TABLE 5.—Continued Adjusted odds ratios Former smokers Current smokers Former smokers Behavior relative to never relative to never relative to current smokers smokers smokers Other — oo - : : Use ST 0.73 0.46" 1.53 Use seatbelt 1.03 0.62" 1.63" NOTE: BRFSS=Behavioral Risk Factor Surveillance System: ST=smokeless tobacco “n<0.,01, "0.0 l1 yr. *BMI=body mass index. “Met. Life=Metropolitan Life height and weight index. SOURCE: Samet and Wiggins. unpublished analyses of the 1987 BRFSS. never smokers and former smokers engaged in significantly more exercise sessions per week than did current smokers. Current smokers exercised for significantly less time per session and had significantly lower overall physical fitness scores compared with never smokers or former smokers. In a second study, the same authors examined the association between physical fitness and smoking among 1,357 Navy men (Conway and Cronan 1988b). Again, current smokers had poorer levels of physical fitness with lower scores than former smokers or never smokers on tests of cardiorespiratory and muscular endurance. Overall, never smokers performed better than former smokers and current smokers. In both studies, participants were young, with an average age of 26 years (study 1) and 28 years (study 2), suggesting that both decrements associated with smoking and improvements associated with quitting can appear at an early age. A cross-sectional study of 781 runners found that as mileage increased, the percentage of self-defined former smokers also increased (Macera, Pate, Davis 1989). These investigators suggested that high-mileage runners seemed to quit smoking at a higher rate than low-mileage runners. Although the sample size was probably too small to show significant differences and the data were cross-sectional, the results support both empirical and anecdotal data about the relationship between abstinence from smoking and increased participation in exercise. Gordon and Polen (1987) studied 1,061 men and women who participated in smoking cessation clinics at Kaiser Permanente medical facilities from 1980 to 1983. Men and women who had increased their exercise after program participation were more likely to be abstinent from smoking 7 to 12 months later. These studies suggest that increasing exercise may be part of a former smoker's efforts to remain abstinent, a direct consequence of cessation, or both. The study by Gordon and Polen (1987) lends support to the first hypothesis. The 1987 BRFSS allows a comparison among current smokers, never smokers, and former smokers on a range of health practices (Table 5). Two measures of physical activity were used. One asked a very general question about any physical activity in the past month, including nonaerobic activities, such as gardening. as well as major aerobic activities. The second identified sedentary lifestyle as the lowest category on A an ‘and a complex scale of life activities. On both measures. men and women who had quit smoking were more active than never smokers. who were in turn more active than current smokers. Among men, those who had been smoke-free for more than 5 years were significantly more active and less sedentary than new quitters, those who had been abstinent less than | year. This difference was not significant among women. Prospective investigations of changes in physical activity after smoking cessation have indicated either no change or an increase in activity (Chapter 10). An additional Prospective study focusing on exercise specifically. rather than weight changes, also found increased exercise among quitters. In a l-year study of a large worksite population, Orleans and associates (1983) found that 72 recent ex-smokers (mean abstinence, 7 months) significantly increased their self-rated levels of activity compared with 347 continuing smokers (p<0.01) and that the ex-smokers achieved significant increases (p<0.01) from a prequitting baseline in the frequency of activities involving moderate exertion, such as walking or climbing stairs. Gordon and Cleary (1986) analyzed data from the 1979-1980 National Survey of Personal Health Practices and Consequences and found a more limited positive relationship. Aerobic exercise in- creased for women who tried to quit smoking but was not related to successful quitting in the last year among women or to any change in smoking behavior among men. More studies are needed to clarify the effects of smoking abstinence on the level of physical activity. The relationship between increased physical activity and smoking abstinence may be a consequence of cessation, may reflect more successful quitting among smokers who have a higher level of prequitting physical activity. may be evidence that former smokers use exercise as a strategy to avoid smoking, or as a way to deal with the possible adverse effects of weight gain. or may be due to some combination of these possibilities. The cross-sectional nature of the data available do not permit a conclusion with regard to these alternatives. Dietary Practices Cross-sectional data from NHIS. BRFSS, and other studies present a mixed picture of the dietary practices of smokers, former smokers, and never smokers. Schoenborn and Benson (1988), reporting on the 1985 NHIS, found that current smokers are more likely to skip breakfast than never or former smokers (Table 3). This finding is consistent with the 1987 NHIS data showing that both former and never smokers are more likely than current smokers to eat no more than or no less than three meals a day (Schoenbom and Boyd 1989) (Table 4). As shown in Table 4, whether former smokers are more likely. less likely, or equally likely to eat three meals than are never smokers depends on gender and whether the day is a weekday or weekend day. Two NHIS Surveys present contradictory results on snacking. The age-adjusted 1985 study indi- cated that among women, former smokers are the most likely to snack, but that there was no significant difference among men (Table 3). Raw percentages in the 1987 NHIS data show that among men, former smokers avoid snacks more than either never or current smokers, but that among women, there is essentially no difference (Table 4). BRFSS data (Table 5) indicate that former smokers are the most likely group to be “trying to lose weight,” although no more likely than never smokers to be obese. 554 Similarly, the 1987 NHIS data show that former smokers of both sexes are the most likely to report that they have changed their diet for the sake of their health (Table 3). In these same NHIS data, not controlled for age, men who are former smokers are more obese than never smokers, although women who are former smokers and never smokers are equally likely to be obese. Among the 10,000 Israeli men in Goldbourt and Medalie’s 1975 study of Government employees, former smokers (duration of abstinence not noted) consumed fewer calories and were more likely to be on some sort of special diet for weight loss, diabetes, heart disease, hypertension, or ulcers. Former smokers surveyed for all three of these data sets may have initiated special diets or quit smoking following the diagnosis of illness. However, the Israeli data demonstrate that among those individuals who had experienced heart attacks or peptic ulcers, former smokers were more likely to report themselves compliant with their diets than current smokers (Goldbourt and Medalie 1975), Former smokers often report retrospectively that they increased food consumption when they quit smoking (Carmody et al. 1986). The first part of this Chapter and a review by Hughes, Higgins, and Hatsukami (1990) indicate that increased hunger and appetite are common smoking withdrawal reactions, often extending beyond the initial 4-week withdrawal period. However. most longitudinal studies of changes in dietary practices after quitting have examined only short-term changes (Chapter 10). The majority of these studies have found evidence for increased dietary intake, especially of sweet foods and simple carbohydrates, after quitting. Ina prospective study Orleans and coworkers (1983) found approximately a 6-pound weight gain at l-year followup over baseline for 72 former smokers who had been abstinent from cigarettes for an average of 7 months. These researchers also found evidence for significant (p<0.01) improvements in overall nutritional practices for former smokers. Better dietary behavior among former smokers when compared with current smokers may reflect changes made by former smokers in their efforts to remain abstinent, a response to their concerns regarding possible weight gain, or an overall desire to be healthy that is motivated by smoking cessation. Adequate data are not available to permit an assessment of these alternative hypotheses. Use of Other Substances Other Tobacco Products In data from the United Kingdom, the cessation of cigarette smoking has been linked to the increased use of other smoked tobacco products, including pipes and cigars, by men (Jarvis 1984). These researchers noted that many of the alleged gender differences in cigarette smoking cessation rates are due to the adoption of pipe and cigar use by men. Comparable analyses have been performed on data from the 1987 NHIS Cancer Epidemiology and Control Supplement (Schoenborn and Boyd 1989) (Volume Appen- dix). When former cigarette smokers who used any other forms of tobacco were reclassified as smokers, the difference in cessation rates between men and women decreased. Data trom the 1987 NHIS indicate that the overall prevalence of the use of smokeless tobacco products and cigars or pipes is low: the prevalence of use ranges from 3.0 to 5.2 percent for men and from 0 to 0.5 percent for women; former cigarette smokers are more likely than never cigarette smokers to be current smokers of pipes or cigars (Table 7). Because the prevalence of pipe or cigar smoking increases as a function of age, it is important to use age adjustments in future investigations of the relationship between cigarette cessation and pipe or cigar smoking. Alcohol Smokers are more likely than nonsmokers to drink alcohol and use other drugs (Istvan and Matarazzo 1984: US DHHS 1988). Cross-sectional data from the 1983 NHIS (Kovar and Poe 1985) show a strong association between smoking status and daily alcohol intake (Figures 3 and 4); former smokers tend to be heavier drinkers than are never smokers, and daily alcohol intake increases with heavier smoking (Kozlowski and Ferrence 1990). The drinking and smoking scales differ for men and women to compensate for the relative rarity among women of very heavy drinking and heavy smoking; at the same levels per day as men, fewer drinks per day are required for women than for men to be placed in the “heavy drinking” category. In the 1987 NHIS, alcohol consumption was divided into beer, wine, and liquor consumption. Published data report on the proportion of respondents consuming “5 or more drinks per week” and “3 or more drinks on days you drank” for each category. These data are generally consistent with the 1983 (Figures 3 and 4) and the 1985 age-adjusted NHIS data (Table 2) and with the age-, education-, and ethnicity-adjusted data from the 1987 BRFSS (Table 5) in showing lower alcohol consumption among former than among current smokers but higher than among never smokers. These data regarding alcohol consumption of former smokers are also consistent with data presented previously in this Chapter on the short-term effects of smoking abstinence on alcohol consumption (Hughes and Hatsukami 1986; Olbrisch and Oades-Souther 1986; Puddey et al. 1985). In the 1987 BRFSS survey, two measures of alcohol were used: the amount consumed and whether drinking and driving occurred together (Tables 5 and 6). Men and women who had quit smoking drank significantly more than never smokers and were sig- nificantly more likely to drink and drive. However, former smokers drank significantly less than current smokers and were significantly less likely to drink and drive. The intermediate position of former smokers seen in the 1987 BRFSS and the 1985 NHIS is paralleled in the 1987 NHIS by the percentage of both sexes who drink five beers or more per week, the percentage of women who drink three glasses or more of wine when they drink wine, and the percentage of men who drink three drinks or more when they drink liquor (Table 4). In the 1987 NHIS, male former smokers are significantly less likely than either comparison group to have three beers or more when they drink beer or three glasses or more of wine when they drink wine. Although a very small percentage of adults drink wine or liquor five times or more per week, men who are former smokers are more likely than current or never smokers to drink this often. Female former smokers are more likely than current or never smokers to drink wine 556 a TABLE 7.—Percent distribution of persons aged 18 and older by tobacco product and use status, according to gender and cigarette smoking status, United States, 1987 Both genders Men Women Tobacco product Never Former Current Never Former Current Never — Former Current and use status Total smokers smokers smokers Total smokers — smokers smokers Total smokers smokers — smokers Total 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Chewing tobacco : Never 93.8 96.7 89.8 92.0 87.6 92.5 83.5 85.3 993 99,3 99.2 99.2 Former 4.2 1.8 73 5.8 8.4 4.1 11.9 10.6 0.4 0.3 0.6 0.6 Current 2.0 1.5 2.9 2.2 4.0 3.4 46 4.1 0.3 0.4 0.2" 0.2" Snuff Never 95.9 93.3 94.3 94.8 92.3 94.6 90.9 90.5 99.2 99.0 99.2 99.4 Former 2.4 | 3.8 3.5 47 2.4 6.1 6.4 0.4 0.3 0.5 0.5 Current 1.7 1.6 i) 1.6 3.0 3.0 3.0 3.1 0.5 0.7 0.3" 0.1" Pipe Never 9b 97.4 79.3 89.7 81.5 93.9 85.9 80.5 99.7 (00.0 99.2 99.5 Former 7.3 L.7 18.5 79 [5.2 4.4 30.4 15.1 0.3 0.0" 0.8 0.4 Current 1.6 0.8 2.2 2.3 3.3 2.2 3.7 44 0.0" _" 0.0" 0.2" Cigars Never 91.1 97.0 80.5 89.7 81.7 92.5 87.8 80.8 99.6 99.8 99.4 99.2 Former 6.4 L8 16.3 6.2 {3.4 4.4 26.9 11.5 0.3 oO." 0.6 0.6 Current 2.5 1.2 3.2 4.1 5.2 3.1 5.3 TR or 0.0" 0.0" or “Data do not meet standard of reliability or precision (more than 30% relative standard error in numerator of percentige or rate). SOURCE: National Health Interview Survey (1987); Schoenborn and Boyd (1989). MALES 100 & PERCENTAGE o «CB | Never Former <1-1O/day 11-20/day 21-30/day 31-40/day >41/day SMOKING STATUS Wl Never RH <12hr ES Never Heavy V2 Ex-Hoavy WE ifday C) 2-3/day CF +/day El >7/day FIGURE 3.—Drinking relative to smoking status for men, 1983 NHIS (Kovar and Poe 1985) © NOTE: Samples for each category are. from never smoker to heaviest smoker, 1.397, 874, 295, 653. 263, 190,57. NHIS=National Health Interview Survey. SOURCE: Kozlowski and Ferrence (1990). five times or more per week; they are as likely as current smokers to drink liquor this often. However, this represents a very small proportion of women. Female former smokers are less likely than current smokers and no more likely than never smokers to drink three beers or more when they drink beer or to have three drinks or more when they drink liquor. These cross-sectional data are consistent with other cross-sectional data that demonstrate a relationship between alcohol use and smoking status (Istvan and Matarazzo 1984). However, the contribution of tobacco cessation to alcohol and drug use by individuals with alcohol and drug problems is unknown (Sobell et al. 1990). The majority of smokers consume approximately | pack per day, and most smokers do not have serious alcohol problems. The most significant effects might be seen in those few individuals who both smoke very heavily, more than 40 cigarettes per day, and use drugs or alcohol heavily (Kozlowski and Ferrence 1990). Bobo (1989) and Miller, Hedrik, and Taylor (1983) reported data that indicate that smoking cessation does not 558 100 8 & PERCENTAGE 8 oe Never Former = <1-10/day 11-20/day 21-30/day >3t/day SMOKING STATUS Never EA 2/day FIGURE 4.—Drinking relative to smoking status for women, 1983 NHIS (Kovar and Poe 1985) NOTE: Samples for each category are. from never smoker to heaviest smoker, 2.661, 789, 505, 786, 205. 176. NHIS=National Health Interview Survey. SOURCE: Kozlowski and Ferrence (1990). impair the course of treatment for alcohol problems and may be associated with better outcomes. Studies of Multiple Health Habits It is of interest to examine not only single behaviors, such as diet or exercise, in relation to smoking cessation, but also combinations of behaviors. Use of alcohol and other substances, use of other tobacco products, coffee consumption. physical activity, and diet have been the health behaviors studied most widely in conjunction with smoking and smoking cessation. Schoenborn and Benson (1988) reported on the following eight unhealthy behaviors surveyed in the 1985 NHIS: sleeping 6 hours or less, skipping breakfast, snacking daily. being less physically active than other persons of the same age, being sedentary in terms of leisure-time sports activities, being significantly overweight (10 percent or more based on the 1983 Metropolitan Life Insurance Company standards), drinking heavily aA rn xo (an average of two drinks or more/day), and having five drinks or more on 10 days or more. The authors used age-adjusted percentages to eliminate age as a confounding factor, With the exception of snacking and being overweight, current smokers engaged in unhealthy habits at significantly higher rates than never smokers (Table 2). Former smokers more closely resembled never smokers than current smokers. Fewer former smokers and never smokers than current smokers slept 6 hours or less, never ate breakfast, were less physically active, or were sedentary. However, former smokers tended to snack daily and be overweight in slightly higher percentages than current smokers, which is concordant with the previously noted findings regarding dietary practices and smoking abstinence. Marsden, Bray, and Herbold (1988) examined substance use and other health prac- tices in a large cross-sectional study of more than 17,000 military personnel. These researchers found the number of positive health practices inversely related to use of alcohol, illicit drugs, and tobacco. On the basis of a very preliminary retrospective study of 35 heart disease patients, Finnegan and Suler (1985) concluded that former smokers (mean duration of abstinence, unspecified) were more likely to maintain diet and exercise changes. Former smokers may have represented a particularly adherent subgroup of patients, but the authors postulated that success in maintaining diet and exercise changes may have been influenced by the psychological effects of attempting cessation. Maron and colleagues (1986) examined seatbelt use in a sample of high school students and found modest but significant negative effects of smoking, frequency of getting drunk, and illicit drug use (cocaine and marijuana), and positive effects of “heart-healthy nutrition” and physical activity on seatbelt use. In a study of 874 community college students, Castro and associates (1989) found that moderate-to- heavy smokers had exhibited more unhealthy behaviors than nonsmokers. As in some of the other cross-sectional studies reported here, these investigators did not distinguish former smokers from never smokers. Among males, former smokers interviewed as part of the 1987 BRFSS (which examined multiple health behaviors) were more likely than current smokers but less likely than never smokers to use seatbelts. However, among females, never smokers and former smokers were equally likely to use seatbelts, and both were significantly more likely to use seatbelts than current smokers (Table 3). Long-time quitters were more likely than new quitters (<1 year) to use their seatbelts, although this association was small and significant only for men who had been abstinent from smoking cigarettes for 5 years or more and for women abstinent for | to 2 years and for 5 years or more (Table 5). Among Multiple Risk Factor Intervention Trial (MRFIT) participants, Schoenen- berger (1982) found that smokers who had quit between baseline and a 3-year followup survey made successful changes across a number of dimensions. Former smokers were more likely to avoid gaining weight, to lower their serum cholesterol, and, if hyperten- sive, to lower their blood pressure. Supporting the conclusions of Schoenenberger (1982) regarding MRFIT participants, Tuomilehto and associates (1986) studied a random sample of 2,119 Finnish subjects at 2 points in time and found that both men and women who had quit smoking between baseline and the 5-year followup reduced 560 their fat intake, increased their physical activity, and made more attempts to reduce body weight than did current smokers. Baseline differences suggested that these quitters (duration of abstinence not specified) may have been more health conscious at the outset. Orleans and colleagues (1983) performed a prospective analysis of health behavior changes experienced by 72 employees quitting smoking between baseline and year one. As part of the “Live for Life” program they included baseline health behavior values, age, and sex as covariates. Their findings indicated an overall positive shift in healthy lifestyle with improvements in subjective health status, emotions, and well-being. New ex-smokers (average abstinence, 7 months) showed improvements over baseline in resting pulse, perceived personal control over preventable illness, knowledge of health risks, overall nutrition practices, regular moderate exercise. and seatbelt use. The only negative changes were body mass and weight changes associated with slightly less than a mean 6-pound weight gain, which took place along with an improvement in overall nutrition, and declines in job satisfaction measured by satisfaction with growth oppor- tunities and personal relationships on the job. Summary In the absence of more systematic longitudinal research, data from cross-sectional and longitudinal studies suggest that abstinence from smoking is related to improve- ments in other positive lifestyle behaviors contributing to overall good health. These behaviors may be used by the former smoker to prevent relapse (e.g.. exercise), to cope with adverse withdrawal symptoms (e.g., increased food intake as a response to increased appetite), or as part of a commitment to a healthier lifestyle. Exercise may help new quitters to remain abstinent and to avoid or minimize weight gain. The data from the MRFIT (Schoenenberger 1982) and other large data bases (Friedman et al. 1979) confirm that former smokers often take active steps to lower their disease risks. These studies should alleviate concerns that smoking cessation may result in unhealthy lifestyle shifts through unwanted symptom substitution. Given the strong association between smoking and other kinds of substance use, it is important to know if smoking cessation impairs the ability to stop other drug use. The limited evidence suggests that this is not the case (Bobo 1989; Miller, Hedrik, Taylor 1983). How multiple drug use and multiple drug withdrawal may interact with cigarette smoking and its cessation is an area requiring study. PARTICIPATION OF FORMER SMOKERS IN HEALTH-SCREENING PROGRAMS The literature presented earlier in this Chapter suggests that former smokers are more likely than current smokers to engage ina variety of health-enhancing behaviors, such as regular physical activity. Another area in which improvement may occur for individuals who stop smoking is participation in, or benefits from. health-screening programs. Participation in programs of health screening by those who are presumably healthy and asymptomatic is a health-enhancing or health-protective behavior, much 561 like wearing seatbelts or performing regular exercise. This participation is to be distinguished from health screening sought for diagnostic purposes. Calnan and Rutter (1986) cautioned, however, that there are important conceptual differences between behaviors such as not smoking or regular flossing and utilization of screening. In the first case. the emphasis is on the individual performing the recommended action. In the second, the individual makes a decision to use the service. but a professional performs the procedure. Smokers exhibit a decreased propensity to use preventive services in contrast to nonsmokers. The data suggest that former smokers occupy an intermediate position between current and never smokers in their seeking of health screening. Data from the large Johnson and Johnson “Live for Life’ worksite trial discussed earlier showed that current smokers were less willing than former or never smokers to complete health risk assessments (Shipley et al. 1988). A survey of randomly selected nonrespondents to the “Live for Life” health screening found that significantly more nonrespondents reported ever having smoked cigarettes and significantly more female nonrespondents currently smoked (Settergren et al. 1983). Additional support for the position that smokers may have lower response rates to health risk appraisals is provided by Seltzer, Bossé, and Garvey (1974), who found current smokers significantly less likely than never smokers to respond to a health questionnaire. One source of data about the health-screening practices of former smokers consists of results from a 1988 nationwide randomized survey of American Association of Retired Persons (AARP) members aged 50 and older to assess differences among current smokers, former smokers (abstinent for | week or longer with a mean duration of 19.3 years), and never smokers (Rimer et al. 1990). In addition to the usual quitting-related variables, respondents were asked about their use of health services, including routine cardiovascular and cancer screening. Questionnaires were received from 3,129 persons, a 54-percent response rate. In this older population for whom health screening is especially important. the never, current, and former smokers differed significantly on utilization of screening (Table 8). The results suggest that smoking may act as a deterrent to appropriate use of screening services for older smokers and possibly for younger smokers as well, or that there is a general unhealthy approach taken by smokers. That former smokers were more likely to avail themselves of preventive checks and services than current smokers suggests that former smokers may have a more preventive health orientation than current smokers, may participate in screening as an approach to maintain abstinence, or may be concerned about the effects of smoking on their health. As with exercise and other health promotion practices, the data are retrospective: therefore, it cannot be determined if the former smokers were always different from current smokers in their health screening habits or if they changed as a result of cessation. The results of the AARP survey suggest that with time former smokers may resemble never smokers in their use of screening services. Maintaining health was the primary reason for quitting among former smokers who responded to the AARP survey; perhaps the subset of smokers who quit was more health conscious at the outset. Or having quit. former smokers may be more willing to take a proactive stand to maintain their health. It is also possible that having admitted vulnerability to the harms of smoking and 562 TABLE 8.—Physician visits and medical tests within the past year among AARP members aged 50 and older, by smoking status Current Former Never smokers smokers smokers Overall (N=339) (N=1489) (N=1316) (N=3147) / 1% 471% 42% 100% p-value" Physician visit 77 88 86 86 <0.001 (21) Complete physical or 50 60 60 59 <0.001 checkup Blood pressure check 79 90 8&7 87 <0.001 Electrocardiogram 41 52 45 48 <0.001 Stool blood test 28 38 36 36 <0.001 Digital rectal 23 34 30 31 <0.001 examination Mammogram 24 41 36 36 <0.014 (women only) Pap smear (women only) 33 43 39 40 <0.006 NOTE: All rates are age adjusted. AARP=American Association of Retired Persons. “Current smokers vs. former or never smokers. SOURCE: Rimer et al. (1990). experiencing the benefits of quitting, former smokers are more amenable to adopting other health-enhancing behaviors. This would be consistent with the tenets of the Health Belief Model (Janz and Becker 1984) and with preliminary findings about the increased value of health expressed by self-defined former smokers (Tipton and Riebsame 1987). In two measures of disease prevention assessed in the 1987 BRFSS data, male former smokers appeared to be more health conscious than current smokers and at least as much as never smokers (Table 5). These individuals are significantly more likely than never smokers to have had their cholesterol tested in the past year: never smokers, in turn, are more likely than current smokers to have had this test. Although former smokers were slightly more likely than never smokers to have had a flu shot in the past month, this difference was not statistically significant. Both former smokers and never smokers were significantly more likely to have had the shot than were current smokers. Female former smokers were more likely to have had their cholesterol tested than were never smokers, but were not significantly different from current smokers. Women in all three smoking categories were similar, indicating no statistically significant differences in their probability of having received a flu shot in the past month. Among former smokers, length of time since cessation did not predict any differences in either of these behaviors among men or women. The 1987 NHIS data show higher rates of preventive care among former smokers than among never or current smokers (Table 4). Women who had quit were significant- ly more likely to report ever having had a digital rectal exam, a stool blood test, and a proctoscopic exam. Women who had stopped smoking were also significantly more likely to have had a Pap smear or a breast examination within the past year and to ever have had a mammogram. However, women did not differ by smoking status in their practice of monthly breast self-examination. These data did not control for age and may reflect the greater number of former smokers in the higher risk ages, in addition to the unavoidable problems inherent in cross-sectional data such as not being able to determine the order of smoking cessation and preventive care. A study of participation among 600 female members of a health maintenance organization showed that female smokers were less likely than former smokers or never smokers to complete a health risk assessment or to obtain mammograms (Rimer et al. 1988, 1989). When residents of a large retirement community were surveyed about their health habits, Chao and colleagues (1987) found differential use of several screening tests, including blood pressure, fecal occult blood tests, mammograms, and Pap tests among current smokers. former smokers, and never smokers, with former smokers having the highest rates of screening. Macrae and colleagues (1984) studied 581 individuals who completed health questionnaires before being offered fecal occult blood tests. These researchers found that whereas smokers were not less likely to decline the initial offer, they were significantly less likely to comply, that is, to follow through with the test. These same investigators suggested that smokers may have been more susceptible to interpersonal pressure publicly, but later succumbed to a strategy of defensive avoidance. Although Macrae and associates (1984) did not distinguish the screening behavior of never smokers and former smokers, other studies reported here suggest that these groups would have been similar. The suggestion that former smokers are more oriented to prevention and early detection is also consistent with Verbrugge’s (1982) conclusions that smokers have poorer health, increased risks due to smoking, and are more oriented to remedial as opposed to preventive health actions. As smokers move toward maintenance of nonsmoking. they appear to value their health more highly (Tipton and Riebsame 1987; Horwitz, Hindi-Alexander, Wagner 1985). This finding is consistent with the greater utilization of screening found among AARP former smokers (Rimer et al. 1990). These findings undoubtedly are affected by the relationship between socioeconomic status (SES) and preventive care utilization. That is, lower SES is associated with less use of preventive services (Dutton 1986). To the extent that they are represented dispropor- tionately among those of Jower SES, current smokers will be at risk for underuse of age-appropriate prevention and early detection services. The literature about the health screening practices of former smokers is suggestive but inconclusive. It appears that former smokers are more likely than current smokers. but perhaps less likely than never smokers. to seek regular cardiovascular and cancer screening. SUMMARY The data suggest that as the duration of abstinence lengthens, former smokers begin to resemble never smokers in their utilization of health screening and their participation in a variety of health-enhancing behaviors, such as physical activity. However, it is not clear if former smokers are different from current smokers at the outset, if the method of cessation affects these outcomes, or if the reason for quitting affects subsequent health practices. There is reason to believe that former smokers, especially those who quit while they are healthy, come to value their health more and take health-enhancing action as an extension of this valuing (Tipton and Riebsame 1987). These conclusions are consistent with the Health Belief Model (Janz and Becker 1984) and the Protection Motivation Theory (Prentice-Dunn and Rogers 1986). Longitudinal, prospective studies would make an important contribution to understanding these issues. Increased participation in screening and other health-enhancing behaviors also may result from enhanced self-esteem and an increased sense of self-control. Ockene and colleagues (1988) concluded that successful behavior change is likely to promote a perception of general self-efficacy. The perception of oneself as capable may general- ize to other areas of one’s life. Kronenfeld and associates (1988) stressed that it may be difficult for most people to change multiple habits simultaneously. Having gained a sense of mastery from stopping smoking, former smokers may attempt to improve other health practices. However, some studies suggest that former smokers seem to undertake a number of health-enhancing steps proximally, if not simultaneously (Schoenenberger 1982; Friedman et al. 1979; Gerace et al.. in press). For example, quitters in MRFIT (baseline smokers who were biochemically verified ex-smokers at the sixth annual visit) reported a greater decrease in their number of alcoholic drinks per day and sucrose consumption than nonquitters (Gerace et al.. in press). CONCLUSIONS 1. Short-term consequences of smoking cessation include anxiety, irritability, frustra- tion, anger, difficulty concentrating, increased appetite, and urges to smoke. With the possible exception of urges to smoke and increased appetite. these effects soon disappear. Smokers who abstain from smoking show short-term impairment of performance on a variety of simple attention tasks, which improves with nicotine administration. Memory, learning, and the performance of more complex tasks have not been clearly shown to be impaired. 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