Throughout the world 4.83 million people die from tobacco products every year⁴ and this number will reach 10 million in 2020. In 51 countries in Europe, 1.2 million people die from tobacco products⁵. In our country approximately 100,000 people die every year from diseases related to tobacco use.

The Eastern European region, where our country is located, is responsible for 25% of the annual tobacco-related deaths in the world, and it is estimated that men in this region are the highest risk group for tobacco related deaths in the world⁶. We presumed that it would be important to determine the tobacco use prevalence and quit rate in the city of Edirne which is in the western European part of our country. In addition because of Edirne's location as a city on the national border and with its other socioeconomic factors it may have different cigarette smoking attitude than the country in general.

The rate of quitting cigarette smoking is an important indicator in the evaluation of the effectiveness of tobacco control programs and an important measure for planning programs to help individuals quit smoking. In the national tobacco control program the goal was to determine the rate of quitting smoking by 2007 and the target was set to reach a rate of 40% in society by 2010⁷.

This study was planned for the purpose of measuring the prevalence of adult cigarette smoking prevalence and quit rates in Edirne, to provide basic information for monitoring it over time to show the need and effectiveness of tobacco control methods.

Sampling: According to the Edirne Health Directorate's year 2001 statistics there were total 93,347 people in 15-64 age group (47,326 men and 46,021 women). The research sample was chosen by calculating from these totals, assuming smoking prevalence for women 25% ± 4 (95% Confidence Interval) (446 women), and for men 65% ± 7 (95% Confidence Interval) (178 men) by national prevalence's from PIAR study; the study was conducted with 645 individuals, 452 of whom were women and 193 men. The sampling procedure was conducted randomly, weighted according to ethnicity (Turkish Gypsy or not), age and gender from eight different neighborhood Public Health Clinics located in the city center.

Survey: Data were collected using a survey, “International Union Against Tuberculosis and Lung Diseases (IUATLD) / Amended WHO smoking questionnaire”⁸ with some questions added about factors that may affect cigarette smoking to be used in multiple analyses. A pilot test was conducted with the survey that was used. The data were collected by a group of sixth year students at a university medical faculty. The data collectors were trained about how to administer the form, and they went to the participants and conducted face-to-face interviews with them to complete the surveys.

Definitions: Current smoker: An individual who smoked cigarettes every day or occasionally during the screening (up to 30 days previously) and who had smoked at least 100 cigarettes during his/her life. Daily smoker: An individual who used any kind of tobacco product at least once a day. Nonsmoker: An individual who did not smoke cigarettes during the screening period. Ex-smoker: An individual who had previously smoked daily but had now completely quit smoking. Never smoker - (i) an individual who had never smoked cigarettes or (ii) an individual who had previously smoked less than 100 cigarettes in his/her life and who is not current smoker. Ever smoker: An individual who had smoked at least 100 cigarettes in his/her life. Quit Rate: ex-smokers / ever smokers⁹.

Statistical methods: Categorical variables were compared with Chi square test and parametric variables were compared using the t test of significance between two means. Some variables that could affect cigarette smoking were analyzed using the "stepwise" logistic regression analysis model.

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Table 1: Demographic findings of participants

The distribution of smoking status of the participants according to their gender and age groups is shown in Table 2. In this study, 68.4% of the men were smoker, 62.2% were daily smoker, 16.1% were ex-smoker, and 15.5% were never-smoker. The mean age when men started to smoke was 16.3±4.1 (7-30); the median age was 16 years.

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Table 2: Smoking Status for Adults in Edirne Province Center

In the present study, 53.8% of the women were smoker, 38.9% were daily smoker, 11.7% were ex-smoker, and 34.5% were never-smoker. The mean age when women started to smoke was 18.8±4.8 (10-43); the median age was 18 years. There was a very narrow gap between the daily smokers and smokers in the men (6.2%), but the gap was wide in women (14.9%).

The quit rate in men was 16.1% and in women it was 11.7%. The quit rate increased after 45 years in men and after 30-35 years in women.

Factors affecting cigarette smoking attitude were examined with analysis of multiple variables (Table 3). The dependent variable was cigarette smoking; the independent variables were age, gender, educational level, ethnicity, alcohol use status, and status of whether or not they have income within last week. Age, (adjusted OR=1.03), being Turkish Gypsy (adjusted OR=6.14), unemployment (adjusted OR=2.13), drinking alcohol (adjusted OR=6.42) and being a high school graduate compared to being illiterate (adjusted OR=2.90) were the factors that significantly affected smoking status.

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Table 3: Logistic Regression Analysis of Some Factors That May Be Related to Smoking Prevalence.

In this study in Edirne City Center, the smoking prevalence in men was found to be 68% and in women 54%, and in the total 58%. These data, as was indicated in the BIGTAS study, suggest that cigarette consumption is higher in the region of Thrace than the country's average and are consistent with the Eastern Europe region epidemiologic data⁶. The highest rate of smoking in women in our country is also likely to be in Edirne. The rate of cigarette smoking in women according to the Turkish Demographic Health Survey in 1998 was 18%, but it was 28% in 2003⁷. According to these data the prevalence of cigarette smoking in women in Edirne Province center is nearly twice that of the national average. In developed countries, because a large percentage of men have quitted, the women and men's smoking prevalence are similar and about 20%. In Turkey, smoking is more prevalent in men than women, constantly. This was also stated by Çan et al.¹¹ and they related this situation to the cultural and societal pressure. This situation may be different in Edirne, and probably in Thrace region in general, because of a difference in general cultural make-up and we suggest that there is not gender distinction for this subject in Thrace region. The effect of the tobacco industry's marketing strategy may also have had an influence on this cultural change.

The Turkish Gypsies in Edirne have a higher prevalence of unemployment, smoking and alcohol use. This may be an important clue in the planning of smoking cessation services to the society. In studies conducted in western societies it has been determined that low socioeconomic groups have higher tobacco use constantly¹².

The high prevalence of cigarette smoking in Edirne is an indicator that there is also a very high level of environmental tobacco smoke. According to the 2001 Turkish Global Youth Tobacco Research (GYTS) 89% of the young people who participated in the study are exposed to passive cigarette smoke at home and 90% in places open to the public; 68.8% of their fathers and 39.7% of their mothers smoked cigarettes in their homes¹³.

Another significant result obtained in this study was the quit rates. The health benefits for those who quit smoking are significant. The earlier they can quit smoking the greater the benefits. The benefits provided by quitting in the adult population can also have some decreasing effect of starting smoking because of prevention of smoking adults serving as wrong role models for young people. The quit rate was 13% in general, 16.1% in men, 11.7% in women. Our National Tobacco Control Program had targeted the determination of quit rates in society by the year 2007 and to raise the quit rate to 40% by 2010; to raise the quit rate among health professionals to 50% by 2008, to raise the quit rates among teachers, religious leaders and administrators, and members of professions to 50% by 2010; and to raise the quit rates during pregnancy to 90% by 2008⁷. However we are not aware of any planned, official program aimed at implementation to achieve these targets. The quit rates in the entire population of our country is not known. According to local studies, quit rate is about 20%⁷. In the US, the quit rate was 29.6% in 1965, and as a result of a 20-year effort it was reported to have risen to 44.8%¹⁴. When these values are compared it is clear how far behind we are and how much effort is needed. The high rate of quitting in the older age groups, in particular, in this study suggests that those who have quit had health problems causing increased awareness and quitting efforts. At the societal level, educational, economic, clinical and legislative measures are urgently needed to increase the quit rates. Because of potent addictive nature of smoking, quitting effort must be supported by pharmacologically and/or behaviorally. There is a significant lack of health services available in our country to help people stop smoking⁷. In fact, smoking cessation services are suggested to be one of the most cost effective health interventions^15,16. Education of health professionals for smoking cessation can significantly increase public health services for cessation.

In conclusion, smoking is a growing problem in Edirne since smoking prevalence, particularly in women, is one of the highest of Turkey, and quit rates are far from behind the national goals. And lack of smoking cessation services is the major problem. Urgent efforts focused especially on socioeconomically deprived groups like unemployed people and gypsies are needed.

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