2011 vol. 35 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 81© 2011 The Authors. ANZJPH © 2010 Public Health Association of Australia

Strong smoker interest in ‘setting an example

to children’ by quitting: national survey data

Submitted: March 2010 Revision requested: June 2010 Accepted: July 2010Correspondence to:George Thomson, Department of Public Health, University of Otago, Box 7343 Wellington, New Zealand; e-mail: george.thomson@otago.ac.nz

George Thomson, Nick Wilson, Deepa Weerasekera, Richard Edwards

Department of Public Health, University of Otago, Wellington, New Zealand

AbstractObjective: To further explore smoker views

on reasons to quit.

Methods: As part of the multi-country ITC

Project, a national sample of 1,376 New

Zealand adult (18+ years) smokers was

surveyed in 2007/08. This sample included

boosted sampling of Māori, Pacific and

Asian New Zealanders.

Results: ‘Setting an example to children’

was given as ‘very much’ a reason to quit

by 51%, compared to 45% giving personal

health concerns. However, the ‘very much’

and ‘somewhat’ responses (combined)

were greater for personal health (81%)

than ‘setting an example to children’ (74%).

Price was the third ranked reason (67%).

In a multivariate analysis, women were

significantly more likely to state that ‘setting

an example to children’ was ‘very much’ or

‘somewhat’ a reason to quit; as were Māori,

or Pacific compared to European; and

those suffering financial stress.

Conclusion: The relatively high

importance of ‘example to children’ as

a reason to quit is an unusual finding,

and may have arisen as a result of social

marketing campaigns encouraging

cessation to protect families in

New Zealand.

Implications: The policy implications could

include a need for a greater emphasis on

social reasons (e.g. ‘example to children’),

in pack warnings, and in social marketing

for smoking cessation.

Key words: quitting motives, smokers,

parents, children.

Aust NZ J Public Health. 2010; 81-4

doi: 10.1111/j.1753-6405.2010.00638.x

Smoking by parents, siblings and

friends has been recognised as

increasing the risk of smoking

uptake.1 Other research has associated

decreased public and private indoor smoking

with decreased risks of starting smoking.2,3

These effects of decreased smoking are

consistent with the body of theory about

the effect of social context on human

behaviour,4 and suggest that decreased

example reduces the risk of starting smoking

and increases quitting.

The attitudes of smokers towards setting

an example to children may have an impact

on quitting behaviour, attitudes towards

supporting smokefree areas (e.g. smokefree

playgrounds),5 and location of smoking

behaviour (e.g. smoking out-of-sight of

children). There is some evidence that one

of the reasons that smokers quit is so as to

set an example for children, although this

has not been a dominant motive.6-10 In a 1990

survey of San Francisco smokers, Latinos

were much more likely than whites to say

it was important to quit as an example for

children.7 A review of 35 studies conducted

before 2001 and that investigated reasons for

quitting, found that in nearly all the studies,

both smokers and ex-smokers put personal

health as the most important reason.6

However, one 2006/07 survey in France

found 60% of smokers gave the health effects

of secondhand smoke on non-smokers as a

reason to quit, 48% gave personal health,

62% the price of cigarettes, and 80% gave

setting an example to children.11

In this study we aimed to further explore

smoker views on: i) reasons to quit, and

ii) on quitting to set an ‘example to children’,

by socio-demographic and smoking-related

variables.

MethodsFor the New Zealand arm of the

International Tobacco Control Policy

Evaluation Survey (ITC Project), smokers

were recruited from the New Zealand Health

Survey (NZHS) sample of 2006/07.12 The

NZHS participants (age 18 and over) were

selected by a complex sample design, which

included systematic boosted sampling of

the Māori, Pacific and Asian populations.

Face-to-face interviews were conducted in

participants’ homes, with a response rate

was 67.9%, resulting in 11,924 interviews.

From the NZHS sample we took smokers

who: i) were 18 years or older; ii) had

smoked more than 100 cigarettes in their

lifetimes; iii) had smoked at least once in the

past 30 days; and iv) had agreed to be willing

to participate in further research when asked

this at the end of the NZHS interview (this

was 85.2% of the adult smokers in the

NZHS). Out of 2,438 potential respondents

who met these criteria, a total of 1,376

completed the NZ ITC Project Wave 1

questionnaire, giving a response rate of

56.4%. But when considering the NZHS

response rate and willingness to further

participate, then the overall response rate is

reduced further to 32.6% (for details see:13).

The computer-assisted telephone survey,

between March 2007 and February 2008,

was usually three to four months after the

NZHS interview. The study protocol was

Smoking Prevention Smoking Prevention

82 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2011 vol. 35 no. 1© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

Thomson et al. Article

cleared by the Multi-Region Ethics Committee in New Zealand

(MEC/06/07/071) and by the Office of Research Ethics, University

of Waterloo, Waterloo, Canada (ORE #13547).

We asked the 12 standard ITC Project questions on reasons to

quit (see Table 1). The results were weighted to reflect the national

population of smokers in New Zealand. The multivariate analysis

involved two models: a) using socio-demographic variables

(age, gender, ethnicity, socioeconomic deprivation, and financial

stress); and b) adding smoking-related beliefs and behaviours

(see a previous article using this dataset for more detail on

these models).14

ResultsOf the 12 reasons offered for wanting to quit, or staying quit,

‘setting an example to children’ received the highest level of

the ‘very much’ response (by 50.8%; 95%CI=47.2–54.3%) see

Table 1. Concern for personal health (44.7%, 95%CI=41.2 –

48.2%), the price of cigarettes (38.1%) and concern about effects

of cigarette smoke on non-smokers (33.5%) were the next most

important reasons. However, when the ‘very much’ and ‘somewhat’

responses were combined, concern for personal health (80.6%)

was higher than ‘setting an example to children’ (73.5%) and the

price of cigarettes (66.5%). A separate analysis by the total of the

‘very much’ responses for all respondents (n=3,679) also indicated

the statistically significant dominance of the ‘example to children’

response (20.8% versus 18.0% for ‘personal health’ and 15.3%

for price (data not shown but available on request).

In univariate analysis, the socio-demographic characteristics

of respondents, which were significantly associated with the

combined ‘very much’ or ‘somewhat’ responses for ‘setting an

example to children’ were: i) women compared to men (crude

odds ratio (OR)=1.64; 95%CI=1.18 – 2.28); ii) those of Māori and

Pacific ethnicity, compared to European (OR=1.51; 95%CI=1.05

– 2.18; OR=2.02; 95%CI=0.99 – 4.13 respectively); and iii) those

under one form of financial stress (i.e. not spending on household

essentials because of smoking, compared to those who said no to

this question (OR=1.61; 95%CI=1.05 – 2.46).

In the multivariate analysis, being a woman remained significant

(e.g. adjusted OR (aOR)=1.64; 95%CI=1.16 – 2.31 in the model

considering socio-demographic variables). Being Māori or Pacific

ethnicity and being under financial stress were still associated

with raised odds ratios (for all: aOR>1.2) but these were no

longer statistically significant. In the model that also considered

smoking beliefs and behaviours, the following were significantly

associated with concern about setting an example to children:

Table 1: Reasons for quitting or staying quit among smokers (all results weighted and adjusted for the complex design and ranked by the “yes – very much” response).

Reason for quitting or staying quita No agreement/Other response (%)

Yes “Some-what” (%)

Yes “Very much” (%)

Crude odds ratiob for “very much” response

“Setting an example for children?” (n=1376) 26.5 22.7 50.8 1.0 Referent

“Concern for personal health?” (n=1376) 19.4 35.9 44.7 0.70 (0.58-0.84) (p<0.001)

“The price of cigarettes?” (n=1376) 33.5 28.4 38.1 0.48 (0.40-0.58) (p<0.001)

“Concern about effect of cigarette smoke on non-smokers?” (n=1376)

38.6 27.9 33.5 0.23 (0.17-0.30) (p<0.001)

“That society disapproves of smoking?” (n=1376) 51.5 26.4 22.1 0.15 (0.12-0.20) (p<0.001)

“Smoking restrictions in public places like restaurants, cafes & pubs?” (n=1376)

59.7 20.8 19.5 0.11 (0.08-0.14) (p<0.001)

“Smoking restrictions at work?” (n=1376) 66.5 19.5 14.0 0.07 (0.05-0.10) (p<0.001)

“Advice from a doctor, dentist or other health professional to quit?” (n=163)

59.0 27.1 13.9 0.20 (0.09-0.42) (p<0.001)

“Availability of telephone helpline/quitline/information line?” (n=1376)

65.2 21.7 13.1 0.04 (0.02-0.06) (p<0.001)

“Free or lower cost stop smoking medicines?” (n=163) 59.5 27.8 12.7 0.16 (0.06-0.36) (p<0.001)

“Advertisements or information about health risks of smoking?” (n=163)

62.9 26.2 10.9 0.11 (0.03-0.28) (p<0.001)

“Warning labels on cigarette packets?”c (n=163) 67.8 23.0 9.2 0.12 (0.04-0.29) (p<0.001)

Notes:a) Depending on their quit status at the time of the survey, there were different questions asked, hence the variable values for number of respondents for some

of the questions. The introductory format of the various questions were as follows: “Even though you mentioned that you are not currently planning to quit, in the past 6 months, have each of the following things led you to think about quitting:…”; “In the past 6 months, have each of the following things led you to think about quitting:…”; “To what extent, if at all, were each of the following things, reasons for your current quit attempt:…”; “To what extent, if at all, have each of the following things helped you to stay quit:…”. For each question the responses offered were “not at all”, “somewhat”, or “very much”?

b) Paired matched odds ratio with exact McNemar significance probability for the change in “very much” for each variable relative to “very much” response for “Setting an example for children”.

c) At the time of the Wave 1 survey there were no pictorial warnings on NZ packs, but a text warning did state that smoking harmed others.

2011 vol. 35 no. 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 83© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

Smoking Prevention Smoker interest in setting an example to children

being a lighter smoker (using a ‘heaviness of smoking’ index:

aOR=1.11, 95%CI=1.01 – 1.22); awareness of secondhand smoke

(SHS) harm (aOR=1.62; 95%CI=1.20 – 2.17); and SHS protective

behaviours by smokers (aOR=1.81; 95%CI=1.40 – 2.35).

DiscussionThis study (along with the French survey, also from the ITC

Project), is unusual in finding ‘setting an example to children’

as being more important than smokers’ concern for health,

as a strong reason to quit or to stay quit. In the New Zealand

case, the importance of this reason was better captured by

allowing respondents to consider the ‘very much’ option in the

survey question.

The difference from most previous findings may also reflect

differences in the nature of the New Zealand smoker sample and

tobacco control policy context. For instance, there may have been

an influence from the spread of local authority smokefree parks

policies, which aim to discourage smoking around children.15

The review by McCaul et al, that found smokers and ex-smokers

putting personal health as the most important reason to quit, was

of studies that were nearly all were set in North America.6

An alternative view is that the data from the French ITC Project

and our study reflects trends that are occurring more widely. We

found no comparable data in other studies collected since 2001,

so further up-to-date evidence from other countries is needed to

investigate this issue.

Since 1998, there have been at least 15 media campaigns in

the US, particularly in California, Massachusetts and Colorado,

which have highlighted a smoker’s responsibility to quit smoking

for the sake of their family (see http://apps.nccd.cdc.gov/MCRC/

Apps/SearchResult.aspx?Mode=QS). New Zealand smokers of all

ethnicities may also have been sensitised to family responsibility

and smoking, because of social marketing over the past eight years

about quitting for family and whanau (extended family).16-18 The

social marketing has included media campaigns featuring ex-

smokers who highlight the effects of smoking on their families.

A previous smaller survey in New Zealand, in 1992, found social

reasons (socially unacceptable, family pressure) for quitting were

less important then, compared to personal health and cost.19 Other

research has indicated that ‘example to children’ as a quit motive

may increase over time.10

Quitting because of cost or financial stress is a common reason

given for quitting or the importance of quitting.6,20 Our results

indicate that this was the third ranked reason, and highlight

the importance of tobacco prices (via high tobacco taxes) in

stimulating quitting. Because there was no tobacco tax rise in New

Zealand between 2001 and 2008 (apart from annual indexation),

and tobacco products appear to have become more affordable in

this period,21 this may have decreased the perception of cost as a

reason to quit.

Ethnic differences in reasons to quit may be related to the

differing role of family and social structures and influences,

for ethnic groups. Perez-Stable et al. argue that famialismo

(family/collective well-being) may explain Latino/non-Latino

differences in reasons to quit.7 The greater likelihood of Māori

and Pacific peoples, in seeing the example of smoking to children

as a reason to quit, may be related to their greater priority on

collective relationships.22

Policy implicationsThe recognition by policymakers of the danger of smoker

examples to children has led to a widening of tobacco control

policy actions. These have included explicit warnings to smokers

of these effects from their smoking on cigarette packaging warning

labels,23 the extension of smokefree outdoor area policies,24 and

making schools completely smokefree. The policy implications

of our findings could include a need for a greater emphasis on

social reasons (e.g. ‘example to children’) in pack warnings, in

social marketing campaigns for smoking cessation, and in the

information around targeted smoking cessation support for new

parents and school teachers.

Research implicationsThe finding of ‘setting an example to children’ as a relatively

important reason to quit or to stay quit, should be explored in

other settings with the same questions, and also with different

approaches to collecting data (e.g. unprompted reasons for quitting

or staying quit). Data analysis by whether there are children in the

interviewee’s household would provide further depth. Gender,25

and ethnic differences in quitting motivation (as opposed to

behaviour), may also be an area for further exploration, considering

the limited research in the area and the importance of addressing

disparities in smoking prevalence. Survey findings such as these

may also be further explained and explored by qualitative research,

in order to provide a more in-depth understanding of smokers’

attitudes and reasons for quitting.

AcknowledgementsThe ITC Project (NZ) team thank: the interviewees who kindly

contributed their time, and our other project partners (see: http://

www.wnmeds.ac.nz/itcproject.html).

FundingThe Health Research Council of New Zealand provided funding

for the ITC NZ Project and the Smokefree Kids Policy Project.

Competing interestsAlthough we do not consider it a competing interest, for

the sake of full transparency we note that some of the authors

have undertaken work for health sector agencies working in

tobacco control.

84 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH 2011 vol. 35 no. 1© 2011 The Authors. ANZJPH © 2011 Public Health Association of Australia

Thomson et al. Article

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