Antismoking Social Norms Increase Cessation Behaviours Among Lower and Higher SES Smokers: An Australian Population-Based Study

Abstract

Background: Disapproval of smoking from close others, observation of others' quitting activity and denormalisation of smoking in the broader community can provide an environment that helps smokers to quit. However, it remains unclear which social norms have the greatest influence, and if there is a similar impact on quitting-related cognitions and behaviors among lower and higher socioeconomic status (SES) smokers. Aim: This study sought to examine the influence on quitting-related cognitions and behaviors of a variety of social norms: subjective (perceived disapproval of smoking among close family and friends); internalized injunctive (feeling embarrassed about being a smoker); and close descriptive norms (living in a household with someone who, successfully or unsuccessfully, tried to quit in the past 12 months). Methods: A telephone survey was conducted among 1454 Australian adult smokers between 2012 and 2014 who were followed-up ∼1 week after the baseline interview. Logistic regression analyses examined prospective associations of baseline social norms with quitting-related cognitions and behaviors at follow-up. Analyses were adjusted for baseline demographic characteristics, addiction level, tobacco control policies (cost increases, plain packaging implementation and mass media campaign exposure) and quitting-related outcomes measured at baseline. Differences in associations between lower and higher SES smokers (based on educational attainment and area-based disadvantage) were examined through interaction terms and stratified analyses. Results: Sixty-three percent of participants perceived disapproval from family and friends, 30% felt embarrassed to be a smoker, and 12% lived with a recent quitter. Baseline disapproval, embarrassment and household quitting activity were each associated with having quitting as a high priority and with setting a firm date to quit in the next month. Both disapproval and embarrassment also predicted engaging in behaviors to limit smoking, and only embarrassment was associated with increased likelihood to talk about quitting with family or friends and to make a quit attempt. No associations were found between social norms and being highly confident to quit and seeking help to quit. Associations were mostly comparable for lower and higher SES smokers, with no significant negative effects of social norms on quitting thoughts and behaviors overall or among subgroups. Conclusion: Within the strong tobacco control environment in Australia, smokers from lower and higher SES groups who perceive that their family and friends disapprove of their smoking, feel embarrassed to be a smoker and/or who live in a household with a recent quitter are more likely to prioritize quitting and intend to quit soon. These findings also indicate that the internalized injunctive social norm (i.e., feeling embarrassed) was the strongest predictor of smokers' quitting related behaviors, including making a quit attempt.