Abstract
We examined young adult smoking cessation behaviors, coding cessation behavior as no attempt, quit attempt (< 30 days), or abstinence (≥ 30 days) during follow-up from July 2005 through December 2008, observed in 592 young adult smokers from the Ontario Tobacco Survey. One in 4 young adults made an attempt; 14% obtained 30-day abstinence. Cessation resources, prior attempts, and intention predicted quit attempts, whereas high self-efficacy, using resources, having support, and low addiction predicted abstinence, indicating that young adult smokers require effective and appropriate cessation resources.
Young adults have had the highest smoking prevalence among all age groups.1,2 Over the past decade, the prevalence of quit attempts increased among Americans aged 45 to 64 years; however, it remained stable among young adults.3 A recent review concluded that the determinants of young adult cessation are not well understood.4 Previous longitudinal studies in this population have long follow-up intervals—3 to 7 years5–12—which means that certain measures (e.g., self-efficacy) may have changed across time and are no longer relevant to predict the later behavior. We examined proximate predictors of young adult smoking cessation behaviors in a prospective study with a 6-month follow-up.
METHODS
We compiled data from 592 young adult smokers (aged 18–29 years) with a 6-month follow-up from July 2005 through December 2008 from the Ontario Tobacco Survey, a population-representative cohort of smokers in Ontario, Canada.13,14 We classified smoking cessation behavior as no quit attempt, attempt to quit (lasting < 30 days), and 30-day abstinence during follow-up. Guided by social cognitive theory,15,16 we chose the following covariates: sociodemographic characteristics, smoking addiction,17,18 quitting history, intentions, beliefs, and social and environmental factors (Table 1).
TABLE 1—
Respondent Characteristics by Young Adult Smoking Cessation Behavior at 6-Month Follow-Up: Ontario Tobacco Survey, July 2005–December 2008
| Characteristic | No Attempt to Quit Smoking (n = 375), No.a (%)bc or Mean ±SD (SE Estimate) | Quit Attempt, < 30 Days (n = 149), No.a (%)bc or Mean ±SD (SE Estimate) | Abstinence, ≥ 30 Days (n = 68), No.a (%)bc or Mean ±SD (SE Estimate) | Pd |
| Continuous variables | ||||
| Age (n = 592), y | 23.47 ±3.50 (0.25) | 23.35 ±3.19 (0.32) | 23.14 ±3.39 (0.56) | .564 |
| Heaviness of smoking index (n = 580) | 1.76 ±1.59 (0.11) | 1.61 ±1.54 (0.16) | 0.67 ±1.19 (0.15) | < .001 |
| Categorized variables | ||||
| Gender (n = 592) | ||||
| Women | 187 (61.2) | 63 (23.1) | 37 (15.6) | .569 |
| Men | 188 (60.9) | 86 (26.9) | 31 (12.1) | |
| Education (n = 591) | ||||
| ≤ high school | 221 (63.0) | 96 (28.0) | 30 (9.1) | .045 |
| > high school | 153 (58.7) | 53 (22.7) | 38 (18.6) | |
| Employment (n = 592) | ||||
| Unemployed | 94 (61.1) | 30 (22.6) | 19 (16.3) | .664 |
| Employed | 281 (61.0) | 119 (26.2) | 49 (12.7) | |
| Marital status (n = 592) | ||||
| Single | 231 (61.7) | 102 (26.2) | 40 (12.1) | .509 |
| Married or common law marriage | 144 (59.5) | 47 (23.7) | 28 (16.8) | |
| Self-efficacy (n = 592) | ||||
| Less or uncertain confidence | 259 (61.6) | 111 (27.5) | 40 (10.9) | .137 |
| Very confident | 116 (59.9) | 38 (21.3) | 28 (18.7) | |
| Perceived health (n = 592) | ||||
| Good, fair, or poor | 197 (60.1) | 84 (27.4) | 33 (12.5) | .668 |
| Very good or excellent | 178 (62.1) | 65 (23.3) | 35 (14.7) | |
| Perceived benefits to quitting (n = 591) | ||||
| Benefit a little or not at all | 89 (65.5) | 20 (20.7) | 12 (13.8) | .644 |
| Benefit quite a bit or a lot | 285 (59.9) | 129 (26.7) | 56 (13.5) | |
| Use of cessation resources or supportse (n = 587) | ||||
| No | 226 (69.5) | 64 (21.6) | 27 (8.9) | .005 |
| Yes | 148 (52.0) | 85 (30.2) | 37 (17.8) | |
| Support to quitf (n = 592) | ||||
| No known support | 39 (54.3) | 16 (42.3) | 5 (3.4) | .006 |
| Yes | 336 (61.7) | 133 (23.9) | 63 (14.4) | |
| Smoking in the home (n = 592) | ||||
| People smoke indoors | 148 (67.4) | 53 (24.3) | 16 (8.2) | .108 |
| No one smokes indoors | 227 (58.4) | 96 (25.9) | 52 (15.7) | |
| Someone to make quitting difficult (n = 592) | ||||
| No | 129 (63.0) | 31 (19.9) | 28 (17.2) | .189 |
| Yes | 246 (60.0) | 118 (28.3) | 40 (11.6) | |
| Exposure to tobacco industry marketingg (n = 591) | ||||
| No | 343 (60.4) | 133 (25.2) | 64 (14.4) | .236 |
| Yes | 31 (67.1) | 16 (27.9) | 4 (5.0) | |
| Exposure to antitobacco mass media campaignsg (n = 592) | ||||
| No | 45 (66.7) | 12 (17.1) | 5 (16.3) | .506 |
| Yes | 330 (60.4) | 137 (26.5) | 63 (13.2) | |
| Prior number of quit attempts (n = 592) | ||||
| 0 | 88 (75.2) | 12 (10.4) | 12 (14.4) | .002 |
| 1 | 130 (66.3) | 30 (19.8) | 22 (14.0) | |
| ≥ 2 | 157 (51.4) | 107 (35.8) | 34 (12.8) | |
| Quit intention (n = 592) | ||||
| No | 256 (73.1) | 53 (17.3) | 27 (9.6) | < .001 |
| Yes | 119 (45.5) | 96 (35.9) | 41 (18.6) | |
| Perceived addiction (n = 590) | ||||
| Less addicted | 180 (59.3) | 66 (21.3) | 45 (19.4) | < .001 |
| Very addicted | 193 (62.7) | 83 (30.8) | 23 (6.4) | |
| Smoking medications make quitting a lot easierh (n = 592) | ||||
| No | 318 (63.1) | 113 (23.7) | 56 (13.2) | .197 |
| Yes | 57 (50.5) | 36 (34.4) | 12 (15.1) | |
| Counseling makes quitting a lot easierh (n = 592) | ||||
| No | 323 (61.5) | 128 (25.7) | 55 (12.8) | .642 |
| Yes | 52 (57.9) | 21 (24.0) | 13 (18.1) | |
Note. Respondents were self-report smokers at baseline who smoked in the past 30 days and at least 100 lifetime cigarettes who also reported their age (n = 592). The heaviness of smoking index is an addiction scale that is calculated according to the number of cigarettes smoked per day and time to first cigarette of the day. These questions tend to have more “don’t know” responses, resulting in slightly more missing data for this variable (n = 12).
Unweighted sample size.
Weighted estimates. Estimates may not sum to 100% because of rounding.
Missing data were not used in the calculation of statistical tests or weighted estimates.
P values were determined using the χ2 test for association, which identifies differences across all levels; this test does not identify between which cells the differences are meaningful; all expected cell values were adequate for testing.
Use of cessation aids and resources include any use of self-help materials, behavioral therapies, pharmacotherapies, physician advice to quit smoking, and participation in a local quit program measured during 6-month follow-up; we measured all other characteristics at the baseline interview.
Support to quit (yes vs no, “don’t know”) was determined from the question “If you decided to quit smoking, do you have someone you can count on for support?”
Exposure to tobacco marketing and antitobacco mass media campaigns were self-reported exposure (yes or no) in the past 6 months measured at the baseline interview.
Perceived knowledge for the benefits of stop smoking medications and counseling.
Using multivariable logistic regression models with covariates associated with the outcome (P < .2), we examined predictors of quit attempts (vs no attempt) and abstinence (vs attempt and no attempt). We conducted analyses using SAS version 9.2,19 accounting for the complex survey design and weighted to the population.
RESULTS
Sixty percent of young adults made no attempt to quit smoking; 25% made an attempt, and 14% were abstinent for 30 days or longer during follow-up. Education, level of addiction, using resources, having support, prior attempts, quit intention, and perceived addiction were significantly associated with young adult cessation behaviors (P < .05; Table 1).
Four factors predicted quit attempts among young adults in the multivariate models: using resources, 2 or more prior quit attempts, quit intention, and knowledge of stop smoking medication benefits (Table 2). Abstinence for 30 days or longer was greater among those who were confident in their ability to quit smoking, had used cessation resources, had support, or had lower levels of addiction (Table 2).
TABLE 2—
Simultaneously Adjusted Multivariable Logistic Regression Models of Factors Predicting Young Adult Smoking Cessation Behaviors: Ontario Tobacco Survey, July 2005–December 2008
| Characteristic | Model 1: Attempt to Quit (< 30 d) vs No Attempt to Quit, OR (95% CI)a | Model 2: Abstinence (≥ 30 d) vs Attempt (< 30 d) and No Attempt to Quit, OR (95% CI)a |
| Age, y | 0.97 (0.89, 1.06) | 0.94 (0.83, 1.07) |
| Heaviness of smoking index | 0.85 (0.68, 1.06) | 0.64* (0.46, 0.89) |
| Gender | ||
| Women (Ref) | 1.00 | 1.00 |
| Men | 1.52 (0.81, 2.87) | 0.74 (0.36, 1.52) |
| Education | ||
| ≤ high school (Ref) | 1.00 | 1.00 |
| > high school | 0.84 (0.42, 1.67) | 1.81 (0.73, 4.50) |
| Self-efficacy | ||
| Less or uncertain confidence (Ref) | 1.00 | 1.00 |
| Very confident | 0.53 (0.26, 1.06) | 3.27* (1.15, 9.28) |
| Use of cessation resources or supportsb | ||
| No (Ref) | 1.00 | 1.00 |
| Yes | 1.86* (1.05, 3.31) | 3.46* (1.66, 7.19) |
| Support to quitc | ||
| No (Ref) | 1.00 | 1.00 |
| Yes | 0.42 (0.16, 1.10) | 4.88* (1.29, 18.44) |
| Smoking in the home | ||
| People smoke indoors (Ref) | 1.00 | 1.00 |
| No one smokes indoors | 1.79 (0.97, 3.32) | 1.31 (0.52, 3.27) |
| Someone make quitting more difficult | ||
| No (Ref) | 1.00 | 1.00 |
| Yes | 1.14 (0.57, 2.29) | 0.72 (0.34, 1.51) |
| Prior number of quit attempts | ||
| 0 (Ref) | 1.00 | 1.00 |
| 1 | 1.46 (0.51, 4.17) | 1.34 (0.45, 4.02) |
| ≥ 2 | 3.50* (1.28, 9.55) | 1.58 (0.54, 4.59) |
| Quit intention | ||
| No (Ref) | 1.00 | 1.00 |
| Yes | 3.94* (2.22, 6.99) | 1.48 (0.74, 2.98) |
| Perceived addiction | ||
| Less addicted (Ref) | 1.00 | 1.00 |
| Very addicted | 1.20 (0.57, 2.51) | 0.58 (0.26, 1.29) |
| Smoking medications make quitting a lot easierd | ||
| No (Ref) | 1.00 | 1.00 |
| Yes | 2.30* (1.16, 4.57) | 1.54 (0.60, 3.95) |
Note. CI = confidence ratio; OR = odds ratio. Data are weighted.
Variance inflation factor statistics were all satisfactory in both models.
Use of cessation aids and resources include any use of self-help materials, behavioral therapies, pharmacotherapies, physician advice to quit smoking, and participation in a local quit program measured during 6-month follow-up; all other characteristics were measured at the baseline interview.
Support to quit (yes vs no, “don’t know”) was determined from the question “If you decided to quit smoking, do you have someone you can count on for support?”
Perceived knowledge for the benefits of stop smoking medications and counseling.
*P < .05.
DISCUSSION
We assessed prospective predictors of cessation among young adult smokers. We identified different predictors for quit attempts and abstinence; only the use of cessation resources—known to increase cessation20,21—contributed to both. We combined all forms of cessation resources; however, resources used for making an attempt may differ from those used to maintain abstinence. There is limited evidence of effective interventions for young adult smokers22–24; thus, the resources used for smoking cessation deserve further attention in this high-risk population.
Intention to quit smoking has been shown to be predictive of both young adult quit attempts7 and smoking cessation.7,8,25 Our findings agree with respect to quit attempts but not smoking cessation. Previous studies measured quit intention 5 to 7 years before measuring cessation.7,8,25 Behavioral intentions are likely to change more frequently; thus, intention measured more than 5 years before behavior change may not appropriately reflect the observed change. Our findings are congruent with the literature on adult smoking cessation, which shows that intention to quit predicts quit attempts but not cessation.26,27
Corresponding with the literature, high self-efficacy for quitting was a strong predictor of abstinence.8 Increased exposure to smokers reduces smoking cessation.5–10,25 Although we did not ask about exposure to smokers per se, the measure of smokers’ support to quit (i.e., social environment) played an important role in young adult cessation.
Smokers with greater addiction were less likely to maintain their abstinence, as in previous studies.6,7,28,29 It is evident that addiction plays an important role in young adult smoking cessation, raising the question about gradual reduction in smoking before full abstinence. In a cohort study of Australian young adult women, smokers were found to be more likely to quit if they reduced to nondaily smoking.30 By contrast, a cohort study of adult smokers concluded that those quitting cold turkey were more likely to abstain than were those cutting down to quit.31 Demonstrating the impact of smoking reduction on young adult cessation is needed to recommend reduction as an effective cessation strategy for this population.
We used prospective data from a population-based sample of young adult smokers with shorter follow-up periods; however, future research using similar data should explore the predictors of long-term smoking cessation and relapse in this population. Findings highlight the fundamental importance of resources in smoking cessation among young adults; a wide range of effective and appropriate cessation resources are needed to help these smokers make quit attempts and maintain abstinence. The setting for this study—Ontario, Canada—has extensive tobacco control initiatives but no unified cessation system or widespread specialized services for young adults.24 The generalizability of findings is unknown; thus, comparative data from other jurisdictions on the effectiveness of these resources would be valuable. The high smoking rates among young adults is concerning. Enhancing cessation efforts in this population has the potential to significantly improve the health of the public.
Acknowledgments
The Ontario Tobacco Survey is an initiative of the Ontario Tobacco Research Unit that receives funding from the Ontario Ministry of Health and Long-Term Care.
The authors would like to acknowledge Joanna Cohen, Roberta Ferrence, John Garcia, Paul McDonald, Robert Schwartz, Peter Selby, and J. Charles Victor for their contributions to the development and design of the Ontario Tobacco Survey. We also thank J. Charles Victor and Michael Chaiton for their invaluable assistance with the Ontario Tobacco Survey data.
Human Participant Protection
The Ontario Tobacco Survey protocols and study instruments received ethical approvals from the University of Toronto and the University of Waterloo.
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