Can a mass media campaign raise awareness of alcohol as a risk factor for cancer and public support for alcohol related policies?

Alcohol consumption increases the risk of several cancers, but public awareness of alcohol as a risk factor for cancer is low. Research indicates that public opinion about alcohol related policies can be influenced by mass media campaigns and awareness of alcohol as a carcinogen. The objective of this study was to test whether a mass media campaign intended to raise awareness of the relation between alcohol and cancer is associated with higher public awareness of alcohol as a risk factor for cancer, and higher levels of support for alcohol related policies. Cross-sectional surveys of a nationally representative sample of N = 6000 Danish adults were conducted pre- (n = 3000) and post campaign (n = 3000) in 2017-2018. Awareness of alcohol as a cancer risk factor significantly increased between the pre and post campaign survey (approximately 5 percentage points). The proportion of respondents who supported minimum unit pricing, a ban on alcohol advertising, and mandatory nutrition labelling was significantly higher post campaign than pre campaign, while support for limited number of retail outlets and limited sale hours were unchanged. For males, but not females, higher support for an 18 year age limit for purchasing alcohol, age limits for buying alcohol at secondary education school parties, and increased enforcement of age limits was found after the campaign than prior to it. Conclusively, the results show that a mass media campaign was associated with an increase in awareness of alcohol as a risk factor for cancer as well as alcohol policy support at a population level.

Association between sunburn and demographic factors and health behaviour among Danish students.

Sunburn is associated with an increased risk for skin cancer. Denmark has one of the highest incidences of melanoma in the world, although it is a relatively northern country. The objective of this study was to determine whether sunburn is associated with demographic factors and health behaviour among young Danes. Cross-sectional data of >55,000 15- to 25-year-old students participating in the Danish National Youth Study were collected in 2014. Multilevel logistic regression analysis was used to determine associations. Overall, 45% of the students had experienced at least one sunburn in Denmark, and 60% had experienced one sunburn abroad in the past year. Females had higher odds for sunburns than males. Education and geographical region were associated with sunburn but with opposite trends related for sunburn experienced in Denmark and abroad. Students who had poor dietary habits (only abroad), indulged in binge-drinking, smoked (only in Denmark), and more physical activity (only abroad) had higher odds for having a sunburns. We conclude that sunburn is prevalent among young Danes, especially those travelling abroad. Although we found some associations with demographic factors and health behaviour, there were no evident tendencies, thus indicating that broad population-based campaigning should be the preferred intervention.

Skin cancer projections and cost savings 2014-2045 of improvements to the Danish sunbed legislation of 2014.

BACKGROUND: Sunbed use increases the risk of skin cancer. The Danish sunbed legislation (2014) did not include an age limit. AIM: To model skin cancer incidences and saved costs from potential effects of structural interventions on prevalence of sunbed use. MATERIALS AND METHODS: Survey data from 2015 were collected for 3999 Danes, representative for the Danish population in regards to age, gender and region. Skin cancer incidences were modelled in the Prevent program, using population projections, historic cancer incidence, sunbed use exposure and relative risk of sunbed use on melanoma. RESULTS: If structural interventions like an age limit of 18 years for sunbed use or complete ban had been included in the Danish sunbed legislation in 2014, it would have reduced the annual number of skin cancer cases with 455 or 4177, respectively, while for the entire period, 2014-2045 the total reductions would be 3730 or 81 887 fewer cases, respectively. The cost savings from an age limit or ban, respectively, are 9 and 129 millions € during 2014-2045. CONCLUSION: Legislative restrictive measures which could reduce the sunbed use exists. Danish politicians have the opportunity, supported by the population, to reduce the skin cancer incidence and thereby to reduce the future costs of skin cancer.

Sunbed use among 64,000 Danish students and the associations with demographic factors, health-related behaviours, and appearance-related factors.

Sunbed use is associated with an increased risk for skin cancer and is particularly dangerous for younger persons. The objective of this study was to assess how demographic factors, health-related behaviours and appearance-related factors are associated with sunbed use. Cross-sectional data from the Danish National Youth Study collected by the National Institute of Public Health during 2014 was used. A total of 64,382 students aged 15-25years were included in the present study. Multilevel logistic regression analyses were used to determine associations. Sunbed use during the past 12months was reported by 22% of students, with a higher proportion among females (29%) than males (12%). Factors associated with sunbed use were older age, studying at a vocational college or a higher preparatory examination school compared to upper secondary school, and lower parental education. Furthermore, being a smoker, been binge-drinking, longer duration of exercise and been dieting were also associated with sunbed use. For females, poor dietary habits were also associated with sunbed use. Feeling overweight was associated with lower odds for sunbed use for males, but with higher odds for females. Lower body satisfaction was associated with higher odds of sunbed use, except for overweight males. Students who were underweight had lower odds for sunbed use, than normal weight students. Conclusively, we found evidence of associations between demographic factors, health-related behaviours and appearance-related factors and sunbed use. Understanding these relations could help to identify high-risk groups and guide preventive strategies for sunbed use and skin cancer prevention.

The Systematic Development of an Internet-Based Smoking Cessation Intervention for Adults.

Objectives The objective of this project was to determine whether intervention mapping is a suitable strategy for developing an Internet- and text message-based smoking cessation intervention. Method We used the Intervention Mapping framework for planning health promotion programs. After a needs assessment, we identified important changeable determinants of cessation behavior, specified objectives for the intervention, selected theoretical methods for meeting our objectives, and operationalized change methods into practical intervention strategies. Results We found that "social cognitive theory," the "transtheoretical model/stages of change," "self-regulation theory," and "appreciative inquiry" were relevant theories for smoking cessation interventions. From these theories, we selected modeling/behavioral journalism, feedback, planning coping responses/if-then statements, gain frame/positive imaging, consciousness-raising, helping relationships, stimulus control, and goal-setting as suitable methods for an Internet- and text-based adult smoking cessation program. Furthermore, we identified computer tailoring as a useful strategy for adapting the intervention to individual users. Conclusion The Intervention Mapping method, with a clear link between behavioral goals, theoretical methods, and practical strategies and materials, proved useful for systematic development of a digital smoking cessation intervention for adults.

What characterises smokers who quit without using help? A study of users and non-users of cessation support among successful ex-smokers.

BACKGROUND: A variety of smoking cessation aids are available; however, the majority of smokers quit unaided. We know little of the differences between users and non-users of cessation support. METHODS: A cross-sectional study based on the Danish Health Examination Survey (DANHES) conducted in 2007-2008. In all, 6445 persons reporting quitting successfully within the last 5 years were included in analyses. Users and non-users of cessation aid (medical or behavioural support) were compared with regards to age, education, years smoked, tobacco amount, tobacco type and smoking-related disease using logistic regression analysis. RESULTS: Quitting unaided was reported by 63%. Adjusted analyses showed that men were more likely to quit unaided than women, and younger compared with older were more likely to quit unaided (eg, OR among women age 45-59 versus age 14-29 were 0.18, 95% CI 0.12 to 0.20). Additionally, those who had smoked for 15 years or more also had lower odds of quitting unaided. Smoking 15 or more grams of tobacco daily was inversely associated with quitting unaided (eg, OR among men were 0.38, 95% CI 0.31 to 0.46). CONCLUSIONS: Quitting smoking without the use of formalised aid was the most common cessation approach. Quitting unaided was more likely among men, younger age groups, those with a shorter history of smoking and those who were light smokers. These results indicate that awareness of unaided cessation in general and to those for whom it is especially relevant should be increased. This could lead to a more efficient use of resources for cessation support.

Design of a school-based randomized trial to reduce smoking among 13 to 15-year olds, the X:IT study.

BACKGROUND: Adolescent smoking is still highly prevalent in Denmark. One in four 13-year olds indicates that they have tried to smoke, and one in four 15-year olds answer that they smoke regularly. Smoking is more prevalent in socioeconomically disadvantaged populations in Denmark as well as in most Western countries. Previous school-based programs to prevent smoking have shown contrasting results internationally. In Denmark, previous programs have shown limited or no effect. This indicates a need for developing a well-designed, comprehensive, and multi-component intervention aimed at Danish schools with careful implementation and thorough evaluation.This paper describes X:IT, a study including 1) the development of a 3-year school-based multi-component intervention and 2) the randomized trial investigating the effect of the intervention. The study aims at reducing the prevalence of smoking among 13 to 15-year olds by 25%. METHODS/DESIGN: The X:IT study is based on the Theory of Triadic Influences. The theory organizes factors influencing adolescent smoking into three streams: cultural environment, social situation, and personal factors. We added a fourth stream, the community aspects. The X:IT program comprises three main components: 1) smoke-free school premises, 2) parental involvement including smoke-free dialogues and smoke-free contracts between students and parents, and 3) a curricular component. The study encompasses process- and effect-evaluations as well as health economic analyses. Ninety-four schools in 17 municipalities were randomly allocated to the intervention (51 schools) or control (43 schools) group. At baseline in September 2010, 4,468 year 7 students were eligible of which 4,167 answered the baseline questionnaire (response rate = 93.3%). DISCUSSION: The X:IT study is a large, randomized controlled trial evaluating the effect of an intervention, based on components proven to be efficient in other Nordic settings. The X:IT study directs students, their parents, and smoking prevention policies at the schools. These elements have proven to be effective tools in preventing smoking among adolescents. Program implementation is thoroughly evaluated to be able to add to the current knowledge of the importance of implementation. X:IT creates the basis for thorough effect and process evaluation, focusing on various social groups. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77415416.

"After all--it doesn't kill you to quit smoking": an explorative analysis of the blog in a smoking cessation intervention.

BACKGROUND: A growing body of literature demonstrates internet-based smoking cessation interventions as a promising aid in helping people quit smoking. However, the underlying mechanisms of how these interventions influence the cessation process are still relatively unknown. Several studies have indicated blogging as a potential source in providing social support to users of internet-based smoking cessation interventions and thereby enhance their change of succeeding in quitting. OBJECTIVE: The study aimed to investigate themes discussed on a blog in an internet-based smoking cessation intervention. In addition, we examined if blogging could provide social support for people in a smoking cessation process. METHOD: The study was based on messages posted from 1 January 2012 to 29 February 2012 on the blog of the internet-based smoking cessation programme DDSP, operated by the Danish Cancer Society. Messages were coded according to themes using Grounded Theory, and additionally data about bloggers were analyzed. RESULT: In total, 1663 messages were posted within the 2-month period, and we identified 16 themes. The majority of messages contained personal stories or experiences (53%), provided emotional support (34%) or congratulated other users (17%). The messages were found capable of supplying social support to members on the blog. In addition, we found that only a minority of users who viewed the blog participated actively in posting messages, and only a minority was highly active bloggers. CONCLUSIONS: The blog offers a unique platform for informal conversations about quitting smoking and is important in providing social support to people in a smoking cessation process.

Alcohol consumption and well-being among 25,000 Danish high school students.

Excessive alcohol consumption among young people is an international public health concern, as alcohol is associated with a range of adverse short- and long-term consequences. Furthermore, alcohol consumption has been associated with well-being in young people, but the association depends on the chosen measure of well-being. The objective of this study was to assess how weekly alcohol consumption was associated with poor well-being (poor school enjoyment, social inclusion in school, mental well-being, life satisfaction, self-esteem, and self-efficacy, and experiencing loneliness). Cross-sectional data from the Danish National Youth Study 2019 was used (a total of 25,910 students aged 15-25 years). For most outcomes, there was a U-shaped association between weekly alcohol consumption and poor well-being e.g. students who never drank, students who only drank occasionally, and students who drank a lot (22 units of alcohol or more a week) had higher odds of poor well-being, compared to the reference group (1-7 units a week). This was the case for measures such as low school enjoyment (only females), poor mental well-being, low life satisfaction, low self-esteem (only females) and low self-efficacy (only males). Among females, odds of low self-efficacy was higher with higher weekly alcohol consumption. Higher weekly alcohol consumption was associated with lower odds of low social inclusion in school, experiencing loneliness often, and (among males) low self-esteem. Conclusively, well-being in general was lowest among never-, occasional- and heavy drinking students. Understanding these associations can help to decrease alcohol consumption and promote well-being among young students.

A cluster randomised controlled trial of an adolescent smoking cessation intervention: short and long-term effects.

BACKGROUND: There is a lack of effective smoking cessation interventions which have a high reach among adolescent smokers. METHOD: We conducted a randomised controlled trial of an adolescent smoking cessation intervention for students aged 15-21 at 22 continuation schools in Denmark. The intervention was a minimal intervention based on events with short counselling and a range of self-help materials. Our 1-month follow up consisted of 514 baseline daily smokers and the 14-month follow up of 369 daily smokers. RESULTS: We found positive short-term effects regarding smoking cessation (adjusted OR 4.50, 95% CI 1.20-16.86), self-efficacy (p=0.01), and intentions to quit (p=0.004). However, none of these effects were maintained at 1-year follow up. The intervention was successful in reaching more than half of all daily smokers in the target group with more than 30% receiving counselling at least once in the intervention period. CONCLUSIONS: This trial shows that a "minimal" intervention can produce short-term effects but that this approach is insufficient in producing long-term effects.

"No alcohol, no party": an explorative study of young Danish moderate drinkers.

BACKGROUND: Danish youth has for years had the highest alcohol consumption in Europe, however recent surveys show that consumption levels have diminished slightly and that the age of first intoxication has been raised. AIM: To explore young moderate drinkers' attitudes, values, and behaviour in relation to alcohol consumption. DESIGN, SETTING, AND PARTICIPANTS: Data consists of 10 individual semi-structured interviews with 16-17-year-old moderate drinkers attending high school in Copenhagen, Denmark. RESULTS: The study shows that the respondents perceive drinking as a necessity for feeling included at parties, but also that they do not feel a need to drink large amounts of alcohol in order to feel this social inclusion. The study finds that respondents employ a number of different behavioural and cognitive strategies aimed at controlling their own and close friends' drinking behaviour, and that short-term negative social implications are of much greater concern than long-term health consequences. In addition, the study shows that parents have a limited direct influence in this group. CONCLUSIONS: The study identifies a group of young people who have clearly defined restrictions as to what they consider positive drinking behaviour. As parents and long-term health consequences only have an limited influence on the respondents' drinking behaviour, these elements should not have primary focus in future interventions. In stead, interventions should take into account the social dynamics involved in drinking and recognise that the social qualities surrounding alcohol weighs higher among this group of young people than the quantity of alcohol consumed.

The development of an adolescent smoking cessation intervention--an Intervention Mapping approach to planning.

The objective of this project was to develop a theory- and evidence-based adolescent smoking cessation intervention using both new and existing materials. We used the Intervention Mapping framework for planning health promotion programmes. Based on a needs assessment, we identified important and changeable determinants of cessation behaviour, specified change objectives for the intervention programme, selected theoretical change methods for accomplishing intervention objectives and finally operationalized change methods into practical intervention strategies. We found that guided practice, modelling, self-monitoring, coping planning, consciousness raising, dramatic relief and decisional balance were suitable methods for adolescent smoking cessation. We selected behavioural journalism, guided practice and Motivational Interviewing as strategies in our intervention. Intervention Mapping helped us to develop as systematic adolescent smoking cessation intervention with a clear link between behavioural goals, theoretical methods, practical strategies and materials and with a strong focus on implementation and recruitment. This paper does not present evaluation data.

Novel sunprotection interventions to prevent skin cancer: A randomized study targeting Danes going on vacation to destinations with high UV index.

BACKGROUND: In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015, of which 90% could have been avoided by behavioral changes. We aimed to test novel interventions in a randomized design. The interventions targeted Danes going on vacation to high UVI destinations aiming to decrease sunburn by increasing use of sun protection to prevent skin cancer in the Danish population. METHODS: We report a randomized behavioral intervention during May-Dec 2018 with 1548 Danish adults on vacation in 2018 for a period of 1-3 weeks. The study population was population-based and aged 18-65 years. We tested two protection routines against minimal intervention control group (2-by2-factorial design): 1) Avoidance of the sun during peak hours and shade, use of the UV-index and planning of indoor/outdoor activity respectively and, 2) Coverage by increasing use of the hat advice and increasing sunscreen amount by application routine. Outcome was use of protection and sunburn. RESULTS: There were no differences in sunburn prevalence between intervention and control groups. Protection routine 1 and 2 both increased the overall protection score compared to non-users. Protection routine 1 increased the reported use of shade and decreased time exposed in the sun. Protection routine 2 increased the use of hat and sunscreen amount. CONCLUSION: Simple measures can help avoid the majority of one of the most widespread cancers worldwide. Vacations to high UVI destinations is a major influence on the annual Danish UV-exposure. We influenced travelers to protect themselves better and to increase sun protection behavior.

Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population.

BACKGROUND: Ninety percent of skin cancers are avoidable. In Denmark, 16,500 cases of melanoma and keratinocyte cancers were registered in 2015. The Danish Sun Safety Campaign has campaigned since 2007, targeting overexposure to ultraviolet radiation. During 2007-2015, the key indicators of skin cancer, i.e. sunbed use and sunburn, showed annual reductions of 6% and 1%, respectively. OBJECTIVES: We aimed to examine the financial savings to society as a result of the campaign reductions in skin cancer cases (2007-2040), and to examine the campaign's cost-benefit and return on investment (ROI). METHODS: The analysis is based on existing data: (1) annual population-based surveys regarding the Danish population's behavior in the sun; (2) skin cancer projections; (3) relative risks of skin cancers from sunburn and sunbed use and (4) historical cancer incidences, combined with new data; (5) benefits from the avoided costs of skin cancer reductions; and (6) the costs of the Danish Sun Safety Campaign. RESULTS: The results were based on a reduction of 9000 skin cancer cases, saving €29 million of which €13 million were derived from sunburn reductions and €16 million from reductions in sunbed use. The ROI was €2.18. CONCLUSION: Skin cancer prevention in Denmark is cost effective. Every Euro spent by the Danish Sun Safety Campaign saved the Danish health budget €2.18 in health expenses.

Correction to: Benefit-Cost Analysis of the Danish Sun Safety Campaign 2007-2015: Cost Savings from Sunburn and Sunbed Use Reduction and Derived Skin Cancer Reductions 2007-2040 in the Danish Population.

Abstract, Results, first sentence, which previously read: "The results were based on a reduction of 9000 skin cancer cases, saving €47 million of which €29 million were derived from sunburn reductions and €16 million from reductions in sunbed use."

'High schools High on life': Development of an Intervention to Reduce Excessive Drinking in Danish High Schools.

Background: Clear documentation of the understanding of the problem, process of development, and content of interventions is essential to enable other researchers to understand why interventions succeed or fail and to enable researcher to build on previous evidence and replicate and adapt findings in other contexts. In this paper we describe the rationale, intervention development, and final design of the 'High schools High on life' intervention; a high school-based, multi-component intervention to reduce excessive drinking among Danish high school students. Methods: The development of the intervention 'High schools High on life' was guided by the planning steps of the Intervention Mapping protocol (IM) in combination with the behavior change wheel and the behavior change techniques, theory, evidence, practice, and new empirical studies of contextual factors in the Danish high school setting. Results: The development process resulted in a multi-component intervention with the following intervention elements: a school environmental component targeting school alcohol policies and norms, a school educational component addressing students' social norms around alcohol, and a parental component encouraging parent-child communication around alcohol. Discussion: Not all steps of IM were followed rigidly. However, IM proved useful as a planning tool in combination with the behavior change wheel and the behavior change techniques, as it provided a systematic approach to the intervention development process. IM forced the research group to be explicit about decisions and choices throughout the planning process. The transparency of the developmental process and theoretical, empirical and practical/contextual foundation of the 'High schools High on life' intervention may enable future intervention studies to build on our findings and accumulate knowledge to reduce excessive drinking among young people. Trial registration: The trial was registered at clinicaltrials.gov (Trial registration number NCT03906500) prior to randomization.

"I did it my way"--an explorative study of the smoking cessation process among Danish youth.

OBJECTIVE: To explore the smoking cessation process of adolescents and their attitudes and beliefs towards smoking cessation and cessation interventions. METHOD: Focus group discussions and individual interviews during April-May 2004 with 26 persons aged 15-21 years who all initiated a quit attempt on 1 January 2004. RESULTS: The approach towards all stages of the youth smoking cessation process varied greatly among both successful and unsuccessful quitters. Apart from 'commitment' or the amount of energy put into a cessation attempt, there were no differences in the way successful and unsuccessful quitters approached the quit attempt. 'Smoking friends' and 'social support' were important for maintaining cessation. Further, participants had negative attitudes towards formalized smoking cessation interventions. CONCLUSION: There are many approaches to the smoking cessation process. Whether an attempt is successful depends more on individual conditions and the amount of commitment invested in the attempt than on the specific cessation strategy used. PRACTICE IMPLICATIONS: Future adolescent smoking cessation interventions should be flexible regarding both structure and content and should focus on the individual learning process, rather than adhering to rigid cessation strategies.

Development in sunburn 2007-2015 and skin cancer projections 2007-2040 of campaign results in the Danish population.

Exposure to ultraviolet radiation is the main risk factor for skin cancer. Denmark has one of the highest incidences of skin cancer in the world. In 2007, a long-term sun safety campaign was launched in Denmark. We have evaluated the effects on prevalence of sunburn and modeled the effects on future melanoma incidence.Sunburn was evaluated by annual cross-sectional surveys representative for the Danish population on age, gender, and region. During 2007-2015, survey data were collected for 33.315 Danes. Cutaneous Melanoma incidences were modeled in the Prevent program, using population projections, historic incidence, sunburn exposure, and relative risk of sunburn on melanoma.The prevalence of sunburn in Denmark was reduced with 1% annually during 2007 to 2015. The campaign is estimated to have reduced the number of skin cancer cases with 664 annually in 2040 and 14.326 totally during 2007 to 2040. If the campaign was terminated in 2015 and sunburn rates return to precampaign level there would be no annual reduction in 2040 while in total the reduction would be 4.024 cases for 2007 to 2040. A continuous campaign until 2040 would yield annual reductions of 2.121 cases by 2040 and a total of 29.729 cases for the entire period.We have showed the value of prevention and the value of long-term planning in prevention campaigning. Sunburn use was reduced significantly during 2007-2015 and further reductions are possible. Consequently, we predict significant fewer skin cancer cases as anticipated.

Sunbed use 2007-2015 and skin cancer projections of campaign results 2007-2040 in the Danish population: repeated cross-sectional surveys.

OBJECTIVE: To evaluate the effect of the Danish Sun Safety Campaign 2007-2015 on the prevalence of sunbed use and to model future effects on the skin cancer incidences 2007-2040. DESIGN: The study has a repeated, cross-sectional design. SETTING: Exposure to ultraviolet radiation is the main risk factor for skin cancer. Denmark has the highest prevalence of sunbed use reported and one of the highest incidences of skin cancer worldwide. PARTICIPANTS: During 2007-2015, survey data were collected for 37 766 Danes, representative of the Danish population with regards to age, gender and region. INTERVENTIONS: In 2007, an ongoing long-term antisunbed campaign was launched in Denmark. PRIMARY AND SECONDARY OUTCOME MEASURES: Sunbed use was evaluated by annual cross-sectional surveys. Skin cancer incidence was modelled in the Prevent programme, using population projections, historic cancer incidence, sunbed use exposure and relative risk of sunbed use on melanoma. RESULTS: The prevalence of recent sunbed use in Denmark was reduced from 32% and 18% to 13% and 8% for women and men, respectively. The campaigns results during 2007-2015 are estimated to reduce the number of skin cancer cases from more than 5000 (746malignant melanoma, 1562 SCC, 2673 BCC) totally during 2007-2040. Keeping the 2015 level of sunbed use constant by continued campaign pressure or introduction of structural interventions would potentially prevent more than 750 skin cancer cases annually in 2040 and 16 000 skin cancer cases in total during 2007-2040. CONCLUSION: We have shown the value of prevention and of long-term planning in prevention campaigning. Sunbed use was reduced significantly during 2007-2015 and further reductions are possible by structural interventions. Consequently, significantly fewer skin cancer cases are anticipated during 2007-2040. The Danish Parliament has population support to enforce structural interventions to avoid a large burden of this disease.

Stress-related expectations about smoking cessation and future quit attempts and abstinence - a prospective study in daily smokers who wish to quit.

Smokers who wish to quit may refrain from doing so if they expect to experience more stress after haven given up. We test if stress-related expectations about smoking cessation are associated with quit attempts and abstinence among smokers who are motivated to quit. The study included 1809 daily smokers in Denmark in 2011-2013. Stress-related expectations (do you think you will be more, less or equally stressed as a non-smoker?) were measured at baseline. Quit attempts, 30-day point prevalence abstinence and prolonged abstinence (defined as having been abstinent since baseline), were measured after 3, 8 and 14 months. We found that the association between expecting to be more stressed if giving up smoking differed between participants who had previously attempted to quit and those who had not: In participants who previously attempted to quit (47%), expecting to be more stressed was associated with significantly lower odds of abstinence compared to smokers who expected the same or a lower level of stress (odds ratios were 0.49 (95% CI: 0.31-0.79) for 30-day abstinence and was 0.28 (95% CI: 0.08-0.99) for prolonged abstinence). In participants who had not previously attempted to quit, expectations about stress were not associated with abstinence. Results indicate that expectations about stress in relation to smoking cessation are an important determinant of cessation in smokers who previously attempted to quit. Addressing stress and how to handle stressful situations may increase the likelihood of a successful quit attempt.