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Dileep G Bal
For those of you who don’t know, in California we had a 25 cent increase in the price of a packet of cigarettes with Proposition 99 in November 1988. Twenty percent of these revenues were earmarked for Health Education, Prevention & Cessation efforts. However, we were unable to get expenditure authority from the legislature for nearly a year. The tobacco industry was very skilful and introduced a whole slew of bills and tied up our smoking legislation so that essentially we got cracking only in late 1989.
Let me just touch on some of the numbers that Gary mentioned and give you the California equivalents. In 1990, the US adult smoking prevalence was 25.5%. In 1991, it was 25.7%, a marginal increase. I think it’s a bit of a blip or artifact. In California in 1988, when the initiative passed, we had an adult smoking prevalence of 26.7%. In 1990 it had decreased to 22.2% and our latest survey, in early-mid 1992, showed it to be 20.0%. The absolute decline since 1988 has been 23.6% in California.
Unlike the 3% increase in the national rates among African-Americans between 1990 and 91, from 26% to 29%, in California African- American rates are actually quite close to non- Hispanic whites.
We’ve got a mix of cessation, prevention and environmental strategies. My own and my colleagues feelings are that the mix varies at different prevalence levels. In other words, without going into the details of the dependency of hard-core smokers, on a somewhat selfish note I’m not unhappy that the national prevalence rate is showing a slight upward blip (even if it is an artifact), because the collective expectation on us is so unrealistic. When the California legislature and the executive branch lean on me, if I should happen to have an upward blip in our prevalence rates in the next couple of years, I can always point to Washington and reply that even the national trend is going up, and ours plateaued at a much lower level, and there are other issues such as strategies for hard-core smokers.
When we get down to prevalences well below 20%, I think the mix between cessation, prevalence and environmental strategies is going to have to be very different – although I’m not sure exactly how. I’m just saying we’re aware we have to keep the pressure up with different mixes of interventions as prevalence rates change.
The expectation in California is, like everything else, crazy. In 1989, when the Assembly Bill 75 passed, the legislative branch in California decided they wanted a 75% reduction in adult prevalence by the year 1999. Essentially they want us to get down to an adult smoking percentage of 6.5% by the year 2000.
The 20- to 24-year-old data, as Gary mentioned, is a quick and dirty surrogate measure of initiation. The key thing I want to tell you is smoking prevalence among Californians by gender shows there is no appreciable fall among males. The major contributor to our prevalence drop seems to be from women; currently prevalence has gone down to 17.5% in 20- to 24-year-old women.
Similarly, and this one’s very bothersome and has, I think, some significance for this meeting, is smoking prevalence by education. If you stratify it by no-college and some- college, we are above what is expected in the some-college group but below what is expected among the no-college group. In other words, although we normally expect tobacco use prevalence to vary inversely with social class and inversely with education, we are seeing resistance now in California. Obviously the some college group has plateaued at a much lower level, and therefore, we might have a shift a little stronger toward cessation, although in California we don’t see that quite yet.
I want to look briefly at the implications of some trends presented by Gary and describe what I consider a new frontier of opportunity with black smokers.
Over the last few years, the trends show that black smokers make more attempts to stop smoking but are less successful. However, we have known for some years, with experience from the Multiple Risk Factor Intervention Trials (MRFIT), that black smokers, and black males specifically, when given the same levels of treatment or exposure to the same type of intervention programmes do equally well as whites in stopping smoking. This was true although these black male smokers had less education and lower incomes.
On the other hand, when we look at the experience from our worksite studies where the protocols for getting people into the programmes are less rigorous than those used in MRFIT, we see less participation of black smokers in the traditional formal programmes. The overall success rates among black smokers in these programmes have also been less. However, the participation rates in the individualised self-help methods are roughly equivalent among black and white smokers.
The NHLBI is currently supporting intervention trials in several minority or ethnic groups. Preliminary reports show that these studies are achieving higher success rates using basic traditional techniques.
The increasing numbers of attempts to give up cigarettes among black smokers in addition to our experiences from MRFIT and the special intervention trials which showed that black smokers can succeed in stopping smoking have important implications for the future. We must not let this opportunity pass, as we failed to take advantage of an earlier opportunity to affect the rate of smoking among blacks. During the 1970s, about 70% of black smokers were smoking Kool cigarettes. In the latter part of the 1970s and the early 1980s, we saw RJ Reynolds, with Salem and More, take market share from Kool. It turned out that Brown and Williamson (B&W) did not even know that their product appealed to blacks until Reynolds started to take the market away. B&W responded with the Kool Jazz Festival and other campaigns with a jazz theme. While many health officials expressed outrage over the new B&W campaign, in reality, the campaign did not work. Meanwhile, a little known product, Newport, came out of nowhere and lured away most black smokers. Smoking cessation programmes can probably have a major impact with populations that are switching brands. Instead of a special effort to get black smokers to stop smoking, we largely focused on criticising the unsuccessful B&W promotions and campaigns.
In conclusion, the higher rates of quit attempts among black smokers make this a high priority population for intervention. I think we will see more effort to target African- American smokers with effective smoking intervention programmes and these efforts will be increasingly successful.
Ellen R Gritz
In response to Gary Giovino’s excellent presentation, I think we should first keep in mind that the overall measures that are being recommended to curb smoking in the near future are those that were reviewed by Mike Pertschuk and Michael Eriksen at the recent American Medical Association conference. These include increasing excise taxes, increasing ordinances restricting smoking, and curbing advertising and tobacco promotion, thereby decreasing initiation as well as promoting cessation.
Considering which smokers and which vulnerable populations will benefit from these systemic and environmental efforts, I have three comments. Firstly, and I know Pat O’Malley is going to address this, we mustn’t forget adolescents. Tom Schelling pointed out that our clinical and public health efforts have been more successful in facilitating cessation than in deterring initiation. It is critical to keep in mind that nicotine addiction is a chronic disease. About half of the adolescents who try cigarettes go on to become long-term, dependent smokers. We need to consider where the balance of our resources should be placed, and what further research and programmatic efforts are needed both to deter initiation and to promote cessation among adolescents. We might consider targeting adolescent girls in particular, who may be the more vulnerable gender because of promotional influences.
Secondly, and this brings me to my favourite topic – women and smoking – I am delighted to hear from all of our speakers this morning that smoking prevalence among women is declining as steadily as among men. In fact, the projections that women’s smoking prevalence would exceed that of men after 1995 have been revised to after the year 2000, or perhaps not at all. But the issue remains whether there are certain more vulnerable groups within the general population of women. A recent report from the Framingham data1 showed that women who were heavy smokers (two packs or more a day) had the hardest time giving up smoking of all the subgroups examined in the cohort. The authors cite attitudinal surveys suggesting that women may feel less vulnerable to the adverse health effects of smoking.2
Finally, turning to smoking-related diseases, there have been both observational and interventional studies3–6 showing that heart disease and an acute cancer diagnosis can prompt cessation dramatically. Nicotine dependence retains an influence, but the success rates are still substantially higher than one might otherwise expect. As clinicians, we must be able to take advantage of this moment of opportunity in a compassionate manner when people develop illnesses suddenly.
Now, in terms of Tom’s excellent point about motivation and which smokers may be left in the population, we are specifically concerned with the hard-core smoker who is less motivated. I can’t resist the opportunity to read an astonishing paragraph from a Wall Street Journal article of 1 April 1993,7 that talked about just this precise problem:
“After smoking for two decades, Donna Brod finally decided she would try to stop. Her mother, a life-long smoker, has been diagnosed with lung cancer, but Mrs Brod says that isn’t what prompted her decision. It was, instead, the financial drain of paying $2 a pack for her beloved Tareyton cigarettes. Instead of quitting, however, she recently traded in her brand for the cheaper Cambridge, at a $1.15 a pack. ‘ I would have quit by now if I hadn’t switched over, ’ said Mrs Brod, a part-time receptionist in a dentist’s office in Mosinee, Wisconsin. ‘ It’s something for us people that don’t have a lot of money but don’t have the willpower to stop.’”
This anecdote contains an amazing paradox: an incredibly powerful teachable moment, a woman’s mother diagnosed as having lung cancer, does not prompt cessation; however, the woman does consider quitting because cigarettes have become too expensive. In the end, she switches to a cheaper brand and cites her lack of motivation, her lack of willpower and also her lack of disposable income. How do we address the barriers that prevented Mrs Brod from moving from contemplation to action? Clinicians take note, this person works in a dentist’s office; where are the health care provider’s support and influence?
According to the same Wall Street Journal article, ‘A recent survey in Massachusetts found plenty of good intentions: 75% of the smokers said they planned to try to quit because of the new tax, and nearly half claimed to have cut down some. Yet 23% of the smokers in the study admitted they had switched to cheaper cigarettes since the higher taxes were imposed at the beginning of the year. And 22% reported travelling to another state solely to buy cheaper packs.’ ‘In the old days, a tax took away smokers. In the 1990s the tax takes away profits,’ according to Greg Connolly, of the Massachusetts Department of Public Health.
These examples illustrate how perversely nicotine dependence may operate, even in the face of environmental and systemic efforts at facilitating cessation. In some cases we have observed backfiring or people being pushed in directions we might never have anticipated. The anti-smoking campaigns of the 1990s will give us new opportunities, as well as potential new pitfalls to be aware of, as we design our next decade of cessation strategies.
I’m Patrick O’Malley and I co-direct with Lloyd Johnston and Jerald Bachman, the Monitoring the Future study, which does annual surveys of students’ smoking behaviour, among other things, and today we’re actually releasing the 1992 results. There are several points I’d like to make. Firstly, we’re reporting on smoking rates among students, using national samples of eighth, tenth and twelfth grade students; the major point is that smoking rates are continuing to be quite high. Now we’re not losing large numbers of people that we have a chance to help with cessation because initiation rates are staying high too. Just listen to the numbers: eighth grade, 16% –that’s one out of every six eighth graders smoked at least one cigarette in the past 30 days. The figure is 22% among tenth graders, and 28% among twelfth graders. And that’s a lot of smoking by young people.
Daily rates, that is, those who smoke one or more cigarettes per day, are 7% among eighth graders, 12% among tenth graders and 17% among twelfth graders. I find these rates extremely high.
In terms of trends, we don’t have long-term data on the eighth and tenth grades, but we do on the twelfth grade. In 1992, twelfth grade, the 30-day prevalence was 28%; in 1984, eight years earlier, it was 29%. There’s been almost no change, and, in fact, if it weren’t for the fact that the samples include some black students, it wouldn’t have gone down at all. There is a decline among black students, but no decline among white students.
In terms of heavier smokers, those who smoke, say, half a pack a day, in 1984 among twelfth graders, it was 12%; in 1992 it’s 10%. So there is a little bit of decline at heavier use levels.
I think the major point is that levels continue to be quite high and the trends are not very promising. In spite of all the things that have been going in the past eight years there’s been very little change.
One might well ask why that is happening. I can’t answer with any certainty, but one of the interesting things that we found in looking at drug use in the twelfth grade surveys over time is the role that perceived risk of harm seems to play. It does seem to have an effect on things like marijuana use and cocaine use. And one of the most fascinating things is that among the twelfth graders, 70% agree that there’s great risk of harm in somebody smoking a pack or more of cigarettes a day. Among tenth graders it’s lower, 60%. And among eighth graders it’s only 50%. So at the very age that children are initiating smoking, half of them are denying that there’s a great risk of harm; obviously there’s still a message that isn’t getting across about the risk of harm related to smoking.
In terms of some racial differences, I mentioned that we do see somewhat of a decline among black students. Black seniors back in the early ’80s were very close to white seniors in smoking rates. By 1992 they’re very much lower. For example, 30-day prevalence is only 9% among black high school seniors, while it is 32% among white high school seniors. Similar differences exist in the eighth grade; 16% of white eighth graders compared to 5% for blacks, roughly a third.
We asked the question ‘Have you ever tried to stop smoking and failed,’ and among the 45% of 1992 eighth-grade students that ever smoked a cigarette, 13% said that they had tried to stop and failed. Among tenth graders it was 15%. So even very young folks do try to stop and there’s quite a number that will have tried to stop and failed.
The other point I would like to make is that we have done some follow-up surveys and found that we have substantial increases with age, after high school graduation, in the proportion of the smokers who try to stop and fail. In our data we’re showing that roughly 22% of the late teens who have smoked in the past year indicate that they tried and failed to stop smoking, and that number increases quite sharply until by around age 30 the figure is between 50 and 60%.
We clearly have some important effects here as the number of young folk smoking is not declining. When you look at the overall population prevalence dropping, it’s because people are stopping smoking; it’s not because we’re losing numbers into the pipeline.
Questions and answers
JOHN HUGHES: I’d just like to make a comment as a clinician on my concerns about the future of smoking. I think there are three main issues. One is the issue of the hard-core smoker, and how you define him or her. I would suggest people look at Naomi Breslau’s work where she uses the same criteria that are in use for other drug dependencies, as well as looking at our own work. We find about 70% of current smokers fulfill dependence criteria. Breslau looks at that on a longitudinal basis in terms of progression and finds that, among young smokers, about 30% progress each year, that is, go from no dependence to mild, mild to moderate, or moderate to severe, so there’s a lot of action those first 10 years, which I think is important. I also think we talk a lot about hard-core and dependent smokers, but I think we have to ask ourselves why are we making a distinction? In other words, is there really a difference that you can specifically measure, that is, a response to pharmacotherapy, or need for intensive therapy, etc. Maybe we’d be better off concentrating on dependent rather than hard-core smokers.
The second trend I think we’re seeing is, by making smoking more a social deviancy, we’re increasing the incidence of comorbidity with psychiatric disorders, such as depression and alcoholism. And the third, of course, is that we’re seeing it more among lower socioeconomic groups.
I run an alcohol and drug abuse clinic and I think that my smokers are going to look more like my cocaine-dependent patients in the next 20 to 25 years. With my cocaine-dependent patients, I spend a lot of time fixing their lives, not just doing a small brief intervention, and I think that’s the real challenge. How to mix the public health and the intensive intervention over the next 20 years when this population is changing.
The last thing I want to mention is a technical comment about our not seeing the number of cigarettes smoked declining over time. My response to that is, perhaps we should expect to see a decline with workplace restrictions, and the fact that we’re not seeing it indicates that we are actually tapping more dependent smokers.
DAVID B ABRAMS: I don’t think we really have a good measure or index of the most clinically relevant dimensions of smoking; dependence and rate of smoking are only part of the problem. Psychological dependence could be another and, as John pointed out, there are a lot of other factors as well, so I think we’ve got to be careful not to regard changes in rate as equal to changes in vulnerability or difficulty with quitting, which I agree with John is the real question behind the dependence question.
But I would go further and say that we don’t really have a measure of the psychological aspects. I think the concept of high or low vulnerability or risk of relapse is appropriate, but the elements within that concept in terms of a multivariate model haven’t been fully worked out. Consequently we don’t have a screening device with enough sensitivity and specificity to be really worthwhile in a patient- treatment matching kind of context.
GARY A GIOVINO: The data I showed were the data that we have available. David and I were talking earlier about depression and smoking and the percentage of smokers who are depressed compared with the percentage of the general population who are depressed. Since 1983 I have looked at the data on smoking by poverty status, and there has been a decline, even among people who are below the poverty level. In 1983, the first year that the NCHS measured poverty status, 32% of adults at or above the poverty level smoked; in 1991 it was 25%. In 1983, 40% of those who were below the poverty line were smokers, that’s 40% below compared with 32% above the poverty line in 1983. In 1991 it was 33% for those below the poverty line and 25% for those at or above it.
We are seeing progress in areas. I think there’s a fine line and a balance we have to watch here. We are seeing progress among even socially disadvantaged people, and that’s good news. We don’t want to start saying that the people who are having difficulties in life won’t be able to quit. On the other hand, I totally agree that there are more and more people who may be having difficulties who may need slightly more intensive interventions.
ROBERT MECKLENBURG: As a dentist, I’d like to respond to Gary Giovino’s comment about physician opportunity and access to patients, and also to Ellen Gritz’s comments about a bad experience of one person working in a dental surgery, and perhaps also to Dr O’Malley’s comments about not really having good access to youngsters.
It does seem to indicate that maybe only one out of five dental people are involved in approaching their patients, while it may be half of the medical profession, although the number may be increasing. We have access to 63% of the population aged 5 and older through the dental profession, and particularly youngsters: we have access to 75% of people aged 5 to 17 within any given 12-month period. And we’re making progress. There has been a dramatic change in the dental profession in the last few years with a number of new policies calling for this sort of action. I just want to bring it to our attention so that we look at the medical and dental professions evenhandedly, since the studies on intervention indicate that they are comparable in their effectiveness.
CAROLE TRACY ORLEANS: I wanted to respond to a comment that Ellen made about switching to generic cigarettes or low- cost cigarettes. I know that the title of this conference is Issues in Smoking Cessation, but I’m increasingly concerned about smokeless or spit tobacco because it’s really beautifully positioned to become the poor man’s tobacco now with its high nicotine content, low cost, and the fact that it is not frequently regulated under worksite restrictions on smoking or clean indoor air laws.
So I’d be interested to know whether you have any statistics, Dr O’Malley, on the current prevalence of spit tobacco use?
PATRICK O’MALLEY: We haven’t seen a significant increase in the last couple of years. It’s been running around the same level. And, of course, it is mostly males.
SAUL SHIFFMAN: Perhaps the overall message is that I think we have to keep our eye on the big picture and expect things to be more complicated and more difficult than we start out assuming. Most of us think it’s so obvious people should be quitting, but we keep expecting things to work better than they have been, and I think we’re learning new respect for forces that keep our interventions from being effective.
DAVID PL SACHS: I have a question for Drs Bal and O’Malley. Patrick, I’m not surprised at your data showing the lack of change in smoking prevalence rates among high school students since, with the exception of what I’ve seen in California, there really hasn’t been anything specifically targeted to discourage uptake of the tobacco product. But Dr Bal, I’ve seen data, presumably from your office, showing that, since Proposition 99 went into effect in 1989, the slope of various parameters, such as number of cigarettes smoked per person in California, has become twice as steep as the slope before then.
Also, I believe it’s your office that’s been running some truly extraordinary counter-ads, not public service ads, but prime time ads on radio and television; gangbusters billboards that are very hard hitting. It would seem to me these should have an impact on decreasing initiation among adolescents and children, and I’m wondering if you have any data on that point.
DILEEP G BAL: Let me start off with that last one. I’m sorry to say that there’s no significant decline in smoking prevalence between 1990 and 1992 observed in our data, both baseline and data from the 1992 survey among the key 12- to 17-year-old age group that Dr O’Malley referred to. In other words, their contribution to prevalence declines in future years at this time seems very questionable. In other words, in the big drop from 22 to 20, the contribution from youngsters was very little.
If we don’t affect the uptake effect much more than we currently do, we’re going to plateau out just like Gary did, (hopefully plateau out much lower), but that’s why our focus is heavy on prevention and environmental factors, because on the cessation side we seem to be doing moderately well.
PATRICK O’MALLEY: Although I think you’re right, David, that there’s been very little mass media attention directed at younger kids, there’s certainly been an enormous amount of effort in the educational systems. Drug abuse programmes almost always have a cigarette component, and there’s plenty of programmes that are aimed directly at cigarettes. It’s clear that they’re not working very well in terms of the overall trends, but there is a fair amount of effort out there.
SAUL SHIFFMAN: I think this comes back to the point that was made earlier, that cessation among youth may have an important role to play.
MANUEL SCHYDLOWER: I think the panel has addressed some of our concerns related to no change in trends of use among young people.
Another major concern is environmental tobacco exposure, and we know that 45% of children 5 years old or younger live in households where at least one adult smokes. I wonder if this panel has any handle on monitoring trends of environmental tobacco smoking in households. Is this something the CDC is doing or any other panellists have worked on?
GARY A GIOVINO: There’s a year 2000 objective to reduce the proportion of children ages 6 and under who are exposed at home to 15%, I believe. We measured it in 1991 and we’ll measure it again throughout the decade. I don’t have the data because they are so new, but they will be out shortly.
JUDITH FITZPATRICK: I believe that smoking is not classified as a medical condition. Dr Gritz, you said it was a medical condition today, and I wondered what was your opinion about having it classified as a medical condition.
ELLEN GRITZ: I referred to nicotine addiction as a chronic disease, using the exact terms that Gary Giovino put up on the board. I am not a physician and therefore cannot make direct comments about this classification, but if you surveyed some of the activist physicians in this audience, like David Sachs, John Hughes, and John Slade, you would find that they would classify nicotine addiction as a disease. DSM-IIIR does have diagnostic categories for nicotine dependence and for nicotine withdrawal.
JUDITH FITZPATRICK: What I’m asking you is would there be an advantage in having it classified as a condition that would be treatable?
ELLEN GRITZ: Well, of course, there would be a tremendous advantage because of the issues of reimbursement, as well as legitimacy of diagnosis.
SAUL SHIFFMAN: Well, in some ways the issue is not just some ruling that it’s a medical condition, but changing the way health care providers think about it and changing the reimbursement system or the financing system, which, of course, we’ll be talking about a good deal later.
Moderator: Saul Shiffman
Panellists: Dileep G Bal, Glen Bennett, Ellen Gritz, Patrick O’Malley