Research articleUse of Smoking-Cessation Treatments in the United States
Introduction
Cigarette smoking continues to be the leading preventable cause of death and disease in the developed world. In the United States, over the last decade, about 40% of smokers report having made a quit attempt each year.1 However, most quit attempts fail—only about 3%–5% of smokers maintain abstinence up to 1 year after quitting.2, 3 Increasing the frequency and success of smoking-cessation attempts is an important clinical and public heath priority.
Randomized controlled trials have demonstrated the efficacy of several behavioral and pharmacologic treatments for smoking cessation.4 Proven behavioral methods include face-to-face counseling5, 6 as well as telephone counseling,7 which is considered a mainstay of treatment efforts in the U.S. In contrast, self-help materials such as booklets or videos have demonstrated marginal efficacy8; accessing similar static materials via the Internet would presumably be no better, although computer-tailored interventions appear to be more effective.9, 10 Alternative treatments such as acupuncture and hypnosis are ineffective.11, 12 Among pharmacologic treatments, nicotine replacement therapy13 (NRT) and bupropion14 have demonstrated efficacy in dozens of randomized placebo-controlled trials. Behavioral and pharmacologic treatments are each effective on their own, but combining them additively improves success rates13 and is widely regarded as the gold standard for treatment.4 While not a treatment per se, receiving social support from friends and family seems to facilitate cessation when support is received naturally,15, 16 although not when social support is engineered through intervention.17
Based on these efficacy findings, the U.S. Clinical Practice Guideline4 recommends that all smokers be advised to use medication and behavioral treatment, and physicians often recommend treatment.18 Yet utilization of these treatments has been modest; in 2000, only 1.3% of U.S. smokers who made quit attempts used a behavioral treatment, and only 21.7% used a pharmacologic treatment.19 In this article, data from the 2003 Tobacco Use Special Cessation Supplement (TUSCS) to the Current Population Survey (CPS)20 were used to report on the proportion of U.S. smokers attempting to quit, by demographics and smoking history, and their use of cessation treatments.
The relationship between treatment use and reported abstinence was also examined. Retrospective surveys often find that smokers who seek behavioral or pharmacologic treatment are less likely to report abstinence.21, 22 For example, a retrospective California survey23 showed that smokers who elected to use over-the-counter (OTC) NRT in their quit attempt had only modestly longer abstinence than those who chose not to use NRT. Although that analysis did not examine behavioral treatment, the authors concluded that NRT was ineffective in an OTC setting due to a lack of behavioral treatment.
Such analyses based on retrospective surveys seem at odds with findings from numerous controlled randomized clinical trials.13 However, evaluating treatment effectiveness from survey data is fraught with problems. Biases in recall can confound the evaluation of treatment. Further, smokers self-select for treatment, based on their perceived need and expectations of difficulty quitting,24 so treatment-seeking itself can index risk for failure, undermining the validity of comparisons of outcome between treatment-seekers and nonseekers. Such “confounding by indication”25 can result in those using even effective treatments appearing to do worse than the untreated, leading to illogically reversed findings (e.g., use of anticoagulants is associated with increased risk of thrombosis25). As one index of systematic self-selection for treatment, the relationship between adoption of treatment and nicotine dependence was examined. Nicotine dependence has been shown to predict failure in cessation.26 However, Canadian population data27 suggested that the relationship between dependence and subsequent cessation is not linear, with smokers at the lowest and highest ends of dependence (assessed by the Heaviness of Smoking Index)28 being most likely to transition to abstinence over a 2- to 4-year period, due either to increased attempts or increased success.
In any case, because of confounding by indication and retrospective biases, it was expected that smokers who sought behavioral and/or pharmacologic treatment would report abstinence rates similar to or even worse than those who quit without treatment.
Section snippets
Data
The CPS, administered by the U.S. Census Bureau, is a nationally representative household survey of the non-institutionalized, civilian U.S. population aged 15 and older. Complete information on the design and methodology of the CPS has been published elsewhere.29 In 2003, the TUSCS, which included questions on tobacco use and cessation treatments, was administered with the CPS (http://riskfactor.cancer.gov/studies/tus-cps/info.html). Of the 181,533 households sampled, 92.6% responded to the
Quit Attempts
By self-report, 43.5% of smokers had made a serious quit attempt in the past 12 months; 38.0% had made a quit attempt lasting 24 hours or more. As shown in Table 2, female smokers were significantly more likely to have made a quit attempt than men, and the likelihood of quit attempts decreased with age. Hispanics and smokers of “other” ethnicity were more likely to have attempted to quit than whites and African Americans, who had similar attempt rates. Smokers with at least some college
Discussion
This analysis documented the likelihood of quit attempts and use of treatments among U.S. smokers in 2002–2003. An estimated 14.5 million adult daily U.S. smokers (43.5%) reported making a serious quit attempt in the previous 12 months. Using a common metric of quit attempts lasting 24 hours or more, 38.0% of adult smokers in the CPS reported quit attempts, slightly less than in older surveys (e.g., 40.6% in 2001,33 41.2% in 200234). Because of differences in survey methods, one cannot conclude
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