In the studied period, 10.0% of the population of Poland, and 41.6% of male and 37.7% of female daily smokers at age 26 years or older were hardcore smokers. The prevalence of hardcore smokers in the general population and among daily smokers found in GATS Poland seems to be the highest that has been described in the literature until now [15, 17]. Kishore et al., analyzing data from GATS conducted in three South-East Asian countries revealed that hardcore smokers constitute between 3.1% in India to 6.0% in Thailand of the adult population which translates into 18.3% in India and into 29.7% in Thailand of daily smokers . Ferketich et al. also estimated that 7.8% of all adult Italians and respectively 33.1% of all smokers in Italy in 2007 were hardcore smokers . Lower prevalence of hardcore smoking among daily smokers was also registered in the US (California (5.2%) and Missouri (7.8%)), England (16%), and Norway (25.0%) [17–20]. The factors that may lie behind these huge disparities in hardcore smoking between countries are difficult to explain except that different studies use different study designs, or focus on selected groups like urban population, patients etc. The different definitions of hardcore smokers may also limit the ability to compare results across studies . Aside methodological issues, countries also differ significantly in terms of their economic, social and cultural context which may play vital roles in influencing the tobacco epidemic phase. Also, the tobacco control environment, access to education or cessation services can be considered in this context.
In GATS Poland, the odds of being a hardcore smoker varied across age groups as in many other studies [16, 17, 19]. However in many studies, a higher concentration of hardcore smokers was observed in older age groups like 65 years or older [16, 19, 21]. Our results showed that the highest odds for hardcore smoking were found among subjects younger than 65 years, in men in the 30–59 age group and in women in the 40–59 age group. We can speculate that at a younger age men and women are less likely to consider smoking cessation than at age 60 and above, due to relatively good health and an absence of alarming symptoms caused by intensive tobacco use.
Consistent with other studies, GATS displayed that young age at smoking onset is strongly related with hardcore smoking [15, 16, 18, 22] The hardcore smokers became regular smokers at a younger age than non-hardcore smokers . Smoking causes nicotine addiction over time . The earlier one starts smoking, the greater the risk of dependence, heavy smoking or difficulty with quitting as an adult [16, 22, 24]. Currently, Polish hardcore smokers appear to be mainly a cohort of middle-aged men and women. However, the recent studies have shown that adolescents are experimenting with cigarettes at relatively younger ages which may indicate that a new, younger cohort of highly addicted individuals may be budding [2, 16]. Declining age of smoking initiation is alarming because negative health impact of smoking will be probably larger in the young cohorts of today [25, 26]. Nonetheless, Emery et al. concluded that even if adolescent smoking increases beyond current levels, it is likely that smoking rates will continue to decline over the next 2 to 3 decades as the current cohort of older smokers diminishes through death and quitting . Programs that delay smoking initiation might have considerable value even if they do not succeed in fully preventing the uptake of smoking . Delaying smoking initiation among adolescents could eventually reduce the rate of heavy or hardcore smoking and increase the potential for successful cessation .
GATS Poland revealed that participants who were unaware of the health risks of smoking were more likely to be hardcore smokers compared to those aware. Most importantly, some reports showed that the knowledge on the harmful risks of tobacco use is still insufficient in Poland . Health knowledge thus seems to be one of the most important factors that might prevent hardcore smoking. There is a need for better education on the risks of smoking which includes, improving the overall knowledge of quitting benefits and reduction of health risks related to smoking cessation . This knowledge is often delivered through the contacts with health care professionals . Brief interventions – doctors advising patients to quit has been considered the simplest approach to increase smoking cessation . Our results (although in most cases on statistically insignificant level) showed that hardcore smokers tended to have less visits to health care professionals and those who visited were less likely of being asked about their smoking habits or advised to quit when compared to non-hardcore smokers.
The main focus of smoking bans in public places or indoor areas is to protect nonsmokers from exposure to environmental tobacco smoke. The added value of this strategy is that it often increases the likelihood of quitting among smokers and is considered as a key factor associated with cessation attempts and success [18, 29–34]. There is a strong and consistent population-level evidence that smoke-free homes are associated with increased smoking cessation and decreased cigarette consumption in adult smokers [35, 36]. As Mills et al. reported, both longitudinal and cross-sectional studies have revealed that smokers who had or who newly implemented a smoke-free home were significantly more likely to make a quit attempt and to be abstinent, after controlling for confounding factors. In longitudinal studies, those who continued to smoke had a modest, but significant, decrease in cigarette consumption at follow-up . Findings from GATS Poland indicated that hardcore smokers were less likely to have smoke-free rules in their homes relative to non-hardcore smokers. Underestimation of the need to protect non-smokers at home or elsewhere from tobacco smoke is also supported by our finding that hardcore smokers were generally less supportive for tobacco control policies. Intensive and comprehensive tobacco control campaigns addressing smoke-free policies are thus urgently needed in Poland in order to curb the tobacco epidemic.
For the purpose of this study we selected subjects who were 26 years or older at the time of the survey. Individuals aged 25 years and younger were excluded from the analysis because they still might have been engaged in the process of smoking uptake and therefore may not have reached a stable level of average daily consumption or solidified their intentions regarding quitting . The GATS was carefully designed, nonetheless contains some limitations . Some potential limitations are associated with the use of self-reports and a cross-sectional design, that have been broadly discussed in previous papers and should not significantly decrease the value of the study [3, 12]. Nevertheless, we admit that because of the cross-sectional design, the direction of any causal association cannot be established in this study. It should also be highlighted that we examined the prevalence of and factors associated with hardcore smoking in Poland using component construct information available from GATS standard questionnaire, and we therefore may have missed some important characteristics (e.g. household income, mental health problems and alcohol or other addictive substance use) that could have impact on hardcore smoking. This missing information does not allow comparing GATS data with many other studies and thus requires a serious consideration in designing the future surveys.