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Predictors of smoking relapse in a national sample of former smokers Miller, Clara Elsie 2000

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PREDICTORS OF SMOKING RELAPSE IN A NATIONAL SAMPLE OF FORMER SMOKERS by CLARA ELSIE MILLER B.Sc.N., Dalhousie University, 1995 A THESIS SUMBITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES School of Nursing We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA August 2000 © Clara Elsie Miller, 2000 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of fl^QQy f X \J(lAC<isL. The University of British Columbia Vancouver, Canada DE-6 (2/88) ABSTRACT 11 Although smoking relapse is the most frequently reported outcome of smoking cessation, with reported rates as high as 85%, the factors associated with relapse are hot fully understood. The purpose of this study was to identify predictors of smoking relapse in a Canadian sample.of former smokers. A secondary analysis was conducted of data collected in the Survey on Smoking in Canada, a national survey panel with four-cycle intervals in 1994-5. In this study, all respondents who reported that they were former smokers at cycle one (N = 3,875) were included. These respondents were divided into two groups. The first group (N = 3,582) remained abstinent from smoking throughout the survey's four cycles, and the second group (N = 293) experienced a smoking relapse sometime between cycles one and four. Multiple logistic regression analysis of sociodemographic variables indicated that age, education, marital status, and employment status were associated with relapse. Statistically significant differences were found between the two groups (relapsers vs. non-relapsers) with respect to the presence of other smokers in the household. Relapsers were more likely to have other smokers in their ill household. Differences were also noted between the groups when comparing subjects' exposure to smoke from cigarettes, if subjects were bothered by cigarette smoke, and if cigarette smoke caused them any physical irritation. Relapsers also differed from non-relapsers in that they appeared to have higher levels of nicotine dependence and reported first starting to smoke at a much younger age. In all four cycles of follow-up, relapsers reported that "stress" was the primary reason for their smoking relapse. Both groups faired poorly when reporting their health knowledge of smoking-related illnesses, incurred both by smokers and non-smokers exposed to tobacco smoke. As well, the majority of these subjects (58%) had not been advised to stop smoking by either their doctor or dentist. The findings of this research contribute to the body of knowledge related to smoking relapse. Health professionals must be encouraged to make a lifetime of difference in the overall health of their patients by assisting them towards a smoke-free future. IV TABLE OF CONTENTS Abstract ii List of Tables viii List of Figures ix Acknowledgements x Dedication xi CHAPTER 1: Introduction 1 1.1 Purpose 2 CHAPTER 2: Literature Review 3 2.1 Smoking Cessation and Relapse 3 2.2 Predictors of Smoking Relapse 5 2.2.1 Sociodemographic Characteristics 5 2.2.2 Control of Body Weight 7 2.2.3 Smoking History 8 2.2.3.1 Nicotine dependence 8 2.2.3.2 Smoking habit 11 2.2.4 Work and Household Tobacco 12 Smoke Exposure 2.2.5 Cigarette Cost and Availability 12 2.2.6 Emotional and Psychological Factors 13 2.2.7 Social Factors 14 2.2.8 Health Knowledge 15 2.2.9 Advice and Support of 15 Health Professionals V 2.2.10 Summary 17 CHAPTER 3: METHODS AND PROCEDURE 19 3.1 Purpose of the Study 19 3.2 Operational Definitions 20 3.2.1 Sociodemographic Characteristics 20 3.2.2 Control of Body Weight 20 3.2.3 Smoking History 20 3.2.3.1 Nicotine dependence 21 3.2.3.2 Smoking habit 22 !3.2.4 Work and Household Tobacco 22 Smoke Exposure 3.2.5 Cigarette Cost and Availability 23 3.2.6 Emotional and Psychological Variables 23 3.2.7 The Social Context 24 3.2.8 Health Knowledge 24 3.2.9 Advice and Support of 24 Dentists and Physicians 3.2.10 Smoking Status 25 3.3 Research Design 25 3.4 The Sample 2 6 3.4.1 Survey Sample 2 6 3.4.2 Weighting 26 3.4.2.1 Cycle 1 weighting 27 3.4.2.2 Cycle 2 weighting 27 VI 3.4.2.3 Cycle 3 weighting 27 3.4.2.4 Cycle 4 weighting 28 3.4.2.5 Standardised weight 28 3.4.3 Sample Selection 28 3.5 Data Collection 29 3.6 Reliability and Validity 30 3.6.1 Reliability of Data Collection 30 3.6.2 Reliability of the Questionnaire 30 3.6.3 Content Validity of the Questionnaire 31 3.6.4 Generalisability 31 3.7 Data Analysis 32 3.8 Ethical Considerations 33 CHAPTER 4: RESULTS 34 4.1 Sociodemographic Characteristics 35 of the Sample 4.2 Smoking History and Context of the Sample 35 4.3 Sociodemographic Characteristics of 37 Relapsers and Non-Relapsers 4.4 Control of Body Weight 40 4.5 Smoking History of Relapsers and 40 Non-Relapsers 4.6 Work and Household Tobacco 42 Smoke Exposure 4.7 Cigarette Cost and Availability 44 Vll 4.8 Emotional and Psychological Variables 45 4.9 The Social Context 45 4.10 Health Knowledge 4 6 4.11 Advice and Support of Dentists 4 9 and Physicians 4.12 Conclusion 50 CHAPTER 5: DISCUSSION 51 5.1 Major Findings 51 5.2 Predictors of Relapse 51 5.2.1 Sociodemographic Variables 51 5.2.2 Nicotine Dependence 54 5.2.3 The Need for Relaxation 56 5.3 Exposure to Environmental Tobacco Smoke 57 5.4 Additional Findings 59 5.5 Smokers Want to Quit 59 5.6 Health Knowledge 60 5.6.1 Medical Advice 61 5.6.2 Nursing Implications 62 5.7 Limitations of the Study 63 5.8 Summary and Conclusions 65 References 69 Appendix 85 Vlll LIST OF TABLES Table 1 Characteristics of Participants at Baseline 36 Table 2 Sociodemographic Characteristics of 37 Relapsers and Non-Relapsers Table 3 Summary of Logistic Regression Analysis 39 of Sociodemographic Variables Associated with Smoking Relapse Table 4 Age Started Smoking and Relapse Status 41 Table 5 Work and Household Tobacco Smoke Exposure 44 and Relapse Status Table 6 Reasons for Smoking Relapse 46 Table 7 Percentage of Respondents Reporting 48 Health Problems NOT Caused by Exposure to . Secondary Smoke Table 8 Percentage of Respondents Reporting Health 4 9 Problems NOT Caused by Smoking IX LIST OF FIGURES Figure 1 Smoking Status by Survey Cycle 32 X ACKNOWLEDGEMENTS First, with immense gratitude, I wish tq acknowledge my thesis supervisor, Dr. Pamela A. Ratner. Her exceptional mentorship, unfailing direction, and immeasurable contributions to this research study provided me with an invaluable learning experience, and a completed thesis of which I am well pleased. I am also very appreciative of the other members of my thesis committee, Dr. Joy L. Johnson and Dr. Roberta Hewat, whose expert guidance, suggestions and thoughtfulness certainly enhanced the quality of my work. Appreciation is also extended to my friend and colleague, Kori Kingsbury, whose kind-hearted, but always truthful comments, encouragement and support sustained me. Finally, with much love and gratitude I wish to acknowledge my son, Jacob. His miraculous birth and first years of life kept me grounded in the central perspective that "this indeed was not my life's work, it was only my thesis." XI DEDICATION This thesis is dedicated to my husband, Roger. I learn from you, I appreciate you, and I love you. 1 CHAPTER 1: INTRODUCTION Although the health consequences of smoking should be well known, an estimated seven million Canadian adults continue to smoke (Health Canada, 1995). The contribution of cigarette smoking to disease is significant both in terms of overall morbidity and mortality, and consequently is -the leading cause of preventable deaths in Canada (Health Canada, 1995). Over the past 25 years, a major public health emphasis has aimed at discouraging individuals from smoking. Most of what is known about smoking cessation, however, has been determined from studies of self-selected groups of smokers attempting to quit through formal cessation programs. Only a few studies have examined predictors of successful cessation in self-quitters, despite the fact that most smokers who have quit have done so without the assistance of special aids or treatment programs (Fiore, Novotny, & Pierce, 1990; Hellman, Cummings, Haughey, Zielezny, & O'Shea, 1991; National Cancer Institute, Office of Cancer Communications, 1977; Schwartz & Dubitzky, 1967). There is a paucity of literature examining the predictors of smoking relapse in the self-quitter population. Yet, relapse is the most frequently recorded smoking cessation outcome. Researchers have reported that 2 anywhere from 35% to 85% of people who quit smoking relapse within three months (Brandon, Tiffany, Obremski, & Baker, 1990; Hughes et al., 1992; Hunt, Barnett, & Brauch, 1971; Nides et al., 1995; O'Connell, Gerkovich, & Cook, 1995). Although smoking relapse events have been well documented, few studies have focused on the factors or characteristics that predispose individuals to the risk of relapse. Purpose The purpose of this study was to identify predictors of smoking relapse in a community-based, nationally representative population, which included smokers who had ceased smoking using a variety of strategies, particularly those not associated with formal programming. It was postulated that this knowledge might guide health professionals to a better understanding of the smoking relapse process, and to better ways of identifying and aiding those most likely to relapse. 3 CHAPTER 2: LITERATURE REVIEW A comprehensive review of the literature was performed, and limited only to scholarly work, which included both theoretical and empirically-based material. This work commenced with a general reading of the literature related to relapse. The review was then narrowed to a focus on smoking relapse and the issues associated with smoking relapse. The literature search was conducted using the CINAHL (Cumulative Index to Nursing & Allied Health Literature) and MEDLINE Standard (MEDical literature analysis and retrieval system onLINE) databases. Not all papers retrieved and reviewed were integrated within the literature review. The review focused primarily on papers that represented excellence in the field. Smoking Cessation and Relapse To gain an appreciation of the complexity of relapse, it must be considered within the broader context of the smoking cessation process. In recent years, it has been acknowledged that smoking cessation is indeed a multifaceted process, and not simply a binary event in which smokers suddenly become nonsmokers (Prochaska & DiClemente, 1983; Prochaska, Velicer, DiClemente, & Fava, 1988; Prochaska et al., 1994). Researchers have demonstrated that the process of smoking cessation entails multiple stages of behaviour 4 change. As captured by Prochaska's stage model of change, smokers progress through identified stages, beginning with no identified need or desire to stop smoking, then contemplation of quitting, moving to make a firm commitment and preparation to quit, progression to action for initial cessation, and lastly, maintenance of abstinence (Prochaska, DiClemente, & Velicer, 1992). Although not identified as a discrete stage of change, relapse is identified as part of the smoking cessation process, thus indicating that smokers can and do "recycle" through the stages of change (Prochaska & DiClemente, 1983). Despite a better understanding of the smoking cessation process, a major limitation of the stage model of change is that it is a descriptive model only, and does not characterise the process of relapse or explain why some people relapse and others do not. One of the most influential theories of relapse is that of Marlatt (Marlatt, 1985; Marlatt & Gordon, 1985). Marlatt conceptualised relapse as a process that is influenced by cognitive and behavioural mechanisms, rather than as a discrete, irreversible event. The key elements of this model include descriptions of certain types of situations in which relapse is likely to occur and coping responses in high-risk situations. Marlatt also distinguished between a lapse (initial- use of the substance) and relapse (full return to 5 regular use of the substance), and suggested that a lapse may precede relapse, but is not a sufficient cause of relapse. Predictors of Smoking Relapse Although relapse is the most frequently reported outcome of smoking cessation attempts, with reported rates as high as 85% (Hunt et al., 1971; Marlatt & Gordon, 1985; Schwartz, 1987), understanding the factors associated with relapse is not simple. Despite the fragmented state of current knowledge, relevant literature points to a number of variables that may be important. For the purpose of clarity and order, these variables have been clustered into the following domains: sociodemographic characteristics, control of body weight, smoking history, work and household tobacco smoke exposure, cigarette cost and availability, emotional and psychological factors, social factors, health knowledge, and advice and support of health professionals. Sociodemographic Characteristics Sociodemographic characteristics such as age, income, marital status, gender, and education have been associated with successful smoking cessation. While some studies have shown no effect of age on smoking cessation outcomes (Curry, Thompson, Sexton, & Omenn, 1989; Ockene, Benfari, Nuttall, Hurwitz, & Ockene, 1982), other studies have indicated that 6 the likelihood of successful cessation decreases as age increases (Eisinger, 1971; Garvey, Heinold, & Rosner, 1989; Glas gow, Klesges, Klesges, & Somes, 1988; Marlatt, Curry, & Gordon, 1988). Researchers have reported that wealthier people are more successful in quitting smoking, as well as people with higher levels of education (Kabat & Wynder, 1987; McWhorter, Boyd, & Mattson, 1990; Venters, Kottke, Solberg, Brekke, & Rooney, 1990). Chassin, Presson, Rose, and Sherman (1996) examined the natural history of smoking from adolescence to adulthood in a community sample of 4,035 participants enrolled in a longitudinal study. The analyses showed less successful cessation among relatively less educated and lower income adults. Gender differences in-smoking cessation have not been consistently found, but when differences have emerged, men reportedly succeed in their cessation attempts more often than women (Bjornson et al., 1995; Jackson, Stapleton, & Russell, 1986; Kabat & Wynder, 1987; Ockene, Hosmer, & Williams, 1987). In addition, researchers have found that being married significantly increases sustained cessation (Derby, Lasater, Vass, Gonzalez, & Carleton, 1994; Kabat & Wynder, 1987; Kaprio & Koskenvuo, 1988; Sanders, Peveler, Mant, & Godfrey, 1993; Stevens & Hollis, 1989). 7 Control of Body Weight A review of eight studies demonstrated a relationship between smoking cessation and weight gain, estimating an average weight gain of 7.5 pounds following smoking cessation (United States Department of Health and Human Services, 1990). Consequently, concern about weight gain following cessation is an oft-cited reason for smoking relapse (Rigotti, 1989). However, weight gain is not necessarily a predictor of smoking relapse; authors from two different experimental studies reported no association between weight gain during initial smoking abstinence and the risk of subsequent relapse (Gross, Stitzer, & Maldonado, 1989; Killen et al., 1996). Controversially, a study by Hall, Ginsberg, and Jones (1986) found that weight gain in the "initial" six months following cessation predicted fewer relapses at their 12-month follow-up. Although Hall et al. has authored many papers about weight gain and smoking relapse, the results of this particular study have not been replicated. Although the trend in the literature associates weight gain with smoking relapse, there is conflicting evidence regarding this association and further investigation is warranted. 8 Smoking History A comprehensive smoking history usually includes information about the amount smoked, previous cessation attempts, number of years.of smoking, age at which smoking commenced, and preferred cigarette brand (nicotine level); all of which may be associated with relapse. Several studies have found that heavier smoking is predictive of relapse once cessation is attempted (Curry, Marlatt, Gordon, & Baer, 1988; McBride, Pirie, & Curry; 1992; Salive et al., 1992), whereas others report no significant associations between number of cigarettes smoked or number of "pack-years" of smoking and relapse (Brandon et al., 1990; Garvey, Bliss, Hitchcock, Heinold, & Rosner, 1992; Swan et al., 1988). These equivocal findings may be largely attributed to the range of methodological approaches used, such as differences in the study designs (prospective vs. retrospective), the number of subjects in the samples, the settings, the characteristics of those studied, and the data analyses. Nicotine dependence Often embedded in the analysis of smoking history is a measure of nicotine dependence, and this variable has been reported as the most prominent factor associated with smoking relapse. Killen and colleagues have consistently reported that the degree of nicotine dependence is 9 associated with the rate and pattern of smoking relapse (Killen & Fortmann, 1994; Killen et al., 1996; Killen, Fortmann, Kraemer, Varady, & Newman, 1992; Killen, Fortmann, Newman, & Varady, 1991). This relationship holds even when differences in other variables such as age, education, body mass index, and intention to remain abstinent are controlled (Pinto, Abrams, Monti, & Jacobus, 1987). The significance of the relationship between nicotine dependence and smoking relapse lends support to the claim that nicotine is a highly addictive drug, as addictive as heroin or cocaine (U.S. Department of Health and Human Services, 1988). Benowitz (1998) reported that the rate and route of nicotine's dosing directly affects its addictive potential, and that the inhalation of nicotine through cigarettes is the most addictive method for the delivery of nicotine. Benowitz further reported that once inhaled, the effects of nicotine reach the brain within seven seconds, faster than an intravenous injection of nicotine. Because of the highly addictive properties of nicotine and its expedient delivery to the brain through cigarette inhalation, the degree of one's nicotine dependence has been reported as the strongest predictor of smoking relapse (Killen & Fortmann, 1994; Killen et al., 1996; Killen, Fortmann, Kraemer, Varady, & Newman, 1992; Killen, Fortmann, 10 Newman, & Varady, 1991; Pinto, Abrams, Monti, & Jacobus, 1987). Because of the powerful association between nicotine dependence and smoking relapse, much research has been done to examine the degree of nicotine dependence and the likelihood of smoking relapse. To date, the most notable and trusted measurement of nicotine dependence is the Fagerstrom Tolerance Questionnaire (Fagerstrom, 1978;' Fagerstrom et al., 1996), and the two most highly correlated indices of this questionnaire are: the number of cigarettes smoked each day, and the calculated time upon waking that a smoker has his or her first cigarette of the day (Heatherton, Kozlowski, Frecker, Rickert, & Robinson, 1989). The amount of time that elapses before one's first cigarette of the day has been recognised as an excellent measure of heaviness of smoking. Heatherton, Kozlowski, Frecker, Rickert and Robinson (1989) referred to this as Time to First Cigarette or TTF and argued that this is an important measure of nicotine dependence because "heavy smokers are faced with the prospect of enduring withdrawal symptoms until they light up their first cigarette of the day" (p.791). Like Heatherton, Kozlowski, Frecker and Fagerstrom (1991), Pomerleau, Pomerleau, Majchrzak, Kloska and Malakuti (1990) found that the number 5 of the 11 Fagerstrom Tolerance Scale that asks about the time of day to the first cigarette is an excellent discriminator between heavy smokers and light smokers. Heavy smokers are more likely to answer yes to smoking within 60 minutes of waking, whereas light smokers are not. Smoking habit The habit of smoking is different from the dependence of nicotine, as described in the previous section. Although the influence of the smoking habit has not been studied in the context of smoking relapse, this factor is commonly addressed with individuals attempting to quit smoking (Fiore et al., 1990; Johnson, Budz, Mackay, & Miller, 1999). For example, it is estimated that a smoker "puffs" on each cigarette at least 10-12 times and that the average smoker consumes a package a day, thus tabulating to an estimated 90,000 "puffs" a year. Clearly, the influence of this hand-to-mouth habit is a notable one for individuals attempting cessation, and many smokers have reported that finding something to do with their mouth and hands when they stop smoking can be a major strategy to aid with successful cessation. Although this hand-to-mouth habit and smoking relapse have not been well reported in the literature, it is plausible that the strength of the habitual component of smoking may affect the likelihood of relapse. 12 Work and Household Tobacco Smoke Exposure Wewers and Ahijevych's (1991) work suggested that workload stress and exposure to others smoking in the workplace are consistent predictors of relapse during the first year following cessation. Curry et al. (1989) conducted research in a work-site smoking cessation program and found a positive association between the number of smokers in the work environment and relapse. Similarly, several studies have identified that the presence of other smokers in one's immediate environment, particularly in the workplace and household, predisposes the "quitter" to relapse (Brandon et al., 1990; Daughton, Roberts, Patil, & Rennard, 1990; Garvey et al., 1992; Gulliver, Hughes, Solomon, & Dey, 1995; Seeker-Walker et al., 1995). Cigarette Cost and Availability Although the price of cigarettes and their availability have not been well studied in the context of smoking relapse, these factors have been associated with the initiation of smoking. Health Canada (1995) reported an increase in smoking initiation, especially among youth, in provinces that reduced provincial tobacco sales tax, thus lowering the cost of cigarettes. Further investigation is required to identify whether cost and availability are also 13 associated with smoking relapse. It is not known if decreases in cigarette cost and increases in availability predispose individuals to smoking relapse. Emotional and Psychological Factors Researchers have reported that negative emotional states such as anger, anxiety, depression, and boredom predispose individuals to smoking relapse (Bliss, Garvey, Heinold, & Hitchcock, 1989; Borland, 1990; Gulliver et al., 1995). Other researchers have confirmed the relationship between stress and relapse (Shiftman, 1982; Swan et al., 1988), and further study has shown stress to be adversely associated with relapse (Ockene et al., 1982). Curry et al. (1988) found that lower stress levels predicted long-term abstinence, but did not predict initial cessation. The results of this particular study, however, have not been replicated. The nature of the relationship between relapse and . stress is not clear. Cohen and Lichtenstein (1990) theorised that the relationship between stress and relapse is bi-directional, claiming that either direction of the effect is theoretically plausible; stress causes relapse and relapse causes stress. Consequently, in cross-sectional studies, what is seen as a predictor or antecedent of relapse may be a consequence. 14 Studies of self-efficacy in the area of smoking cessation have been numerous (for excellent reviews see: Mudde, Kok, & Strecher, 1995; Strecher, DeVellis, Becker, & Rosenstock, 1986). Several researchers have reported an association between self-efficacy and smoking relapse (Condiote & Lichtenstein, 1981; Haaga & Stewart, 1992). Stuart, Borland, and McMurray (1994) contend that high self-efficacy is positively related to successful smoking cessation, and so may be related to relapse. Social Factors Social support, in the form of encouragement from significant others, is also associated with positive smoking cessation outcomes (Brandon et al., 1990; Brandon, Zelman, & Baker, 1987; Garvey et al., 1992). Mermelstein, Lichtenstein, and Mclntyre (1983) found that subjects whose partners provided positive encouragement, rather than "policing" and "nagging", reported fewer relapses. Further study by Mermelstein, Cohen, Lichtenstein, Baer, and Kamarck (1986), involving the role of social support in smoking cessation and maintenance, included two longitudinal, prospective studies. Their findings showed a significant difference between relapsers and long-term abstainers and the presence of smokers in the subjects' social support 15 networks..Those with fewer smokers in their social surroundings were less likely to relapse. Health Knowledge Several research efforts have identified a sense of personal susceptibility to illness as a necessary ingredient in the decision to attempt cessation (Croog & Richards, 1977; Hammermesh & Hammermesh, 1983). Linking health-related symptoms to smoking has been reported as a major precipitant to unaided quitting (Weinberger, Greene, Hamlin, & Jerin, 1981). In light of the demonstrated links between perception of health and health-related symptoms with smoking cessation, there also may be an important link between perception of health and relapse, although this association has not been studied. Advice and Support of Health Professionals Several studies have investigated the role of health professionals and their success in assisting clients that attempt smoking cessation. Bass (1994, 1995, 1996) reported that as little as a three-minute medical intervention can increase clients' smoking cessation rates by as much as seven percent. Additionally, nurse-delivered smoking cessation interventions have made significant differences in increasing cessation rates and, as a result, contribute to relapse prevention (Johnson et al., 1999; Taylor, Houston-16 Miller, Killen, & DeBusk, 1990; Taylor et al., 1996; Wewers, Bowen, Stanislaw, & Desimone, 1994). Taylor et al. (1990) conducted a randomised trial of a nurse-managed smoking cessation intervention for inpatients diagnosed with myocardial infarction. The nurse-delivered intervention was largely conducted by telephone, initiated in the hospital, and focused on relapse prevention. The results of the study were impressive with a 12-month smoking cessation rate of 71% in the intervention group and 45% in the control group. Assuming that all surviving patients lost to follow up were smoking, the 12-month smoking cessation rate was 61% in the intervention group compared with 32% in the control group. These results led the researchers to conclude that nurse-managed smoking cessation interventions could significantly reduce smoking rates and smoking relapse at 12 months in patients who had myocardial infarctions. Taylor et al. (1996) later conducted a similar study, however, their study population was not limited to patients who had myocardial infarctions, but included smokers hospitalised for a variety of conditions. The twelve-month confirmed cessation rates were 21% and 31% for the usual-care and intervention groups, respectively (odds ratio = 1.7; 95% confidence interval = 1.2 - 2.3), and again the 17 researchers concluded that a nurse-managed smoking cessation program can significantly increase cessation rates and prevent relapse for hospitalised patients. Similarly, Johnson et al. (1999) conducted a randomised controlled trial to determine the efficacy of a nurse-delivered smoking cessation intervention for hospitalised patients with cardiac disease. The six-month, self-reported cessation rates were 46% in the intervention group, compared with 31% in the control group (subjects lost to follow up were assumed to be smokers). Clearly, the literature points to the value of health professionals' advice and support in the prevention of smoking relapse. Summary The health consequences of smoking and the need for continued smoking cessation efforts are well documented. Understanding why smoking relapse is the most common outcome of smoking cessation and what factors predispose individuals to the risk of smoking relapse, however, are not as evident. The studies reviewed suggest that certain factors may precipitate relapse. For the purpose of clarity and order, these variables were organised within the following domains: sociodemographic characteristics, control of body weight, smoking history, work and household tobacco smoke exposure, cigarette cost and availability, emotional and psychological 18 factors, social factors, health knowledge, and advice and support of health professionals. The literature pertaining to these domains is occasionally conflicting, largely due to the wide range of methodological and procedural approaches used. Further, most of the existing research does not examine the "self-quitter" population; rather investigations to date have mostly sampled smokers who have made cessation efforts through organised programs or interventions. Because most studies have used populations from smoking cessation programs, sample selection biases may have confounded the effects of the factors studied. Additionally, relapse studies investigating the ,Canadian population are largely deficient. Because of these noted deficiencies, additional research is required, particularly examining predictors of smoking relapse in a community-based population, and within a Canadian context. The current state of knowledge poses many additional research questions; however, this secondary analysis was directed, by necessity, by the available data. 19 CHAPTER 3: METHODS AND PROCEDURE Purpose of the Study The purpose of this study was to answer the question: What are the predictors of smoking relapse in a Canadian population of smokers who quit smoking and then relapsed? More specifically: a) Are sociodemographic characteristics, such as age, income, marital status, gender, and education predictive of smoking relapse in this population? b) Is an individual's concern about body weight predictive of smoking relapse? c) Is an individual's smoking history, such as nicotine dependence and habitual factors, predictive of smoking relapse? d) Is exposure to work and household tobacco smoke predictive of smoking relapse? e) Are reductions in cigarette cost and increases in cigarette availability predictive of smoking relapse? f) Are emotional and psychological characteristics, such as depression, stress, and boredom predictive of smoking relapse? g) Are social characteristics, such as lack of social support predictive of smoking relapse? 20 h) Is an individual's knowledge of the health effects of smoking predictive of smoking relapse? i) Is the advice and support of dentists and physicians predictive of smoking relapse? Operational Definitions To answer these research questions the concepts identified in the questions were operationalised as follows: Sociodemographic Characteristics The sociodemographic characteristics examined included conventional variables, such as age, income, marital status, gender, and education. These data were obtained via standard questions. See the Appendix for items la - In. Control of Body Weight A question pertaining to whether subjects had restarted smoking to control their body weight was included in the survey. The question was answered with a simple "yes" or "no.".For item wording, see the Appendix for item 2a. Smoking History Smoking history was measured with an array of questions about smoking initiation, patterns, and cessation attempts. Specific questions included: "How old were you when you smoked your first whole cigarette? In what month and year did you smoke your first whole cigarette? Have you ever smoked cigarettes daily? Did you stop smoking, 1 to 5 years 21 ago, or more than 5 years ago? In the past year, how many times have you quit smoking for at least 24 hours? In the past 3 months, how many times have you stopped smoking for more than 1 week? Did you normally smoke manufactured cigarettes or did you roll your own (Health Canada, 1995)?" See the Appendix for the items 3a - 3o. Nicotine dependence As discussed in the literature review, the Fagerstrom Tolerance Questionnaire is the most notable and widely researched measurement of nicotine dependence. The questionnaire has criterion-related validity, confirmed with attempts to stop smoking, withdrawal symptoms, and highly correlated biochemical intake variables, such as carbon monoxide and cotinine assays (Fagerstrom, 1978; Fagerstrom et al., 1996; Pomerleau, Carton, Lutzke, Flessland, & Pomerleau, 1994; Tate & Schmitz, 1993). As well, construct validity of the questionnaire has been confirmed with a factor analysis. A one-dimensional construct was identified, thus indicating a good fit with the hypothesised measurement structure (Tate & Schmitz, 1993). Because of the lack of available data, all eight questions from the Fagerstrom Tolerance Questionnaire, including the number of cigarettes smoked per day were not considered. However, one important question from the 22 Fagerstrom Tolerance Questionnaire to determine nicotine dependence was asked: "How soon after you wake up do you smoke your first cigarette?" See the Appendix for item 3i. Smoking habit A question pertaining to whether subjects had restarted smoking because of habit was included in the survey. The question was answered with several possible responses. Each response was then coded to identify the first and second reason given for the resumption of smoking: "yes," "yes (second choice)", or "no." For item wording, see the Appendix for items 31-3o. Work and Household Tobacco Smoke Exposure Work and household tobacco smoke exposure were measured by conventional factors, such as reported smoking restrictions at the subject's place of work, the reported number of people in the subject's household, and the reported number of people in the subject's household who smoke every day or almost every day. These questions included: " At your place of work, is smoking restricted completely, allowed only in certain places, or not restricted at all? How many people are living in your household? How many of the other people in your household smoke cigarettes (excluding yourself)? Do you smoke inside your home every day or almost every day? Excluding yourself, 23 how many people smoke inside your home every day? Are you bothered by cigarette smoke? Does cigarette smoke cause you any physical irritation (Health Canada, 1995)?" See the Appendix for items 4a - 4o. Cigarette Cost and Availability Cigarette cost was measured by the use of a derived variable that identified provinces that reduced their provincial cigarette taxes. Respondents were asked questions such as: "Did the price of cigarettes affect your decision to stop smoking? Did the price of cigarettes affect your decision to restart smoking (Health Canada, 1995)?" A similar process was used to measure the subjects' return to smoking because of an increase in cigarette availability. Questions asked of the respondents included: "Did the availability of cigarettes affect your decision to start smoking again (Health Canada, 1995) ?" See the Appendix for items 5a - 51. Emotional and Psychological Variables Questions that pertained to the subjects' emotional and psychological states when they returned to smoking were also asked. These questions included asking the subjects: "What were the main reasons you started smoking?" The emotional and psychological responses included: "to relax or calm down," "to combat boredom," "stress/nerves/to relax," and 24 "no reason/felt like it." A maximum of two main reasons were recorded for each subject. See the Appendix for items 6a -6p. The Social Context The subject's social context was measured by questions that inquired about the subject's family and/or friends who smoked and if this was a contributing factor to their restarting smoking. Also, subjects were asked if they restarted smoking because they were going out more to bars or parties. Because of the lack of available data, important variables, such as the subject's social support network, were not considered. See the Appendix for items 7a - 7h. Health Knowledge Health knowledge was measured by the questions asked of subjects pertaining to their beliefs regarding illnesses caused by smoke from cigarettes in both non-smokers and smokers. These illnesses included lung cancer, other cancers, heart disease, stroke, bronchitis, emphysema, asthma, other respiratory diseases, low birth weight, and fetal problems. See the Appendix for items 8a - 8ee. Advice and Support of Dentists and Physicians The advice and support offered by dentists and physicians were measured by questions that first inquired whether the subjects had seen a doctor and a dentist in the 25 past 12 months, and if so, did the doctor or dentist advise them to stop smoking. Because of the data available, the advice and support offered by other health professionals, such as nurses were not included in the analysis. See the Appendix for items 9a - 9e. Smoking Status There is substantial debate in the literature regarding the appropriate definition of smoking status. The following operational definitions guided this study: "Former smoker:" For the purpose of this study, all subjects reported that they were former smokers at baseline (cycle 1). A former smoker was a person who smoked at least 100 cigarettes in his/her life, but who at baseline reported that they no longer smoked. "Relapser:" A person who reported smoking cigarettes daily or occasionally (in cycles 2, 3, or 4). That is, a person who reported returning to smoking following identification at baseline as a former smoker. "Non-relapser:" A person who reported that he or she remained a former smoker throughout the study, including all three cycles of follow-up. Research Design This comparative, correlational study involved a secondary analysis of data collected for the Survey on 26 Smoking in Canada (Health Canada, 1995), in which a survey panel with four cycle intervals (May, 1994; August, 1994; November, 1994; and February, 1995) were used. The Sample Survey Sample The target population for the Survey on Smoking in Canada was all persons 15 years of age and older living in Canada. Because the survey was conducted using a sample of telephone numbers, households that did not have telephones were excluded from the sample population. However, people without telephones account for less than 3% of the Canadian population (Health Canada, 1995), and the survey estimates were weighted to account for persons without telephones. The sample was obtained using a refinement of random-digit dialling namely the Elimination of Non-Working Banks method. The sample included 1,000 respondents in each of five regions (Atlantic Canada, Quebec, Ontario, the Prairies, and British Columbia) stratified by age group (15-19, 20-24, 25-64, and 65+ years). Weighting This secondary analysis utilised data from the Survey on Smoking in Canada (Health Canada, 1995). These data were contained on a microdata file with statistical weights on each record, to represent the number of persons in the 27 target population that the record represented. A separate weight was calculated for each cycle. Cycle 1 weighting The weighting for the first cycle, May 1994, of the Survey on Smoking in Canada consisted of several steps: calculation of a basic weight, an adjustment for non-response, an adjustment for sub-sampling households, an adjustment for selecting one person in the household, and an adjustment for post-stratification to Province-Sex-Age Group totals. Cycle 2. weighting Weighting for cycle two, August 1994, began with the calculated "Person Weight" from cycle one. This weight was adjusted to account for non-response between cycles one and two, and then adjusted to agree with the population controls. Cycle 3 weighting Weighting for cycle three, November 1994, began with the calculated "Person Weight" from cycle one. This weight was adjusted to account for non-response between cycles one and three, and then adjusted to agree with the population controls. Each of the steps calculated in cycle two weighting was used in weighting for cycle three, the only 28 difference being that the weights were calculated for those persons who responded in cycle three. Cycle 4 weighting Weighting for cycle four, February 1995, began with the calculated "Person Weight" from cycle one. This weight was adjusted to account for non-response between cycles one and four, and then adjusted to agree with the population controls. Each of the steps calculated in cycle two weighting was used in weighting for cycle four, the only difference being that the weights were calculated for those persons who responded in cycle four. Standardised weight For the purpose of the secondary analyses, a standardised weight was assigned to each study subject. This standardised weight was calculated by dividing each individual's study weight by the mean weight of all the study subjects. In this way, the summed weight factor equalled the sample size, permitting reasonable tests of statistical significance. Sample Selection The sample for this study was derived from the 15,804 randomly selected respondents. For the purpose of this study, all of those respondents who reported that they were 29 former smokers at cycle one, May 1994, (N = 3,875) were included. Data Collection Data collection for the Survey on Smoking in Canada (Health Canada, 1995) used computer-assisted telephone interviewing, and the survey questions and response categories were programmed for the application. The interviewer first read the question to the respondent and then entered the respondent's answer. Thus, data collection and data capture occurred simultaneously, and the application was programmed to ensure that only valid answers were entered. The survey was divided into three sections: initial contact, smoking questions, and follow up. The questions themselves were mostly taken from other Statistics Canada surveys, and those developed at a workshop that was attended by researchers and analysts specialising in the field of tobacco use. The data for this study were derived from the variables related to potential predictors of smoking relapse. More specifically, the variables that are associated with the domains presented in the literature review were analysed. For a complete list of the variables analysed and their specific domains, please refer to the Appendix. 30 Reliability and Validity Reliability of Data Collection Every effort was made by Health Canada and Statistics Canada to eliminate any potential sources of systematic or random error. Random error was kept to a minimum by monitoring all computer-assisted telephone interviewing. This monitoring was conducted by senior interviewers who were responsible for ensuring that all interviews were done correctly, and that all interviewers were familiar with the concepts and procedures of the survey. Monitoring of the interviewers consisted of supervisors listening to select telephone interviews and observing the responses as they were entered into the computer-assisted telephone interview application. Reliability of the Questionnaire For the purpose of the primary study, the Survey on Smoking in Canada (Health Canada, 1995), systematic error was kept to a minimum by carefully selecting questions that correctly measured the variables, and wherever possible, taking more than one measure of a concept. However, as is true with all secondary analyses, the Survey on Smoking in Canada (Health Canada, 1995) was not designed with the purpose of this analysis in mind. Therefore, some variables, measurements, and factors that are pertinent to the research 31 question of this study are absent, and are discussed further in the section "Limitations of the Study." Content Validity of the Questionnaire Experts that attended a workshop on data monitoring for tobacco use assessed the content validity of the survey questions and predetermined responses. These experts were members of Health Canada and Statistics Canada, as well as independent and university-based researchers and analysts specialising in the field of tobacco use. Despite these rigorous efforts, it must be acknowledged that the survey data are limited to self-reports and consequently are subject to the biases of honest forgetting, poor recall, and social desirability. Generalisability The study population for the Survey on Smoking in Canada generally represented all persons 15 years of age and older living in Canada with the following two exceptions: residents of the Yukon and Northwest Territories; and full-time residents of institutions. Because the survey was conducted using a sample of telephone numbers, households (and thus persons living in households) that did not have telephones were excluded from the sample population. However, the survey estimates were weighted to include persons without telephones. Therefore, the findings of this 32 research are generalisable to non-institutionalised adults, living in the 10 provinces of Canada and who have telephones. Data Analysis • The inclusion criteria for this study limited the subjects to the following: former smokers who reported that they were not currently smoking at cycle one of the survey, and who had smoked at least 100 cigarettes in their lifetime (N = 3,875) . These cases were divided into two groups. The first group (N = 3,582) remained abstinent from smoking throughout the survey's four cycles, and the second group (N = 293) experienced a smoking relapse between cycle one and cycle four (i.e., they reported being a current smoker at cycles two, three, or four). See Figure 1. Figure 1 Smoking Status by Survey Cycle Cycle 1 Cycles 2-4 ^^-^^^ Non-Relapsers ^•""^ (N = 3,582) Former Smokers (N =3,875) ^ ^ - \ ^ ^^^^. Relapsers (N = 293) 33 The investigator used appropriate descriptive statistics to describe the sample, and the prevalence rate of smoking relapse was determined. Chi-square analyses and t-tests were used depending upon the nature of the variables. Multivariate logistic regression analyses were conducted to identify the unique contributions of various factors, and to identify those factors with the strongest relationships with smoking relapse. Ethical Considerations In that this research study consisted of a secondary analysis of data that are available in the public domain, few ethical considerations were relevant. The office of Research Services at the university waived the necessity of an independent ethical review. The data were provided on microdata tapes with no identifying characteristics, and the anonymity of the subjects was guaranteed. The investigator adhered to the guidelines for tabulation, analysis, and release as instructed by Health Canada (1995). 34 CHAPTER 4: RESULTS The results and analyses of this study are presented in the following chapter. First, the sociodemographic characteristics and the smoking history of the sample are summarised. Second, the sociodemographic characteristics of the relapsers and non-relapsers are compared. The sociodemographic characteristics that were found to be statistically significant are highlighted, and further examined by conducting multivariate logistic regression analyses. Third, variables including control of body weight, smoking history, nicotine dependence, smoking habit, work and household tobacco smoke exposure, cigarette cost and availability, and emotional and social factors are analysed. Fourth, the results of a Pearson Chi-Square analysis conducted to determine whether there were differences in the health knowledge of the two groups (relapsers vs. non-relapsers) are presented. Finally, the smoking cessation advice and support that respondents received from their physicians and dentists are described. The reader should note that the sample size varies in the analysis, primarily because respondents were lost to follow-up over the four cycles, some refused to respond to certain items, and some questions were asked in some but not 35 all cycles. The total number of respondents for each statistical test is provided. Sociodemographic Characteristics of the Sample The age, sex, martial status, education, and income adequacy of the respondents are presented in Table 1. In this study sample, all Canadian provinces were represented, 7.9% of the subjects from the Atlantic region, 23.6% from Quebec, 39.1% from Ontario, 15.4% from the Prairies, and 14.0% from British Columbia. Smoking History and Context of the Sample The majority (82.8%) of this study sample smoked their first whole cigarette before the age of 19 years (M = 16.2 years, SD = 5.0). The majority had been abstinent from smoking for more than 5 years (72.3%) and 7.9% had stopped smoking less than one year before the survey. Seventy-eight percent of the sample did not live with anyone else that smoked inside their home every day; 21% lived with one to three people that smoked inside their home every day. Of the study sample (N = 3,875), 293 subjects reported restarting smoking between cycle one and cycle four, representing a 13.2% cumulative incidence rate of smoking relapse. 36 Table 1 Characteristics of Participants at Baseline (N = 3,875) Characteristic Frequency % 168 4.3 590 15.2 1546 39.9 989 25.5 582 15.0 2252 58.1 1623 41.9 2572 66.4 305 7.9 354 9.1 644 16.6 Less than Secondary 1044 29.8 Completed Secondary 14 94 42.7 Completed Community College/Trade School 459 13.1 Completed University 505 14.4 Income Adequacy13 (Combination of household size and reported household income) Lower 882 26.2 Lower Middle 1146 34.1 Upper Middle 905 26.9 Upper 430 12.9 Age Sex Mari High Group 15-24 years 25-34 years 35-54 years 55-69 years 70+ years Male Female tal Status Married Widowed Separated/Divorced Single est Level of Education3 a 373 missing cases (9.6%) b 512 missing cases (13.2%) 37 Sociodemographic Characteristics of Relapsers and Non-Relapsers Using Pearson Chi-Square analysis, age, sex, marital status, and education were found to differ significantly between those subjects who relapsed (N = 293) and those who did not relapse (N = 3,582). The two groups did not differ in terms of their income adequacy. Table 2 reports the sociodemographic characteristics of relapsers and non-relapsers. Table 2 Sociodemographic Characteristics of Relapsers and Non-Relapsers Sociodemographics Non-Relapsers Relapsers x2 Age Group (n = 15-24 years 124 25-34 years 498 35-54 years 1418 55-69 years 974 70+ years 568 Sex (n = Male 2114 Female 14 68 Marital Status (n = Married 2412 Widowed 297 Separated/Divorced 303 3582) (73.8%) (84.4%) (91.7%) (98.5%) (97.6%) 3582) (93.8%) (90.4%) 3582) (n 44 92 128 15 14 (n 137 155 (n = 293) (26.2%) (15.6%) (8.3%) (1.5%) (2.4%) = 292) (6.1%) (9.6%) = 293) (93.8%) 159 (6.2%) 54.3*** (97.1%) 9 (2.9%) (85.6%) 51(14.4%) 38 Single Education 570 (88.5%) In = 3220) Less than Secondary 993 (95.1%) Completed Secondary 1373 (91.8%) Completed Community College/Trade School 386 (84.1%) Completed University 468 (92.7%) Employment Status Employed Student Retired/other Income Adeguacy (n = 3240) 1648 (90.9%) 78 (76.5%) 1514 (94.2%) (n = 3104) 74(11.5%) (n = 283) 51 (4.9%) 122 (8.2%) 73(15.9%) 37 (7.3%) (n = 283) 165 (9.1%) 24(23.5%) 94 (5.8%) (n = 260) 52.6*** 46.4*** (Combination of household size and reported household income) Lower Lower Middle Upper Middle Upper 822 (93.1%) 1055 (92.1%) 822 (90.8%) 405 (94.2%) 61 (6.9%) 91 (7.9%) 83 (9.2%) 25 (5.8%) 5.8 *** p < .001 To examine these differences multivariately and to control for confounding variables, a logistic regression analysis was conducted. The sociodemographic variables were entered simultaneously. Age, education, marital status, and employment status were treated as "dummy" variables. Only four of these variables contributed significantly to the prediction of relapse: marital status, age, employment status (work activity) and education. The results are reported in Table 3. 39 Table 3 Summary of Logistic Regression Analysis of Sociodemographic Variables Associated with Smoking Relapse Variable Category Non-Relapser Relapser Odds Ratio (95% CI) Income Adequacy Lower-Upper 0.99 (0.85 - 1.15) Marital Status Married 2412 159 1.00 Widowed 297 9 2.12 (0.84 - 5.37) Separated/Divorced 303 51 3.49 (2.36 - 5.19) Single 570 74 1.19 (0.82 - 1.73) Age Group 15-24 years 124 44 19.40 (7.38 - 50.99) 25-34 years 498 92 10.33 (4.45 - 24.00) 35-54 years 1418 128 4.80 (2.21 - 10.86) 55-69 years 974 15 0.67 (0.27 - 1.63) 70+ years 568 14 1.00 Employment Status Employed 1648 165 1.00 Student 78 24 1.47 (0.77 - 2.80) Retired/Looking for Work/ Keeping House • 1514 94 1.47 (1.04 - 2.06) Sex Male 2114 137 Female 1468 155 Education Less than Secondary 993 51 Completed Secondary 1373 122 Completed Community College/Trade School 386 73 Completed University 468 37 1 .00 1 . 2 1 1 .00 . 9 1 2 . 3 4 1 .08 (0 (0 (1 (0 89 -61 -52 -66 -1 . 6 3 ) 1 . 3 5 ) 3 . 6 0 ) 1 .76 ) 40 Control of Body Weight In cycle two, 121 of the study participants that had reported experiencing a relapse in the previous three months were asked if they had restarted smoking to control their body weight. Only three of the 121 (2.5%) subjects said that they had. Smoking History of Relapsers and Non-Relapsers Independent t-tests and chi-square analyses, appropriate to the level of measurement, were used to identify any smoking history differences between those who relapsed and those who did not relapse. No significant differences were noted regarding the age at which subjects smoked their first whole cigarette (t = 1.60, df = 3,777, p = .11); those who remained abstinent smoked their first, on average, at 16.2 years compared to 15.7 years for relapsers. However, significant differences existed between the two groups when tested for the age group in which subjects started smoking. Those who started smoking before the age of 12 years or between 18 and 19 years were most likely to relapse. Table 4 is a crosstabulation of the age group that subjects started smoking and their relapse status. 41 Table 4 Age Started Smoking and Relapse Status Age Started Smoking Relapse %2 NO YES (n = 3490) (n = 290) Age Less than 12 Years 260 (89.0%) 32 (11.0%) 74.64*** 12-13 Years 597 (92.6%) 48 (7.4%) 14-15 Years 1026 (93.9%) 67 (6.1%) 16-17 Years 605 (94.4%) 36 (5.6%) 18-19 Years 381 (83.2%) 77 (16.8%) More than 20 Years 621 (95.4%) 30 (4.6%) ***p < .001 Other smoking history data were only available on those subjects that relapsed. Of those that relapsed, only 4 of 200 (2%) who responded attributed their relapse to the "smoking habit." One hundred and seventy-six of 187 (94.1%) relapsers reported smoking manufactured cigarettes, whereas 11 of 187 (5.9%) reported smoking "roll your own," or both. Of the 66 study participants that experienced a smoking relapse between cycles 3 and 4 of the survey, 48 (72.7%) were highly nicotine dependent, reporting that they smoked their first cigarette of the day within 60 minutes of waking. One hundred and eleven of 175 (63%) of those that relapsed between cycles 1 and 2 reported stopping smoking for more than one week in the past three months. This group 42 averaged 3.8 such attempts (SD = 5.5). One hundred and nineteen of 175 (68%) of these same study participants that relapsed between cycles 1 and 2 reported quitting smoking for 24 hours, at least once in the past year. Only in cycle four were relapsers asked about the kind of cigarettes they currently smoked. Of those who responded to this question, 107 of 153 (70%) reported smoking "light" cigarettes; however, 73 of 153 (48%) said that they smoked regular cigarettes when they first began smoking cigarettes, and later switched to "light cigarettes." Work and Household Tobacco Smoke Exposure Pearson Chi-Square analyses were conducted to identify any significant differences between the two groups (relapsers and non-relapsers) regarding work and household tobacco smoke exposure. There were no differences between the groups' exposure to workplace smoking restrictions. Significant differences were found, however, when the presence of other smokers (excluding the subject) in the household was examined. An independent t-test revealed significant differences (t = -4.10, df = 313.5, p < .001) in that the number of people that smoked in relapsers' households was greater (M = 0.6; SD = 1.1) than in non-relapsers' households (M = 0.3; SD = 0.8). 43 Significant differences were also noted between relapsers and non-relapsers when examining the subject's exposure to smoke from cigarettes. If subjects were exposed more often to cigarette smoke, if subjects were bothered by cigarette smoke, and if cigarette smoke caused the subjects any physical irritation, they were less likely to relapse (see Table 5) . 44 Table 5 Work and Household Tobacco Smoke Exposure and Relapse Status Variable Relapse %2 Category NO YES Cigarette Smoke Exposure (n = 3093) (n = 195) Every day 724 (91.2%) 70 (8.8%) 40.43*** Almost every day 278 (94.2%) 17 (5.8%) At least once/week 810 (92.0%) 70 (8.0%) At least once/month 590 (96.9%) 19 (3.1%) > Once a month 691 (97.3%) 19 (2.7%) Bothered by Cigarette Smoke (n = 3103) (n = 293) Yes 1944 (96.3%) 72 (3.7%) 47.14*** No 1159 (90.5%) 121 (9.5%) Cigarette Smoke Causes Physical Irritation (n = 3110) (n =263) Yes 1777 (94.4%) 106 (5.6%) 27.87*** No 1333 (89.5%) 157 (10.5%) ***p < .001 Cigarette Cost and Availability Only 1 of 197 (0.7%) study participants who relapsed reported that his or her relapse was due to an increased availability of cigarettes, however 43 of 197 (22%) study participants that relapsed during one of the four cycles 45 reported resuming smoking because the cost of cigarettes was lowered. Emotional and Psychological Variables The primary reason reported by study participants that experienced a smoking relapse, in any of the four cycles, was "to relax or calm down;" 79 of 212 (37.3%) subjects acknowledged this as their reason for relapse. Twenty-six of 212 (12%) subjects reported that their reason for restarting smoking was to "combat boredom" and only 2 of 212 (1%) subjects reported that "curiosity" led to their smoking relapse. The Social Context For the purpose of this study, only relapsers were questioned about the reasons attributed to their smoking relapse. Thirty-six of 212 (17%) of the study participants that relapsed during any of the four cycles reported smoking because their "family and friends smoke," and 22 of 212 (10%) attributed their smoking relapse to their social environment, which included "going out more to bars and parties." Table 6 displays, in rank order, the various reasons reported by relapsers for their smoking relapse, in all four cycles. 46 Table 6 Reasons for Smoking Relapse Reason Frequency (n = 212) To Relax or Calm Down 7 9 37.3 Lower Costs 43 20.3 Family/Friends Smoke 36 17.0 To Combat Boredom 26 12.3 Going out more to bars/parties 22 10.4 Smoking Habit 4 1.9 Curiosity 2 0.9 Health Knowledge All study participants were questioned about the relationship between smoking and health problems, as well as the relationship between secondary smoke and health problems. For the purpose of this study, secondary smoke was defined as spending at least 10 minutes in the presence of someone smoking, or in a room where people are smoking. The majority of study participants indicated that they believed secondary smoke could not cause lung cancer (63%), other cancers (83%), heart disease or heart problems (87%), stroke (100%), respiratory disease (50%), and low birth weight/fetal problems (99%) in non-smokers. When these same subjects were questioned about smoking-related illnesses in "smokers," 48% believed that being a smoker could not cause 47 lung cancer. Subjects also believed that smokers were not at risk for other cancers (68%), heart disease or heart problems (68%), stroke (98%), respiratory disease (64%), and low birth weight/fetal problems (99%). When subjects were questioned about the harmful effects of "smoking for many years" (Health Canada, 1995), 74% thought it was very likely that smoking could cause emphysema. Other diseases were considered to be possible outcomes by varying numbers: lung cancer (88%), asthma (71%), and stroke (48%). The subjects believed, however, that it was not at all likely that multiple sclerosis (76%) or bladder cancer (52%) were risks faced by smokers that smoked for "many years" (Health Canada, 1995). An overwhelming majority of the study participants (99%) believed that people could become addicted to cigarettes, and ninety-five percent of the study participants believed that quitting smoking could improve people's health, even after they had smoked for "many years" (Health Canada). Forty-one percent of subjects believed that smokers could quit at anytime. Pearson Chi-Square analyses were conducted to determine whether there were any differences in the health knowledge of the two groups, relapsers and non-relapsers. These results are shown in Tables 7 and 8. 48 Table 7 Percentage of Respondents Reporting Health Problems NOT Caused by Secondary Smoke Variable Non- Relapsers x2 Relapsers (n = 2567) (n =219) Lung Cancer Other Cancer Heart Disease/Problems Stroke Bronchitis, Emphysema Respiratory Disease Fetal Weight/Problems Other 1630 2122 2229 2555 1772 1271 2542 2375 (63 (82 (86 (99 (69 (49. (99. (92. 5%) 7%) 9%) 6%) 1%) 5%) 1%) 6%) 121 185 169 (56 (86 (79 214 (100 146 105 213 212 (68 (49. (99. (99. 5%) 4%) 0%) 0%) 2%) 1%) 5%) 1%) * p < .05 ** p < .01 *** p < .001 As reported in the preceding table (Table 7), significant differences were found when the health problems NOT caused by secondary smoke were examined. Non-relapsers were more likely than relapsers to believe that lung cancer and heart disease could NOT be caused by secondary smoke. 4.13* 1.97 10.39** 0.92 0.06 0.02 0.49 49 Table 8 Percentage of Respondents Reporting Health Problems NOT Caused by Smoking Variable Non- Relapsers %2 Relapsers (n = 2933) (n =254) Lung Cancer Other Cancer Heart Disease/Problems Stroke Bronchitis, Emphysema Respiratory Disease Fetal Weight/Problems Other 1402 1989 2039 2866 1898 1872 2895 2736 (47 (67 (69 (97 (64 (63 (98 (93 8%) 8%) 5%) 7%) 7%) 8%) 7%) 3%) 123 170 125 247 198 153 252 243 (48 (67 (49 (97 (78 (60 (99 (96 4%) 2%) 4%) 2%) 3%) 5%) 6%) 0%) 0 0 43 0 18 1 1 2 04 04 36 23 94 13 56 8 7 *** p < .001 Significant differences were also found when health problems NOT caused by smoking were examined. Non-relapsers were more likely than relapsers to believe that heart disease was NOT a health problem caused by smoking; however, relapsers were more likely to believe that smoking did NOT cause bronchitis and emphysema. Advice and Support of Dentists and Physicians Only those participants that had relapsed were asked if either their physician or dentist had advised them to quit smoking. The majority of relapsers (58%) were not advised to stop smoking by either their physician or dentist. 50 Conclusion In conclusion, relapsers, compared with non-relapsers, were more likely to be young (under 35 years of age), to have completed a community college or trade school program, to be separated or divorced and- unemployed. As well, relapsers were more likely to have other smokers in their household, be exposed to more smoke from cigarettes, and be less bothered by cigarette smoke. Relapsers were nicotine dependent, for the most part, and reported that they started smoking at a relatively young age (less than 12 years, or 18-19 years). Both relapsers and non-relapsers faired poorly when reporting their health knowledge of smoking-related illnesses, incurred both by smokers and non-smokers exposed to secondary smoke. 51 CHAPTER 5: DISCUSSION This final chapter provides a discussion of some of the major findings of the study, an examination of the study's limitations, a summary of the importance of this work, and conclusion. Major Findings This study examined an important issue, predictors of smoking relapse. As discussed earlier in the literature review, smoking relapse is the most commonly reported outcome of smoking cessation, yet few studies have focused on the factors or characteristics that predispose individuals to the risk of relapse. The evidence presented in this study demonstrates that there are specific predictors of smoking relapse, which are noteworthy and warrant further discussion. The findings that specific sociodemographic characteristics, nicotine dependence, the need to relax and calm dowm, and exposure to environmental tobacco contributed significantly to smoking relapse will be examined more closely. Predictors of Relapse Sociodemographic Variables On univariate analysis, the sociodemographic variables associated with relapse were gender, marital status, age, employment status, and education. Controlling for 52 confounding, the logistic regression model pointed to four significant attributes associated with relapse: separated and divorced respondents were 3.5 times as likely as married respondents to relapse. Youth were also more likely to relapse. Fifteen to 24 year olds and 25 to 34 year olds were 19 and 10 times more likely, respectively, to relapse than were 70+ year olds. In contrast, those who were students, retired, keeping house, or looking for work were slightly more likely (1.5 times) to relapse than those who were employed. Finally, there was no trend noted in the educational strata, although those with completed college (non-university) and trade school programs were 2.3 times more likely to relapse than were people with less than a high school diploma. This may be associated with their work environment rather than education, which may have served as a marker in this analysis. That is, those with trade school diplomas and community college educations, which are often technical in nature, may work in settings in which smoking is a social norm (Millar & Bisch, 1989; Health Canada, 1991, 1992). Blue-collar occupations have the highest rates of smoking among occupations in Canada. Approximately one half of the workers in fishing, forestry, mining, transportation, and construction are smokers - - about double the national average (Health Canada, 1999). 53 These study findings do not differ largely from what has been reported in the published literature and described in the literature review in Chapter 2. Sociodemographic characteristics including age, income, marital status, gender and education have all been associated with successful smoking cessation in other studies, but findings are variable. To review more closely, some studies have shown no effect of age on smoking cessation outcomes (Curry, Thompson, Sexton, & Omenn, 1989; Ockene, Benfari, Nuttall, Hurwitz, & Ockene, 1982), while other studies have indicated that the likelihood of successful cessation decreases as age increases (Eisinger, 1971; Garvey, Heinold, & Rosner, 1989; Glasgow, Klesges, Klesges, & Somes, 1988; Marlatt, Curry, & Gordon, 1988). However, the results of this study found that relapsers were more likely to be less than 34 years of age. Researchers have reported that people with higher levels of education (Rabat & Wynder, 1987; McWhorter, Boyd, & Mattson, 1990), and being married significantly increased sustained smoking cessation (Derby, Lasater, Vass, Gonzalez, & Carleton, 1994; Rabat & Wynder, 1987; Raprio & Roskenvuo, 1988; Sanders, Peveler, Mant, & Godfrey,. 1993; Stevens & Hollis, 1989). The results of this study also established these associations. 54 Although gender differences and smoking relapse are reported in the published literature, these reports are few and inconsistent. The results of this study, however, concurred with the larger body of literature and found no association between gender and smoking relapse, when confounding variables were controlled. Finally, researchers have reported that wealthier people are more successful in quitting smoking (Kabat & Wynder, 1987; McWhorter, Boyd, & Mattson, 1990). The results of this study however, did not establish the same association. An explanation for this discrepancy and non-association may be attributed to the study's measurement of income. In this study, income was measured using the categorical variable, income adequacy whereas, in most studies a numerical value is assigned to represent income. Nicotine Dependence Because of the highly addictive properties of nicotine and its expedient delivery to the brain through cigarette inhalation, nicotine dependence has been strongly associated with smoking relapse (Benowitz, 1998; Fagerstrom, 1978; Fagerstrom et al., 1996; U.S. Department of Health and Human Services, 1988). In keeping with the current literature, this study reported that the majority of relapsers (73%) were highly nicotine dependent, reporting that they smoked 55 their first cigarette of the. day within 60 minutes after waking. It can not be over stated that the delivery of effective smoking cessation treatments must include strategies that deal with the addictive properties of nicotine and its association with relapse. One such strategy that deals with nicotine dependence is the use of nicotine replacement medications. Nicotine replacement therapy is considered a cornerstone in clinical guidelines for smoking cessation in North America; however, less than two percent of former smokers have used nicotine replacement as an aid to smoking cessation (Fiore et al., 1996). This finding is troubling because it is plausible that the low use of nicotine replacement is associated with higher rates of smoking relapse. Further research should be directed towards understanding and overcoming the barriers that impede the implementation of successful strategies, such as nicotine replacement for the treatment of nicotine dependence. If research is not directed in this area, the rate of smoking relapse could potentially become critical, because research indicates that smokers are appearing to become more highly nicotine dependent (Fagerstrom et al., 1996; Hughes, 1996). 56 The Need for Relaxation In all four cycles of follow-up, the primary reason that subjects reported a smoking relapse was "to relax and calm down." The need for relaxation has been identified as a possible response to life stresses (Wright & Leahey, 1991). It has been argued that life stresses can interfere with the ability to maintain smoking cessation, and should be taken into account when treating relapsers (Shiftman, 1982; Swan et al., 1988). The treatment of reducing stress in these clients who relapse, however, is not a simple matter. As discussed earlier in the literature review, the nature of the relationship between stress and relapse is unclear. Is it stress that causes relapse or relapse that causes stress, or is the relationship bi-directional (Cohen & Lichtenstein, 1990)? Some smokers have claimed that smoking a cigarette calms them down (Abrams et al., 1987; Ockene et al., 1982). However, conclusive evidence has demonstrated that nicotine is not a depressant, but a stimulant that actually increases a person's heart rate, blood pressure and respiratory rate (Johnstone, 1942). Clearly, this is not the calming effect that smokers perceive from smoking cigarettes. What smokers may be perceiving is the euphoriant effect that nicotine 57 delivers as well, as it is also'a mood elevating drug that produces effects smokers perceive as pleasurable (Johnstone, 1942). Because the physiological effects of nicotine are both euphoriant and stimulant, the strategies directed towards stress reduction for the prevention of smoking relapse are complex. It is not clear in the findings of this study what respondents imply when they report "to relax and calm down" as the cause of their smoking relapse. If this response is associated with stress, guarded interpretation is advised. Stress is an ambiguous concept that encompasses many different meanings for many different people. This broad term likely encompasses many affective states and requires further exploration to identify the psychological and social factors that place individuals at risk for smoking relapse. Exposure to Environmental Tobacco Smoke This study also found significant differences when the presence of other smokers (excluding the subject) in the household were examined. Statistically significant differences were noted between the number of people that smoked in a relapser's household. When more household members smoked participants were more likely to relapse. Differences were also noted between the two groups (relapsers and non-relapsers) when examining subjects' 58 exposure to smoke from cigarettes, if subjects were bothered by cigarette smoke, and if cigarette smoke caused the subjects any physical irritation. The findings indicate that participants were at greater risk for relapse when other people in their household smoked, and they were not as bothered by secondary smoke, suggesting that there may be an association between a person's tolerance of secondary smoke and their risk of relapse. Many studies have examined issues pertaining to the initiation of smoking by youth (for an excellent review see Abernathy, 1997). Most research findings suggest that there is very little new smoking initiation after age 21 (Chen & Kandel, 1995). Chassin et al. (1984, 1996) reported that tobacco tolerance in young people is associated with the commencement of smoking. For example, if youths are bothered by cigarette smoke, they are less likely to begin smoking. It is plausible that the tobacco intolerance observed in those who do not initiate smoking might also be related to smoking relapse. This is an interesting finding that directs researchers to further investigate the association between a person's lack of tolerance to tobacco smoke and smoking relapse. 59 Additional Findings Additional results in this study also included more general smoking-related findings. For example, the majority of smokers indicated they wanted to quit smoking, they hold a lack of health knowledge regarding the health risks associated with smoking and second hand smoke, and the majority of physicians and dentists are not recommending smoking cessation to their smoking clients. Smokers Want to Quit This author has often heard individuals claim that most smokers do not want to quit, and that "smokers just don't have enough.will power to quit;" the findings of this study suggest the contrary. Many of the relapsers made multiple attempts to quit smoking. The majority of relapsers (63%) had tried quitting smoking within three months of data collection. Also, 68% of the relapsers reported stopping smoking in the past year for 24 hours. In addition, 70% of the relapsers reported that they currently smoked "light cigarettes" even though they smoked regular cigarettes when they first began smoking. These findings suggest that most smokers really do try to quit smoking, and they attempt strategies they believe to be helpful such as reducing the amount of nicotine in their cigarette by switching to "lighter" brands. 60 Fiore et al.'s (1996) work is consistent with these findings and identified that smokers usually make several serious attempts before becoming smoke-free. As the evidence continues to mount regarding the difficulty that smokers experience when attempting to stop smoking, it would seem that smokers engaging in this process could benefit from gestures of empathy and support opposed to criticism about their lack of "will power." Health Knowledge Another troubling finding is the lack of health knowledge possessed by the sample regarding smoking-related illnesses and risks. The majority of the participants believed that lung cancer (63%), other cancers (83%), heart disease or heart problems (87%), stroke (100%), respiratory disease (50%), and low birth weight and fetal problems (99%) could NOT be caused in nonsmokers by exposure to secondary smoke. When these same respondents were questioned about smoking-related illnesses in smokers, 48% believed that being a smoker did NOT cause lung cancer. Subjects also believed that smokers were NOT at risk for other cancers (68%), heart disease or heart problems (68%), stroke (98%), respiratory disease (64%), and low birth weight and fetal problems (99%) . 61 When subjects were questioned about the harmful effects of "many years of smoking," 74% believed it was very likely that smoking could cause emphysema, lung cancer (88%), asthma (71%), and stroke (48%). The subjects believed it was not at all likely that multiple sclerosis (76%) or bladder cancer (52%) were risks faced by those that smoked for many years. These findings suggest that health professionals are not doing enough to educate Canadians, as represented in this study sample, about the health risks associated with smoking. These health risks include those faced by smokers and those of non-smokers exposed to secondary smoke. Medical Advice In the same context, doctors and dentists do not seem to be addressing smoking cessation with their patients. Among relapsers, 58% reported that their doctors and dentists did NOT advise them to stop smoking. This finding is disturbing because a randomised controlled trial has shown that smokers who are subjected to a brief intervention by their physicians are twice as likely to quit (Kottke, Battista, DeRriese & Brekke, 1988) . This finding should prompt health professionals to be more attentive in presenting clients with clear messages concerning the importance of smoking cessation and the health risks 62 associated with tobacco use. As well, health professionals need to educate smokers about the ill-health effects of smoking on non-smokers. As discussed in the literature review (Chapter 2), the evidence demonstrates that health professionals can make a difference in a client's smoking cessation outcome; however, the next important question should focus on how this difference can be incorporated into the practice of each health professional. Nursing Implications Research has demonstrated that nurses can make a significant difference in the smoking cessation outcomes of their smoking clients. Nurse-delivered interventions initiated in the hospital that focus on smoking cessation and relapse prevention have reported impressive results (Johnson et al., 1999; Taylor, Houston-Miller, Killen, & DeBusk, 1990; Taylor et al., 1996). As well, the Canadian Nurses Association (1997) has mandated nurses to assist Canadians who are affected by tobacco and nicotine addiction by becoming involved in tobacco prevention, protection, and cessation. As discussed throughout this study, major building blocks toward successful smoking cessation include a better understanding of the smoking cessation process and the prevention of smoking relapse. This study has contributed to nurses' and 63 other health professionals' knowledge about variables associated with smoking relapse in a Canadian population. It is hoped that this knowledge might guide nurses to a better understanding of the smoking relapse process, and to better ways of identifying and aiding those clients who are most likely to relapse. Limitations of the Study A major limitation of this data set, as is true with all secondary analyses, is that it was not designed with the primary purpose of this study in mind. First, as reported in the literature review of this proposal, the strength of one's self-efficacy is an important factor that may predispose an individual to smoking relapse. However, there were no questions or variables in the Survey on Smoking in Canada (Health Canada, 1995) that measured self-efficacy, thus this concept was not analysed for the purpose of this study. Second, the literature reviewed in this study emphasised nicotine dependence as a powerful predictor of smoking relapse. Various measures have been developed and validated, notably Fagerstrom's (1978) Nicotine Tolerance Test. Heatherton, Kozlowski, Frecker, Rickert, and Robinson (1989) devised and validated a simpler measure of nicotine dependence that asks the number of cigarettes smoked each 64 day and the duration of time from waking to the first cigarette of the day. A limitation of the Survey on Smoking in Canada (Health Canada, 1995), however, is the lack of available data documenting the subject's number of cigarettes smoked per day. Third, the literature reviewed in this study included studies demonstrating positive smoking cessation outcomes when nurses intervened with their smoking clients. However, the Survey on Smoking in Canada included data from questions that only referred to doctors and dentists as health professionals. Because of this lack of available data, the advice and support offered by other health professionals, such as nurses were not considered in this analysis. Fourth, the findings of the study should be viewed with some caution in that the smoking status of all respondents was measured by self-report and was not biochemically validated. Because the telephone was used to collect data for the survey conducted by Health Canada, biochemical measurement of smoking status was not possible. However, the underreporting of smoking status associated with self-report may not be of great concern particularly with this study, primarily because of the assured anonymity of all respondents, and the lack of association to whom they were reporting. For instance, evidence has suggested that smokers 65 with smoking-related diagnoses may feel compelled to report to health care practitioners that they are not smoking (Velicer, Prochaska, Rossi, & Snow, 1992), however, this is clearly not the case with this study. Finally, because this research study was based within the framework of a secondary analysis, variables, measurements, and factors pertinent to the research question were absent. This lack of information is a problem in most if not all secondary analyses, simply because the research question of the secondary analysis is limited to the data collection procedures designed for the primary study. Summary and Conclusions Although the health consequences of smoking should be well known, an estimated seven million Canadian adults continue to smoke (Health Canada, 1995). The contribution of cigarette smoking to disease is significant both in terms of overall morbidity and mortality, and consequently is the leading cause of preventable deaths in Canada (Health Canada, 1995). Even though numerous Canadian smokers attempt to reduce their health risk by engaging in the smoking cessation process, their most frequently reported outcome is relapse. In an attempt to better understand smoking relapse, this study set out to identify predictors of smoking relapse 66 in a community-based, nationally representative population, which included smokers who had ceased smoking using a variety of strategies, particularly those not associated with formal programming. It was postulated that this knowledge might guide health professionals to a better understanding of the smoking relapse process, and to better ways of identifying and aiding those most likely to relapse. This comparative, correlational study involved a secondary analysis of data collected for the Survey on Smoking in Canada (Health Canada, 1995), in which a survey panel with four cycle intervals (May, 1994; August, 1994; November, 1994; and February, 1995) were used. The sample for this study was derived from the 15,804 randomly selected respondents. For the purpose of this study, all of those respondents who reported that they were former smokers at cycle one, May 1994, (N = 3,875) were included. These cases were then, divided into two groups. The first group (N = 3,582) remained abstinent from smoking throughout the survey's four cycles, and the second group (N = 293) experienced a smoking relapse between cycle one and cycle four (i.e., they reported being a current smoker at cycles two, three, or four). The results of this study found that relapsers, compared with non-relapsers were more likely to be young, to 67 have completed a community college or trade school program, to have been separated or divorced, and unemployed. As well, relapsers were more likely to have other smokers in their household, be exposed to more smoke from cigarettes, and be less bothered by cigarette smoke. Relapsers were also highly nicotine dependent and reported starting smoking at a relatively young age (less than 12 years). Both relapsers and non-relapsers faired poorly when reporting their health knowledge of smoking related illnesses, incurred both by smokers and non-smokers exposed to secondary smoke. Notwithstanding the acknowledged limitations of this study, the results contribute to the body of knowledge related to smoking relapse. First, this study includes the "self-quitter" population that has been overlooked in the published literature. Second, this study provides evidence regarding sociodemographic variables that predict relapse: marital status, age, employment status and education. Third, the analysis provides evidence, consistent with the current literature, that the stronger a person's nicotine dependence, the greater the likelihood that he or she will experience a smoking relapse. Fourth, both stress (as perceived by the individual) and secondary smoke exposure are related to smoking relapse. Fifth, health professionals must examine how they are "getting the message out" to the 68 Canadian public regarding smoking-related risks for both smokers and non-smokers. 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APPENDIX Coding of Variables and Questionnaire Items Item Variable Description Value Page # 8 6 Variable C1SSTY1 C2SSCHG C3SSCHG C4SSCHG Description Former smoker (cycle 1) (Derived variable) Change in smoking status between Cycle 1 and cycle 2 (Derived variable) Change in smoking status between Cycle 2 and cycle 3 (Derived variable) Change in smoking status between Cycle 3 and cycle 4 (Derived variable) Value Inclusion Criteria 2 Former Smoker Coverage no te : <2> If C1Q01=3 (Not a t a l l ) •*(Does not smoke a t present time) and C1Q02=1 (Yes) *(Smoked at least 100 cigarettes in lifetime) 1 Respondent restarted smoking since cycle 1 Coverage note: <1> If CIQ01=3 and CISSTY1=2 and C2Q01=1 or 2 1 Respondent restarted smoking since cycle 2 Coverage note: <1> If C2SSTY1=2 and C3SSTY=1 1 Respondent restarted smoking since cycle 3 Coverage note: <1> If C3SSTY1=2 and C4SSTY=1 Code Sample 134 156 189 227 3875 (pg.246) 196 (pg. 251) 142 (pg. 258) 127 (pg. 267) C1FINWT C2FINWT C3FINWT C4FINWT LONGWT LONGHHWT Final weight Final weight-cycle 2 Final weight-cycle 3 Final weight-cycle 4 Longitudinal weight- all 4 cycles Weighting 999999V9999 999999V9999 999999V9999 999999V9999 999999V9999 Longitudinal household weight- all 4 cycles 999999V9999 124 125 125 125 125 125 86 Item Variable Description Value Page # 87 la IDNOM Identification Number Record Layout According to Domains SOCIODEMOGRAPHIC FACTORS 0000001:016000 ID 121 lb PROVCODE Province lc Id le If REGION Sex MST AGEGP1 Region Respondent's sex Marital Status Age group ig AGEGP4 Age group 0 1 2 3 4 5 6 7 8 9 1 2 3 4 5 1 2 1 2 3 4 15:49 52 57 62 67 78 1 2 3 4 Newfoundland Prince Edward Island Nova Scotia New Brunswick Quebec Ontario Manitoba Saskatchewan Alberta British Columbia Atlantic Quebec Ontario Prairie British Columbia Male Female Married Widowed Separated/Divorced Single Years 50-54 years 55-59 years 60-64 years 65-69 years 70+ years 15-19 years 20-24 years 25-64 years 65+ years 121 121 122 122 122 87 Item Variable Description lh AGEGP8 Age group li C2Q24 Highest level of education completed lj C2ED0 Grouped highest level of education Ik C1Q21 Total household income for 1993 (before taxes and deductions) 11 C1INCAD Income adequacy {Derived variable) Value Page # 88 1 15-19 years 123 2 20-24 years 3 25-34 years 4 35-44 years 5 45-54 years 6 55-64 years 7 65-69 years 8 70+ years 01 No schooling 154 02 Some elementary 03 Completed elementary 04 Some secondary 05 Completed secondary 06 Some community college, technical, CEGEP or nurse's training 07 Completed community college, technical, CEGEP or nurse's training *' 08 Some university or teacher's college 09 Completed university or teacher's college 10 Other education or training 97 Don't know 98 Refused 99 Not stated 1 Less than secondary 160 2 Completed secondary 3 Completed community 4 Completed university 9 Not stated 00 No income 133 01 Less than $20,000 02 $20,000-$29,999 03 $30,000-$39,999 04 $40,000-$59,999 05 $60,000-$79,99 06 $80,000 or more 97 Don't know 98 Refused 99 Not stated 1 Lower 137 2 Lower middle 2 Upper middle 3 Upper 9 Not stated Item Variable Description Value Page # 8 9 lm C2Q20 Which of the following best describes your main activity during the past 12 months? 01 Working at a job or business 02 Looking for work 03 A student 04 Retired 05 Keeping house 06 Unable to work (due to illness/injury, etc.) 07 Or some other activity 97 Don't know 98 Refused 99 Not stated 153 In C2Q21 Were you mainly working full-time or part-time? Full-time Part-time Valid skip Don't know Refused Not stated 153 CONTROL OF BODY WEIGHT 2a C2Q10 1 Restarted smoking to control weight 1 2 3 6 7 • 8 9 Yes Yes (second choice) No Valid skip Don't know Refused Not stated SMOKING HISTORY 147 3a C1Q04 Age respondent smoked first whole cigarette 04:95 Years 96 Valid skip 97 Don't know 98 Refused 99 Not stated 126 3b C1AGGPST Age group started smoking 01 Less than 12 years 02 12-13 years 03 14-15 years 04 16-17 years 05 18-19 years 06 More than 20 years 96 Valid skip 99 Not stated 135 89 Item Variable Description 3c C3Q15 Past year, times quit for 24 hours 3d C1Q07 Stopped smoking 3e C1Q08MM Month and year stop smoking 3f C1Q08YY Month and year stop smoking 3g C2Q15 In the past 3 months, how many times have you stopped smoking for more than 1 week? 3h C2Q17 Manufactured cigarettes or roll your own Value Page # 90 000:365 996 Valid skip 997 Don't know 998 Refused 999 Not stated 1 Less than 1 year ago 2 1-5 years ago 3 More than 5 years ago 6 Valid skip 7 Don't know 8 Refused 9 Not stated 01:12 Month 96 Valid skip 97 Don't know 98 Refused 99 Not stated 93:94 Year 96 Valid skip 97 Don't know 98 Refused 99 Not stated 00:17 Weeks 96 Valid skip 97 Don't know 98 Refused 99 Not stated 1 Smoke manufactured ci 2 Roll your own 3 Both 6 Valid skip 7 Don't know 8 Refused 9 Not stated 172 127 127 127 152 rettes 152 90 Item Variable Description 3i C4Q19 How soon after you wake up do you smoke your first cigarette? 3j C4Q21 Do you usually smoke "light" cigarettes or regular cigarettes? 3k C4LIGHT Dse of light and regular cigarettes 31 C2Q10_9 Restarted smoking... habit 3m C3Q09_5 Restarted smoking... habit 3n C4Q09_5 Restarted smoking... habit Value Page # 91 1 Within 5 minutes 215 2 6-30 minutes 3 31-60 minutes 4 More than 60 minutes 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Light 218 2 Regular 3 No usual type 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Currently smoke light/light when started 231 2 Currently smoke light/regular when started 3 Currently smoke regular/light when started 4 Currently smoke regular/regular when started 6 Valid skip 1 Yes 149 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Yes 169 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Yes 203 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 91 Item Variable 3o LNS2K 5 Description Reason for change from non-smoking to smoking all cycles... habit (•Derived variable) Value 1 2 6 9 Yes No Valid skip Not stated Page # 240 92 WORK AND HOUSEHOLD TOBACCO SMOKE EXPOSURE 4a C2Q22 At your place of work, is smoking restricted completely, allowed only in designated areas, restricted only in certain places, or not restricted at all? 1 Restricted 2 Allowed only in designated areas 3 Restricted only in certain places 4 Not restricted at all? 6 Valid skip 7 Don't know 8 Refused 9 Not stated 153 4b 4c 4d 4e HHSIZE C1Q20 C1NSMOK C2Q18 Number of people in the household People in household that smoke cigarettes (excluding respondent) Number of people in household who smoke (Derived variable) Do you smoke cigarettes inside your home every day or almost every day? 01:13 00 96 97 98 99 00 99 1 2 6 7 8 9 07 08 People Valid skip Don't know Refused Not stated People Not stated Yes No Valid skip Don't know Refused Not stated 123 133 135 152 4f C2Q19 Excluding yourself, how many people smoke 00:20 People inside your home every day? 97 Don't know 98 Refused 99 Not stated 153 4g C2SMOKHM Number of people who smoke inside the home 00:20 People (Derived variable) 99 Not stated 159 4h HHAGEG1 Number of children in household age 0-5 00:03 People 04 4 or more 123 92 Item Variable Description Value Page # 93 41 HHAGEG2 Number of children in household age 6-11 00:02 People 03 3 or more 123 4j HHAGEG3 Number of children in household age 12-14 00:02 People 03 3 or more 123 4k HHAGEG4 Number of children in household age 15-16 00:01 People 02 2 or more 123 41 HHAGEG5 Number of children in household age 17-19 00:02 03 People 3 or more 124 4m C3Q29 Are you exposed to smoke from cigarettes? 1 Every day 18 6 2 Almost every day (5-6 days/week) 3 At least once week (1-4 days/week) 4 At least once month (12-51 times/year) 5 Less than once a month (less than 12 times/year) 6 Valid skip 7 Don't know 8 Refused 9 Not stated 4n C3Q30 4o C3Q31 Are you bothered by cigarette smoke? Does cigarette smoke cause you any physical irritation? 1 2 6 7 8 9 1 2 6 7 8 9 Yes No Valid skip Don't know Refused Not stated Yes No Valid skip Don't know Refused Not stated 186 186 CIGARETTE COST AND AVAILABILITY 5a C1TAXCDT Indicates a decrease of provincial taxes Yes No 121 93 Item Variable Description 5b C2Q10_4 Restarted smoking... lower prices 5c C3Q09_4 Restarted smoking... lower prices 5d C4Q09_4 Restarted smoking... lower prices 5e C2Q10_5 Restarted smoking... increased availability 5f C2Q11 Did cigarette prices affect your decision to start smoking? 5g C3Q10 Did cigarette prices affect your decision to start smoking? Value Page # 94 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 3 6 7 8 1 2 3 6 7 8 9 Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated choice) choice) choice) choice) choice) choice) 148 169 203 148 147 170 94 Item Variable Description Value Page # 95 5h C4Q10 Did cigarette prices affect your decision to start smoking?. 1 Yes 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 204 5i C2COST Cost a change in smoking status (Derived Variable) 1 Yes, cost was a factor in change 2 No, cost was not a factor 6 Valid skip 9 Not stated 156 5j C3COST Cost a factor in change of smoking status (Derived variable) Yes No Valid skip Not stated 189 5k C4COST Cost a factor in change of smoking status (Derived variable) Yes No Valid skip Not stated 228 51 LNS2SK_4 Reason for change from non-smoking to smoking all cycles... lower cost (Derived variable) Yes No Valid skip Not stated 240 EMOTIONAL AND PSYCHOLOGICAL FACTORS 6a 6b C2Q10 2 C3Q09 2 Restarted smoking... relax or calm down Restarted smoking... stress/nerves/relax 1 2 3 6 7 8 9 1 2 3 6 7 8 9 Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated choice) choice) 147 168 95 Item Variable Description 6c C4Q09_2 Restarted smoking... stress/nerves/relax 6d LNS2SK_2 Reason for change from non-smoking to Smoking all cycles...to relax (Derived variable) 6e C2Q10_3 Restarted smoking... combat boredom 6f C3Q09_3 Restarted smoking... combat boredom 6g C4Q09_3 Restarted smoking... combat boredom 6h LNS2SK_1 Reason for change from non-smoking to smoking all cycles...combat boredom (Derived variable) Value Page # 96 202 1 2 3 6 7 8 9 1 2 6 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 6 9 Yes Yes (second No Valid skip Don't know Refused Not stated Yes No Valid skip Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes No Valid skip Not stated choice) choice) choice) choice) 239 148 168 203 239 96 Item Variable Description 6i C2Q10_10 Restarted smoking... curiosity 6j C3Q09_7 Restarted smoking... curiosity 6k C4Q09_7 Restarted smoking... curiosity 61 LNS2SK_7 Reason for change from non-smoking to smoking all cycles...curiosity (Derived variable) 6m C2Q10_11 Restarted smoking...no reason/felt like it 6n C3Q09_8 Restarted smoking...no reason/felt like it Value Page # 97 149 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 1 2 6 9 1 2 3 6 7 8 9 1 2 3 6 7 8 9 Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes No Valid skip Not stated Yes Yes (second No Valid skip Don't know Refused Not stated Yes Yes (second No Valid skip Don't know Refused Not stated choice) choice) choice) choice) choice) 169 204 240 150 170 97 Item Variable Description Value Page # 98 60 C4Q09 Restarted smoking...no reason/felt like it 1 Yes 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 204 6p LNS2SK_8 Reason for change from non-smoking to 1 Yes smoking all cycles... no reason/felt like it 2 No (Derived variable) 6 Valid skip 9 Not stated 241 SOCIAL FACTORS 7a C2Q10 6 Restarted smoking... family/friends smoke 1 Yes 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 14£ 7b C3Q09 6 Restarted smoking... family/friends smoke 1 Yes 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 169 7c C4Q09 6 Restarted smoking... family/friends smoke 1 Yes 2 Yes (second choice) 3 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 203 7d LNS2SK_6 Reason for change from non-smoking to smoking all cycles... family/friends smoke (Derived variable) Yes No Valid skip Not stated 240 98 Item Variable 7e C2Q10 8 Description Restarted smoking... going to bars/parties Value 1 2 3 6 7 Yes Yes (second choice) No Valid skip Don't know Refused Not stated Page # 149 99 7f C3Q09 1 7g C4Q09 1 Restarted smoking... going to bars/parties Restarted smoking... going to bars/parties Yes Yes (second choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) No Valid skip Don't know Refused Not stated 168 202 7h LNS2SK_1 Reason for change from non-smoking to smoking all cycles...going to bars/parties (Derived variable) Yes No Valid skip Not stated 239 HEALTH KNOWLEDGE 8a C3Q25 Do you believe that smoke from cigarettes cause health problems in a non-smoker? Yes No Valid skip Don't know Refused Not stated 181 8b C3Q2 6_1 What health problems or illness could be caused... lung cancer? (second choice) (third choice) (fourth choice) Yes Yes Yes Yes No Valid skip Don't know Refused Not stated 182 99 Item Variable Description 8c C3Q2 6_2 What health problems or illness could be caused... other cancer? 8d C3Q26_3 What health problems or illness could be caused... heart disease/heart problems? 8e C3Q26_4 What health problems or illness could be caused...stroke? 8f C3Q26_5 What health problems or illness could be caused... bronchitis, emphysema, asthma? Value Page # 100 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated 182 182 182 183 100 Item Variable Description 8g C3Q26_6 What health problems or illness could be caused...other respiratory disease? 8h C3Q2 6_7 What health problems or illness could be caused...low birth weight/fetal problems? 8i C3Q2 6_8 What health problems or illness could be caused...other? 8j C3Q27 Do you believe that smoke from cigarettes could cause health problems in a smoker? 8k C3Q28_1 What health problems or illness could be caused... lung cancer? Value Page # 101 183 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 6 7 8 9 1 2 3 4 5 6 7 8 9 Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated 183 183 184 184 101 Item Variable Description 81 C3Q28_2 What health problems or illness could be caused... other cancer? 8m C3Q28_3 What health problems or illness could be caused... heart disease/heart problems? 8n C3Q28_4 What health problems or illness could be caused...stroke? 80 C3Q28_5 What health problems or illness could be caused... bronchitis, emphysema, asthma? Value Page # 102 18.4 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 9 1 2 3 4 5 6 7 8 10 Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated Yes Yes (second choice) Yes (third choice) Yes (fourth choice) No Valid skip Don't know Refused Not stated 184 185 185 102 Item Variable Description 8p C3Q28_6 What health problems or illness could be caused...other respiratory disease? 8q C3Q28_7 What health problems or illness could be caused...low birth weight/fetal problems? 8r C3Q28_8 What health problems or illness could be caused...other? 8s C3Q32A Smoking for many years will cause... EMPHYSEMA? 8t C3Q32B Smoking for many years will cause... MULTIPLE SCLEROSIS? Value 1 Yes 2 Yes (second choice) 3 Yes (third choice) 4 Yes (fourth choice) 5 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Yes 185 2 Yes (second choice) 3 Yes (third choice) 4 Yes (fourth choice) 5 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Yes 186 2 Yes (second choice) 3 Yes (third choice) 4 Yes (fourth choice) 5 No 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Very likely 187 2 Somewhat likely 3 , Not at all likely 6 Valid skip 7 Don't know 8 Refused 9 Not stated 1 Very likely 187 2 Somewhat likely 3 Not at all likely 6 Valid skip 7 Don't know 8 Refused 9 Not stated Page # 103 185 103 Item Variable Description Value C3Q32C Smoking for many years will cause... 1 LDNG CANCER? 2 3 6 7 C3Q32D Smoking for many years will cause... 1 BLADDER CANCER? 2 3 6 7 C3Q32E Smoking for many years will cause... 1 A STROKE? 2 3 6 7 C3Q32F Smoking for many years will cause... 1 ASTHMA? 2 3 6 7 8y C3HPR0B Belief in health problems caused by smoking 1 (Derived variable) 2 3 4 9 8z C4Q16A Do you think people have to smoke for 1 many years before it will damage their 2 health? 6 7 104 Page # 104 Very likely 187 Somewhat likely Not at all likely Valid skip Don't know Refused Not stated Very likely 187 Somewhat likely Not at all likely Valid skip Don't know Refused Not stated Very likely 188 Somewhat likely Not at all likely Valid skip Don't know Refused Not stated Very likely 188 Somewhat likely Not at all likely Valid skip Don't know Refused Not stated Health problems in non-smoker, and smoker 194 Health problems in non-smoker, NOT smoker Health problems NOT non-smoker, BUT smoker Health problems NOT non-smoker, NOT smoker Not stated Yes 209 No Valid skip Don't know Refused Not stated Item Variable 8aa C4Q16B Description Value Do you think smoking an occasional 1 cigarette can damage people's health? 2 6 7 Yes No Valid skip Don't know Refused Not stated Page # 209 105 8bb C4Q16C Do you think smoking helps people to relax? 1 2 6 7 Yes No Valid skip Don't know Refused Not stated 210 C4Q16D Do you think quitting can improve people' s 1 health, even after they have smoked for 2 many years? 6 7 Yes No Valid skip Don't know Refused Not stated 210 3dd C4Q16E Do you think people can become addicted 1 to cigarettes? 2 6 7 Yes No Valid skip Don't know Refused Not stated 210 C4Q16F Do you think smokers can quit at anytime? 1 2 6 7 Yes No Valid skip Don't know Refused Not stated 210 ADVICE AND SUPPORT OF HEALTH PROFESSIONALS 9a C4Q27A Have you seen a DOCTOR in the past 12 months? 1 2 6 7 8 9 Yes No Valid skip Don't know Refused Not stated 225 105 Item Variable Description Value 9b C4Q27B Did the doctor advise you to stop smoking? 1 2 3 6 7 9c C4Q27C Have you seen a DENTIST in the past 1 12 months? 2 6 7 9d C4Q27D Did the dentist advise you to stop smoking? 1 2 3 6 7 9e C4MEDIC Medical advise about quitting smoking. 01 (Derived variable) 02 03 04 05 06 07 08 09 96 99 106 Page # 106 Yes 225 No Not applicable (already stopped) Valid skip Don't know Refused Not stated Yes 226 No Valid skip Don't know Refused Not stated Yes No Not applicable Valid skip Don't know Refused Not stated Saw only doctor/advised to quit 232 Saw only doctor/not advised to quit Saw only dentist/advised to quit Saw only dentist/not advised to quit Saw both doctor and dentist/both advised to quit Saw both doctor and dentist/only doctor advised to quit Saw both doctor and dentist/only dentist advised to quit Saw both doctor and dentist/neither advised to quit Saw neither doctor and dentist Valid skip Not stated 226 (already stopped) 

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