Smoking cessation patterns and predictors among adult Californians of Korean descent.

This paper describes smoking cessation among adult California residents of Korean descent, based on a telephone survey (N = 2,830). The overall quit rate (number of former smokers divided by number of ever-smokers) was 55.0% (55.8% among males and 49.6% among females). Acculturation was negatively associated with 90-day abstinence after controlling for demographic, social support, health belief, environmental, lifestyle, and respiratory illness history variables (OR = 0.59, 95% CI = 0.38-0.91). Those with lower acculturation, higher body mass index, a social network discouraging smoking, home smoking restriction, correct beliefs about smoking harm, and significant concern about one's health were most likely to quit smoking for 90 days or longer. Results suggest that social and situational conditions should be included in the design of smoking cessation interventions among Koreans.     

Smoking cessation in China: findings from the 1996 national prevalence survey

OBJECTIVES: To describe patterns of smoking and smoking cessation in China within the context of the stages of change model, using data from the 1996 national prevalence survey. DESIGN: A cross sectional survey was carried out using the 145 preselected disease surveillance points, which provide a representative sample for the entire country. A standardised questionnaire on smoking was interviewer administered. SETTING: The country of China. SUBJECTS: 122,220 people aged 15-69 years. MAINTENANCE MEASURES: Smoking cessation patterns, as defined by smoking status (current or former) and stage of change (precontemplation, contemplation, and action). RESULTS: The sample included 45,995 ever smokers of whom 4336 had quit. About 72% of current smokers reported not intending to give up their smoking behaviour, and about 16% of current smokers said they intended to do so, but have not taken any action. Of all ever smokers, the percentage of former smokers was 9.5%, and 12% of current smokers had quit at least once, but relapsed by the time of the survey. The patterns were similar in men and women with regard to the stated intent to quit. Among males, the percentage of former smokers increased with age but the percentage intending to quit was constant at about 15% across age strata. The most common reason for quitting was illness. Participants with a university education were more likely to have made an attempt to quit. CONCLUSIONS: The percentage of smokers contemplating quitting was low in China in 1996. The study shows that smokers in China must be mobilised to contemplate quitting and then to take action.     

Smoking cessation in general practice: the effects of a quitline.

This cross-sectional study assessed changes between 1999 and 2003 in attitudes among Swedish general practitioners (GPs) toward smoking cessation activities and also assessed the effect of a nationwide quitline on GPs' smoking cessation activities. A random sample of 621 Swedish GPs answered a questionnaire mailed to their home addresses in spring 2003. When possible, the results of the present study were compared with results from a similar study conducted in 1999. Main outcome measures were GPs' self-reported activities, perceived barriers to engaging in smoking cessation, and referrals to the quitline. Between 1999 and 2003, GPs increased their overall smoking cessation activities and were more aware of the complexity of smoking cessation support. Significantly more GPs experienced smoking cessation support as "too time consuming" and preferred to refer smokers to counselors specializing in smoking cessation. GPs referring patients to the quitline were more likely to be active in other smoking cessation activities. One out of five GPs had advised their patients to use oral smokeless tobacco as a means to stop smoking. A paradigm shift regarding awareness of the complexity of smoking cessation support may be ongoing amongst Swedish GPs. The nationwide smoking cessation quitline appears to have had a positive effect on GPs' engagement in smoking cessation.     

The California Tobacco Control Program's effect on adult smokers: (1) Smoking cessation

Objectives

To estimate national population trends in long‐term smoking cessation by age group and to compare cessation rates in California (CA) with those of two comparison groups of states.

Setting

Retrospective smoking history of a population sample from the US: from CA, with a comprehensive tobacco‐control programme since 1989 with the goal of denormalising tobacco use; from New York and New Jersey (NY & NJ), with similar high cigarette prices but no comprehensive programme; and from the tobacco‐growing states (TGS), with low cigarette prices, no tobacco‐control programme and social norms relatively supportive of tobacco use.

Participants

Respondents to the Current Population Survey–Tobacco Use Supplements (1992–2002; n = 57 918 non‐Hispanic white ever‐smokers).

Main outcome measures

The proportion of recent ever‐smokers attaining long‐term abstinence (quit ⩾1 year) and the successful‐quit ratio (the proportion of all ever‐smokers abstinent ⩾1 year).

Results

Nationally, long‐term cessation rates increased by 25% from the 1980s to the 1990s, averaging 3.4% per year in the 1990s. Cessation increased for all age groups, and by >40% (p<0.001) among smokers aged 20–34 years. For smokers aged <50 years, higher cigarette prices were associated with higher quitting rates. For smokers aged <35 years, quitting rates in CA were higher than in either comparison group (p<0.05). Half of the ever‐smokers had quit smoking by age 44 years in CA, 47 years in NY & NJ, and by age 54 years in TGS.

Conclusion

Successful smoking cessation increased by 25% during the1990s in the US. Comprehensive tobacco‐control programmes were associated with greater cessation success than were with high cigarette prices alone, although both effects were limited to younger adults.There is considerable evidence that cigarette smoking will cause the premature death of approximately half of those who start and continue to smoke, with half of these deaths occurring before age 70 years.^1,2 Public health efforts to rapidly reduce the estimated 438 000 smoking‐related deaths in the US each year have targeted increasing successful quitting among current smokers.^1,3 The British Doctors Study² evaluated the relationship between age of smoking cessation and later mortality. The study suggests that smokers who quit successfully by age 35 years may avoid much of the excess mortality risk from smoking, those who quit successfully by age 50 years will avoid approximately half of the excess mortality risk accrued by continuing smokers and those who quit by age 60 years will avoid about one‐third of the excess mortality risk. These ages are useful cut‐points to assess progress towards tobacco‐control goals in population groups.There are several reasons to expect that successful cessation rates may have increased in the US during the 1990s. Many health economists feel that price increases are among the most effective policy approaches to reduce smoking behaviour.⁴ Significant increases in cigarette prices have consistently been associated with reductions in both per capita cigarette usage and smoking prevalence, with the latter presumed to occur largely through increased quitting.⁵ Real cigarette prices increased nationally in the US during the 1980s and 1990s, with the largest increase imposed by the tobacco industry in 1999, associated with the consolidated settlement in 1998 of lawsuits brought by attorneys general from 46 states.⁶ In addition, during the 1990s, many individual states increased their excise taxes on tobacco products.⁷ These high prices may have encouraged more smokers both to try to quit and to successfully maintain cessation. Thus, quitting indices should have increased across the US, with more marked increases seen in states with higher cigarette prices.In addition, during the 1990s, nicotine replacement products such as the nicotine patch and nicotine gum became widely available, following randomised trials that showed their efficacy.⁸ Older smokers and those who smoked more heavily were more likely to use these cessation aids; by 2001, approximately 40% of smokers aged >35 years had used nicotine replacement products to assist in quitting, leading to an expectation that the major increase in successful quitting would occur in older smokers.⁹During the 1990s, there were marked differences among US states in initiatives targeting tobacco cessation. Thus, it is of interest to assess changes in quitting rates not only for the US as a whole but also among groups of states that differed in their tobacco‐control initiatives. Among US states, California (CA) was the first to begin a comprehensive tobacco control programme in 1989, which had one specific programme goal to encourage smoking cessation and a broader mandate to change community norms regarding tobacco use.^10,11 Through the 1990s, CA was unique in spending an average of $3.67 per person per year on a comprehensive public health programme to change smoking‐related norms.¹² The programme included price increases and other interventions, and a mass media campaign in which about one‐quarter of the advertisements encouraged smokers to quit.¹³ There is considerable evidence that such a mass media programme can effectively motivate smokers to initiate an attempt to quit.^14,15,16 CA also pioneered the Smokers'' Helpline, an evidence‐based cessation approach^17,18 that has been an integral part of the CA Tobacco‐Control Program since 1993.¹⁹ In addition, CA passed the first state‐wide law banning smoking in the workplace in 1995, and there is mounting evidence that smoke‐free workplaces encourage smoking cessation.²⁰ Thus, it might be expected that CA would have higher rates of successful smoking cessation than states without such a comprehensive tobacco control programme.In comparison, the adjacent states of New York and New Jersey (NY & NJ) have a combined population size similar to CA, and both were similar to CA in the level of cigarette excise taxes during the 1980s and 1990s, yielding similar high cigarette prices.⁷ However, neither state supported a comprehensive tobacco‐control programme during the 1990s, with funding for tobacco control averaging about $0.20 per capita in NY during this time, and less in NJ (Ursula Bauer, personal communication 2005). It might be expected that NY & NJ would have lower rates of smoking cessation than CA and higher cessation rates than states with lower excise taxes and cigarette prices during the study period.A third contrasting group are the six US states that accounted for >90% of tobacco production in the US during the study period.²¹ These have consistently had among the lowest excise taxes and cigarette prices in the nation,⁷ and none had a state‐specific tobacco‐control programme in the 1990s. In addition, evidence suggests that social norms are more supportive of tobacco use in tobacco‐growing regions.²² These tobacco‐growing states (TGS) are Kentucky, Tennessee, North Carolina, South Carolina, Virginia and Georgia, which together have a population slightly larger than CA, or NY & NJ. These states might be expected to show the lowest rates of successful smoking cessation during the study period.In this report, we assess changes in rates of successful smoking cessation from the 1980s to the 1990s in the US as a whole. We consider trends in cessation rates for three age groups of smokers: young adults (20–34 years), early middle‐aged adults (35–49 years) and late middle‐aged adults (50–64 years). We then compare rates of cessation in the 1990s for the three comparison groups of states: CA (high cigarette price and a comprehensive tobacco‐control programme), NY & NJ (high price but no comprehensive programme) and the TGS (neither high price nor programme). We limit consideration to non‐Hispanic whites because of considerable differences in tobacco‐use behaviour among race or ethnic groups that may confound the analysis,²³ and do not assess trends in cessation within state groups because of small sample sizes.     

Smoking cessation in homeless populations: a pilot clinical trial.

This study, which tested two motivational interviewing treatment approaches, assessed the feasibility of conducting a community-based smoking cessation intervention among homeless smokers. Participants (N = 46) were recruited from multiple facilities in the Kansas City area and were randomized to two counseling conditions in which they received five individual motivational interviewing sessions, six group meetings, and their choice of 8 weeks of 21-mg nicotine patch or 4-mg nicotine lozenge. The two counseling conditions consisted of motivational interviewing targeted either to smoking behaviors exclusively (smoking only) or to smoking and other addictions or life events that could affect ability to quit (smoking plus). Group meetings were designed to provide educational information and social support. Measures of feasibility assessed included the proportion of participants who returned for randomization among those eligible, adherence to prescribed nicotine replacement therapies, retention rates at the week 26 final study visit, and biochemically verified 7-day abstinence at week 26. Most participants (69.6%) chose nicotine patches, and 32% of those participants reported using at least four patches per week. Carbon monoxide verified 7-day abstinence rates in the smoking-only and smoking-plus groups were 13.04% and 17.39% (ns), respectively, at week 8 and 8.70% and 17.39% (ns), respectively, at week 26. Participants who used at least four patches per week were more likely to have quit at 8 weeks than were those who used fewer patches (33.3% vs. 10.5%, p = .30). Results support the feasibility of conducting a smoking cessation intervention among homeless smokers. Findings also show promising effects for nicotine replacement therapy and counseling in this population. Developing programs to improve smoking cessation outcomes in underserved populations is an essential step toward achieving national health objectives and for ultimately reducing tobacco-related health disparities.     

Mentholated cigarettes and smoking cessation: findings from COMMIT. Community Intervention Trial for Smoking Cessation

OBJECTIVE: To examine the association between the use of menthol cigarettes and smoking cessation, amount smoked, and time to first cigarette in the morning. BACKGROUND: The majority of African American smokers smoke mentholated cigarettes. Some evidence suggests that African Americans may be more nicotine dependent than whites. One theory is that menthol in cigarettes is responsible for enhancing the dependence producing capacity of cigarettes; however, few studies have prospectively examined the association between menthol use and indicators of nicotine dependence. METHODS: Baseline smokers from the Community Intervention Trial for Smoking Cessation (COMMIT) completed a telephone tobacco use survey in 1988 and were re-interviewed in 1993. Use of mentholated cigarettes was assessed by self report at baseline. Indicators of dependence examined were six month cessation in 1993, amount smoked among continuing smokers in 1993, and time to first cigarette in the morning in 1988. Multivariate regression techniques were used to assess the association of baseline menthol use with these outcomes while controlling for other factors related to dependence. RESULTS: Overall, 24% of the sample smoked a mentholated brand in 1988. No consistent associations were observed for menthol use and indicators of dependence in both overall and race specific analyses. Factors significantly associated with increased menthol use were female sex, age 25-34 years, African American and Asian race/ethnicity, greater education, greater than 60 minutes to the first cigarette in the morning, two or more past quit attempts, and use of premium brand cigarettes. Canadian respondents and those who smoked 15-24 cigarettes per day had lower rates of menthol use. Use of mentholated cigarettes was not associated with quitting, amount smoked, or time to first cigarette in the morning. CONCLUSION: Future work is needed to clarify the physiological and sociocultural mechanisms involved in mentholated cigarette smoking.     

Smoking cessation treatment on the Internet: content, quality, and usability.

The explosive growth in access to the Internet suggests that the Internet may be a viable channel through which we can reach and treat the large population of smokers who are unlikely to use other modes of intervention. We applied national guidelines from the U.S. Public Health Service to assess the quality of interventions for smoking cessation that are available on the Internet. The Public Health Service guidelines were codified into two instruments to record and to rate quality of the intervention contents. Usability guidelines established by the National Cancer Institute were used to develop an instrument to assess Web site usability. Of the 202 Web sites identified in searches, 77% did not provide direct intervention over the Internet and were excluded from analyses. A total of 46 Web sites were included in our review. Usability assessments showed mixed results. Web sites were visually well organized and used consistent graphical design; however, reading difficulty averaged above the 8th-grade level. Over 80% of Web sites provided no coverage of one or more of the key components of tobacco treatment recommended in the guidelines. Ironically, areas receiving the least coverage were those most amenable to the interactive capabilities of the Internet, such as providing tailored, personalized advice to quit and arranging follow-up contact. Smokers seeking quality tobacco dependence treatment on the Internet may have difficulty distinguishing among the numerous Web sites available. Web sites that provide direct treatment often fail to fully implement treatment guidelines and do not take full advantage of the interactive and tailoring capabilities of the Internet.     

Smoking reduction in the Lung Health Study.

We examined the ability of smokers who failed to quit smoking in the Lung Health Study to reduce the number of cigarettes per day and maintain this reduction and whether reduction predicted increased or decreased future cessation. In the Lung Health Study, among smokers with early lung disease who wished to stop smoking, 3923 were randomized to a special intervention of counseling and nicotine gum for smoking cessation and to bronchodilator therapy or placebo. Among the 1722 who were still smoking at the first year follow-up, 27% smoked the same, 43% smoked 1%-49% fewer, and 30% smoked at least 50% fewer cigarettes per day. Reduction in cigarettes per day was accompanied by reduction in expired-air carbon monoxide. About half of the less-than-50% reducers and one-fifth of the at-least-50% reducers maintained or exceeded this reduction over the next 4 years. Reduction was associated with nicotine gum use. Greater reduction at year 1 predicted more quit attempts in year 2 but not more point prevalence abstinence at year 2 nor more quits or abstinence between years 2 and 5. We conclude that reduction can be maintained but such reduction neither predicts an increased nor decreased probability of future cessation.     

Value to smokers of improved cessation products: evidence from a willingness-to-pay survey.

The present study demonstrated the use of willingness to pay to value hypothetical new smoking cessation products. Data came from a baseline survey of participants in a clinical trial of medications for smoking cessation (N=356) conducted in New Haven, Connecticut. We analyzed individual willingness to pay for a hypothetical tobacco cessation treatment that is (a) more effective than those currently available and then (b) more effective and attenuates the weight gain often associated with smoking cessation. A majority of the respondents (n=280; 84%) were willing to pay for the more effective treatment, and, of those, 175 (63%) were willing to pay more if the increased effectiveness was accompanied by attenuation of the weight gain associated with smoking cessation. The present study suggests the validity of using willingness-to-pay surveys in assessing the value of new smoking cessation products and products with multifaceted improvements. From these data, we calculated estimates of the value of a quit. For the population studied, this survey suggests a substantial market for more effective smoking cessation treatments.     

Smoking cessation interventions among Chinese Americans: the role of families, physicians, and the media.

This article describes the results from two studies of Chinese Americans. In one study, a convenience sample of patients completed face-to-face interviews to assess smoking patterns in the home, knowledge of tobacco, and ways in which health interventions could be communicated to the community. The other study involved two focus group discussions with the primary purpose of learning how spouses, health care workers, and the media can participate in smoking cessation interventions. A convenience sample of 795 patients at the Charles B. Wang Community Health Center in New York City's Chinatown was interviewed using face-to-face interviews. The focus group discussions were conducted using 15 volunteers. One discussion was conducted in Mandarin and the other in Cantonese. Although 92.7% of the respondents prefer people not smoke in the home, only 21% ban smoking with few exceptions. The focus group participants indicated that often the smoker is the oldest male and he also is the person who establishes the rules. Nearly half of the respondents receive most of their health-related information from their physician, and the focus group participants stated that physicians are highly regarded in their culture. Finally, the majority of respondents receive health-related information from Chinese language media. These results will assist in the planning of a smoking cessation intervention targeting Chinese Americans. The physician represents a key player in any intervention, and public health antismoking messages may be communicated effectively through Chinese language media.     

Smoking cessation by socioeconomic status and marital status: the contribution of smoking behavior and family background.

We studied socioeconomic status and marital status as predictors of smoking cessation, adjusting for previous smoking behavior and family background by using a large Finnish prospective twin dataset unselected for smoking behavior. The data were collected by postal surveys in 1981 and 1990, and the sample comprised 3,069 current smokers, of whom 20% had quit smoking by 1990. Logistic regression analyses of all twin individuals and conditional logistic regression analysis of discordant pairs were used to predict smoking cessation. High education predicted smoking cessation among both men (OR=2.32, 95% CI=1.31-4.10) and women (OR=3.98, 95% CI=1.85-8.51) as did high social class among women. Additionally, starting at a late age, smoking a small number of cigarettes per day, and a low level of nicotine per cigarette predicted cessation. Socioeconomic differences in cessation diminished only slightly when we adjusted for smoking behavior factors. Among the twin pairs who were discordant in terms of smoking cessation, the twin who continued smoking also smoked more on average at baseline (men: OR=.94, 95% CI=.89-.99; women: OR=.82, 95% CI=.71-.94). The male twins who continued smoking had a smaller probability of getting married during the follow-up than had the cotwin who had quit smoking (OR=3.91, 95% CI=1.02-15.02). Indicators of socioeconomic status were important predictors of smoking cessation even when we adjusted for previous smoking behavior. For men, marriage was associated with an increased probability of cessation     

Homelessness and smoking cessation: insights from focus groups.

Smoking prevalence among homeless persons is approximately 70%, yet little is known about tobacco use patterns or smoking cessation practices in this population. We assessed smoking attitudes and behaviors, psychosocial and environmental influences on smoking, barriers to and interest in quitting, and preferred methods for cessation among some homeless smokers. Six 90-min focus groups of current smokers (N = 62) were conducted at homeless service facilities. Participants had a mean age of 41.5 years (SD = 9.3), were predominantly male (69.4%) and African American (59%), and smoked an average of 18.3 cigarettes/day. Although most reported that they were motivated to quit, a number of barriers to quitting were identified. Participants reported that the pervasiveness and social acceptance of tobacco use in homeless settings contributed to smoking more cigarettes per day, adopting alternative smoking behaviors such as smoking cigarette butts and making their own cigarettes, and experiencing difficulty in quitting. High levels of boredom and stress also were cited as reasons for continued smoking. Smoking frequently occurred in combination with alcohol or illicit drug use or to achieve a substitute "high." Most participants (76%) reported that they planned to quit smoking in the next 6 months. Many were interested in using pharmacotherapy in combination with behavioral treatments. Results suggest that, although motivated to quit smoking, homeless smokers are faced with unique social and environmental barriers that make quitting more difficult. Interventions must be flexible and innovative to address the unique needs of homeless smokers. Smoking restrictions at homeless service facilities and funding for smoking cessation assistance in this underserved population may help to reduce prevalence.     

Dietary acrylamide exposure among Finnish adults and children: the potential effect of reduction measures

A deterministic exposure assessment using the Nusser method that adjusts for within-subject variation and for nuisance effects among Finnish children and adults was carried out. The food consumption data covered 2038 adults (25–74 years old) and 1514 children of 1, 3 and 6 years of age, with the data on foods’ acrylamide content obtained from published Finnish studies. We found that acrylamide exposure was highest among the 3-year-old children (median?=?1.01?µg?kg^?1?bw^?day^?1, 97.5th percentile?=?1.95?µg?kg^?1?bw^?day^?1) and lowest among 65–74-year-old women (median?=?0.31?µg?kg^?1?bw^?day^?1, 97.5th percentile?=?0.69?µg?kg^?1?bw^?day^?1). Among adults, the most important source of acrylamide exposure was coffee, followed by casseroles rich in starch, then rye bread. Among children, the most important sources were casseroles rich in starch and then biscuits and, finally, chips and other fried potatoes. Replacing lightly roasted coffee with dark-roasted, swapping sweet wheat buns for biscuits, and decreasing the acrylamide content of starch-based casseroles and rye bread by 50% would result in a 50% decrease in acrylamide exposure in adults. Among children, substituting boiled potatoes for chips and other friend potatoes and replacing biscuits with sweet wheat buns while lowering the acrylamide content of starch-based casseroles by 50% would lead to acrylamide exposure that is only half of the original exposure. In conclusions, dietary modifications could have a large impact in decreasing acrylamide exposure.     

Dietary acrylamide exposure among Finnish adults and children: the potential effect of reduction measures

A deterministic exposure assessment using the Nusser method that adjusts for within-subject variation and for nuisance effects among Finnish children and adults was carried out. The food consumption data covered 2038 adults (25-74 years old) and 1514 children of 1, 3 and 6 years of age, with the data on foods' acrylamide content obtained from published Finnish studies. We found that acrylamide exposure was highest among the 3-year-old children (median = 1.01 μg kg(-1) bw day(-1), 97.5th percentile = 1.95 μg kg(-1) bw day(-1)) and lowest among 65-74-year-old women (median = 0.31 μg kg(-1) bw day(-1), 97.5th percentile = 0.69 μg kg(-1) bw day(-1)). Among adults, the most important source of acrylamide exposure was coffee, followed by casseroles rich in starch, then rye bread. Among children, the most important sources were casseroles rich in starch and then biscuits and, finally, chips and other fried potatoes. Replacing lightly roasted coffee with dark-roasted, swapping sweet wheat buns for biscuits, and decreasing the acrylamide content of starch-based casseroles and rye bread by 50% would result in a 50% decrease in acrylamide exposure in adults. Among children, substituting boiled potatoes for chips and other friend potatoes and replacing biscuits with sweet wheat buns while lowering the acrylamide content of starch-based casseroles by 50% would lead to acrylamide exposure that is only half of the original exposure. In conclusions, dietary modifications could have a large impact in decreasing acrylamide exposure.