Knowledge and Attitude Towards Smoking-related Cancers Among Older Greek-Australian : A Mixed- Methods Study

Special Article � Tobacco and Smoking Cessation

J Fam Med. 2015; 2(6): 1043.

Knowledge and Attitude Towards Smoking-related Cancers Among Older Greek-Australian : A Mixed- Methods Study

Mohammadnezhad M¹*, Wilson C², Ratcliffe J³, Tsourtos G4, Ullah Sh5 and Ward P4

¹Department of Health Education and Promotion, Tehran University of Medical Sciences, Iran

²Flinders Centre for Innovation in Cancer, Flinders University, Australia

³Flinders Health Economics Group, School of Medicine, Flinders University, Australia

4Discipline of Public Health, Flinders University, Australia

5Flinders Centre for Epidemiology and Biostatistics, Flinders University, Australia

*Corresponding author: Mohammadnezhad M, Department of Health Education and Promotion, Tehran University of Medical Sciences, Tehran, 1414743777, Iran

Received: November 13, 2015; Accepted: December 24, 2015; Published: December 28, 2015


Smoking tobacco products presents as one of the highest preventable risk factors for all cancers, especially in older people. Greek peopleare one of the largest ethnic communities in Australia and have the highest smoking rate. This study aimed to understand knowledge and attitude towards smoking-related cancers among older Greek-Australian (GSs) using a mixed methods design. This study conducted in two stages sequentially. The first stage involved analysing qualitative data that were collected through face-toface semi-structured interviews with20current GSs. The data were analysed using content analysis. This analysis assisted in informing the second stage; acomparison of survey responses collected from 96 GSs and 103 Greek nonsmokers (GNSs), using a convenience sampling method. Statistical analysis centred on comparing the attitudes of these 2 groups. Belief on lack of any relationship between smoking and cancers or lack of harmful of smoking, and lack of benefit of quitting smoking formed smokers’ knowledge. The results also demonstrated that low level of English skill was the only significant predictor of knowledge among GSs. Low level of education, socio-economic status, and lack of preparation to quit smoking were identified as predictors of positive attitude towards amoking among GSs. This study highlighted the main behavioural correlates of smoking-related behaviour among GSs that need to be considered on smoking cessation intervention.

Keywords: Knowledge; Attitude; Smoking-related cancers; Older Greek- Australian; Mixed methods


Smoking in adults was responsible for about 22 percent of all deaths from cancer and for about 11 percent of all cardiovascular disease deaths worldwide [1]. According to the US Surgeon General (2004), numerous cancers and chronic diseases have been recognized as being related to smoking. They include cancers of the stomach, uterus, cervix, pancreas, and kidney; acute myeloid leukaemia; pneumonia; abdominal aortic aneurysm; periodontal disease [2] and cataract [3]. Cancers of the nasal cavities and nasal sinuses, liver, and bone marrow (myeloid leukaemia) have also be linked to smoking [4]. The risk of developing oesophageal cancer is about 7.5 times greater in smokers than in lifetime non-smokers and smokers are two to three times more likely to develop cancer of the bladder and other urinary organs than lifelong non-smokers [5,6]. Lung cancer is the most common form of cancer worldwide [7]. In 2008, about 1.37 million deaths were due to lung cancer worldwide and it is estimated that this figure will continue to increase [8].

The harmful effects of smoking are particularly serious for older people [9,10], and the mortality rate among older people is double that of non-smokers of similar ages [11]. Even in older people smoking has been identified as a major risk factor in eight of the top 16 causes of death [12].

Greek-Australians have a high rate of smoking compared with other ethnic groups. For instance, a survey in the Greek community of Sydney revealed that smoking among Greek-Australian males was doubled that of the general population (43 percent compared to 23 percent) [13]. The rate of smoking consumption is higher among Greek-born Australians aged 70 and over (approximately 18.4 percent) compared with Australian-born people in the same age group (12 percent) [14].

Health-related knowledge can be an important factor that contributes to disparate views on the relationship between smoking and cancer [15]. The results of previous studies among older smokers show that they have different levels of knowledge and varying perceptions about the harms of smoking and the benefits of smoking cessation [15,16]. Both starting and quitting smoking can be linked to specific predisposing factors and understanding these factors can provide a framework to assist with the design of an appropriate educational intervention tailored to the smokers’ characteristics including age, ethnicity, and culture. Greek-Australians are one of the largest ethnic groups in Australia, and it is important to understand attitudes to smoking in this group and how these might be addressed in order to facilitate quit attempts.

Materials and Methods

Stage one: Qualitative study

A qualitative study was conducted to understand knowledge of the links between smoking and cancer and attitudes to cessation among a sample of older Greek-Australian smokers (GSs). We recruited participants into the study using a snowball sampling. Twenty Greek smokers who were more than 50 years old were interviewed for this study (twelve males and eight females). Face-toface in-depth interviews were conducted by a trained and experienced researcher with assistance from a translator. Participants were asked about their understanding of the smoking-related cancers and risks (see previously published article; [17]. Manual data analysis started after completing the data collection. The audio-taped interviews were translated and then their a content analysis of the complete dataset was undertaken and emerging themes were identified (see previously published article; [18]. Information of the participants’ recruitment, data collection, and data transcription and analysis are available in our previous published articles.

Stage two: Quantitative study

On the basis of the results of the interviews, a survey was developed. In this study, we have hypothesized that factors that been identified in the qualitative component as related to the decision to smoke may differ between older Greek-Australian non-smokers (GNSs) and GSswhich need to be answered by a quantitative study.

Study participants and sites

Any person who self-identified as Greek-Australian, who was aged 50 or over, and who consented to be a participant were considered as inclusion criteria for this study. For the smoking groups they needed to be a current smoker at the time of the survey and who had smoked at least 100 cigarettes during his/her lifetime [19,20]. The survey data were collected from participants who met the study inclusion criteria while attending the Glendi festival (an annual Greek festival) at the Adelaide showground in 2012 and from the Greek Orthodox Community of South Australia (GOCSA).

Sampling and sample size

Convenience sampling was adopted for all participants. As there was no other study relevant to our study setting, we choose to calculate the power based on posterior power analysis from our dataset. The power analysis was based on two primary outcome measures (knowledge and attitude) between two groups (GSs and GNSs). Assuming an alpha error of 0.05 and a beta error of 20%, power analysis indicated that a maximum of 84 participants would be required per group to detect the differences with respective standard deviations at 5% level of significance. A total of 199participants (103 GNSs, and 96 GSs) were recruited for this survey.

Data collection instrument

A self-administrated questionnaire was developed on the basis of the results of the qualitative study and on the findings of the literature review in relation to the hypotheses.In order to collect information that addresses the objectives of the study, a questionnaire comprised four sections that represented various relevant domains was used.

Participants’ demographic information: This component included questions to capture and measure participants’ sociodemographic status including information on age, gender, marital status, educational status, employment status, salary, and the number of household members.

Smoking characteristics: This part included questions about the age at which the participant commenced smoking (<19 years, 20-24, 25 and over), the total years he/she had smoked, and the number of cigarettes smoked in the preceding 24 hours [21].

Stage of change in readiness to quit smoking and quit attempts: This part measured readiness-to-quit using the ‘stages of change’, a key theoretical component of the Trans-theoretical Model (TTM) of health-behaviour change [22]. The stages of change included one 5-stage question. In the first stage (the ‘Pre-contemplation’ stage), smokers are not planning to quit within the next six months. In the ‘Contemplation’ stage smokers are seriously thinking about quitting in the next six months. ‘Preparation’ is the phase in which smokers who have tried to quit in the past year seriously think about quitting in the next month. ‘Action’ is a period ranging from 0 to 6 months after smokers have commenced the change to quitting, and ‘Maintenance’ is defined as the period beginning six months after the action has started and continues until smoking has ceased to be a problem” [23]. Because this study focused on smokers who were smokers at the time of the study, only the first three stages of readiness-to-quit were measured.

Knowledge and attitudes to smoking: This section included the items were chosen based on the literature review and also the information from the qualitative study. This part included 15 questions to measure participants' knowledge of smoking and smoking related cancers. Response options of 15 items included “True”, “False”, and “don’t know”. The maximum score for the knowledge section was 15 and the lowest possible score was 0.

Fourteen items asked about participants’ attitudes to smoking. Response options included Likert-scale items; “strongly agree”, “agree”, “disagree”, “strongly disagree”, and “no idea”. They were assigned numbers 1-5. In this manner the responses to the various items were quantified and then summed across statements to provide a total score for the individual. For example, for some of the items the response scored 1-5 and for the other statement scored 5-1. The maximum score possible for ‘attitude’ was 70 and the lowest possible score was 14.

Validity and reliability of the questionnaire

Several components of the questionnaire have been used many times in other validated instruments in previous studies. Before their use in this study, all the measures that were developed in English were translated into Greek and then back-translated through a rigorous process; next they were pilot-tested for cross-cultural validation [24,25]. Smoking-history items were adapted from those which have been used in many national surveys [26,27]. The stage-of-change was also used in previous studies. This questionnaire had been used in previous studies of Greek smokers [28]. To further validate the questionnaire content-validity was applied to this research. The researcher sent the questionnaire to his four academic supervisors who provided guidance and feedback. The content of each item in the questionnaire was then re-evaluated and refined accordingly. Appropriate changes, in accordance to the results of the questionnaire testing, were then made and the revised questionnaire was translated by a nationally-accredited Greek translator. After translation, the questionnaire was checked by four Greek PhD students to ensure the accuracy of the translation.

Data collection

In-principle agreements were gained from the organization’s managers to administer the questionnaire at the Glendi Festival and GOCSA. The questionnaire was administered at the Glendi Festival during two days (27th and 28th October 2012) to recruit Greek- Australian. Once informed consent had been received an information sheet (both Greek and English versions) and a letter of introduction (both Greek and English versions) were issued to people who met the inclusion criteria; then the questionnaire was distributed (two versions in Greek and English were offered). A bilingual translator was available for the Greek participants who may have required assistance to complete the questionnaire. It nearly took about 30 minutes to complete the questionnaire. Participants could answer at that time, but if they agreed to complete the questionnaire at a later time they were provided with a pre-paid envelope.

Data analysis

Statistical analysis consisted of descriptive statistics (i.e. frequency distributions and cross-tabulations) and inferential statistics. The Χ² test was used to compare smokers and non-smokers for the categories of variables. A multiple regression model was used to examine the significance and direction of the linear relationship between the independent (continuous and categorical) variables or predictors with the continuous (knowledge and attitude) dependent or outcome variables. Odds ratios (ORs) with 95 percent confidence intervals (CIs) for each variable were calculated “as an estimate of the likelihood of smoking, and probability values were determined” [29]. Raw data were coded for data entry. In this study the coded and cleaned data were analysed by using SPSS for Windows software (Version 20.0). All significance tests were two-tailed and a p-value <0.05 was considered statistically significant.

Ethical considerations

This study was approved by the Social and Behavioural Research Ethics Committee (SBREC) of Flinders University.


Stage one: Qualitative study

Their mean age was 64.6 years (SD=9. 96 years). The mean age of smoking commencement was 19 years (SD=3.72 years). The mean years of smoking were 45.5 years (SD=10.8 years), and most of the respondents [11] said that they had smoked for more than 50 years. The mean number of cigarettes smoked each day was 16.5 (SD=9.98 cigarettes). Eleven of the participants mentioned that they had attempted quitting at least twice, with a maximum of 15 times. Most [13] were suffering currently from diseases such as cancer or heart disease.

Knowledge about smoking-related cancers

Of the 13 respondents who suffered from different kinds of diseases, eight had smoking-related diseases such as cancer and had experienced heart attack. When they were asked about the relationship between smoking and their disease, four of them denied any relationship. The other four were uncertain about the relationship.

Eight participants who had signs of disease made judgements about the relationship between smoking and their health condition based on their own or their family’s personal experiences rather than on the medical facts. P14 (a 53-year-old female) believes that her high blood pressure is hereditary and has nothing to do with her smoking. Similarly, her close relatives got cancer, so she believes she will probably get it too, whether or not she smokes:

I have smoked a lot of cigarettes in the past because my father was dying of lung cancer and his younger brother also got lung cancer. I probably am a good candidate [for lung cancer] and I could get it because I used to smoke at one stage a lot but now I don’t smoke a lot and so it is not a problem.

Four of the respondents confined their remarks to agreeing that smoking consumption is harmful for their health without describing any effects or supplying further information. However, one of them, in responding to the question ‘Is there any relationship between smoking and disease?’ (he had bladder cancer and three heart attacks/ strokes) denied that there was any relationship.

P5 (a 73-year-old male), started smoking when he was 12. He had an operation following a colonoscopy and cancer diagnosis four years ago. P5 agreed that smoking was harmful and he named some of the symptoms; however, he denied any relationship between his own disease and smoking. He believes that the kind of tobacco he smokes is not harmful and free of side-effects. He also believes that his low consumption of cigarettes protected him from harm. Here P5 explains these perceptions:

Up to now I have never coughed because I have never changed tobacco. I have smoked all the time since 1960. I started off with Drum tobacco and. I have never changed. If you get some from somebody else one cigarette or two days before I want to smoke I stop coughing. With a Dram smoke no cough, no nothing.

Three of the respondents said that while they believed that smoking is harmful, they also thought that quitting smoking has no health benefits. To justify this claim, they referred to people who had died of cancer even when they had never been smokers or they said they knew a lot of doctors who smoked cigarettes.

P2 (a 71-year-old male) maintains smoking is not harmful (postitive attitude towards smoking) because he knows many nonsmokers who have died of cancer.

Government tries to money to me. Because I can’t give up smoking it means I am left with only 33 dollars. I smoke Drum tobacco. […]. Its cost maybe is two dollars and the government makes 500 percent profit! Want to stop making tobacco it means they make profit from cigarettes and put this advertise on cigarette packets that it makes your health damage, it causes cancer. I don’t believe it. There are a lot of people who have never smoked and who get cancer.

Eight of the participants acknowledged that quitting smoking would be advantageous to their health, although they did not identify in what way and their decisions seemed mostly influenced by their own previous experiences of smoking-related diseases.

One of the interviewees, even though he had had three heart attacks, and gall-bladder cancer, only mentioned that quitting smoking improved his lung function, as well as bringing some financial benefit.

Attitude towards smoking

Some had a positive attitude towards smoking. They expressed beliefs such as: I can't live without smoking’ (P9 and P19) and ‘I don't believe that I will get cancer from smoking cigarettes’ (P2).

Some of their life events may have influenced participants to adopt a positive attitude towards smoking.

P10 (a 65-year-old female), started smoking when she was about 20 and she smokes about two packets a week. She came from a family with many smokers; her father died of lung cancer. Her uncle had lung cancer. She believes that she is probably a good candidate for developing cancer. She rationalized her continuing smoking by pointing out that in her family the smokers are healthy while some non-smokers have cancer:

In my family all family members who smoke cigarettes are healthy while two of [my wife’s] family members who haven't ever smoked have cancer. (P10).

According the results of the qualitative study three hypotheses were grouped up. They include:

• The level of knowledge about smoking-related cancers is different among Greek-Australian older smokers compare with Greek-Australian non-smokers.

• Greek Australian older smokers have a different attitude towards smoking compare with Greek-Australian nonsmokers.

• Predictors of knowledge about smoking-related cancers and attitude towards smoking are different between Greek-Australian smokers and non-smokers.

These hypothesis were examined in the stage two (quantitative study) and the results are reported below:

Stage Two: Quantitative Study

The frequency of female participation was higheir in the GNS group (55.3 percent). GNS group had a higher mean age of 65.1 years (SD= 10.4) (p<0.0001). There was a significant difference in marital status between two groups (Χ²=41.08, p<0.001). While the majority of respondents in both groups were married, the frequency of married participants was higher in the non-smoking group (69.9 percent). On the other hand, the frequency of divorced respondents was higher in the smoking group (21.9 percent).

In terms of income, no statistically significant differences were found between groups (Χ²=8.99, p=0.43). Most respondents reported a ‘low’ household income (less than $AUD40K) in both GSs (45.8 percent) and GNSs (36.9 percent). Mean household membership was higher among GSs (2.35, SD=1.03) compared with GNSs (2.26, SD=1.03) (Table 1).