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Different cigarette-smoker classification factors and subjective state in acute abstinence. Psvchopharmacology 64(2):23 1-235, August 8, 1979, WILLIAMS, S.G.. HUDSON, A., REDD, C. Cigarette smoking, manifest anxiety and somatic symptoms. Addictive Behaviors 7(4):427-428, 1982. WORLD HEALTH ORGANIZATION. The craving for alcohol. Report of the WHO Expert Committee on Mental Health and on Alcohol. Quarterly Journal of Studies on Alcohol 16:33--66, 1955. 578 VOLUME APPENDIX NATIONAL TRENDS IN SMOKING CESSATION 579 CONTENTS Introduction 0.0... eens beeen ees SRB Sources of Data... 000.00 ccc cece vee ee cece tree e etre ees. 583 ’ National Center for Health Statistics Surveys... 002.000.0022 eee ee 583 Office on Smoking und Health Surveys... 00.0000 ee S84 Measures of Quitting Behavior .........0000 000000000000 c cece L584 Percentage of Former Smokers in the Entire Population. ...............0.. S85 Percentage of Ever Smokers Who Are Former Smokers ("Quit Ratio”) 2.2... S85 The Smoking Continuum 2.0.00... 00.0. tees S85 Other Measures 2... eee S88 Trends in the Proportion of Ever Smokers Who Are Former Smokers (“Quit Ratio’) 0. tet eeteeeee s TRH Trends by Gender... 00... cee ee eee S88 Trends by Race... 0. eet eee es SY3 Trends by Age 2.0... eet n teens S93 Trends by Level of Educational Attainment .....0.00.000 00000000 595 Long-Term Abstinence and Relapse a. 2) National Health and Nutrition Examination Survey Epidemiologic Followup Study 0.0.0.0... 0. cc cnet nents 596 The Smoking Continuum ........... Neb etee cette tect e eee eeee e599 Percentage of Ever Smokers Who Have Never Tried to Quit... 0. .....0.0000. 599 Percentage of Those Smoking at 12 Months Prior to a Survey Interview Who Quit for at Least | Day During Those 12 Months .........0...0..5.. 606 Percentage of Ever Smokers Who Had Been Abstinent for Less Than | Year . 606 Percentage of Ever Smokers Who Had Been Abstinent for | to4 Years ...... 606 Percentage of Ever Smokers Who Had Been Abstinent for at Least 5 Years ... 607 Interpretation of Continuum Findings ........0.00.. 00000 cece eee 007 Other Measures Related to Smoking Cessation .0.....000...000000 000s ees 608 Intention to Smoke in 5 Years... 0... ee eens 608 Receipt of Advice to Quit From a Doctor 2.0.0.0 00 eee 609 Conclusions ............, bv b eee ete e tees eeteeteetreseetveeeeee, 610 References ..........00.0005. beens eee t eet e teed bebe beet beeen es 22. 613 INTRODUCTION This volume appendix discusses national trends in smoking cessation over the last 25 years, specifically updating and expanding descriptions of the national trends in quitting activity presented in previous Surgeon General's reports (US DHHS 1980, 1983, 1988, 1989a). This Section does not provide a detailed discussion of psychoso- cial, pharmacologic, and behavioral factors known to be related to cessation, because this information is available from other sources (US DHEW 1979; US DHHS 1980, 1988, 1989a). Data are utilized from 5 national cross-sectional surveys on adult tobacco use that were performed by the Office on Smoking and Health (OSH) (formerly the National Clearinghouse for Smoking and Health) and the 12 National Health Interview Survey (NHIS) supplements and the National Health and Nutrition Examination Survey (NHANES) Epidemiologic Followup Study (NHEFS), both performed by the National Center for Health Statistics (NCHS). The surveys were conducted between 1965 and 1987. The national surveys and the measures of quitting activity are described below, followed by a discussion of the data. Information on smoking cessation during pregnancy is also included in Chapter 8. Information on smoking behavior was obtained from these surveys by means of self-report (i.e., without biochemical validation). As discussed in Chapter 2, self-report is considered a valid measure of smoking status in cross-sectional surveys, although some underreporting of daily cigarette consumption likely occurs. SOURCES OF DATA National Center for Health Statistics Surveys Survey data collected by NCHS and available for inclusion in this Report were derived from the 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979, 1980, 1983, 1985, and 1987 supplements to NHIS and the 1982 to 1984 NHEFPS. Cigarette smoking status (current, former, and never) is assessed in the same manner in all surveys. The constructs assessed on the NHIS supplements vary from survey year to survey year. Variables assessed include attempts to quit smoking among current smokers, duration of abstinence among former smokers, and receipt of advice to quit from a doctor. NHIS, across-sectional household interview survey, samples the civilian, noninstitu- tionalized population of the United States (NCHS 1958, 1985, 1989). Weighting Procedures are used to provide national estimates. Sample sizes for the smoking supplements (ages 20+) vary from approximately 9,700 in 1980 to over 80,000 in 1966. NHEFS was a followup study of persons enrolled in NHANES-I, which assessed lifetime patterns of Cigarette smoking behavior among current and former smokers. Whereas NHANES-I participants were drawn from a national probability sample of the civilian, noninstitutionalized population, NHEFS participants included only those who underwent the medical examination in NHANES-I. Personal interviews with each Participant or a proxy (for deceased NHANES-I participants) were completed for 12,200 of the 14,407 original examinees. Proxy interviews were conducted with 1,697 583 representatives of deceased NHANES-I examinees. The interval between NHANES-I and NHEFS was about 10 years (Madans et al. 1986: NCHS 1987). Office on Smoking and Health Surveys OSH has commissioned five national surveys of tobacco use among adults in this country, referred to as the Adult Use of Tobacco Surveys (AUTSs). The surveys ask detailed questions designed to assess the knowledge, attitudes, and practices of adults regarding all forms of tobacco use. These cross-sectional surveys were conducted in 1964, 1966, 1970, 1975, and 1986 (US DHEW 1969, 1973, 1976; US DHHS 1989b). The similar or identical wording of several standard questions for all five surveys facilitates comparisons. Constructs assessed included tobacco use behavior, intentions regarding future smoking behavior among ever smokers, and receipt of a doctor's advice to quit smoking. Some differences in the conduct and design of the studies occurred. The mode of interviewing changed with time. The 1964 survey obtained data solely from personal household interviews. Whereas personal household interviews were the major mode of data collection in the 1966 survey, telephone interviews and mailed questionnaires were also used to collect data from eligible household members not available when the interviewer was present in the house. The 1970 and 1975 surveys conducted telephone interviews when possible and personal household interviews in nontelephone households. The 1986 survey was conducted entirely by telephone. The 1964 and 1966 surveys drew samples only from the contiguous United States. Other AUTSs collected data from residents of all 50 States. The actual number of respondents for each survey was 4,635 in 1964, 4,061 in 1966, 5.191 in 1970, 12,029 in 1975, and 13.031 in 1986 (US DHEW 1969, 1973, 1976: US DHHS 1989b). In each survey, weighting procedures were used to adjust for an oversampling of ever smokers in the original study population. Comparisons between the 1986 AUTS and the others will not be exact, because the 1986 AUTS weights to an estimate of the adult U.S. population. whereas the other surveys weight to their respective sample sizes. MEASURES OF QUITTING BEHAVIOR As documented in several previous Surgeon General's reports (US DHEW 1979; US DHHS 1988. 1989a) and discussed in Chapter 2 of this Report. smoking cessation is a multifactorial process for overcoming an addictive behavior. One model characterizes this process as having several stages—precontemplation, contemplation, action, and maintenance (Prochaska and DiClemente 1983: Chapter 2). People frequently cycle and recycle through the various stages (marked by frequent relapse episodes) on their way to becoming long-term ex-smokers (Prochaska and DiClemente 1983; Cohen et al. 1989), This analysis of national trends in smoking cessation will use several measures to describe the quitting process. The 1989 Surgeon General's Report (US DHHS 1989a) discusses three measures of quitting behavior. These interrelated parameters are discussed below. 584 Percentage of Former Smokers in the Entire Population This measure of quitting behavior has been used to calculate the number of former smokers in the population. Based on data from the 1987 NHIS. for example, 23.6 percent of the 162.6 million civilian, noninstitutionalized adults 20 years of age and older were former cigarette smokers. There were, therefore, approximately 38.5 million former smokers 20 years old or older in the United States in 1987. The percentage of former smokers in the entire population is limited as a measure of quitting activity primarily because it does not take into account the percentage of the population that has ever smoked (and thus is “at risk” of quitting). It also does not differentiate between people who have been abstinent for a short period and people who have maintained abstinence for several years (US DHHS 1989a). Percentage of Ever Smokers Who Are Former Smokers (“Quit Ratio”) By dividing the number of ever smokers into the number of former smokers, perspective is given to the magnitude of quitting in a population. The term “quit ratio” has been used to describe this measure (CDC 1986: Pierce, Aldrich et al. 1987: US DHHS 1988, 1989a; Fiore et al. 1989) and is the term used below; this measure has also been termed the “quit rate” (Kabat and Wynder 1987) or the “cessation rate” (Jarvis 1984). The term “ratio” is mostly used in sciences when the numerator and the denominator are two separate and distinct quantities (Elandt-Johnson 1975). “Quit ratio” is used here, even though the numerator is included in the denominator, because of its repeated use in the literature as well as in previous Surgeon General's reports. The percentage of ever smokers who have discontinued smoking indicates the prevalence of abstinence (Ossip-Klein et al. 1986). In 1987, 23.6 percent of the population were former cigarette smokers and 29.1 percent of the population were current smokers. The quit ratio among ever smokers was 44.8 percent; that is, nearly one-half of all living adults who ever smoked cigarettes had quit. Quit ratios by gender and age were recently published for 36 States and the District of Columbia based on 1988 data from the Behavioral Risk Factor Surveillance System (Anda et al. 1990) (Table 1). The measure is limited because it treats all former smokers equally, regardless of duration of abstinence. It also classifies current smokers who had never tried to stop smoking in the same manner as it does current smokers who had been abstinent for a long period of time and relapsed shortly before the time of the survey (US DHHS 1989a),. The Smoking Continuum The 1989 Surgeon General's Report defined a 10-category smoking continuum based on data from the 1986 AUTS. This continuum expanded on the smoking status variable (current, former, and never) to incorporate the timing and duration of quit attempts (US DHHS 1989a). Respondents were asked whether they had ever made a serious attempt to quit, and if the response was affirmative, they were then asked about the timing of 585 98¢ TABLE 1.—Quit ratio’ in selected States, by age group and gender—BRFSS, 1988 18-34 35-49 50-64 265 Men Women Total State % (495% cl) ‘ (495% Cl) % (495% Cl) % (495% Cl) G% (495% CD % (495% Cl) % (495% Cl) Alabama 24.5 (7.0) 4.3 (7.3) 54.3 (8.3) 65.8 (10.4) 47.4 (5.6) 37.3 (5.9) 43.2 (4.1) Arizona 45.5 (7.9) 54.2 (8.0) 61.2 (9.9) 67.9 (8.8) 60.1 (6.2) 49.8 (6.0) 55.4 (4.3) California 40.1 (5.7) 54.3 (5.6) 64.3 (6.9) 65.6 (7.8) 56.9 (4.4) 493 (4.5) 53.7 (3.2) Connecticut 38.6 (7.4) 49.0 (7.3) 60.7 (9,3) 749 (8.0) 55.1 (6.4) 50.4 (5.8) 52.8 (4.3) District of Columbia 37.2 (8.8) 45.4 (9.9) 56.5 (11.6) 59.4 (12.5) 52.0 (8.0) 43.4 (7.3) 47.6 (5.5) Florida 437 (7.4) 45.3 (7.2) $2.3 (7.7) 776 (5.7) 58.5 (4.8) 50.4 (5.2) 54.8 (3.5) Georgia 39.5 (5.6) 40.3 (8.7) S3.1 (12.7) 70.2 (17.2) 44.2 (7.2) 46.6 (6.8) 44.3 (5.2) Hawaii 33.7 (7.1) 45.0 (7.6) 61.5 (9.1) 70.9 (9.9) 49.6 (5.8) 44.3 (6.3) 47.3 (4.3) Idaho 42.6 (7.1) 49.2 (6.9) 58.3 (8.3) 777A (6.2) 61.3 (5.5) 44.2 (5.5) 54.0 (3.9) Iinois 35.1 (6.7) 42.6 (6.6) 53.6 (8.0) 64.1 (8.3) 48.9 (5.3) 42.4 (5.2) 45.8 (3.6) Indiana 33.1 (5.5) 42.2 (5.8) S5h.9 (6.7) 79.1 (5.9) 51.6 (4.4) 41.2 (4.6) 47.0 (3.2) lowa 30.0 (9.2) 59.5 (10.5) 55.4 (12.3) 71.1 (10.9) 60.3 (8.1) 39.1 (7.2) 50.7 (5.8) Kentucky 22.6 (5.6) 33.6 (6.9) 4&2 (7.0) 63.6 (7.0) 42.6 (4.9) 3h. (4.5) 378 G4) Maine 38.3 (7.2) 50.4 (7.4) 65.3 (8.4) 72.7 (8.7) 60.5 (5.9) 44.5 (5.5) 53.2 (4.1) Maryland 41.1 (9.0) 45.6 (8.3) S79 (9.9) 70.9 (9.3) 53.0 (7.3) 48.0 (6,5) 50.6 (5.0) Massachusetts 35,2 (6.6) 50.8 (7.0) 59.8 (9.5) 75.5 (7.1) 56.2 (6.3) 47.6 (5.2) 51.9 (4.2) Michigan 37.4 (7.0) 50.5 (7.3) S5S.0 (40.3) 65.9 (13.4) 52.0 (6.4) 45.5 (5.8) 48.9 (4.5) Minnesota 41.2 (4.4) $5.2 (4.3) 64.6 (5.4) 76.0 (5.0) 60.4 (3.4) 49.2 (3.8) 55.4 (2.5) Missouri 35.8 (7.1) 42.9 (7.5) 57.5 (8.4) 79.2 (7.0) 54.7 (6.1) 43.5 (5.4) 49.6 (4.1) Montana 45.7 (9.6) 58.8 (7.7) 58.8 (8.2) 79.0 (7.1) 62.0 (6.4) $4.1 (6.2) 58.6 (4.5) L8¢ TABLE 1.—Continued 18-34 35-49 50-64 265 Men Women Total State % (495% Cl) % (495% Cl) % (498% Cl) % (495% Cl) %__ (495% CI) %__ (495% CI) % (495% Cl) Nebraska 39.6 (7.4) 57.6 (8.3) 57.6 = (9.0) 74.5 (7.8) $9.0 (5.9) 47.2 (6.1) 54.0 (4.3) New Hampshire 35.2 (7.0) 53.0 (7.4) 60.3 (9.9) 74.2 (9.2) 53.8 (6.1) 48.6 = (6.0) S15 (4.6) New Mexico 38.4 (8.7) 47.0 (9.2) 53.4 (9.8) 64.7 (11.7) 494° (7,3) 46.3 (7.0) 48.0 (5.2) New York 29.8 (7.4) 42.7 (8.1) 66.3 (8.9) 80.3 (8.2) 54.2 (6.8) 46.8 (6.5) 50.5 (4.7) North Carolina 37.0 (6.8) 47.5 (6.7) 47.9 (8.5) 72.3 (7.9) 50.4 (5.7) 43.4 (5.2) 47.3 (3.9) North Dakota 38.7 (7.1) 50.9 (6.8) 62.2. (7.9) 73.3 (7.4) $8.3 (5.1) 45.5 (5.6) 53.1 (3.8) Ohio 30.6 (6.5) 42.3 (7.6) 57.4 (9.0) 67.3 (8.4) 52.0 (6.2) 37.4 (5.7) 44.9 (4.2) Oklahoma 37.1 (9.1) 43.6 (8.6) $5.9 (10.2) 62.9 (13.4) 53.4 (7.0) 39.6 (6.7) 47.5 (5.1) Rhode Island 34.7 (6.4) 44.8 (6.8) 55.6 (8.4) 69.8 (7.2) St.t (5.6) 446 (5.1) 47.8 (3.8) South Carolina 28.9 (5.8) 41.5 (6.6) 58.7 (7.6) 72.2 (8.8) 46.0 (5.1) 42.1 (5.4) 44.4 (3.8) South Dakota 374 (9.2) 52.3 (8.6) 60.8 (9.2) TL (8.7) 55.6 (5.8) 50.5 (6.7) 53.4 (4.3) Tennessee 29.0 (4.8) 40.9 (5.7) 49.5 (6.8) 67.2 (7.9) 434 (4.5) 39.4 (4.1) 41.8 (3.2) Texas 38.8 (8.6) 45.7 (8.4) 53.7 (10.5) 69.3 (12.5) 52.5 (6.7) 41.4 (6.8) 47.9 (4.8) Utah 33.5 (7.5) 50.9 (8.1) 68.3 (11.3) 80.1 (9.2) 65.2 (5.8) 40.5 (8.6) 56.6 (5.0) Washington 37.7 (7.3) 54.8 (7.5) 53.7 (8.7) 82.5 (7.9) 58.2 (5.8) 46.1 (5.8) 53.0 (4.2) West Virginia 38.5 (7.1) 43.4 (6.5) 49.1 (7.2) 69.4 (7.2) 54.5 (5.2) 38.4 (5.0) 47.6 (3.7) Wisconsin 35.0 (6.9) 52.0 (7.3) 62.2 (8.5) 76.0 (9.1) 63.8 (5.6) 46.3 (6.7) 56.5 (4.4) Median prevalence 37.2 47.0 57.5 71,1 $4.2 44.6 50.5 NOTE: BRFSS=Behavioral Risk Factor Surveillance System. “Defined us the percentage of ever smokers who were former smokers at the time of the survey. h . : Confidence interval. SOURCE: BRFSS 1988 (Anda et al. 1990) their most recent quit attempt. This measure provides information on the recent quitting history of the population (Pierce, Giovino et al. 1989; US DHHS 1989a). The trend analyses presented below will use an eight-category continuum (Table 2) among ever smokers to incorporate data from the 1978, 1979, 1980, and 1987 NHISs. As opposed to the 1986 AUTS. the questions asked in these NHISs do not permit a dichotomous classification of current smokers who had never tried to quit according to interest in quitting. In addition to a description of the overall smoking continuum, several segments of the continuum, or measures derived from the continuum, will be described separately. These measures include the following: ¢ The percentage of ever smokers who have never tried to quit: * The percentage of people smoking at 12 months prior to a survey interview who had been abstinent for at least 1 day during those 12 months: * The percentage of ever smokers who had stopped smoking for less than | year: ¢ The percentage of ever smokers who had stopped smoking for | to 4 years; and * The percentage of ever smokers who had stopped smoking for at least 5 years. Other Measures Respondents to AUTSs were asked to estimate the possibility that they would be smoking 5 years after the survey. This question gives a measure of intention to smoke. Finally, respondents to several NHISs and to all OSH tobacco use surveys were asked if a physician had ever advised them to stop smoking. TRENDS IN THE PROPORTION OF EVER SMOKERS WHO ARE FORMER SMOKERS (“QUIT RATIO”) Using data from NHISs for 1965 to 1987, trends in the proportion of ever cigarette smokers in the U.S. adult population who have stopped smoking cigarettes (quit ratio) are presented by gender and by race in Figures |] and 2, respectively. Trends for the total adult population, as well as trends by age and by education, are shown in Table 3. These data, with the exception of the age-specific estimates, are age-adjusted to the 1985 population. In these analyses, the quit ratio was regressed on the calendar year of data collection. The R° statistic, supplied for each trend analysis, is a measure of the strength of the linear relationship. R~ values may range from O (no linear trend) to 1.0 (a perfect positive or negative linear relationship). Trends by Gender As shown in Figure 1. the quit ratio for both genders has been increasing in an approximately linear fashion (R“=0.94 for males and 0.97 for females) since 1965, and 588 68¢ TABLE 2.—Cigarette smoking continuum by year, percentage of ever cigarette smokers, NHISs, United States, 1978-87, adults aged 20 and older Cigarette smoking continuum 1978 1979 19K0) 1987 !. Current smokers who had never tried to quit 25.9 26.1 25.4 18.9 2. Current smokers who had quit previously but 22.7 21.4 23.1 20.0 not in past year 3. Current smokers who had quit for <7 days 6.6 6.0 5.9 7.0 in past year 4. Current smokers who had quit for >7 days in 8.5 8.6 78 8.4 past year 5. Former smokers who had quit within past 3 mo 1.3 1.6 1.4 8 6. Former smokers who had been abstinent for 2.7 2.6 2.7 2.8 3-12 mo 7, Former smokers who had been abstinent for 9.0 10.0 9.5 10.4 1-S yr 8. Former smokers who had quit 25 yr earlier 23.3 23.6 24.1 30.7 Percentage of those smoking during the year prior to the survey who tried to quit during that year (Categories 3+445+6 divided by 1+2+3+4+546) 28.2 28.4 26.8 34.0 Percentage of those smoking during the year prior to the survey who quit during that year and were still abstinent at the time of the survey 6.) 6.3 6.2 78 (Categories 5+6 divided by 1+2+3+445+6) NOTE: NHIS=National Health Interview Survey. SOURCE: NHISs 1978, 1979, 1980, 1987. 06S 60 50 |------------ +--+ 2-2 eon en nn ne en nn ee en en ee ne ne nen eee eee eee Ro 4O |------ 2-22 ee eee ee eee eee ee eee eee eee pg cee emer ER TA eee eee er FEMALES B30 [r- A. -SRL.22 2 eeeeeeepgenn ee MTT 8 nnn ene BO ee MALES FEMALES Slope of Regression Line 0.70 0.76 o 2 g R 0.94 0.97 ES 10 | ------- 22222 e nee ec eee ence cee cece eee eee ne te cee enc ene ete eet Bete ee nee ene eee eens Zz, (ot) QO o a gl_1 1 1 1 4 oj poy yp pp 1964 1969 1974 1979 1984 YEAR FIGURE 1.—Trends in the quit ratio, United States, 1965-87, by gender NOTE: Quit ratio is the proportion of ever smokers who are former smokers. NHIS=National Health Intreview Survey; OSH=Office on Smoking and Health. SOURCE: NHISs 1965, £966, 1970. 1974, 1976, 1977, 1978, 1979, 1980. 1983. 1985, 1987: OSH, 16S ve AO | ------- 2222 nen ee eee ee eee eee eal LN ae eee eee eee A WHITES Whites Blacks Slope of Regression Line 0.72 0.45 Re 0.96 0.86 (10 | ------2222222e cece eee e cece cee eee eee cece eee eee eee ennnn nnn enee cee eeeeeeecocenecaeaessesseeereeeees < Zz i O fa | i | | i | | | | | Do I ! | | | ! | L { | | | 1964 1969 1974 1979 1984 YEAR FIGURE 2.—Trends in the quit ratio, United States, 1965-87, by race NOTE: NHIS=National Health Interview Survey; OSH=Office on Smoking and Health. SOURCE: NHISs 1965, 1966, 1970, 1974, 1976, 1977, 1978, 1979, 1980, 1983, 1985, 1987: OSH, unpublished data. cos TABLE 3.—Trends in quit ratio (%) (percentage of ever cigarette smokers who are former cigarette smokers), by age and by education, NHISs, United States, 1965-87, adults aged 20 and older Age (yr) Educational level Less than High Overall high schoot school Some College Year population 20-24 25-14 45--64 265 graduate graduate college graduate 1965" 29.6 [7.8 23.6 30.9 48.7 — -— — — 1966 29.5 17.0 23.4 30.9 50.5 33.3 28.0 28,7 39.7 1970 35.3 20.8 29.8 36.1 56.9 38.1 33.6 34.9 48.2 1974 36.3 20.9 29.3 39.7 S7.8 38.0) 35.2 36.6 47.9 1976 37.1 22.0 29.4 40.4 59.6 39.5 35.0 37.2 46.1 1977 36.8 22.9 29.6 39.5 58.7 38.3 34.0 36.8 48.6 1978 38.5 22.8 31.9 40.1 62.4 38.7 36.3 41.0 49.7 1979 39.0 22.6 348 42.4 61.7 40.8 36.7 37.5 50.6 1980 39.0 22.2 33.0 40.9 61.0 39.4 36.5 40.6 48.7 1983 41.8 214 34.3 46.4 64.7 42.1 38.7 41.2 54.9 1O8S 45.0 26.0 38.2 49.7 68.0 41.3 40.5 46.0 61.1 1987 44.8 23.8 37.2 49.2 69.2 44.3 41.1 45.5 59.1 Trend information (1965-87) Change"/yr 0.68 0.26 0.61 0.84 0.86 0.44 0.55 0.74 0.88 Standard error (+) 0.04 0.06 0.05 0.06 0.06 0.05 0.05 0.08 0.13 R* 0.96 0.64 0.93 0.95 0.96 O.88 0.92 0.90 0.83 NOTE: The data stratified by education are age adjusted to the 1985 population. NHIS=National Health Interview Survey. “For 1965, data stratified by education were unavailable. "In percentage points, SOURCE: NHISs 1965, 1966, 1970, 1974. 1976, 1977, 1978, 1979, 1980, 1983, 1O8S5, 1987, the rates of increase for both are also similar (0.70 percentage points/year for males and 0.76 percentage points/year for females). The quit ratio has been consistently higher for males than for females. Using data from the 1970 and 1975 AUTSSs. Jarvis (1984) reclassified as current smokers males who gave up smoking cigarettes but who con- tinued to smoke cigars and/or pipes. When the use of other forms of smoking tobacco was considered, the difference between males and females in the quit ratio (termed as the “cessation rate” by Jarvis) was reduced by more than two-thirds. Data from the 1987 NHIS Cancer Epidemiology and Control supplement (Schoen- bom and Boyd 1989) were analyzed to update the work of Jarvis (Table 4). The weighted percentage of ever cigarette smokers who were former cigarette smokers among males was 48.7 percent. The corresponding number among females was 40.1 percent. When former cigarette smokers who smoked cigars and/or pipes were reclas- sified as current smokers (without changing the denominator). the prevalence of cessation among ever smokers became 45 percent for males and 40 percent for females. Furthermore, when former cigarette smokers who used any other form of tobacco (cigars, pipes, snuff, and/or chewing tobacco) at the time of the survey were classified as current tobacco users, the figures became 42.1 percent for males and 39.9 percent for females (OSH, unpublished data). Thus, reclassification of former cigarette smokers who were smoking cigars and/or pipes as current smokers reduced the difference in the quit ratio between males and females from 8.6 to 5.0 percentage points. Former cigarette smokers who were using any other form of tobacco were reclassified as current tobacco users, and this reclassification further reduced the difference to 2.2 percentage points. Trends by Race Trends by race are presented in Figure 2. The quit ratio among both whites and blacks has been increasing steadily since 1965 (R°=0.96 for whites and 0.86 for blacks). While the change per year since 1965 is higher for whites (0.72 percentage points/year) than it is for blacks (0.45 percentage points/year), the lines have been essentially parallel since 1974 (Fiore et al. 1989). Use of the 1987 NHIS data to reclassify as current smokers all former cigarette smokers who were smoking cigars or pipes reduced the quit ratio from 46.4 to 44.2 percent among whites and from 31.5 to 30.2 percent among blacks. Further reclassification, as current tobacco users, of former cigarette smokers who were using any other form of tobacco reduced the numbers to 42.5 percent for whites and 29.1 percent for blacks (OSH, unpublished data). Trends by Age Table 3 provides information on the quit ratio stratified by age. For all age categories, the quit ratio increased from 1965 to 1987, The rate ot change was highest in the age categories of 45-64 years and 65 years and older, Reclassification of the 1987 data to account for cigar and pipe smoking and for any other tobacco use lowered the numbers from 23.8 percent to 23.4 and 22.2 percent. respectively, among the 20-24-year-olds: from 37.2 percent to 35.6 and 34.3 percent, respectively, among 25—44-year-olds: from 593 49.2 percent to 46.4 and 45.0 percent, respectively. among 45-64-year-olds: and from 69.2 percent to 66.2 percent and 62.8 percent, respectively, among those 65-years-old and older (Table 4) (OSH. unpublished data). A detailed analysis of trends in the quit ratio by age for the period 1974 through 1987 has been completed (Novotny et al., in press). Differences in quit ratios between age groups may reflect actual differences in quitting activity by age—that is, older persons may be more prone to quit and maintain abstinence than younger smokers, perhaps because of the occurrence of smoking- related symptoms or illness. However, continuing smokers are less likely than former smokers to survive to old age (Chapter 3): this selective mortality will artifactually increase the quit ratio among older age groups. TABLE 4,.—Effect of adjusting for use of other tobacco products on quit ratio (percentage of ever cigarette smokers who are former cigarette smokers), 1987, NHIS, United States Quit ratio (%) Adjusting for / Adjusting for cigars/pipes/snuft/che wing Unadjusted® cigars/pipes tobacco” Gender Males 48.7 45.0 42.1 Females 40.1 40.0 39.9 Race Whites 46.4 44.2 42.5 Blacks 31.5 30.2 29.4 Age (yr) 20-24 23.8 23.4 22.2 25-44 37.2 35.6 34.3 45-64 49.2 46.4 45.0 265 69.2 66.2 62.8 Education (yr) (43.0%; 8.9%)". AFTER SECOND QUIT® 203 (35.2%: 3.1%)° 371 (64.4%: 5/7%)° FIGURE 3.—Flow chart of quitting history, attempts lasting longer than 1 year, NHEFS NOTE: NHEFS=National Health and Nutrition Examination Survey (NHANES-D Epidemiologic Followup Study. “Of the 6.640 ever regular cigarette smokers, 155 quit within the year preceding the NHEFS interview. Data on the first quit attempt were missing for 35 people (4 were current smokers. 6 were former smokers, and 25 were deceased at the time of the interview). POF the 3,566 people who quit for at least | year, data were not available on 16 (15 were former smokers and | was deceased at the time of the interview). “The first number represents the percentage of the reference number one row above (e.g. 1.340 is 37.6% of 3.566); the second number represents the percentage of the total number of ever regular cigarette smokers in this sample (e.g., 1,340 is 20.7% of 6,460). 4Of the 1,340 people who relapsed after their first 21-yr period of abstinence. 74 quit within the year preceding the interview and 26 never retumed to regular smoking. Data were not available on 16 others (11 were current smokers, 3 were former smokers, and 2 were deceased at the time of the interview). “Of the 576 people who quit twice for at feast 1 yr, data were not available for 2 (both were former smokers at interview). 86S 100 A Oa oe —A— As Q 60 | --------- 22-2222 e ence cece eee eee eee ee ee ne ne ee eee eee eee eee eee ened 8 ee a Z_ 40 [o-oo nnn nnn nnn nn neces rence ssa cesnnsec cn nncascaaescasnnacesaesaancnnnecnsnnencnnaneneesnerrasteecstnesssacerad a wr) OQ < © 20 20 fone rrr nnncencanncnesencnnseencnnsasccensasancaasseaesaasaseeananasaccsnsscceccnnsececnnnaseenenen Z. [eal Oo o x 9 | | | | ! 1 2 3 4 5 6 7 8 9 10 11 YR AFTER STOPPING SMOKING FIGURE 4.—Estimated duration of abstinence on first 1-year or longer quit attempt, product-limit method, N=3,363 SOURCE: NHANES-I Epidemiologic Followup Study 1982-84; OSH, unpublished data. THE SMOKING CONTINUUM A number of surveys have sought detailed information on respondents’ quitting histories. An eight-point smoking continuum among ever smokers can be developed from the 1978, 1979, and 1980 NHIS tobacco supplements, the 1986 AUTS, and the 1987 NHIS. Smoking continuums for the four NHISs are presented in Table 2. and are similar over time. The data in Table 2 can be used in various ways. For example, by focusing on those who were smoking during the year before the survey (categories | through 6). the proportion that tried to quit during that year (categories 3+4+5+6 divided by categories 1+2+344+5+6) and the proportion that quit during that year and were still abstinent at the time of the survey (categories 5+6 divided by categories 1+2+3+4+5+6) can be estimated. The proportion who tried to quit during the year before the survey was higher in 1987 (34 percent) than in 1978, 1979. and 1980 (27 to 29 percent). The proportion who quit during the year before the survey and were still abstinent at the time of the survey remained stable at 6 to 8 percent from 1978 to 1987. Data are presented below on various components of the smoking continuum. Data from NHIS years not included in Table 2 are often presented in the following sections because, whereas these surveys did not provide all the questions necessary to construct a complete continuum, enough information to define one or more components of the continuum was collected. These data are broken down by education (Table 5 and Figures 5—9) because educational attainment is a strong sociodemographic predictor of smoking and quitting behavior (US DHHS 1989a: Pierce, Fiore et al. 1989). Data from other stratified analyses (i.e., gender, race, and age) are also presented in Table 5. The data on the continuum have been age-adjusted to the overall 1985 population. Percentage of Ever Smokers Who Have Never Tried to Quit There is no overall clear and significant trend from 1974 to 1987 in the percentage of ever smokers who have never tried to quit. Education has a consistent effect on quitting—lower levels of educational attainment are associated with a higher prob- ability of never having tried to quit (Figure 5). The difference between genders in the proportion of ever smokers who have never tned to quit has been decreasing with time (Table 5). While the proportion of females in this category has been decreasing over the years, it has remained fairly constant for males. The data also show that, on average, over time, females are more likely than males to have never tried to quit smoking. Trend data broken down by race show that blacks have been consistently more likely than whites to have never tried to quit smoking; however. the difference between the races has been narrowing with time. The data also show that the likelihood of having ever tried to quit smoking increases with age. For all age categories, the percentage of ever smokers who have never tried to quit has been decreasing with time (especially for the oldest age group). 599 009 TABLE 5. —Selected measures of quitting activity (%), NHISs, United States, adults aged 20 and older* Gender Race Age (yr) Education (yr) Overall Male Female Whites Blacks 20-24 25-44 45-64 265 <12 12 13-15 216 Never tried to quit” 1974 22.5 20.1 25.8 20.1 34.4 28.5 22.8 22.4 16.5 26.3 23.9 19.0 15.3 1987 {8.7 18.5 19.5 17.7 26.5 26.6 20.3 16.9 1.0 25.5 18.5 16.7 [3.9 Mean 234 22.0 25.6 22.6 30.1 31.7 24.7 22.2 15.3 28.0 24.2 20.0 16.9 Quit for at least 1 day* 1978 27.8 25.8 30.2 26.9 36.5 41.6 27.8 22.5 26.4 26.7 27.4 30,2 29.2 1987 31.6 31.1 32.1 30.6 37.7 40.6 32.6 26,5 29.8 29.0 30.5 33.8 34.8 Mean 28.0 26.7 29.6 27.1 35.0 38.8 29.1 22.3 26.5 27.4 27.6 28.7 30.8 Off less than yr" 1965" 4.6 4.8 4.2 48 29 5.1 4.7 39 48 3.0 3.6 4.0 4.7 1987 4.6 4.5 47 45 49 6.2 5.5 3.6 2.5 4.1 45 48 48 Mean 4.3 4.3 4.4 4.3 3.7 6.9 5.0 2.9 2.6 3.0 4.5 4.8 5.3 Ott tt yr' 1965" 8.0 8.7 6.7 6.2 6.1 6.5 78 76 10.0 7.4 9.1 9.0 t4.1 197 {0.5 10.2 10.8 11.0 i) 11.6 10.9 10.4 8.4 V7 10.6 12.3 12.1 Mean 9.2) 9.4 9.0 9.4 7A 10.0 O8 7.6 8.7 7.0 9.0 10.4 12.3 Off 25 ye 1965° [2.4 14.0 8.7 12.7 8.3 1.2 73 15.4 30.2 12.2 12.2 14.6 18.3 1987 29.8 32.8 25.5 30.9 20.7 4.7 22.1 36.7 58.3 22.4 27.4 32.6 42.0 Mean 21.7 24.3 17.5 20.8 14.3 2.9 15.2 27.0 46.4 18.1 21.9 25.2 33.1 NOTE: NHIES=National Health Interview Survey, “Data were age-adjusted to the overall U.S. population in 1985, "Never tried 10 quit = percentage of ever smokers who have never tried to quil. “Quit for at least | day = percentage of those smoking at 12 mo prior to interview who quit for at least | day during those 12 mo. “ON <1 yr = percentage of ever smokers who have been abstinent for <1 yr. “1966 (not 1965) is the first year for which data are available for the four education strata, ‘Off 1-4 yr = percentage of ever smokers who have been abstinent for [—4 yr. FOI 25 yr= percentage of ever smokers who have been abstinent tor at least 5 yr.