Young adult smokers: are they different?

Abstract

To compare smoking-cessation interest and behaviors in younger and older smokers to develop better smoking-cessation strategies for younger smokers.
Mail survey with phone follow-up of age-stratified members of a large Midwestern health plan to identify current and former smokers, followed by a second follow-up survey of this subgroup 12 months later.
The follow-up survey asked about change in smoking status, quit attempts, interest in quitting, and experience with various aids to quitting. Analyses compared adults age 18-24 years with adults age 25-65 years.
Follow-up surveys were completed by 66.5% of subjects. Young adults smoked at much higher rates than older adults (24.5% vs 17.1%), but were less likely to smoke daily or to smoke as many cigarettes. Young adults were as likely to be interested in quitting and more likely to report a quit attempt in the past year (60.6% vs 49.6%; P = .009), but these attempts were much more likely to be unaided (51.2% vs 33.7%; P = .0003). They also were more likely to report decreasing smoking in response to new restrictions on smoking in restaurants and bars (37.2 % vs 24.7%; P = .001).
Higher rates of smoking among young adults don't reflect less interest in quitting, fewer quit attempts, or less success in quitting compared with older adults. However, their reports of receiving or using much less help in quitting suggest that health plans and clinicians might be able to increase this group's cessation with more active support.

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I METHODS I
Young Adult Smokers: Are They Different?
Leif I. Solberg, MD; Raymond G. Boyle, PhD, MPH; Maribet McCarty, PhD;
Stephen E. Asche, MA; and Merry Jo Thoele, MPH
R
increased more than those of their non-college peers, but the less well-
educated young adults still have the highest rates in this age group. The
Prevention Priorities Project has demonstrated that smoking-cessation
assistance is one of the most important and cost-effective clinical preven-
tive services.4However, efforts to reduce smoking overall will be unsuc-
cessful unless a way can be found to change these trends among those who
are just beginning their smoking habits. Relatively little published infor-
mation exists about the cessation patterns and activities of a representa-
tive cross-section of young adults, because what has been published about
this age group’s smoking has largely been limited to the minority who are
in 4-year colleges. There also is no published information that directly
compares smoking-cessation patterns and activities of younger versus
older adults who have been drawn from the same population.
It is particularly important to understand whether there are any impor-
tant differences between younger and older adult smokers that might
affect smoking-cessation interventions with young adults. To develop
more effective interventions for young adults, we compared the smoking-
cessation behaviors and changes in smoking status over a 12-month peri-
od of a broadly representative sample of younger (age 18-24 years) and
older (age 25-65 years) smokers. Both samples were drawn randomly from
a large Midwestern health plan’s membership, which closely approxi-
mates the state’s population in socioeconomic class and race/ethnicity.
(Am J Manag Care. 2007;13:626-632)
© Ascend Media
ecent reports from the National Health Interview Survey and
the Monitoring the Future Project both confirm that 18- to
24-year-olds have the highest smoking prevalence of any age
group.1-3Smoking rates of young adults in college have
METHODS
First, we conducted a baseline cross-sectional survey of health plan
members stratified by age to identify those with any history of smoking.
A follow-up survey was conducted 12 months later of those respondents
who indicated current or former smoking on the baseline survey.
Study Setting
This project was conducted at HealthPartners, an integrated health-
care system providing medical services through a large network of owned
and contracted clinics. As one of the
largest healthcare organizations in
Minnesota, HealthPartners provides
coverage to more than 670 000 mem-
bers. About 30% of these enrollees
Objective: To compare smoking-cessation interest
and behaviors in younger and older smokers to
develop better smoking-cessation strategies for
younger smokers.
Study Design: Mail survey with phone follow-up
of age-stratified members of a large Midwestern
health plan to identify current and former smokers,
followed by a second follow-up survey of this
subgroup 12 months later.
Methods:The follow-up survey asked about
change in smoking status, quit attempts, interest
in quitting, and experience with various aids to
quitting. Analyses compared adults age 18-24
years with adults age 25-65 years.
Results: Follow-up surveys were completed by
66.5% of subjects. Young adults smoked at much
higher rates than older adults (24.5% vs 17.1%),
but were less likely to smoke daily or to smoke
as many cigarettes. Young adults were as likely to
be interested in quitting and more likely to report
a quit attempt in the past year (60.6% vs 49.6%;
P = .009), but these attempts were much more
likely to be unaided (51.2% vs 33.7%; P = .0003).
They also were more likely to report decreasing
smoking in response to new restrictions on
smoking in restaurants and bars (37.2 % vs 24.7%;
P = .001).
Conclusions: Higher rates of smoking among
young adults don’t reflect less interest in quitting,
fewer quit attempts, or less success in quitting
compared with older adults. However, their
reports of receiving or using much less help in
quitting suggest that health plans and clinicians
might be able to increase this group’s cessation
with more active support.
For author information and disclosures,
see end of text.
In this issue
Take-away Points / p 632
www.ajmc.com
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receive care in 1 of the 22 multispecialty owned clinics
(HealthPartners Medical Group).
Identification of Smokers
All 18- to 24-year-old enrollees of HealthPartners (n =
40 274) and 25- to 65-year-old enrollees (n = 282 074) with
1 year of continuous enrollment as of June 1, 2004, were eli-
gible for the baseline survey. Enrollees were stratified by age
group. A random sample of 5580 members age 18-24 years and
4420 members age 25-65 years were identified as the baseline
study sample (N = 10 000). We oversampled 18- to 24-year-
old enrollees to ensure an adequate comparison sample. The
primary purpose of this survey was to identify smokers and to
collect baseline information related to smoking characteris-
tics, quitting interest, and demographics. We defined current
smokers as those who had smoked 100 or more cigarettes in
their lifetime and now smoked every day or on some days.
Infrequent smokers had smoked on 1 or more days in the past
30 days but reported smoking fewer than 100 cigarettes in
their lifetime. Former smokers had smoked 100 or more ciga-
rettes in their lifetime, but had not smoked at all in the past
30 days at the time of completing the survey. Baseline survey
respondents identified as currently smoking, smoking infre-
quently, or no longer smoking were sent a follow-up survey 12
months later. Those who reported that they never smoked at
baseline did not receive a follow-up survey.
Survey Development and Measures
Baseline survey items were adapted from a recent survey of
health plan members,5Minnesota state surveys,6and national
surveillance system surveys.7The survey instrument included
information about current health status (rating of health, any
diagnosis of asthma or depression), smoking status, and
demographic characteristics (sex, race, employment, school
enrollment, education, health insurance type). Current and
infrequent smokers were asked about previous quit attempts,
use of medications to quit, and interest in quitting.
To increase the response rate, we limited the baseline
survey to 15 questions over 2 pages. We conducted a cog-
nitive pretest of the instrument with health plan members
(n = 16) before administration to the entire sample, and
made minor changes. The follow-up survey used the same
smoker categories, but items were added to assess change in
smoking status between baseline and follow-up. The fol-
low-up survey also included questions about use of cessation
services. The format and content of follow-up questions
were based on information gathered from focus group mem-
bers (n = 7), who also completed a pilot version of the
instrument.
Data Collection Procedures
We used HealthPartners administrative enrollment
records to obtain subjects’ age, sex, and address, and to deter-
mine whether a subject was the primary policy holder. The
initial survey was mailed in late summer 2004 to reach the
college students in our sample population at their home
address. A $2 bill was included in the mailing as an incen-
tive, and postcard reminders were sent to all nonresponders
about 1 week after the original survey mailing.8A second
survey was sent to nonresponders approximately 3 weeks
after the first survey was sent. Subjects who did not respond
to the mail surveys were contacted by telephone beginning
5 weeks after the first mailing and asked to complete the
survey by phone. Up to 6 telephone calls were made to
reach nonresponders. The 12-month survey was mailed in
the summer of 2005 using similar methods for follow-up of
nonrespondents.
Analysis
Contingency tables and Pearson χ2tests were used to com-
pare the younger (age 18-24 years) and older (age 25-65
years) subjects. We initially compared 3 age groups: 18-24,
25-44, and 45-65, but the latter 2 groups were so similar
that reporting on all 3 groups only served to confuse the
comparisons.
Different subsamples of the data were utilized for different
analyses. The sample of all baseline survey completers was
utilized to describe the sociodemographic characteristics of
survey respondents and to estimate smoking prevalence. The
subsample of baseline survey completers who were current
smokers was used to describe respondents with respect to
sociodemographic characteristics, smoking frequency, quit
interest, and quit attempts. Respondents who completed
the 1-year follow-up survey and who also were former
smokers, nondaily smokers, or daily smokers at baseline
comprised the denominator in an analysis describing
changes in smoking status over time. Respondents who
completed the follow-up survey and who were daily smokers
at baseline served as the denominator for analyses describ-
ing smoking behavior and quit interest at the follow-up as
well as quit activities undertaken in the 12 months before
the follow-up.
This study was powered at 90% to detect a 3.2% difference
in current smoker rates when the rate in 1 group was 20%
(20.0% vs 23.2%), and to detect a 2.8% difference when
the rate in 1 group was 15% (15.0% vs 17.8%). These cal-
culations assume use of the baseline survey completer sample
(n = 7161), a 2-sided test of proportions, and a type I error
rate of 0.05.

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RESULTS
Baseline surveys were completed by 3756 younger adults
and 3405 older adults. Response rates adjusted for 209 unde-
liverable surveys and 24 ineligible subjects (because of lan-
guage barriers or death) were 69.1% and 78.6%, respectively.
Among older adults, 88.5% of baseline surveys were complet-
ed by mail and 11.5% by phone (compared with 85.6% and
14.4%, respectively, for younger adults). The eligible sample
for the follow-up survey consisted of 1352 younger adults and
1583 older adults who had indicated being current, infre-
quent, or former smokers. Follow-up surveys were obtained
from 809 young adults and 1144 older adults for response
rates of 60% and 72%, after adjusting for the same reasons as
above. Older and younger adults who were daily or nondaily
smokers at baseline had similar follow-up response rates
(unadjusted rate of 62.0% for older adults, 58.1% for younger
adults). However, among those not smoking at baseline,
follow-up response rates differed by age group (unadjusted
response rate of 78.4% for older adults and 63.6% for younger
adults; P <.001). Among older adults, 89.2% of follow-up sur-
veys were completed by mail and 10.8% by phone (compared
with 75.2% and 24.8% for younger adults).
Among the older adult sample, nonrespondents to the
survey were more likely than respondents to be male (54.1%
vs 44.4%; P <.001), to be younger (mean age 39.8 vs 44.1
years; P <.001), and to have insurance through Medicaid
(9.0% vs 3.2%; P <.001). There were no differences with
respect to metro/nonmetro residence. Among the younger
adult sample, nonrespondents to the survey were more like-
ly than respondents to be male (50.8% vs 43.5%; P <.001)
and to have insurance through Medicaid (15.9% vs 10.5%;
P <.001). There were no differences with respect to age or
metro/nonmetro residence.
Attributes of Baseline Survey Respondents
This section, which describes all baseline survey respon-
dents, does not involve any corresponding tables. About 56%
I Table 1. Characteristics of Current Smokers at Baseline*
Daily SmokersNondaily Smokers
Age
18-24 y
(n = 552)
Age
25-65 y
(n = 418)
Age
18-24 y
(n = 359)
Age
25-65 y
(n = 160)
Respondent
CharacteristicsPP
Female 56.2 52.4.2454.949.4 .25
White83.193.5<.00186.388.0 .60
Employed full-time
52.6 74.3 <.00158.9 81.1 <.001
Current school enrollment
Not in any school 53.5 96.9 <.00140.2 88.7<.001
GED/high school 4.40.51.7 0.7
College program (2 y)19.7 1.018.02.7
College program (4 y)21.0 0.836.04.7
Graduate school 1.50.84.2 3.3
Health insurance type
Commercial79.793.0<.001 89.193.1.16
Medicaid20.3 7 .0 10.96.9
Rates health as excellent8.28.6.82 14.311.9.46
One or more close friends smoke99.6 95.2 <.00198.690.5 <.001
Smokes >10 cigarettes per day 45.569.2 <.001 6.06.1.97
Smokes within 5 min of waking11.2 21.8<.001 0.6 1.3.59
Quit interest in next 6 mo 57 .966.3 .008 68.465.1 .51
Any quit attempts in past year58.552.3 .0657 .749.6 .13
*Values are percentages except where indicated.

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of the baseline survey respondents
were female and most identified
themselves as white (87%), although
a significantly higher proportion of
the younger than the older sample
were nonwhite (16.6% vs 10.0%; P
<.0001). Most were residents of the
Minneapolis/St. Paul metropolitan
area (79%) and had commercial
medical insurance (93%), although
the younger sample was more likely
to be on medical assistance programs
than the older sample (10.5% vs
3.5%; P <.0001). We found expect-
ed differences in the proportion
employed and enrolled in school,
with 73.1% of the older and 44.7%
of the younger sample employed
full-time (P <.0001). The majority
of the younger subjects (65.3%)
were enrolled in an education pro-
gram compared with 8.1% of the
older subjects (P <.0001).
Among all respondents, individu-
als in the younger age group were sig-
nificantly more likely (P <.0001)
than individuals in the older age group to be current smok-
ers (24.5% vs 17.1%), infrequent smokers (3.7% vs 0.5%),
and never smokers (63.8% vs 53.5%). In contrast, the older
sample consisted of more former smokers (28.9% vs 8.1%). In
addition, the younger group was more likely to report having
close friends who smoked than the older group (70.4% vs
54.7%; P <.0001).
Attributes of Current Smokers
In Table 1 we report the characteristics of the current
smokers in the baseline survey (ie, the infrequent smokers and
quitters were eliminated) separately for daily and nondaily
smokers. Among these current smokers, daily smoking was
more common among the older than the younger smokers
(72.3% vs 60.6%; P <.001). The sociodemographic differ-
ences between the younger and older adult samples noted
above among all respondents were generally true of this subset
of current smokers, although some differences occurred only
for the daily smokers. For example, among daily smokers only,
younger smokers were less likely than older smokers to smoke
more than 10 cigarettes a day, to have a cigarette within 5
minutes of waking, and to be interested in quitting in the next
6 months. However, among the nondaily smokers, younger
and older smokers were equally likely to be interested in quit-
ting in the next 6 months. Younger and older smokers were
equally likely to report making a quit attempt in the past year.
Nearly all of the current smokers had close friends who
smoked, but for young adult smokers, this was universal.
Change in Smoking Status from Baseline
to Follow-up 1 Year Later
We compared and tested for differences in the distributions
of follow-up smoking status by age after first stratifying on
baseline smoking status at baseline (Table 2). Table 2 also
illustrates change in smoking status in the 12 months from
baseline to follow-up. Those who were former and daily smok-
ers at baseline showed differences in their follow-up smoking
status by age group, with younger adults more likely than older
adults to have changed smoking status between the baseline
and the follow-up measurements. However, the most change
between baseline and follow-up smoking status occurred
among nondaily smokers, where 44% of those who were
nondaily smokers at baseline migrated into other smoking cat-
egories at follow-up. For this group of nondaily smokers at
baseline, follow-up smoking patterns were identical for both
age groups.
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I Table 2. Smoking Status at 12-Month Follow-up Stratified by Baseline
Smoking Status
Baseline and Follow-up
Smoking StatusAge 18-24 yAge 25-65 yP*
Former smoker
n = 190 n = 765
Follow-up status
<.001
Not smoking78.2%94.9%
Smoking some days16.7%3.0%
Smoking daily5.2%2.1%
Nondaily smoker
n = 207n = 101
Follow-up status
.99
Not smoking25.9%25.5%
Smoking some days 56.5%56.4%
Smoking daily 17 .6%18.1%
Daily smoker
n = 320 n = 258
Follow-up status
.02
Not smoking11.4% 12.7%
Smoking some days 14.0%3.7%
Smoking daily 74.7%83.6%
*P values are from the Pearson χ2test for differences in follow-up smoking status by age within
each stratum of baseline smoking status.

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To test whether quit rate differences (ie, not smoking at
follow-up) by age group among daily smokers (11.4% for
younger adults, 12.7% for older adults) existed after control-
ling for the higher cigarette smoking frequency and addiction
found in the older adult group, we conducted a logistic regres-
sion analysis predicting nonsmoking status versus daily or
nondaily smoking at follow-up. This model used only data
from individuals who were daily smokers at baseline and
included predictors of age group (younger/older), amount
smoked at baseline (>10 cigarettes per day vs <10 cigarettes
per day), and whether smoking occurred within 5 minutes of
waking (yes/no). The age group association still was not signif-
icant (odds ratio = 0.65; 95% confidence interval = 0.37,
1.14) but continued in the direction observed in the bivariate
analysis, with a lower quit rate among the younger compared
with the older daily smokers. Computing follow-up quit rates
for baseline daily smokers within strata defined by either the
amount smoked at baseline or smoking within 5 minutes of
waking yielded similar results, with quit rates always direction-
ally lower among younger than older adults, but never statis-
tically significantly different (data not shown).
Characteristics of Daily and Nondaily
Baseline Smokers 1 Year Later
Table 3 summarizes the smoking and quitting behaviors at
follow-up of the 578 individuals identified as daily smokers
and the 308 identified as nondaily smokers in the baseline sur-
vey, some of whom were not smoking at follow-up. Among
daily smokers, young adults were more likely to report making
quit attempts in the past year, but much less likely to use any
resources to aid them in those quit attempts. They primarily
had tried to quit cold turkey and infrequently reported using
help from a doctor or medical clinic. Among nondaily smok-
ers there were far fewer differences by age group, with younger
smokers less likely to use nicotine-replacement therapy or
help from a doctor or medical clinic.
In the follow-up survey, we had asked daily smokers at
baseline to report on clinician actions at their most recent
doctor’s office visit. Among those who reported any medical
discussion of smoking (66.9% of young adults and 72.5% of
older adults; P = .15), similar proportions of younger (98.1%)
and older (98.4%) adults reported being asked whether they
smoked. Younger and older smokers also were equally likely to
report being asked to quit smoking (77.6% and 74.9%, respec-
tively). But older adults were more likely to report being asked
by a clinician to set a quit date than younger adults (19.3% vs
9.4%; P = .004), and marginally more likely to have a clini-
cian suggest that they use a cessation medication (31.6% vs
23.4%; P = .07).
Impact of Local Smoking Restrictions
On March 31, 2005 (about 4 months before our follow-up
survey), smoking bans in restaurants and bars went into effect
in several cities and counties in the metropolitan area, includ-
ing Minneapolis and St. Paul. In the follow-up survey we
asked current smokers whether the new smoking restrictions
were causing them to smoke less or to try to quit. More than
a third of younger adults reported smoking fewer cigarettes
compared with about a quarter of older adults (37.2% vs
24.7%; P = .001), but younger adults were just as likely as
older adults to report trying to quit because of the restrictions
(16.2% and 13.5%, respectively).
DISCUSSION
This study provides previously unavailable information
directly comparing the smoking-cessation patterns and behav-
iors over time of a broad sample of younger and older adult
smokers. Compared with the older adults, the young adults
were lighter, less frequent smokers who were still fluctuating
in their smoking behavior over time. Contrary to popular
belief, they were as interested in quitting, more likely to make
quit attempts, and as likely to have quit 1 year later. However,
their quit attempts were much more likely to be made without
medication or counseling assistance, and they were much less
likely to have received help from medical sources. (As plan
members, these young adults had greater access to assistance
and medications, so the finding that so few use smoking-ces-
sation aids is even more striking.) New environmental restric-
tions on public smoking were at least as likely to affect their
smoking as that of older adults, perhaps in part because this
age group tends to spend more time in restaurants and bars.9
What makes these findings particularly important and
unique is that these subjects were broadly representative of
younger and older smokers in Minnesota. At least in
Minnesota, where only 6% of the population is uninsured and
most low-income people on medical assistance are included in
health plan rolls through a contract with the state, an insured
population reflects the community quite well. This is impor-
tant because most of the existing literature on smoking and
cessation behaviors of young adults comes from studies of the
minority who are students in 4-year colleges or are in the mil-
itary.10-15In a separate analysis of the young adult responders
in this study, we demonstrated that college students are more
likely to smoke fewer than 11 cigarettes per day and to have
quit smoking at follow-up and are much less likely to smoke
daily and to smoke immediately on awakening.16However, we
confirmed in this more representative sample the 3 separate
studies of DeBernardo et al, Hines, and Morrison et al in col-