A population study of low-rate smokers: Quitting history and instability over time.

Abstract

This study used one longitudinal and two cross-sectional population surveys to compare stability of low-rate daily smokers (<5 CPD) with other daily smokers and occasional smokers. Most low-rate smokers do not maintain consumption level for long; 36% retained their smoking status after 20 months compared to 82% and 44% for regular daily and occasional smokers, respectively. Analysis revealed a dynamic process; established smokers of all consumption levels quit smoking as well as modified (decreased or increased) consumption level. Low-rate and occasional smokers quit at higher rates than regular daily smokers (odds ratios > 3:1), but were continuously replenished by new members, many "converted" from regular daily smokers. The overall trend is an increasing proportion of low-consumption smokers, even while smoking prevalence declines. The dynamic process described has implications for tobacco control efforts and for addiction theory.Key words: Low-rate smokers, chippers, occasional smokers, smoking reduction, cessation, dynamics of smoking behavior.Low-rate smokers 3 Low-rate smoke rs consume five or fewer cigarettes per day (CPD). Their low consumption behavior is of theoretical and practical interest. Theoretically, there is the question of how many of them will maintain such a low daily consumption , given that nicotine regulation is generally ineffective when people smoke 5 CPD or less (Benowitz, Jacob, Kozlowski, & Yu, 1986). More practical questions include: how many of these low-rate smokers used to smoke more but cut down their CPD in response to anti-smoking campaigns, and whether the reduced consumption increases the probability of cessation.Previous studies have shown that a subgroup of low-rate smokers maintains low consumption for an extended period of time. Shiffman called these smokers "chippers" and defined them as smokers who have maintained < 5 CPD for at least two years (Shiffman, 1989). He and his colleagues demonstrated that chippers do not exhibit characteristic features of nicotine dependence (Shiffman, Paty, Gyns, Kassel, & Elash, 1995), even though they absorb the same amount of nicotine per cigarette and show similar cardiovascular responses as dependent smokers (Shiffman, Fischer, Zettler-Seg al, & Benowitz, 1990;Shiffman et al., 1992). These studies, however, do not address the question of how many low-rate smokers in the general smoking population are chippers. Hence, the issue of how many low-rate smokers will maintain daily low consumption has not been resolved.With regard to the probability of cessation, a lower consumption generally predicts a higher cessation rate (USDHHS, 1988). However, this is not always true (Hughes, 2000). Smokers who cut down CPD to a certain level may not share the characteristics of smokers who have always consumed that same level, and nicotine intake is only one of many factors that affect cessation rate. In fact, consumption that is consistently as low as 5 CPD suggests that factors other than nicotine regulation must also play a significant ro...

Changing age-specific patterns of cigarette consumption in the United States, 1992–2002: Association with smoke-free homes and state-level tobacco control activity

“…Using a longitudinal population survey, Zhu et al (2003) observed that the majority of light smokers (defi ned as intermittent or daily and smoking less than 5 CPD) identifi ed in California in the early 1990s did not maintain a stable consumption level over a 20-month period. The changes in consumption observed in these longitudinal data could be represented by a dynamic model of quitting and relapse, in which heavier smokers reduced smoking prior to making a quit attempt ( Farkas, 1999 ) and relapse among former smokers began with a period of light smoking.…”

“…Although cigarette consumption levels below 5 cigarettes/day (CPD) have been labeled as insuffi cient for nicotine regulation and physiological dependence ( Benowitz, Jacob, Kozlowski, & Yu, 1986 ), some smokers may maintain stable behavior at these low levels because of psychological dependence. Alternatively, for heavier smokers, a period of light or intermittent smoking may be part of a dynamic process of attempting to quit ( Zhu, Sun, Hawkins, Pierce, & Cummins, 2003 ).…”

“…Although cigarette consumption levels below 5 cigarettes/day (CPD) have been labeled as insuffi cient for nicotine regulation and physiological dependence ( Benowitz, Jacob, Kozlowski, & Yu, 1986 ), some smokers may maintain stable behavior at these low levels because of psychological dependence. Alternatively, for heavier smokers, a period of light or intermittent smoking may be part of a dynamic process of attempting to quit ( Zhu, Sun, Hawkins, Pierce, & Cummins, 2003 ).Using a longitudinal population survey, Zhu et al (2003) observed that the majority of light smokers (defi ned as intermittent or daily and smoking less than 5 CPD) identifi ed in California in the early 1990s did not maintain a stable consumption level over a 20-month period. The changes in consumption observed in these longitudinal data could be represented by a dynamic model of quitting and relapse, in which heavier smokers reduced smoking prior to making a quit attempt ( Farkas, 1999 ) and relapse among former smokers began with a period of light smoking.…”

How should we define light or intermittent smoking? Does it matter?

“…The variation is in how nondaily smoking is defi ned: specifi cally, whether a defi nition is descriptive but imprecise ( " nondaily, " " some-day use, " " occasional, " " occasional but not regularly " ); whether a minimum is specifi ed for lifetime consumption (e.g., at least 100 cigarettes or 100 times); or whether the defi nition is based on cigarettes smoked per day, average number of cigarettes smoked per day, or days or times smoked in a week or a month ( Biener & Albers, 2004 ;Borland, 1994 ;DiFranza et al, 2000 ;Etter, 2004 ;Etter, Le Houezec, & Perneger, 2003 ;Evans et al, 1992 ;Fergusson & Horwood, 1995 ;Fornai et al, 2001 ;Gilpin et al, 1997 ;Hennrikus, Jeffery, & Lando, 1996 ;Hines, Fretz, & Nollen, 1998 ;Hines, Nollen, & Fretz, 1996 ;Holmen, Barrett-Connor, Holmen, & Bjermer, 2000 ;Kenford et al, 2005 ;Koontz et al, 2004 ;Luoto, Uutela, & Puska, 2000 ;McDermott, Dobson, & Owen, 2007 ;Morley et al, 2006 ;Okuyemi et al, 2004 ;Okuyemi, Richter, et al, 2002 ;Paavola, Vartiainen, & Puska, 2001 ;Sargent, Mott, & Stevens, 1998 ;Stanton et al, 2007 ;Stone & Kristeller, 1992 ;Wetter et al, 2004 ;Zhu et al, 2003 ).…”

“…Low-level daily or low-rate daily also has a range of defi nitions from fewer than 5 CPD or no more than 5 CPD ( Kenford et al, 2005 ;Zhu, Sun, Hawkins, Pierce, & Cummins, 2003 ) to, collectively, the group averaging fewer than 10 CPD ( Zvolensky et al, 2007 ). Low-rate smoker is defi ned more consistently as no more than 5 CPD or 1 -5 CPD ( Etter, 2004 ;Owen, Kent, Wakefi eld, & Roberts, 1995 ), but low-level smoker or low-level use has more varied defi nitions ranging from nondaily or no more than 1 pack per week to 1 -20 CPD ( Arcavi, Jacob, Hellerstein, & Benowitz, 1994 ;Dierker et al, 2007 ;Hatsukami et al, 2006 ;Hyland, Rezaishiraz, Bauer, Giovino, & Cummings, 2005 ;Mucha, Stephenson, Morandi, & Dirani, 2006 ).…”