False promises: the tobacco industry, "low tar" cigarettes, and older smokers

To investigate the role of the tobacco industry in marketing to and sustaining tobacco addiction among older smokers and aging baby boomers, We performed archival searches of electronic archives of internal tobacco company documents using a snowball sampling approach. Analysis was done using iterative and comparative review of documents, classification by themes, and a hermeneutic interpretive approach to develop a case study. Based on extensive marketing research, tobacco companies aggressively targeted older smokers and sought to prevent them from quitting. Innovative marketing approaches were used. "Low tar" cigarettes were developed in response to the health concerns of older smokers, despite industry knowledge that such products had no health advantage and did not help smokers quit. Tobacco industry activities influence the context of cessation for older smokers in several ways. Through marketing "low tar" or "light" cigarettes to older smokers "at risk" of quitting, the industry contributes to the illusion that such cigarettes are safer, although "light" cigarettes may make it harder for addicted smokers to quit. Through targeted mailings of coupons and incentives, the industry discourages older smokers from quitting. Through rhetoric aimed at convincing addicted smokers that they alone are responsible for their smoking, the industry contributes to self-blame, a documented barrier to cessation. Educating practitioners, older smokers, and families about the tobacco industry's influence may decrease the tendency to "blame the victim," thereby enhancing the likelihood of older adults receiving tobacco addiction treatment. Comprehensive tobacco control measures must include a focus on older smokers.     

Tobacco industry research on smoking cessation

BACKGROUND: Smoking rates are declining in the United States, except for young adults (age 18 to 24). Few organized programs target smoking cessation specifically for young adults, except programs for pregnant women. In contrast, the tobacco industry has invested much time and money studying young adult smoking patterns. Some of these data are now available in documents released through litigation. OBJECTIVE: Review tobacco industry marketing research on smoking cessation to guide new interventions and improve clinical practice, particularly to address young adult smokers’ needs.     

Parents who quit smoking and their adult children's smoking cessation: a 20-year follow-up study

Aims   Extending our earlier findings from a longitudinal cohort study, this study examines parents' early and late smoking cessation as predictors of their young adult children's smoking cessation.
Design   Parents' early smoking cessation status was assessed when their children were aged 8 years; parents' late smoking cessation was assessed when their children were aged 17 years. Young adult children's smoking cessation, of at least 6 months duration, was assessed at age 28 years.
Setting   Forty Washington State school districts.
Participants and measurements   Participants were 991 at least weekly smokers at age 17 whose parents were ever regular smokers and who also reported their smoking status at age 28. Questionnaire data were gathered on parents and their children (49% female and 91% Caucasian) in a longitudinal cohort (84% retention).
Findings   Among children who smoked daily at age 17, parents' quitting early (i.e. by the time their children were aged 8) was associated with a 1.7 times higher odds of these children quitting by age 28 compared to those whose parents did not quit [odds ratio (OR) 1.70; 95% confidence interval (CI) 1.23, 2.36]. Results were similar among children who smoked weekly at age 17 (OR 1.91; 95% CI 1.41, 2.58). There was a similar, but non-significant, pattern of results among those whose parents quit late.
Conclusions   Supporting our earlier findings, results suggest that parents' early smoking cessation has a long-term influence on their adult children's smoking cessation. Parents who smoke should be encouraged to quit when their children are young.     

Reducing risk in smokers

PURPOSE OF REVIEW: Tobacco smoking is a leading cause of lung cancer and chronic obstructive pulmonary disease. For smokers who want to quit, nicotine replacement therapy and bupropion are frequently recommended. Currently, disagreement surrounds the extent of risk reduction from quitting, the consequences of the change of nicotine replacement therapy to over-the-counter status, and the safety and efficacy of new tobacco products being marketed by tobacco companies. This article reviews the current evidence relevant to these and other developments in smoking interventions and describes the most effective strategies that smokers can use to reduce their risk. RECENT FINDINGS: Although it may take approximately 10 to 30 years of abstinence for former smokers' risk of lung cancer to reach that of never smokers, quitting at any time is substantially less risky than continuing to smoke. Quitting after diagnosis also prolongs survival. Bupropion and nicotine replacement therapy are effective pharmacotherapies, doubling quit rates compared with self-quitting. However, many users of over-the-counter nicotine replacement therapy are using it inappropriately. More research is needed to determine the long-term health effects of modified tobacco products and their efficacy in helping smokers quit. Switching to "low tar" filter cigarettes to reduce lung cancer risk, however, is clearly ineffective. The most effective interventions for quitting continue to be a combination of behavioral and pharmacologic approaches. SUMMARY: Health care practitioners should encourage all smokers to attempt cessation and emphasize pharmacotherapy as an important aid to quitting. Professionals who educate patients on the appropriate use of pharmacotherapy and follow-up on smokers' attempts to quit will help reduce the societal burden and personal risks of smoking.     

Older adults' and case managers' perceptions of smoking and smoking cessation

OBJECTIVE: This study explores older smokers' and case managers' perceptions of smoking and smoking cessation. METHODS: Data were collected from 48 case managers via focus group sessions and questionnaires and from 20 smoking clients via structured interviews. RESULTS: Case managers identified barriers to addressing clients' smoking at the client, staff, and organizational levels. Clients and case managers lacked information on the benefits of smoking cessation in older adults. The majority of clients interviewed had no plans to quit smoking. DISCUSSION: Results suggest that smoking cessation programs for this population need to be geared to clients who are not ready to quit. Education about the benefits of quitting smoking in older adults is needed for both case managers and smokers.     

Association of tobacco dependence and quit attempt duration with Rasch-modeled withdrawal sensitivity using retrospective measures

Aim   To examine whether Rasch modeling would yield a unidimensional withdrawal sensitivity measure correlating with factors associated with successful smoking cessation.
Design   The psychometric Rasch modeling approach was applied to estimate an underlying latent construct (withdrawal sensitivity) in retrospective responses from 1644 smokers who reported quitting for 3 or more months at least once.
Setting   Web-based, passcode-controlled self-administered computerized questionnaire.
Participants   Randomly selected convenience sample of 1644 adult members of an e-mail invitation-only web panel drawn from consumer databases.
Measurements   Lifetime Tobacco Use Questionnaire, assessing tobacco use across the life-span, including demographics and respondent ratings of the severity of withdrawal symptoms experienced in respondents' first and most recent quit attempts lasting 3 or more months.
Findings   Rasch-modeled withdrawal sensitivity was generally unidimensional and was associated with longer periods of smoking cessation. One latent variable accounted for 74% of the variability in symptom scores. Rasch modeling with a single latent factor fitted withdrawal symptoms well, except for increased appetite, for which the fit was marginal. Demographic variables of education, gender and ethnicity were not related to changes in sensitivity. Correlates of greater withdrawal sensitivity in cessation attempts of at least 3 months included younger age at first quit attempt and indicators of tobacco dependence.
Conclusion   The relationship between tobacco dependence symptoms and Rasch-model withdrawal sensitivity defines further the relationship between sensitivity and dependence. The findings demonstrate the utility of modeling to create an individual-specific sensitivity measure as a tool for exploring the relationships among sensitivity, dependence and cessation.     

Smoking cessation patterns and predictors of quitting smoking among the Japanese general population: a 1-year follow-up study

Aim   To examine the percentage of Japanese adult smokers who make quit attempts and succeed in smoking cessation over a 1-year period, and to identify predictors of attempts to stop and successful smoking cessation.
Design and setting   This study used Ipsos JSR Company's access panel, whose sampling framework is based on the Basic Resident Register in Japan. We tracked and monitored a selected sample of smokers who were at least 20 years of age through a baseline postal questionnaire survey in 2005 and a follow-up survey 1 year later.
Participants   The original response rate was 72.1% (1874 of 2600 smokers). There were 1627 current smokers in the baseline survey, and of those, 1358 were followed-up 1 year later.
Findings   Among the current smokers, 23.0% reported that they had attempted to quit smoking at least once in the past year. Of those who made quit attempts, 25.6% had achieved 1-week abstinence successfully and 13.5% reported having achieved sustained 6-month abstinence successfully at the time of the follow-up survey. The predictors associated with quit attempts were non-daily smoker, higher motivation to quit and previous attempts to stop smoking. Among smokers who made quit attempts, only 13.5% used nicotine replacement therapy. Higher nicotine dependence was associated with lower probability of success in quitting.
Conclusions   Japanese smokers attempt to quit at a lower rate than smokers in the United Kingdom and United States, but factors that predict attempts (primarily markers of motivation) and success of attempts (primarily dependence) are similar to those found in western samples.     

Does parental smoking cessation encourage their young adult children to quit smoking? A prospective study

AIMS: To investigate the extent to which parental early and late smoking cessation predicts their young adult children's smoking cessation. DESIGN: Parental early smoking cessation status was assessed when children were in 3rd grade, parental late smoking cessation was assessed when children were in 11th grade, and young adult children's smoking cessation was assessed 2 years after high school. SETTING: Forty Washington State school districts participated in the Hutchinson Smoking Prevention Project. PARTICIPANTS AND MEASUREMENTS: Participants were the 1553 families in which parents were ever regular smokers who had a young adult child smoking at least weekly at 12th grade who also reported their smoking status 2 years later. Questionnaire data were gathered on parents and their young adult children (49% female and 91% Caucasian) in a cohort with a 94% retention rate. FINDINGS: Parents who quit early had children with 1.8 (OR = 1.80; 95% CI = 1.22, 2.64) times higher odds of quitting smoking for at least 1 month in young adulthood compared to those whose parents did not quit early. In contrast, there was no association (OR = 0.84; 95% CI = 0.47, 1.51) between parents quitting late and their young adult children's smoking cessation. CONCLUSIONS: Parental early smoking cessation is associated with increased odds of their young adult children's smoking cessation. Parents who smoke should be encouraged to quit when their children are young.     

A cohort study to examine whether time and risk preference is related to smoking cessation success

Aim   To identify whether time and risk preference predicts relapse among smokers trying to quit.
Design   A cohort study of smokers who had recently started to quit. Time and risk preference parameters were estimated using a discrete choice experiment (DCE).
Participants   A total of 689 smokers who began quitting smoking within the previous month.
Measurements   Time discount rate, coefficient of risk-aversion measured at study entry and duration of smoking cessation measured for 6 months.
Findings   In the unadjusted model, Cox's proportional hazard regression showed that those with a high time discount rate were more likely to relapse [hazard ratio: 1.18, 95% confidence interval (CI): 1.11–1.25]. A high coefficient of risk-aversion reduced the hazard of relapse (0.96, 0.96–0.97). When adjusted for other predictors of relapse (age, gender, self-efficacy of quitting, health status, mood variation, past quitting experience, the use of nicotine replacement therapy, nicotine dependence), the hazard ratios of time discount rate and the coefficient of risk-aversion is 1.17 (95% CI: 1.10–1.24) and 0.98 (95% CI: 0.97–0.99), respectively.
Conclusions   Those who emphasize future rewards (time–patient preference) and those who give more importance to rewards that are certain (higher risk-aversion) were significantly more likely to continue to abstain from smoking.     

Self-help smoking cessation interventions in pregnancy: a systematic review and meta-analysis

Aims   Self-help smoking cessation interventions for pregnant smokers are of importance due to their potential to be wide-reaching, low-cost and their appeal to pregnant smokers who are interested in quitting smoking. To date, however, there has been no systematic assessment of their efficacy. This systematic review aimed to assess the efficacy of self-help interventions for pregnant smokers and to investigate whether self-help material intensity, type or delivery are associated with cessation.
Methods   The literature was searched for randomized and quasi-randomized controlled trials of self-help smoking cessation interventions for pregnant smokers without significant cessation counselling. Fifteen trials met the inclusion criteria and relevant data were extracted independently.
Results   The primary meta-analysis pooled 12 trials comparing usual care (median quit rate 4.9%) with self-help (median quit rate 13.2%) and yielded a pooled odds ratio (OR) of 1.83 [95% confidence interval (CI) 1.23–2.73], indicating that self-help interventions on average nearly double the odds of quitting compared with standard care. However, a further meta-analysis failed to find evidence that intervention materials of greater intensity increase quitting significantly over materials of lesser intensity (pooled OR = 1.25, 95% CI 0.81–1.94). There was insufficient evidence to determine whether the tailoring of materials or levels of one-to-one contact were related to intervention efficacy.
Conclusions   Self-help interventions appear to be more effective than standard care although, due mainly to a lack of trials, it is unclear whether more sophisticated and intensive approaches increase intervention effectiveness.     

Do cigarette prices motivate smokers to quit? New evidence from the ITC survey

Aims To examine the importance of cigarette prices in influencing smoking cessation and the motivation to quit. Design We use longitudinal data from three waves of the International Tobacco Control Policy Evaluation Survey (ITC). The study contrasts smoking cessation and motivation to quit among US and Canadian smokers and evaluates how this relationship is modified by cigarette prices, nicotine dependence and health knowledge. Different price measures are used to understand how the ability to purchase cheaper cigarettes may reduce the influence of prices. Our first model examines whether cigarette prices affect motivation to quit smoking using Generalized Estimating Equations to predict cessation stage and a least squares model to predict the change in cessation stage. The second model evaluates quitting behavior over time. The probability of quitting is estimated with Generalized Estimating Equations and a transition model to account for the ‘left‐truncation’ of the data. Settings US and Canada. Participants 4352 smokers at Wave 1, 2000 smokers completing all three waves. Measurements Motivation to quit, cigarette prices, nicotine dependence and health knowledge. Findings Smokers living in areas with higher cigarette prices are significantly more motivated to quit. There is limited evidence to suggest that price increases over time may also increase quit motivation. Higher cigarette prices increase the likelihood of actual quitting, with the caveat that results are statistically significant in one out of two models. Access to cheaper cigarette sources does not impede cessation although smokers would respond more aggressively (in terms of cessation) to price increases if cheaper cigarette sources were not available. Conclusions This research provides a unique opportunity to study smoking cessation among adult smokers and their response to cigarette prices in a market where they are able to avoid tax increases by purchasing cigarettes from cheaper sources. Higher cigarette prices appear to be associated with greater motivation to stop smoking, an effect which does not appear to be mitigated by cheaper cigarette sources. The paper supports the use of higher prices as a means of encouraging smoking cessation and motivation to quit.     

Smoking cessation and glycaemic control in type 2 diabetic patients

Aim:  To elucidate the relationship between glycaemic control, blood pressure and body-weight change after smoking cessation in type 2 diabetic patients.
Methods:  We examined HbA_1c, blood pressure and body weight in 15 type 2 diabetic patients before, 6 and 12 months after quitting smoking. Sixteen type 2 diabetic patients who did not quit smoking served as control.
Results:  Body weight slightly increased after quitting smoking. Although HbA_1c levels showed no change in the control group, those in patients who quit smoking significantly increased (6.8 ± 0.3% before quitting smoking; 7.4 ± 0.3% 6 months after quitting smoking, p < 0.05; 7.8 ± 0.4% 12 months after quitting smoking, p < 0.001). Fasting blood glucose also increased in patients who quit smoking. The increase in body weight after quitting smoking did not correlate with the deterioration of glycaemic control. Diastolic blood pressure showed no change in control, whereas that in patients who quit smoking increased at month 12 (69 ± 3 vs. 76 ± 3 mmHg, p < 0.01). The increase in HbA_1c at month 12 after quitting smoking correlated with body mass index before quitting smoking ( r  = 0.72, p < 0.005) and serum triglyceride before quitting smoking ( r  = 0.68, p < 0.01).
Conclusions:  Glycaemic control and diastolic blood pressure deteriorated in type 2 diabetic patients after quitting smoking. Type 2 diabetic patients who want to stop smoking need a caution to prevent deterioration of glycaemic control and blood pressure after quitting smoking.     

Determinants of smoking and cessation in older women

BACKGROUND: although the benefits of quitting smoking even at an advanced age have been proved, few campaigns target the older population. The goals of this study were to analyse the characteristics of older women smokers help and support those wanting to quit. METHODS: we assessed the determinants of smoking cessation in a prospective cohort study performed in 7,609 older women. A questionnaire about smoking habits was sent to the 486 eligible smokers. Smoking dependence and smokers' readiness to quit was assessed. Participants who had quit smoking during follow-up were asked about their previous reasons for quitting and the methods used to quit. RESULTS: 372 women of the 424 (88%) responded to our questionnaire and were included. The most common reasons for smoking were relaxation, pleasure, and habit. Major obstacles to quitting smoking were 'no benefit to quitting at an advanced age', 'smoking few or "light" cigarettes yields no negative health consequences', and 'smoking does not increase osteoporotic risk'. During the 3-year follow-up period, 57 of the 372 (15%) women successfully quit smoking. Being an occasional smoker (OR=2.4) and reporting 'quitting is not difficult' (OR=3.7) were positively associated with having recently quit smoking. Only 11% of successful cessations were reported to have received physician advice. CONCLUSIONS: these data illustrate the specific smoking behaviour of older women, suggesting that cessation interventions ought to be tailored to these characteristics. Willingness to quit was associated with a low education level. The most frequent obstacles to quitting were all based on incorrect information.     

Do smokers know how to quit? Knowledge and perceived effectiveness of cessation assistance as predictors of cessation behaviour

AIMS: Despite the existence of effective cessation methods, the vast majority of smokers attempt to quit on their own. To date, there is little evidence to explain the low adoption rates for effective forms of cessation assistance, including pharmaceutical aids. This study sought to assess smokers' awareness and perceived effectiveness of cessation methods and to examine the relationship of this knowledge to cessation behaviour. DESIGN: A random-digit-dial telephone survey (response rate = 76%) with 3-month follow-up was conducted with 616 adult daily smokers in South-Western Ontario, Canada. MEASUREMENTS: A baseline survey assessed smoking behaviour, as well as smokers' awareness and perceived effectiveness of cessation assistance. A follow-up survey measured changes in smoking behaviour and adoption of cessation assistance at 3 months. FINDINGS: Participants demonstrated a poor recall of cessation methods: 45% of participants did not recall nicotine gum, 33% did not recall the nicotine patch and 57% did not recall bupropion. Also, many participants did not believe that the following cessation methods would increase their likelihood of quitting: nicotine replacement therapies (36%), bupropion (35%), counselling from a health professional (66%) and group counselling/quit programmes (50%). In addition, 78% of smokers indicated that they were just as likely to quit on their own as they were with assistance. Most important, participants who perceived cessation methods to be effective at baseline, were more likely to intend to quit (OR = 1.80, 95% CI: 1.12-2.90), make a quit attempt at follow-up (OR = 1.80, 95% CI: 1.03-3.16) and to adopt cessation assistance when doing so (OR = 3.62, 95% CI: 1.04-12.58). CONCLUSIONS: This research suggests that many smokers may be unaware of effective cessation methods and most underestimate their benefit. Further, this lack of knowledge may represent a significant barrier to treatment adoption.     

Epidemiology of smoking in Europe

Tobacco is the most important preventable cause of mortality in European countries, accounting for over half a million deaths per year. A review is presented on the epidemiology of tobacco smoking in Europe, using a comprehensive approach on the health effects of smoking, the prevalence of tobacco consumption, and its evolution in the past decade. Tobacco industry efforts to promote and maintain smoking through production and pricing are also reviewed. Thirty out of every 100 European adults smoke everyday and one of every ten adults smokers will die from tobacco smoking; a higher ratio of 1:15 is found in Eastern Europe. The prevalence of smokers is decreasing among young adults in some European countries, while it is increasing among young women in Southern and Eastern Europe. Smoking cessation and prevention interventions should be implemented, such as banning smoking in public areas, banning direct and indirect advertising of tobacco products, crop reduction, and rising cigarette prices. These interventions should be designed, coordinated, and developed by and among the different sectors involved in tobacco control initiatives, together with social network at the local, regional, and national levels, with the support of national and international organizations.     

Sex differences in the effects of stressful life events on changes in smoking status

Aims   Stressful life events known to be associated with substance use were examined to determine if there were sex-specific responses to stress resulting in changes in smoking status.
Participants and measurements   A community-based sample of ever smokers from the Americans' Changing Lives study ( n  = 1512, 45% female based on sample weights) was used to examine the interactive effects of sex and stressful life events on the likelihood of two outcomes; relapse among former smokers and failure to quit among current smokers. Logistic regression procedures were used to calculate odds ratios. Factors known to be associated with smoking status (e.g. depression, self-esteem, social support) were assessed as control variables.
Findings   In the sample of former smokers ( n  = 729) interpersonal loss events were associated with continued abstinence, whereas change of residence and adverse financial events were associated with increased occurrence of relapse. Women were more likely than men to relapse in response to a financial event. In the sample of current smokers ( n  = 783), financial events were associated with continued smoking, whereas health events were associated with increased likelihood of quitting. Women were more likely than men to continue smoking in the presence of an adverse financial event and less likely than men to quit in response to an adverse health event.
Conclusions   Overall, stressful life events appear to have a greater deleterious effect on continued abstinence and the ability to quit smoking for women when compared to men. In particular, health and financial events are important risk factors for women and tobacco use.     

Smoker sensitivity to retail tobacco displays and quitting: a cohort study

Aims   To assess whether sensitivity to point of sale (POS) cigarette displays influences quitting behaviour.
Design   Prospective cohort study.
Setting   Victoria, Australia.
Participants   A total of 222 adult smokers were surveyed at baseline in 2006 and followed-up 18 months later.
Measurements   Baseline sensitivity to POS displays, which included the frequency of 'noticing displays', 'impulse purchasing behaviour' and 'deciding on brand based on POS displays'; smoking status at follow-up.
Findings   At follow-up, 17.0% were no longer smokers. After adjusting for covariates, compared to those with low POS display sensitivity, smokers who had a medium or high level of sensitivity to POS displays were significantly less likely to have quit at follow-up [odds ratio (OR) = 0.32, 95% confidence interval (CI) = 0.14–0.74; OR = 0.27, 95% CI = 0.08–0.91, respectively].
Conclusions   The presence of cigarette pack displays in stores may make it more difficult for smokers to quit smoking successfully.     

Depressive symptoms and smoking among Hong Kong Chinese adolescents

AIMS: To examine associations among depressive symptoms, smoking, smoking trajectories and quitting smoking in Hong Kong. DESIGN: Prospective longitudinal design, with wave 1 at baseline (T1) and wave 2 (T2) 12 months later. SETTING AND PARTICIPANTS: Form 1 (equivalent to 7th grade in the United States) students, mean age = 12.7 years, n = 1894. MEASUREMENTS: Self-reported smoking status, attempts to quit and depressive symptoms. FINDINGS: At both waves, current as well as ex-smokers had higher depressive symptoms than never smokers. T1 smoking predicted T2 depressive symptoms among those with low baseline depressive symptoms. Depressive symptoms at T1 predicted smoking at T2 among non-smokers at T1. Trajectories were defined by separating participants who were never smokers at both waves ('non-smokers'), those who smoked at both waves ('persistent smokers'), those who smoked at one time but were not smoking at either wave ('past smokers), and those who had never smoked at T1 but reported smoking a year later ('new smokers'). Persistent, past and new smokers had higher depressive symptoms at both waves than non-smokers. Smokers who reported not wanting or trying to quit and those who had been unsuccessful at quitting had higher depressive symptoms at T2 than those who successfully quit. CONCLUSION: Our results suggest that depressive symptoms promote tobacco use in Asian adolescents by making it more likely that an adolescent will begin smoking and less likely that she or he will quit. These findings elucidate risk factors in Hong Kong for two important public health concerns for adolescents: smoking and depression.     

A Review of Life-Course Familial and Lifestyle Factors of Smoking Initiation and Cessation

Smoking raises the risk of cardiovascular diseases in active and passive smokers throughout life. Taking a life-course approach, we reviewed current literature on the familial and lifestyle factors of smoking initiation and cessation. Single-parent and parental smoking are risk factors of smoking in young people, while smoking cessation of parents and family support predict quitting in both young and adult smokers. Results on the familial influences on relapses are limited and mixed in adolescents and adults. Regarding behavioral factors, poor eating habits and alcohol drinking would increase, and a high physical activity level would decrease, the likelihood of smoking in both adolescents and adults. Nutritional status of children improves with parental smoking cessation. In addition, disordered eating may hinder smoking cessation in women. Familial and behavioral factors interplay in their associations with smoking initiation and cessation in the life-course, which warranted further investigations for formulating better smoking prevention and cessation programs.