TABLE 5-Continued

Ad,ju\ted odd\ ratw\

Behavior
______
Other

Former \moher<
rrliltive to nevrr
  \mokrrr

Current \moherr
relative to fnexer
  \moher\

U\e ST               0.73             0.16"                I 53
U\e \eatbelt             I .03             0.6?             I .h3"

Physical Activity

Evidence from the 1985 NHIS. the 1987 BRFSS, and other cross-sectional studies
suggests that smokers are less likely than nonsmokers to make regular exercise part of
their lives (Goldbourt and Medalie 1975: Schoenborn and Benson 1988: Martin and
Dubbert 1982). These differences may be the consequence of cessation and result partly
from changes in physiologic function, such as lung function, that make exercise more
pleasurable or tolerable for former smokers compared with current smokers (Castro et
al. 1989). They also may retlect the former smokers' efforts to maintain abstinence.
Blair and colleagues (1980) found mixed results in their studies of workers in a South
Carolinacompany. Among men living within a 0.5 mile of work, current smokers were
less likely than never smokers to walk to work. Among women, former smokers were
more likely than either never smokers or current smokers to walk to work. (Mean
duration of abstinence for former smokers was not reported.) There were no significant
differences between smoking categories in other measures of physical activity, such as
time spent sitting, use of stairs versus elevator, level of leisure time versus physical
activity. and participation in a company exercise program. However. many measures
for former smokers were between those of current smokers and never smokers.

The 1985 NHIS used 2 measures of physical activity, the perception of being less
physically active than others and a more rigorous definition of sedentary behavior based
on subjects' reports of participation in 23 leisure activities during the preceding 2 weeks
(Schoenbom and Benson 1988). The perception of being less physically active was
significantly more common among current smokers than former smokers and never
smokers (Table 3). When separated by sex. these differences appear to be greater for
men than for women. Men who were former smokers were significantly less likely to
report being sedentary than current smokers and not significantly different from never
smokers. Among women. former smokers were significantly less likely than current
smokers and never smokers to be sedentary.

In two studies among Navy personnel. Conway and Cronan (1988a.b) studied the
relationship among smoking. exercise. and physical fitness. The first study (Conway
and Cronan 1988a) included 3.035 Navy personnel randomly selected from a group
who volunteered to participate in an evaluation of physical fitness and health. Both


TABLE 6.-Summary of data from 1987 BRFSS, behaviors of former smokers
     aged 18 and older by duration of abstinence

Behavior

MEN

Alcohol consumption
Any alcohol/ma
>5 drinks/episode
260 drinks/m0
Drinking and driving

Weight/diet/exercise
Obese (BMIJh
Obese (Met. Life)'
Trying to lose pound\
More exercise
Eating fewer kcal
Physical activity
Sedentary

Preventive care

Cholesterol test
Flu shot past month

Other

Use ST
Use seatbelt

WOMEN

Alcohol consumption
Any alcohol/ma
i1S drinks/episode
%Odrinks/mo
Drinking and driving

Weight/diet/exercise
Obese (BMIjh
Obese (Met. Life)'
Trying to lose pounds
More exercise
Eating fewer kcal
Physical activity
Sedentary

Preventive care

Cholesterol test
Flu shot past month

Adjusted odd\ ratlos by duration of abrttnence

13-21 mo relative to
I-12-moquitters

1.01               I .02
I .03               I .os
I 00               I .26
1.27               I.14

l.51d            1 .16L
I .45"            1.38"
I .02               I.18
0.85               I .06
0.92               I .16
0.98               1.13
I .02              0.88

0.94              I .03
0.88              0.96

0.64"
I .02

I .02            I .2R"
0.97              I .03
1.30              I .03
I .55              0.60

1.28            1.31"
1.07               1.16
1.17               1.15
0.97               I.10
1.10              1.01
I .os               1.06
0.95              0.95

0.89               I .05
1.26              0.97

25-60 mo relative to     261 mo relative to
I-1 2-mo quitter\      I-I?-moquitters

0.97            0.73"
I .09            I .22"

1 .09
0.95
I .09
I.17

I .13"
I .39"
I .08
0.86
1.37
I .25*
O.Sd

0.98
0.95

I .22"
0.83
1.15
0.72

I .42"
1 .30d
I .w
0.98
0.90
I.1 I
0.90

0.88
I .04

552


TABLE 6.-Continued

Adjusted odds ratios by duration of abstinence

Behavior


Other

13-24 mo relative to     25-60 mo relative to
l-l 2-mo quitters      I-I?-moquitten

261 mo relative to
I-I?-moquitter\

Use ST
Use seatbelt

0.49              0.27               I .07
I .28"              I.14            1.24.

NOTE: BRFSS=Beharlordl Ri\k Factor Survetllance Syrtem: ST=\mokelev tobacco
`Signtticantly different from I-12.mo quttten lp4.051. There were no significant difference\ nmung the three
categories of cesmon >I yr.
"BMI=body ma\\ index.
`Met. Life=Metropohtan Life hetght and weight Index.
SOURCE: Samet and W&t\. unpublished analye\ of the 19X7 BRFSS.

never smokers and former smokers engaged in significantly more exercise sessions per
week than did current smokers. Current smokers exercised for significantly less time
per session and had significantly lower overall physical fitness scores compared with
never smokers or former smokers. In a second study. the same authors examined the
association between physical fitness and smoking among 1,357 Navy men (Conway
and Cronan 1988b). Again, current smokers had poorer levels of physical fitness with
lower scores than former smokers or never smokers on tests of cardiorespiratory and
muscular endurance. Overall, never smokers performed better than former smokers
and current smokers. In both studies, participants were young, with an average age of
26 years (study 1) and 28 years (study 2). suggesting that both decrements associated
with smoking and improvements associated with quitting can appear at an early age.

A cross-sectional study of 78 1 runners found that as mileage increased, the percentage
of self-defined former smokers also increased (Macera, Pate, Davis 1989). These
investigators suggested that high-mileage runners seemed to quit smoking at a higher
rate than low-mileage runners. Although the sample size was probably too small to
show significant differences and the data were cross-sectional, the results support both
empirical and anecdotal data about the relationship between abstinence from smoking
and increased participation in exercise. Gordon and Polen ( 1987) studied 1,061 men
and women who participated in smoking cessation clinics at Kaiser Permanente medical
facilities from 1980 to 1983. Men and women who had increased their exercise after
program participation were more likely to be abstinent from smoking 7 to 12 months
later. These studies suggest that increasing exercise may be part of a former smoker's
efforts to remain abstinent, a direct consequence of cessation, or both. The study by
Gordon and Polen ( 1987) lends support to the first hypothesis.

The 1987 BRFSS allows a comparison among current smokers, never smokers, and
former smokers on a range of health practices (Table 5). Two measures of physical
activity were used. One asked a very general question about any physical activity in
the past month, including nonaerobic activities, such as gardening. as well as major
aerobic activities. The second identified sedentary lifestyle as the lowest category on


a complex scale of life activities. On both measures. men and women who had quit
smoking were more active than nev'er smokers. who were in turn more active than
current smoLer\. Among men, those who had been smoke-free for more than 5 years
here significantly more active and less sedentary than neu quitters, those who had been
abstinent less than I year. This difference was not significant among women.

Prospective investigations of changes in physical activity after smoking cessation
have indicated either no change or an increase in activity (Chapter IO). An additional
prospective study focusing on exercise specifically. rather than weight changes, also
found increased exercise among quitters.  In a l-year study of a large worksite
population, Orleans and associates ( 1983) found that 71 recent ex-smokers (mean
abstinence, 7 months) significantly increased their self-rated levels of activity compared
with 347 continuing smokers (~~0.01) and that the ex-smokers achieved significant
increases (p<O.O I ) from a prequitting baseline in the frequency of activities involving
moderate exertion, such as walking or climbing stairs. Gordon and Cleary (1986)
analyzed data from the 1979-1980 National Survey of Personal Health Practices and
Consequences and found a more limited positive relationship. Aerobic exercise in-
creased for women who tried to quit smoking but was not related to successful quitting
in the last year among women or to any change in smoking behavior among men.

More studies are needed to clarify the effects of smoking abstinence on the level of
physical activity. The relationship between increased physical activity and smoking
abstinence may be a consequence of cessation, may reflect more successful quitting
among smokers who have a higher level of prequitting physical activity. may be
evidence that former smokers use exercise as a strategy to avoid smoking, or as a way
to deal with the possible adverse effects of weight gain. or may be due to some
combination of these possibilities. The cross-sectional nature of the data available do
not permit a conclusion with regard to these alternatives.

Dietary Practices

Cross-sectional data from NHIS. BRFSS, and other studies present a mixed picture
of the dietary practices of smokers, former smokers, and never smokers. Schoenbom
and Benson (1988). reporting on the 198.5 NHIS, found that current smokers are more
likely to skip breakfast than never or former smokers (Table 3). This finding is
consistent with the 1987 NHIS data showing that both former and never smokers are
more likely than current smokers to eat no more than or no less than three meals a day
(Schoenbom and Boyd 1989) (Table 4). As shown in Table 4, whether former smokers
are more likely. less likely, or equally likely to eat three meals than are never smokers
depends on gender and whether the day is a weekday or weekend day. Two NHIS
surveys present contradictory results on snacking. The age-adjusted 1985 study indi-
cated that among women, former smokers are the most likely to snack, but that there
was no significant difference among men (Table 3). Raw percentages in the 1987 NHIS
data show that among men, former smokers avoid snacks more than either never or
current smokers, but that among women. there is essentially no difference (Table 4).

BRFSS data (Table 5) indicate that former smokers are the most likely group to be
"trying to lose weight," although no more likely than never smokers to be obese.

554


Similarly, the 1987 NHIS data show that former smokers of both sexes are the most
likely to report that they have changed their diet for the sake of their health (Table 3).
In these same NHIS data. not controlled for age, men who are former smokers are more
obese than never smokers, although women who are former smokers and never smokers
are equally likely to be obese.  Among the 10.000 Israeli men in Goldbourt and
Medalie's 1975 study of Government employees. former smokers (duration of
abstinence not noted) consumed fewer calories and were more likely to be on some sort
of special diet for weight loss, diabetes, heart disease, hypertension. or ulcers. Former
smokers surveyed for all three of these data sets may have initiated special diets or quit
smoking following the diagnosis of illness. However, the Israeli data demonstrate that
among those individuals who had experienced heart attacks or peptic ulcers, former
smokers were more likely to report themselves compliant with their diets than current
smokers (Goldbourt and Medalie 1975).

Former smokers often report retrospectively that they increased food consumption
when they quit smoking (Carmody et al. 1986). The first part of this Chapter and a
review by Hughes, Higgins, and Hatsukami (1990) indicate that increased hunger and
appetite are common smoking withdrawal reactions, often extending beyond the initial
4-week withdrawal period. However, most longitudinal studies of changes in dietary
practices after quitting have examined only short-term changes (Chapter IO). The
majority of these studies have found evidence for increased dietary intake, especially
of sweet foods and simple carbohydrates, after quitting. In a prospective study Orleans
and coworkers (1983) found approximately a 6-pound weight gain at l-year followup
over baseline for 72 former smokers who had been abstinent from cigarettes for an
average of 7 months. These researchers also found evidence for significant (p<O.Ol)
improvements in overall nutritional practices for former smokers.

Better dietary behavior among former smokers when compared with current smokers
may reflect changes made by former smokers in their efforts to remain abstinent. a
response to their concerns regarding possible weight gain, or an overall desire to be
healthy that is motivated by smoking cessation. Adequate data are not available to
permit an assessment of these alternative hypotheses.

Use of Other Substances

Other Tobacco Products

In data from the United Kingdom, the cessation of cigarette smoking has been linked
to the increased use of other smoked tobacco products, including pipes and cigars, by
men (Jarvis 1984). These researchers noted that many of the alleged gender differences
in cigarette smoking cessation rates are due to the adoption of pipe and cigar use by
men. Comparable analyses have been performed on data from the 1987 NHIS Cancer
Epidemiology and Control Supplement (Schoenbom and Boyd 1989) (Volume Appen-
dix). When former cigarette smokers who used any other forms of tobacco were
reclassified as smokers, the difference in cessation rates between men and women
decreased.


Data from the I987 NHIS indicate that the overall prevalence of the use of smokeless
tobacco products and cigars or pipes is low; the prevalence of use ranges from 3.0 to
5.2 percent for men and from 0 to 0.5 percent for women: former cigarette smokers are
more likely than never cigarette smokers to be current smokers of pipes or cigars (Table
7). Because the prevalence of pipe or cigar smoking increases as a function of age, it
is important to use age adjustments in future investigations of the relationship between
cigarette cessation and pipe or cigar smoking.

Alcohol

Smokers are more likely than nonsmokers to drink alcohol and use other drugs (Istvan
and Matarazzo 1984: US DHHS 1988). Cross-sectional data from the 1983 NHIS
(Kovar and Poe 1985) show a strong association between smoking status and daily
alcohol intake (Figures 3 and 4): former smokers tend to be heavier drinkers than are
never smokers, and daily alcohol intake increases with heavier smoking (Kozlowski
and Ferrence 1990). The drinking and smoking scales differ for men and women to
compensate for the relative rarity among women of very heavy drinking and heavy
smoking: at the same levels per day as men, fewer drinks per day are required for women
than for men to be placed in the "heavy drinking" category.

In the 1987 NHIS, alcohol consumption was divided into beer, wine, and liquor
consumption. Published data report on the proportion of respondents consuming "5 or
more drinks per week" and "3 or more drinks on days you drank" for each category.
These data are generally consistent with the 1983 (Figures 3 and 4) and the 1985
age-adjusted NHIS data (Table 2) and with the age-, education-, and ethnicity-adjusted
data from the 1987 BRFSS (Table 5) in showing lower alcohol consumption among
former than among current smokers but higher than among never smokers. These data
regarding alcohol consumption of former smokers are also consistent with data
presented previously in this Chapter on the short-term effects of smoking abstinence
on alcohol consumption (Hughes and Hatsukami 1986; Olbrisch and Oades-Souther
1986; Puddey et al. 1985).

In the 1987 BRFSS survey, two measures of alcohol were used: the amount consumed
and whether drinking and driving occurred together (Tables 5 and 6). Men and women
who had quit smoking drank significantly more than never smokers and were sig-
nificantly more likely to drink and drive. However, former smokers drank significantly
less than current smokers and were significantly less likely to drink and drive.

The intermediate position of former smokers seen in the 1987 BRFSS and the 1985
NHIS is paralleled in the 1987 NHIS by the percentage of both sexes who drink five
beers or more per week, the percentage of women who drink three glasses or more of
wine when they drink wine, and the percentage of men who drink three drinks or more
when they drink liquor (Table 4). In the 1987 NHIS, male former smokers are
significantly less likely than either comparison group to have three beers or more when
they drink beer or three glasses or more of wine when they drink wine. Although a very
small percentage of adults drink wine or liquor five times or more per week, men who
are former smokers are more likely than current or never smokers to drink this often.
Female former smokers are more likely than current or never smokers to drink wine

556


TABLE 7.-Percent distribution of persons aged 18 and older by tobacco product and use status, according to gender and
     cigarette smoking status, United States, 1987

Tobacco product
and use status

Total

  Both genders

Never     Fomler
wlokers     smokers

Current
smokers

          Men                          Women

     Never    Former    Current           Never   Former   Current
Total   \moker>   smohers   smoher5     Total   smokers  wwkers   smokers

Total

Chewing tobacco
Never
Former
Current

Snufl
Never
Formrr
Current

Pipe
Never
Former
Current

Cigars
Never
Formrr
Current

100.0     IWO

93.X      96.7
4.2       I .x
2.0       I .s

Y5.Y      Y3.3
2.4       I.1
1.7       I .6

01.1      Yl.4
7.3       I .7
I .6       0.x

8Y.X      02.0      X7.6    02.5
7.3       5.x       x.3     4. I
2.`)       2.2       4.0     3.4

04.3      94.x      02.3    Y4.6
3.x       3.5       4.7     2.4
I .Y       I .6       3.0     3.0

79.3      x0.7      8 I.5    Y3.Y
IX.5       7.0      15.2     4.4
2.2       2.3       2.3     2.2

x03      x0.7      Xl.7    Y2.S
16.3       6.2      13.1     4.4
3.2       3.1       5.2     3. I

I(w).0     Ion.0     100.0

x3.s     X.5.3     YY.3
I I.Y     IO.6      0.4
3.6      4. I      0.3

00.9     Y0.S     YY.2     YY.0
h. I      6.4      0.4      0.3
3.0      3.1      0.5      0.7

x5.`)     x03     YY.7
30.4     IS.1      0.3
3.7      4.4     (HP

x7.x     x0.x     YY.6     YY,X
2h.Y     I I.5      0.3     O.ll'
5.3      7.X     0. 1,'     0.0"

loo.0

09.3
0.3
0.4

lot).0
00"

I00.0     Iwo



YY.2     YY.2
0.6      0.6
0.2"     02



00.2     YY.4
0.5      0.5
0.3"     0. I"



YY.2     YY.5
0.x      0.4
0.0:'     0."'



09.4     YY.2
0.6      0.6
0.0"      0. I"


  Never  Fommr <l-lo/day 11-2Olday 213lday 3lWday

SMOKING STATUS

* l/day 0 2-3/day 0 4-6,fday O L7lday

FIGURE 3.-Drinking relative to smoking status for men, 1983 NHIS (Kovar
       and Poe 1985)

NOTE: Samples for each category are. from never smoker to hewlest smoker. 1.397. X74.295.653.
263. 100. S7. NHIS=Natlonal Health IntervIew Survey.

SOURCE: Kozlowrki and Ferrence (1990).

five times or more per week; they are as likely as current smokers to drink liquor this
often. However, this represents a very small proportion of women. Female former
smokers are less likely than current smokers and no more likely than never smokers to
drink three beers or more when they drink beer or to have three drinks or more when
they drink liquor.

These cross-sectional data are consistent with other cross-sectional data that
demonstrate a relationship between alcohol use and smoking status (Istvan and
Matarazzo 1984). However, the contribution of tobacco cessation to alcohol and drug
use by individuals with alcohol and drug problems is unknown (Sobell et al. 1990). The
majority of smokers consume approximately 1 pack per day, and most smokers do not
have serious alcohol problems. The most significant effects might be seen in those few
individuals who both smoke very heavily, more than 40 cigarettes per day, and use
drugs or alcohol heavily (Kozlowski and Ferrence 1990). Bobo (1989) and Miller,
Hedrik, and Taylor ( 1983) reported data that indicate that smoking cessation does not

558


          Fofmw  4.1Oldmy ll-2Oiday 214Ww ,3Vdy

SMOKING STATUS

     aNever !!?&12/yr    NIvrrHuvy
     O tc+luvy rnl/deyU~2/dy

FIGURE 4.-Drinking relative to smoking status for women, 1983 NHIS
       (Kovar and Poe 1985)

NOTE: Samples for each category are. from never smoker to heavle\t
smoker. 2.661,789. SOS, 7X6.10.5. 176. NHIS=National Health Interview Survey.

SOURCE: KoAow4.i and Ferrence ( 1990).

impair the course of treatment for alcohol problems and may be associated with better
outcomes.

Studies of Multiple Health Habits

It is of interest to examine not only single behaviors, such as diet or exercise, in
relation to smoking cessation, but also combinations of behaviors. Use of alcohol and
other substances, use of other tobacco products, coffee consumption. physical activity,
and diet have been the health behaviors studied most widely in conjunction with
smoking and smoking cessation.

Schoenbom and Benson (1988) reported on the following eight unhealthy behaviors
surveyed in the 1985 NHIS: sleeping 6 hours or less, skipping breakfast, snacking daily.
being less physically active than other persons of the same age, being sedentary in terms
of leisure-time sports activities, being significantly overweight (IO percent or more
based on the 1983 Metropolitan Life Insurance Company standards). drinking heavily


(an average of two drinks or more/day), and having five drinks or more on IO days or
more. The authors used age-adjusted percentages to eliminate age as a confounding
factor. With the exception of snacking and being overweight, current smokers engaged
in unhealthy habits at significantly higher rates than never smokers (Table 2). Former
smokers more closely resembled never smokers than current smokers. Fewer former
smokers and never smokers than current smokers slept 6 hours or less, never ate
breakfast, were less physically active, or were sedentary. However, former smokers
tended to snack daily and be overweight in slightly higher percentages than current
smokers. which is concordant with the previously noted findings regarding dietary
practices and smoking abstinence.

Marsden, Bray, and Herbold (1988) examined substance use and other health prac-
tices in a large cross-sectional study of more than 17.000 military personnel. These
researchers found the number of positive health practices inversely related to use of
alcohol. illicit drugs, and tobacco. On the basis of a very preliminary retrospective
study of 35 heart disease patients. Finnegan and Suler (1985) concluded that former
smokers (mean duration of abstinence, unspecified) were more likely to maintain diet
and exercise changes. Former smokers may have represented a particularly adherent
subgroup of patients, but the authors postulated that success in maintaining diet and
exercise changes may have been influenced by the psychological effects of attempting
cessation.

Maron and colleagues (1986) examined seatbelt use in a sample of high school
students and found modest but significant negative effects of smoking, frequency of
getting drunk, and illicit drug use (cocaine and marijuana), and positive effects of
"heart-healthy nutrition" and physical activity on seatbelt use. In a study of 874
community college students, Castro and associates (1989) found that moderate-to-
heavy smokers had exhibited more unhealthy behaviors than nonsmokers. As in some
of the other cross-sectional studies reported here, these investigators did not distinguish
former smokers from never smokers.

Among males. former smokers interviewed as part of the 1987 BRFSS (which
examined multiple health behaviors) were more likely than current smokers but less
likely than never smokers to use seatbelts. However. among females, never smokers
and former smokers were equally likely to use seatbelts, and both were significantly
more likely to use seatbelts than current smokers (Table 3). Long-time quitters were
more likely than new quitters (<I year) to use their seatbelts, although this association
was small and significant only for men who had been abstinent from smoking cigarettes
for 5 years or more and for women abstinent for 1 to 2 years and for 5 years or more
(Table 5).

Among Multiple Risk Factor Intervention Trial (MRFIT) participants. Schoenen-
berger (1982) found that smokers who had quit between baseline and a 3-year followup
survey made successful changes across a number of dimensions. Former smokers were
more likely to avoid gaining weight, to lower their serum cholesterol, and, if hyperten-
sive, to lower their blood pressure. Supporting the conclusions of Schoenenberger
(1982) regarding MRFIT participants, Tuomilehto and associates (1986) studied a
random sample of 2, I 19 Finnish subjects at 2 points in time and found that both men
and women who had quit smoking between baseline and the 5-year followup reduced

560


their fat intake, increased their physical activity. and made more attempts to reduce
body weight than did current smokers.  Baseline differences suggested that these
quitters (duration of abstinence not specified) may have been more health conscious at
the outset.

Orleans and colleagues (1983) performed a prospective analysis of health behavior
changes experienced by 72 employees quitting smoking between baseline and year one.
As part of the "Live for Life" program they included baseline health behavior values.
age, and sex as covariates. Their findings indicated an overall positive shift in healthy
lifestyle with improvements in subjective health status, emotions, and well-being. New
ex-smokers (average abstinence, 7 months) showed improvements over baseline in
resting pulse. perceived personal control over preventable illness, knowledge of health
risks, overall nutrition practices, regular moderate exercise. and seatbelt use. The only
negative changes were body mass and weight changes associated with slightly less than
a mean 6-pound weight gain, which took place along with an improvement in overall
nutrition, and declines in job satisfaction measured by satisfaction with growth oppor-
tunities and personal relationships on the job.

Summary

In the absence of more systematic longitudinal research, data from cross-sectional
and longitudinal studies suggest that abstinence from smoking is related to improve-
ments in other positive lifestyle behaviors contributing to overall good health. These
behaviors may be used by the former smoker to prevent relapse (e.g.. exercise), to cope
with adverse withdrawal symptoms (e.g., increased food intake as a response to
increased appetite), or as part of a commitment to a healthier lifestyle. Exercise may
help new quitters to remain abstinent and to avoid or minimize weight gain. The data
from the MRFIT (Schoenenberger 1982) and other large data bases (Friedman et al.
1979) confirm that former smokers often take active steps to lower their disease risks,.
These studies should alleviate concerns that smoking cessation may result in unhealthy
lifestyle shifts through unwanted symptom substitution.

Given the strong association between smoking and other kinds of substance use. it is
important to know if smoking cessation impairs the ability to stop other drug use. The
limited evidence suggests that this is not the case (Bobo 1989; Miller. Hedrih. Taylor
1983). How multiple drug use and multiple drug withdrawal may interact with cigarette
smoking and its cessation is an area requiring study.

PARTICIPATION OF FORMER SMOKERS IN HEALTH-SCREENING
                  PROGRAMS

The literature presented earlier in this Chapter suggests that former smokers are more
likely than current smokers to engage in a variety of health-enhancing behaviors, such
as regular physical activity.  Another area in which improvement may occur for
individuals who stop smohin g i\ participation in. or benefits from. health-screening
programs. Participation in programs of health screening by those who are presumably
healthy and asymptomatic is ;I health-enhancing or health-protective behavior. much


like wearing vzatlxlts or performing regular exercise.  This participation is to be
distinpui\hed from health \creeninp bought for diagnostic purposes. Calnan and Rutter
( 1986) cautioned, however. that there are important conceptual difference\ between
behavior5 such as not smoking or regular flossing and utilization of screening. In the
first case. the emphasis is on the individual performing the recommended action. In
the second, the individual makes a decision to use the service. but a professional
performs the procedure. Smokers exhibit a decreased propensity to use preventive
services in contrast to nonsmokers. The data suggest that former smokers occupy an
intermediate position between current and never smokers in their seeking of health
screening.
Data from the large Johnson and Johnson "Live for Life" worksite trial discussed
earlier showed that current smokers were less willing than former or never smokers to
complete health risk assessments (Shipley et al. 1988). A survey of randomly selected
nonrespondents to the "Live for Life" health screening found that significantly more
nonrespondents reported ever having smoked cigarettes and significantly more female
nonrespondents currently smoked (Settergren et al. 1983). Additional support for the
position that smokers may have lower response rates to health risk appraisals is provided
by Seltzer, Boss& and Garvey (1974). who found current smokers significantly less
likely than never smokers to respond to a health questionnaire.
One source of data about the health-screening practices of former smokers consists
of results from a 1988 nationwide randomized survey of American Association of
Retired Persons (AARP) members aged 50 and older to assess differences among
current smokers, former smokers (abstinent for 1 week or longer with a mean duration
of 19.3 years), and never smokers (Rimer et al. 1990). In addition to the usual
quitting-related variables. respondents were asked about their use of health services,
including routine cardiovascular and cancer screening. Questionnaires were received
from 3. I79 persons, a %-percent response rate. In this older population for whom
health screening is especially important. the never, current, and former smokers differed
significantly on utilization of screening (Table 8). The results suggest that smoking
may act as a deterrent to appropiiate use of screening services for older smokers and
possibly for younger smokers as well, or that there is a general unhealthy approach
taken by smokers. That former smokers were more likely to avail themselves of
preventive checks and services than current smokers suggests that former smokers may
have a more preventive health orientation than current smokers. may participate in
screening as an approach to maintain abstinence, or may be concerned about the effects
of smoking on their health. As with exercise and other health promotion practices. the
data are retrospective: therefore. it cannot be determined if the former smokers were
always different from current smokers in their health screening habits or if they changed
as a result of cessation.

The results of the AARP survey suggest that with time former smokers may resemble
never smokers in their use of screening services. Maintaining health was the primary
reason for quitting among former smokers who responded to the AARP survey; perhaps
the subset of smokers who quit was more health conscious at the outset. Or having quit.
former smokers may be more willing to take a proactive stand to maintain their health.
It is also possible that having admitted vulnerability to the harms of smoking and

562


TABLE 8.-Physician visits and medical tests within the past year among
     AARP members aged 50 and older, by smoking status

Current      Former
smokers     smokers
(N=339)    (N=l489)
II%       47%

Never
smokers
(N=l316)
42%

Overal I
(N=3147)
100%

p-value'

Physician visit
(21)

77        88         86        X6        <O.ool

Complete physical or
checkup

Blood pressure check

Electrocardiogram


Stool blood test

50        60         60        59        <O.OOl




79        90         x7        x7        <O.OOl


41        52         4s        4X        <o.oo I


28        3x         36        36        <o.oo I

Digital rectal
examination

23        34         30        31        <O.OOl

Mammogram
(women only)

24        41         36        36        co.0 13

Pap smear (women only)

33        43         39        40        <0.006

NOTE: All rates are age adjusted.  AARP=Amencan Aw~~atwn of Retired Perwn\
"Current smoker\ vs. former or never hmoken.
SOURCE: Rlmer er al. (IWOL

experiencing the benefits of quitting, former smokers are more amenable to adopting
other health-enhancing behaviors.  This would be consistent with the tenets of the
Health Belief Model (Janz and Becker 1984) and with preliminary findings about the
increased value of health expressed by self-defined former smokers (Tipton and
Riebsame 1987).

In two measures of disease prevention assessed in the 1987 BRFSS data, male former
smokers appeared to be more health conscious than current smokers and at least as much
as never smokers (Table 5). These individuals are significantly more likely than never
smokers to have had their cholesterol tested in the past year; never smokers. in turn, are
more likely than current smokers to have had this test. Although former smokers were
slightly more likely than never smokers to have had a flu shot in the past month, this
difference was not statistically significant.  Both former smokers and never smokers
were significantly more likely to have had the shot than were current smokers. Female
former smokers were more likely to have had their cholesterol tested than were never
smokers, but were not significantly different from current smokers. Women in all three
smoking categories were similar, indicating no statistically significant differences in
their probability of having received a flu shot in the past month. Among former

563


smokers. length oftime since cessation did not predict any differences in either ofthese
behaviors among men or women.

The 1987 NHIS data show higher rates of preventive care among former smokers
than among never or current smokers (Table 4). Women who hadquit were significant-
ly more likely to report ever having had a digital rectal exam. a stool blood test. and a
proctoscopic exam. Women who had stopped smoking were also significantly more
likely to have had a Pap smear or a breast examination within the past year and to ever
have had a mammogram. However. women did not differ by smoking status in their
practice of monthly breast self-examination. These data did not control for age and
may reflect the greater number of former smokers in the higher risk ages. in addition
to the unavoidable problems inherent in cross-sectional data such as not being able to
determine the order of smoking cessation and preventive care.
A study of participation among 600 female members of a health maintenance
organization showed that female smokers were less likely than former smokers or never
smokers to complete a health risk assessment or to obtain mammograms (Rimer et al.
1988. 1989). When residents of a large retirement community were surveyed about
their health habits, Chao and colleagues (1987) found differential use of several
screening tests. including blood pressure, fecal occult blood tests, mammograms, and
Pap tests among current smokers. former smokers. and never smokers, with former
smokers having the highest rates of screening. Macrae and colleagues (1984) studied
581 individuals vvho completed health questionnaires before being offered fecal occult
blood tests. These researchers found that whereas smokers were not less likely to
decline the initial offer, they were significantly less likely to comply, that is. to follow
through with the test. These same investigators suggested that smokers may have been
more susceptible to interpersonal pressure publicly. but later succumbed to a strategy
of defensive avoidance. Although Macrae and associates ( 1983) did not distinguish the
screening behavior of never smokers and former smokers. other studies reported here
suggest that these groups would have been similar.

The suggestion that former smohers are more oriented to prevention and early
detection is also consistent with Verbrugge's (1981) conclusions that smokers have
poorer health. increased risks due to smoking. and are more oriented to remedial as
opposed to preventive health actions.  As smokers move toward maintenance of
nonsmoking. they appear to value their health more highly (Tipton and Riebsame 19X7:
Horwitz, Hindi-Alexander. Wagner 1985). This finding is consistent with the greater
utilization of screening found among AARP former smokers (Rimer et al. 1990). These
findings undoubtedly are affected by the relationship between socioeconomic status
(SES) and preventive care utilization. That is. lovver SES is associated with less use of
preventive services (Dutton 1986). To the extent that they are represented dispropor-
tionately among those of lower SES, current smokers will be at risk for underuse of
age-appropriate prevention and early detection services.

The literature about the health screening practices of fomrer smokers is suggestive
but inconclusive. It appears that former smokers are more likely than current smokers.
but perhaps less likely than never smokers. to seek regular cardiovascular and cancer
screening C.

564


SUMMARY

The data suggest that as the duration of abstinence lengthens, former smokers begin
to resemble never smokers in their utilization of health screening and their participation
in a variety of health-enhancing behaviors, such as physical activity. However, it is not
clear if former smokers are different from current smokers at the outset, if the method
of cessation affects these outcomes. or if the reason for quitting affects subsequent
health practices. There is reason to believe that former smokers, especially those who
quit while they are healthy, come to value their health more and take health-enhancing
action as an extension of this valuing (Tipton and Riebsame 1987). These conclusions
are consistent with the Health Belief Model (Janz and Becker 1984) and the Protection
Motivation Theory (Prentice-Dunn and Rogers 1986). Longitudinal. prospective
studies would make an important contribution to understanding these issues.

Increased participation in screening and other health-enhancing behaviors also may
result from enhanced self-esteem and an increased sense of self-control. Ockene and
colleagues (1988) concluded that successful behavior change is likely to promote a
perception of general self-efficacy. The perception of oneself as capable may general-
ize to other areas of one's life. Kronenfeld and associates (1988) stressed that it may
be difficult for most people to change multiple habits simultaneously. Having gained
a sense of mastery from stopping smoking, former smokers may attempt to improve
other health practices. However, some studies suggest that former smokers seem to
undertake a number of health-enhancing steps proximally, if not simultaneously
(Schoenenberger 1982; Friedman et al. 1979; Gerace et al., in press). For example,
quitters in MRFIT (baseline smokers who were biochemically verified ex-smokers at
the sixth annual visit) reported a greater decrease in their number of alcoholic drinks
per day and sucrose consumption than nonquitters (Gerace et al., in press).

CONCLUSIONS

1, Short-term consequences of smoking cessation include anxiety, irritability, frustra-
tion, anger, difficulty concentrating, increased appetite. and urges to smoke. With
the possible exception of urges to smoke and increased appetite. these effects soon
disappear.

2. Smokers who abstain from smoking show short-term impairment of performance
on a variety of simple attention tasks, which improves with nicotine administration.
Memory, learning, and the performance of more complex tasks have not been
clearly shown to be impaired. Whether the self-reported improvement in attention
tasks upon nicotine administration is due entirely to relief of withdrawal effects or
is also due in part to enhancement of performance above the norm is unclear.
3. In comparison with current smokers, former smokers have a greater perceived ability
to achieve and maintain smoking abstinence (self-efficacy) and a greater perceiv,ed
control over personal circumstances (locus of control).
4. Fomler smokers, compared with current smokers, practice more health-promoting
and disease-preventing behaviors.


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