Cessation of Cigarette Smoking -- United States, 1989

Smoking-initiation and smoking-cessation interventions are important in reducing the prevalence of cigarette smoking in the United States. However, progress in smoking cessation has varied appreciably by smokers' age, race, sex, educational attainment, and state of residence (1,2). To monitor progress in smoking cessation in relation to these factors, data from the 1989 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed.

In 1989, health departments from 39 states and the District of Columbia participated in the BRFSS, a monthly random-digit-dialed telephone interview survey of adults aged greater than or equal to 18 years, to obtain information on selected health behaviors (3). Respondents were asked if they had ever smoked at least 100 cigarettes and if they currently smoked. The "quit ratio" was the percentage of ever smokers who were former smokers when interviewed. Ratios were weighted to represent the adult population of each participating state. To compare quit ratios between states, the weighted state-specific ratios were standardized for the age, race, sex, and educational attainment of the 1980 U.S. population. Quit ratios for subgroups (age, race, sex, and educational attainment) were standardized by adjusting for the other three variables.

The weighted quit ratio varied from 43% in Kentucky to 59% in Montana (median: 51%), and the standardized quit ratio from 41% in Oklahoma to 55% in Hawaii (Table 1). In general, standardized ratios were lowest in states in the Ohio River Valley and the south and highest in states in the Rocky Mountain and mid-central regions (Figure 1). The standardized quit ratio was also greater in persons greater than 35 years of age, whites, men, and persons with high school education or more (Table 2). Reported by: the following state BRFSS coordinators: L Eldridge, Alabama; J Contreras, Arizona; W Wright, California; M Adams, Connecticut; A Peruga, District of Columbia; S Hoecherl, Florida; J Smith, Georgia; A Villafuerte, Hawaii; J Mitten, Idaho; B Steiner, Illinois; S Joseph, Indiana; S Schoon, Iowa; K Bramblett, Kentucky; J Sheridan, Maine; A Weinstein, Maryland; L Koumjian, Massachusetts; J Thrush, Michigan; N Salem, Minnesota; J Jackson-Thompson, Missouri; M McFarland, Montana; S Spanake, Nebraska; K Zaso, L Powers, New Hampshire; L Pendley, New Mexico; J Marin, O Munshi, New York; C Washington, North Carolina; M Maetzold, North Dakota; E Capwell, Ohio; N Hann, Oklahoma; J Grant-Worley, Oregon; C Becker, Pennsylvania; R Cabral, Rhode Island; M Mace, South Carolina; S Moritz, South Dakota; D Ridings, Tennessee; J Fellows, Texas; L Post-Nilson, Utah; J Bowie, Virginia; K Tollestrup, Washington; D Porter, West Virginia; M Soref, Wisconsin. Office of Surveillance and Analysis, Div of Chronic Disease Control and Community Intervention, and Office on Smoking and Health, Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The differences between states in the weighted quit ratio can be explained only in part by state-specific differences in age, race, sex, and educational attainment of the populations, since these differences persisted after standardization for differences in sociodemographic composition. Other factors affecting smoking cessation that may explain the variations in smoking cessation by state include the percentage of heavy smokers (1), societal norms and attitudes about smoking cessation (1), and the existence, strength, and scope of smoking cessation services (4). Restrictions on smoking also may play a role in the variations by state in smoking cessation (1). In general, states with the lowest quit ratios have the highest prevalence of current cigarette smoking (2).

Concerns about the health effects of smoking (5) and the occurrence of smoking-related illnesses (6) may contribute to the higher quit ratios for persons aged greater than 35 years. Because continuing smokers are less likely than former smokers to survive to older ages, this differential mortality contributes to the higher quit ratios observed for older age groups (7). In addition, the higher quit ratios for older than for younger age groups may represent a longer opportunity to quit.

Findings in this and other reports (8) show that blacks were less likely than whites to be former smokers regardless of educational attainment. Limited use of established smoking cessation programs by blacks contributes to these racial differences (9). Nonetheless, trend data suggest that the rate of increase in the quit ratio since 1974 has been similar for whites and blacks (1,7).

Although men were more likely than women to be former smokers, the rate of increase in quit ratios over time has been similar for men and women (1,7). This finding is consistent with a diffusion phenomenon (i.e., quitting activity adopted initially by men that later diffused into the female population where it follows a pattern similar to that for men). Additionally, more men than women who quit cigarette smoking begin using cigars, pipes, or snuff or chewing tobacco (7). Thus, differences in smoking cessation by sex are smaller when use of other forms of tobacco are considered (7).

Greater difficulty in quitting among persons of low socioeconomic status may contribute to the lower quit ratios among persons with high school education or less (1). These and other findings suggest that smoking cessation interventions should target younger persons and persons of low socioeconomic status. In addition, such interventions should be aimed at blacks, who in general have a lower rate of smoking cessation than do whites (10).

Continued efforts are essential to motivate smokers to quit. Growth in tobacco-use prevention and control coalitions, which bring together a broad range of persons and organizations with the common goal of reducing the prevalence of tobacco use (11), will likely strengthen smoking cessation efforts by fostering a social climate that motivates smokers to quit. The American Stop Smoking Intervention Study, a planned 7-year project of the National Cancer Institute and the American Cancer Society, will substantially increase resources for tobacco control coalitions in the United States (12) and may accelerate progress in smoking cessation.

References

1. CDC. Reducing the health consequences of smoking: 25 years of

progress--a report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1989; DHHS publication no. (CDC)89-8411.

2. CDC. Regional variation in smoking prevalence and cessation: behavioral risk factor surveillance, 1986. MMWR 1987;36:751-4.

3. Remington PL, Smith MY, Williamson DF, Anda RF, Gentry EM, Hogelin GC. Design, characteristics, and usefulness of state-based behavioral risk factor surveillance: 1981-87. Public Health Rep 1988;103:366-75.

4. CDC. Smoking and health: a national status report. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1988; DHHS publication no. (CDC)87-8395.

5. Pechacek TF, Danaher BG. How and why people quit smoking: a cognitive-behavioral analysis. In: Kendall PC, Hollon SD, eds. Cognitive-behavioral interventions: theory, research and procedures. Vol 21. New York: Academic Press, 1979.

6. Ockene JK, Hosmer D, Rippe J, et al. Factors affecting cigarette smoking status in patients with ischemic heart disease. J Chronic Dis 1985;38:985-94.

7. CDC. The health benefits of smoking cessation: a report of the Surgeon General, 1990. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (CDC)90-8416.

8. Novotny TE, Warner KE, Kendrick JS, Remington PL. Smoking by blacks and whites: socioeconomic and demographic differences. Am J Public Health 1988;78:1187-9.

9. Orleans CT, Schoenbach VJ, Salmon MA, et al. A survey of smoking and quitting patterns among black Americans. Am J Public Health 1989;79:176-81. 10. Fiore MC, Novotny TE, Pierce JP, et al. Methods used to quit smoking in the United States: do cessation programs help? JAMA 1990;263:2760-5. 11. CDC. State coalitions for prevention and control of tobacco use. MMWR 1990;39:476-7, 483-5. 12. McKenna J, Carbone E. Huge tobacco control project begun by NCI, ACS. J Natl Cancer Inst 1989;81:93-4.

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