Smoking, respiratory disease and health service utilisation: the paradox
Introduction
Smoking is well documented as a major cause of ischaemic heart disease, chronic lung disease and cancers (Wald & Hackshaw, 1996). However, relatively few studies have examined the relationship between smoking and health service utilisation relative to need.
Some studies have shown that smokers use more health services compared with those who have never smoked (Ashford, 1973; Gutzwiller, La Vecchia, Levi, Negri, & Wietlisbach, 1989; Sippel, Pedula, Vollmer, Buist, & Osborne, 1999; Jee, Kim, & Suh, 1993) . Other investigators have found the inverse relationship, that smokers are less likely to use health services (Oakes, Friedman, Seltzer, Siegelaub, & Collen 1974; Yamamoto, Masaki, & Nakamura, 1996) . Yet others have shown that whilst certain aspects of health care utilisation are increased, others, such as the use of preventive services (Osterberg et al., 1998), outpatient services (Vogt & Schweitzer, 1985; Kaplan, Wingard , McPhillips, Williams-Jones, & Barrett-Connor 1992; Izumi, 2001) or inpatient care (Weinkam, Rosenbaum & Sterling 1987), are decreased in smokers.
It may be that smokers take little responsibility for their health and under-utilise appropriate services (Ashford, 1973; Jee et al., 1993) . Justification for this view is the finding that smokers use preventive services less frequently than non-smokers (Krick & Sobal, 1990) and are more likely to engage in other unhealthy lifestyles (Castro, Newcomb, McCreary, & Baezconde-Garbanati, 1989). Yet smokers are not a homogenous group. Prochaska and DiClemente (1983) developed a model proposing that they could be categorised according to their stages of change. This model identifies smokers who have not considered and do not plan to quit smoking (the precontemplation stage), and others who want to and have made some plans (contemplation stage) or actually taken some action to quit (stages of preparation and action). One study has shown that smokers differ in other health behaviours depending on their stage of smoking cessation (Unger, 1996). Pre-contemplators were found to be more likely to have sedentary lifestyles and to drink to excess compared with those in other stages. Thus among smokers, the stage of change may also be related to health care utilisation patterns. Furthermore it is possible that these associations vary throughout a smoker's life and according to health status, with younger, relatively healthy smokers possibly exhibiting different behaviour from less healthy smokers.
We tested the hypothesis of association between stage of change and health behaviour within a large workforce, focusing primarily on relatively healthy working smokers. We first examined the relationship between need for health care, as measured by reported health, and utilisation of ambulatory and in-patient health services, among the smokers compared with those who had never smoked. Secondly we compared smokers who were not interested in quitting with others, in terms of possible indicators of need and utilisation.
Section snippets
Methods
The report is based on a study of officers in the Hong Kong Police force in 1995 (Hedley et al., 1997) and the detailed methods are explained elsewhere (Lam et al., 2000). All 11,038 officers working in the traffic, foot-patrol and marine divisions of the Hong Kong Police were asked to complete a structured health and lifestyle questionnaire under controlled conditions. The data presented in this paper come from sections of the questionnaire related to personal history, reported morbidity,
General characteristics
There was a response rate of 90% (9915 responders). We excluded 562 responders (5.7%) who did not provide sufficient information on their smoking habit to allow them to be used in the analysis. Among the remainder, the mean age was 33 years (range 18–58), and 91% were male. The prevalence of current smoking was 46.6% (3.842 officers) for men and 11.9% (98 officers) for women, and there were 262 (2.9%) former smokers. About one third of current smokers (1391 people) were in the non-motivated
Discussion
The results of the study are in keeping with the prior hypothesis that, in a healthy working population, smokers under-utilise health services relative to need as identified by the number of respiratory symptoms. This study focuses only on a working and therefore relatively healthy population and so the results may not be applicable to a less healthy smoking population. Also, since the study participants were mainly young and male, we need to be careful in attempting to extrapolate to other
Acknowledgements
We would like to thank R Fielding, CM Wong for being part of the Hong Kong Police Study project team, and A Lamb, L Aharonson-Daniel, ASM Abdullah, J Cheang, M Chi, D Ho, D Kwan, and S Ma for assisting in fieldwork and data processing. This study was funded by the Hong Kong Police.
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- 1
Formerly at Department of Community Medicine, University of Hong Kong, Hong Kong.