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Predictors of cessation in a cohort of current and former smokers followed over

13 years
Andrew Hyland a; Qiang Li a; Joseph E. Bauer a; Gary A. Giovino a; Craig Steger a; K. Michael Cummings a
a
Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, NY

Online Publication Date: 01 December 2004

To cite this Article Hyland, Andrew, Li, Qiang, Bauer, Joseph E., Giovino, Gary A., Steger, Craig and Cummings, K.
Michael(2004)'Predictors of cessation in a cohort of current and former smokers followed over 13 years',Nicotine & Tobacco
Research,6:6,S363 — S369
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 Nicotine & Tobacco Research Volume 6, Supplement 3 (December 2004) S363–S369

Predictors of cessation in a cohort of current and

former smokers followed over 13 years

Andrew Hyland, Qiang Li, Joseph E. Bauer, Gary A. Giovino, Craig Steger,
K. Michael Cummings

[Received 30 September 2003; accepted 31 August 2004]

The present study attempted to identify predictors of smoking cessation in a cohort of cigarette smokers followed
over 13 years. Data are reported on 6,603 persons who resided in one of 20 U.S. communities involved in the
National Cancer Institute’s Community Intervention Trial for Smoking Cessation (COMMIT) study, were current
Downloaded By: [Roswell Park Cancer Institute] At: 13:15 9 October 2008

smokers in the COMMIT trial in 1988, and completed detailed tobacco use telephone surveys in 1988, 1993, and
2001. A person was classified as a former smoker if at the time of follow-up he or she reported not smoking for at
least 6 months prior to the interview. Reasons and methods for quitting also were assessed in 1993 and 2001. Among
smokers in 1988, 24% had stopped smoking by 1993 and 42% were not smoking by 2001. The most frequently cited
reasons for quitting were health and cost reasons, while assisted methods to quit were more common in more recent
years. Measures of nicotine dependence were much more strongly associated with cessation than measures of
motivation. Other predictors included male gender, older age, higher income, and less frequent alcohol consumption,
although the gender effect no longer existed when cessation from cigarettes as well as other tobacco products was
considered as the outcome. The present study shows that nicotine dependence is a major factor predicting long-term
cessation in smokers. This finding has implications for tobacco control policy and treatment approaches.

Introduction 1986). It has long been established that both motiva-

Tobacco smoking is the leading cause of illness and
death in the United States, resulting in more than
440,000 deaths per year (Centers for Disease Control
and Prevention [CDC], 2002a). Over 8.6 million people
in the United States have a chronic disease attribu-
table to smoking (CDC, 2003). Adult smoking rates in
the United States fell from 25 percent in 1993 to 23.3
percent in 2000 (CDC, 2002b). Previous studies have
shown that over 60% of the smokers wish they could
quit (Marbella, Layde, & Remington, 1995; Ockene,
Chiriboga, & Zevallos, 1996). However, among smokers
who make at least one serious attempt, over 60% will
relapse (Hymowitz et al., 1997; Ossip-Klein et al.,
Andrew Hyland, Ph.D., Qiang Li, M.S., Joseph E. Bauer, Ph.D.,
Gary A. Giovino, M.S., Ph.D., Craig Steger, M.A. and
K. Michael Cummings, Ph.D., M.P.H., Department of Health
Behavior, Roswell Park Cancer Institute, Buffalo, NY.
Correspondence: K. Michael Cummings, Ph.D., M.P.H., Department
of Health Behavior, Division of Cancer Prevention and Population
Sciences, Roswell Park Cancer Institute, Elm and Carlton Streets,
Buffalo, New York 14263 USA. Tel.: z1 (716) 845-8456; Fax:
z1 (716) 845-8487; E-mail: michael.cummings@roswellpark.org
tional and dependence factors are critical in predicting
who is likely to succeed in stopping smoking (Russell,
1978).
Prospective national data from the 1970s and
1980s from the First National Health and Nutrition
Examination Survey (NHANES I) Epidemiologic
Follow-up Survey found that those who were older,
of White race, had higher incomes, and smoked fewer
cigarettes per day were more likely to stop smoking
(McWhorter, Boyd, & Mattson, 1990). National data
from the 1986 Adult Use of Tobacco Survey found
that fewer cigarettes per day was associated with
quitting among younger smokers only and that an
inverse association was observed among older smokers
(Coambs, Li, & Kozlowski, 1992). Another study
examining the same data revealed that White race and
older age were associated with successful smoking
cessation (Hatziandreu et al., 1990). More recent
prospective data from the Community Intervention
Trial for Smoking Cessation (COMMIT) study found
greater baseline levels of desire to quit, past serious
quit attempts, fewer cigarettes per day, and longer

ISSN 1462-2203 print/ISSN 1469-994X online # 2004 Society for Research on Nicotine and Tobacco
DOI: 10.1080/14622200412331320761
 364 PREDICTORS OF CESSATION OF CURRENT AND FORMER SMOKERS
duration of smoking after waking to predict cessation;
however, the dependence factors were far more
strongly associated with cessation (Hymowitz et al.,
1997).
Since the NHANES I study was conducted over 20
years ago, many aspects of smoking have changed.
For example, external factors such as tobacco control
programs and policies are now present in many
locations, the cigarettes consumed today are consider-
ably different from those smoked in the 1970s (e.g.,
low-tar cigarettes went from being a minority of
cigarettes sold to 80% of all cigarettes sold in 1998),
and the U.S. population has changed demographically
with greater racial/ethnic diversity and an aging
population. We felt the literature was lacking a
recent, large-scale, population-based prospective
study that examines the long-term predictors of
smoking cessation and whether the methods and
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reasons for quitting have changed over time as the
tobacco control environment has changed.
Using data from a cohort of smokers who originally
participated in the COMMIT trial and were interviewed
in 1988, 1993, and 2001, we set out to address the
following three study questions: (a) How have the
reasons and methods used to quit changed between
1988–1993 and 1993–2001? (b) What are the individual-
level predictors of smoking cessation over a 13-year
follow-up? and (c) What is the relative explanatory
power of dependence indicators compared with motiva-
tional indicators for predicting smoking cessation?
Method
Data source
The data analyzed come from the COMMIT study
conducted between 1988 and 1993. A detailed
description of the study design has been reported
previously (COMMIT Research Group, 1991, 1995a,
1995b). In brief, the study was a matched-pair,
randomized trial of 22 small to medium communities
in 10 states or provinces in the United States and
Canada. In 1988 and 1993, two cross-sectional
telephone surveys regarding adult smoking behaviors
were conducted. In 2001, we reinterviewed all U.S.
subjects who finished both the 1988 and 1993 surveys.
Data collection
From January to May 1988, a telephone interview was
conducted to identify cohorts of cigarette smokers in
each of the 22 study communities. The study was
conducted in two stages. In the first stage, approxi-
mately 5,400 households within each community were
identified and information on demographic factors
and smoking behaviors was gathered. Current smokers
were defined as those who smoked at least 100
cigarettes in their lifetime and reported smoking at
the time of interview. Former smokers were defined as
those who smoked at least 100 cigarettes in their
lifetime and did not smoke during the 6-month period
prior to the interview. In the second stage, a sample
of current or former smokers aged 25–64 years was
reinterviewed. Detailed questions were asked about
current and past smoking habits, brand and type of
cigarette smoked, and desire to quit; socioeconomic
data also were collected. Overall, the survey gathered
data on 22,046 smokers aged 25–64 years.
In 1993, a 20-minute telephone interview was
conducted with a sample of the 1988 cohort, and
12,435 subjects from the U.S. COMMIT communities
completed the interview. Questions were asked about
current smoking status, changes in smoking patterns,
and exposure to community and state smoking
cessation programs.
In 2001, we conducted another telephone interview
among study participants in the United States who
completed both the 1988 and 1993 surveys
(N~12,435). Information was collected about current
smoking status, changes in smoking behavior since
1993, desire to quit, number of quit attempts since
1993, and use of pharmacotherapy. Among the 6,603
subjects (53%) who completed the survey, 904 subjects
(7%) were confirmed dead, 1,505 (12%) refused to
participate, and 3,423 (28%) could not be located.
Cohort members who were younger; less educated;
and resided in California, New Jersey, and one of the
Massachusetts communities were more likely to be
lost to follow-up.
Outcome measures
Cigarette smoking cessation was based on self-report
information. Those who reported not smoking any
cigarettes in the 6 months prior to the interview were
classified as former smokers; all others were classified
as current smokers. In a second analysis, we defined
cessation as no use of cigarettes and other tobacco
products (i.e., pipes, cigars, cigarillos, or smokeless
tobacco) in the 6 months prior to the interview.
Among those who made a serious attempt to stop
smoking, reasons for quitting were assessed in 1993
(for quit attempts between 1988 and 1993) and in 2001
(for quit attempts between 1993 and 2001). Reasons
included the expense of smoking; current or future
health concerns; the effect of cigarette smoke on
nonsmokers; pressure from family, friends, or co-
workers; workplace smoking restrictions; setting an
example for children; advice from a doctor or dentist
to quit; illness or death of a friend or relative; and
olfactory reasons.
Similarly, methods used to quit were assessed in
1993 (for quit attempts between 1988 and 1993) and in
2001 (for quit attempts between 1993 and 2001).
Methods used included switching to low-tar cigarettes,

decreasing the number of cigarettes smoked per day,
substituting other tobacco products, quitting with
friends or family members, participating in a stop-
smoking program, following instructions in a book
or pamphlet, calling a telephone helpline, seeing a
physician for help, quitting cold turkey, using a stop-
smoking medication, or some other method. Methods
were then aggregated into either assisted methods—
which included participating in a stop-smoking
program, calling a telephone helpline, seeing a
physician, or using a stop-smoking medication—or
unassisted methods, which comprised other quit
methods.
For both assessments (reasons for quitting and
methods used to quit), response options were close
ended. Respondents could nominate more than one
reason or method, and answers covered the entire
period in question and could not be linked to a
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specific quit attempt and resultant outcomes of that
attempt.
Independent variables
Independent variables examined in the analysis include
the following: age in 1988 (25–34, 35–44, 45–54, 55z),
gender (male or female), race/ethnicity (White, non-
Hispanic; Black, non-Hispanic; Hispanic; other), annual
household income in 1988 (vUS$10,000; US$10,000–
$25,000; US$25,001–$40,000; wUS$40,000), years of
education (v12, 12, 13–15, 16z), frequency of alcohol
consumption (daily, 3–4 times/week, 1–2 times/week,
1–3 times/month, v1 time/month, never), number of
cigarettes smoked per day in 1988 (§25, 15–24, 5–14,
or v5), age started smoking (v16 years, 16–19 years,
w19 years), time to first cigarette in after waking in
1988 (v10 minutes, 10–30 minutes, 31–60 minutes,
w60 minutes), use of noncigarette products (none
vs. pipe tobacco, cigars, smokeless tobacco), usual
type of cigarette consumed (premium, discount/generic
brand), number of serious quit attempts in the year
prior to the 1988 survey (0, 1, §2), desire to stop
smoking measured in 1988 (not at all, a little,
sometimes, a lot), presence of another smoker in the
household in 1988 (0, 1z smokers), and residence in a
COMMIT intervention or comparison community in
1988.
Statistical methods
Data were analyzed for the 6,603 cohort participants
who were smokers in 1988 and who completed all
three surveys. Cessation behavior and reasons for
quitting were assessed with descriptive statistics. A
logistic regression model was constructed to assess
the association between the independent variables
measured in 1988 and smoking cessation in 2001.
SUDAAN release 7.5.3 was used to adjust for
NICOTINE & TOBACCO RESEARCH 365
sampling of smokers within communities; however,
these results were nearly identical to those obtained
assuming subjects came from a simple random sample
of smokers.
Results
Quitting behavior and relapse back to smoking
(1988–2001)
Among the entire sample of 6,603 current smokers
in 1988, 23.8% had quit smoking by 1993 (5.3%
annualized quit rate), and 42.2% were not smoking
when interviewed again in 2001 (4.1% annualized quit
rate). Among all 5,127 current smokers in 1993, 72%
made at least one serious quit attempt from 1993 to
2001. Some 34% of those who made a quit attempt, or
30.2% of the entire sample, had stopped smoking by
2001 (4.4% annualized quit rate). The annualized quit
rate over the entire study period was less than the
rates observed for 1988–1993 and 1993–2001 due to
relapse (e.g., 17% of former smokers in 1993 were
smokers in 2001).
Reasons for quitting
Reasons for quitting among smokers in 1993 who
reported at least one serious quit attempt between
1993 and 2001 are shown in Table 1. The most
common reasons for serious quit attempts were
‘‘concern for current and future health’’ (92%);
‘‘expense’’ (59%); ‘‘concern for the effect on others’’
(56%); and ‘‘setting a good example for children’’
(52%), which are similar to the results observed in a
similar analysis based on COMMIT data between
1988 and 1993 (Hymowitz et al., 1997). Compared
with the earlier study, the percentage reporting
pressure from family and friends and doctor’s
advice to quit was greater between 1993 and 2001,
whereas the percentage who reported bad breath,
smell, or taste as reasons for quitting decreased.
Persons who were smokers in 2001 were more likely to
nominate each reason listed, compared with quitters in
2001, except for the two reasons related to second-
hand smoke.
Methods for quitting
Methods used in quit attempts in 1988–1993 and
1993–2001 are presented in Table 2. Assisted methods
to quit increased from 45% to 60%; this increase was
driven by increases in the percentage of smokers who
tried to quit with a stop-smoking medication and by
going to a physician for help. The percentage of
smokers who reported trying to quit all at once (cold
turkey) decreased from 84% to 74%.
 366 PREDICTORS OF CESSATION OF CURRENT AND FORMER SMOKERS

Table 1. Reasons for quitting among those who made at least one serious attempt to quit in 1988–1993 and
1993–2001.

Overall percent Overall percent Percentage

nominated in 1993 nominated in 2001 difference between
Reason (n~9,021)a (n~4,311) 1993 and 2001

Concern for your own current or future health 90.2 91.6 1.4*
Expense associated with smoking 60.7 58.7 22.0*
Concern for the effect of smoke on others 55.8 55.7 20.1
Setting a good example for children 55.1 51.8 23.3*
Advice from doctor or dentist 40.7 49.9 9.2*
Pressure from family, friends, or co-workers 43.7 46.5 2.8*
Bad breath, smell or taste 47.3 35.7 211.6*
Illness or death of a friend or relative 20.9 24.3 3.4*
Smoking restriction at work 19.7 19.5 20.2

Note. aResults come from Hymowitz et al., 1997.

*pv.05 for z test of the difference between percentages in 1993 and 2001.

Table 2. Methods used to quit among those who made at least one serious attempt to quit in 1988–1993 and
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1993–2001.

Overall percent Overall percent Percentage

nominated in 1993 nominated in 2001 Difference between
Methods used to quit (n~8,110) (n~4,311) 1993 and 2001

Assisted methods (used any) 44.9 60.2 15.3*

Use a stop smoking medication 35.2 52.3 17.1*
Go to a physician for help 26.9 33.0 6.1*
Participate in a smoking cessation program 12.1 11.8 20.3*
Call a toll-free number 2.7 4.5 1.8*
Unassisted methods (used any) 98.6 96.6 22.0*
Switch to lower tar or nicotine cigarettes 31.7 29.5 22.2*
Gradually decrease the number of cigarettes 48.1 57.4 9.3*
Substitute other tobacco products 5.0 6.9 1.9*
Stop smoking with a friend/relative 23.7 25.0 1.3
Follow instructions in a booklet 28.2 27.1 21.1
Quit all at once, cold turkey 84.1 73.5 210.6*
Use other methods 11.0 14.9 3.9*

*pv.05 for z test of the difference between percentages in 1993 and 2001.

Predictors of quitting (i.e., pipes, cigars, cigarillos, and smokeless tobacco),

Results of logistic regression analysis relating charac-
teristics of smokers and the result of cigarette smoking
cessation from 1988 to 2001 are shown in Table 3.
Statistically significant predictors of a greater like-
lihood of quitting include male gender, older age,
higher income, fewer cigarettes smoked per day,
longer time to first cigarette after waking, less frequent
alcohol consumption, and a strong desire to quit.
When cessation was defined as no use of any
tobacco products in the 6 months prior to interview,
gender was the only variable for which the statistical
significance changed between the models of these
two outcomes. The relative risk for quitting was
1.01 among females compared with males (95%
CI~0.90–1.13) with the more restrictive definition
of cessation, compared with a relative risk for
cigarette cessation for females of 0.84 (95%
CI~0.75–0.94), as shown in Table 3. Among the
217 subjects who reported no cigarette smoking at
follow-up but reported use of other tobacco products
91% were males, which explains the differential
findings.
Discussion
The present study represents one of the largest and
longest-term assessments of smoking behavior in a
population of smokers. The findings indicate the
strongest predictors of cessation were measures of
nicotine dependence and age, whereas measures of
motivation to quit were less predictive of cessation.
The finding that those who are more dependent on
nicotine, as measured by the number of cigarettes
smoked per day and the time to first cigarette after
waking, is consistent with previous findings (Coambs
et al., 1992; Hymowitz et al., 1997; McWhorter et al.,
1990). The magnitude of association of dependence
indicators is similar to those observed during the
previous 5-year assessment of cessation in this cohort
(Hymowitz et al.). On the contrary, indicators of
 NICOTINE & TOBACCO RESEARCH 367

Table 3. Results of logistic regression analysis relating characteristics of smokers and the result of cigarette smoking
cessation from 1988 to 2001 (n~6,603).

Percent Sample Relative risk

Characteristic quit size (95% CI)

Overall 42.2 6,603

Sex Male 42.8 3,101 Referent
Female 41.7 3,502 0.84 (0.75–0.94)
Age in 1988 25–34 34.6 2,015 Referent
35–44 39.8 2,239 1.30 (1.14–1.49)
45–54 49.5 1,467 2.04 (1.74–2.37)
55–64 53.6 882 2.41 (2.01–2.90)
Race White, non-Hispanic 41.8 5,738 Referent
Black, non-Hispanic 45.8 391 1.04 (0.83–1.31)
Hispanic 46.1 334 0.89 (0.70–1.15)
Other 40.7 135 0.77 (0.52–1.13)
Annual household income in 1988 (US$) v10,000 37.4 422 Referent
10,000–25,000 39.6 1,680 1.14 (0.90–1.45)
25,001–40,000 40.7 2,107 1.19 (0.94–1.52)
w40,000 46.4 2,017 1.43 (1.12–1.82)
Education in 1988 v12 41.4 804 Referent
12 43.4 1,495 1.09 (0.90–1.33)
13–15 40.9 2,924 0.97 (0.80–1.16)
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§16 44.3 1,368 0.98 (0.80–1.22)

Frequency of alcohol consumption in 1988 Daily 37.3 780 Referent
3–4 times/week 41.3 622 1.36 (1.07–1.71)
1–2 times/week 41.9 1,481 1.31 (1.08–1.59)
1–3 times/month 42.5 1,168 1.40 (1.14–1.72)
v1 time/month or never 44.1 2,507 1.52 (1.26–1.83)
Cigarettes smoked daily in 1988 §25/day 37.9 2,720 Referent
15–24/day 40.0 2,354 0.98 (0.86–1.11)
5–14/day 51.5 1,177 1.45 (1.21–1.73)
v5/day 59.1 352 1.97 (1.48–2.64)
Age started smoking ƒ15 37.3 1,398 Referent
16–19 41.3 3,357 1.07 (0.93–1.23)
§20 47.6 1,848 1.15 (0.97–1.35)
Time to first cigarette after waking in 1988 (minutes) v10 34.5 2,054 Referent
10 to 30 41.1 1,992 1.33 (1.16–1.53)
31 to 60 45.8 1,188 1.58 (1.34–1.86)
w61 52.7 1,356 1.77 (1.47–2.13)
Regular use noncigarette products in 1988 No 42.4 6,395 Referent
Yes 37.9 206 0.76 (0.55–1.05)
Pricing tier of cigarette in 1988 Premium 42.4 6,044 Referent
Discount 35.2 310 0.82 (0.63–1.06)
Generic 43.2 88 1.02 (0.65–1.60)
Quit attempts prior to 1988 0 40.7 4,028 Referent
1 44.4 1,256 1.12 (0.97–1.29)
§2 45.0 1,305 1.01 (0.86–1.17)
Desire to quit in 1988 Not at all 39.0 980 Referent
A little 40.1 1,036 1.18 (0.97–1.44)
Somewhat 40.6 2,179 1.13 (0.95–1.35)
A lot 45.7 2,389 1.37 (1.14–1.64)
Number of other household smokers in 1988 0 43.5 3,647 Referent
§1 40.7 2,956 0.93 (0.83–1.03)

Note. Adjusted for COMMIT intervention status and all independent variables listed in the table. When the outcome is considered to be
no cigarette smoking or use of pipes, cigars, cigarillos, or smokeless tobacco in the 6 months prior to the 2001 interview, the only
variable that changes statistical significance is gender, such that the relative risk for quitting in females is 1.01 compared with males
(95% CI~0.90–1.13); see Results section for more detail.

motivation to quit, as measured by past quit attempts
and the desire to stop smoking, were less strongly
associated with quitting, which also is consistent with
past research (Farkas et al., 1996; Ossip-Klein et al.,
1986). Only those who expressed ‘‘a lot’’ of desire to
quit at baseline were significantly more likely to be
abstinent 13 years later, compared with those who
expressed no desire to quit. Unlike the 5-year follow-
up study on cessation (Hymowitz et al.), having
made a past serious quit attempt prior to 1988 was
not a statistically significant predictor of subsequent
cessation in the present study. Changes in motivation
and quitting history made after the 1988 interview
(e.g., some people will have increased their motivation
to quit after 1988 but have had low motivation when
surveyed) may have diluted the effects of these
measures. Also, motivation to stop smoking may be
a necessary but not sufficient condition for predicting
cessation.
Older age was another strong predictor of successful
cessation, with increased cessation rates observed
among those who were aged 45 years or older in
 368 PREDICTORS OF CESSATION OF CURRENT AND FORMER SMOKERS
1988, another finding consistent with previous studies
(Hatziandreu et al., 1990; Hymowitz et al., 1997;
McWhorter et al., 1990).
When only cigarette smoking cessation was consi-
dered as the endpoint, females had lower quit rates;
however, when cessation from all tobacco products
was considered, the gender difference was no longer
observed, a finding observed previously (Jarvis, 1984).
This finding is due to the preponderance of noncigar-
ette tobacco use in males in this sample. Furthermore,
data from the present study reveal a marginally lower
cessation rate among other tobacco users, which may
have implications when considering the public health
value of potentially reduced exposure products, which
are increasingly available. No other differences were
observed for other predictors using this more
restrictive definition of cessation. In this population,
use of noncigarette products in 2001 was six times
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greater among males compared with females, although
the overall use in the past 6 months was low (6%).
Social acceptability of noncigarette tobacco products
is low for women, and these products are less likely to
be considered as an option for continued nicotine use
for women who are trying to quit smoking. For men,
however, noncigarette tobacco products are more
likely to be an acceptable alternative to cigarettes.
These findings suggest that other forms of nicotine
consumption need to be taken into account when
looking at gender differences in smoking cessation.
One factor not associated with cessation was race/
ethnicity. Aggregate National Health Interview Survey
data from 1987 to 1990 indicate that Blacks are less
likely to be former smokers, compared with non-
Hispanic Whites, even after adjustment for education
level (U.S. Department of Health and Human
Services, 1998). Prospective NHANES I data from
the 1970s also found higher quit rates among Whites
(McWhorter et al., 1990). Two possible explanations
for this discrepancy are that the COMMIT data
involve more recent prospective data and a broad
array of control variables including sociodemographic
factors and indicators of dependence and motivation.
It has been argued that mentholated cigarettes may
partially explain previously reported racial differences
in cessation by increasing nicotine delivery and
enhancing the dependence-producing capacity of
cigarettes, thereby making it more difficult for
menthol smokers to quit (Hyland, Garten, Giovino,
& Cummings, 2002). The majority of Black smokers
consume mentholated cigarettes; however, previously
reported prospective COMMIT data did not find
mentholated smokers to have lower quit rates than
nonmentholated smokers (Hyland, Garten et al.,
2002).
The two leading reasons why people try to stop
smoking (i.e., health and cost) also were the leading
reasons observed in the 5-year follow-up of this
population (Hymowitz et al., 1997). However, smokers
were more likely to indicate advice from their physi-
cian as a reason for quitting and were less likely to
indicate bad breath or bad smell as reasons. As
smokers age, their reasons for quitting likely change
toward things that are more health oriented and less
focused on aesthetics.
In more recent years, the percentage of smokers in
this population who tried to quit using an assisted
method such as using a stop-smoking medication or
going to a physician increased by about one-third, and
a lower percentage of smokers reported trying to quit
cold turkey between 1993 and 2001, compared with
1988 and 1993. Studies show that stop-smoking
medications double the likelihood of cessation
(Hughes, 1996) and brief physician advice boosts
quit rates by 30% (Fiore et al., 2000). In this
population, more smokers are using proven assisted
methods of quitting. This is due in part to the much
wider availability of assisted methods and stop-
smoking medications currently than many years ago.
Data were not shown comparing the individual-level
predictors of smoking cessation from 1988–1993 to
1993–2001; however, the results were nearly identical.
The strengths of this analysis include the long-term
follow-up, large sample size, and the fact that it is
population based. Its principal limitation is that only
one-third of the cohort completed interviews in 1988,
1993, and 2001. The overall estimated cessation rate in
this analysis may be biased slightly because those who
were younger, who have lower quit rates; and those
who resided in California or one of the Massachusetts
communities (where large state-based programs were
in force and smokers have been shown to have higher
quit rates; Hyland, Cummings, Bauer, Li, & Giovino,
2002) were more likely to be lost to follow-up. The
impact of this bias on quit rates was found to be small
(Hyland, Cummings et al., 2002), and these factors do
not threaten the internal validity of the observed
predictors of cessation. A second limitation is that the
baseline measures to predict smoking cessation may
have changed over time, which is a common issue in
long-term cohort studies. If the change in measures
(e.g., desire to quit, quit attempts, amount smoked) is
differential for different levels of a variable of interest,
then this would reduce the magnitude of effect size so
that observed effects are conservative; however, this
also could explain why measures of motivation were
not statistically significant in this analysis.
The present findings reinforce the concept that
nicotine dependence is a major barrier to achieving
smoking cessation. Policy and treatment strategies
that address this issue are likely to make the greatest
impact. Higher cigarette prices (Jha & Chaloupka,
2000) and smoke-free worksite regulations (Fichtenberg
& Glantz, 2003) have been well-established predictors
of smoking cessation and reduced smoking. Findings
from the present study show that those who are more
nicotine dependent have lower long-term quit rates,

and this is a target group that could derive greater
benefit from more intensive intervention. While
research needs to be conducted on the impact and
potential adverse effects, an example of a potential
novel intervention is to offer free or low-cost stop-
smoking pharmacotherapies and treatment programs
on a population-wide basis, which could be funded by
increases in cigarette excise taxes or through tobacco
company settlement funds.
Acknowledgment
The COMMIT study was conducted between 1988 and 1993 and was
funded by the National Cancer Institute (NCI). The 2001 follow-up
survey of the COMMIT cohort also was funded by the NCI, through
the State and Community Tobacco Control Interventions Research
Initiative (R01 CA 86225). Data analysis was supported partially by
the Roswell Park Cancer Institute NCI-funded Cancer Center Support
Grant, CA16056-26, and by the Biomathematics/Biostatistics Core
Resource.
Downloaded By: [Roswell Park Cancer Institute] At: 13:15 9 October 2008
References
Centers for Disease Control and Prevention. (2002a). Annual
smoking-attributable mortality, years of potential life lost, and
economic costs—United States, 1995–1999. Morbidity and Mortality
Weekly Report, 51, 300–303.
Centers for Disease Control and Prevention. (2002b). Cigarette
smoking among adults—United States, 2000. Morbidity and
Mortality Weekly Report, 51, 642–645.
Centers for Disease Control and Prevention. (2003). Cigarette
smoking-attributable morbidity—United States, 2000. Morbidity
and Mortality Weekly Report, 52, 842–844.
Coambs, R. B., Li, S., & Kozlowski, L. T. (1992). Age interacts with
heaviness of smoking in predicting success in cessation of smoking.
American Journal of Epidemiology, 135, 240–246.
COMMIT Research Group Community Intervention Trial for
smoking cessation (COMMIT): Summary of design and interven-
tion. (1991). Journal of the National Cancer Institute, 83, 1620–1628.
COMMIT Research Group Community Intervention Trial for
smoking cessation (COMMIT): II. Changes in adult cigarette
smoking prevalence. (1995a). American Journal of Public Health, 85,
193–200.
COMMIT Research Group Community Intervention Trial for
smoking cessation (COMMIT): I. Cohort results from a four-
year community intervention. (1995b). American Journal of Public
Health, 85, 183–192.
Farkas, A. J., Pierce, J. P., Zhu, S. H., Rosbrook, B., Gilpin, E. A.,
Berry, C., & Kaplan, R. M. (1996). Addiction versus stages of change
models in predicting smoking cessation. Addiction, 91, 1271–1280.
NICOTINE & TOBACCO RESEARCH 369
Fichtenberg, C. M., & Glantz, S. A. (2002). Effect of smoke-free
workplaces on smoking behaviour: Systematic review. British
Medical Journal, 325, 188.
Fiore, M. C., Bailey, W. C., Cohen, S. J., Dorfman, S. F., Gritz, E. R.,
Heyman, R. B., Holbrook, J., Jaen, C. R., Kottke, T. E., Lando,
H. A., Mecklenbur, R., Mullen, P. D., Nett, L. M., Robinson, L.,
Stitzer, M., Tommasello, A. C., Villejo, L., & Wewers, M. E.
(2000). Treating tobacco use and dependence. Clinical practice
guideline. Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service.
Hatziandreu, E. J., Pierce, J. P., Lefkopoulou, M., Fiore, M. C., Mills,
S. L., Novotny, T. E., Giovino, G. A., & Davis, R. M. (1990).
Quitting smoking in the United States in 1986. Journal of the
National Cancer Institute, 82, 1402–1406.
Hughes, J. R. (1996). Pharmacotherapy of nicotine dependence. In
C. R. Schuster & M. J. Kuhar (Eds.), Pharmacological aspects of
drug dependence: Toward an integrative neurobehavioral approach
(Handbook of Experimental Pharmacology Series, pp. 599–626).
New York: Springer-Verlag.
Hyland, A., Cummings, K. M., Bauer, J., Li, Q., & Giovino, G.
(2002). State and community tobacco control programs and indicators
of cessation. Paper presented at the American Public Health
Association Meeting, Philadelphia, Pennsylvania.
Hyland, A., Garten, S., Giovino, G. A., & Cummings, K. M. (2002).
Mentholated cigarettes and smoking cessation: Findings from
COMMIT. Tobacco Control, 11, 135–139.
Hymowitz, N., Cummings, K. M., Hyland, A., Lynn, W. R.,
Pechacek, T. F., & Hartwell, T. D. (1997). Predictors of smoking
cessation in a cohort of adult smokers followed for five years.
Tobacco Control, 6(Suppl 2), S57–S62.
Jarvis, M. (1984). Gender and smoking: Do women really find it
harder to give up?. British Journal of Addiction, 79, 383–387.
Jha, P., & Chaloupka, F. J. (2000). The economics of global tobacco
control. British Medical Journal, 321, 358–361.
Marbella, A. M., Layde, P. M., & Remington, P. (1995). Desire and
efforts to quit smoking among cigarette smokers in Wisconsin.
Wisconsin Medical Journal, 94, 617–620.
McWhorter, W. P., Boyd, G. M., & Mattson, M. E. (1990). Predictors
of quitting smoking: The NHANES I follow-up experience. Journal
of Clinical Epidemiology, 43, 1399–1405.
Ockene, J. K., Chiriboga, D. E., & Zevallos, J. C. (1996). Smoking in
Ecuador: Prevalence, knowledge, and attitudes. Tobacco Control, 5,
121–126.
Ossip-Klein, D. J., Bigelow, G., Parker, S. R., Curry, S., Hall, S., &
Kirkland, S. (1986). Task force 1: Classification and assessment of
smoking behavior. Health Psychology, 5(Suppl.), 3–11.
Russell, M. A. H. (1978). Smoking addiction: Some implications for
cessation. In J. Schwartz (Ed.), Progress in smoking cessation
(pp. 206–222). New York: American Cancer Society.
U.S. Department of Health and Human Services. (1998). Tobacco use
among U.S. racial/ethnic groups—African Americans, American
Indian and Alaska Natives, Asian Americans and Pacific Islanders,
and Hispanics: A report of the surgeon general. Atlanta, GA: U.S.
Department of Health and Human Services, Centers for Disease
Control and Prevention.