Original Article Journal of Addictions Nursing & Volume 24 & Number 2, 71Y81 & Copyright B 2013 International Nurses Society on Addictions

Racially Classified Social Group Differences in Cigarette Smoking, Nicotine Dependence, and Readiness to Quit Mary Kay Rayens, PhD m Ellen J. Hahn, PhD, RN, FAAN m Anita Fernander, PhD m Chizimuzo T. C. Okoli, PhD, MPH

Abstract The purpose was to determine racially classified social group differences in smoking, nicotine dependence, and readiness to quit between African American and Caucasian smokers. The cross-sectional study included 53 African American and 839 Caucasian smokers participating in a larger population-based cessation intervention study. Data were analyzed from the interview conducted before the intervention; half of the participants were in the treatment group, recruited from those who had joined a cessation contest, whereas control group participants were recruited using random-digit dialing and were not in the contest. African Americans began smoking later, smoked fewer cigarettes daily, reported lower nicotine dependence, and had greater readiness to quit smoking than Caucasians. Of those who had ever used an evidence-based method, African American smokers were more likely to only use evidence-based quit methods, whereas Caucasian smokers were more likely to mix evidence-based with ‘‘cold turkey.’’ Controlling for demographics and treatment group, racially classified social group was a predictor of readiness to quit smoking. Later, age of initiation, positive partner support, and using evidence-based quit methods also predicted greater readiness to quit. Keywords: disparities, racially classified social group, smoking, smoking cessation

Mary Kay Rayens, PhD, and Ellen J. Hahn, PhD, RN, FAAN, College of Nursing and College of Public Health, University of Kentucky, Lexington. Anita Fernander, PhD, College of Medicine, University of Kentucky, Lexington. Chizimuzo T. C. Okoli, PhD, MPH, College of Nursing, University of Kentucky, Lexington. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Mary Kay Rayens, PhD, College of Nursing, University of Kentucky, 543 CON, 751 Rose Street, Lexington, KY 40536-0232. E-mail: [email protected] DOI: 10.1097/JAN.0b013e31829293b0 Journal of Addictions Nursing

A

lthough there have been declines in national smoking prevalence in recent years, adult smoking continues to be high with 21.0% of African Americans and 21.6% of Caucasians reporting smoking (Centers for Disease Control and Prevention [CDC], 2011). These smoking rates are far above the ‘‘Healthy People 2020’’ target of 12% (U.S. Department of Health and Human Services, 2010). Cigarette use is responsible for an estimated 443,000 premature deaths and $193 billion in direct healthcare expenditures and productivity losses annually (CDC, 2008b). Although smoking prevalence among African Americans is nearly equal to that of Caucasians (CDC, 2009), African Americans experience an unequal burden of tobacco-related disease and mortality. Tobacco-caused cancers, cardiovascular disease, and cerebrovascular disease are higher among African Americans than Caucasians and other racially classified social groups (RCSGs; Huxley et al., 2012). In addition, disparities in secondhand smoke (SHS) exposure continue despite recent downward trends; nonsmoking African Americans have higher serum cotinine, a biomarker of exposure to nicotine, than nonsmoking Caucasians (Huxley et al., 2012). Quitting smoking is one of the tobacco-related disparities between African Americans and Caucasians. Although African Americans typically express more confidence in their ability to stop smoking and are more likely to try to quit than Caucasians, they are less likely to be successful in achieving long-term smoking abstinence (Cropsey et al., 2009; Fiore et al., 2008; Ludman et al., 2002; Watson et al., 2003). In the 1990Y2000 NHANES study of smoking cessation among U.S. adults aged 18Y64 years, only 14.6% of African Americans reported being former smokers, compared with 25.8% of Caucasians (King, Polednak, Bendel, Vilsaint, & Nahata, 2004). Consistent with this finding, a study of coronary artery risk development in young adults (CARDIA) revealed that smoking cessation rates among African Americans were lower than among Caucasians (African American women = 25.0%, Caucasian women = 35.1%; African American men = 19.2%, Caucasian men = 31.3%; Kiefe et al., 2001). African Americans have unique smoking patterns that may affect quit attempts and relapse. Compared with Caucasians, African Americans are generally light smokers (G15 cigarettes www.journalofaddictionsnursing.com

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per day; Okuyemi, Ahluwalia, Richter, Mayo, & Resnicow, 2001; Payne & Diefenbach, 2003; Trinidad, Perez-Stable, White, Emery, & Messer, 2011). They begin smoking at a later age (Ellickson, McGuigan, & Klein, 2001; Moon-Howard, 2003; Trinidad et al., 2011; White, Nagin, Replogle, & Stouthamer-Loeber, 2004) and smoke at lower rates (CDC, 2009) but often show higher levels of nicotine dependence (Ahijevych, Tyndale, Dhatt, Weed, & Browning, 2002; Benowitz, Bernert, Caraballo, Holiday, & Wang, 2009; Murray, Connett, Buist, Gerald, & Eichenhorn, 2001; Nollen et al., 2006; Payne & Diefenbach, 2003; U.S. Department of Health and Human Services, 2006). In a nationally representative sample of U.S. adults, African American smokers had substantially higher serum cotinine levels compared with Caucasian or Mexican Americans at all levels of self-reported smoking (Benowitz et al., 2009), suggesting that African Americans may exhibit higher nicotine uptake and absorption than other RCSGs. Another recent study found that African American smokers had significantly higher hair nicotine levels than Caucasians controlling for number of cigarettes smoked per day (Apelberg et al., 2012). This potential difference in nicotine metabolism may contribute to the fact that, although African Americans smoke fewer cigarettes, they have greater difficulty maintaining long-term abstinence. Furthermore, limited access to smoking cessation therapies and socioeconomic resources may partially explain disparities in smoking cessation among RCSGs (Fiore et al., 2008; Weden, Astone, & Bishai, 2006). Few recent studies have examined factors associated with readiness to quit among African American smokers. Age, number of prior quit attempts, beliefs about smoking and quitting, the desires of others, and number of doctor visits have been associated with readiness to quit among rural African American smokers (Schorling et al., 1997). Motivation to quit smoking was related to number of cigarettes smoked per day, number of harm reduction strategies, and intention to quit in an African American sample of urban smokers (Woods, Harris, Ahluwalia, Schmelzle, & Mayo, 2001). In a study of stage of change among smokers seeking cessation treatment, African Americans were more likely than Caucasians to be in the preparation stage of change (47% vs. 34%; Audrain et al., 1997). Stage of change is a method of categorizing smokers and recent quitters into one of five stages of readiness to quit including precontempation (no plan to quit), contemplation (plan to quit in the next 6 months), preparation (plan to quit in the next 30 days), action (succeeded in not smoking for up to 6 months); and maintenance (succeeded in not smoking for more than 6 months). Stage of change was associated with home smoking restrictions among African American urban smokers; the more ready the smoker was to quit, the more likely they were to restrict smoking at home (Okah et al., 2003). More recently, higher positive smoking expectancies have been shown to be related to lower intention to quit smoking among African Americans (Pulvers et al., 2004). It is important to examine RCSG differences in readiness to quit, smoking, and cessation behaviors so that appropriate cessation strategies can be tailored to meet the needs of dif72

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ferent populations. The purpose of the study was to determine differences in cigarette smoking and cessation indicators between African American and Caucasian smokers. Factors associated with readiness to quit were explored, including age of cigarette initiation, cigarettes smoked per day, nicotine dependence, SHS exposure at home and in vehicles, cessation attempts, and methods of quitting. METHODS Design The study was cross-sectional and included 892 cigarette smokers who participated in the baseline interview of a larger controlled trial of a population-based cessation intervention study (Hahn et al., 2005). The purpose of the larger study was to evaluate the impact of a Quit-and-Win Contest on tobacco quit rates at 3-, 6-, and 12-month postintervention by comparing quit rates among contest participants (i.e., those in the treatment group exposed to the intervention) to quit rates among tobacco users who were recruited at the same time but who were not enrolled in the contest. The intervention included a 30-day quit period to be eligible for large cash prizes, provider advice via weekly mailings, online and telephone quit assistance, media campaign, and community support. Smokers who joined the contest and participated in the study formed the treatment group, whereas the control group was composed of tobacco users recruited using random-digit dialing methods who were not contest participants and who lived in the same state but reported not having been exposed to the promotional media campaign including paid radio, television, and billboard advertising. Many of the treatment participants resided in an urban area (contest location), whereas many of those in the control group lived in rural areas. Data were collected via telephone interview. Sample Consistent with state population demographics, 90% of the sample was Caucasian. African Americans comprised more than half of the remaining participants, and each of the remaining RCSGs were represented by at most 11 participants. For this reason, RCSG comparisons were limited to the African American and Caucasian subgroups. Although 1,006 tobacco users participated in the baseline interview of the larger study (including 494 and 512 in treatment and control, respectively), 114 were omitted from this analysis either because their selfreported RCSG was neither African American nor Caucasian or because they used another form of tobacco but did not smoke cigarettes. Of the participants included in this analysis, 53 were African Americans and 839 were Caucasians. Consistent with the higher relative proportion of African Americans in urban areas of the state, there was a greater percentage of African Americans in the treatment group (centered in an urban area) than in the control group (recruited from outside the urban area). The study was approved by the university institutional review board, and all participants gave consent to participate. April/June 2013

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Measures The interview guide included items to assess RCSG, age, gender, education, marital status, and employment status. A binary variable indicated whether the participant was in the treatment or control group. Tobacco Use and Age of Initiation. The survey determined the form(s) of tobacco used by the participants with a yes/no question for each of cigarettes, cigars, pipes, and spit tobacco, using items from national surveys of adult tobacco use (CDC, 2004; Substance Abuse and Health Services Administration, 2002). Responses to these four items were combined to form an indicator variable for using multiple forms of tobacco (vs. cigarettes only). Frequency of cigarette smoking was assessed with, ‘‘During the last 30 days, how many cigarettes did you smoke on a typical day when you smoked cigarettes?’’ Response choices ranged from ‘‘less than 1’’ to ‘‘more than 40.’’ The age of initiation item was ‘‘How old were you when you smoked a whole cigarette for the first time?’’ Responses ranged from ‘‘8 years or younger’’ to ‘‘24 years or older.’’ Nicotine Dependence. The six-item Fagerstrom Test for Nicotine Dependence (FTND) measured nicotine dependence including frequency, urgency, and difficulty refraining from smoking (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991). Summary scores range from 0 to 10. The FTND is a valid and reliable measure of nicotine dependence (Heatherton et al., 1991). Item-level measurement bias is not observed when using the FTND with African American smokers (Johnson, Morgan-Lopez, Breslau, Hatsukami, & Bierut, 2008). Smoking at Home or in the Vehicle. Two items assessed family exposure to cigarette smoke (Okoli, Hall, Rayens, & Hahn, 2007). The first, ‘‘Which kind of tobacco smoke does your family come in contact with in your home?’’, determined home exposure; a similar question assessed exposure in the car or truck. Possible responses for both items included ‘‘cigarette smoke,’’ ‘‘cigar smoke,’’ ‘‘pipe smoke,’’ and ‘‘none.’’ Any participant who responded that their family came in contact with tobacco smoke was coded as positive for exposure in that location. Readiness to Quit Smoking. Stage of change was assessed using a five-item categorical scale (Etter & Perneger, 1999) to determine whether the tobacco user (a) ever intends to quit smoking or using tobacco (precontemplation), (b) is seriously considering quitting within the next 6 months (contemplation); (c) has firm plans to quit in the next 30 days (preparation), (d) has succeeded in not smoking or using tobacco for up to 6 months (action), and (e) has not smoked or used tobacco for more than 6 months (maintenance). Participants were identified in one of the stages. For example, if a participant answered ‘‘yes’’ to questions aYc and ‘‘no’’ to questions d and e, they were in the preparation stage. Because an inclusion criterion was that the participants were current smokers, the highest degree of readiness possible was preparation. Partner Support for Quitting Smoking. The Partner Interaction Questionnaire (Cohen, 1990) assessed partner support for quitting including how often their partner (spouse, romantic partner, friend, or relative) shows certain behaviors, with reJournal of Addictions Nursing

sponse choices ranging from never (0) to always (4). The participant identified their partner as the person who would follow their quitting progress most closely. Ten positive and ten negative items are scored separately to form the positive and negative subscales. An example of a positive item is ‘‘compliment you for not smoking or using tobacco,’’ whereas ‘‘comment on your lack of willpower’’ is a negative one. In a prior study, Cronbach’s alpha for the PIQ positive and negative subscales were 0.89 and 0.82, respectively (Cohen, 1990). In this sample, the reliabilities for the positive and negative subscales were 0.93 and 0.87. Quit Attempts and Methods Used for Quitting. Quit attempt status was determined by asking if the participant had ever tried to quit smoking cigarettes, with a yes/no response choice (CDC, 2004). For those who had tried to quit, additional questions determined methods used for quitting including ‘‘cold turkey,’’ individual or group counseling, nicotine gum, patch, inhaler or nasal spray, and medications (e.g., Zyban) based on the clinical practice guidelines (Fiore et al., 2000). Participants responded twice, once to indicate which method(s) they had ever used as well as which they had used on their most recent quit attempt. Responses were combined to form a quit method measure, with categories of cold turkey only, evidencebased (i.e., counseling, nicotine replacement [NRT], or other medications) only, or a combination of the two. A second variable was formed to indicate whether the method used on the most recent quit attempt was cold turkey only or evidence based. An additional binary variable was created to indicate whether the participant had ever used an evidence-based quit method, with those who had only used cold turkey or who had never tried to quit forming the reference group. Data Analysis Descriptive analyses were used for data summary, including means and standard deviations or frequency distributions, as appropriate. Differences between the African American and Caucasian groups were determined using the two-sample t test, MannYWhitney U test, or chi-square test of association. Predictors of the readiness to quit smoking cigarettes were determined using multinomial logistic regression. Demographic and personal characteristics included as regressors in the model were RCSG, age, gender, education, marital status, employment status, and the two indicators for exposure to cigarette smoking at home and in the vehicle. Other potential predictors included positive and negative partner support, age at first cigarette, cigarettes smoked per day, use of multiple forms of tobacco, nicotine dependence, and ever use of an evidence-based quit method. The study group indicator was included in the model as a control variable because it was assumed that those in the treatment group would be more ready to quit because they had joined the contest. The chi-square test of parallel lines was used to ascertain whether the proportional odds assumption for the ordinal logistic model was justified. The likelihood ratio test determined the significance of the model, and the deviance chi-square test assessed the model goodness-of-fit. Because the chi-square test www.journalofaddictionsnursing.com

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of parallel lines for the model assuming an ordinal outcome was significant (# 2 = 59.8, p G .001), the proportional odds hypothesis was rejected. Nominal logit modeling was used as an alternative because this regression strategy does not require proportional odds across the levels of the dependent variable. Because of the concern that multicollinearity could distort regression estimates, the variance inflation factors were assessed for the regression. Data analyses were performed using SAS (version 9.3; SAS Institute Inc., Cary, NC); an alpha level of .05 was used throughout.

RESULTS The average age was 40.1 years (SD = 13.2 years), with a range from 18 to 81 years. There was no difference in age between African Americans (M = 41.3, SD = 10.3) and Caucasians (M = 40.1, SD = 13.4; t = 0.8, p = .4). Most participants were women, Caucasians, unmarried, and employed and had at least some postsecondary education (Table 1). All were cigarette smokers, and most smoked cigarettes exclusively rather than also using other forms of tobacco. There were no RCSG differences on any demographic or personal factor. The majority reported family exposure to cigarette smoke at home and in the vehicle. Although there was no RCSG difference in home exposure, African Americans reported less family exposure to cigarette smoke in the car. There was a difference in partner support for quitting between the two RCSGs. Although African Americans rated negative partner support as significantly higher (M = 20.2, SD = 11.7) than did Caucasians (M = 13.8, SD = 10.4; t = 4.3, p G .0001), they also reported a higher level of positive partner support (M = 20.7, SD = 12.7) compared with Caucasians (M = 17.8, SD = 11.8). However, this latter difference was not significant (t = 1.7, p = .09). Compared with Caucasians, African Americans were older at age of initiation, smoked fewer cigarettes on a typical day, and had lower nicotine dependence scores (Table 2). There was a significant association between RCSG and readiness to quit smoking, with African Americans more ready to quit than Caucasians. In particular, 93% of African Americans were in the contemplation or preparation stages, compared with 74% of Caucasian smokers. Similarly, about two thirds of African Americans were in the treatment group compared with about half of Caucasians, and this difference was significant. More than four fifths of participants had tried to quit smoking at least once in the past, and the percentage of those who had attempted to quit did not differ by RCSG. Considering all prior quit attempts, about half of the participants in each RCSG had only ever used cold turkey as a method. Of those who had ever used an evidencebased quit method, African Americans were more likely to have used evidence-based methods solely compared with Caucasians who had tried both cold turkey and evidencebased quit strategies. Controlling for treatment group, the nominal multinomial model assessed whether demographic and personal 74

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characteristics, partner support, and tobacco use and cessation indicators predicted readiness to quit smoking. The likelihood ratio test showed that the model was a significant improvement over the null, intercept-only model (# 2 = 446.5, p G .001), and the deviance chi-square test indicated that the model fit the data well (# 2 = 1097.5, p 9 .9). Significant predictors in the nominal logit model were race (# 2 = 8.6, p = .01), marital status (# 2 = 6.9, p = .03), positive partner support (# 2 = 31.6, p G .001), age of cigarette initiation (# 2 = 6.0, p = .05), and ever having used an evidence-based quit method (# 2 = 28.3, p G .001). Variance inflation factors for this model were all less than two, indicating that associations among the predictors were unlikely to have distorted regression estimates. With precontemplation as the reference category, two models were estimated to determine which variables in the overall model predicted a higher stage of readiness (Table 3). African Americans were nearly six times more likely to be in contemplation compared with Caucasians. Married participants had nearly seven times the odds of being in contemplation compared with those who were divorced, separated, widowed, or single. Positive partner support was predictive of higher stage of readiness; for every 10-unit increase in positive support, the odds of being in contemplation increased by a factor of 1.78. Those who had initiated smoking later in life were less ready to quit: For every 1-unit increase in age of initiation category, the odds of being in contemplation decreased by a factor of 0.74. Those who had ever tried to quit by using an evidence-based strategy were more than twice as likely to be in contemplation compared with those who had not tried any of these methods. The control variable, a binary indicator for treatment group, was significant. For the model comparing preparation to the reference category of precontemplation, African Americans were nearly 2.5 times more likely than Caucasians to be in preparation, but this difference was not significant (p = .1). Marital status was significant; married participants were more than twice as likely to be in preparation compared with other participants. Positive partner support was predictive of being in preparation; for every 10-unit increase in positive support, the odds of being in preparation increased by a factor of 2.44. The link between age of initiation and being in preparation was not significant. Having tried at least one evidence-based cessation strategy in the past increased the odds of being in preparation by a factor of 4.55. The control variable (treatment group) was a significant predictor of readiness to quit.

DISCUSSION Consistent with the literature, African Americans in our study smoked their first cigarette later in life (Trinidad et al., 2011; White et al., 2004) and smoked fewer cigarettes per day (Okuyemi et al., 2001; Payne & Diefenbach, 2003) than Caucasians. One study revealed that most African April/June 2013

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TABLE 1

Demographic Characteristics, Forms of Tobacco Used, Cigarette Smoke at Home and in the Vehicle, and Treatment Group Status by Ethnic Group, With Comparisons Using Chi-Square Tests of Association (N = 892) African American, n (%)

Caucasian, n (%)

#2 (p value)

Male

16 (30.8)

292 (35.0)

0.4 (.5)

Female

36 (69.2)

542 (65.0)

eHigh school diploma

24 (45.3)

414 (49.3)

9High school diploma

29 (54.7)

425 (50.7)

Yes

21 (39.6)

424 (50.6)

No

32 (60.4)

414 (49.4)

Yes

39 (73.6)

561 (67.0)

No

14 (26.4)

277 (33.0)

Yes

53 (100.0)

839 (100.0)

No

0 (0.0)

0 (0.0)

Yes

5 (9.4)

76 (9.1)

No

48 (90.6)

763 (90.9)

Yes

1 (1.9)

8 (1.0)

No

52 (98.1)

830 (99.0)

0 (0.0)

30 (3.6)

Demographic Characteristic Gender

Education 0.3 (.6)

Married 2.4 (.1)

Employed for wages 1.0 (.3)

Current cigarette smoker V

Current cigar smoker G0.1 (.9)

Current tobacco pipe user 0.4 (.5)

Current spit tobacco user Yes No

53 (100.0)

2.0 (.2)

807 (96.4)

Use multiple forms of tobacco Yes

5 (9.4)

99 (11.8)

No

48 (90.6)

740 (88.2)

Yes

41 (77.4)

628 (74.9)

No

12 (22.6)

211 (25.1)

Yes

31 (58.5)

618 (73.7)

No

22 (41.5)

221 (26.3)

Treatment

35 (66.0)

417 (49.7)

Control

18 (34.0)

422 (50.3)

0.3 (.6)

Cigarette smoke at home 0.2 (.7)

Cigarette smoke in vehicle 5.8 (.02)

Intervention group

Americans report earlier age of initiation and those who start smoking early in life are more likely to quit smoking (Ellickson, Orlando, Tucker, & Klein, 2004). This is not conJournal of Addictions Nursing

5.3 (.02)

sistent with our finding that those who initiated smoking later in life were more ready to quit than those who started to smoke early in life. Assessing age of initiation may be a www.journalofaddictionsnursing.com

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75

TABLE 2

Age of Initiation and Current Cigarette Use, Readiness to Quit and Cessation Indicators by Ethnic Group, With Comparisons Based on the MannYWhitney U Test or the Chi-Square Test of Association (N = 892) African American, n = 53

Caucasian, n = 839

Test Statistic (p value)

2 (3.8)

38 (4.5)

U = 18.0 (G.0001)

Age of cigarette initiation 8 years or younger 9Y12 years

3 (5.6)

153 (18.3)

13Y16 years

18 (34.0)

403 (48.3)

17Y20 years

17 (32.1)

172 (20.6)

21Y23 years

9 (17.0)

35 (4.2)

24 years or older

4 (7.5)

34 (4.1)

G1

0 (0.0)

4 (0.5)

1Y5

6 (11.3)

57 (6.8)

Cigarettes per day

6Y10

18 (34.0)

98 (11.7)

11Y15

6 (11.3)

89 (10.6)

16Y20

15 (28.3)

263 (31.4)

21Y25

5 (9.4)

100 (12.0)

26Y30

1 (1.9)

84 (10.0)

31Y35

0 (0.0)

35 (4.2)

36Y40

0 (0.0)

61 (7.3)

940

2 (3.8)

46 (5.5)

0

1 (2.1)

1 (0.1)

1

3 (6.4)

8 (1.1)

2

6 (12.8)

69 (9.3)

3

4 (8.5)

82 (11.1)

4

9 (19.2)

107 (14.4)

5

11 (23.4)

135 (2.1)

6

10 (21.3)

158 (6.4)

7

1 (2.1)

101 (12.8)

8

1 (2.1)

59 (8.5)

9

1 (2.1)

21 (19.2)

4 (7.5)

219 (26.1)

Contemplation

26 (49.1)

285 (34.0)

Preparation

23 (43.4)

334 (39.9)

Yes

45 (84.9)

739 (88.1)

No

8 (15.1)

100 (11.9)

Cold turkey only

22 (50.0)

338 (46.8)

Evidence-based only

11 (25.0)

97 (13.4)

Cold turkey and evidence-based

11 (25.0)

287 (39.8)

U = 20.2 (G.0001)

Nicotine dependence U = 8.0 (.005)

Stage of readiness to quit smoking Precontemplation

# 2 = 10.3 (.006)

Have ever tried to quit smoking cigarettes? # 2 = 0.5 (.5)

Quit methods ever used # 2 = 6.3 (.04)

Continues 76

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TABLE 2

Age of Initiation and Current Cigarette Use, Readiness to Quit and Cessation Indicators by Ethnic Group, With Comparisons Based on the MannYWhitney U Test or the Chi-Square Test of Association (N = 892), Continued African American, n = 53

Caucasian, n = 839

Test Statistic (p value)

Cold turkey only

27 (61.4)

419 (60.3)

# 2 G .1 (.9)

Evidence-based method(s) only

17 (38.6)

276 (39.7)

Quit method(s) used on last attempt

critical component of determining readiness to quit among African Americans. Research has suggested that African Americans have higher levels of nicotine dependence (Murray et al., 2001; Nollen et al., 2006), but this finding is not uniform across studies. Consistent with other studies (Kandel & Chen, 2000; Kandel et al., 2005), African Americans in our study reported lower nicotine dependence than did Caucasians. The lack of consisTABLE 3

tency across studies may be because of the lack of similarity in assessing nicotine dependence. Some studies use biochemical assessments, such as cotinine levels, whereas others use selfreport measures of nicotine dependence, such as the FTND. No single method adequately assesses nicotine dependence because of its multifaceted nature of complex biological and psychological components. The FTND measure used in this study has been found to be more highly correlated with other

Multinomial Logistic Regression Model With Readiness Group as the Outcome With Significant Predictors Bolded (n = 718)

Predictor

Contemplation(PrecontemplationasReference)

Preparation (Precontemplation as Reference)

95% Confidence Interval for Odds Ratio

95% Confidence Interval for Odds Ratio

Odds Ratio

# 2 (p value)

Odds Ratio

# 2 (p value)

African American

5.97

1.45, 24.52

6.1 (.01)

3.32

0.73, 15.18

2.4 (.1)

Age

0.99

0.98, 1.01

0.5 (.5)

0.99

0.96, 1.01

1.7 (.2)

Female

0.71

0.41, 1.24

1.5 (.2)

0.61

0.33, 1.15

2.3 (.1)

eHigh school education

1.18

0.71, 1.97

0.4 (.5)

0.89

0.50, 1.58

0.2 (.7)

Married

1.78

1.08, 2.95

5.0 (.03)

2.10

1.18, 3.71

6.4 (.01)

Employed

0.86

0.51, 1.44

0.3 (.6)

0.71

0.39, 1.28

1.3 (.3)

Family exposure to cigarette smoke at home

0.64

0.29, 1.40

1.2 (.3)

0.68

0.29, 1.57

0.8 (.4)

Family exposure to cigarette smoke in the car

1.72

0.84, 3.51

2.2 (.1)

1.74

0.80, 3.77

1.9 (.2)

Positive partner support

1.06

1.03, 1.09

1.09

1.06, 1.13

Negative partner support

1.01

0.98, 1.04

0.2 (.7)

1.01

0.98, 1.04

0.3 (.6)

Age at first cigarette

0.74

0.58, 0.95

5.7 (.02)

0.80

0.61, 1.06

2.5 (.1)

Cigarettes per day

1.05

0.89, 1.23

0.3 (.6)

0.94

0.78, 1.13

0.5 (.5)

Multiple forms of tobacco

0.46

0.20, 1.09

3.1 (.08)

0.51

0.20, 1.32

1.9 (.2)

Nicotine dependence

1.01

0.85, 1.20

0.90

0.74, 1.09

1.2 (.3)

Ever used evidencebased method

2.05

1.20, 3.53

4.55

2.49, 8.30

Treatment group (control variable)

62.84

Journal of Addictions Nursing

14.79, 266.98

13.9 (G.001)

G0.1 (.9) 6.8 (.009) 31.5 (G.001)

189.88

44.08, 817.92

28.0 (G.001)

24.3 (G.001) 49.6 (G.001)

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measures of nicotine dependence (both self-report and biochemical measures) among heavy smokers versus light smokers (Okuyemi et al., 2007). The finding that African American participants smoked fewer cigarettes per day than Caucasians is likely the reason they reported lower nicotine dependence scores on the FTND. The fact that African Americans in our study did not report disproportionately high levels of SHS exposure could be another reason why their nicotine dependence scores were lower than Caucasian smokers. Disparities in cotinine levels among African Americans could have more to do with higher exposure to SHS reported by this RCSG (CDC, 2010; Pirkle, Bernert, Caudill, Sosnoff, & Pechacek, 2006). Despite the fact that African Americans typically report the highest home exposure to SHS among all RCSGs (CDC, 2008a), African Americans and Caucasians in our study did not differ on family exposure to SHS at home. In fact, this sample of African Americans was less likely than Caucasians to expose their families to SHS in vehicles. One explanation for this low exposure to SHS may be that African Americans were also more ready to quit smoking than Caucasians. The more ready the smoker is to quit, the more likely they are to restrict smoking at home (Borland et al., 2006; Okah et al., 2003). There is also evidence that restricting smoking at home and in the car facilitates quitting (Mills, Messer, Gilpin, & Pierce, 2009). African American smokers were more ready to quit than Caucasians, consistent with other studies (Audrain et al., 1997). Almost all African American smokers were at least considering quitting, and 4 of 10 were preparing to take action to quit smoking. Caution is warranted in interpreting these results given that a higher proportion of African American smokers were in the treatment group and African Americans made up only a small portion of the sample. However, controlling for study group, RCSG remained a predictor of readiness to quit, and African Americans were six times more likely to be in contemplation relative to Caucasians. McBride et al. (2001) found that two thirds of a low-income population of African American smokers were in the preparation stage, and most were light smokers. Consistent with our findings, Okuyemi et al. (2001) found that 40% of African Americans who were light smokers were in the preparation stage. Studies conducted among Caucasians have shown that light smokers are more likely than regular/heavy smokers to be at more advanced stages of readiness to quit (Hennrikus, Jeffery, & Lando, 1996; Owen, Kent, Wakefield, & Roberts, 1995). Not only were the African American smokers more ready to quit, but they also were more likely to use evidence-based quit methods; Caucasians used evidence-based methods and cold turkey. This finding is not consistent with evidence that African Americans are typically less likely to use tobacco treatment, have limited access to primary care providers, and are more likely to use cold turkey as a quit method (Fiore et al., 2008). Despite the fact that African Americans who are light smokers are more interested in quitting, they are asked about smoking less often by their physicians than those who are heavier smokers (Okuyemi et al., 2001). In a study of urban 78

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African American smokers, few reported using pharmacotherapies to help them quit; rather, they relied on nonmedicinal methods such as candy, gum, and/or prayer, or they reduced the number of cigarettes or switched brands (Woods et al., 2001). One focus group study reported that African American current and former smokers distrust physicians and have had negative experiences with them (Fu et al., 2007). Few had used pharmacotherapy or counseling to try to quit smoking, and they lacked knowledge about the benefits of cessation medications. Similarly, another study found that African Americans may not use NRT because they worry about the dose, delivery, and absorption of nicotine, concerned that NRT might increase nicotine dependence (Yerger, Wertz, McGruder, Froelicher, & Malone, 2008). The inconsistency between the literature and the current study on this issue may be explained by the relatively small number of African Americans or by the lack of socioeconomic disparity (including education and employment status) between African American and Caucasian smokers in this study. Further studies with a larger number of African American smokers are needed. African Americans in our study were more likely than Caucasians to use evidence-based quit methods only such as individual or group counseling, NRT, and prescription medications despite the fact that the two RCSGs were similar in socioeconomic status. Given that the use of evidence-based methods was a predictor of readiness to quit and African Americans in our study were more ready to quit than Caucasians, this finding may have more to do with readiness to quit than RCSG differences. Another predictor of readiness to quit was positive partner support. Despite the fact that positive partner support was associated with readiness to quit, a recent review of randomized controlled trials including a partner support component found that these interventions have not produced significant increases in quit rates (Park, Schultz, Tudiver, Campbell, & Becker, 2004). Further research is needed to develop and test the effectiveness of partner support interventions that are integrated into existing tobacco treatment services and tailored to targeted populations, including RCSGs. Several limitations affect interpretation of the results. The primary limitation is the inequity of sample sizes between the African American and Caucasian subsamples; the former comprised 6% of the combined sample. Given this was a secondary analysis of study data and not a planned comparison, it was impossible to estimate in advance the statistical power of the comparisons between these RCSGs (Hoenig & Heisey, 2001). Future studies would benefit from a more equitable distribution of participants between the RCSGs. Although differences between the RCSGs were detected in this study, the relatively small number of African American smokers may have made it difficult to detect other ethnic differences. Future research warrants including a larger sample size of African American smokers and smokers of other RCSGs. As with other clinical trials (Benowitz, 2002), the treatment group participants in this study were more highly April/June 2013

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motivated to quit than the average population of smokers, making it difficult to generalize the results to all smokers. The inclusion of the control group, which comprised half of the sample, partially mitigates this limitation given that those who participated as controls may have been more representative of typical smokers in the population. However, the control participants were primarily from rural communities. Given that rural dwellers are more likely than the general population to smoke cigarettes (Rayens & Zhang, 2007), the control group allowed for a more balanced sample with respect to smoking prevalence. In addition, treatment group status was included as a control variable in the regression to address this limitation statistically; this adjustment was particularly important in this study because African Americans were overrepresented in the treatment group. Another limitation is that we did not assess cigarette brand choice. The fact that nicotine dependence was lower in these relatively light smokers may be because of brand choice. African American smokers are typically more likely to smoke menthol cigarettes than other RCSGs (Giovino et al., 2004). Mentholated cigarettes can slow nicotine metabolism and decrease the number of cigarettes smoked per day (as has been observed among African Americans; Benowitz, Herrera, & Jacob, 2004). Although the FTND as a measure of nicotine dependence does not reflect measurement bias in the African American population (Johnson et al., 2008), time to first cigarette may have been a better alternative to assess dependence, particularly for menthol brand smokers and light smokers (Collins & Moolchan, 2006). However, time to first cigarette was not assessed in this study. Finally, the cross-sectional study design did not allow assessment of change in readiness to quit or successful cessation over time. Although these data were from a larger, longitudinal study, the attrition of African Americans over time precluded longitudinal analysis of readiness and quit outcomes. CONCLUSIONS African American smokers were more likely to start smoking later in life, smoked fewer cigarettes per day, reported less nicotine dependence and lower family exposure to SHS, and were more ready to quit than their Caucasian counterparts. African American smokers in this sample were more likely than Caucasians to use evidence-based quit methods only, including medications and counseling. The fact that this sample of African Americans was more ready to quit smoking than Caucasians might be one explanation why they reported lower family exposure to SHS and more frequent use of evidencebased quit methods. In addition to RCSG, positive partner support, marital status, later age of initiation, and use of evidence-based quit methods were associated with readiness to quit. Further studies are needed to replicate this finding, particularly because the percentage of African Americans in this sample was limited. Nurses in all settings need to ensure access to evidence-based tobacco treatment services (Fiore et al., 2008) and reduce exposure to SHS in working with all RCSGs. Although culturally specific interventions have been shown to Journal of Addictions Nursing

be effective, it is important for nurses to consider individual differences in providing culturally specific tobacco treatment with both African Americans and Caucasians. Assessing age of initiation is a critical component of screening for tobacco treatment services especially with African Americans. Furthermore, nursing education programs need to incorporate evidence-based tobacco treatment principles into undergraduate and graduate curricula (Butler et al., 2009). Making effective tobacco dependence treatment modalities widely available and affordable to smokers of all RCSGs and in all healthcare settings will reduce the disease and economic burden associated with tobacco use. Acknowledgment: This study was funded by the American

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