35



30



25



20



15

go
s
is5
ii
Q-0

YEARS

    <12 yr
- Education

                        ?16 yr
+   12yr
   Education   + 13-15 yr
                 Education    -a-  Education

FIGURE S.-Percentage of ever smokers who never tried to quit, by education,
      United States, 197447

  SOURCE: NHlSs 1974, 1976, 1978. 1979, 19X0. 1987; OSH, unpublisheddata.
5


                                         //
                                                   I I
1978            1979           1980                      1987

YEAR

  m cl2 yr   w 12yr    p`
                       13-15 yr   111 216 yr

        Education       Education       Education        Education

FIGURE &-Percentage of persons smoking at 12 months prior to the survey
      interview who quit for at least I day during those 12 months,
      United States, 197840, 19X7, by education
<Ol `KC-F  Nv)tlS\ l`b7X I Q7c) IUXO I')X7. O`GII. unrwhl~\hrd d;it;~.


8

6

4

                                                                           __________________





.____-____ -_                                                                         ____________





                              --_____--____



  I

I    I    I    I    I    I    I    I    I    I    1    I    I    I    I    I    I    I    I    I    I    I    I    I

1965            1970            1975            1980            1985            1990
YEAR

+   <12 yr     -8   12yr
    Education         Education   ++ 13-15 yr
                               Education  * E%z%h

FIGURE 7.-Percentage of ever smokers who had been abstinent for less than
      1 year, United States, 1966437, by education
SOURCE: NHISs 196f1. 1970. 1978, 1979, 1980. 1983. 198.5. 1987; OSH. unpublished data.


I    I    I    I    I    I    I    I    I    1    I    I    I    I    I    I    I    I    I    I    I    I    I    I

1965             1970            1975             1980             1985             1990

YEAR

e   <12 yr    +   12yr
    Education        Education   + 13-15 yr
                               Education   ++ 216yr
                                             Education

FIGURE &-Percentage of ever smokers who had been abstinent for l-4 years,
     United States, 1966437, by education

SOURCE: NHlSs 1966. 1970, 197X. 1979, 1980. 1983. 19X5. 1987: OSH, unpublisheddata.


  50





  40





  30





  20

8
s 10
5
; *
c-8 0

____________-___________________________------------------------------------------------------------------------------------





  I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I    I

1965             1970            1975            1980             1985            1990

YEARS

    Cl2 yr
- Education

+   12 yr
   Education   + 13-15 yr
                 Education  * E~~~~`on

FIGURE 9.-Percentage of ever smokers who had been abstinent for 5 years or
      more, United States, 1966-87, by education
SOURCE:  NHISs 1966, 1970, 1978, 1979, 1980, 1983, 1985, 1987: OSH. unpublished data.


Percentage of Those Smoking at 12 Months Prior to a Survey Interview Who
      Quit for at Least 1 Day During Those 12 Months

The percentage of those smohing at I:! months prior to a survey interview who
stopped for at least I day during those 12 months is a measure of quitting activity-that
is,, quitting attempts-independent of the success of those attempts. Trend data show
that this percentage was slightly higher in 1987 than in the 3 earlier years (1978. 1979.
and 1980) in all educational strata (Figure 6).

Data show an effect of all demographic variables (gender, race, education, and age)
on quitting for at least 1 day (Table 5). Females are significantly more likely to be in
this category than are males. Blacks, more than whites, are more likely to have been
abstinent for I day or more. Although the effect of education is not statistically
significant, the data suggest a positive trend. Overall, the likelihood of being abstinent
for at least I day tends to be higher in the more highly educated groups (Figure 6).
especially in 1987. Finally, there is a J-shaped relationship between quitting for at least
I day and age. The proportion in this category is highest in the two younger age groups,
lowest in the 45-64.year-old group. and intermediate in the oldest ape group.

Percentage of Ever Smokers Who Had Been Abstinent for Less Than 1 Year

The data in Figure 7 show trends. analyzed according to education. in the proportion
of ever smokers who. at the time of the survey, had been abstinent for less than I year.
In general, no stable trend over the years or absolute change in this proportion from
1965 to 1987 is seen. This lack of a consistent pattern is also evident when the data are
classified by gender, race, and age. In every subgroup. the proportion of ever smokers
who had been abstinent for less than I year in I985 increased; the reason for this increase
is unclear. Data from the 1988 NHIS. which were not available when this Report was
prepared, should help clarify recent trends in this measure of quitting.

The data show effects of most of the demographic variables on the likelihood of being
in this category (Table 5). In general. the two younger age groups are more likely than
the two older age groups to have been abstinent for less than 1 year. A higher proportion
of whites than blacks have been abstinent for less than I year. However, given that the
trend in this proportion has been generally stable for whites and increasing for blacks,
the gap between the races has closed with time. The level of education is positively
associated with the likelihood of being in this category. Those with the least education
(<12 years) are slightly less likely to be recent quitters compared wcith other education
groups.  There is no difference between the sexes in the likelihood of being in this
category.

Percentage of Ever Smokers Who Had Been Abstinent for 1 to 3 Years

Figure 8 presents data on trends in the proportion of ever smokers. who at the time
of the survey had been abstinent from 1 to 4 years, are stratified by education. While
no consistent patterns appear across time, the data show that education is positively
associated with being abstinent for 1 to4 years. Those with the highest education level


( 16+ years) are the most likely to have quit I to 4 years earlier. and those with the lowest
educational level (<12 years) are the least likely.

The data also show that for 1965-1978, the proportion of males who had been
abstinent for I to 4 years is slightly higher than that for females (although across the
entire time period 1965-87, there is no difference in the proportions between the sexes).
Given that the proportion off cigarettes for 1 to 4 years has been increasing significantly
for females and remained stable for males with time, the gap between the genders has
closed (Table 5). Whites are more likely than blacks to have been abstinent for I to 4
years. The data do not show any consistent patterns with respect to age.  Across time.
on average, the proportion of those in the 45X34-year age group in this category is
slightly lower than in the other age groups.

Percentage of Ever Smokers Who Had Been Abstinent for at Least 5 Years

Data on the proportion of ever smokers who, at the time of the survey. had been
abstinent for 5 years or more show positive trends with time for the overall population
and for every population subgroup (trends across education shown in Figure 9).
Overall, the proportion of ever smokers in this category has more than doubled from
12.4 percent in 1965 to 29.8 percent in 1987. Data from the 1955 Current Population
Survey (the first large survey of tobacco use conducted among a probability sample of
the U.S. population) indicate that 5.0 percent of those who ever smoked cigarettes were
abstinent for at least 4.5 years in 1955 (Haenszel, Shimkin, Miller 1956).

The data also show strong effects of all four demographic variables on the likelihood
of being abstinent for at least 5 years. Figure 9 shows that those with the most education
(l6+ years) are the most likely to have been abstinent for 5 years or more than those in
the other categories. On average, over time, the data show that increasing education
is associated with increasing likelihood of being in this category (Table 5). Also seen
in the data are a gender effect (males are more likely than females to have been abstinent
for 5+ years), a race effect (whites are more likely than blacks to be in this category ).
and a strong effect of age (increasing age is associated with increasing likelihood of
being abstinent for at least 5 years). The age effect is due, at least in part. to the fact
that older persons have had a longer opportunity to quit and maintain long-term
abstinence compared with younger persons. The gaps between the races and across age
groups (and to a lesser extent, across education) have been increasing with time.

Interpretation of Continuum Findings

In the period spanned by these data, a slightly increasing proportion of smokers are
attempting to quit and are maintaining abstinence. Slightly less than a third of the
people who were smoking at 12 months before the 19X7 survey quit smoking for at least
1 day during those I2 months. Trends categorized by sociodemographic subgroups
show that females. blacks. younger persons. and more highly educated persons are more
likely than the appropriate comparison groups to have quit for at least I day during rhe
last year.


One way to determine whether these quit attempts have been successful is to examine
trends in the proportion of ever smokers who have been abstinent for I to 4 years.
Although blacks are more likely than whites to have quit for I day or more, whites are
more likely to have successfully maintained abstinence for 1 to 4 years. Younger
smokers are more likely to have quit for 1 day or more than older smokers; however,
there are only small absolute differences across age groups in the percentage who have
been abstinent for 1 to 4 years. The positive trend across educational categories with
respect to quitting for I day or more parallels important differences seen in the
likelihood of being abstinent for I to 4 years. Those with the lowest level of education
were the least likely to make an attempt to quit and the least likely to maintain long-term
abstinence. Those with the highest level of education were the most likely to have made
a quit attempt and the most likely to maintain long-term abstinence. Finally. although
females were more likely than males to have quit for at least I day. there were no gender
differences in abstinence for 1 to 4 years.

The data on the increasing proportion of ever smokers who have been off cigarettes
for at least 5 years show that more ever smokers are entering this category by
successfully quitting and abstaining than are exiting by death or relapse. Overall, this
proportion has increased 242 percent between 196.5 and 1987. Consistent with other
data showing that males began quitting earlier than females (Fiore et al. 1989),
proportionately more males than females are in this category. Similarly, whites began
quitting earlier, and are therefore, more likely than blacks to have stopped smoking for
5 years or more. There is also evidence that those with the highest level of education
have been abstinent for a longer period than those with less education. Finally, older
people were more likely to have been abstinent for at least 5 years. This positive
relationship reflects the accumulation of successful quitters with age and, probably to
some extent, the benefits of cessation on survival.

OTHER MEASURES RELATED TO SMOKING CESSATION

Intention to Smoke in 5 Years

Intention to smoke or quit is a predictor of future smoking behavior (Collins, Emont,
Zywiak, in press: Cummings et al. 1988; Pierce, Dwyer et al. 1987; Pederson, Basker-
ville. Wanklin 1982). Current and former smokers responding to the five OSH-spon-
sored surveys of tobacco. use were asked to assess the likelihood that they would be
smoking in 5 years. There is little change in the responses of former smokers since
1964. In each survey year. fewer than 3.2 percent of all former smokers responded that
they would be smoking again in 5 years. Thus. former smokers overestimate the
likelihood that they will remain abstinent. (See the previous Section, Long-Term
Abstinence and Relapse.)

In Table 6, the predicted likelihood of future smoking behavior among current
smokers is presented for each survey year by gender. The sharp dropoffs that occurred
between 1966 and 1970 may have occurred a\ a result of the widespread television
broadcast of antismoking public service announcements (PSAs) from 1968 to 1970


TABLE 6.-Percentage of those intending to smoke in 5 years, by gender,
     AUTSs, United States, 1964436, current smokers aged 21
       and older

Year

Definitely will be smoking   Probably nilI be smoking

Male       Female       Male       Female

Total (definitely + probably I

Male       Female

1964      25.2        20. I         SO.6       9.4       75.x       74.5

1966      22.3        15.6        53.7       55.3       76.0       7 I .O

1970      IO.9        IO.2         39.1        11.1       50.0       s1.3

1975       11.7        12.0         31.2       AS.9       55.9       57.9

1986       7.3         6.4        35.2       3x.x       42.6       lS.3

VOTE:  AUTS=Adult Lks of Tobacco SW-W!
SOCRCE: Al:TS\ lYh4. IYM. lY70. 1975. IYXh

under the Federal Communications Commission's Fairness Doctrine (US DHHS
1989a). Longitudinal data collected between 1964 and 1975 supported the hypothesis
that the Fairness Doctrine PSAs influenced smokers' attitudes about quitting (Horn
1979). The percentage of smokers who "thought seriously about giving up smoking"
increased from 56 percent before the PSAs to about 85 percent at the end of. and 5 years
after, the PSAs. The proportion of smokers who tried to quit and the overall cessation
rate also increased over the same timeframe.

The slight increases in intention to smoke from 1970 to 1975 might reflect a decay
effect after the removal of the antismoking commercials. The reduction between 1975
and 1986 could reflect an increase in antismoking activity. such as the growth of the
nonsmokers' rights movement (US DHHS 1989a).

Receipt of Advice to Quit from a Doctor

Advice to quit smoking by a doctor increases patient cessation rates (Glynn. Manley,
Pechacek, 1990; Kottke et al. 1988; Schwartz 1987; US Preventive Services Task Force
1989). Data from Table 7 show that the percentage of current smokers who report
having ever been advised by a doctor to stop smoking increased steadily for both
genders between 1964 and 1987. Male current smokers were 3.1 times more likely to
report having received advice from a doctor to stop smoking in 1987 than in 1964;
female current smokers were 3.2 times more likely to have reported receipt of such
advice in 1987 than in 1964.

The data for former smokers, while less consistent, also show increases with time.
Male former smokers were I .5 times more likely to report having received advice from
a doctor to stop smoking in 1987 than in 1964. Female former smokers were 2.1 times
more likely to report having received such advice in 1987 than in 1964.
In summary, large increases in the percentages of current and former smokers who
reported having received advice to quit occurred between 1976 and 1987.

609


I~.4lSl,E 7.--Percentage N ho report ha\ ing e\ er rewi\ ed ad\ ice to quit from a
     doctor, by smoking status and gender, United States, 196187,
     adults aged 21 and older

AUTS IYM
AUTS IYhh
ACTS IY70
NH6 1`471
AUTS I')75
NHIS lY7h
AUTS IYXh
NHIS 1'4x7

CONCLUSIONS

I. By 1987. more than 38 million Americans had quit smoking cigarettes. nearly half
of all living adults who ever smoked.

2. The percentage of ever cigarette smokers who are former cigarette smokers (quit
ratio) has increased from 29.6 percent in 1965 to 44.8 percent in 1987 at an average
rate of 0.68 percentage points per year. The quit ratio has increased among men
and women, among blacks and whites. and among all age and education subgroups.
Between 1966 and 1987, the rate of increase in the quit ratio among college
graduates was twice the rate among high school dropouts.

3. About one-third of all former cigarette smokers who have maintained abstinence for
at least I year may eventually relapse. As the duration of abstinence increases,
relapse becomes less likely.

4. Quitting activity. as measured by the proportion of people smoking at I2 months
before a survey who quit for at least I day during those I2 months, has increased
slightly over time. Between 1978 and 1987. this proportion increased from 27.8 to
3 I .6 percent.

5. Female smokers were more likely than male smokers to have quit smoking cigarettes
for at least 1 day during the previous year; however, there were no gender differen-
ces in the proportion abstinent for I to 4 years. Men were more likely than women
to have been abstinent for 5 years or more. These findings do not take into account
the use of tobacco products other than cigarettes.

610


6. Black smokers were more likely than white smokers to have quit for at least I day
during the previous year. Blacks, however. were less likely than whites to have
been abstinent for I year or more.

7. Younger smokers (aged 20 to 44) were more likely than older smokers to have quit
for at least I day during the previous year.

8. Smokers with less education tend to be less likely to have quit for at least I day
during the previous year compared with those having more education. In addition,
those with lower levels of education are less likely to have been abstinent for I year
  or more.

9. In 1964, about three-fourths of all current smokers predicted that they would
"definitely" or "probably" be smoking in 5 years. In 1986, fewer than half of all
current smokers felt the same way. Moreover, while more than 20 percent of current
smokers in 1964 predicted that they would "definitely" be smoking in 5 years. only
about 7 percent of current smokers in 1986 so predicted.

IO. Current smokers in 1987 were more than three times as likely as current smokers
in 1964 to report having received advice from a doctor to stop smoking.

hl I


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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES. 7'lrc Hcwlrl~ Cotr.rc~r/trettc~e.s of
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h I 5


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616


GLOSSARY

AARP
ACS
AR
AUTS
BM
BMI
BP
BPS
BRFSS
BUPA
CASS
cc
CCDPHP

CDC
CHD
CI
cig
CNS
co
COHb
COPD
CPS
CPS-I
CPS-II
cv
CVD
DBP
DHEW
DHHS
DLCOSB
DPA
DSM-III-R
FEV I
FVC I
HANES

American Association of Retired Persons
American Cancer Society
attributable risk

Adult Use of Tobacco Survey
bone mass
body mass index
blood pressure
Baseline Prevalence Survey
Behavioral Risk Factor Surveillance System
British United Providence Association
Coronary Artery Surgery Study
closing capacity
Center for Chronic Disease Prevention
and Health Promotion
Centers for Disease Control
coronary heart disease
confidence interval
cigarettes

central nervous system
carbon monoxide

carboxyhemoglobin
chronic obstructive pulmonary disease
Center for Preventive Services
Cancer Prevention Study I
Cancer Prevention Study II
closing volume
cardiovascular disease
diastolic blood pressure
Department of Health. Education. and Welfare
Department of Health and Human Services
carbon monoxide diffusing capacity
dual photon absorptiometry
Diagnostic UIKI Stutistiwl MUI~MI~ cfMerltcr/ Disordo-s
I -set forced expiratory volume
I -set forced vital capacity
Health and Nutrition Examination Survey

617


HB,Ag
HCN
HDL-C
HA10
HR
IARC
LDL-C
Ml
MMEF
MRC
MRFIT
NCHS
NCI
NHANES-I
NHEFS
NHIS
NHLBI
NNS
OSH
PBI
PCA
PDL
PEF
PHS
POMS
PPA
ppd
PSA
REE
RR
SBP
SCN -
SD
SES
SGA
SIDS
SPA
ST
STD
TLC
TQ
vc
WHO
WHR

hepatitis B surface .mtigen
hvdrogen c\ snide
high-den\it) lipoprotein chole\trrol
health maintenance organization
heart rate
International Agency for Research on Cancer
lowdensity lipoprotein cholesterol
myocardial infarction
mid-maximum expiratory flow
Medical Research Council
Multiple Risk Factor Intervention Trial
National Center for Health Statistics
National Cancer Institute
National Health and Nutrition Examination Survey I
NHANES Epidemiologic Followup Study
National Health Interview Survey
National Heart, Lung. and Blood Institute
National Natality Survey
Office on Smoking and Health
penile brachial index
percent cortical area
predicted diffusing capacity
peak expiratory flow
Public Health Service
Profile of Mood States
phenylpropanolamine
packs per day
public service announcement
resting energy expenditure
relative risk
systolic blood pressure
thiocyanate
standard deviation
socioeconomic status
small gestational age
sudden infant death syndrome
single photon absorptiometry
smokeless tobacco
sexually transmitted disease
total lung capacity
Fagerstrom Tolerance Scale
vital capacity
World Health Organization
ratio of waist to hip circumference

618