Elsevier

Social Science & Medicine

Volume 60, Issue 3, February 2005, Pages 483-490
Social Science & Medicine

Smoking, respiratory disease and health service utilisation: the paradox

https://doi.org/10.1016/j.socscimed.2004.06.001Get rights and content

Abstract

We compared need for and utilisation of health services among young, healthy smokers who did not want to quit “the non-motivated”, and “motivated smokers”, relative to never-smokers. This cross-sectional study included 9915 Hong Kong police officers. We assessed smoking status, differentiating non-motivated from motivated smokers. Need was measured as the number of respiratory symptoms, and utilisation as the number of doctor consultations. All smokers had significantly more respiratory symptoms, but relatively lower utilisation. After adjusting for other factors, the odds ratio for utilisation was 0.77 (95% CI 0.64–0.93) for motivated smokers and 0.62 (95% CI 0.50–0.77) for non-motivated, relative to never-smokers (p for trend<0.001). Young, relatively healthy smokers, particularly the non-motivated, utilise less health services relative to the amount of symptoms. This has implications for planning smoking cessation services.

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.

References (36)

  • C.C. Butler et al.

    Qualitative study of patients’ perceptions of doctors’ advice to quit smokingImplications for opportunistic health promotion

    British Medical Journal

    (1998)
  • F.G. Castro et al.

    Cigarette smokers do more than just smoke cigarettes

    Health Psychology

    (1989)
  • Census and Statistics Department, Hong Kong (1997a). Hong Kong residents’ health status and doctor consultation,...
  • Census and Statistics Department, Hong Kong (1997b). Hospitalization, General Household Survey. Special Topics Report,...
  • I.K. Crombie et al.

    Does passive smoking increase the frequency of health service contacts in children with asthma?

    Thorax

    (2001)
  • Festinger, L. (1975). A theory of cognitive dissonance. Stanford, CA: Stanford University Press, p....
  • Florey, C.V., Leeder, S.R. (1982). Methods for cohort studies of chronic airflow limitation. Vol. 12, pp. 67–134. WHO...
  • F. Gutzwiller et al.

    Smoking, prevalence of disease and health service utilization among the Swiss population

    Revue d Epidemiologie et de Sante Publique

    (1989)
  • Cited by (0)

    1

    Formerly at Department of Community Medicine, University of Hong Kong, Hong Kong.

    View full text