The 1964 Surgeon General's report on the effects of cigarette smoking on respiratory and cardiovascular health prompted interest in ways to decrease the prevalence of smoking 1, which has been a prominent public health goal since the report was issued. However, cigarette smoking continues to be a major determinant of poor health in the United States. Although the prevalence of smoking has declined since the 1964 report 12, 43 million adult smokers in the United States continue to smoke, which represents 20% of the adult population 3. Research suggests that smoking and secondhand smoke exposure combined were responsible for 438,000 premature deaths, 5.5 million years of potential life lost, and over $90 million productivity losses in the United States each year for the period between 1997 and 2001 4.

Over the years there has been a great deal of research on smoking cessation, including research on predictors of smoking cessation and successful quit attempts. However, given that intention to quit smoking is shown to be one of the key steps in the process towards smoking cessation 5, it is important to study all quit attempts, even those that are not successful 6. Furthermore, the fact that these individuals are at least trying to quit smoking suggests that they are motivated, but are just unable to maintain long-term abstinence. In order to adequately address all barriers to smoking cessation among these smokers and increase the proportion of successful quit attempts, it is important to understand the characteristics of smokers who have unsuccessfully tried to quit smoking. There is also a sense of urgency with regard to how soon these smokers are reached, particularly since having many failed attempts may result in frustration, fear, defiance, and loss of interest in quitting 7.

Most studies that address determinants of quit attempts are based on specific populations such as adolescents or young adults 8910, hospital/clinic and/or chronically-ill patients 911121314, specific race/ethnic background, or non-US populations 1516171819. Few studies have assessed quit attempts in the general population 2021. However, these studies, as well as the others in specific populations, have not undertaken comprehensive analysis of the many factors thought to be associated with quit attempts. The lack of such comprehensive analyses limits the identification of factors most strongly associated with quit attempts. Although studies have investigated the relationship between socio-demographic factors and quit attempts, these studies do not adjust for other factors that may play a role in quit attempts. For example, studies have shown that factors such as physician advice to quit smoking 161722, smoking risk perception 14, nicotine dependence 1314202324, weight concern 2526, and history or presence of a tobacco-related condition 121327 are associated with quit attempts. In addition, some of these studies on smoking quit attempts are based on individuals who have successfully quit smoking, and thus factors are assessed in relation to successful quit attempts. However, these factors may not relate in the same fashion with unsuccessful quit attempts. The purpose of this study was to thoroughly assess factors associated with having ever or recently (i.e., within the past 12 months) attempted to quit smoking among current smokers, using data from a sample of Florida residents in 2007.

The sample characteristics are shown in Table 2. The majority of the 3,560 current smokers in the Tobacco Callback Survey reported their race as White (84.1%) with a slightly greater proportion of females than males (63.1%). Over 83% of the participants reported a high school education or above. More than 58% were overweight or obese using standard definitions. Approximately 42% reported to have tried to quit smoking completely during the past 12 months while about 83% reported to have ever tried to quit smoking completely. More than 50% of these smokers reported ever having a tobacco-related medical condition.

There were no significant first order interactions between any of the variables, including the variables "ever had a tobacco-related medical condition" and "provider advice for quitting smoking." Thus, no interaction terms were included in the final regression models.

Most smokers have thought about quitting smoking at one point or another, for various reasons. We found that about eight in 10 Florida smokers have attempted to quit at some point in their lifetime, while four in 10 Florida smokers reported having recently tried to quit. However, the fact that they are still smoking highlights the difficulty most smokers have with achieving successful cessation as well as the importance of characterizing individuals who at least attempt to quit, since they may be more likely to benefit from smoking cessation programs. In this study, we assessed factors associated with ever attempting to quit smoking and recent quit attempts among a sample of current adult smokers in Florida.

In the present study, older smokers were more likely than younger smokers to have ever attempted quitting smoking but were less likely to have tried quitting in the past 12 months, even after controlling for nicotine dependence, perceived benefits of quitting, smoking risk perception, and history or presence of tobacco-related medical conditions. This finding is consistent with another US population based survey of smokers which found older smokers to be least likely to attempt quitting in the past year and be less likely to be successful at quitting 20. A potential explanation for the difference in quit attempts by age group could be due to resistance to smoking cessation advice due to difficulty quitting, particularly those with many failed attempts, as well as due to changes in social norms regarding tobacco use 20. It could also be that young smokers try to quit smoking more frequently than older smokers; however the number of quit attempts is not known. We also found that non-Hispanic blacks were the most likely to have reported a quit attempt in the past 12 months while Hispanics were the least likely to have tried quitting smoking in their lifetime, even after controlling for potential confounders. A US population based survey also found blacks to be more likely to report a recent quit attempt although they were least likely to be successful 20. Again, racial/ethnic differences in quit attempts could be related to social and cultural norms as well as frequency of quit attempts.

The results also showed that history of having a tobacco-related medical condition was associated with greater likelihood of having attempted to quit smoking, both in the last 12 months or in their lifetime. This finding is not entirely surprising given that one reason individuals give for attempting to quit is their health 173132. Furthermore, when smokers have been asked if being diagnosed with a medical condition (e.g., heart disease) would increase their desire to quit smoking, the majority have agreed 12. Studies have also shown a link between diagnosis of cardiovascular disease and increased motivation to quit smoking and smoking cessation 113334. In addition, nationally representative data do show the prevalence of smoking to be lower among adults with a history of stroke or myocardial infarction (18%) compared to adults without a history of cardiovascular events (26%) 35. However, in a study of emergency department patients it was found that patients with a diagnosis of a cigarette-related medical condition (i.e., cardiovascular and respiratory diseases, peptic ulcer disease, and cancers such as of the lip, esophagus, lung, etc.) were less motivated to quit smoking when compared to smokers without such conditions 13. Nevertheless, the desire to quit smoking may be contingent on whether the smoker believes their medical condition is related to their smoking, and/or whether they believe quitting will help their condition (since it is already present). In fact, in the present study we did find that smokers who perceive that there are health benefits to quitting smoking are more likely to have ever attempted to quit smoking, which is consistent with a study of emergency patients 14.

We also found that greater level of nicotine dependence was associated with being more likely to have ever attempted to quit smoking, although a statistically significant association was not observed for recent quit attempts. Although our findings are plausible given that greater nicotine dependence has been associated with readiness to quit smoking 14, our findings are inconsistent with other studies that have noted an inverse relationship between degree of nicotine dependence and quit attempts 2024. However, the differing findings could be related to difference in the definition of nicotine dependence. In agreement with previous studies however 24, we found greater number of smoked cigarettes per day in the past 30 days was inversely related to both recent and lifetime quit attempts. Although the association between nicotine dependence and quit attempts are not entirely clear, our findings suggest that highly dependent smokers are not giving up on quitting smoking and recognize the importance of quitting.

One of the very encouraging findings from our study was related to healthcare provider advice. In agreement with previous studies 1617223637, we found that smokers who were advised by their healthcare provider to stop smoking were about 50% more likely to attempt to quit smoking, both in their lifetime and recently. Thus, consistent with the Public Health Service Clinical Practice Guidelines Treating Tobacco Use and Dependence 38, healthcare providers should continue to advise their patients to stop smoking, regardless of the frequency of smoking by their patients or other patient characteristics 36. The importance of such advice is greatest for individuals with medical conditions, given the greater contact these smokers have with the healthcare system. In fact, increasing to 85% the proportion of healthcare professionals who counsel their high-risk patients (e.g., with coronary heart disease) about smoking cessation is one Healthy People 2010 goal 39.

Finally we found that those who lost more than 3 kg in the past year were more likely to have recently tried to quit smoking. This finding could be due to those with a medical condition (i.e. being medically ill), who lost weight because of their illness, deciding to quit smoking as part of their treatment or recovery regimen. Alternatively, it might be that these individuals are making an overall effort to improve their health, including both weight loss and smoking cessation attempts.

There are several limitations to this study. First, a number of variables that may also be related to quit attempts were not available in the dataset. These include extent of knowledge of the health effects associated with smoking, diagnosis of tobacco related cancers, diagnosis of mental health conditions such as depression, and the smoking status of the family and friends particularly if these individuals live with the participant 82040. Second, we do not know the extent of participants' awareness and perceived effectiveness of smoking cessation support, factors which have been associated with greater likelihood of a quit attempt 41. It would have also been beneficial to know the frequency of quit attempts as well as the timing of these quit attempts. Finally, the results may not be generalized to other populations outside Florida or the United States.

In conclusion, we found smokers who had a tobacco-related medical condition, who had greater nicotine dependence, who were advised by their physician to quit smoking, and/or who strongly believed that there are health benefits to quitting smoking were more likely to have smoking quit attempts, either in the past 12 months or ever. In addition, many older smokers appear have given up on quitting smoking given that they are more likely to have ever tried quitting smoking yet not in the past 12 months. However, Blacks and Hispanics appear have tried quitting smoking more recently than in the past. The present study further highlights the importance of awareness of the health implications associated with smoking, particularly if education is provided by a health care provider. Given blacks and older smokers may be less successful at quit smoking 20, these groups should be targeted for smoking cessation education. Further research is needed to understand the relationship between nicotine dependence, race/ethnicity, and quit attempts however. In addition, research is needed to characterize smokers with tobacco-related medical conditions and/or greater nicotine dependence in order to develop targeted smoking cessation interventions. Nevertheless, the information provided by this study can guide the development of targeted intervention programs for smokers who appear to want to quit.

The authors declare that they have no competing interests.

ED was the lead author of the manuscript. WZ managed the data and performed all statistical analyses. MB, MW, YH, KA, ND, AC, and DL assisted in the writing of the manuscript. YH and KA also provided statistical support. In addition, YH provided the data and assisted with data management issues. DL was the PI for the grant funding the study. All authors read and approved the final manuscript version.