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Preventive Medicine 60 (2014) 83–87

Contents lists available at ScienceDirect

Preventive Medicine
journal homepage: www.elsevier.com/locate/ypmed

Factors associated with intent to quit tobacco use in Cyprus adolescents


Elena Charis G. Savvides a,1, Costas A. Christophi a,b,⁎, Martha Paisi a, Despina Pampaka a,
Taru Kinnunen c, Gregory N. Connolly d
a
Cyprus International Institute for Environmental and Public Health in association with Harvard School of Public Health, Cyprus University of Technology, 95 Irinis Street, 3041 Limassol, Cyprus
b
Department of Environmental Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
c
Harvard School of Dental Medicine, 188 Longwood Avenue, Boston, MA 02115, USA
d
Division of Public Health Practice, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA

a r t i c l e i n f o a b s t r a c t

Available online 24 December 2013 Objectives. To identify factors associated with adolescent smokers' desire to quit based on the 2006 Cyprus
Global Youth Tobacco Survey.
Keywords: Methods. A cluster sample design was used to select a representative sample of students from all registered
Cigarette smoking middle and high schools in Cyprus with N40 students in academic year 2005–2006. Multivariable logistic
Smoking cessation
regression was used taking into account the weight associated with each of the respondents.
Youth smoking
Intention to quit
Results. Out of the total sample with available information (N = 12,629), 1591 students were current
Global Youth Tobacco Survey smokers (weighted frequency = 14%) and were included in the analysis, with 734 (46.1%) of them
Cyprus reporting that they want to quit smoking. In both males and females, strong predictors of intention to
quit smoking include past quit attempts and physical activity. Intention to quit is also associated with the
belief that smoking is harmful to them and inversely associated with having peers who smoke, in boys,
and the belief that smoking is harmful to others and perceiving smokers as less attractive, and inversely
associated with pocket money, in girls.
Conclusions. The present study has identified factors that appear to influence youth's intention to quit
tobacco, which is of major importance in developing successful tobacco cessation programs targeting
adolescents.
© 2013 Elsevier Inc. All rights reserved.

Introduction to tobacco use lowers the risk for tobacco-induced morbidity and mor-
tality (CDC, 1998; Doll et al., 2004).
Considering global tobacco consumption among youth, prevention Different factors determine cessation in adolescents compared to
policies alone are not sufficient and, as suggested by Article 14 of the adult smokers, hence, specialized cessation programs are needed that
WHO Framework Convention on Tobacco Control, a successful tobacco will take into account predictors of tobacco use and motivators to quit.
control policy should include a strategy to treat tobacco depen- While several risk factors for youth tobacco use experimentation and
dence through cessation efforts and medication (WHO Tobacco Free initiation have been identified in the MPOWER package (WHO, 2008),
Initiative). Targeting youth for cessation has many advantages as these including tobacco use by peers and family (Feighery et al., 1998), easy
efforts could reach a large number of potential smokers and people access to tobacco products, unsupportive family environment (Miller,
are more likely to quit successfully if they have not yet developed a se- 1997), poor academic achievement (Morin et al., 2011), and lack of
vere tobacco dependence and/or nicotine addiction (US Department of self-confidence skills (US Department of Health and Human Services,
Health and Human Services, 1994). Also, reducing the lifetime exposure 1994), less is known about youth's intentions, motivation, and abilities
to quit tobacco.
In Cyprus, the Global Youth Tobacco Survey (GYTS) was conducted
in 2006 and reported a weighted prevalence of current smoking of
⁎ Corresponding author at: Cyprus International Institute for Environmental and Public
Health in association with Harvard School of Public Health, Cyprus University of 12.7% among middle-school boys, 35.7% among high-school boys,
Technology, 95 Eirinis Street, 3041 Limassol, Cyprus. 7.0% among middle-school girls, and 23.2% among high-school girls
E-mail addresses: esavvides@gmail.com (E.C.G. Savvides), costas.christophi@cut.ac.cy, (Christophi et al., 2008). It was further reported that smoking peers
cchristo@hsph.harvard.edu (C.A. Christophi), martha.paisi@cut.ac.cy (M. Paisi), was the strongest predictor of adolescent smoking; other predictors
despina.pampaka@cut.ac.cy (D. Pampaka), taru_Kinnunen@hsdm.harvard.edu
(T. Kinnunen), gconnoll@hsph.harvard.edu (G.N. Connolly).
of cigarette smoking included having parents and grandparents that
1
Present address: Ministry of Labour and Social Insurance, 7 Byron Avenue, 1465 smoke, concerns about weight, access to pocket money, ease of buying
Nicosia, Cyprus. cigarettes, owing an item with a cigarette logo on it, and false consensus,

0091-7435/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ypmed.2013.12.016
84 E.C.G. Savvides et al. / Preventive Medicine 60 (2014) 83–87

defined as thinking that half or more of the students in their class smoke All analyses accounted for the sampling frame of the study and the weight
(Christophi et al., 2009). associated with each questionnaire thus reducing bias. Characteristics of
There have been attempts for implementing smoking prevention interest were described as frequencies and percentages and compared using
and cessation programs targeting adolescents at schools in Cyprus, the chi-square test. Logistic regression analysis was used to assess the effects
of different variables on the likelihood of intending to quit smoking both in
such as Fred Goes to School (personal communication with the Cyprus
univariate models and multivariable models, which included all variables with
Ministry of Education). However, these have not been developed
p-values less than 0.20 in the univariate analyses; odds ratios (OR) are reported
based on actual data from Cyprus and lack both process and outcome with the corresponding 95% confidence intervals. A goodness of fit test was also
evaluation. In order to effectively structure cessation programs, it is nec- performed. A p-value b 0.05 was considered to be statistically significant and all
essary to understand a variety of factors, such as the level of tobacco use, tests presented are two-sided. The Statistical Analysis Software (SAS) version
environmental and social aspects, and characteristics that distinguish 9.2 (SAS Cary Inc., NC, USA) was used for all analyses.
adolescent smokers with intent to quit from those without.
Therefore, it is of paramount importance to look into how youth can
be aided in their personal process to cessation and how programs can be Results
developed that will correctly target personal, social, and environmental
factors. Models exist, such as the transtheoretical model, which describe Out of the total sample of 12,629 students with available informa-
the different stages of change (Prochaska and DiClemente, 1983). The tion, there were 1591 (weighted frequency = 14%) who reported that
data collected through the 2006 Cyprus GYTS provide the tools and op- they are current smokers and provided valid information as to whether
portunity to look at this issue closely in a large sample of adolescents they want to quit smoking or not, with 46.1% of them reporting they
aged 12–17. The objectives of the present study are to identify factors want to quit smoking now. The distributions of current smokers with
that influence adolescent smokers' desire to quit and identify motiva- and without intention to quit are similar with respect to age, school,
tors for smoking cessation that could assist in developing effective and sex; similarly, for social and familial circle characteristics, but not
tobacco cessation programs targeting youth and ensure sustainability for self efficacy or physical activity (Table 1).
of participation and increase the success rate of such programs. Table 1 also presents characteristics of smoking behavior, beliefs,
and other characteristics, such as availability of pocket money; current
Material and methods smokers with and without intention to quit are similar with respect to
cigarette consumption, age of initiation, and the belief that smoking
Description of the sample
affects weight. However, current smokers with the intention to quit
reported the need to smoke first thing in the morning less often and
In Cyprus, the GYTS was conducted in 2006 by the Cyprus International In-
stitute for the Environment and Public Health (CII), in collaboration with the having less pocket money available. In addition, a higher percentage of
Harvard School of Public Health and the Ministries of Health and Education of them believed that smoking is harmful for them, that smoking is harm-
Cyprus. Details of the study can be found elsewhere (Christophi et al., 2008). ful for others, and that smokers are less attractive. Finally, the two
Standardized methodology was followed in selecting the sample, administering groups were different in terms of daily smoking and past quit attempts,
the questionnaire, and processing the data (Global Tobacco Surveillance System with a higher proportion of current smokers with the intent to quit
Collaborating Group, 2005, 2006; Global Youth Tobacco Survey Collaborating being daily smokers and having tried to quit at least once before.
Group, 2003). Briefly, a two-stage cluster sample design was used to select a The results of the univariate logistic regression analyses are present-
representative sample of students from all registered middle and high schools ed in Table 2. The strongest predictor of intention to quit smoking is past
in Cyprus, with 40 or more students, in the academic year 2005–2006. In the quit attempts. Physical activity is also a strong predictor of adolescents'
first stage, all middle schools with 1st, 2nd, and 3rd grades and high schools
intention to quit smoking and factors related to personal beliefs, namely
with 4th, 5th, and 6th grades were sampled, with the probability of selection
believing smoking is harmful to them, believing that secondhand smoke
being equal to the school's enrollment size; in the second stage, classes within
chosen schools were selected using a systematic equal-probability sampling is harmful to others, and believing that smoking affects negatively a
with a random start. Participation was voluntary and the self-administered smoker's physical appearance, have been found to be strongly associat-
questionnaires were completed anonymously. ed with intention to quit too. Craving to smoke first thing in the morn-
ing, being a daily smoker, availability of pocket money, reporting that it
Demographics, explanatory, and outcome variables would be difficult to quit smoking now, and cigarette consumption
were found to be negatively associated with intention to quit. On the
The main outcome of interest is intention to quit smoking, defined as replying contrary, the belief that smoking helps lose weight, age of initiation,
affirmative to the question ‘Do you want to stop smoking now?’. Demographic and smoking habits of peers, parents, and grandparents were not asso-
variables included sex and age. Consumption was defined as the product of ciated in a statistically significant way with intention to quit in current
the number of days having smoked within the last month and the number of
smokers in our data (data not shown). Similar results were observed
cigarettes smoked on those days, grouped in categories of b 30, 30–150, 150–
in a stratified analysis by sex.
300, and N300 cigarettes smoked last month. Other smoking behavior variables
included having one or more past quit attempts, being a daily smoker, age of Interactions between several characteristics of interest with sex
initiation, and an indicator of nicotine dependence (having smoked or felt like were found to be statistically significant, including the interaction of
smoking first thing in the morning). Variables targeting self-efficacy, knowledge gender and the belief that smoking is harmful and the belief that
and beliefs were also evaluated. Self-efficacy was defined by the perceived ability smoking is harmful for others. Hence, multivariable logistic regression
to stop smoking; knowledge and beliefs included knowledge of health risks asso- models were computed separately for males and females adjusting for
ciated with smoking, knowledge of the harmful effects of secondhand smoking, age group, peers smoking, parents smoking, self-efficacy, physical activ-
the belief that smoking affects appearance, and the belief that smoking affects ity, consumption, daily smoking, wanting to smoke first thing in the
weight. Finally, the social and familial circle influence was evaluated by whether morning, past quit attempts, the belief that smoking is harmful to
peers, parents, or grandparents were smokers. Physical activity, defined as the
them and/or others, physical appearance, availability of pocket money,
number of days per week exercising or participating in sports activities of high in-
and the belief that smoking affects weight; Table 3 presents these
tensity for at least 30 min, and the availability of pocket money were also assessed.
results. Both models were significant and their fit was adequate.
Statistical analysis In both males and females, after adjusting for the effect of all other
covariates in the model, a highly important characteristic is past quit
A weight that reflects the likelihood of sampling a specific student and com- attempts. Physical activity is also significant in both sexes but more so
pensates for different patterns of non-response was assigned to each of the re- in girls. The belief that smoking affects physical appearance with
spondents, based on the original overall national two-stage sampling process. smokers perceived to be less attractive than non-smokers is significant
E.C.G. Savvides et al. / Preventive Medicine 60 (2014) 83–87 85

Table 1
Characteristics of current smokers with and without intention to quit — 2006 Cyprus Global Youth Tobacco Survey.

Characteristic Overall n = 1591 n (%) Intention to quit n = 734 n (%) No intention to quit n = 857 n (%) p-value

Demographics
Age 0.36
13 years old or younger 104 (6.0) 43 (5.5) 61 (6.4)
14 years old 152 (9.5) 65 (8.6) 87 (10.2)
15 years old 290 (16.6) 145 (18.2) 145 (15.3)
16 years old 396 (24.6) 193 (25.7) 203 (23.7)
17 years old or older 642 (43.3) 284 (42.0) 358 (44.4)
Gender 0.59
Female 688 (44.6) 302 (43.6) 386 (45.5)
Male 895 (55.4) 425 (56.4) 470 (54.5)
Social and familial circle
Peers 0.12
None smoking 50 (3.0) 28 (3.7) 22 (2.3)
≥1 smoking 1529 (97.0) 704 (96.3) 825 (97.7)
Parents 0.44
None smoking 494 (30.5) 234 (31.6) 260 (29.5)
≥ 1 smoking 1090 (69.5) 497 (68.4) 593 (70.5)
Grandparents 0.68
None smoking 790 (56.4) 356 (55.7) 434 (57.0)
≥1 smoking 625 (43.6) 292 (44.3) 333 (43.0)
Smoking behavior
Cigarette consumption (number of cigarettes smoked last month) 0.19
b30 441 (27.9) 224 (29.7) 217 (26.2)
30–150 383 (23.3) 185 (24.7) 198 (22.2)
150–300 286 (18.9) 126 (18.3) 160 (19.3)
N300 447 (29.9) 188 (27.3) 259 (32.3)
Daily smoking 0.019
Yes 641 (39.2) 325 (42.8) 316 (36.1)
No 950 (60.8) 409 (57.2) 541 (63.9)
Need to smoke first thing in the morning 0.012
No 407 (27.5) 208 (31.3) 199 (24.3)
Yes 1087 (72.5) 467 (68.7) 620 (75.7)
Age of Initiation 0.38
b10 years old 216 (13.0) 95 (12.4) 121 (13.6)
N10 years old 1345 (87.0) 627 (87.7) 718 (86.4)
Past quit attempts b.001
None 615 (41.4) 181 (27.2) 434 (53.4)
One or more 881 (58.6) 493 (72.8) 388 (46.6)
Self-efficacy (perceived ability to quit smoking) 0.018
Fairly/very difficult 1234 (85.5) 574 (88.4) 660 (83.1)
Fairly/very easy 223 (14.5) 81 (11.6) 142 (16.9)
Beliefs
Smoking harmful for self b.001
Definitely/probably not 138 (8.6) 42 (6.0) 96 (10.8)
Definitely/probably yes 1430 (91.4) 676 (94.0) 754 (89.2)
Smoking harmful for others b.001
Definitely/probably not 333 (20.6) 114 (14.8) 219 (25.7)
Definitely/probably yes 1229 (79.4) 608 (85.2) 621 (74.3)
Perceived effect of smoking on physical appearance b.001
More attractive/no difference 1075 (69.2) 452 (63.7) 623 (74.0)
Less attractive 510 (30.8) 280 (36.3) 230 (26.0)
Belief that smoking affects weight 0.16
Gain 104 (6.7) 53 (7.4) 51 (6.1)
No difference 711 (46.2) 310 (43.4) 401 (48.6)
Lose 750 (47.1) 359 (49.2) 391 (45.3)
Other
Pocket money b.001
34 Euro or less 906 (58.8) 454 (65.2) 452 (53.2)
34 Euro or more 680 (41.2) 280 (34.8) 400 (46.8)
Physical activity b.001
2 or less days/week 879 (55.1) 357 (47.5) 522 (61.8)
3 or more days/week 707 (44.9) 376 (52.5) 331 (38.2)

in girls but not boys. Furthermore, the belief that smoking is harmful to significant after adjusting for the effects of other covariates in the
them is found to be significant in boys but not in girls, whereas the model in either sex (data not shown).
reverse is true for the belief that smoking is harmful to others. The avail-
ability of pocket money is inversely significantly associated with intent Discussion
to quit in girls but not boys whereas having peers smoking is associated
with a lower likelihood of intending to quit in boys but not girls. The present study has shown a strong association between intention
All other covariates, including age, parents smoking, self efficacy, daily to quit and past quit attempts. Consistent with previous studies, current
smoking, cigarette consumption, the need to smoke first thing in the smokers who had one or more previous quit attempts (a group that
morning, and the perceived effect of smoking on weight are no longer represents 59% of the current smokers in our sample), are more likely
86 E.C.G. Savvides et al. / Preventive Medicine 60 (2014) 83–87

Table 2
Univariate logistic regression analyses for predictors of intention to quit — 2006 Cyprus Global Youth Tobacco Survey.

Characteristic Overall Girls Boys

OR 95% CI OR 95% CI OR 95% CI

Factors associated with an increased intent to quit


Past quit attempts (one or more attempts vs. none) 3.1 2.2, 4.3 2.6 1.7, 4.1 3.4 2.3, 5.1
Physical activity (3 or more vs. 2 or less days/wk) 1.8 1.3, 2.4 2.0 1.3, 3.0 1.6 1.2, 2.3
Believe smoking is harmful to them (yes vs. no) 1.9 1.3, 2.7 1.5 0.8, 2.8 2.2 1.4, 3.5
Believe that smoking is harmful to others (yes vs. no) 2.0 1.5, 2.6 3.2 2.1, 4.8 1.6 1.2, 2.2
Physical appearance (less attractive vs. more) 1.6 1.2, 2.2 1.7 1.1, 2.6 1.6 1.1, 2.3
Factors associated with a decreased intent to quit
Need to smoke first thing in the morning (yes vs. no) 0.7 0.5, 0.9 0.6 0.4, 0.9 0.8 0.6, 1.2
Daily smoking (yes vs. no) 0.8 0.6, 0.96 0.8 0.6, 1.05 0.7 0.5, 1.03
Pocket money (more than 34 Euro vs. less or none) 0.6 0.5, 0.8 0.6 0.4, 0.8 0.6 0.4, 0.8
Self-Efficacy (no vs. yes) 0.6 0.4, 0.9 0.6 0.4, 0.9 0.6 0.4, 1.1
Consumption (number of cigarettes smoked last month)
– N300 vs. b30 0.7 0.5, 1.04 0.7 0.5, 0.99 0.7 0.5, 1.2
– 150–300 vs. b30 0.8 0.6, 1.2 0.9 0.6, 1.3 0.8 0.4, 1.4
– 30–150 vs. b30 1.0 0.7, 1.3 1.1 0.7, 1.6 0.9 0.6, 1.4

to want to quit, youth and adults smokers alike (Hyland et al., 2006; suggests that there are gender differences among adolescents in regards
McCuller et al., 2006). This could be useful to consider in designing to reasons to quit smoking with adolescent girls being more concerned
cessation programs as past quit attempts not only indicate higher about their future health than boys, and boys frequently citing perfor-
motivation to quit but also predict the success of such attempt (Hyland mance related reasons for quitting smoking (Aung et al., 2003).
et al., 2006). The importance of perceptions is evident in our study. Perceiving
Physical activity was found to be highly associated with intention to that smoking is unhealthy for themselves and others, and perceiving
quit. Students engaged in at least thirty minutes of vigorous physical ac- smokers to be less attractive, all seem to contribute into making an
tivity on three or more days a week were more likely to want to quit adolescent more motivated to quit smoking though at a different level
smoking. Other studies in high risk adolescent smokers also found a in boys and girls. Youth places a great deal of emphasis on physical
positive association between intention to quit and moderate physical appearance and social image and tends to mimic role models and
activity (Prokhorov et al., 1996) and findings suggest that adult smokers peers by adopting similar behaviors and habits. By educating adolescents
concerned with their athletic performance are more motivated to try to on the dangers and misconceptions of smoking and guiding them
quit (Hyland et al., 2006). towards the development of negative prototypes of smokers, could
Beliefs about the effect of smoking on physical appearance were improve the efficacy of cessation programs.
found to be associated with intention to quit in girls but did not reach Students' smoking habits are affected by the amount of pocket
statistical significance in boys, though the magnitude of the effect is money they receive with an inverse association being observed be-
similar, with current smokers that believe smoking makes people less tween availability of pocket money and intention to quit; youth
attractive being more likely to want to quit. This is in line with more smokers reporting having more than 34 Euros available as pocket
general societal changes and the importance of physical appearance money are less likely to intend to quit smoking, although this associa-
and peer approval to adolescents. tion did not reach statistical significance in boys. This can be explained
Similarly, beliefs with respect to smoking's health effects for them- by the high cost of cigarettes which combined with a lack of pocket
selves and for others were found to be associated with intent to quit; money is restricting the amount of cigarettes adolescents can purchase
girls were motivated to quit due to the effects of their smoking on and is restricting students from spending money elsewhere; as students
others, while concern for their own health is a motivator of cessation grow older, the need to spend money for other things also increases.
for boys. These findings are consistent with similar studies in youth The influence of peers smoking that was previously found to be pre-
which showed that intentions to quit smoking are related to adolescent dictive of smoking, both in this group of adolescents (Christophi et al.,
smokers' concern for their own health (Backinger and Leischow, 2001; 2009) and in other studies in youth (Leatherdale et al., 2006; Otten
Duncan et al., 1992; Engels et al., 1998; Tucker et al., 2002) and the et al., 2007) also appears to be inversely associated with intent to quit.
health of those around them (Woodruff et al., 2008) and that adoles- The need to smoke first thing in the morning, a symptom of nicotine
cents' smoking behavior was associated with perceived health benefits dependence, was found to be inversely associated with intention to quit
of quitting (Leatherdale, 2008). Furthermore, it has been previously in the univariate analyses, though it did not remain statistically signifi-
shown that it is less likely for a young individual with a positive attitude cant in our data after adjusting for other covariates in the model. Al-
towards smoking to be motivated to quit (Dozois et al., 1995). Research though nicotine dependence is characterized by both nicotine seeking
and avoidance of nicotine withdrawal symptoms (Prokhorov et al.,
1996), the need to smoke first thing in the morning is a strong indicator
Table 3 of dependency and can be a useful measure in adolescent smokers in
Multivariable logistic regression analysis for predictors of intention to quit — 2006 Cyprus whom dependence has been found to ensue shortly after smoking initi-
Global Youth Tobacco Survey. ation (DiFranza et al., 2000). Other studies have also indicated lower
Characteristic Girls Boys nicotine dependence as a predictive factor of future cessation in adoles-
cents (Hyland et al., 2006) while nicotine dependence has been de-
OR 95% CI OR 95% CI
scribed as a barrier to cessation attempts even for non-daily smokers
Past quit attempts 2.4 1.4, 4.1 2.8 1.9, 4.3
(Backinger et al., 2003; Duncan et al., 1992), suggesting that it would
Physical activity 2.3 1.5, 3.6 1.8 1.04, 3.0
Physical appearance 1.7 1.02, 2.8 1.5 0.9, 2.3 be important not to limit participation in cessation programs to daily
Believe that smoking is harmful to others 2.9 1.7, 4.8 1.2 0.8, 1.9 smokers only.
Believe smoking is harmful to them 0.9 0.4, 2.0 3.3 1.5, 7.1 Smokers' beliefs about smoking cessation were also considered. The
Pocket money 0.6 0.4, 0.8 0.7 0.4, 1.1 belief of how easy/difficult it would be to be able to stop smoking, if they
Peers 0.7 0.2, 2.8 0.2 0.1, 0.9
wanted to, was associated with intent to quit in our sample in the
E.C.G. Savvides et al. / Preventive Medicine 60 (2014) 83–87 87

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The authors declare that they have no conflicts of interest. young people: a report of the Surgeon General. Atlanta, Georgia.
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Acknowledgments bacco Control- Article 14- Demand reduction measures concerning tobacco depen-
dence and cessation. Retrieved February 26, 2012, from http://www.who.int/
tobacco/control/measures_art_14/en/index.html.
We would like to thank the sponsors of the study as listed above and World Health Organisation, 2008. WHO Report on the Global Tobacco Epidemic, 2008 -
all the students that participated in the survey. The MPOWER package. WHO, Geneva.