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Trends in Quit Attempts Among Adult Cigarette Smokers — United States, 2001–2013



MMWR Weekly
Vol. 64, No. 40
October 16, 2015

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Trends in Quit Attempts Among Adult Cigarette Smokers — United States, 2001–2013

Weekly
October 16, 2015 / 64(40);1129-35

S. René Lavinghouze, MA1; Ann Malarcher, PhD1; Amal Jama, MPH2; Linda Neff, PhD1; Karen Debrot, DrPH1; Laura Whalen, MPH1

During 1965–2012, the prevalence of cigarette smoking among adults (aged ≥18 years) in the United States decreased from 42.4% to 18.1%, partly because of increases in smoking cessation (1,2). Quitting smoking is beneficial to health at any age, and cigarette smokers who quit before age 35 have premature mortality rates similar to those of persons who never smoked (1,2). To assess progress made toward the Healthy People 2020 target of increasing the proportion of U.S. adult cigarette smokers who made a quit attempt during the past year to ≥80% (objective TU-4.1),* CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) for the years 2001–2010 and 2011–2013 to provide updated state-specific trends in quit attempts among adult smokers (survey methodology changes required separate analysis of 2011–2013). During 2001–2010, the proportion of smokers who reported a quit attempt during the preceding 12 months increased in 29 states and the U.S. Virgin Islands. During 2011–2013, quit attempts increased in Hawaii and Puerto Rico and decreased in New Mexico. In 2013, past year quit attempts were reported most frequently by smokers in Puerto Rico and Guam (76.4%) and least frequently by those in Kentucky (56.2%). In every state, older smokers were generally less likely to report a past year quit attempt than were younger smokers.

Evaluating variation in health risk behaviors and the use of health services is needed to develop interventions and promotion strategies that address public health at multiple levels (2,3). Proven interventions that increase cessation are important for reducing smoking-related morbidity and mortality and include mass media campaigns, telephone-based tobacco cessation services (quitlines), higher prices for tobacco products, comprehensive smoke-free laws, better health insurance coverage of effective cessation treatments, and health systems changes to integrate tobacco dependence treatment into routine clinical care (1,3). The findings in this report support previous findings on variations in quit attempts among states (2) and underscore the continued need for surveillance and evaluation of health risk behaviors to guide preventive health care services (1–3).

The BRFSS is an ongoing, state-based, random-digit–dialed telephone survey of the noninstitutionalized, civilian population aged ≥18 years conducted annually in all 50 states, the District of Columbia (DC), Guam, Puerto Rico, and the U.S. Virgin Islands.† During 2001–2013, BRFSS sample sizes ranged from 212,510 (2001) to 491,773 (2013). Median survey response rates ranged from 44.5% (2002) to 54.6% (2010). In 2011, BRFSS added cellular (wireless-only) telephone households to the survey and the sample weighting methodology was updated to accommodate declining response rates and to maintain a representative sample for the U.S. population (4). Because of this change in methodology, data from 2001–2010 and those from 2011–2013 were analyzed separately.

Past year quit attempts of ≥1 day among current smokers (persons who had smoked ≥100 cigarettes during their lifetime and currently smoked "every day" or "some days") were assessed for the years 2001–2010; for the years 2011–2013, past year quit attempts were assessed for both current and former smokers (persons who had smoked ≥100 cigarettes in their lifetime, but did not currently smoke).

The percentage of smokers making quit attempts§ and 95% confidence intervals were calculated for survey years 2001–2013. For 2001–2010, multivariable logistic regression was used to analyze linear trends in quit attempts for each state, DC, Puerto Rico, and the U.S. Virgin Islands, controlling for sex, age, and race/ethnicity. The Wald chi-square test was used to test for statistical significance (p<0.05). For 2011–2013, differences in quit attempts were determined from non-overlapping 95% confidence intervals, because there were too few years to support regression modeling. Quit attempt proportions by age groups were calculated for years 2011–2013 combined.

In 2013, approximately two thirds of all adult smokers surveyed reported that they had attempted to quit or did quit in the past year (median = 65.9%), with the proportion making a quit attempt ranging from 56.2% (Kentucky) to 76.4% (Puerto Rico and Guam) (Table 1). During 2001–2010, there was a significant linear increase in the proportion of adult cigarette smokers who had made a quit attempt in the past year in 29 states and the U.S. Virgin Islands (Figure). The median was 56.1% in 2001 and 58.8% in 2010. During 2011–2013, the proportion who had made a quit attempt increased in Hawaii and Puerto Rico and decreased in New Mexico.

During 2011–2013, across all states and DC, the proportion of smokers who reported they had made a quit attempt generally was lower among older respondents (Table 2). The median proportion who had made a quit attempt across states among persons aged 18–24 years, 25–44 years, 45–64 years, and ≥65 years was 73.2%, 68.7%, 60.9%, and 56.4%, respectively. With the exception of smokers in Montana aged ≥65 years (49.8%), more than half of smokers, regardless of age group, reported having tried to quit in the past year. Jurisdictions with the highest proportion of respondents reporting having made a quit attempt by age group were DC (18–24 years, 83.5%), Florida (25–44 years, 74.6%), and New York (45–64 years, 68.6%, and ≥65 years, 68.0%). States with the lowest proportion of respondents reporting having made a quit attempt by age group were Maryland (18–24 years, 62.6%), West Virginia (25–44 years, 57.1%), Nevada and South Dakota (45–64 years, 52.9%), and Montana (≥65 years, 49.8%).

Discussion

During 2001–2010, the proportion of adult cigarette smokers who had made a quit attempt in the past year increased linearly in 29 states and the U.S. Virgin Islands; during 2011–2013, this proportion increased in Hawaii and Puerto Rico and decreased in New Mexico. During 2011–2013, a majority of smokers in all age groups tried to quit in almost all states, although the proportion of smokers who attempted to quit decreased with increasing age. In 2013, approximately two thirds of smokers had made a quit attempt in the past year, although state proportions ranged from 56.2% to 76.4%. These results reflect the importance of ongoing state-based surveillance and evaluation in examining state variations and identifying health issues and disparities (2,3). These data can help states to develop health promotion and prevention programs and to monitor their progress in tobacco control.

Helping tobacco users to quit can reduce tobacco-related disease, death, and health care costs (1,3). Increasing taxes on tobacco products, passing and implementing indoor smoke-free laws, improving health insurance coverage of cessation services, and integrating tobacco dependence treatment into routine clinical care have all helped increase cessation rates (1,3). State per capita tobacco control program expenditures are one measure of the state's ability to implement effective tobacco control program components, including smoking cessation interventions; in the past decade, states with the highest expenditures have had the greatest declines in cigarette smoking (1,3,5). As part of CDC's National Tobacco Control Program, all states are funded to work toward implementation of comprehensive tobacco control programs that comprise evidence-based strategies to increase smoking cessation, including mass media campaigns with graphic anti-smoking ads, such as the Tips from Former Smokers (Tips) campaign.¶ Tips profiles former smokers who are living with serious long-term health effects from smoking and secondhand smoke exposure, and refers smokers who want help quitting to the national toll-free portal number, 1–800-QUIT-NOW. During the first phase of the campaign (March 19–June 10, 2012), calls to the quitline increased and resulted in an additional 1.6 million smokers making a quit attempt (1,6).

Variations by states in the proportion of cigarette smokers who reported having made a quit attempt in the past year might be attributed to a number of factors, including differences in population demographics; tobacco control program infrastructure, programs, and policies; and awareness, availability, accessibility, and use of smoking cessation treatments (1,3,7). Nationally, younger persons, African Americans, and those with higher than a high school diploma were more likely to report a quit attempt in the past year than were older persons, whites, and those with less education (1,8). With the requirement by the Patient Protection and Affordable Care Act** that non-grandfathered private insurance plans cover FDA-approved cessation medications,†† access to effective cessation treatments is anticipated to increase.

The findings in this report are subject to at least four limitations. First, only current smokers with an unsuccessful quit attempt in the preceding 12 months were included in the 2001–2010 analysis; therefore, the 2001–2010 data do not provide a complete representation of total past-year quit attempts. Second, during 2001–2010, U.S. adults with wireless-only service (24.5%) were not included in the survey, although they are twice as likely to smoke cigarettes as the rest of the population (9). Because wireless-only households tend to be a younger demographic and younger persons are more likely to report a quit attempt (1), these data might underestimate actual quit attempts in some states. Third, modeling was limited to linear trends; it is possible that trends for some states are nonlinear. Finally, the median response rate for 2001–2013 ranged from 41.2% to 54.6%. While lower response rates can increase the potential for bias, national estimates from state-aggregated BRFSS data have been shown to be roughly comparable with smoking estimates from other surveys with higher response rates (9,10).

Examination of state variations can be used to identify effective public health programs and guide programs, promotions, and policies (2,3). To increase the number of cessation attempts, state tobacco control programs can focus their cessation activities on promoting health systems changes that make screening and treatment for tobacco use the standard of care in clinical settings; improving insurance coverage of evidence-based cessation treatments and promoting their use; and increasing use of state quitlines with mass media campaigns that contain graphic anti-smoking ads, such as Tips (3). Other effective interventions for increasing quit attempts and cessation include increasing the unit price of tobacco products and making workplaces and public places smoke-free (1,3). Sustained, comprehensive state tobacco control programs with adequate infrastructure and funded at CDC-recommended levels can accelerate progress toward increasing tobacco cessation and reducing tobacco-related diseases and deaths in the United States (3).

1Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, 2Contractor, DB Consulting Group, Inc.

Corresponding author: S. René Lavinghouze, rlavinghouze@cdc.gov, 770-488-5905.

References

US Department of Health and Human Services. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.

CDC. Surveillance for certain health behaviors among states and selected local areas—United States, 2010. MMWR Surveill Sum 2013;63(SS-01).

CDC. Smoking and tobacco use: best practices for comprehensive tobacco control programs—2014. Atlanta, GA: US Department of Health and Human Services, CDC; 2014. Available at http://www.cdc.gov/tobacco/stateandcommunity/best_practices.

CDC. Methodologic changes in the Behavioral Risk Factor Surveillance System in 2011 and potential effects on prevalence estimates. MMWR Morb Mortal Wkly Rep 2012;61:410–3.

Farrelly MC, Pechacek TF, Chaloupka FJ. The impact of tobacco control program expenditures on aggregate cigarette sales: 1981–2000. J Health Econ 2003;22:843–59.

CDC. Increases in quitline calls and smoking cessation website visitors during a national tobacco education campaign—March 19–June 10, 2012. MMWR Morb Mortal Wkly Rep 2012;61:667–70.

Schauer GL, Malarcher AM, Zhang L, Engstrom MC, Zhu SH. Prevalence and correlates of quitline awareness and utilization in the United States: an update from the 2009–2010 National Adult Tobacco Survey. Nicotine Tob Res 2014;16:544–53.

CDC. Quitting smoking among adults—United States, 2001–2010. MMWR Morb Mortal Wkly Rep 2011;60:1513–9.

Blumberg SJ, Luke JV. Wireless substitution: early release of estimates from the National Health Interview Survey, July–December 2009. National Center for Health Statistics; 2010. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201005.pdf .

Pierannunzi C, Hu SS, Balluz L. A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004–2011. BMC medical research methodology 13.1 (2013):49. Available at http://www.biomedcentral.com/1471-2288/13/49.

* Additional information available at https://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives.

† Available at http://www.cdc.gov/brfss.

§ Only current smokers with an unsuccessful quit attempt in the past 12 months were included in calculating quit attempts for 2001–2010; former smokers who had quit in the past year were not included because until 2009, former smokers were not asked when they had last smoked.

¶ Additional information available at http://www.cdc.gov/tobacco/campaign/tips.

** Information on the Affordable Care Act available at http://www.hhs.gov/healthcare/about-the-law/index.html.

†† Available at http://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/ —http://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions. See also the following: 1) Department of Health and Human Service (HHS) interim final regulations related to grandfathered health plans (June 17, 2010) at 75 FR 34538 (June 17, 2010) and amended interim final regulations at 75 FR 70114 (November 17, 2010); 2) Affordable Care Act, Section 1251, which limits the application of Public Health Services Act section 2707 to non-grandfathered group health plans and health insurance coverage; and 3) May 2014 sub-regulatory guidance from the U.S. departments of HHS, Labor, and Treasury clarifying this provision with regard to tobacco cessation coverage, which defined a comprehensive benefit based on the 2008 PHS Guideline at http://www.dol.gov/ebsa/faqs/faq-aca19.html.