Oh et al. BMC Public Health 2010, 10:74 http://www.biomedcentral.com/1471-2458/10/74 Background The prevalence of smoking among women varies greatly across European countries, ranging from less than 10% to over 30% [1]. Overall, however, Europe has some of the highest levels of female smoking in the world [2]. Furthermore, while smoking among men has declined in some European countries, it is still increasing or stabi- lised among women in most European countries [3-5]. Reasons for smoking initiation differ across cultures but certain factors have an established association with smoking. Parental, sibling, and friend smoking all have been shown to be strongly associated with an indivi- dual’s smoking status [6-13]. Low academic achievement as well as low socioeconomic status are also associated with smoking status [8,12,14-16]. Women, just like men, begin to smoke in increasing proportions in the popula- tion because of marketing [17] and the tobacco industry significantly targets women with focused advertisements and promotions [18]. Women appear to have different reasons for smoking than men; for example, tension reduction and stimulation are thought to be more strongly associated with women smoking than with men [19,20]. There is also evidence that weight concerns play a role in the decision to smoke among women [21-24]. Over 60% of lung cancer cases in European women are attributed to their smoking history [25,26]. Thus with smoking rates in women rising, it is not surprising that lung cancer rates in women have also increased in most European countries [27,28]. In order to prevent further increases in smoking-related mortality, it is important that anti-tobacco measures target women in Europe. Many European countries have recently made substan- tial changes in policy toward smoking and tobacco. The European Community as an entity, in addition to all major European Region countries, except the Czech Republic, has ratified the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The FCTC became international law in 2004 and is a comprehensive tobacco control treaty which includes an article for 100% smoke-free policies. In the same year, Ireland implemented a nation-wide ban on smoking in bars and restaurants. Since then, other European coun- tries, including France, Italy and Sweden, have followed with similar national smoke-free legislation. Other mea- sures against tobacco include increasing taxes on tobacco, improving consumer information, health warn- ing labels on tobacco products, banning tobacco adver- tising promotion and sponsorship, and facilitating access to smoking cessation treatment [29]. The objective of this study is to determine if ever smoking and smoking initiation are associated with cer- tain characteristics or beliefs about smoking in women in five European countries. In particular, this study aims Page 2 of 11 to elucidate if these characteristics or beliefs about smoking are different for women in countries at differ- ent stages in the tobacco epidemic, with northern Eur- opean countries generally being at a more advanced stage of the epidemic than southern European countries. As current policies are being rapidly reformed in Eur- ope, and as rates of smoking are rising among European women, understanding reasons why European women smoke is crucial in guiding future tobacco control measures. Methods Participants As part of the Women in Europe Against Lung Cancer and Smoking (WELAS) Project, supported by the Eur- opean Commission, a cross-sectional land-line telephone survey on health attitudes and knowledge was con- ducted from June to July 2008 in five European coun- tries: France, Ireland, Italy, Czech Republic, and Sweden [30]. These countries were chosen because they are at different stages of the tobacco epidemic and at different stages of enacting tobacco control measures. This study was approved by the International Agency for Research on Cancer ethical review committee. In total, 5 000 women participated in this survey, with 1 000 women from each participating country. Of the women reached who were eligible for participation, response rates were 64.8% in France, 41.4% in Italy, 59.0% in Sweden, 54.6% in Ireland, and 30.6% in the Czech Republic. Sampling The goal was to have a sample of women from each country that was nationally representative with regard to age and smoking status. Our sampling frame included all adult women 18 years of age and older who had a listed telephone number in the five participating coun- tries. When a household was reached, the woman inter- viewed was selected at random from all adult women living in that household. To ensure adequate power to examine subsamples of smokers and nonsmokers for each question, smokers were oversampled to reach 28% of subjects; weighting was done in the analyses to make results representative of each country’s female population. Measures The survey was identical across countries, with attention given to translation issues. Surveys were translated by native speakers from each participating country and translations were checked by another native speaker in each country. All participants were asked questions about demographics, beliefs about smoking, and tobacco