Health Education Research, Vol. 16, No. 1, 49-57,
February 2001
© 2001 Oxford University Press
Smoking cessation between teenage years and adulthood
Department of Epidemiology and Health Promotion, National Public Health Institute, Mannerheimintie 166, 00300 Helsinki, Finland
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Abstract |
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Most smokers begin smoking in adolescence. It is less well known how young people quit smoking and the factors that are associated with this process. A 15-year follow-up study on the North Karelia Youth Project has made it possible to assess these factors using a longitudinal study design. The project began in 1978 with students in Grade 7 of junior high school (age 13 years) and concluded in 1980 when the students reached Grade 9 (age 15 years). The follow-up study included four additional surveys. The present analyses are based on the data collected at ages 15, 21 and 28. The original sample comprised 903 students and the response rate of the last survey was 71%. A quarter (26%) of daily smokers and about half (46%) of occasional smokers at age of 15 had quit by the age of 28. The cessation rate was higher among females than males (P = 0.006). The cessation rate was higher among married (P = 0.015), employed (P = 0.01) and white-collar workers (P = 0.006). Cessation was less prevalent among those who had friends (P < 0.001) and family (P = 0.012) members who smoked. The cessation rate was lower among those who consumed fatty milk (P = 0.050), had less leisure-time physical activity (P = 0.032) and consumed more alcohol (P < 0.001). One-third of all teenage smokers stop smoking before the age of 28, averaging a 2.3% annual decline. Cessation is greater among occasional than daily smokers and greater overall among females.
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Introduction |
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Smoking and smoking cessation are not stable and clear behaviors among young people; they can mean different things and change many times between adolescence and adulthood. Usually, there is an increase in smoking prevalence from adolescence to young adulthood and then a decline after the mid-20s (Chassin et al., 1996
; Paavola et al., 1996). There are only a few longitudinal studies on smoking cessation from adolescence to adulthood (Chassin et al., 1990; Swan et al., 1991; Fergusson et al., 1995). A Finnish longitudinal and qualitative study followed smoking status of subjects at the ages of 14, 20 and 27 (Pulkkinen and Kallio, 1988). Smoking among women increased up to the age of 17 after which it started to decline. Men's smoking increased up to the age of 20 and a slight decline emerged after the age of 23. Adolescent smoking status is a strong predictor of later smoking (Pulkkinen and Kallio, 1988; Swan et al., 1991; Paavola et al., 1996). The continuity of smoking from teenage to adulthood is stronger particularly when smoking was a regular behavior during teenage years (Pulkkinen and Kallio, 1988; Paavola et al., 1996). Only few of those who had not experienced smoking by the age of 14 became smokers (Pulkkinen and Kallio, 1988). Less addicted adolescents are more likely to quit, but earlier experience with quitting is not associated with a higher likelihood of cessation (Sargent et al., 1998; Ershler et al., 1989). Once young people become weekly smokers they are unlikely to give up (Kelder et al., 1994). Pulkkinen found that among those who were regular smokers at age 14, 16% of boys and 19% girls had quit at age 20 (Pulkkinen and Kallio, 1988). They had mostly smoked 2–3 years during teenage years. The median cessation age in California, USA for those who start smoking as adolescents is expected to be 33 years for males and 37 years for females (Pierce and Gilpin, 1996).
Several studies show that young smokers are willing to quit; the majority tries but most attempts are unsuccessful (Pulkkinen and Kallio, 1988; Tuakli et al., 1990; Towsend et al., 1991; Stone and Kristeller, 1992; Dozois et al., 1995; Gillespie et al., 1995; Breslau and Peterson, 1996; Dappen et al., 1996; Hines, 1996; Stanton et al., 1996; Burt and Peterson, 1998; Hu et al., 1998; Lamkin et al., 1998; Stanton et al., 1999). The results of the study Health Behaviour Among Finnish Adult Population (Helakorpi et al., 1998) show that among 15–24 year olds, 25% of males and 23% of females smoke daily. During the 1980s and 1990s smoking prevalence has slightly decreased among men and has been about the same among female in this age group. The desire to quit does not differ very much among different age groups. In all age groups one-tenth of smokers want to continue smoking and half of smokers would like to quit. Among 15–24 year olds, 20% had attempted to quit during the previous month, but the proportion of those who really quit was only 2%. No difference between genders was found.
The likelihood of quitting among young people is strongly dependent on the extent of smoking among their peers (Pulkkinen and Kallio, 1988; Ershler et al., 1989; Rose et al., 1996; Burt, 1998; Flay et al., 1998; Sussman et al., 1998). Chassin et al. (Chassin et al., 1996) found that young people quit less if their parents smoke, but in one study parental smoking was unrelated to both quit attempts and cessation (Rose et al., 1996). Engels et al. (Engels et al., 1998) found that those with a positive attitude towards smoking and lower self-efficacy at the age of 14–17 years were less likely to be motivated to quit 3 years later.
The most important stated reasons for young people to quit are health (Pulkkinen and Kallio, 1988; Stone and Kristeller, 1992; Dozois et al., 1995) and financial reasons (Gillespie et al., 1995). Sussman et al. (Sussman et al., 1995) reported that the most important reason to quit was `if my girlfriend/boyfriend asked me to quit'. On the other hand, smokers who tried to quit because of social pressure from others were less likely to succeed (Rose et al., 1996). The adolescents' own idea on how to promote successful smoking cessation among young people was to have a friend with whom to quit (Tuakli et al., 1990).
In some studies females have been less successful at quitting (Burt and Peterson, 1998) and other studies found women to be more likely to make an attempt to quit, but their attempts were not very successful (Rose et al., 1996). Socioeconomic variables like education are related to smoking cessation, such that cessation is more common among higher socioeconomic status groups (Breslau and Peterson, 1996; Rose et al., 1996). Education is strongly associated with smoking (Paavola et al., 1996) and with smoking cessation such that those with more years of education make more attempts to quit (Hu et al., 1998) and quit more often than those with fewer years of education (Chassin et al., 1996; Rose et al., 1996). Being employed has been associated with successful cessation (Rose et al., 1996; Stanton et al., 1996). It is not very clear whether having children has an effect on cessation, but Rose et al. (Rose et al., 1996) found that living with children was associated with failed cessation. People who were married made more attempts to quit.
There is also evidence that non-smokers have healthier eating habits and are more physically active (Townsend et al., 1991; Kelder et al., 1994). In addition, smoking cessation is more common among those who have a healthier lifestyle (Rose et al., 1996). Alcohol use is strongly related to smoking (Pulkkinen and Kallio, 1988; Tuakli et al., 1990; Townsend et al., 1991; Dappen et al., 1996; Flay et al., 1998).
The results of the effects of the North Karelia Youth Project intervention (Sussman et al., 1995) and on the onset and predictors of smoking (Paavola et al., 1996), based on the same data, have been published earlier. The main result of the intervention was that long-term smoking prevention effects can be achieved by adopting a social influence model combined with community and mass media interventions (Vartiainen et al., 1998). Smoking prevalence was lower up to the age of 21, at age 28 there were no differences in smoking between groups. The aim of this study was to assess the rate of smoking cessation from adolescence to adulthood and to learn how socioeconomic factors, other health behaviors, and smoking in the family, among friends and in the workplace are associated with cessation.
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Method |
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A 2-year risk factor prevention program, the North Karelia Youth Project, began in 1978 among students in Grade 7 (age 13) and concluded when the same students were in Grade 9 (age 15) in autumn 1980. The project was carried out at four schools in the county of North Karelia, Finland. The aim of the project was to prevent the main cardiovascular risk factors among adolescents. The smoking prevention part of the program was particularly based on teaching skills to resist the social influences that promote smoking.
The study began with a pre-test survey in 1978. After that, five follow-up surveys were carried out. The last survey was in 1993, when the subjects were 28 years old.
The study was designed to test the efficacy of a school-based intervention program. Three pairs of matched schools were chosen for the study. Two schools (one urban, one rural) were selected from another county in eastern Finland as controls and the intervention program was carried out in four North Karelian schools (two urban, two rural). For each matched pair, one school was chosen from the county capital and the other from a rural community. The schools were upper-level comprehensive schools (junior high schools). Comprehensive schooling is compulsory for all Finnish citizens and covers for the entire age group. All schools in the study were co-educational.
Between 1978 and 1980 the six schools had a combined enrollment of 903 students who continued from Grade 7 to 9. The participation rates of the pre-test survey (fall 1978) and the post-test survey (fall 1980) were 897 students (99%) and 851 students (94%), respectively. These two surveys included a self-administered questionnaire and a cardiovascular risk factor examination at school. Permission from the parents was asked prior to participation in the survey. The survey was carried out by specially trained project nurses. Adolescents' answers to the questionnaire were confidential and were not given to teachers or parents. All technical details have been published earlier (Vartiainen, 1982). The students filled in the questionnaire at school in the spring of 1981, and postal surveys were done in fall 1982 and in 1986. The new addresses of those who had moved were obtained from the National Population Register based on the subjects' social security numbers. The questionnaires were sent to their homes, and they were asked to complete and return them in an enclosed envelope. In the most recent survey (1993–94) the subjects were asked to complete the questionnaire at home and to participate in a cardiovascular risk factor examination carried out by a trained project nurse at a health center. In this last survey the participation rate was 71%. The other participation rates are presented in Table I.
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In all the surveys, self-reported smoking status was determined by asking the following question: Do you smoke now? The response choices were: (1) not at all, (2) less than once a month, (3) once or twice a month, (4) one to two times per week and (5) daily. Categories (2), (3) and (4) were regarded as occasional smokers. The data on smoking used in the present analyses are from the surveys of 1980 (at the end of the intervention) among students in Grade 9 (15 years old), 1986 (21 years old) and 1993 (28 years old). Socioeconomic factors, health behavior, and smoking in the family, among friends and in the workplace were measured at the age of 28.
First those who were daily smokers at age 15 and non-smokers at age 28 were defined as `quitters'. Quitting rates between ages 15 and 21 and between ages 21 and 28 were defined in the same way. When we analyzed the association between background variables and cessation, quitters were the subjects who were at least occasional smokers at age 15 and non-smokers at age 28.
The attrition rate was about a quarter at the last survey. Difference between drop-outs and participants were analyzed at age 15: there was no difference in smoking status. In the original sample 51% were boys and 49% girls. In the most recent survey the drop-out rate was slightly higher among males than females: 49% of participants were males and 51% females.
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Results |
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Smoking status from age 15 to 28 years of age is shown in Table II
. At the age of 15, 16% were daily and 13% occasional smokers. The difference in smoking between boys and girls was not statistically significant. At some point between 15 and 28 years of age, 26% of daily smokers and 46% of occasional smokers had ceased smoking. The cessation rate was higher both among daily and occasional smokers among females than among males (P = 0.006).
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Table III
presents smoking status and its changes from the age of 15 to 21. At some point between the ages of 15 and 21, 22% of daily smokers and 32% of occasional smokers had ceased smoking. The cessation rate was higher among females (P = 0.0004). The gender difference was especially large among occasional smokers: 43% of females and 12% of males had ceased smoking before the age of 21.
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Smoking prevalence was highest at the age of 21: 35% of men and 23% of women smoked daily (Table IV
). During the next 7 years 12% of daily smoking men and 20% of daily smoking women had ceased smoking. Among occasional smokers the gender difference was even greater: 60% of females and 37% had ceased smoking before the age of 28 (P = 0.015 for the gender difference).
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Over a 6-year period until the age of 21, 22% of daily smokers had quit (Table III
). Between the ages of 21 and 28 (7 years) the cessation rate was 16% (Table IV). This yields an annual quitting rate of 2.3% between ages 15 and 28, 4.1% between ages 15 and 21, and 2.5% between ages 21 to 28.
To analyze the association between cessation and socioeconomic factors, smoking among `significant others', and other health behavior, we analyzed the subjects who were at least occasional smokers at the age of 15 in 1980 and who were surveyed at the age of 28 in 1993 (n = 183). Smoking cessation in this group was 35% (n = 64) between the ages of 15 and 28 (Table V). The analysis show the percentage with each characteristic who quit.
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The difference between genders was significant. 27% of teenage male smokers had quit before age 28 and 43% of females, respectively. There were no differences in cessation between groups with different educational levels, but 52% of white-collar workers had quit compared to the 29% of blue-collar workers.
Significant differences were found according to marital status. Married people had quit most and the divorcees the least. Employment was also a significant factor, because 36% of the employed compared to the 15% of unemployed had stopped smoking. Cessation was not significantly related to income or having children.
The cessation rate was lower among those smokers whose spouses smoked daily. The smoking status of a best friend was a highly significant factor: 20% had quit if their friend was a smoker and 52% had quit if their best friend was not a smoker. Smoking among fellow workers and daily exposure to passive smoking were not significant variables.
The association between health behavior and smoking cessation was researched. Leisure time was associated significantly with cessation such that the cessation rate was higher among those with more physical activity. The cessation rate was lower among those consuming fatty milk. The type of fat used on bread or for cooking was not associated with cessation. Alcohol consumption was related very significantly to smoking cessation: subjects who consumed less alcohol were more likely to quit smoking.
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Discussion |
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TopAbstractIntroductionMethodResultsDiscussionReferences |
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In this study one-fourth of the 15-year-old daily smokers and half of the occasional smokers had quit by the age of 28. Other longitudinal studies (Kelder et al., 1994
; Fergusson et al., 1995; Gillespie et al., 1995; Chassin et al., 1996; Stanton et al., 1996, 1999; Flay et al., 1998) have indicated quite similar results. Cross-sectional studies have shown that the annual cessation rate among adults is about 2% (Helakorpi et al., 1998). The results of this study give similar rates for young adults. If we take the period from 15 to 28 years of age, cessation among daily smokers was approximately 2.3% annually. Annual cessation rate was higher during the first period (15–21 aged) than the last period (21–28). Because so few smokers are successful quitters, smoking prevalence is relatively persistent from adolescence to adulthood. However, only 7% of 28-year-old smokers thought that they would still be smokers in 5 years. This means that smokers are very willing to quit, but in practice only a few actually succeed and there is thus a clear need for effective smoking cessation programs. The cessation rate was higher among girls than boys during all periods and in both groups of smokers. The largest differences between genders during all the periods were among those who were occasional smokers at onset. Most of the male occasional smokers became daily smokers while most of the girls continued as occasional smokers or had quit smoking. In other studies quit attempts have been more common among women, but men have usually been more successful. It is possible that as smoking rates among girls reach or even surpass those of boys, their cessation rates may also eventually approach or surpass those of boys.
There were no significant differences in smoking cessation between educational groups. This is surprising, because many other studies have shown an association between education and smoking cessation. One reason could be that we asked the subjects to report their years of education as opposed to their actual level of education. The amount of education can include many kinds of short courses, which can be taken, for example, during unemployment, but income level was also not related to cessation. On the other hand, there were differences between white-collar and blue-collar workers; white-collar workers had a higher cessation rate. This supports the interpretation that the social environment is an important factor in cessation.
Cessation was more common if the best friend was a non-smoker. The family members' smoking status was also significantly associated with smoking cessation. This also reflects the importance of social environment. Smoking among fellow workers or exposure to passive smoking were not significant variables. This study also supports the finding that smokers who are married and employed smoke less and quit more. The impact of social pressure is obvious. Having children did not seem to have any relation to smoking cessation, not even among women. Having children could encourage people to quit, but may also increase stress and thus hinder cessation.
There were associations between smoking cessation and other forms of health behavior. Subjects who consumed less alcohol were much more likely to quit. Those who had leisure time activity were also more likely to quit.
The results on the relatively low cessation rates support the importance of preventing the onset of smoking in adolescence. At the same time it would be important to develop cessation programs tailored for adolescents. In addition to nicotine addiction, cessation programs should stress the importance of the social influences and support of family, friends and other people as one of the main determining factors of continued smoking. Program developers should keep in mind that smoking and smoking cessation are only one part of an adolescent's lifestyle, which is considerably influenced by the surrounding social environment. The increasing smoking prevalence among girls and women is very worrying, thus gender-specific approaches in smoking cessation programs should probably be developed and evaluated as well.
The school-based smoking prevention programme was carried out when the subjects were 13–15 year olds. The quitting rates were similar in both intervention and control groups. Such programmes were not effective in influencing quitting later in life.
There are some limitations in the current study. Although a 13-year follow-up is most valuable, our analyses rely on just three observation points and many things occur in people's lives between these points. Thus the dynamics of smoking during these years may not be fully captured. The sample was relatively small, especially for studying factors associated with quitting. The small number of quitters did not allow us to use multi-factorial analyses. Although the response rate was quite good, it is likely that non-respondents smoked more and quit less.
Despite these limitations the study provides some insight in the dynamics of smoking from the teenage years to adulthood. The continuity of daily smoking was high. At the same time cessation in adolescence is possible.
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Received on November 6, 1999; accepted on May 23, 2000
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