Quitting-related beliefs, intentions, and motivations of older smokers in four countries: findings from the international tobacco control policy evaluation survey
Introduction
Older people represent the fastest growing segment of the population in the western world (White, 1997). Although a lower percentage of older people smoke than in most adult age groups, the sheer number of older smokers ensures that this group will eventually become a major contributor to health care costs (Orleans, 1997). Cigarette smoking is the leading cause of premature death among older people, primarily due to cardiovascular disease and cancer. Smoking complicates a number of illnesses common among older people, including heart disease, high blood pressure, circulatory and vascular conditions, duodenal ulcers, osteoporosis, and diabetes, and impairs the effectiveness of many medications prescribed to treat those chronic conditions (Morgan et al., 1996). Thus, smoking is a serious health hazard for older adults.
Evidence has accrued to demonstrate that older smokers, despite their 30 or 40 years of smoking, can still benefit considerably from quitting smoking (Heramnson et al., 1988, Hirdes & Maxwell, 1994, LaCroix & Omenn, 1992, U.S. Department of Health and Human Services, 1990). Cessation of smoking extends years of life and years of active life by preventing or reducing the impact of acute and chronic illnesses that limit independence.
Having smoked for a long time and having survived, many older smokers may be resistant to quitting. Many older smokers may feel that smoking will not affect them. For example, Orleans, Jepson, Rimer, and Resch (1994) found older smokers saw themselves as much less at risk for 9 of 10 proven smoking health dangers, indicating a pervasive optimistic bias, or unrealistic assessment of their actual health risks. Consistent with this finding, Wakefield, Kent, Roberts, and Owen (1996) reported that older smokers age 60 and over tend to be less convinced of the negative health effects of smoking, to perceive that they were not personally at risk from their smoking in the future, to believe that smoking had not affected their own health so far, and to believe there was a safe daily level of cigarette consumption. These findings suggest that there is a pervasive tendency among this age group to underestimate the harm of smoking, that is, they tend to hold a variety of self-exempting beliefs. Self-exempting beliefs have been conceptualized as a form of cognitive dissonance reduction strategy developed when there is a perceived inconsistency between beliefs held and behaviors engaged in by a person (Festinger, 1957). According to cognitive dissonance theory (Festinger, 1957), exposure to information designed to persuade smokers of the risk of smoking creates an unpleasant tension and through recourse to various forms of denials, smokers may be able to partially relieve the tension.
The general reluctance to quit smoking may also stem from the fact that many older smokers may feel that it is too late to do anything about it as the damage is thought to have been done. Alternatively, they may represent a relatively resistant ‘hard-core’ group of smokers as the more motivated would have already quitted. There is also a perception among older smokers that little will be gained from quitting and that quitting will be more difficult for them given the duration of smoking (Parry, Thomson, & Fowkes, 2001). Moreover, after a lifetime of smoking, and perhaps many failed attempts to quit, many older smokers may doubt their ability to quit successfully (Kviz, Clark, Crittenden, Warnecke, & Freels, 1995).
To date, the role of these beliefs and their relative contribution towards the maintenance of current smoking behavior and future smoking intent among older smokers has not been examined. Thus, the present study aimed to examine beliefs that might characterize older smokers and determine the extent to which these factors might relate to intentions to quit smoking among this age group. A secondary aim was to identify a set of relevant motivators of quitting useful for designing policies and programs that might help older smokers to quit successfully. The use of comparative data from four countries in the present study would also allow for identification of any country variation and help to determine the universality of the factors identified.
Section snippets
Study population
The sample for the present study was based on a cohort of 9045 adult smokers (aged 18 years and older) recruited from United Kingdom, United States, Canada, and Australia to participate in a random digit dialed telephone survey, the International Tobacco Control Policy Evaluation Survey (ITCPES). Smokers were defined as those who reported having smoked at least 100 cigarettes in their lifetime and who had smoked at least once in the past 30 days. For the purpose of the present study, the sample
Characteristics of older smokers compared with young smokers
Univariate analyses revealed that there were significant differences between young and older smokers (see Table 1). Although young and older smokers did not differ in gender distribution, older smokers were less educated and in poorer health. Compared with younger smokers, a significantly greater proportion of older smokers reported endorsing all four self-exempting beliefs: having the genetic makeup that protects from smoking harm, believing that medical evidence is exaggerated, that everyone
Discussion
We found that the challenges older smokers face and the way they think about smoking are remarkably consistent across the four countries in this study. Thus, the conclusions we draw apply equally at least to these four affluent and largely English-speaking countries. Further studies are needed to determine the universality of these factors to older smokers of other cultures.
In contrast to the similarity between countries, we found some potentially important differences in beliefs about smoking
Acknowledgements
This research was supported by a grant from the Canadian Institutes for Health Research, Robert Wood Johnson Foundation, Cancer Research, UK, Canadian Tobacco Control Research Initiative, National Health and Medical Research Council of Australia, Centre for Behavioural Research and Program Evaluation, and National Cancer Institute of Canada/Canadian Cancer Society.
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