FACTORS INFLUENCING NONDAILY SMOKING AND CESSSATION: A TRI-ETHNIC STUDY Taneisha S. Scheuermann Preventive Medicine and Public Health University of Kansas Medical Center
Funded by Pfizer Global Research Awards for Nicotine Dependence PI: Jasjit Ahluwalia, MD, MPH, MS, University of Minnesota Medical School
WHY THIS STUDY? Some day smokers (% of current smokers) 38.5 % for Latinos 30.5% for American Indians or Alaska Natives 25.6% for African Americans 23.6% for Asians 21.7 % for Non-Latino Whites Data from the National Health Interview Survey, 2010
HEALTH RISKS Lung cancer Dose-response relationship between cigarette smoke and lung cancer incidence, no established threshold Long-term nondaily smoking associated with increased risk of lung cancer mortality Cardiovascular disease Any cigarette smoke is harmful, immediate effects on cardiovascular health by several pathways
STUDY OVERVIEW Two phases Phase 1 Focus groups with nondaily smokers (4 24 days/30 days) (N = 58) Phase 2 Quantitative online survey with nondaily and daily smokers (N = 2,400 )
PHASE 1: METHODS Participant criteria: Nondaily smokers (4-24 days/30 days) Self-identify as African American, White, or Latino Smoked > one year Smoke at current rate > 6 months Be a current smoker (> 1 cig. In past 30 days) > 100 cigarettes lifetime > 25 years of age Not pregnant or nursing
PHASE 1: FOCUS GROUPS 6 Focus Groups (N = 52 participants) 3 groups with African Americans (n = 28) 3 groups with non-latino Whites (n = 24) Additional FG 1 group with Latinos Collected urine for NNAL and cotinine (n = 57)
QUANTITATIVE RESULTS Total AA White p Age 42.9 45.5 39.2.05 Female 44.2% 46.4% 41.7%.73 Married/Partnered 48.1% 64% 36%.16 CPD 3.8 3.2 4.3.41 Days Smoked/Past Month 13.5 13.5 13.5.96 Years as NDS 10.8 10.9 10.7.93 Former Daily 36.5% 21.1% 78.9% <.01 Menthol 57.7% 85.7% 25.0% <.01 TTFC < 30 min 17.3% 12.5% 21.4%.40
RESULTS CONT. Total AA White p Past Month Alcohol 6.6 6.2 7.1.68 Social Smoker 55.8% 46.4% 66.7%.14 Smoke Alone 25.0% 16.7% 32.1%.20 Motivation to Quit 6.9 8.0 5.8 <.05 Confidence to Quit 7.2 7.7 6.8.32 Intend to Quit < 30 days 13.5% 14.3% 12.5%.60 Quit Attempts (past yr) 11.3 17 7.10
SOCIAL ASPECTS OF SMOKING Social Smoking Smoking was described as a social activity but also seeing other people smoke was a trigger for smoking It's just something especially when someone else is around and they pull a cigarette out, I immediately go for mine I'm going to light one, too, to socialize. African American male
IDENTITY AS A SMOKER Yes, I am a smoker No, I am not a smoker If I smoke, then I'm a smoker. African American male I feel like if you smoke everyday, on a regular, then I think you would be considered a smoker. White female
SOCIAL ENVIRONMENT Some participants had people in their lives who did not know they smoked, some because they just didn t smoke around them, others because they deliberately hid their smoking. It s just that I m usually by myself most of the time, so most people don t know that I smoke. It s not that I m a closet smoker; they just don t usually see me. African American female I wouldn t smoke at work. I wouldn t let that be known at work because I think it would be not a good idea. I work in the health field so I wouldn t want people to look at me that way. White female
SOCIAL DISAPPROVAL Participants discussed social disapproval for their smoking and smoking in general. For some, this disapproval influenced them to smoke less, or not smoke at certain times. None of my relatives smoke, so they re always encouraging me to stop, but I don t smoke too much around them. When they do, they re always saying something about it, so I feel like I kind of have to hide it. African American male My children influence the not smoking every day or not smoking at home because they don t want me to. White female
ATTITUDES TOWARD SECONDHAND SMOKE Participants generally seemed to have an awareness of the dangers of second hand smoke and reported avoiding smoking around nonsmokers. I think only for myself it s a little bit different because I have a child, and for the fact that he doesn t like for me to smoke, so usually I ll either go outside the house or park the car and get out, just for the fact that I know he doesn t like it and people talk about secondhand smoke. African American female
HEALTH CONCERNS AND BELIEFS All participants were aware that smoking was harmful. Some personally knew people, including family members, that had developed and even died from smoking related illness. Many minimized the risks of smoking nondaily breathing the air outside you can get cancer, even if you are an occasional smoker I don t think anybody is exempt from developing any kind of sickness. White female
HEALTH CONCERNS AND BELIEFS Some reported shortness of breath and chest congestion. Two participants discussed having cancers and heart attacks in the past but did not link this directly to smoking.
HEALTH CONCERNS AND BELIEFS NDS as harm reduction Several participants discussed cutting down the amount they smoked as a way to reduce their health risks from smoking. Some gave concern about health risks from smoking as a reason they smoke nondaily. I don t smoke every day number one for the cancer risk. It s a killer.. I m definitely worried about the cancer. White male
PERCEPTIONS OF ADDICTION Nicotine Dependent Repeated failed attempts at cessation Experienced cravings and feeling on edge or irritable. none of us can seem to be able to quit. I don t know if just being an occasional smoker is really any better than being a full-time smoker because regardless, you go back to it... White Female
PERCEPTIONS OF ADDICTION Not nicotine dependent Participants expressed a sense of control over their smoking. Participants explained that they could take it or leave it and would not have to go out of their way to get a cigarette.
PERCEPTIONS OF ADDICTION Definitions of what it meant to be addicted generally involved smoking when it wasn t convenient and high frequency smoking (i.e., daily). There was a time I was absolutely addicted to cigarettes. The reason I don t think I am now is because I don t smoke as much... African American male
QUITTING ATTITUDES AND BELIEFS - Several participants reported being motivated to quit smoking and many described previous quit attempts. Other participants expressed that even though they know that smoking is bad for them, they are not actively ready to quit. Yeah, I keep trying to quit. I keep telling myself I do not need them, but there are moments when I give in to the temptation and part of it, you're rationalizing in your head. So I keep trying to quit but it's not effective. White female
QUITTING ATTITUDES AND BELIEFS Barriers to Quitting A few African American participants described situations that prompted smoking relapse including negative life events and emotions. A few White participants referenced social barriers such as other people around them smoking or being in environments where they usually smoke. I stopped for a few months, and then an event came up and I started back again. African American female To me it's definitely going out, being around friends that smoke also. That would make it really hard for me to just stop completely. White female
KEY POINTS Among NDS, smoking urges/cravings may be limited to specific situations, some exercise effortful control Social factors both help to keep people smoke (e.g., social smoking) but also help them to limit their smoking Nondaily smokers are aware of the harmful effects of smoking but may not believe that nondaily smoking carries serious risks NDS do report feeling addicted to cigarettes as well as difficulty remaining abstinent. NDS may be willing to use quit assistance but are concerned about side effects.
BIOMARKER RESULTS ( N = 57) Days smoked/ 30 days 13.0 (SD = 5.4) CPD on days smoked (cigarettes only) 3.3 (SD = 2.1) Median creatinine-normalized urinary cotinine ng/mg = 490.9ng/mg Median creatinine-normalized urinary NNAL ng/mg = 140.7 pg/mg
PHASE 2 OVERVIEW Phase 2 Online Panel Survey (N 2,400) Nondaily Light Moderate to Heavy Total African American 401 193 200 794 Latino 400 190 196 786 White 400 195 201 796 Total 1201 578 597 2376
DEFINITIONS Nondaily Smokers: smoked 4-24/30 days Daily Smokers: smoked 25-30/30 days Light smokers - <10 cpd Moderate to heavy smokers - >10 cpd
SMOKING CHARACTERISTICS NDS Light Moderate to Heavy Mean (SD) Days smoked/ 14.52 (5.91) 29.43 (1.46) 29.80 (0.88) <0.0001 past month CPD 5.40 (5.25) 7.41 (2.72) 20.60 (8.49) <0.0001 Total Cigarettes in a Month 81.93 (95.59) 219.02 (82.51) 614.15 (255.07) <0.0001 Years smoking 15.99 (12.31) 21.16 (13.21) 24.56 (12.83) <0.0001 Years smoking nondaily* Years smoking daily* 11.45(11.22) -- -- -- -- 19.14 (13.43) 23.03 (12.88) <0.0001 P
CONVERTED AND NATIVE NONDAILY SMOKERS Native never smoked daily for > 6 months Converted previously smoked daily > 6 months Converted Nondaily n = 904 Native Nondaily n = 297 p Mean (SD) Days smoked/past month 14.99 (5.85) 13.11 (5.91) <0.001 CPD on days smoked 5.78 (5.58) 4.25 (3.86) <0.001 Years smoking cigarettes 17.03 (12.69) 12.86 (10.49) <0.001 Years smoking nondaily, 11.92 (11.70) 10.01 (9.51) 0.005
SOCIAL SMOKING Social Smoking Smoke mainly with people Smoke mainly alone Smoke as often by yourself as with others Native Converted Light Moderate NDS NDS to Heavy p 43.1% 36.5% 14.2% 8.0% <0.0001 35.0% 40.5% 38.4% 29.3% 21.9% 23.0% 47.4% 62.6%
HARM REDUCTION Questions Do you currently set a limit for how many cigarettes you smoke a day to decrease your health risks from smoking? In the last year, have you changed to a different cigarette brand to decrease your health risks from smoking? Native NDS Converted NDS Light Moderate to Heavy p 47.1% 54.8% 49.8% 29.8% <.0001 15.5% 20.8% 14.9% 12.1% <.0001
NICOTINE DEPENDENCE Dependence Measures Smoked first cigarette within 30 minutes Native NDS Converted NDS Light Moderate Heavy % or Mean p 23.9% 43.0% 63.5% 87.4% <.0001 Self-rated addiction on a scale of 0-100. 29.5 (25.9) 44.5 (31.5) 65.2 (27.3) 83.4 (19.8) <.0001
QUITTING PLANS AND BEHAVIOR Quit Intention and Attempts Will quit in the next 6 months Will quit in the next 30 days 1 or more quit attempts in the past 12 months Number of quit attempts in the past 12 months Longest quit attempt in the past 12 months (days) Native NDS Converted NDS Light Moderate to Heavy 26.9% 29.9% 24.9% 22.9% 0.0195 12.8% 9.6% 6.1% 4.7% <.0001 45.8% 60.6% 42.7% 32.8% <.0001 8.7(13.6) 7.8 (12.6) 5.0 (6.8) 4.2 (8.3) <.0001 80.5 (76.9) 74.0 (70.6) 79.6 (68.7) 80.9 (70.8) 0.5896 P
PHYSICIAN ADVISE Tobacco use treatment provided to daily vs. nondaily smokers Tobacco use interventions In the last 12 months, did a doctor or other health professional ask if you smoked cigarettes? In the last 12 months, did a doctor or other health professional advise you to stop smoking cigarettes? In the last 12 months, did a doctor or other health professional give you assistance in quitting smoking? In the last 12 months did a doctor or other health professional arrange follow-up about quitting? Did you try to quit when your doctor or other health professional advised you to stop smoking Nondaily smokers are the referent group in the logistic regression Odds p Ratio 1.21 0.03 1.53 <.0001 1.20 0.06 1.00 0.99 0.85 0.10
CONCLUSIONS The majority of nondaily smokers are not social smokers Nondaily smoking is sustained long-term Nondaily smokers who were former daily (converted) exhibit important differences from native nondaily smokers (e.g., nicotine dependence, harm reduction). Nondaily smokers are less likely to be advised to quit by their physicians than daily smokers There is the potential to target smoking cessation messaging and intervention to specific characteristics of nondaily and daily smokers.