Discussion

This study aimed to gain insight into smokers with no intention to quit in the upcoming six months by qualitatively analysing free-text comments they provided at the end of a SBQ. The differences between those who provided a comment and those who did not (in the whole sample) were also examined. The results indicated that the groups differed in age and education level, both of which were greater in the group that supplied comments. The finding that those providing comments were more educated is in line with findings in other studies (Riiskjær, Ammentorp, & Kofoed, Reference Riiskjær, Ammentorp and Kofoed2012). Those who commented were also more dependent on cigarettes, more motivated and determined to quit smoking and more likely to report that they could imagine themselves as a non-smoker. These findings could be due to more ‘extreme’ participants being more likely to comment. Riiskjær Ammentorp and Kofoed (Reference Riiskjær, Ammentorp and Kofoed2012) reported a similar finding in their investigation of patient surveys which found that the least and most satisfied patients were those who were most likely to provide a comment.

An additional interesting finding that emerged from the quantitative comparison was the higher likelihood of those who commented to have made a quit attempt in the six months after joining the study. However, there was no difference in the groups in prolonged abstinence so these extra quit attempts did not lead to higher levels of smoking cessation in those who commented. These findings can be linked to other research which has reported that smokers who are motivated to quit are more likely to make a quit attempt but are not more likely to maintain abstinence from smoking (Hyland et al., Reference Hyland, Borland, Li, Yong, McNeill and Fong2006; Zhou et al., Reference Zhou, Nonnemaker, Sherrill, Gilsenan, Coste and West2009). This trend has been attributed to the tendency for smokers who are highly motivated to quit also being those who are most dependent on cigarettes and therefore likely to have the most difficulty in quitting. As previously mentioned, those who provided a comment were indeed more highly dependent on smoking.

A key theme to emerge from the qualitative analysis was the notion of justification of smoking whereby participants used their positive health behaviours and general perceived good health to rationalize their continuing to smoke. It may be that these smokers see their healthy behaviours such as exercising regularly and avoiding alcohol as counter balancing the negative impact of tobacco smoke on their bodies. Other researchers have reported this type of attitude elsewhere and have named these beliefs ‘Compensatory Health Beliefs’ (Knäuper, Rabiau, Cohen, & Patriciu, Reference Knäuper, Rabiau, Cohen and Patriciu2004). Rabiau and colleagues argue that the activation of these beliefs allow the individual to engage in the desired unhealthy behaviour without the associated guilt (Rabiau, Knäuper, & Miquelon, Reference Rabiau, Knäuper and Miquelon2006). In this way the individual can dismiss the necessity of quitting smoking based on the false belief that they are negating the impact of smoking on their body by engaging in a compensatory behaviour. This finding suggests that health messages to smokers should emphasize that the detrimental impact of smoking on health cannot be offset by engaging in other positive health behaviours.

This justification of smoking can also be understood in the context of the ‘considerate’ smoker as described by Poland (Reference Poland2000) who suggests that the increased awareness of the notions of health risks and the management of one's own health has placed more pressure on people to take responsibility for the risky behaviours in which they engage. People are expected to monitor themselves and carefully consider the risks that they take in everyday life (Poland, Reference Poland2000). It is perhaps in fulfilment of this new role that smokers try and explain their negative health behaviours in the context of the positive steps they take to maintain their health. In this way they can see themselves and be seen by others to be purposefully ensuring their own future good health.

Participants who provided comments also indicated that they felt persecuted by both government policy and non-smokers. They expressed anger at their perceived demonization and a number of comments suggested a perception that the public's attitude to them was worse than that to people addicted to illegal drugs or alcohol. This tendency of smokers to point to other behaviours which potentially jeopardise health has been reported elsewhere (Poland, Reference Poland2000). Other comments detailed the sense of smokers’ rights and freedom of choice being eroded. The distribution of the questionnaire coincided with the introduction of the UK smoking ban in 2007 and this could have affected or prompted some of these comments. A number of studies have identified an associated increase in perceived stigmatization among smokers following the introduction of smoke-free legislation (Ritchie, Amos, & Martin, Reference Ritchie, Amos and Martin2010; Stuber, Galea, & Link, Reference Stuber, Galea and Link2008).

There was also an overriding sense of smokers being marginalized by society in many of the comments. Again, this may be reflective of the timing of this survey as the smoking ban did have the effect of excluding smokers from the public realm, at least while they were smoking. Some research has suggested that smokers who perceive high levels of stigma are more likely to quit (Stuber et al., Reference Stuber, Galea and Link2008) but it is clear that strong feelings of stigma have not prompted these particular smokers to quit or even plan to quit in the next six months. This stigma can also represent an additional burden on those who are already struggling to cope (Bayer, Reference Bayer2008). While it is necessary to offer information about the dangers of smoking this theme suggests that it is also important to ensure support is available to people who experience stigma due to their smoking behaviour (Ritchie et al., Reference Ritchie, Amos and Martin2010).

In the related theme of restricting smoking instead of quitting completely many participants argued that they had gained control over their smoking by cutting down their cigarette consumption. Some participants were satisfied with the level they had reached but others saw it as a way of progressing towards complete abstinence. This is a particularly interesting theme as the idea of cutting down over abrupt cessation is a controversial one. The established practice in the NHS SSS is to recommend abrupt cessation and the notion that this is the most effective way to quit has been supported by a number of studies (Cheong, Yong, & Borland, Reference Cheong, Yong and Borland2007; West, McEwen, Bolling, & Owen, Reference West, McEwen, Bolling and Owen2001). However there is growing support for the idea that cutting down can be a potentially useful path to cessation, especially for smokers with little initial motivation to quit and particularly when combined with the use of NRT (Fagerström, Reference Fagerström2005; Fagerström, Tejding, Westin, & Lunell, Reference Fagerström, Tejding, Westin and Lunell1997; Moore et al., Reference Moore, Aveyard, Connock, Wang, Fry-Smith and Barton2009; Tønnesen, Reference Tønnesen2002). Bolliger et al. (Reference Bolliger, Zellweger, Danielsson, Biljon, Robidou and Westin2000) demonstrated in a randomized controlled trial that 9.5% of a small group of smokers with little motivation to quit had achieved point prevalent abstinence two years after the date of randomization following a program of cutting down and NRT as compared to 3% in a group cutting down and using a placebo. The fact that smokers in the current study were unmotivated to quit and many who commented highlighted the appeal of cutting down suggests that a program of this sort could potentially be effective in promoting eventual cessation to smokers with no immediate intention of quitting.

Some participants providing comments indicated a lack of awareness of support available while others described dissatisfaction with the support in quitting they had been offered in the past. The reasons for this dissatisfaction varied between participants with some feeling there was a lack of empathy from smoking cessation advisors. Considerable variability has been found in the training that NHS SSS advisors in the UK currently receive (McDermott, Beard, Brose, West, & McEwen, Reference McDermott, Beard, Brose, West and McEwen2013). This highlights the importance of training NHS SSS advisors to a high standard so they can effectively encourage behaviour change whilst maintaining an understanding and supportive stance. Other participants mentioned that they felt under pressure to quit at a faster rate due to the NHS SSS six week course structure. It should be noted, however, that this data was gathered in 2007–2008 and it is possible that since then services in the UK have become more flexible in the length of support and number of sessions they will offer a smoker.

Other comments related to the topic of support included many ‘cries for help’, with these participants beseeching the research team for assistance in quitting smoking. These comments suggest that participants were not aware of the free cessation support that is available in the UK. Greater advertisement and promotion of the support available is needed to ensure all smokers wanting help to quit are aware how to avail of assistance.

Free-text comment sections can be useful for garnering opinion on the tools used to address the research question (Garcia et al., Reference Garcia, Evans and Reshaw2004). The feedback on the questionnaire provided by some participants’ comments varied from emotive reactions to being sent an invitation to participate in smoking research to more detailed observations on individual questionnaire items. The anger expressed by some participants is perhaps evocative of the theme described above of the curtailment of smokers’ freedoms.

Those who provided feedback on individual questions in the free-text comment section fell into two groups. Firstly, some were critical of the inclusion of certain items which they felt were irrelevant to smoking. An example of this was participants who were particularly unhappy with questions which focused on socio-economic status. This may be reflective of the reluctance of people to acknowledge a causal link between socio-economic status and health behaviours (Blaxter, Reference Blaxter1997; Putland, Baum, & Ziersch, Reference Putland, Baum and Ziersch2011). It may also be linked to the previously mentioned stigma some smokers experience and the complex relationship between smoking and socio-economic status (Putland et al., Reference Putland, Baum and Ziersch2011). Perhaps a brief explanation of the necessity of these types of items in health surveys could both improve responses to these questions and the questionnaire in general. Secondly, some participants used the free-text comments’ section to explain and clarify their answers to particular questions. This use ties into the idea that free-text sections act as a ‘safety net’ to ensure researchers do not miss any relevant issues not covered by closed questions as discussed by O’Cathain and Thomas (Reference O’Cathain and Thomas2004). This section also affords participants the opportunity to present their own opinions without being forced to filter these views through closed questions which are representative of the researchers’ agenda.