Determining the probability of future smoking among adolescents.

AIMS: To determine whether the probability of future current established smoking among adolescents is related to both previous smoking experience and cognitions regarding future smoking. DESIGN, SETTING AND PARTICIPANTS: The analyses used two principal datasets: (1) a US longitudinal sample of 7960 adolescents 12-18 years old in 1989 reinterviewed at 15-22 years in 1993, (2) a California longitudinal sample of 3376 adolescents 12-17 years old in 1993 reinterviewed at 15-20 years in 1996. MEASURES: Previous smoking experience was categorized as never smoked, puffed, non-recent or recent experimenting, and non-recent or current established smoking (> or = 100 cigarettes in life-time). Smoking intentions and efficacy expectations were used to classify adolescents as having low- or high-risk cognitions. FINDINGS: High-risk cognitions (HRCs) increased the probability of future current established smoking (FCES) within each level of previous smoking experience over low-risk cognitions (LRCs); the probability of FCES for those with LRCs was about the same as those in the previous experience group with HRCs. In the US sample, the 4-year probability of FCES ranged from 5.6% for committed never smokers (with LRCs) to 83.0% for current established smokers with HRCs. Development of HRCs among middle-school never smokers occurred rapidly through age 14 years. However, current established smoking did not increase until age 14 years and stabilized by age 19 years. Where sample size was sufficient, these findings were validated in the California sample. CONCLUSIONS: Effective prevention programs should aim to convert HRCs to LRCs regardless of past behavior, particularly among middle-school never smokers and high-school experimenters.

Association between household and workplace smoking restrictions and adolescent smoking.

CONTEXT: Recent marked increases in adolescent smoking indicate a need for new prevention approaches. Whether workplace and home smoking restrictions play a role in such prevention is unknown. OBJECTIVE: To assess the association between workplace and home smoking restrictions and adolescent smoking. DESIGN, SETTING, AND SUBJECTS: Data were analyzed from 2 large national population-based surveys, the Current Population Surveys of 1992-1993 and 1995-1996, which included 17,185 adolescents aged 15 to 17 years. MAIN OUTCOME MEASURES: Smoking status of the adolescents surveyed, compared by presence of home and workplace smoking restrictions. RESULTS: After adjusting for demographics and other smokers in the household, adolescents who lived in smoke-free households were 74% (95% confidence interval [CI], 62%-88%) as likely to be smokers as adolescents who lived in households with no smoking restrictions. Similarly, adolescents who worked in smoke-free workplaces were 68% (95% CI, 51%-90%) as likely to be smokers as adolescents who worked in a workplace with no smoking restrictions. Adolescent smokers were 1.80 (95% CI, 1.23-2.65) times more likely to be former smokers if they lived in smoke-free homes. The most marked relationship of home smoking restrictions to current adolescent smoking occurred in households where all other members were never-smokers. Current smoking prevalence among adolescents in homes without smoking restrictions approached that among adolescents in homes with a current smoker but with smoking restrictions. CONCLUSIONS: Parents with minor children should be encouraged to adopt smoke-free homes. Smoke-free workplaces can also augment smoking prevention. These findings emphasize the importance of tobacco control strategies aimed at the entire population rather than at youth alone. JAMA. 2000;284:717-722

Characterizing and identifying "hard-core" smokers: implications for further reducing smoking prevalence.

OBJECTIVES: Some smokers may never quit. Depending on how many of these "hard-core" smokers exist, tobacco control efforts could reach the limits of a minimum achievable smoking prevalence. We defined the hard core as heavy smokers with weak quitting histories who expect never to quit smoking. We compared them with other smokers and analyzed whether they represent a meaningful barrier to further reducing smoking prevalence. METHODS: We used data from the 1996 California Tobacco Surveys (18616 adults; response rate = 72.9%). RESULTS: In 1996, 5.2% of California smokers 26 years and older (1.3% of the California population) were hard-core smokers. Compared with other smokers, hard-core smokers were more likely to be retired non-Hispanic White males, with 12 years or less of education and incomes below $30,000 a year, who live alone. They began smoking at younger ages and attributed fewer negative health consequences to smoking than other smokers. CONCLUSIONS: Current tobacco control efforts have a long way to go before they "hit the wall." Nonetheless, the group of hard-core smokers represents a challenge because they appear to be largely unaffected by the messages of tobacco control.

The effects of household and workplace smoking restrictions on quitting behaviours.

OBJECTIVE: To assess the association of household and workplace smoking restrictions with quit attempts, six month cessation, and light smoking. DESIGN: Logistic regressions identified the association of household and workplace smoking restrictions with attempts to quit, six month cessation, and light smoking. SETTING: Large population surveys, United States. SUBJECTS: Respondents (n = 48,584) smoked during the year before interview in 1992-1993, lived with at least one other person, and were either current daily smokers or were former smokers when interviewed. MAIN OUTCOME MEASURES: The outcome measures were an attempt to quit during the last 12 months, cessation for at least six months among those who made an attempt to quit, and light smoking (< 15 cigarettes a day). RESULTS: Smokers who lived (odds ratio (OR) = 3.86; 95% confidence interval (CI) = 3.57 to 4.18) or worked (OR = 1.14; 95% CI = 1.05 to 1.24) under a total smoking ban were more likely to report a quit attempt in the previous year. Among those who made an attempt, those who lived (OR = 1.65, 95% CI = 1.43 to 1.91) or worked (OR = 1.21, 95% CI = 1.003 to 1.45) under a total smoking ban were more likely to be in cessation for at least six months. Current daily smokers who lived (OR = 2.73, 95% CI = 2.46 to 3.04) or worked (OR = 1.53, 95% CI = 1.38 to 1.70) under a total smoking ban were more likely to be light smokers. CONCLUSIONS: Both workplace and household smoking restrictions were associated with higher rates of cessation attempts, lower rates of relapse in smokers who attempt to quit, and higher rates of light smoking among current daily smokers.

Does parental smoking cessation discourage adolescent smoking?

BACKGROUND: We examined the relationship of smoking cessation in parents to smoking and uptake and cessation by their adolescent children. METHODS: We analyzed a cross-sectional sample of 4,502 adolescents, ages 15-17 years, who lived in two-parent households that were interviewed as part of the 1992-1993 Tobacco Supplement of the Current Population Survey, which questioned householders 15 years of age and older about their smoking history. Ever smokers reported smoking at least 100 cigarettes in their lifetime. Former smokers were ever smokers who had quit. RESULTS: Multivariate analyses, adjusted for demographic characteristics of adolescents, as well as father's age, education, and family income, found that adolescents whose parents had quit smoking were almost one-third less likely to be ever smokers than those with a parent who still smoked. Furthermore, adolescent ever smokers whose parents quit smoking were twice as likely to quit as those who had a parent who still smoked. Parental quitting is most effective in reducing initiation if it occurs before the child reaches 9 years of age. CONCLUSION: Encouraging parents to quit may be an effective method for reducing adolescent smoking, through decreased uptake and increased cessation. The earlier parents quit, the less likely their children will become smokers.

Home smoking restrictions: which smokers have them and how they are associated with smoking behavior.

Home smoking restrictions have primarily been promoted as a means of protecting non-smokers from secondhand tobacco smoke. However, research suggests that smokers who live in smoke-free homes may modify their smoking behavior. Population-based survey data from California (n = 8904) were used to confirm this association and to examine demographic and social characteristics of smokers who reported home smoking restrictions. Report of a recent quit attempt and intention to quit were associated with family preference that the smoker not smoke, with home smoking restrictions appearing to be a concrete expression of this social pressure. In contrast, light smoking (< 15 cigarettes/day) was negatively related to family preference (light smokers may not offend non-smokers) but very positively related to the level of home smoking restrictions. Additionally, smoke-free homes appear to prolong time to relapse following cessation. Male smokers were more likely than females to report smoke-free homes, and such reports decreased with age. While Hispanics and Asians were more likely to report smoke-free homes than Non-Hispanic whites, African Americans were less likely to report them. After adjusting for demographics, smokers were nearly 6 times more likely to report smoke-free homes if they lived with a non-smoking adult and child compared to when there was no child or adult non-smoker in the household, and over 5 times more likely to report a smoke-free home if they believed in the harmfulness of secondhand smoke. Tobacco Control efforts to promote smoke-free homes may give family members leverage to encourage smokers to quit, and to modify smokers' behavior in ways that would help them quit and stay quit.

When does cigarette fading increase the likelihood of future cessation?

OBJECTIVE: To determine which smokers report cigarette fading, how much they fade, when fading leads to quitting, and, if not, whether it can be maintained. METHODS: Subjects were 1,682 adult smokers interviewed by telephone in 1990 and 1992 as part of the California Tobacco Survey. Data from three timepoints in the same subjects were compared. At Time 1 (one year before the baseline survey), all respondents were daily smokers who recalled their average daily cigarette consumption retrospectively at baseline. At Time 2 (baseline survey), all respondents were current smokers who provided concurrent data on their average daily cigarette consumption. At Time 3 (follow-up), smoking status and current cigarette consumption among nonabstinent respondents were assessed. RESULTS: Nearly 18% of smokers reduced consumption between Times 1 and 2. The mean reduction was 13 cigarettes per day. Only moderate to heavy smokers who reduced consumption to below 15 cigarettes per day were more likely to be in cessation at Time 3 (24.9% versus 5.8%, respectively). The cessation rate for moderate to heavy smokers that became light smokers by baseline was similar to that for smokers who were already light smokers 1 year before baseline. Continuing smokers who reduced consumption between Times 1 and 2 maintained a mean reduction of 11.4 cigarettes per day. CONCLUSIONS: Cigarette fading increases cessation among moderate to heavy smokers who become light smokers.

Has the California tobacco control program reduced smoking?

CONTEXT: Comprehensive community-wide tobacco control programs are considered appropriate public health approaches to reduce population smoking prevalence. OBJECTIVE: To examine trends in smoking behavior before, during, and after the California Tobacco Control Program. DESIGN: Per capita cigarette consumption data (1983-1997) were derived from tobacco industry sales figures. Adult (> or =18 years) smoking prevalence data were obtained from the National Health Interview Surveys (1978-1994), the California Tobacco Surveys (1990-1996), the Current Population Surveys (1992-1996), and the California Behavioral Risk Factor Survey and its supplement (1991-1997). Trends were compared before and after introduction of the program, with the period after the program being divided into 2 parts (early, 1989-1993; late, 1994-1996). MAIN OUTCOME MEASURES: Change in cigarette consumption and smoking prevalence in California compared with the rest of the United States. RESULTS: Per capita cigarette consumption declined 52% faster in California in the early period than previously (from 9.7 packs per person per month at the beginning of the program to 6.5 packs per person per month in 1993), and the decline was significantly greater in California than in the rest of the United States (P<.001). In the late period, the decline in California slowed to 28% of the early program so that in 1996 an average of 6.0 packs per person per month were consumed. No decline occurred in the rest of the United States, and in 1996, 10.5 packs per person per month were consumed. Smoking prevalence showed a similar pattern, but in the late period, there was no significant decline in prevalence in either California or the rest of the United States. In 1996, smoking prevalence was 18.0% in California and 22.4% in the rest of the United States. CONCLUSIONS: The initial effect of the program to reduce smoking in California did not persist. Possible reasons include reduced program funding, increased tobacco industry expenditures for advertising and promotion, and industry pricing and political activities. The question remains how the public health community can modify the program to regain its original momentum.

Beyond stages of change: the quitting continuum measures progress towards successful smoking cessation.

OBJECTIVE: To extend the quitting continuum to categorize smokers in the early stages of the process of smoking cessation. DESIGN: A prospective computer assisted telephone interview study with initial interviews in 1990 and reinterviews in 1992. SETTING AND PARTICIPANTS: In California, 2514 current smokers and quitters of less than 5 years duration, selected randomly from a large scale cross-sectional survey in 1990. RESULTS: We focus on smokers with high addiction (> or = 15 cigarettes/day) and without a strong quitting history (> or = 1 week in last year or > or = 1 year ever) at baseline (N = 822). Having an intention to quit and a limited quitting history (1-6 days in last year) was predictive of progress at follow-up into higher continuum levels ultimately associated with successful cessation. Furthermore, smokers with one trait were much more likely to progress than those with none. Accordingly, the lowest level of the earlier continuum was further subdivided into three subgroups (making eight levels overall). Over approximately a 2-year period, most smokers either progressed or regressed only one or two levels along the quitting continuum. CONCLUSIONS: Better than expected progress along this expanded quitting continuum could be a criterion for a successful intervention. Tailored interventions that move smokers to a higher level on the continuum should be a priority for future research.

Can strategies used by statewide tobacco control programs help smokers make progress in quitting?

Many states have recently adopted programs to encourage smokers to quit. Here, we seek evidence that strategies generally used by these programs have the potential to influence smoking cessation. In California, 1,736 smokers from a population-based telephone survey were interviewed in 1990 and 1992. We examined the association of demographic and program-related variables (reporting of work area smoking bans; belief in the harmfulness of environmental tobacco smoke, including in-home smoking restrictions; and quitting assistance) with quitting progress. Smokers were categorized into levels in a previously developed Quitting Continuum, which considers their addiction level and quitting history. Smokers in each higher continuum category had an increased likelihood of future successful cessation. Smokers progressed if they were at a higher continuum level in 1992 than in 1990. College graduates showed 2.3 times more progress than did high school dropouts. Smokers reporting work area smoking bans showed 1.6 times more progress than did workers not reporting such restrictions. Smokers with the strongest beliefs (home smoking restrictions) regarding the harmfulness of environmental tobacco smoke showed 3.4 times more progress than smokers with no belief. Smokers who reported having some form of cessation assistance showed 3.0 times more progress. The more program-related factors were reported, the higher the rate of progress was: 13.1% for those reporting no factors, 23.4% for one factor, and 40.6% for two or more. These results suggest but do not prove that strategies promoted by statewide tobacco control programs can potentially be effective and that these efforts should be continued and expanded.

Tobacco industry promotion of cigarettes and adolescent smoking.

CONTEXT: Whether tobacco advertising and promotion increases the likelihood that youths will begin smoking has important public policy implications. OBJECTIVE: To evaluate the association between receptivity to tobacco advertising and promotional activities and progress in the smoking uptake process, defined sequentially as never smokers who would not consider experimenting with smoking, never smokers who would consider experimenting, experimenters (smoked at least once but fewer than 100 cigarettes), or established smokers (smoked at least 100 cigarettes). DESIGN: Prospective cohort study with a 3-year follow-up through November 1996. SETTING AND PARTICIPANTS: A total of 1752 adolescent never smokers who were not susceptible to smoking when first interviewed in 1993 in a population-based random-digit dial telephone survey in California were reinterviewed in 1996. MAIN OUTCOME MEASURE: Becoming susceptible to smoking or experimenting by 1996. RESULTS: More than half the sample (n=979) named a favorite cigarette advertisement in 1993 and Joe Camel advertisements were the most popular. Less than 5% (n=92) at baseline possessed a promotional item but a further 10%(n=172) were willing to use an item. While having a favorite advertisement in 1993 predicted which adolescents would progress by 1996 (odds ratio [OR] = 1.82; 95% confidence interval [CI], 1.04-3.20), possession or willingness to use a promotional item was even more strongly associated with future progression (OR=2.89; 95% CI, 1.47-5.68). From these data, we estimate that 34% of all experimentation in California between 1993 and 1996 can be attributed to tobacco promotional activities. Nationally, this would be over 700000 adolescents each year. CONCLUSION: These findings provide the first longitudinal evidence to our knowledge that tobacco promotional activities are causally related to the onset of smoking.

Which adolescent experimenters progress to established smoking in the United States.

INTRODUCTION: This study examined the adolescent smoking uptake process, specifically, the progression from experimentation to established smoking. Although adolescent smoking uptake has been described as consisting of five stages (preparation, initial trying, experimentation, regular smoking, and addiction), there is no accepted method of identifying which experimenters will proceed to become addicted. METHODS: Using a nationally representative sample of adolescents between the ages of 12 and 18 at baseline, we examined their transition from experimentation (had at least a puff but has not smoked 100 cigarettes) to established smoking (smoked at least 100 cigarettes in lifetime) four years later. RESULTS: At follow-up, 31% of the experimenters at baseline had progressed to established smoking. Baseline level of smoking experience was the strongest independent predictor of established smoking, with current experimenters (smoked in the past 30 days but less than 100 cigarettes in lifetime) having the greatest risk of progressing to established smoking compared to puffers (puffed but have not smoked a whole cigarette). Furthermore, this effect was modified by age; older current experimenters at baseline had more than double the risk of younger current experimenters of progressing to established smoking at follow-up. Absence of a firm commitment not to smoke was a significant predictor among older experimenters but not in younger experimenters. Other important predictors of the transition from experimentation to established smoking were exposure to other smokers and perceived school performance. CONCLUSIONS: We found that, even among experimenters, there is an identifiable group of adolescents who are at higher risk of progressing to established smoking that can be targeted for intervention.

Depressive symptoms in California adolescents: family structure and parental support.

PURPOSE: To examine the relationship between family structure, parental social support, and depressive symptoms among California adolescents. METHODS: The depressive symptom instrument consisted of a previously validated self-report scale. The sample was the 1993 California Youth Tobacco Survey respondents (N = 5,531). The analysis classified adolescents in the highest 15% on the depressive symptom scale as having notable depressive symptoms and related the prevalence of depression to family structure (two-parent, single-mother, single-father, and neither parent present) and to parental support (adolescents naming parents as someone they could talk to about problems). RESULTS: Girls reported significantly higher rates of depressive symptoms than boys. Although adolescents in single-parent households tended to show slightly higher rates of depressive symptoms, these rates did not differ significantly across the four types of family structures for either sex. Significantly higher rates of depressive symptoms were found among both boys and girls who resided with parent(s) not named as supportive than those who lived with supportive parent(s). Girls appeared particularly vulnerable if they lived in a nonsupportive, single-father household. CONCLUSION: Lack of perceived parental social support is highly related to depressive symptoms in California adolescents. Helping parents establish and maintain supportive relationships with the children in their household may decrease the likelihood of depressive symptoms among adolescents.

Duration of smoking abstinence and success in quitting.

BACKGROUND: For most smokers, quitting is a difficult process. Many smokers try to quit repeatedly before they succeed, with some relapsing even after a lengthy period of abstinence. Few population-based cohort studies have examined relapse among former smokers. Quantification of the relationship between the duration of abstinence and the likelihood of continued abstinence is important for the evaluation of ongoing public health interventions and the design of smoking-cessation programs. PURPOSE: We analyzed longitudinal data from a large, representative population cohort of former smokers and estimated the probability of future relapse for different durations of abstinence at baseline (e.g., 1 to <3 months and 3 to <6 months). METHODS: From the 1990 California Tobacco Survey that used a random-digit-dialed computer-assisted telephone survey to interview 24296 California adults (baseline interview) from June 1990 through February 1991, a stratified random sample of 4642 adults was reinterviewed from March 1992 through July 1992. Both surveys assessed smoking status using standard questions about the lifetime use of 100 cigarettes and the self-classification of current smoking: 1) "Have you smoked at least 100 cigarettes in your lifetime?" and 2) "Do you smoke cigarettes now?" We included all 1449 former smokers at baseline interview who answered "yes" to the first question and "no" to the second and who also provided a valid date at both of the surveys when asked, "When did you last smoke regularly?" All data were weighted to account for the study design and to ensure that the estimates were representative of the California population by age, sex, race/ethnicity, education, and geographic region. RESULTS: Only about 12% of the former smokers who had quit for less than 1 month at baseline remained continuously abstinent at the follow-up interview. This percentage increased to 25% for those who had quit from 1 to less than 3 months; it increased again to 52% if the duration of quitting was from 3 to less than 6 months, but it increased only slightly to 59.2% for those who had quit from 6 to less than 12 months. Overall, the likelihood of remaining continuously abstinent until the follow-up interview was about 90% for former smokers who had quit for 3 months or longer and 95% for those who had quit for 1 year or longer. CONCLUSIONS AND IMPLICATIONS: We suggest that self-reported cessation for more than 3 months be considered as an intermediate criterion for success both in longitudinal studies and the cross-sectional evaluation of community interventions. If a more stringent criterion is needed, we recommend self-reported cessation for at least 1 year.

Addiction versus stages of change models in predicting smoking cessation.

Prospective data from the California Tobacco Surveys (n = 2066) were used to perform a critical test of the Prochaska et al. (1991) stages of change model. When the stages of change model was used as a stand alone predictor, smokers in preparation at baseline were more likely to be in cessation at follow-up than smokers in pre-contemplation at baseline (ORadj = 1.9). When stage membership was combined with baseline measures of addiction including smoking behaviors and quitting history, it was not a significant predictor of future cessation. A prediction equation that combined daily vs. occasional smoking, cigarettes per day smoked, life-time quits of at least a year, and quits of more than 5 days in the previous year discriminated smokers in cessation at follow-up of 1 to 2 years better than did the stages of change model. The area under the ROC curve for the equation based on addiction measures was 69.3% vs. 55.1% for the stages of change. Cessation rates ranged from 7.7% to 35.7% for the four-category addiction equation compared with 15.1% to 24.9% for stages of change model.

Validation of susceptibility as a predictor of which adolescents take up smoking in the United States.

Smoking onset has 4 levels, with a "susceptibility" level preceding early experimentation. This study assessed the predictive validity of smoking susceptibility in a longitudinal study of a nationally representative sample of 4,500 adolescents who at baseline reported never having puffed on a cigarette. At follow-up 4 years later, 40% of the sample had experimented with smoking, and 8% had established a smoking habit. Baseline susceptibility to smoking, defined as the absence of a firm decision not to smoke, was a stronger independent predictor of experimentation than the presence of smokers among either family or the best friend network. However, susceptibility to smoking was not as important as exposure to smokers in distinguishing adolescents who progressed to established smoking from those who remained experimenters at follow-up.

Is stage-of-change a useful measure of the likelihood of smoking cessation?

We compared two stage-of-change models that differentiate smokers by their level in the quitting process. The original 1983 model by Prochaska and DiClemente (1) divided smokers first by relapse status and then by intention to quit; their revised 1991 model (2) reversed the primacy of these factors. No published data justify whether the revision improves prediction of cessation. We used data from a population-based panel of 1,921 smokers interviewed in 1990 and 1992 for the California Tobacco Surveys. Model variables (quitting intention and recent quitting history) were used in a logistic regression to predict 30-day or longer cessation at follow-up and quit attempts made during the year preceding the survey. Predictive power of the revised model was not better than predictive power of the original model. New approaches to differentiating smokers on likelihood to quit should emphasize quitting behavior rather than intention to quit.

Adolescents' perceptions of their peers' health norms.

OBJECTIVES: The purpose of this study was to determine the relative importance adolescents place on preventive health behaviors. METHODS: Data were from a survey of California adolescents (n = 5040). Respondents were asked how important it was to their peers to avoid drugs, marijuana, cigarettes, heavy drinking, and drinking and driving and to maintain seat belt use, fitness, weight control, and healthy eating habits. Results were compared with data from a similar national survey (n = 6126). RESULTS: California teenagers perceived that their peers gave top priority to weight control: 85% of California teenagers believed that weight control was of high concern to girls in their age group. Avoiding drugs, not drinking and driving, and maintaining fitness ranked in the top five behaviors. The lowest ranked health behaviors were seat belt use, heavy drinking, and, last, eating healthily. In the national survey, healthy eating also ranked last. Although not identical in rank, teenage priorities for other health behaviors were consistent with the California results. CONCLUSION: Efforts are needed to bring adolescent health norms more into line with the objective risks of their health choices during this critical period of socialization.

Nicotine patch use in the general population: results from the 1993 California Tobacco Survey.

BACKGROUND: Evidence from controlled clinical trials indicates that use of a transdermal nicotine patch improves abstinence rates up to a year after initial smoking cessation. Whether these results can be generalized to the general population has not been extensively investigated. PURPOSE: We sought to determine what characteristics of smokers trying to quit are associated with nicotine patch use in the general population and whether there is evidence that patch use promotes successful smoking cessation. METHODS: As part of the 1993 California Tobacco Survey, 3281 respondents who had attempted to quit smoking cigarettes within the last year were asked whether they had used a prescribed medication to help them quit smoking and, if so, what type of medication it was. They were also asked whether they used other assistance. RESULTS: Compared with nonusers, patch users (nearly 11% of quitters) were more likely to be female, white or Asian, middle-aged, and to smoke more heavily. Many people relapsed to smoking while they were still using a patch. However, no evidence suggested that the patch was addictive. Use of a nicotine patch did not result in a statistically significant difference in abstinence rates among those who did not also use some other form of assistance (logrank test, P = .466). It did make a statistically significant difference when used in combination with another aid (logrank test, P = .017). At 6 months, abstinence rates were 15% for those without other forms of assistance whether or not they used a patch, 10.9% (95% confidence interval [CI] = 5.1-16.8) for those with other assistance who did not use a patch, and 18.8% (95% CI = 5.7-31.8) for those with other assistance who did use a patch. CONCLUSIONS: The nicotine patch appears to be an important aid to smokers who want to quit, primarily when used as an adjuvant to other forms of assistance. IMPLICATIONS: Further studies are needed to determine what factors are associated with quitting success among patch users.