PAST
QUIT
SMOKING
ASSISTANCE
AND
DOCTORS'
ADVICE
FOR
WHITE
AND
AFRICAN
AMERICAN
SMOKERS
Norman
Hymowitz,
PhD,
John
Jackson,
Robert
Carter,
and
Haftan
Eckholdt,
PhD
Newark,
New
Jersey
Data
for
473
African-American
and
white
smok-
ers
showed
that
whites
were
more
likely
than
African
Americans
to
use
formal
cessation
programs
to
quit
smoking,
to
report
that
their
doctor
told
them
to
stop
smoking,
and
to
use
nicotine
replacement
therapy.
While
physicians
advised
a
high
proportion
of
smokers
of
each
race
group
to
quit
smoking
and
were
quite
aggressive
in
prescribing
nicotine
replace-
ment
therapy,
they
were
deficient
in
providing
necessary
behavioral
support
to
their
patients.
(J
Nat!
Med
Assoc.
1996;88:249-252.)
Key
words
*
smoking
cessation
*
African
Americans
Smoking
rates
have
decreased
to
less
than
30%
of
the
American
population.'
This
decline
represents
a
substantial
improvement
over
previous
decades,
but
the
current
rate
of
decline
remains
considerably
higher
than
the
"trajectory"
needed
to
reach
the
National
Cancer
Institutes'
Year
2000
goal
of
15%.2
Moreover,
the
response
to
the
antismoking
campaign
has
been
uneven.
African
Americans
have
a
higher
prevalence
of
ciga-
rette
smoking
than
the
general
population,3
are
less
likely
to
use
quit
smoking
aids
and
programs,4
and
have
not
quit
smoking
at
the
same
rate.3
Recent
surveys
actu-
ally
reveal
an
upturn
in
smoking
rates
among
African
Americans.s
From
the
Department
of
Psychiatry,
University
of
Medicine
and
Dentistry
of
New
Jersey,
New
Jersey
Medical
School,
Newark,
New
Jersey.
This
research
was
supported
in
part
by
grant
no.
PHS-NHLBI
2
R44
HL42738-02,
subcontract
to
Norman
Hymowitz,
PhD.
Requests
for
reprints
should
be
addressed
to
Dr
Hymowitz,
Dept
of
Psychiatry,
New
Jersey
Medical
School,
ADMC
1429,
30
Bergen
St,
Newark,
NJ
07103.
African
Americans
also
bear
an
excess
burden
of
tobacco-related
disease.6
Rates
of
heart
disease,
stroke,
and
lung,
esophageal,
and
other
cancers
are
higher
among
African
Americans
than
the
general
population.6
Despite
their
high-risk
status,
African
Americans
are
less
likely
to
receive
physicians'
advice
to
stop
smok-
ing.7
It
is
estimated
that
physicians
see
about
70%
of
smokers
during
the
year8
and
are
in
a
unique
position
to
encourage
quit
attempts
and
to
lend
support
and
assis-
tance
to
smokers.8
Data
from
the
Stanford
Five
City
Project9
suggested
that
Hispanics
and
other
minorities
were
less
likely
than
whites
to
receive
advice
from
their
physician
to
quit
smoking.
Such
bias
in
encouraging
smoking
cessation
may
have
serious
adverse
health
consequences
for
minority
group
smokers.
This
study
examines
the
past
quit
smoking
experience
of
African
Americans
and
whites,
their
use
of
quit
smoking
aids
and
programs,
and
receipt
of
physician
advice.
METHOD
Subjects
Five
hundred
smokers,
ages
21
to
65
years,
were
recruited
via
electronic
and
print
media
to
participate
in
a
stop
smoking
study.
To
be
eligible,
subjects
had
to
smoke
no
less
than
10
cigarettes
per
day,
express
a
will-
ingness
to
try
to
stop
smoking,
and
accept
random
assignment
to
experimental
conditions.
Of
the
500
par-
ticipants
enrolled
in
the
study,
473
were
either
white
or
African
American.
Only
data
for
whites
and
African
Americans
are
presented
here.
Procedure
At
the
first
(baseline)
visit,
subjects
received
a
gen-
eral
overview
and
orientation,
and
completed
a
baseline
questionnaire.
The
questionnaire
assessed
demograph-
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
88,
NO.
4
249
QUIT
SMOKING
ASSISTANCE
TABLE
1.
BASELINE
CHARACTERISTICS
Male
Female
Variable
White
Black
PValue
White
Black
PValue
No.
patients
114
78
113
168
Mean
age
(years)
44
(9.68)*
41
(9.70)
44
(9.96)
44
(10.44)
%
some
college
74
49
.0005
67
67
%
gross
income
>$20,000
84
(0.36)
53
(0.50)
.0001
73
62
%
married
69
35
.0002
40
25
.0110
Mean
health
rating
2.04
(0.68)
2.08
(0.68)
2.13
(0.71)
2.31
(0.68)
.0385
Mean
cigarettes/day
31
(12.20)
22
(10.25)
.0001
27
(10.89)
19
(9.72)
.0001
Mean
age
started
smoking
15
(3.80)
16
(4.34)
16
(3.95)
17
(4.26)
(years)
%
menthol
brands
13
79
.0001
20
79
.0001
%
tried
to
quit
in
past
96
88
.03
94
90
Mean
no.
past
quit
attempts
6
(10.81)
5
(5.67)
5
(3.72)
7
(13.21)
*Numbers
in
parentheses
indicate
standard
deviation.
ic,
psychosocial,
health,
and
smoking
variables.
Particular
attention
was
paid
to
past
quit
attempts,
use
of
quit
smoking
aids,
and
doctors'
advice
to
quit
smok-
ing.
If
the
subject
indicated
that
their
doctor
had
advised
them
to
stop
smoking
in
the
past,
they
were
asked
to
respond
to
a
series
of
questions
concerning
the
quality
and
nature
of
the
interventions,
if
any,
that
accompanied
the
doctors'
advice.
RESULTS
The
study
group
was
comprised
of
114
white
males,
113
white
females,
78
African-American
males,
and
168
African-American
females.
White
males
and
females
had
higher
incomes
and
were
more
likely
to
be
married.
White
males
were
more
highly
educated
than
African
American
males,
and
white
females
rated
their
health
better
than
African
American
females.
As
shown
in
Table
1,
white
males
and
females
smoked
more
cigarettes
per
day
than
African
Americans,
although
the
different
race/sex
groups
start-
ed
smoking
at
a
similar
age.
African
Americans
were
much
more
likely
than
whites
to
smoke
menthol
ciga-
rettes.
A
high
proportion
of
the
smokers
reported
that
they
tried
to
quit
smoking
in
the
past,
and
members
of
each
race/sex
group
who
reported
that
they
tried
to
quit
smoking
in
the
past
made
a
similar
number
of
past
quit
attempts
(Table
1).
Whites,
however,
were
more
likely
than
African
Americans
to
report
attending
a
cessation
program,
using
hypnosis,
and
in
the
case
of
males,
using
nicotine
replacement
therapy
to
quit
smoking
in
the
past
(Table
2).
A
majority
of
smokers
from
each
group
reported
that
their
doctor
told
them
to
stop
smoking
in
the
past
(white
males,
80%;
white
females,
81%;
African-American
males,
64%;
and
African-American
females,
72%).
The
difference
between
white
and
African-American
males
achieved
statistical
significance
(X2
=
7.14;
P<.05)
while
the
difference
among
women
approached
signifi-
cance
(P=.078).
When
the
"Doctors'
Advice"
data
were
subjected
to
multiple
logistic
regression
analysis,
race
(odds
ratio
[OR]=
1.87),
age
(OR=.95),
and
self-health
rating
(OR=.50)
emerged
as
significant
and
independent
pre-
dictors
of
who
received
advice
to
quit
smoking.
Whites,
older
smokers,
and
those
with
the
poorest
health
ratings
were
most
likely
to
be
advised
by
their
doctor
to
quit
smoking.
Forty
percent
of
the
smokers
who
reported
that
their
doctor
told
them
to
stop
smoking
reported
that
their
doctor
gave
them
cessation materials
(eg,
brochure),
28%
reported
receiving
brief
cessation
coun-
seling,
18%
reported
that
their
doctor
encouraged
them
to
select
a
quit
date,
and
10%
reported
that
their
doctor
scheduled
a
follow-up
visit
to
talk
about
smoking.
Fifty-four
percent
of
smokers
who
were
told
by
their
doctor
to
quit
smoking
reported
use
of
nicotine
replace-
ment
therapy
(Table
2).
Forty
five
percent
used
nicotine
gum,
and
55%
used
the
nicotine
patch.
Eleven
percent
reported
past
use
of
both
products,
with
little
or
no
dif-
ferences
by
race
or
sex.
Multiple
logistic
regression
analyses
showed
that
sex
(OR=.58),
race
(OR=1.87),
age
(OR=.97),
income
(OR=.50),
and
the
score
on
the
modified
Fagerstrom
Tolerance
Questionnaire
(OR=.87)
were
significant
and
independent
predictors
of
past
use
of
nicotine
replace-
ment
therapy.
Females,
whites,
older
smokers,
those
with
the
highest
income,
and
those
who
scored
highest
on
the
addiction
scale
were
most
likely
to
use
nicotine
replacement
therapy.
250
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
88,
NO.
4
QUIT
SMOKING
ASSISTANCE
TABLE
2.
PAST
SMOKING
CESSATION
ASSISTANCE
Male
Female
Assistance
White
Black
White
Black
No.
patients
114
78
113
168
%
tried
cessation
program
24*
9
34*
17
%
tried
hypnosis
41
*
6
43*
20
%
tried
nicotine
replacement
47*
20
50*
39
*Chi-square
significant
at
P<.01.
While
a
high
proportion
of
smokers
reported
that
their
doctor
prescribed
nicotine
replacement
therapy,
few
reported
receiving
behavioral
assistance
or
using
the
product(s)
for
the
appropriate
duration
of
time
(3
to
6
months
for
nicotine
gum
and
8
to
12
weeks
for
the
nico-
tine
patch).
Only
18%
of
the
subjects
who
used
the
gum
and
20%
who
used
the
patch
reported
receiving
behav-
ioral
support,
primarily
self-help
material.
Eighty
percent
of
smokers
who
used
the
gum
and
69%
of
those
who
used
the
patch
used
the
product(s)
for
1
week
or
less.
DISCUSSION
The
data
presented
are
for
a
unique
sample
of
smok-
ers
(ie,
smokers
who
enrolled
in
a
quit
smoking
pro-
gram).
Hence,
they
may
not
be
representative
of
smokers
in
the
community
at
large.
Indeed,
our
findings
that
more
than
90%
of
them
reported
that
they
tried
to
quit
smok-
ing
in
the
past
and
that
approximately
80%
of
the
whites
and
70%
of
the
African-American
smokers
reported
that
their
doctor
told
them
to
quit
smoking
in
the
past
(Table
1)
exceed
rates
in
the
general
population.9"11
Despite
the
uniqueness
of
the
population
in
the
pre-
sent
study,
key
aspects
of
the
baseline
data
are
note-
worthy
and
may
have
considerable
generality
and
importance.
White
males
were
more
likely
to
report
that
they
tried
to
quit
smoking
in
the
past
than
African-
American
males,
and
they
were
significantly
more
like-
ly
to
use
a
formal
cessation
program,
hypnosis,
or
nico-
tine
replacement
therapy.
While
white
and
African-
American
females
did
not
differ
in
the
likelihood
of
try-
ing
to
quit
in
the
past,
white
women
were
more
likely
to
report
participating
in
a
formal
cessation
program
(indi-
vidual
or
group)
and
hypnosis,
although
the
difference
in
past
use
of
nicotine
replacement
therapy
did
not
achieve
statistical
significance.
Orleans
et
al4
reported
that
African
Americans
tend-
ed
to
underuse
quit
smoking
programs
and
aids.
The
dif-
ferential
use
of
quit
smoking
aids
and
programs
high-
lights
a
serious
shortcoming.
Whether
the
problem
is
one
of
availability
of
quit
smoking
programs,
access,
or
economics,
it
is
clear
that
African
Americans
have
not
received
as
much
formal
help
in
stopping
smoking
as
whites.
This
finding,
in
turn,
may
be
related
to
the
lower
quit
rates
among
African
American
adults
and
must
command
the
attention
of
the
public
health
community.
In
our
study,
whites,
older
smokers,
and
those
with
the
poorest
health
ratings
were
most
likely
to
receive
doc-
tors'
advice
to
quit
smoking.
The
Centers
for
Disease
Control
similarly
reported
that
older
smokers
and
those
in
poorest
health
were
most
likely
to
receive
doctors'
advice,
although
race/ethnicity,
education,
and
socioeco-
nomic
status
did
not
emerge
as
significant
predictors.1'
The
Stanford
Five-City
Project
reported
a
significant
difference
between
whites
and
minorities
in
receiving
doctors'
advice
to
quit
smoking.9
Whereas
51.1%
of
non-Hispanic
whites
reported
that
their
doctor
told
them
to
stop
smoking,
only
32.6%
of
Hispanics
reported
being
told
by
their
doctor
to
stop
smoking.
Other
minor-
ity
groups
also
were
less
likely
than
non-Hispanic
white
subjects
to
report
physician
advice,
although
the
number
of
subjects
in
the
sample
was
small.9
Our
study,
as
well
as
the
Stanford
Five-City
Project,
emphasize
the
need
for
physicians
to
make
a
concerted
effort
to
advise
all
of
their
patients
who
smoke,
young
and
old,
those
in
good
health
as
well
as
those
in
poor
health,
and
smokers
from
all
raciaVethnic
groups,
to
quit
smoking.
Physicians
also
must
provide
stop
smok-
ing
assistance.8
Of
smokers
who
were
advised
by
their
doctor
to
quit
smoking,
only
18%
were
advised
to
select
a
quit
date,
and
only
10%
reported
receiving
follow-up
support.
These
findings
are
remarkably
similar
to
find-
ings
from
surveys
of
physician
smoking
intervention
behaviors
conducted
at
the
start
of
the
Community
Intervention
Trial
for
Smoking
Cessation
(COMMIT),12
and
they
support
the
general
call
for
more
effective
physician
office-based
intervention
on
smoking.7
More
than
half
of
the
smokers
who
reported
that
their
doctor
advised
them
to
quit
smoking
reported
past
use
of
nicotine
gum
and
the
nicotine
patch.
Despite
this,
few
smokers
used
the
nicotine
products
for
the
appro-
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
88,
NO.
4
251
QUIT
SMOKING
ASSISTANCE
priate
length
of
time
or
received
necessary
adjuvant
smoking
cessation
support.
Nicotine
replacement
thera-
py
is
an
important
quit
smoking
aid
and
may
increase
the
physician's
antismoking
armamentarium
many
fold.13
However,
like
any
other
medication,
patients
must
receive
proper
guidance
and
support
to
maximize
adherence
and
clinical
effectiveness.
Unfortunately,
the
present
data
suggest
that
too
many
physicians
are
not
providing
the
degree
of
supervision
and
support
that
patients
deserve.
Literature
Cited
1.
US
Dept
of
Health
and
Human
Services.
Smoking
and
Health
in
Americas.
Report
of
the
Surgeon
General,
in
Collaboration
With
the
Pan
American
Health
Organization.
Washington,
DC:
US
Government
Printing
Office;
1992.
DHHS
publication
(CDC)
92-8419.
2.
Pierce
JP,
Fiore
MC,
Novotny
TE,
Hatziandreu
EJ,
Davis
RM.
Trends
in
cigarette
smoking
in
the
United
States.
Projections
to
the
Year
2000.
JAMA.
1989;261:61-65.
3.
Fiore
MC,
Novotny
TE,
Pierce
JP,
Hatziandreu
EJ,
Patel
KM,
Davis
RM.
Trends
in
cigarette
smoking
in
the
United
States.
The
changing
influence
of
gender
and
race.
JAMA.
1
989;261
:49-55.
4.
Orleans
CT,
Schoenback
VJ,
Salmon
MA,
Strecher
VJ,
Kalsbeek
W,
Quade
D,
et
al.
A
survey
of
smoking
and
quitting
patterns
among
black
Americans.
Am
J
Public
Health.
1989;79:176-1
81.
5.
Centers
for
Disease
Control.
Cigarette
smoking
among
adults
United
States,
1991.
JAMA.
1993;269:1931.
6.
Robinson
RG,
Pertschuck
M,
Sutton
C.
Smoking
and
African
Americans.
In:
Samuel
SE,
Smith
MD,
eds.
Improving
the
Health
of
the
Poor.
Menlo
Park,
Calif:
The
Henry
J.
Kaiser
Family
Foundation;
1992:123-181.
7.
Satcher
D,
Robinson
RG.
The
CDC
and
the
NMA-
partnership
to
control
tobacco
in
the
African-American
commu-
nity.
J
Natl
Med
Assoc.
1994;86:493-496.
8.
US
Dept
of
Health
and
Human
Services.
Tobacco
and
the
Clinician.
Public
Health
Service,
National
Institutes
of
Health;
1994.
NIH
publication
94-3693.
9.
Frank
E,
Winkleby
MA,
Altman
DG,
Rockhill
B,
Fortmann
SR
Predictors
of
physician's
smoking
cessation
advice.
JAMA.
1991;266:3139-3144.
10.
Brink
SG,
Gottlieb
NH,
McLeroy
KR,
Wisotzky
M,
Burdine
JN.
A
community
view
of
smoking
cessation
counsel-
ing
in
the
practices
of
physicians
and
dentists.
Public
Health
Rep.
1994;109:135-142.
11.
Centers
for
Disease
Control.
Physician
and
other
health
care
professional
counseling
of
smokers
to
quit-United
States,
1991.
JAMA.
1993;270:2536-2537.
12.
Lindsay
EA,
Ockene
JK,
Berger
L,
Hymowitz
N,
Pomrehn
P,
Wilson
DM.
Physicians'
and
dentists'
roles
in
COM-
MIT-the
Community
Intervention
Trial
for
Smoking
Cessation.
In:
NCI
Monograph
5,
Tobacco
and
the
Clinician.
Public
Health
Service:
National
Institute
of
Health;
1994:334-341.
NIH
publi-
cation
94-3693.
13.
Fiore
MC,
Jorenby
DE,
Baker
TB,
Kenfored
SL.
Tobacco
dependence
and
the
nicotine
patch.
Clinical
guide-
lines
for
effective
use.
JAMA.
1992;268:2687-2694.
252
JOURNAL
OF
THE
NATIONAL
MEDICAL
ASSOCIATION,
VOL.
88,
NO.
4
