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Smoking Cessation During Previous Year Among Adults -- United States, 1990 and 1991

MMWR 42(26);504-507

Publication date: 07/09/1993


Table of Contents

SUMMARY
Reported By
Editorial Note

REFERENCES

POINT OF CONTACT FOR THIS DOCUMENT:

Tables
Adjusted Odds Ratios (AORs) For Three Measures Of Abstinence


SUMMARY

Although most smokers in the United States report that they want to stop using cigarettes (1), 46 million persons aged greater than or equal to 18 years continue to smoke (2). Current information about factors predictive of smoking or cessation is required to develop and assess measures effective in reducing smoking prevalence. To characterize the patterns of attempting to quit smoking and smoking cessation among U.S. adults during 1990 and 1991, CDC's National Health Interview Survey-Health Promotion and Disease Prevention (NHIS-HPDP) supplement collected self-reported information on cigarette smoking from a representative sample of the U.S. civilian, noninstitutionalized population aged greater than or equal to 18 years. This report summarizes findings from this survey.

The overall response rate for the 1991 NHIS-HPDP was 87.8%. Participants (n=43,732) were asked: "Have you smoked at least 100 cigarettes in your entire life?" Those who responded "yes" (i.e., ever smokers) were asked: "Around this time last year, were you smoking cigarettes every day, some days, or not at all?" They were then asked: "Do you smoke cigarettes now?" Those who responded "yes" were asked: "Do you now smoke cigarettes every day or some days?"; those who responded "no" were asked: "Do you now smoke cigarettes not at all or some days?" The time period from the reference time 1 year earlier (about which the ever smoker reported the frequency of smoking) to the date of interview was considered the study period.

Current every-day smokers were persons who stated that they smoked now and that they smoked every day. Those who stated that they did not smoke at all at the time of the survey were considered former smokers. Some-day smokers were those who smoked on some days. These definitions differ slightly from traditional definitions used by CDC's National Center for Health Statistics because they incorporate the concepts of every-day and some-day smoking. Current every-day smokers who stated that they quit for at least 1 day during the past year, some-day smokers, and former smokers were all considered to have been abstinent from smoking for at least 1 day during the study period. Those former smokers who quit smoking cigarettes for at least 1 month at the time of the survey in 1991 were considered to have maintained abstinence.

For this analysis, three racial/ethnic categories were used: white, non-Hispanic; black, non-Hispanic; and Hispanic. Other racial/ethnic groups were not included because numbers were too small for meaningful analysis. Data were adjusted for nonresponse and weighted to provide national estimates. Investigators used the Software for Survey Data Analysis (SUDAAN) to calculate 95% confidence intervals (CIs) and adjusted odds ratios (3).

Among U.S. adults who had smoked at least 100 cigarettes during their lifetimes as of 1991, an estimated 40.5 million smoked cigarettes every day at the beginning of the study period. Approximately 17.0 million (42.1%) of these did not smoke cigarettes for at least 1 day during the subsequent 12 months. Hispanics (52.1% {95% CI=46.4%-57.8%}) and blacks (48.7% {95% CI=45.2%-52.2%}) were more likely than whites (40.3% {95% CI=39.0%- 41.6%}) to quit smoking cigarettes for at least 1 day. Abstinence for at least 1 day, by age, was highest among persons aged 18-24 years (56.7% {95% CI=52.9%-60.5%}) and, by education, was lowest among those with less than 12 years of education (36.5% {95% CI=34.1%-38.9%}). These relations were also evident after statistical adjustment was made for other sociodemographic variables (Table 1).

Among persons who reported that they did not smoke cigarettes for at least 1 day during the previous year, 13.8% (2.3 million) were abstinent for 1 month or more at the end of the study period. Hispanics (16.3% {95% CI=10.3%-22.2%}) and whites (14.0% {95% CI=12.6%-15.4%}) were more likely than blacks (7.9% {95% CI=5.1%- 10.7%}) to remain abstinent; this difference remained after statistical adjustments were made for sex, age, education, and poverty status (Table 1). Persons aged greater than or equal to 65 years (19.4% {95% CI=14.6%-24.2%}) and college graduates (18.8% {95% CI=14.9%-22.7%}) were the most likely to maintain abstinence. Persons at or above the poverty level* (14.8% {95% CI=13.4%-16.3%}) were more likely to maintain abstinence than those below the poverty level (7.5% {95% CI=4.7%-10.3%}).

* Poverty statistics are based on definitions developed by the Social Security Administration that include a set of income thresholds that vary by family size and composition.

Of all persons who were daily smokers at the beginning of the study period, 5.7% quit smoking and maintained abstinence for at least 1 month. Among persons who were daily smokers at the beginning of the study period, college graduates and persons at or above the poverty level were more likely than those with fewer years of formal education and persons below the poverty level, respectively, to abstain from cigarette smoking for 1 month or more.

Reported By

Reported by the Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

The findings from this survey indicate that, in 1990 and 1991, approximately 42% of daily smokers abstained from smoking cigarettes for at least 1 day but that approximately 86% of these persons subsequently resumed smoking. The high relapse rate is likely because of the addictive nature of nicotine (4). However, because relapse occurs later in the process of maintenance, the overall rate of cessation will be lower than suggested by this report. From 1974 through 1991, an estimated 45.8- 53.5 million persons aged greater than or equal to 18 years smoked; of these, approximately 1.2 million persons became former smokers each year (CDC, unpublished data), suggesting that approximately 2.5% of U.S. smokers quit smoking permanently each year.

Education level and age are both important predictors for cessation attempts and maintaining abstinence. The findings in this report are consistent with previous studies noting that increasing level of education correlates directly with smoking cessation prevalence and inversely with prevalence of smoking (2). In addition, although persons aged greater than or equal to 65 years were less likely to abstain for 1 day, those who did abstain were the most likely to be successful in maintaining abstinence during the study period. This finding may suggest that older persons may be more motivated than younger persons to overcome nicotine addiction (5).

In 1991, among the three racial/ethnic groups studied, the maintenance rate of abstinence from smoking was higher for Hispanics and whites than for blacks. Potential explanations for the high relapse rate among blacks include the use of cigarettes with higher tar and nicotine yields (4), a higher prevalence of nicotine dependency among persons who smoke (6), and comparatively limited access to preventive health services (4,7). Smoking-cessation programs are important for all racial/ethnic groups. Programs have been developed for Asian/Pacific Islanders, American Indians/Alaskan Natives (T. Stratton, California Department of Health Services, personal communication, 1993), and Hispanics (8). The elevated prevalence of cigarette smoking among (2 ) and the higher smoking-attributable death rate for (9) blacks indicate the need for specific efforts to reduce the adverse impact of tobacco use among blacks. CDC and the National Medical Association are initiating a targeted mass media campaign in July 1993 called "Legends" that contrasts the deaths of black civil-rights leaders to preventable smoking-related deaths. In addition, a toll-free telephone number ({800} 232-1311) is available to request a smoking-cessation guide, Pathways to Freedom. This guide addresses important topics including nicotine addiction, possible misconceptions about the safety of smoking menthol cigarettes, stress-reduction techniques, preparing for quitting, relapse-prevention techniques, and the cultural meaning of smoking (6).


REFERENCES

1. Thomas RM, Larsen MD. Smoking prevalence, beliefs, and activities by gender and other demographic indicators. Princeton, New Jersey: The Gallup Organization, Inc, 1993.

2. CDC. Cigarette smoking among adults -- United States, 1991. MMWR 1993;42:230-3.

3. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30 {Software documentation}. Research Triangle Park, North Carolina: Research Triangle Institute, 1989.

4. Public Health Service. The health consequences of smoking: nicotine addiction. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (CDC)88-8406.

5. Hatziandreu EJ, Pierce JP, Lefkopoulou M, et al. Quitting smoking in the United States in 1986. J Natl Cancer Inst 1990;82:1402-6.

6. Royce JM, Hymowitz N, Corbett K, Hartwell TD, Orlandi MA, for the COMMIT Research Group. Smoking cessation factors among African Americans and whites. Am J Public Health 1993;83:220-6.

7. Hymowitz N, Sexton M, Ockene J, Grandits G, for the MRFIT Research Group. Baseline factors associated with smoking cessation and relapse. Prev Med 1991;20:590-601.

8. Marin G, Marin BV, Perez-Stable EJ, Sabogal F, Otero-Sabogal R. Changes in information as a function of a culturally appropriate smoking cessation community intervention for Hispanics. Am J Community Psychol 1990;18:847-64.

9. CDC. Smoking-attributable mortality and years of potential life lost -- United States, 1988. MMWR 1991;40:62-3,69-71.


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Table 1

TABLE 1. Adjusted odds ratios (AORs)* for three measures of abstinence from
cigarette smoking during the previous year, by sex, race/ethnicity,+ age group, level
of education,& and poverty status&& -- United States, National Health Interview Survey,
1991**
==============================================================================================
                                                                   Maintenance++
                                                                    among all persons
                                                                        who
                    Abstinence for            Maintenance         were daily smokers
                    >=1 day                 among abstainers      1 year earlier
Category            AOR     (95% Cl***)      AOR    (95% Cl)       AOR    (95%CI)
----------------------------------------------------------------------------------------------
Sex
Male                 1.0     Referent        1.0    Referent       1.0    Referent
Female               1.0     (0.9-1.2)       1.1    (0.9-1.3)      1.0    (0.9-1.3)

RacelEthnicity
White, non-Hispanic  1.0     Referent        1.0    Referent       1.0    Referent
Black, non-Hispanic  1.6     (1.3-1.8)       0.6    (0.4-0.9)      0.8    (0.5-1.2)
Hispanic             1.7     (1.3-2.1)       1.3    (0.9-2.1)      1.7    (1.1-2.7)

Age group (yrs)
18-24                1.0     Referent        1.0    Referent       1.0    Referent
25-44                0.5     (0.5-0.6)       0.9    (0.6-1.3)      0.7    (0.5-0.9)
45-64                0.4     (0.3-0.5)       0.9    (0.6-1.4)      0.6    (0.4-0.8)
>=65                 0.5     (0.4-0.6)       1.5    (1.0-2.4)      0.9    (0.6-1.4)

Education (yrs)
<12                  1.0     Referent        1.0    Referent       1.0    Referent
12                   1.3     (1.1-1.5)       1.0    (0.7-1.4)      1.2    (0.9-1.6)
13-15                1.6     (1.3-1.8)       1.1    (0.8-1.5)      1.4    (1.0-1.9)
>=16                 1.6     (1.3-2.0)       1.5    (1.0-2.2)      1.9    (1.3-2.7)

Poverty status
At/above
poverty level        1.0     Referent        1.0    Referent       1.0    Referent
Below poverty level  1.0     (0.8-1.1)       0.5    (0.3-0.8)      0.5    (0.4-0.8)
Unknown              0.7     (0.6-0.9)       0.9    (0.6-1.4)      0.8    (0.5-1.1)
----------------------------------------------------------------------------------------------
*The odds ratios presented for each sociodemographic variable are adjusted for the other
four sociodemographic variables in the table.
+Excludes 268 respondents of other or unknown race; race/ethnicity and education were both
    unknown for four respondents.
&Excludes 24 respondents of unknown education status.
&&Poverty statistics are based on definitions developed by the Social Security Administration
  that include a set of income thresholds that vary by family size and composition.
**Sample size=9415.
++Abstinence from smoking cigarettes for at least 1 month preceding the interview. Excludes
  92 respondents who abstained from cigarettes for <1 month or for whom duration of
  abstinence was unknown.
***Confidence interval.
==============================================================================================

and weighted to provide national estimates. Investigators used the
Software for Survey Data Analysis (SUDAAN) to calculate 95%
confidence intervals (CIs) and adjusted odds ratios (3).
     Among U.S. adults who had smoked at least 100 cigarettes
during their lifetimes as of 1991, an estimated 40.5 million smoked
cigarettes every day at the beginning of the study period.
Approximately 17.0 million (42.1%) of these did not smoke
cigarettes for at least 1 day during the subsequent 12 months.
Hispanics (52.1% {95% CI=46.4%-57.8%}) and blacks (48.7% {95%
CI=45.2%-52.2%}) were more likely than whites (40.3% {95% CI=39.0%-
41.6%}) to quit smoking cigarettes for at least 1 day. Abstinence
for at least 1 day, by age, was highest among persons aged 18-24
years (56.7% {95% CI=52.9%-60.5%}) and, by education, was lowest
among those with less than 12 years of education (36.5% {95%
CI=34.1%-38.9%}). These relations were also evident after
statistical adjustment was made for other sociodemographic
variables (Table 1).
     Among persons who reported that they did not smoke cigarettes
for at least 1 day during the previous year, 13.8% (2.3 million)
were abstinent for 1 month or more at the end of the study period.
Hispanics (16.3% {95% CI=10.3%-22.2%}) and whites (14.0% {95%
CI=12.6%-15.4%}) were more likely than blacks (7.9% {95% CI=5.1%-
10.7%}) to remain abstinent; this difference remained after
statistical adjustments were made for sex, age, education, and
poverty status (Table 1). Persons aged greater than or equal to 65
years (19.4% {95% CI=14.6%-24.2%}) and college graduates (18.8%
{95% CI=14.9%-22.7%}) were the most likely to maintain abstinence.
Persons at or above the poverty level* (14.8% {95% CI=13.4%-16.3%})
were more likely to maintain abstinence than those below the
poverty level (7.5% {95% CI=4.7%-10.3%}).
     Of all persons who were daily smokers at the beginning of the
study period, 5.7% quit smoking and maintained abstinence for at
least 1 month. Among persons who were daily smokers at the
beginning of the study period, college graduates and persons at or
above the poverty level were more likely than those with fewer
years of formal education and persons below the poverty level,
respectively, to abstain from cigarette smoking for 1 month or
more.
Reported by: Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion; Div of Health
Interview Statistics, National Center for Health Statistics, CDC.
Editorial Note: The findings from this survey indicate that, in
1990 and 1991, approximately 42% of daily smokers abstained from
smoking cigarettes for at least 1 day but that approximately 86% of
these persons subsequently resumed smoking. The high relapse rate
is likely because of the addictive nature of nicotine (4). However,
because relapse occurs later in the process of maintenance, the
overall rate of cessation will be lower than suggested by this
report. From 1974 through 1991, an estimated 45.8- 53.5 million
persons aged greater than or equal to 18 years smoked; of these,
approximately 1.2 million persons became former smokers each year
(CDC, unpublished data), suggesting that approximately 2.5% of U.S.
smokers quit smoking permanently each year.
     Education level and age are both important predictors for
cessation attempts and maintaining abstinence. The findings in this
report are consistent with previous studies noting that increasing
level of education correlates directly with smoking cessation
prevalence and inversely with prevalence of smoking (2). In
addition, although persons aged greater than or equal to 65 years
were less likely to abstain for 1 day, those who did abstain were
the most likely to be successful in maintaining abstinence during
the study period. This finding may suggest that older persons may
be more motivated than younger persons to overcome nicotine
addiction (5).
     In 1991, among the three racial/ethnic groups studied, the
maintenance rate of abstinence from smoking was higher for
Hispanics and whites than for blacks. Potential explanations for
the high relapse rate among blacks include the use of cigarettes
with higher tar and nicotine yields (4), a higher prevalence of
nicotine dependency among persons who smoke (6), and comparatively
limited access to preventive health services (4,7).
Smoking-cessation programs are important for all racial/ethnic
groups. Programs have been developed for Asian/Pacific Islanders,
American Indians/Alaskan Natives (T. Stratton, California
Department of Health Services, personal communication, 1993), and
Hispanics (8). The elevated prevalence of cigarette smoking among
(2 ) and the higher smoking-attributable death rate for (9) blacks
indicate the need for specific efforts to reduce the adverse impact
of tobacco use among blacks. CDC and the National Medical
Association are initiating a targeted mass media campaign in July
1993 called "Legends" that contrasts the deaths of black
civil-rights leaders to preventable smoking-related deaths. In
addition, a toll-free telephone number ({800} 232-1311) is
available to request a smoking-cessation guide, Pathways to
Freedom. This guide addresses important topics including nicotine
addiction, possible misconceptions about the safety of smoking
menthol cigarettes, stress-reduction techniques, preparing for
quitting, relapse-prevention techniques, and the cultural meaning
of smoking (6).
References
1. Thomas RM, Larsen MD. Smoking prevalence, beliefs, and
activities by gender and other demographic indicators. Princeton,
New Jersey: The Gallup Organization, Inc, 1993.
2. CDC. Cigarette smoking among adults -- United States, 1991. MMWR
1993;42:230-3.
3. Shah BV. Software for Survey Data Analysis (SUDAAN) version 5.30
{Software documentation}. Research Triangle Park, North Carolina:
Research Triangle Institute, 1989.
4. Public Health Service. The health consequences of smoking:
nicotine addiction. Rockville, Maryland: US Department of Health
and Human Services, Public Health Service, 1988; DHHS publication
no. (CDC)88-8406.
5. Hatziandreu EJ, Pierce JP, Lefkopoulou M, et al. Quitting
smoking in the United States in 1986. J Natl Cancer Inst
1990;82:1402-6.
6. Royce JM, Hymowitz N, Corbett K, Hartwell TD, Orlandi MA, for
the COMMIT Research Group. Smoking cessation factors among African
Americans and whites. Am J Public Health 1993;83:220-6.
7. Hymowitz N, Sexton M, Ockene J, Grandits G, for the MRFIT
Research Group. Baseline factors associated with smoking cessation
and relapse. Prev Med 1991;20:590-601.
8. Marin G, Marin BV, Perez-Stable EJ, Sabogal F, Otero-Sabogal R.
Changes in information as a function of a culturally appropriate
smoking cessation community intervention for Hispanics. Am J
Community Psychol 1990;18:847-64.
9. CDC. Smoking-attributable mortality and years of potential life
lost -- United States, 1988. MMWR 1991;40:62-3,69-71.
* Poverty statistics are based on definitions developed by the
Social Security Administration that include a set of income
thresholds that vary by family size and composition.



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