Who kicks the habit and how they do it: Socioeconomic differences across methods of quitting smoking in the USA

Abstract

Although the prevalence of smoking has declined among US adults, an estimated 22.5% of the adult population (45.8 million adults) regularly smoked in 2002. Starting from this level, it will not be possible to achieve the Healthy People national health objectives of a reduction in the prevalence of smoking among adults to less than 12% by 2010 unless the rate of smoking cessation substantially rises from its current average of about 2.5%/year. To achieve that goal it is imperative that we better understand what factors are associated with successful quitting so that policies and resources can be better targeted. We describe the socioeconomic characteristics of smokers who attempt to and successfully quit and show how those characteristics differ across three methods they use in their cessation behavior. The results highlight socioeconomic differences across the methods smokers use and provide evidence that can be used to better target smoking cessation information and resources to smokers most likely to use particular methods. Better targeting is likely to lead to more quits. While it is unlikely that cessation rates can be raised by enough to achieve the reduction in national smoking prevalence that the Healthy People initiative has set, a better understanding of who chooses which method will move us closer to that goal.

Introduction

Cigarette smoking and the use of other forms of tobacco causes approximately 5 million deaths per year globally, making it one of the leading causes of death among adults in the world. According to the World Health Organization (1999), World Health Organization (. (2006)), the current trends in smoking will lead to double the number of deaths (about 10 million) by 2020. Most of this increase stems from tobacco use in low-income countries: Murray and Lopez (1996) predict tobacco-related deaths in low-income countries will more than quadruple. But the large number of current smokers in the formerly socialist economies and the established market economies mean that tobacco control efforts in these countries remain critical for public health. The European Partnership to Reduce Tobacco Dependence (2001) observes, for example, that: “unless more is done to help the 200 million European adult smokers stop, the result will be 2 million European deaths a year by 2040.” Recent research indicates that only a limited number of European countries strongly implement initiatives including high taxes on cigarettes, public place smoking bans, advertising bans, large health warning labels on tobacco products, and nationally funded treatments to help smokers stop smoking (Joossens & Raw, 2006). Although nicotine replacement therapy (NRT) products such as nicotine patches and nasal sprays are widely available in both Europe and the US, products approved for sale ‘over-the-counter’ in Europe are typically available only in pharmacies while in the US they are widely available in retail and grocery stores. While the tobacco control initiatives and new quitting technologies have likely contributed to the decline in the prevalence of smoking among US adults, there were still an estimated 22.5% of the adult population (45.8 million adults) who regularly smoked in 2002 (CDC, 2004).

For practical and policy reasons it is important to better understand characteristics of smokers who try to quit and who successfully quit. From a policy perspective, a better understanding will contribute towards meeting public health goals. For example, the US has set a national health objective (titled Healthy People) to reduce the prevalence of smoking among adults to less than 12% by 2010 (CDC, 1993; US Department of Health and Human Services, 2001). This objective cannot be attained unless the rate of long term smoking cessation substantially rises from its current average of about 2.5%/year.¹ With a better understanding of the factors associated with successful quitting, policies and resources can be better targeted in the US and other countries.

While a substantial body of research documents socioeconomic differences between smokers and nonsmokers—smokers are more likely to be poor, less well educated, white or African American, and male—this knowledge is not directly relevant to the goal of increasing the rate of smoking cessation (CDC, 2004; Escobedo & Peddicord, 1996; US Department of Health and Human Services (1998), US Department of Health and Human Services [USDHHS] (. (2000))). More pertinent are documented differences across socioeconomic groups in the type of smokers who successfully quit each year. Although as many women as men attempt to quit smoking, they are less likely to succeed (CDC, 1986; Royce, Corbett, Sorensen, & Okene, 1997). In general younger smokers attempt to quit more than older smokers (Derby, Lasater, & Vass, 1994; US Department of Health and Human Services, 2001). In a time-series study of trends in quitting behavior by age, Gilpin and Pierce (2002) show that although middle-aged smokers showed higher quit rates through the 1960s, the 1990 quit rates were higher for younger smokers. Differences in quitting behavior by race are most pronounced between whites and African Americans, with whites more likely to quit smoking than African Americans (Gilpin & Pierce, 2002; Hahn, Folsom, Sprafka, & Norsted, 1990; King, Poldenak, Bendel, Vilsaint, & Nahata, 2004). It is well established that more highly educated smokers are more likely to quit smoking (CDC, 2004; Gilpin & Pierce, 2002).

To supplement the above knowledge, policy analysts need to understand differences in the socioeconomic characteristics of smokers who use different methods to try to quit or who successfully quit. Such knowledge will aid in the targeting of resources to encourage smokers to quit.

A better understanding of who tries different cessation methods is especially important because new and effective methods have recently been developed. Until 1984, smokers who wanted to quit could choose from among a rather limited and ineffective set of methods to try to quit that included abstinence (cold turkey), hypnosis, psychological counseling, and nonpharmaceutical smoking cessation products. Based on a meta-analysis of evidence from clinical trials, the current Public Health Service's Clinical Practice Guidelines concludes that: “numerous effective pharmacotherapies for smoking cessation now exist….that reliably increase long-term abstinence rates’, and identifies buproprion, nicotine gum, nicotine inhaler, nicotine nasal spray, and the nicotine patch as first-line pharmacotherapies (US Department of Health and Human Services, 2000). The results of the meta-analysis suggest that compared to the control groups (cold turkey quitting), product use approximately doubles the probability of successful smoking cessation. In 1984 the Federal Drug Administration approved the first clinically effective pharmaceutical smoking cessation product, Nicorette Gum™ for sale in the US. Since then, pharmaceutical firms have discovered and developed several additional pharmaceutical products to help smokers quit. Researchers have demonstrated in clinical trials that pharmaceutical smoking products are effective—smokers using them quit at approximately double the rate of smokers given a placebo (Hughes, Goldstein, Hurt, & Shiffman, 1999). Many of these products are available as over the counter medications, including nicotine gum and nicotine patches. Others are still available only by prescription.

While the effectiveness of these new pharmacotherapies has been clinically established, less is known about who is actually using them. Such knowledge is important because of the substantial public health interest in smoking behavior and the efforts being made to convince people to quit smoking. The limited research on this topic suggests that, in recent years, smokers increasingly seek some type of assistance to try to quit, such as counseling or NRT products, and that whites are more likely than African Americans to use pharmaceutical products (Zhu, Melcer, Sun, Rosbrook, & Pierce, 2000). In this study we will help fill this gap in our understanding by directly investigating the methods smokers choose when they attempt to quit. Our study will shed new light on socioeconomic differences in smoking behavior.

This study uses data from two large micro-data sets: the 1995–1999 waves of the Simmons National Consumer Survey (NCS), and the 2000 US National Health Interview Survey (NHIS), to describe and contrast the socioeconomic characteristics of smokers who attempt to quit, who succeed in quitting, and who choose one of the three methods to try to quit. To analyze the methods smokers choose, we explicitly account for how methods differ with respect to how much smokers have to pay to use them. We first categorize methods by an estimate of what each method will cost to use. We then analyze the probability that a smoker chooses a method in each category as a function of socioeconomic characteristics.