Research ArticlesSmoking cessation with and without assistance: A population-based analysis
Introduction
Studies have consistently shown that various methods of assistance for smoking cessation such as behavioral counseling or nicotine replacement therapy (NRT) can significantly increase success rates in quitting.1, 2, 3 Two important questions, however, are often overlooked in these experimental studies: (1) How many smokers in the general population use any of these methods of assistance when they try to quit smoking? (2) How successful are smokers who use assistance compared with those who try to quit without it?
Fiore and his colleagues4 provided the first systematic analysis of the use of assistance for smoking cessation in the general population. The 1986 Adult Use of Tobacco Survey (AUTS), a U.S. population survey conducted by telephone, formed the basis for the study. In that survey, respondents who made a “serious” quit attempt (self-defined) were asked to identify the methods they used to quit (free or paid program/course, counseling by psychologist or psychiatrist, nicotine gum, hypnosis, or acupuncture). The researchers found that, in the 10 years preceding the survey, about 15% of respondents used assistance in at least one of their quitting efforts; only 7.9% reported using assistance in their most recent attempt.
The same study also found that the success rate for those who sought assistance was half the rate of those who did not seek assistance. Although the result was somewhat unexpected, the analysis showed that those who sought assistance were much heavier smokers than were those who quit unassisted. The fact that heavy smoking predicts relapse,4, 5, 6, 7 may partially explain why those who sought help were less successful than were those who did not. Other arguments also have been advanced and debated as to whether those seeking assistance have a greater psychological vulnerability to relapse than those who do not seek assistance.5, 8 In any case, the potential advantages of assistance did not overcome the initial disadvantages of those who sought help.
The fact that only a fraction of smokers used assistance suggested two different courses of action. One was to abandon the effort of providing smoking-cessation assistance because of low return.9 The other was to increase effort to make methods of assistance more accessible and to promote the use of assistance in the general population.4
The world of tobacco control has changed significantly since the publication of the Fiore et al. paper.10, 11, 12 The current social climate makes smoking much less desirable, and many smokers are actively trying to quit. New advances in the field of assistance for smoking cessation have occurred as well, such as the development and marketing of NRTs and, recently, a non-nicotine agent, bupropion.13, 14, 15 In addition to the availability of new cessation aids, emphasis has increased, both within public health administration and within the health care system, on the need to assist smokers to quit smoking.16, 17, 18, 19 California is a good example. The Department of Health Service allocates a significant amount of money to fund various cessation services that are free to the state’s smokers.20, 21 At the same time, agencies such as Medi-Cal (a federal and state program that provides medical coverage for individuals on public assistance, the medically needy, and medically indigent) provide free NRT and bupropion to their insurees if they also attend behavioral-counseling programs. With all the changes that have occurred, a new population-based analysis of assistance for smoking cessation is warranted.
This study uses California telephone-survey data to examine two issues: What percentage of smokers in California use assistance to quit smoking and who are they? How does the success rate of those individuals who use assistance compare with the rate of those who do not use assistance? We chose California for the study because it has, in many ways, led the nation in tobacco control in the last 10 years and because a recent statewide population-survey data set is available, the 1996 California Tobacco Survey.
Section snippets
Subjects
We selected the subjects from respondents to the 1996 California Tobacco Survey (CTS). The criteria for inclusion in the analysis were these: at least 18 years old, smokers 12 months prior to the survey, and in the 12 months preceding the survey had made at least one intentional quit attempt that lasted at least 24 hours. The last criterion was necessary because the question of seeking assistance is only relevant to those who have tried to quit smoking. A total of 4480 respondents met these
Use of assistance
Approximately one in five (19.9%, 95% CI=1.2) individuals who tried to quit smoking in the past year used at least one form of assistance. All percentages were weighted to estimate population values from those sampled in the 1996 CTS (n=4480).
The percentages for use of different types of assistance were as follows: 3.1% (95% CI=0.7) for self-help materials, 2.9% (95% CI=0.5) for counseling, 11.7% (95% CI=1.2) for NRT, and 2.2% (95% CI=0.4) for counseling plus NRT.
Demographics
Table 1 shows by demographics
Discussion
Two main findings in the present study contrast with those obtained in the 1986 AUTS.4 First, this study indicates a substantial increase in the use of assistance. Approximately one in five (19.9%) individuals used assistance in their most recent quit attempt, compared with only 7.9% in the 1986 survey. Second, the individuals who used assistance had more than double the long-term cessation rate of those who quit without assistance (15.2% vs 7.0%), in contrast to the Fiore et al. study in which
Acknowledgements
The authors thank Elizabeth Gilpin and Alka Sood for helpful comments on earlier drafts of this paper. The data collection for this research was carried out under Contract 95-23211, funded by the California Department of Health Services, Tobacco Control Section, Sacramento, California. The analysis and writing were funded by a grant from National Cancer Institute, 5 P01-CA72092. All subjects provided consent over the telephone before participating in the 1996 California Tobacco Survey. Survey
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