This investigation examined demographic, smoking and depression characteristics of a large international sample of English and Spanish-speaking smokers attempting to quit by participating in Internet-based smoking cessation randomized trials. Smokers in the current investigation were similar to community samples of smokers [8
], smokers enrolled in traditional, face-to-face smoking cessation programs [29
], smokers who use the Internet [10
] and Internet users [30
] in terms of gender, age, education, nicotine dependence, and number of cigarettes smoked currently. Smoking patterns were very similar across regions of the world among persons who speak English or Spanish, suggesting that smoking cessation methods might work similarly in smokers from different regions who share similar characteristics and who turn to the Internet for help in quitting. In this report, data are presented by WHO regional categorization and by country for larger sub-samples. We chose to present the data in this format to support international efforts to adapt Internet interventions to the characteristics of smokers who seek help from the Web to quit and to develop means to reach those who do not currently use these methods. We believe international health agencies currently underutilize the Web for tobacco control and other health interventions. Increasing Internet access focused on such health interventions would help scale up efforts to prevent unnecessary morbidity and mortality.
Participants from the Eastern Mediterranean and South-East Asian regions were most alike in gender composition, marital status and education. Differences between the regions can potentially be explained by the greater prevalence of male smokers [31
] and tobacco use being viewed as a traditionally male behavior [33
] in countries within these regions. Ten percent of women compared to 50% of men smoke in the Eastern Mediterranean [32
]. Attitudes about female smoking behavior suggest greater social disapproval [35
] and greater permissiveness towards alternative forms of tobacco consumption (e.g., water pipes) among family members of female tobacco users [34
Of the 157 countries represented in this investigation, English is the national or official language of 30 countries and Spanish of 20. Other than the samples from South Africa and India, all of the countries profiled included English- and Spanish-speaking smokers, regardless of the country’s dominant language, suggesting the possibility that Internet-based cessation trials can provide a service to smokers in countries where services may not be available in their language of preference. We did not ascertain participants’ native language and the country affiliation refers to where participants reside, therefore, it is difficult to assess whether this assumption is accurate. In fact, many of the participants may be expatriates from English or Spanish-speaking countries or they may have sufficient knowledge of a non-native language to be able to use the Internet site. Nonetheless, it appears as though this smoking cessation Website reached smokers who were interested in quitting and who resided in countries where languages other than English and Spanish are the official languages.
Participants began smoking around the age of 15, became regular smokers three years later and currently smoked approximately 20 cigarettes a day. South-East Asian smokers were older when they smoked their first cigarette and when they became regular smokers, indicated fewer daily cigarettes smoked and endorsed a lower nicotine dependence score. This latter finding makes sense given their overall younger age, which translates to fewer years smoking and, possibly, less addiction. The study Website that recruited these participants is intended for individuals seeking to quit smoking cigarettes and does not address other forms of tobacco products. In India, the largest country represented in this region, bidis
, cigarettes, and chewing tobacco are the more common forms of tobacco consumption. Approximately 65% of men and 33% of women use tobacco, but 35% and 3%, respectively, smoke [36
]. The level of nicotine dependence in this investigation reflects dependence among cigarette smokers similar to that found in traditional smoking cessation studies.
Traditional smoking cessation methods were actually used by very few smokers (e.g., NRT and groups) and there were disparities in terms of utilization of smoking cessation methods between high, middle and low income countries. However, 27.5% more smokers reported a quit attempt than reported the use of smoking cessation aids in the previous 6 months, suggesting that a sizable number of participants may have used nothing (i.e., cold turkey) in their quit efforts. The countries with the largest percentage of participants using NRTs in the previous six months included the USA, Mexico, U.K., Canada, Ireland, and Australia. In these countries, NRTs are more accessible given that they are available over the counter and smokers from some of these countries are reimbursed by their country’s national health plans [14
]. Except for participants from Mexico, fewer than half of participants from these countries indicated using nothing to quit, suggesting that they may have greater access to other types of cessation aids in addition to NRTs. Self-help methods were also popular among participants; however, it is unclear what types of self-help methods were used.
There is evidence that depressed individuals are more likely to begin or continue smoking and less likely to quit [37
] and, consequently, tend to report higher rates of smoking behavior and nicotine dependence [38
]. Similarly, the risk of depression onset is higher for heavy smokers than for non-smokers [40
] and for current smokers versus ex-smokers [41
]. Data from this investigation demonstrated that depression symptoms and clinical-level depression were very prevalent in smokers across the world. Almost 50% of the sample endorsed elevated symptoms of depression during the previous two weeks, with over a third meeting diagnostic criteria for a lifetime MDE. The rate of screening positive for current MDE reported by the entire sample was consistent with rates of current MDE among smokers in a multinational sample [41
] and smokers at the start of a smoking cessation treatment program [42
There are several limitations to the data presented in this report. First, the data are representative of a specific sample of smokers who searched the Web for smoking cessation resources and were willing to participate in an online smoking cessation study and able to read in English or Spanish. Although this report included smokers from 157 countries, this report solely described characteristics of smokers who resided in countries included in the WHO regions. This study excluded smokers who reported fewer than five cigarettes per day, who are under the age of 18, who do not have Internet or email access, who are not interested in quitting, and who reside in countries or territories not included in WHO regional categorizations. Second, the sample likely had an overrepresentation of highly educated smokers who may have greater resources, including access to smoking cessation aids and interventions. Smokers with limited resources may not be aware or have access to opportunities available on the Internet to improve their health. Third, a significant portion of the English-speaking sample was from the USA, while a greater proportion of Spanish-speaking participants were from Spain. Although we obtained data on ethnic and racial background, it is difficult to draw conclusions about the cultural influences on smoking behavior and depression history given the complexity of cultural factors and its influence on behavior. Finally, this report does not include analyses on the cost-effectiveness of Web-based smoking cessation trials, which is an important factor to consider when designing such interventions.