoughts about smoking also changed with people’s age,
indicating variations in its psychosocial role over time and
life stage. As these differences were not the central focus
of this study, and are probably well-documented elsewhere,
we have not included a detailed description or analysis here.
Notwithstanding, the following paragraphs provide a general
outline of some of the key age and life stage differences
observed during these groups.
▪
▪
▪
Young adult smokers tended to think that smoking
was a temporary phase, and that certain life events
would result in them quitting. These life events most
commonly included: pre-determined ages such as 21, 25
or 30; changing from study to work; new relationships;
pregnancy; or children. Typically, this group believed
they would be able to quit when the time came. Given
their belief that they were only smoking for a short time,
this group tended to dismiss the warnings about long
term health effects as having little relevance.
The 24–35 age range included a mix of smokers, some
of whom fitted well into the young adult smoker attitude
set, and some of whom appeared to have attitudes
and beliefs that were more similar to the over 35
adult smokers. In many ways, this age group reflected
something of a transition period, during which smoking
changed from being a short-term activity to being more
embedded as an unwanted habit.
Once over 35, it was apparent that attitudes among
smokers had substantially developed. Among these
groups, smoking had become more embedded and more
problematic in their lives. Most had tried to quit at least
once, and recognised how difficult it was. They had also
started to feel some of the health effects, most obviously
in relation to breathing, fitness and general immunity; but
more serious and specific symptoms were also reported.
Consequently, there was a tendency for some to have
become more defensive about their smoking, and more
dismissive of attempts to persuade them to quit. For
some, it was as if they had to defend smoking because
they were aware of the control it had over them, they
▪
For some among the over 50s age group, the presence
of smoking-related health effects, including heart disease,
emphysema and other lung diseases, left them almost
resigned to the inevitability of a life affected by smoking.
For some, it was as if they had accepted smoking and
its consequences as a fact of their lives. For many of
these older smokers, it was no longer possible to deny
the effects, and yet they were also cognisant of smoking
being an addiction and, given the number of attempts
they had made, had little confidence in their ability
to stop. Some were making attempts to reduce the
amount they smoked, but this seemed to be the most
they could hope for.
▪
For others among the older participants (especially
in Dubbo, Group 6), the belief that they did not
currently have any smoking related diseases reinforced
for them that they were one of the lucky ones who
were not going to be affected by smoking. A couple
of participants in this group reported that they had
regularly attended their doctor for health checks, and
each time when their doctor gave them a clear bill of
health, they interpreted this as an indication that smoking
was not causing any damage.
In this context, it is worth noting that the researcher felt
there had been somewhat of a shift in some of these
attitudinal differences from previous qualitative research. In
particular, it was apparent that smoking was being perceived
as more problematic at a younger age than in past research.
Similarly, acceptance of the health effects messages seemed
to be higher and participants seemed to be less resistant
to these messages and defensive of their smoking than they
had previously. These differences can be understood in
the context of higher levels of awareness of the impact of
smoking and a greater degree of social pressure to
quit smoking.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Social and cultural context of smoking
Participants were prompted to discuss how circumstances
had changed for smokers in recent years. There was a
perception that smokers were more outcast now than
previously. This was a strong and consistent finding across
the groups, and underlines a substantial change in the social
milieu regarding the acceptability of smoking. Participants
consistently reported experiencing more negative thoughts
about their smoking, especially in public, than they had in the
past. There was some feeling that these changes in the social
milieu of smoking had reached the point of smokers being
discriminated against.
The sense of being outcast was associated with a perception
that non-smokers have been granted more allowance to
complain about smokers and to directly taunt people about
their smoking. Participants felt that the recent and imminent
smoking rules in venues have contributed to the perception
that it is now more okay to complain about smokers than it
ever has been.
The graphic warning labels, along with their associated
advertisements, have also painted smoking in a more
gruesome light. The consequences of this are that nonsmokers have even more evidence on which to base their
complaints about smokers and more ammunition with which
to give smokers a hard time.
“I think it is more a secret shame, you know.”
“I feel guilty. I try to find somewhere where there’s no passers
by, so no one will give me dirty looks.”
“It is becoming more, you know, like socially unacceptable, and
then I’ve been hassled before for flicking a cigarette butt on the
floor.”
“You’re more aware of where you’re smoke and I tend to sort
of you know, ‘do you mind?’ That comes up a lot. Especially
when you’re outside and you’re standing next people.”
“People really hate you … they hate it, like, people who smoke
are the lowest scum of the earth.”
“We’re definitely more discriminated against.”
“Yeah, they just give you dirty looks.”
“Oh just in the workplace over the last year I’ve noticed non
smokers have a dig at smokers that take a cigarette every two
hours or something.”
“It seems a bit out of proportion.”
“Like it can be ostracising. Like, a lot of people who are avid
non-smokers, like, even if they can smell it on you they’ll take a
step back.”
“Just the stigma … it’s more or less like you are a second class
citizen.”
“It is weird, because now we’re the outcasts. Before everyone
who didn’t smoke was.”
“The irony is that we all started because of peer group
pressure, and yet now we’re trying to ignore the peer group
who are pressuring us to stop!”
“It’s not as accepted as it used to be, especially in the
workplace.”
“You feel like a bit of a leper.”
“I think it is the stigma of it now too. Like, you feel like a leper
or a murderer or worse, really.”
“I feel embarrassed smoking now.”
70
“It is socially acceptable to put down smokers.”
“Everyone tells you [that] you stink.”
“The whole perception of smoking [has changed]. Now, it’s
looked at as dirty … if you spark up, they just look at you in
that way.”
“I hate that you get bagged out for it, you know, from everyone.
But it’s still legal.”
A factor that was especially evident with some of the
younger participants, but also a factor among some of the
older age groups, was a reported tendency to be spending
more time among smoker friends than non-smokers. This
was partly associated with venue rules, but also because
smokers felt more comfortable in the company of other
smokers, where they knew that they would not be constantly
hassled about their smoking. In this sense, smoking was
still valued for its social aspects, and for the opportunity it
provided to have a break and chat with others.
“So you sort of mix with people who smoke so you know, you
get more friendly with them ‘cause you know you can get along
with them.”
“A lot more places you can’t, that you normally would. It’s sort
of like, ‘Oh hell, can’t smoke here’, and it sort of feels a bit weird
to look for a spot where you can.”
“You tend to hang with people that smoke you know,
conversation flows easier and you’ve got someone you can
smoke with, you know in the nightclub or…”
“And you feel out of place. Like, I went to a Christmas party
last year … and the people who arranged the Christmas party,
they were non-smokers and good Christian people, and I wasn’t
game enough to light up a smoke. No way.”
“Just the social feeling of it, even when you’re at work. All
the smokers gather around in a group and have a yarn while
they’re having a cigarette.”
“It’s kind of funny, actually, you almost have an instant
connection with someone who does smoke. Like, if you see a
group of people smoking out the front of the building, everyone
just huddles and you just smoke together.”
“We actually don’t socialise with a few of the people who have
given up smoking … we used to get together … but because
they don’t smoke anymore, we sort of go, ‘Oh no, we won’t
worry about inviting them, we’ll invite someone else.”
In essence, smokers from across the age ranges talked
about making social decisions based on smoking. Examples
were provided where they would choose to spend time
with friends who smoke, they would choose venues where
they knew smoking was possible, and if there was a choice
of transport they would go in the car where smoking was
allowed. Some also noted that their friendship groups had
tended to become smoker groups.
Some smokers, especially amongst the older age groups
(35+), talked about being the only ones at social gatherings
who smoked, and that they were less likely to be catered
for these days with smoking areas or ashtrays. Some also
mentioned being embarrassed about having to leave a
social group to go outside for a cigarette, feeling that this
demonstrated a weakness.
“Something that has changed for me, I don’t like to smoke in
the street, but basically that’s the only place I can smoke.”
“I went to a 40th birthday party … there was probably 35
people there, and there was myself, my husband and another
guy that smoked. We were stood in the corner, they had no
ashtrays for us or anything.”
Younger smokers (18–24) talked about the reduced number
of people smoking when they went out, and noted that,
consequently, asking for a cigarette or a light was becoming
a less useful mechanism for starting conversations. Similarly,
some also noted that being out socially with non-smokers
could cause difficulties for the group.
“It’s harder to get a light on the street.”
“A lot of my friends are you know a few years younger than me
anyway and they haven’t been smoking for as long as I have so
they have quit and kind of been able to stay non smoking. And
the number of us who smoke is getting fewer and fewer now.
And I kind of have that feeling of I am going to be the last one
still smoking. I’m going to be going out on my own to have
a cigarette.”
“One of the things I hate … is the whole stigma thing ... when
I’m out with my mates and they have to wait for me because
I’m having a cigarette or I have to go out here because I’m
having a cigarette, I’m going to this part of the bar because I’m
having a cigarette, and they get the shits, and they’re just like,
‘Why do you have to do it?’, sort of thing. It’s a pain in
the arse.”
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
“Well, more people are giving up, sort of thing, so you’re more
a leper if you go out in a group of people, sort of thing, you’re
likely to find you’re the odd one out.”
“Kids give you a hard time too, I’ve noticed … I got home
the other day and there was a note on the fridge saying that
anyone that smokes will be put in the naughty corner.”
“I feel like it can be quite anti-social. If you’re in a group of
ten people and you’ve all gone out to dinner or a work party or
whatever and you’re the only one that smokes and you keep
leaving the table … that embarrasses me actually. I still do it,
but it does [feel antisocial].”
“They go on about it these days … ‘mum, don’t you know that
that’s disgusting?’.”
“My youngest sone, he said to me … ‘you should give up
smoking’ … it was more like he ordered me, like he was the
boss … that was my twelve year old.”
“When the grandchildren come home, I have to stop smoking.”
As noted in a subsequent section of this report, this
perception of being outcast appeared to be considerably
stronger amongst metropolitan smokers than with those
from the regional groups.
Some mentioned that the smoking restrictions had prompted
them to change their smoking in certain circumstances to a
form of binge smoking, having several cigarettes when they
got a chance, to make sure that they made up for or were
prepared for the gap before the next smoking opportunity.
“I have a tendency to binge smoke, I suppose you could
call it. If I’m at work, if I’m working at an office and you go
out for a smoke, I’ll go out and I’ll have three in a row and
then go back upstairs for a couple of hours and work away
and then go back down and have three in a row again. So,
that’s definitely changed the way I smoke.”
“You probably feel like, oh God knows when I’m going
to have another chance so let’s get them all out of the
way now.”
Some of the older participants talked about how they could
not smoke around their grand children, and parents discussed
how their own children would constantly pressure them to
quit smoking. These restrictions added to the sense of
being outcast.
“They scream their head of and they say, ‘Are you going for a
walk again?’.”
Price was also mentioned in every group as a factor that
had changed substantially about smoking in recent times.
Participants commented that cigarettes seemed to be a
much greater proportion of their spending these days, with
$50–$100 per week being a typical spend among these
groups. Some, especially amongst the younger groups
but also in older ages, reported that the price meant that
smokers were now much more reluctant to share their
cigarettes. Some also noted that this had become more of
an issue in relation to occasional smokers who might ask for
cigarettes when they were out drinking. Smokers seemed
to experience a sense of kinship in the price and the way this
had changed the idea of handing out cigarettes, as if it had
become an unwritten understanding that it was now too
expensive to ask.
“I can remember when you used to go out and there’d always
be the person there that had the packet of cigarettes and
everyone would just smoke from the cigarettes, and the next
time you went out, you didn’t sort of keep check on who bought
the cigarettes. But, you can’t do that now.”
“I don’t even give them to people that ask.”
“If someone comes up and asks me for a cigarette, I tell them
to go and get a job and buy your own. They’re too dear to give
away.”
72
Smokers have developed an acute sense of feeling judged
and outcast in recent years, which is linked to changes
in legislation and to the graphic nature of advertising and
warning labels. The strength of these feelings suggests that
there is an increasing need for demonstrating empathy
with smokers.
Quitting and quit services
Participants were prompted to talk about their thoughts,
attitudes and experiences of quitting. Almost all participants
mentioned that they had at least thought about quitting, with
only a small number having never made at least one quit
attempt. Quitting attempts had lasted from a matter of days
to several years.
Several women specifically mentioned that they had quit for
a year or more during pregnancy and their children’s infancy.
Several, including some in each group, mentioned that they
were currently in the process of cutting down the amount
that they smoked. Some expected that this would eventually
lead to quitting while others were aiming at reaching a low
level of smoking that they believed was acceptable.
As might be expected, younger participants did not
experience the same degree of urgency about quitting as
did the older smokers. For them, quitting was something to
concern themselves about in the future.
“I thought about it, but I decided not to yet.”
“I don’t wanna quit yet.”
“If I wanted to [I could quit], but at the moment it’s the lesser
of two evils, something I can do while I’m working. Something
that doesn’t affect the way that I think and all those sort of
things.”
When prompted to discuss issues of regret, almost all
participants reported they would like to have never smoked.
It was apparent that the degree of regret was also directly
related to age. Similarly, almost all suggested that if there
was some magical way of stopping, they would choose it
either straight away or after one last cigarette. In several of
the groups, these admissions provided an interesting contrast
to their forceful and argumentative denial of the health
effects and their defence of their right to continue smoking.
“I don’t think anyone is actually proud that they smoke.”
“I just wish they could give you like a magic cure that … you
just go to sleep tonight and you wake up tomorrow, and you
don’t have to [smoke].”
A small number disagreed, saying that smoking was such a
central component of their self-perception that they could
not imagine not being or having been a smoker.
“It would erase part of who I am.”
“I’d feel naked without it.”
Participants in the older age groups were especially adamant
that they would welcome the proverbial magic pill if it would
make quitting easy. These reactions reflected the difficulties
that they have previously experienced with quitting attempts
and their concern that they may not be able to quit. They
also reflect smokers’ comments about being addicted.
“We know it’s bad for you and you’d love dearly to be able to
just say – or if someone come in here and said look, I’ll give you
an injection, you’ll never want to smoke again, I say bring it on.”
“Just let me finish my pack of cigarettes first … if you’re going
to give it up for the rest of your life … you just want to enjoy
the last one.”
The main reasons for wanting to quit were the cost of
smoking and the health effects. Cost appeared to have a
relatively higher priority among younger smokers, but was
also an issue across the ages. However, the cost of nicotine
replacement was consistently mentioned as something of a
barrier to quitting.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
“If the patch was cheaper, I’d consider using it, but it’s cheaper
to buy two packs of cigarettes and you only used to get one
thing of patches that’d last half as long.”
Cosmetic issues were an additional quitting motivator for
some, especially among women in the younger groups,
though this was rarely rated as a sufficient reason to quit.
A few of the women reported experiences of the condition
of their skin improving when they stopped smoking. These
women felt this would be a significant prompt for them
to quit again. However, others who had not had similar
experiences either doubted the link or felt that it was not
personally relevant.
“Like, the look and stuff. Like, I do think about that, like, quite
often.”
The looks, yeah, that scares me. I suppose with lung cancer
and stuff like that you can hide it, but with mouth, throat
cancer, you can’t.”
When asked about the type of assistance that they would
most value in the process of quitting, the most common
response was related to financial assistance with nicotine
replacement therapies (NRT). As detailed later in this
report, participants typically felt that the price of NRT was
high relative to smoking, and reported that if authorities
were serious about assisting smokers to quit they would
provide appropriate financial support. Some mentioned
feeling that it was rather anomalous that people addicted
to other drugs were provided with this kind of support (e.g.
methadone), while smokers had to pay for replacement
therapies themselves.
“Like every time I quit I think, man if I was getting something
for this or if I was getting helped out, ‘cause usually it is at
times when I’m like totally broke. Yeah if the government was
willing to pay for patches and stuff then that would seriously
help out …”
“Stop putting on ads and start giving out aids.”
“I get a bit frustrated when the – if you’re taking an illegal
drug, like heroin or something like that, you get all the help in
the world and it doesn’t cost you anything. But if you’re taking
a legal drug like this, you’ve got to pay to get off. If you’re a
heroin addict, you go to the doctor, the doctor sends you to a
methadone clinic or whatever it may be. You’re taking a legal
drug that they get money off you for and they give you nothing
back.”
“If you’re a heroin addict, they give you everything
for nothing.”
“There was no incentive for me to quit knowing that patches
were the same, actually about the equivalent of the price of my
cigarettes.”
In line with the reported perception of being judged and
ostracised by non-smokers, some reported that the kind
of assistance they would really value in quitting would be a
degree of empathy and support from the people around
them, rather than being nagged about their smoking. This
included non-smokers developing an appreciation of the
addictive nature of quitting and the associated difficulties
with quitting; and Quitline services that were empathetic.
“Have a referral line that doesn’t, you know, dismiss you.”
“I always think with my boyfriend’s parents, when they’re
nagging me to quit, I just smoke more around them because
they’re nagging me. Like, you know … Yeah, I don’t mean to
but it’s just, you know, they won’t stop nagging you so,
you know, maybe if they’d just back off then I’d probably quit
but …”
“A bit more support from the people who are nagging.”
74
Participants were prompted to discuss their feelings about
their ability to quit. A common response was that they
believed they could quit if they wanted to, but the bigger
issue was the ‘really wanting’ to. While these responses
sound somewhat flippant, they reflect a basic notion that
the mental attitude was a principal factor in a successful quit
attempt. However, they also reflect an approach to quitting
that is primarily focused on attitude, with little attention paid
to strategies.
Participants also tended to assess their self-efficacy with
respect to quitting based on previous attempts. In
particular, some of the older smokers who had stopped
for a time and then returned to smoking recognised that
quitting was difficult, and were less confident in their ability
to succeed, than were some of the younger smokers who
had not yet seriously attempted quitting. Some also based
perceptions of their own self-efficacy on the experiences
of other smokers around them, noting that seeing others
experience difficulties with quitting confirmed for them that
it was not going to be easy.
“It’d be hard … I think I could, but it would be hard.”
“I did for six months, and that was without anything … so I will
be able to do the same again eventually, when I
want to.”
“You’ve just got to find something else to substitute it with. Just
finding that right thing is the most difficult part about doing it.”
“If you sort of think that you’re not going to smoke all week and
you’re not going to – the problem is, okay, I could probably stop
Monday to Thursday. Friday night, if I go out and touch drink,
I know that I won’t wear a patch because I’ll definitely want to
smoke. So if you’re sort of that committed, then you could do
it, well good on you.”
Some, especially among the women, but also including some
of the men, were concerned they would put on weight if
they stopped smoking. This sentiment was expressed across
the age groups. Some reported that they had previously
experienced weight gain during quit attempts, and that this
left them concerned. Some questioned whether they would
be any healthier if quitting smoking resulted in weight gain.
“I would love to give up … but I don’t want to put
on weight.”
“Health is a tossy-turning one, because … you’d be healthier
fitness wise, but who’s to say you’d be the size
you are?”
“I’ve got many of my, um, colleagues in the office that are
women and when I ask them, you know, why don’t you stop it
or something, they say when I stop I might put
on weight.”
“I would love to give up, I just wish it was easier.”
“It’s mind over matter.”
“If you want to do it, you’ll do it, and that’s all there is to it.”
“I think we all know that’s it’s not doing you any good, put it
that way, but you’ve got to want to give up.”
Participants commonly mentioned the use of various forms
of NRT in their previous and anticipated future quit attempts.
It was apparent that NRT plays a much greater role in
smokers’ minds than it has previously, and that there is now
a stronger belief in the need for nicotine replacement during
the quitting process.
Social situations, stress and emotional difficulties were
commonly reported as the major obstacles to quitting.
Those who had attempted to quit typically reported that
they had gone back to smoking either when they were
stressed or when they were out drinking. Some also noted
that other smokers were not particularly helpful when they
were trying to quit.
Similarly, stress and emotional difficulties were commonly
reported as the reasons for putting off quitting. Participants
felt that quitting would be too difficult when they were
experiencing emotional difficulties. This seemed to be
especially the case amongst the older groups of smokers,
probably related to their past experiences of stressful events
triggering slip-ups.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
“People that we are around a lot, they would be like, ‘Oh, just
have a cigarette, it’ll be alright’, you know.”
“You wouldn’t want too many stressful things ahead of you …
whether its family issues or whatever it might be, you want a bit
of a clean path ahead of you.”
“But if they came up with a magic pill to quit smoking, we’d
have to come up with a magic pill for me to help me to control
my stress.”
“A bit of stress coming onto you, and then, that’s it. It’s the
straw that breaks the camel’s back.”
“Just some sort of stress relief basically, yeah. Something will
happen and you’ll think oh yeah, I’ve got to, like, you know, I’d
like to punch someone’s lights out or do that.”
“Just found it’d be easier to go back to it than sort of stress
about it, have the nerves build up and don’t just quickly relieve
it and was able to move on. So from one simple argument, it
just started up again after six months or however long so …”
“You can take my kids for a while [that would make a
difference].”
“No, its just sort of, you know, we’ve recently moved into a new
house and my wife has just got a new job and all these things
are happening and its just too hard.”
“I’ve just gone through a very difficult time in my life, it’s very
hard to do at the moment.”
“Oh, I have given it away in the past, it lasted about six
months. But then as soon as something happens, if I get
depressed or anything like that … that triggers it off again.”
In a related finding amongst younger smokers, there was a
common expectation that quitting would be prompted by
a change in life circumstances: becoming pregnant, getting
married, etc. In essence, these thoughts reflected a belief
that they would no longer smoke when they settled down
into responsible adult life, and that life would become more
stable, controlled and predictable with these changes in life
circumstances. In one group of 25–34 year olds (Parramatta,
G8), when this expectation was expressed by one of the
25 year old, single participants, the older participants who
had already experienced the stresses of becoming parents
and the subsequent break up of relationships scoffed at the
notion of life becoming settled.
“I would probably give up smoking if, like, someone I knew got
something from smoking. Like, actually know someone whose,
you know, because I don’t know anyone who has got anything
from it so it doesn’t bother me for me. Yeah, but also I don’t
want my son to do it. Like, it’s a bad habit.”
“I’d like to, when you get older that’s when everything happens
and you get sick and stuff. So I’d like to be healthy then.”
“I mean, you’d think, if I was in a different situation, like having
a family or whatever, you’d be thinking more of the future …
but just at the moment, it’s not a big issue.”
“I think if I settled down … have a steady partner and look
forward to getting married and having kids and doing that sort
of thing, I think your priorities would change.”
Thoughts about quitting appear to be focused primarily
on attitudes, rather than strategies; while unsuccessful
quit attempts appear to be related to a lack of effective
strategies to assist smokers through the process.
These findings confirm that a critical factor in facilitating
smokers in quitting would be to assist them in developing
strategies for quitting, and especially in formulating
mechanisms to deal with stress during their quit attempts.
76
Quitting services
Participants from across the groups commented that, while
they experienced a lot of social pressures to quit, there was
little in the way of support to assist them in the process.
While smokers were aware that the Quitline existed, few
believed that it was likely to be able to offer them anything
of value in the process of quitting, and hence were unlikely to
use this service.
A small number reported previous experiences of the
Quitline, almost all of which had been assessed as being of
little or no value. This left them disinclined to use the service
again and, when mentioned in the groups, tended to confirm
others’ low expectation of the service.
“I called the Quitline once and they said they’re not able to
take your call, all the operators are busy.”
“I rang the Quitline once and they just took my name and they
sent me a Quit book. No [it wasn’t helpful] because it was
just a little booklet … I thought I might have been able to do
a course or something … to discuss it more. But it was just,
take down you’re name and number and we’ll send you an
information pack”
“I think that Quitline would be a bit phoney, it’d be like a Kids
Helpline for adults or something.”
“Like, what could they do? Say stop smoking now, you know, or
you can quit one day? It’s going through your head already.”
“What can someone say on the phone to make you quit
smoking?”
When it was mentioned, some indicated that the call back
service could be of value to them. Some also mentioned
that having access to tips and hints for quitting might be of
some use.
“I didn’t know there was such a thing [as the call back service]
… it’d be useful to know you’re not alone.”
“Statistics on what we’ve found is successful is when you’re
thinking about giving up.”
“They might give you a process that you could follow.”
Although the issue was not directly raised in all of the groups,
only one person across the research mentioned that they
had taken part in a Quit course in the past. On hearing
that these existed and an explanation of what the courses
offered, others in the groups where it was mentioned
indicated that they might be interested in this kind of
assistance if they were attempting to quit. That smokers do
not know that Quit courses exist is an obvious barrier to
their potential value.
“I suppose like Alcoholics Anonymous, if they had groups where
you could go along, like a quit smoking group where you could
actually have five or six people that were quitting at the same
time as you and your process – and they became your, I don’t
know, if you had a problem, I’m going to have a smoke, I’m
going to call them first, they might talk me out of it, you know
what I mean?”
“I’ve got no idea [if quit courses exist].”
“That Quitline is a joke.”
“I don’t see what they could tell you over the phone that your
mum couldn’t tell you about smoking.”
“Or that you couldn’t figure out for yourself.”
Some mention was made of Quitline advertising, and the
number of people who mentioned the call back service
suggests that this component of the message had been
communicated. However, it was apparent that these
advertisements had not addressed smokers’ key needs with
respect to quitting services, in that they did not have an
appreciation that these services would be of any value in
their quitting process. For example, in some of the groups
participants were presented with the information that calling
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
the Quitline number was associated with an increased
likelihood of a successful quit attempt. They felt that this
would be useful information to assist in demonstrating the
value of the service.
“I look at that ad, that lady that was on the headset and she
turns around and, you know, she goes, you know, when you call
up, you know, we give you support, blah, blah, it just sounds like
a load of crap, you know.”
Participants were prompted to identify the basis on which
they felt that they were addicted. Being addicted was
typically determined by how early after waking up in the
morning a person had a cigarette; by the mood changes that
resulted when they hadn’t had a cigarette for a while; by the
difficulties they experienced when trying to quit; and by the
lengths that they went to in ensuring they did not run out
of cigarettes.
“I can feel it if I haven’t had a cigarette in four hours, I need to
have a cigarette.”
There is a need to promote the services offered
through the Quitline, especially the call-back service
and other support.
Most importantly, the value that these services offer to
smokers in terms of how they can help and the difference
they can make to quit attempts, must be communicated.
“Just getting up in the morning and not being able to go a few
minutes without one.”
However, it is fundamental that delivery of the Quitline
services meets the expectations that are created through
the promotions of these services.
“You know, having to rush one in opportune moments.”
Attitudes to addiction
“It’s the first thing you do when you wake up in the morning.”
Participants differed on whether they thought of themselves
as addicted. As might be expected, there was a general
sense that the older participants who were heavier smokers
and had smoked for longer were more likely to think of
themselves as being addicted. There was more variation
amongst the younger and lighter smokers in terms of
whether they considered themselves to be addicted.
“It’s an addiction. It’s not so much liking it, it’s – I don’t know.
Most people in here have probably tried to give up numerous
times, I know I have … and it’s just difficult because of the
addiction.”
“Everyone sort of knows that they’re addicted to smoking, it’s
whether they want to accept the fact or not.”
“Sure. You’d have to be kidding yourself if you said
you’re not.”
“It is a sickness, you are addicted too.”
“You promise you won’t laugh? It’s like a friend but it’s very
hard to get divorced.”
78
“You go nuts if you don’t get one, you ask strangers if you
can’t afford ten bucks, it’s just it’s a mental thing where you’ve
gotta.”
“Just that I get angry when I don’t have one … that sort of
thing.”
“It takes the edge off straight away.”
“But you know what I do? If I run out of money and if I know
I haven’t got any more money to buy more cigarettes, I’ll buy
a packet of patches, I’ll put a patch on when I wake up in
the morning and about lunchtime, I’ll take that patch off and
smoke for the rest of the day. That way I’ll know I’ve saved a
bit and I’m not smoking as much.”
“If I’m running out of cigarettes I get so panicky.”
An attitude that was especially common among younger
smokers, but also present in older ages, was that they would
choose to spend their last few dollars on cigarettes rather
than on food, drink or any other item. They felt that this was
something of an indication of the extent of their addiction.
A broad range of attitudes was expressed towards the
notion of addiction, from those who regarded addiction as
a weakness and therefore as a reason to quit; to those who
felt that it put the issue of smoking outside their personal
control, making it too hard to quit.
Some felt they were not so much addicted to cigarettes as
to the habit of smoking. These people felt that to change
their smoking, they would need to come up with a way of
changing their associated habitual behaviours.
Among some of the younger (18–24 year old) smokers, the
idea of being addicted was somewhat appealing, as it helped
them to define themselves as serious smokers. For some of
this group, being addicted was almost cool.
“I don’t think it’s the cigarettes you’re addicted to; I think it’s
just the habit. I really think it is. Like, just sitting here, you just
feel like going like [demonstrates hand movement of smoking].”
“I’m addicted to smoking in certain situations, but not all.”
“Habitual rather than addicted is a nicer word for us to use.”
“I don’t think I’m addicted to this, I think I’m addicted to the
social, to the filling in time … I smoke one milligrams.”
“I think they are two separate things. I think if you could get
rid of your habit, you’d still have the nicotine withdrawals …
but your actual action of smoking would be gone.”
“It’s not about the fact that you’re addicted to something.
Having an addiction is almost cool.”
A small number of participants from across all of the groups
reacted quite negatively to the idea of being addicted,
claiming that they did not like the thought of cigarettes
having control over them. Some regarded the idea of being
addicted as a sufficient reason to want to quit. However, this
was not a common attitude.
“I have discovered that smoking a cigarette is not what satisfies
you. It’s the habit of satisfying that desire, the craving to
smoke, that satisfies you.”
“I think it’s more of a mental things, where it’s like, why should
I let something so little control me? Like, why is a little habit
getting the better of me?”
“It’s a habit, that’s all … a habit that you can’t break.”
“It is such a horrible word.”
“Well you can get things for the nicotine, but it’s the actual
habit and you’ve really got to want to give up smoking, not for
anybody else but for yourself.”
“I reckon addiction the word can come off a little strong. I
have a coffee every morning as well and I wouldn’t say I’m
addicted to coffee.”
“You see, you could be addicted to the habit of smoking …
that’s what mainly a lot of us are. It’s something to do. It
becomes, as I said, a lifestyle.”
“Yeah, addiction, the word addiction has such a negative, like,
context to it. Like, you know, what else do you get addicted
to? You get addicted to drugs that usually ends up destroying
homes and … and heaps of deaths, you know, you turn to
crime. Like, when would a smoker turn to crime? Like, it’s not
necessary. It’s sort of, you know, it’s like using a really hard, like
it’s using a really, really harsh word to describe something …”
“If they weren’t [addictive], you’d look at them to say you’re an
idiot wasting your money.”
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Some also reacted quite negatively to the idea of nonsmokers referring to them as being addicted. They felt that
this was indicative of the low regard that non-smokers had
for smokers and demonstrated a lack of empathy. While
they felt it was acceptable for smokers to think of themselves
as being addicted, they did not accept this from non-smokers
as they felt it was more judgemental than helpful. Some
noted that there seemed to be a perception that it was more
of a weakness to be addicted to smoking than to other drugs.
“People get pitied if they are alcoholics, but there is no such
thing as feeling sorry for smokers.”
These reactions suggest that caution would need to be
taken with the use of messages about addiction, to ensure
that they were not interpreted as being judgemental or
accusatory.
Further, the diversity of reactions to the concept of
addiction suggest that any related messages would benefit
from focusing on the behavioural and habitual aspects of
smoking that are indicative of addiction, rather than the
specific fact of addiction. Smokers relate well and strongly
to these kinds of behaviours, but not consistently to the
concept of addiction.
Perceptions of health consequences
Participants were prompted to discuss their awareness
of and attitudes regarding the health consequences of
smoking. These discussions highlighted the impact that the
introduction of the graphic warning labels and the associated
advertising has had, with mouth cancer and gangrene being
among the top-of-mind health consequences.
Other diseases and health effects that were commonly top
of mind across the groups included cancer, specifically lung
cancer; coughs; shortness of breath during activity; and poor
fitness. With further prompting, participants also mentioned
throat cancer, emphysema, asthma, circulatory diseases and
heart disease.
In each of the groups there was some mention of smokers
being more likely to get colds, and of colds being worse and
lasting longer than for non smokers.
80
As noted later in this section of the report, some of the
older smokers (and one 30 year old) reported already
experiencing serious health effects such as emphysema,
heart disease and lung disease. Further, participants across
all of the groups mentioned that they experienced shortness
of breath during activity, with stairs being reported as a
common experience of the health effects of smoking.
Participants from across the groups also mentioned
relatives who had smoking-related diseases, with some
reports of quite drastic and advanced disease states. It was
apparent that this kind of personal information did affect
smokers sense of the perceived likelihood of being affected
themselves, although it was not sufficient reason to quit.
“I’ve had a couple of aunts and uncles die from lung cancer and
… other smoking-related diseases, and the funerals are always
a bit bad. But, anyway …”
“My folks want me to get rid of it but I’m a fourth generation
smoker and my dad hasn’t died of emphysema but both my
pops have on both sides and both their fathers have died of
emphysema on their sides as well. So I should probably quit
smoking because something is going to happen but well, I’ve
got four years to catch up to my dad’s smoking so I’m all right.
Yeah, he quit when he was 25 as well so I’ve only got four years
to go, so that’s not too bad.”
In all of the groups, when presented with information about
the inevitability of emphysema and when challenged to
consider that these experiences of shortness of breath might
indicate early symptoms of emphysema, it was notable that
this information had a considerable impact on smokers. The
mood and energy of the groups darkened substantially during
these discussions, and it was apparent that smokers were
seriously contemplating the impact that smoking was having,
and whether in fact they might not get away without being
affected as they had been hoping.
There was a general sense that the disabling effects of
diseases were of greater concern than the thought of dying.
However, while someone within each of the groups had
some story of an uncle, grandmother or other relative with
advanced cases of emphysema who could not do anything
without their oxygen tank, these effects were generally
regarded as a risk associated with chance and probabilities
rather than a definite reality.
“No, actually death wouldn’t be that bad because you’d be
gone, that’d be it. Living with [gasping] with an oxygen tank
would be much worse than death.”
“Losing your voice and, you know, everything else that goes
along with the operation, and having to speak with … they’re
all scary things.”
These reactions suggest that there is likely to be
considerable utility in a message about the inevitability of
emphysema.
In response to the graphic warning labels and recent
advertising, while smokers accepted that disease such as
mouth cancer and gangrene might be associated with
smoking, they felt that they were so rare and unlikely that
they did not provide sufficient motivation to quit smoking.
To an extent, this perception affected participants’ reactions
to each newly mentioned disease.
In this context, participants commonly scoffed at, or disputed,
new information about specific health effects, dismissing the
information with a comment of ‘smoking causes everything’.
On the other hand, it was apparent during the section of
the groups when smokers were prompted to create a list
of smoking related diseases, that as the list got longer, the
implication became more serious. These reactions suggest
that it is not so much new diseases that concern smokers,
but the fact that smoking is associated with so many diseases
that is problematic. This suggests to them that, even if they
do manage to be one of the lucky ones who are not affected
by lung cancer or heart disease, then likely as not some other
smoking-related disease will get them.
“Yeah, truthful things where, okay, not everyone is going to get
lung cancer, not everyone is going to get emphysema or, you
know, badly, to a bad degree, but you’re going to get something
from it and, you know, that’s not to scare people. It’ll make
them think about changing. That would be the way to go.”
“I believe that I’m definitely putting myself at risk of all those
sort of smoking-related illnesses, but I don’t know that I’m
definitely going to get one. I know I’m probably increasing my
chances of maybe getting one but …”
These findings suggest that messages about the inevitability
of disease have a greater capacity to affect smoker’s
thoughts and intentions about quitting, compared with
those that focus or rely on the risk of disease.
Communicating the long list of smoking-related diseases
demonstrates that health consequences are inevitable
rather than a matter of chance.
Participants were prompted to discuss the kinds of health
effects they had already experienced. They commonly
mentioned coughs and colds (including that the frequency
and severity of these was worse for smokers), asthma and
shortness of breath. Within each of the groups, at least one
person mentioned that going up stairs was the time when
they most obviously noticed the effect of smoking.
“Well, I don’t think about having my foot cut off, but, like, I do
realise how affected I am now by smoking, you know.”
“I think you need an immediate reason to quit, that’s – I don’t
know, like you don’t see the long-term effects now. I mean, and
you don’t want to either. You’re just quite happy being in your
own world.”
“You know, when you’re running to catch a bus or something
and by the time you get on there you’re just like [wheezing],
the guy’s like a dollar twenty and you’re like just give me five
minutes.”
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
“Going up hills, you know, stairs.”
“Coughing as well, like when you get a cold and you get
it worse.”
many felt was too far off in the future to be a concern. In
essence, the existence of smoking-related symptoms seemed
to prompt smokers to acknowledge that they were kidding
themselves with their arguments about not being affected,
and left them in a space of contemplating the need to quit
sooner rather than later.
“I just can’t climb hills.”
“I get asthma now and I never used to.”
“Shortness of breath … walking upstairs.”
“I find the hardest thing is, its harder to stay fit.”
“Stairs do it for me … like, if you’ve got about fifteen or twenty
steps, by the time you get to the top you notice your breath is
gone.”
“I’m actually an asthmatic, which is why I only smoke one
milligrams. So if I’m having a bad day as far as, you know,
chest feelings and all that sort of thing, I start thinking about,
‘Oh god, first stage of emphysema’.”
“I notice that the way I breathe has changed. It’s become
more intense now … because you learn to pace yourself and
regulate your breathing.”
“I find it hard to breathe, harder to breathe.”
“You walk to the letterbox panting.”
“I have a two storey house, when I go upstairs I say, oh no, I
have to quit.”
“If you showed Carolyn trying to keep up with her mates
walking up the hill.”
“After a big night I’ll wake up and I’ll have the dirtiest throat,
and I’ll just cough and … my breathing is not right …. Yeah,
that’s probably the worst bit.”
“We could put it aside and say, look, it’s just because I’m unfit,
next year I’ll start running, you know.”
“When I’m thinking I want to quit, it’s because I know what it is
doing to me … I can actually see what it’s doing to me rather
than know what’s going to happen a few years down the track.
I’m starting to get affected by ... shortness of breath and a few
other things that are happening and I think, well, you know, if I
don’t quit then it’s going to
kill me.”
This finding suggests that shortness of breath at the
top of stairs could be used as a ‘smoker moment’ that
would create a strong sense of personal relevance in
communication concepts.
“Just going for a walk, or I’m walking from maybe the car to
work, which is not far at all. But I find it hard to do that. I
know that’s bad. I know there’s something wrong, it shouldn’t
be like that.”
Interestingly, some smokers in the 35 and over age groups
described these limitations on their health and fitness as
being age related, rather than necessarily a consequence
of smoking.
“I know I shouldn’t do it. I know it’s going to make me sick, but
its just [that] the addiction is too strong for me to give it up.
Really, that’s my excuse.”
It also appeared that discussions about the health effects
smokers already experienced prompted them to think more
seriously about the possible long-term effects. This was
in contrast to discussion of cancer and heart disease that
82
“It’s affecting us in, only small effects and that’s why we’re
like that’s okay, it’ll be all right, it’ll be all right, you know. But
when the day, because I think about this all the time, when the
day comes to happen, it does affect me, where the disease,
you know, cancer or whatever is hurting me and I’ve got to
go through all that stuff, then maybe you start thinking and
contemplating about it. But right now, who does?”
This finding suggests that communications that included
references to the already experienced health effects, such
as shortness of breath, and related these symptoms to
more serious long-term consequences, would be likely to
have a high degree of salience and relevance, and would
provide an effective prompt to think about smoking
and quitting.
These findings also suggest that the ‘Every cigarette is doing
you damage’ message still has some salience. That is, the
effective communication of health effects messages is still
dependent on smokers developing an understanding that it
is the cigarette they are smoking now that is the problem,
rather than the one that they may or may not smoke in
the future. However, it seems that more work needs to
be done to effectively communicate to smokers how this is
the case.
Some of the women in the groups mentioned that they
were concerned about the cosmetic effects of smoking, such
as wrinkles and unhealthy skin. They felt that this provided
some motivation to not be a smoker in the future (i.e. to
stop before these effects happened), but it was apparent
that these were not sufficient reasons to do something about
it today.
“I look at my mother and I think I don’t want to look like you
when I’m 55. She’s so lined and I know obviously some of it
is age and some of it is sun, but I swear, if you put another
woman next to her that’s never smoked that’s the exact same
age, I think my mother looks a lot worse.”
“But when I look at my mum I go, well you smoke a pack a day
and you look like that. I only smoke, you know, five a day, so I’ll
be alright.”
Some, especially amongst the over 35 year old smokers,
were quite fatalistic with respect to disease and death, and
argued that their smoking had little impact on their health.
These were the same people who mentioned they could get
hit by a bus tomorrow. Some of these smokers indicated
they believed that diseases were genetically determined,
and that smoking was only a trigger for those who had
a predisposition. This attitude justified their continued
smoking if they did not already present with a smokingrelated disease. However, even among these smokers there
were some who reported that they would really prefer to
have never smoked or would like to be able to quit.
“I look at it this way, I’m going to die one day, so whether I
smoke or don’t smoke, it doesn’t matter.”
“The philosophy of life is you could walk out that door and be
hit by a car, so …”
“Life’s too short to worry about things.”
“If you get it then yes, but you know, you sort of live for now,
don’t you, and you worry about it when it comes, if you do
happen to get it. I just know so many who have had heart
attacks and blood pressure and cancer and all the rest of it
that have never smoked, hardly ever drunk and I think well, you
know, is everything true that they tell you and, sort of, when my
number is up, it’s going to be up and, I mean, I could walk out
of here and get hit by a bus.”
“My philosophy is you could walk out here and get hit by
a truck.”
Some participants mentioned that they engaged in a range
of activities that they believed minimised the health impact
of their smoking. These included staying fit generally, taking
nutritional supplements and having regular check-ups with
their health care providers. Some of the older smokers
specifically mentioned that their regular check-ups confirmed
for them that they were not suffering from smoking-related
diseases, and therefore justified their continued smoking.
“I book in every two years and have a chest x-ray and things
like that, as a matter of course.”
“One of the places I worked, we used to do a lung function
tests every year and I’d blow more than twice the nonsmokers.”
“I mean, I exercise too, I don’t have any of the symptoms you’re
talking about there. There’s nothing wrong with me.”
“But every time I get tested, my lungs and that are good.”
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
When discussing the notion of health effects from smoking,
it was apparent that there was a reasonable level of
misunderstanding with respect to disease and causality.
Some participants, especially among the older groups, did
not clearly understand the notion of causality or accept the
causal role of smoking. This poor understanding contributed
to a degree of disbelief about the claimed smoking-related
diseases. For example, some argued that if a certain disease
could be caused by a factor other than smoking (e.g. liver
cancer was believed to be caused by alcohol, breast cancer
was thought to be genetic), then it could not also be caused
by smoking. Some suggested that if a disease could develop
in a person who had never smoked (e.g. asthma in children,
lung cancer in a non-smoker), then it was not caused by
smoking. Similarly, some reported that knowing people who
had smoked for a long time without developing any diseases
was a signifier that the risks were exaggerated.
“There are a lot of causes, there are a lot of other things that,
like, just can happen in your life that would make [cancer]
happen as well, I think.”
“I had a cousin who died at 28, and she had breast cancer and
she’d never smoked a cigarette in her life, so … you know, you
get cancer from anything these days.”
“Well, my pop got gangrene, and he’s never smoked a day in
his life, so there you go.”
“Isn’t gangrene supposed to be associated with diabetes,
anyway?”
“A person who had not smoked their whole life can turn
around and die from lung cancer … so it’s like, you’re not
necessarily going to die from smoking.”
“There’s a whole cocktail of things out there that can kill you, it
doesn’t just have to be cigarette.”
attributed to the fact that smoking results in harmful or toxic
chemicals being distributed throughout the body via the
blood stream. On hearing this explanation, others agreed
that they had some comprehension of this mechanism, having
heard of it in previous smoking-related communications and
in general conversations.
However, it was apparent that this concept was neither
top-of-mind nor well understood. During the discussions,
when smokers were prompted to consider this concept, they
felt that it helped them to understand and accept the broad
diversity of smoking-related diseases.
As smokers indicated that they already had some concept
of smoking being associated with a large number of toxic
chemicals, the main value in the explanation was that it
prompted them to think more about these toxic chemicals
being distributed throughout the body, rather than just going
into their airways. With this perception they were better
able to understand and accept the extensive list of smokingrelated diseases, and especially to accept that smoking might
have an impact on diseases other than just those related to
the airways.
“Yeah, theoretically it could be anywhere, ‘cause it all goes in
your blood in the end.”
“It’s all the toxic chemicals that are in cigarettes.”
“Yeah, the toxins and stuff in cigarettes going through your
blood stream.”
“It reduces the amount of blood that travels through
your arteries.”
“It’s probably a blood cancer that’s travelled to and just settled
into a particular area.”
“It’s supposed to be in the tobacco, the toxins and all that.”
“Well, it’s the toxins … in the tobacco that’s affecting the
blood cells.”
Toxic chemicals
Participants were asked to explain how they understood
that smoking was related to a range of different health
consequences. Within each of the groups at least one
participant was able to explain that the health effects were
84
“The chemicals get in [the blood] and stay in there and … it
buggers the oxygen and thickens the blood … that’s how you
end up with blood clots.”
When discussing the issue of toxins, some smokers
rationalise that they are exposed to a wide range of toxins
on a daily basis, either through food, work or environmental
pollutants, and therefore question whether the impact of
tobacco smoke toxins is any worse.
“Well, apart from the chemicals in cigarettes, you know,
I worked in a timber mill … and we were working with
formaldehyde … you used to breathe it in. So I mean, if
anything’s going to kill me, it’s probably the formaldehyde.”
“Carcinogens are in a lot of things other than cigarettes …
you might have that tomato that has been sprayed with a
chemical.”
“I just think we need more of that woman with mouth cancer
on TV, and that’ll make sure people won’t smoke … because
that’s an absolutely horrible ad.”
“I mean, fair enough, you can squeeze out an artery and this
white stuff will come out on TV and you’ll be like it doesn’t
really affect me … but if you see that woman with cancer, you
see what it can actually do.”
“I’ve had enough of it … immune to it.”
“Yeah, [if it is really graphic] it gets your attention and then,
like, people are talking oh, did you see that ad on TV about
smoking? … did you see her mouth? Like, that kind
of thing.”
“I’m for making it graphic.”
These findings suggest that there is likely to be some
value in messages that are aimed at increasing smokers’
understanding of the way that the toxic chemicals in smoke
are distributed through the body and thereby cause cell
damage in all organs and tissues.
Perceptions of recent advertising
Participants were prompted to discuss recent advertising,
and to identify the advertisements that they recalled as
having had some impact on them.
During these discussions, there were mixed views about
the impact of graphic advertising, such as mouth cancer and
gangrene. Some of the younger smokers in particular argued
that the nature of modern media was such that there was
an expectation that imagery would become more graphic,
rather than less.
“I’m just sick of the graphic ads, they piss me off.”
“Instead of trying to, like, scare people, they should try
and help.”
“The best idea would be to take today’s ads and show them
thirty years ago, and then that would stop an entire generation
from smoking.”
“If it’s going to put my kids off smoking, I’m happy for it to be
out there.”
Interestingly, those smokers who held the perception that
graphic advertising had been overdone were mostly the
metropolitan smokers who also reported higher levels of
social pressure about their smoking. In this sense, there was
an apparent relationship between the pressure experienced
and graphic advertising, with some smokers feeling that
these advertisement contributed to non-smokers being given
permission to hassle them about their smoking.
When prompted to discuss these advertisements in
terms of impact and credibility, smokers were cognisant
that the recent advertising had emphasised that smokingrelated diseases could be extremely disfiguring. However,
believability and personal relevance were questioned
by some.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
In this sense, participants commonly felt that the recent
advertisements had focused on extreme smoking
consequences, and that while these were thought provoking,
they did not really believe that they were personally likely to
be affected by these diseases.
“Seeing commercials on TV where you see, you know, people
with gangrene and all that and you think … okay I’m never
going to get that, that’s not going be me … But like, I reckon
it would be pretty cool if, you know, I turn on the tele one day
and I saw an ad with someone who has had one of the, like a
small thing ‘cause then it feels like more close to home.”
“The ads at the moment, you see those people with gangrene
and you’re just, like bullshit, as if they’ve got it. It’s just a bunch
of actors and stuff.”
Other than the recent warning labels campaigns, the quit
advertisements most commonly mentioned as having an
impact included Parents and Echo. The surgeon’s delivery
of the message of Echo appears to have had an important
impact in terms of the consequences of smoking.
“I remember that one … I don’t think I can stop smoking, I
don’t think I can operate.”
“They cover everyone’s excuses, that’s the thing. Like, at least
one of us has used those excuses.”
“That clever one with the words … you know … it’s the one
where he says no to the surgery.”
“That sticks in my mind, ’cause she says I don’t think I can give
up and he says I don’t think I can operate.”
“It seems totally unrealistic. Who do we know who’s going to
get a leg amputated?”
“Smoking just stops gangrenous wounds healing, it does not
cause gangrene at all. That’s been a fraud for many years.”
“I think maybe they’ve had one or two cases of them, okay, but
it’s been proven … some of them patients have never smoked,
but they were using them as smoking examples.”
“But it’s not you … it just comes back to it won’t happen to
you. You sort of see it, you just sort of move on.”
“But to be honest, you know, [Gangrene] is a little bit
exaggerated, you know. It doesn’t come from the tobacco this
one. That is more … diabetes.”
“Oh, I’m not saying it’s not true, but they exaggerate it.”
“I have never seen anybody, like a real person, with [mouth
cancer]. If they showed us a real person, maybe.”
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Other advertisements, mentioned by at least a few
participants across the groups, as having had some impact
included Emphysema (Radio), Bubblewrap, Hook and various
Quitline advertisements. Interestingly, Hook was mentioned
in several groups, with participants having a strong recall
of the image of the hook in the smokers’ lip. Several
participants recalled the Quitline advertisements, although
this was commonly in the context of the service where there
were mixed views among smokers.
NRT advertising was also commonly mentioned, with the
main two campaigns being the No Gary No advertisements
and the testimonial advertisement for NRT that tracked
a woman through the process of quitting. These were
mentioned as memorable ads, with No Gary No in particular
being catchy and prompting recall. However, it was not
clear during the groups that these ads had any impact on
quitting intention or behaviours. Responses to the woman’s
quit attempt were mixed, with some valuing this TVC as
providing a positive approach to quitting, while others rating
it low in terms of identification, impact and effect.
Reactions to tag lines: Every cigarette is doing you damage
“I think the best smoking ad was the one where that lady did
the quit smoking, and they showed her progress and you just
see how she gets on … you see how she changes. Like, she
doesn’t have a green arm or anything like that, you can just see
how she’s changed and she looks better and she feels better.”
“It’s just how good she feels when she’s stopped smoking.”
“By saving enough money to have a holiday.”
There was a high degree of awareness of this tag line,
especially after prompting.
When prompted to discuss its meaning and impact,
participants understood that it was attempting to convey
that each cigarette could be harmful. However it was
apparent that they did not really believe this message, as they
consistently talked about the health effects of smoking being
related to long-term and heavy smoking.
“My friends’ little kid … if I light up, this eight year old child
comes out and he goes, ‘No Gary No’ … “
“So is every breath you take in the city.”
On the whole, smokers agreed that information about
health effects was most likely to be effective in moving them
towards quitting.
Among participants who were parents, there was a belief
that recent advertising was having a strong effect on children.
They reported that these advertisements, and the associated
pack warning labels, had prompted their children to give
them a hard time about their smoking, and believed that this
was an intended outcome of the recent campaigns.
“I hide mine in the little drawer at home and never, like I said
before, never smoke in the house, never smoke round the kids,
but they know that I smoke and they’re pointing at the pictures
now saying I don’t want that to happen to you, mum, I mean,
do you know how that makes you feel? That someone has got
half their leg missing on the packet and they go well mum, I
don’t want you – I wish you wouldn’t do that anymore ‘cause I
don’t want that to happen to you.”
“With that ad with the girl on the face which ended up being
fake, it wasn’t real at all, about her face going from smoking,
my daughter goes, my four-year-old, you’re going to die mum,
you’re going to die so …”
“Well, it’s true.”
“I can’t feel it, so …”
“Every time you have a smoke it’s trying to make you
feel bad.”
“It’s probably damn right.”
“A friend was down the other day and she hadn’t had a
cigarette for a month and every time she wants a cigarette she
now thinks that there’s – what she thinks of is – to stop her to
have a cigarette is that there’s twenty poisons in each cigarette
that you’re lighting up, sort of thing. So before she thinks it, or
she’s having a thought about having a cigarette, she’ll think of
that and then not have one and she’s lasted a month so far.”
“Another nail in the coffin.”
“Every hole I drill in a concrete floor is doing me damage.”
“It didn’t do me any damage yet.”
These responses suggest that there is likely to be
considerable value in communications that assist smokers
to improve their understanding of how every cigarette is
doing damage.
Messages that focus on the way that chemicals from
tobacco smoke spread through the body with each
cigarette smoked, causing damage wherever they go, has
the potential to achieve this.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
Reactions to tag lines: Quitting is hard, not quitting is harder
Attitudes to government and tobacco industry
There were reasonable levels of recall of this tag line,
although not as obvious as for the above line.
Each group raised the topic of the government’s role in
tobacco without prompting, primarily in the context of
tobacco tax and the perception that governments are not
offering sufficient support to smokers who want to quit.
Most participants understood that the message as challenging
them to think about the consequences of continuing to
smoke being worse than the difficulty experienced during
the quitting process. However, a few were confused by the
message, taking it as suggesting that it was not worth trying
to quit.
“Well if you quit, you’re better off in the long run, if you don’t
quit you’re worse off in the long run.”
In all of the groups some smokers commented that the
government was not really serious about getting people to
quit as they did not want to lose the money they made from
tobacco tax. It was apparent that this issue united some
smokers into an ‘us and them’ mindset. That is, it confirmed
for them that smokers were an outcast group, which seemed
to reinforce the sense of individuality and rebellion that they
prided themselves on.
“Well, they are both hard so don’t do them.”
“Quitting is hard.”
“They’re saying coping with the illness is harder.”
“It’s very impressive, you know. I mean, it’s quite true.”
“And when they say not quitting is harder, it’s a challenge
to you.”
“Right, so you say, ‘I’d like to quit’, but doing it is
another matter.”
“Saying it and doing it is a big difference.”
“Not quitting is harder for you in the future. You’re going to be
in big trouble.”
“The government makes too much money off them.”
“If they thought it was that bad for us and it wasn’t a positive
for them to get those tax dollars, they’d just say you can’t have
them any more.”
However, this was not a universal opinion, and in each group
at least some smokers responded that the cost of smokingrelated diseases to the health system outweighed the income
from tobacco tax.
The issue of what was being done to assist smokers in
quitting was also discussed in this context. In each group,
some smokers commented that if the government was really
serious about having smokers quit they would either fund
NRT or ban cigarettes.
Participants consistently suggested that more assistance
should be provided to them through funding nicotine
replacement therapies. This comment was commonly
referenced to the support programs and funding that was
available to people with other kinds of drug habits, such as
the methadone program. Smokers questioned why their
addiction and associated difficulties were not treated as being
as valid as those of people who were addicted to
illegal drugs.
88
“Well I’m just curious, you know, if we’re paying for all these,
you know, any quitting campaigns, why isn’t the government
then trying to subsidise, like, patches and gum can be quite
expensive.”
“And why not send it out in a pack?”
“They’re another business, they’re out to make money.”
“Everyone’s gotta make a living.”
“I mean it sucks that we smoke and they shouldn’t be selling it,
but well, there’s nothing we can really do about it.”
“Why don’t they go tax something else? I mean, they give
methadone away for free, don’t they?”
“But, it’s up to us whether we have a cigarette or not.”
“Yeah, why can’t they give us patches?”
“They’re providing a product and we’re stupid enough to buy it.
That’s our fault.”
“Why should we have to pay $30 to try to quit, whereas they
give druggos, you know, their methadone?”
“Don’t you think they should help people want to get off them
…that really want to stop smoking, don’t you think that they
should?”
Within each group there was also some unprompted
discussion of the issue of banning cigarettes. It was in this
context that some commented that the only reason smoking
was not banned was because of the short-term financial gains
that benefited the tax system.
On the other hand, there were no negative feelings
expressed towards tobacco companies, with the most
common response being that they were simply commercial
organisations operating in a free market economy, and
therefore they had every right to sell their product.
However, some participants did note that they would feel
differently about the tobacco industry if they knew they were
withholding information about their product.
“Yeah, it’s up to us whether we stay addicted or not.”
“At the end of the day, it’s your choice to smoke or not … it’s
personal responsibility.”
“Well, they’re still producing a product and it’s a legal product.”
“It’s like the people that make hops for the beer. They’re in a
business. We’re just at the other end. We’re on the wrong end
of it. We’re the ones who are making them rich but it’s up to
us but what can you do? It’s like big newspapers, it’s like the
rich people, sort of thing. You sort of think oh bugger them, you
know, here we are struggling, but that’s what they do …”
Participants were prompted to discuss their thoughts
about the sponsors of quit smoking advertising. Typically,
participants believed that these were likely to be sponsored
by the government, either state or federal, and most likely
by health departments. Some participants mentioned that
the advertising was sponsored by quit organisations and by
cancer organisations.
There was some sense that advertising had more credibility
when it was sponsored by quit or cancer organisations
than government, as participants reasoned that these
organisations had a relatively singular agenda, with the sole
motivation being better health outcomes.
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NSW Smokers’ Attitudes and Beliefs: Changes Over Three Years
By contrast, they believed that government agendas were
potentially influenced by a range of other political factors, and
therefore it was not clear that the only intended outcome
was about reducing the incidence of smoking-related
diseases.
“They want to let you know that the governments are good
guys and they’re trying to save Australia and you have to vote
for us again.”
“The Cancer Council [has more credibility] because you can get
cancer from cigarettes, sort of thing. Like it’s more their thing
than just the government being the government, sort of.”
Summary of geographic differences
While the extent of this qualitative research project was
insufficient to reach definitive conclusions about geographic
differences, it was apparent during the groups that there are
some variations in attitudes to smoking and quitting between
the metropolitan and rural smokers.
Amongst the younger age groups in the regional location
(18–24 and 25–34), attitudes and beliefs did not appear to
have changed over recent years in the way that they have
among metropolitan smokers.
In particular, the regional smokers did not experience the
same degree of social pressure about their smoking and
seemed to be less affected by the graphic nature of warnings
and advertisements. In terms of the latter, it was apparent
that graphic warnings and advertising still had a high degree
of salience among regional smokers, while metropolitan
smokers seemed to have reached a saturation point.
The younger smokers in particular (18–24) did not report
any of the social pressures that the metropolitan participants
had spoken of. Interestingly, several of these participants
were young mothers, and reported that smoking was
common amongst their social group of young parents.
Several also mentioned that they started smoking in front of
their parents at a young age (mid-teens), and that smoking
was both common and accepted among their family group.
90
In a related finding, younger participants in the regional
location also reported low levels of intention to quit.
Among the regional smokers, there was a greater sense of
disregard for regulations, with common reports that smokers
tend to take little notice of non-smoking areas in some
locations, and that these were not especially well policed.
The experience of regional smokers tended to be that it was
not much of a hassle finding somewhere to smoke.
“It’s not like that many people really obey those rules.”
“You just go outside or go wherever you can smoke, it’s not
really a big deal.”
“Yeah, well the only people who can police it are the police and
they’re not going to be at every single pub. So all right, and
the security guards at the bars, they don’t want to kick you out
because they want your business. So they’ll just say oh right,
put it out, just don’t listen to them.”
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