Distribution of daily smokers by stage of change: Current population survey results

Abstract

Background

Population-based national estimates of stage of change among daily smokers are unknown. This study described the proportion of U.S. daily smokers, 18 and older, by stage of change. Selected sociodemographic characteristics were delineated.

Methods

Cross-sectional data were collected via telephone or face-to-face interview in daily smokers who responded to the Current Population Survey in 1992–1993 (n = 39,706), 1995–1996 (n = 34,865), or 1998–1999 (n = 30,153). Main outcomes included stage of change: (1) Precontemplation—not interested in quitting smoking in next 6 months; (2) Contemplation—interested in quitting smoking in next 6 months but not next 30 days; (3) Preparation—interested in quitting smoking in next 30 days and stopped at least 1 day during past year.

Results

During 1992–1993, 59.1% of respondents were precontemplators, 33.2% contemplators, and 7.7% in preparation stage. This distribution was similar in subsequent surveys (1995–1996; 1998–1999). Gender differences were not apparent. Whites were more likely to be precontemplators. As education and income increased, the percentage in precontemplation decreased. Rural residents were more likely in precontemplation and less frequently in preparation.

Conclusions

Among daily smokers, little movement in stage of change was apparent in the United States during the 1990s. Tobacco control efforts must receive high priority to address these static patterns.

Introduction

Approximately 23% of the adult population in the United States currently smoke [1]. Overall, 19.1% smoke daily while 4.1% report smoking on some days [1]. The proportion of current smokers is significant, although it has also been reported that 70% of smokers in the United States have made at least one prior quit attempt [2]. The intent to quit, also known as the stage of change variable [3], has received considerable attention in the health promotion literature over several decades. However, the stage of change distribution remains unknown among those adults who smoke every day. Beginning in the early 1990s, stage of change information has been obtained regularly from daily smokers in Tobacco Use Supplements to the Current Population Survey conducted by the Census Bureau.

Given the significance of tobacco use and the need for public health agencies to plan and implement suitable treatment, reliable estimates of the percentage of daily smokers in the population who state their intention to quit may be useful information. Toward this end, an Expert Advisory Panel convened by the National Cancer Institute recommended that all tobacco treatment programs (1) target specific stages of cessation; (2) address specific populations; and (3) emphasize quitting, maintenance of abstinence, relapse prevention, and recycling through the stages of cessation [4].

According to the Transtheoretical model of change [3], [5], [6], current smokers may be classified into different stages of change, or readiness to quit smoking, which include precontemplation, contemplation, and preparation. While the majority of research in the United States has been conducted using nonprobability sampling designs, a population-based study described stage of change among rural African–American smokers [7] and observed that 53% of respondents were in precontemplation, 29% in contemplation, and 18% in preparation stages of cessation. Velicer and others have also described the distribution of stages of change among current smokers in representative samples in Rhode Island and California, as well as a convenience sample in a nationwide worksite study [8]. More recently, LaForge and co-workers described stage distributions in a population-based sample that included smokers and nonsmokers who were accessed via a random-digit-dial telephone survey in the continental United States [9].

Based on findings from large studies that involved self-defined current smokers only [8], the authors have concluded that typical samples of current U.S. smokers contain approximately 40% precontemplators, 40% contemplators, and 20% in preparation stage of change. They also observed that the percentage of smokers classified as precontemplators decreased as education level increased. Minor differences in stage were noted by race, although patterns were inconsistent and may have been limited by the small numbers of minorities represented in two of the samples. Stage distribution, by age, was stable across the three samples, with the exception of smokers of ages 65 and older, who demonstrated differences by sample location. Gender differences were not apparent. Level of income or residential setting was not examined.

In contrast, a recent European study of stage of change distribution in current smokers reported significantly different proportions, compared to U.S. samples. According to Etter and colleagues [10], in a representative sample of smokers in Geneva Switzerland, 73.6% were in precontemplation, 22.3% in contemplation, and 4.1% in preparation. The Swiss sample included smokers who had ever been “regular” smokers (i.e., had smoked ≥1 cigarette per day during ≥6 months). The Swiss proportions were similar to those in two Spanish studies [11], [12] and one each in The Netherlands [13] and Finland [14] and higher than the distributions of 40, 40, and 20%, respectively, found in U.S. surveys cited above by Velicer and co-workers [8].

While the Transtheoretical model of change has received widespread attention in the smoking cessation literature, information about the stage of change distribution has included self-defined current smokers who engage in the behavior every day or some days only. To date, a U.S. population-based study that describes daily smokers, based on stage of change, has yet to be reported. In addition, the contribution of selected social and demographic characteristics known to be associated with higher smoking prevalence has yet to be adequately delineated, with regard to stage of change, in a national representative study of daily smokers. The objectives of the current study were (1) to describe the proportion of adult U.S. daily smokers, ages 18 and older, according to stage of change; and (2) to report selected social and demographic characteristics associated with smoking (age, gender, education, race, income, and residence) according to stage of change, among U.S. daily smokers, ages 18 and older.