Smokers with financial stress are more likely to want to quit but less likely to try or succeed: findings from the International Tobacco Control (ITC) Four Country Survey

Financial strain and cognitive-based smoking processes: The explanatory role of depressive symptoms among adult daily smokers

Little work has focused on the underlying mechanisms that may link financial strain and smoking processes. The current study tested the hypothesis that financial strain would exert an indirect effect on cognitive-based smoking processes via depressive symptoms. Three clinically significant dependent variables linked to the maintenance of smoking were evaluated: negative affect reduction motives, negative mood abstinence expectancies, and perceived barriers for quitting. Participants included 102 adult daily smokers (M_age=33.0years, SD=13.60; 35.3% female) recruited from the community to participate in a self-guided (unaided; no psychological or pharmacological intervention) smoking cessation study. Results indicated that depressive symptoms explain, in part, the relation between financial strain and smoking motives for negative affect reduction, negative mood abstinence expectancies, and perceived barriers for quitting. Results indicate that smoking interventions for individuals with high levels of financial strain may potentially benefit from the addition of therapeutic tactics aimed at reducing depression.

Financial Stress and Smoking within a Large Sample of Socially Disadvantaged Australians

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

Smoking Patterns and Smoking Cessation Willingness-A Study among Beneficiaries of Government Welfare Assistance in Poland

This study examines the prevalence and tobacco use patterns among adult social assistance beneficiaries and their interest in quitting. The results are based on data collected in a cross-sectional survey conducted among adults in the Piotrkowski district. A sample of 3636 social assistance beneficiaries produced a total of 1817 respondents who completed face-to-face questionnaires. Overall, 37.1% of the respondents, including 52.8% men and 29.6% women, were current smokers. Over one third of the smokers reported their willingness to quit. In the study population, several characteristics were significantly associated with the current daily smoking: male gender, low educational attainment, unemployment or temporary employment, lack of awareness of smoking-associated health risks, use of e-cigarettes, and exposure to environmental tobacco smoke (ETS). The intention to quit smoking among the daily smokers was positively correlated with their awareness of smoking-associated health risks, lack of previous quit attempts, and low exposure to ETS. Smoking prevalence among social assistance recipients tends to be higher than in the general population, but more than half of the smokers are willing to quit. There is an urgency to develop policies tailored to the needs of these disadvantaged population groups.

An Ecological Momentary Intervention for Smoking Cessation: Evaluation of Feasibility and Effectiveness

BACKGROUND

Despite substantial public health progress in reducing the prevalence of smoking in the United States overall, smoking among socioeconomically disadvantaged adults remains high.

OBJECTIVE

To determine the feasibility and preliminary effectiveness of a novel smartphone-based smoking cessation app designed for socioeconomically disadvantaged smokers.

METHODS

Participants were recruited from a safety-net hospital smoking cessation clinic in Dallas, Texas, and were followed for 13 weeks. All participants received standard smoking cessation clinic care (ie, group counseling and cessation pharmacotherapy) and a smartphone with a novel smoking cessation app (ie, Smart-T). The Smart-T app prompted 5 daily ecological momentary assessments (EMAs) for 3 weeks (ie, 1 week before cessation and 2 weeks after cessation). During the precessation period, EMAs were followed by messages that focused on planning and preparing for the quit attempt. During the postcessation period, participant responses to EMAs drove an algorithm that tailored messages to the current level of smoking lapse risk and currently present lapse triggers (eg, urge to smoke, stress). Smart-T offered additional intervention features on demand (eg, one-click access to the tobacco cessation quitline; "Quit Tips" on coping with urges to smoke, mood, and stress).

RESULTS

Participants (N=59) were 52.0 (SD 7.0) years old, 54% (32/59) female, and 53% (31/59) African American, and 70% (40/57) had annual household income less than US $16,000. Participants smoked 20.3 (SD 11.6) cigarettes per day and had been smoking for 31.6 (SD 10.9) years. Twelve weeks after the scheduled quit date, 20% (12/59) of all participants were biochemically confirmed abstinent. Participants responded to 87% of all prompted EMAs and received approximately 102 treatment messages over the 3-week EMA period. Most participants (83%, 49/59) used the on-demand app features. Individuals with greater nicotine dependence and minority race used the Quit Tips feature more than their counterparts. Greater use of the Quit Tips feature was linked to nonabstinence at the 2 (P=.02), 4 (P<.01), and 12 (P=.03) week follow-up visits. Most participants reported that they actually used or implemented the tailored app-generated messages and suggestions (83%, 49/59); the app-generated messages were helpful (97%, 57/59); they would like to use the app in the future if they were to lapse (97%, 57/59); and they would like to refer friends who smoke to use the Smart-T app (85%, 50/59). A minority of participants (15%, 9/59) reported that the number of daily assessments (ie, 5) was "too high."

CONCLUSIONS

This novel just-in-time adaptive intervention delivered an intensive intervention (ie, 102 messages over a 3-week period), was well-liked, and was perceived as helpful and useful by socioeconomically disadvantaged adults who were seeking smoking cessation treatment. Smartphone apps may be used to increase treatment exposure and may ultimately reduce tobacco-related health disparities among socioeconomically disadvantaged adults.

A qualitative analysis of low income smokers' responses to tobacco excise tax increases

BACKGROUND

While increasing the excise tax applied to tobacco products reduces consumption and smoking prevalence, it may also cause hardship among smokers who do not quit. We explored how smokers living on a low income respond to increasing tobacco excise taxes.

METHODS

Using a social justice perspective, we explored the increasing costs of tobacco with a sample of 27 adult smokers who live below the poverty line (i.e., with an income less than 60% of the median New Zealand income). Face-to-face interviews were conducted in Dunedin, New Zealand, a city with marked income differences, and were undertaken shortly after a further tobacco excise tax increase. The interview guide explored participants' smoking practices, their perceptions of excise tax as a strategy to reduce smoking prevalence, and the strategies they used to manage their tobacco needs.

RESULTS

We identified three key themes: depriving the poor; tobacco as a precious commodity, and desperation. While many participants described smoking as a pleasure or coping mechanism, they also saw it as a burden that they struggled to manage. Despite trying to quit, most had failed to become smokefree and felt victimised by a punitive policy system that coerced change without supporting it. They managed financial pressure by reducing their tobacco consumption but also used increasingly desperate measures, including recycling waste tobacco; participants reported feeling demeaned by measures they saw as their only option.

CONCLUSION

Providing intensive cessation support for lower income smokers could avoid further alienating a group already experiencing considerable disadvantage.

A Smoke-Free Community Housing Policy: Changes in Reported Smoking Behaviour-Findings from Waterloo Region, Canada

In 2010, Waterloo Region Housing (Canada) enacted a smoke-free (SF) housing policy that made all new leases in their community-housing portfolio (2722 units) 100 % SF. Existing lease holders were 'grandfathered'-meaning tenants could still smoke in their homes. A survey to measure support for the policy and how the policy had impacted smoking behaviour was delivered to all 2722 households in the Waterloo Region Housing portfolio in 2010 (pre-policy), 2011 and 2013 (post-policy). The proportion of households that completed the survey was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Support for the SF housing policy was 72 % pre-enactment (2010), and increased to 78 % in 2011 and 79 % in 2013; however, most smokers do not support the policy. In 2010, prior to the SF policy, 65 % of tenants who smoke reported someone smoked inside their home; in 2013 this was reduced to approximately half of smokers (52 %). In 2013, 44 % of smokers reported smoking outside more often than before the SF policy was enacted, almost half of tenants with a smoke-free lease (46 %) and more than a third of tenants who have a grandfathered lease (34 %) reported they smoke less since the smoke-free policy. There has been no significant change in the proportion of respondents (>50 %) who reported being exposed to second-hand smoke in their home. This SF housing policy is associated with increased reported outdoor smoking and reduced smoking. Smoke-free policies may support smokers interested in quitting.

Point-of-sale cigarette marketing and smoking-induced deprivation in smokers: results from a population-based survey

BACKGROUND

Strict restrictions on outdoor cigarette marketing have resulted in increasing concentration of cigarette marketing at the point-of-sale (POS). The association between POS cigarette marketing and smoking-induced deprivation (SID) has never been studied. The aim of this study was to examine this association and how it is mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes.

METHODS

Data from a telephone survey of 939 smokers were collected in Omaha, Nebraska. POS cigarette marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions such as cigarette price discounts within their respective neighborhoods. SID was measured with the following question: "In the last six months, has there been a time when the money you spent on cigarettes resulted in not having enough money for household essentials such as food? [yes/no]" We used structural equation modeling to examine the study aim.

RESULTS

There was overwhelming evidence for an association between higher levels of POS cigarette marketing and a higher probability of SID (p < 0.001). This association was partly mediated by cravings to smoke, urges to buy cigarettes, and unplanned purchases of cigarettes during a visit to a neighborhood store (p < 0.001).

CONCLUSION

Given that POS cigarette marketing is associated with a higher probability of experiencing SID, policies that ban POS cigarette marketing might help some smokers afford essentials household items such as food more easily and thus have better standards of living.

A clinical trial to examine disparities in quitting between African-American and White adult smokers: Design, accrual, and baseline characteristics

BACKGROUND

African-Americans smoke fewer cigarettes per day than Whites but experience greater smoking attributable morbidity and mortality. African-American-White differences may also exist in cessation but rigorously designed studies have not been conducted to empirically answer this question.

METHODS/DESIGN

Quit2Live is, to our knowledge, the first head-to-head trial designed with the primary aim of examining African-American-White disparities in quitting smoking. Secondary aims are to identify mechanisms that mediate and/or moderate the relationship between race and quitting. The study is ongoing. Study aims are accomplished through a 5-year prospective cohort intervention study designed to recruit equal numbers of African-Americans (n=224) and Whites (n=224) stratified on age (<40, ≥40) and gender, key factors known to impact cessation, and all within a restricted income range (≤400% federal poverty level). All participants will receive 12 weeks of varenicline in combination with smoking cessation counseling. The primary outcome is cotinine-verified 7-day point prevalence abstinence from smoking at week 26. Secondary outcomes are cotinine-verified 7-day point prevalence abstinence from smoking at weeks 4 and 12.

DISCUSSION

Findings from Quit2Live will not only address if African-American-White disparities in quitting smoking exist but, more importantly, will examine mechanisms underlying the difference. Attention to proximal, modifiable mechanisms (e.g., adherence, response to treatment, depression, stress) maximizes Quit2Live's potential to inform practice. Findings will provide an empirically-derived approach that will guide researchers and clinicians in identifying specific factors to address to improve cessation outcomes and reduce tobacco-related morbidity and mortality in African-American and White smokers.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT01836276.

The Association of Exposure to Point-of-Sale Tobacco Marketing with Quit Attempt and Quit Success: Results from a Prospective Study of Smokers in the United States

The aim was to assess the association of exposure to point-of-sale (POS) tobacco marketing with quit attempt and quit success in a prospective study of smokers in the United States. Data were collected via telephone-interview on exposure to POS tobacco marketing, sociodemographic and smoking-related variables from 999 smokers in Omaha, Nebraska, in the United States. Exposure to POS tobacco marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions in their respective neighborhoods stores. These three variables were combined into a scale of exposure to POS tobacco marketing. About 68% of the respondents participated in a six-month follow-up phone interview and provided data on quit attempts and smoking cessation. At the six-month follow-up, 39.9% of respondents reported to have made a quit attempt, and 21.8% of those who made a quit attempt succeeded in quitting. Exposure to POS marketing at baseline was not associated with the probability of having made a quit attempt as reported at the six-month follow-up (p = 0.129). However, higher exposure to POS marketing was associated with a lower probability of quit success among smokers who reported to have attempted to quit smoking at six-month follow-up (p = 0.006). Exposure to POS tobacco marketing is associated with lower chances of successfully quitting smoking. Policies that reduce the amount of exposure to POS marketing might result in higher smoking cessation rates.

What Are the Major Determinants in the Success of Smoking Cessation: Results from the Health Examinees Study

Understanding mechanisms underlying smoking-related factors should be prioritized in establishing smoking prevention and cessation policy. The aim of this study was to identify factors significantly associated with smoking initiation and/or smoking cessation as well as the most important determinants of successful smoking cessation in a developed non-Western setting. Based on multiple logistic regression models, the odds ratios (ORs) for smoking initiation and cessation were estimated among males (N = 24,490) who had participated in the Health Examinees (HEXA) study. The Cox proportional hazards regression model was used to assess the association between selected predictors of smoking cessation and the likelihood of reaching this goal. Finally, Kaplan–Meier curves were constructed to illustrate the distribution of time from age at smoking initiation to age at smoking cessation. We found that the ORs for successfully quitting smoking increased with age, married status, educational achievement, having a non-manual job, drinking cessation and disease morbidity. Those exposed to secondhand smoking showed less likelihood of quitting smoking. A continual decrease in the ORs for successfully quitting smoking was observed according to increased smoking duration, smoking dose per day and lifetime tobacco exposure (p_trend <0.001). Among the selected predictors, lifetime tobacco exposure, educational attainment, alcohol drinking status and birth cohort were the major determinants in the success of smoking cessation. Our findings suggest that lifetime tobacco exposure, educational attainment, alcohol drinking status and birth cohort can determine success in smoking cessation. Public interventions promoting a smoke-free environment are needed to reinforce discouraging the initiation of, reducing, and quitting cigarette smoking.

Perceived stress and smoking-related behaviors and symptomatology in male and female smokers

INTRODUCTION

Stress has been found to be a significant risk factor for cigarette smoking. Stress affects males and females differently, as does the use of smoking for stress reduction. Few studies have examined gender differences with the interrelation of perceived stress and smoking behaviors and nicotine related symptomatology. Our study investigates this association, as well as the influence of sociodemographic variables.

METHODS

This is a retrospective analysis of 62 smokers (41 males, 21 females) enrolled in a smoking cessation study. At the screening visit sociodemographic information, smoking behaviors and survey measures were completed. These included the Perceived Stress Scale (PSS), Minnesota Nicotine Withdrawal Scale (MNWS), and others. Analyses were conducted using multiple linear regression models.

RESULTS

PSS score was found to have a negative association with number of cigarettes smoked in males (slope -0.29±0.08; p=0.0009) and females (slope -0.20±0.18; p=0.26) with no difference in effect between genders (p=0.64). Linear regression of MNWS on PSS revealed a positive association for both males (slope 0.41±0.068; p<0.0001) and females (slope 0.73±0.14; p<0.0001). There was a significant difference in effect between genders (p=0.04).

CONCLUSIONS

A strong positive association was observed between perceived stress and nicotine withdrawal symptomatology in smokers of both sexes, with a larger effect seen in women. These findings emphasize the importance of stress reduction in smokers, which may lead to fewer withdrawal symptoms and more effective smoking cessation.

Tobacco use among low-income housing residents: does hardship motivate quit attempts?

PURPOSE

The purpose of this study was to examine material hardship among smokers to determine whether such hardship was positively associated with current attempts to quit tobacco use.

METHODS

We analyzed cross-sectional data from the Health in Common (HIC) study, an observational study to investigate social and physical determinants of cancer risk-related behaviors among residents of low-income housing in three cities in the Boston metropolitan area. In this study, three indicators of hardship were used: food hardship, financial hardship, and material hardship (food and financial hardship combined). Logistic regression models were used to obtain the odds of currently trying to quit among current smokers in the HIC (n = 170) across hardship types experienced, adjusting for sociodemographic and psychosocial factors.

RESULTS

Fully adjusted models revealed no statistically significant association between trying to quit tobacco use and indicators of material hardship: food hardship and financial hardship present (OR 1.33 (0.42-4.2); food hardship and no financial hardship OR 3.83 (0.97-15.13); and financial hardship but no food hardship OR 0.5 (0.1-2.39).

CONCLUSIONS

These findings suggest that even in the presence of material hardship, low-income housing resident tobacco users are not more likely to quit tobacco use; therefore, cessation efforts focused on the financial benefits of quitting may be insufficient to motivate quit attempts among low-income smokers.

The EARN-Health Trial: protocol for a randomised controlled trial to identify health effects of a financial savings programme among low-income US adults

INTRODUCTION

A theory within the social epidemiology field is that financial stress related to having inadequate financial savings may contribute to psychological stress, poor mental health and poor health-related behaviours among low-income US adults. Our objective is to test whether an intervention that encourages financial savings among low-income US adults improves health behaviours and mental health.

METHODS AND ANALYSIS

A parallel group two-arm controlled superiority trial will be performed in which 700 participants will be randomised to the intervention or a wait list. The intervention arm will be provided an online Individual Development Account (IDA) for 6 months, during which participants receive a $5 incentive (£3.2, €4.5) for every month they save $20 in their account (£12.8, €18), and an additional $5 if they save $20 for two consecutive months. Both groups will be provided links to standard online financial counselling materials. Online surveys in months 0 (prior to randomisation), 6 and 12 (6 months postintervention) will assess self-reported health behaviours and mental health among participants in both arms. The surveys items were tested previously in the US Centers for Disease Control and Prevention national health interviews and related health studies, including self-reported overall health, health-related quality of life, alcohol and tobacco use, depression symptoms, financial stress, optimism and locus of control, and spending and savings behaviours. Trial data will be analysed on an intent-to-treat basis.

ETHICS AND DISSEMINATION

This protocol was approved by the Institutional Review Board of Stanford University (Protocol ID: 30641). The findings of the trial will be disseminated through peer-reviewed publication.

TRIAL REGISTRATION NUMBER

Identifier NCT02185612; Pre-results.

'Cigarettes are priority': a qualitative study of how Australian socioeconomically disadvantaged smokers respond to rising cigarette prices

Despite substantial modelling research assessing the impact of cigarette taxes on smoking rates across income groups, few studies have examined the broader financial effects and unintended consequences on very low-income smokers. This study explored how socioeconomically disadvantaged smokers in a high-income country manage smoking costs on limited budgets. Semi-structured face-to-face interviews were conducted with 20 smokers recruited from a welfare organization in NSW, Australia. Participants discussed perceived impact of tobacco costs on their essential household expenditure, smoking behaviour and quit cognitions. Interviews were audio-taped, transcribed verbatim and analysed using thematic framework analysis. Instances of smoking-induced deprivation and financial stress, such as going without meals, substituting food choices and paying bills late in order to purchase cigarettes were reported as routine experiences. Price-minimization strategies and sharing tobacco resources within social networks helped to maintain smoking. Participants reported tobacco price increases were good for preventing uptake, and that larger price rises and subsidized cessation aids were needed to help them quit. Socioeconomically disadvantaged smokers engage in behaviours that exacerbate deprivation to maintain smoking, despite the consequences. These data do not suggest a need to avoid tobacco taxation, rather a need to consider how better to assist socioeconomically disadvantaged smokers who struggle to quit.

Financial strain and smoking cessation among men and women within a self-guided quit attempt

INTRODUCTION

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt.

METHODS

Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time.

RESULTS

Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI=.80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI=.91-1.21, observations=92; p=.48).

CONCLUSIONS

Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest that financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation.

Social Inequality in Cigarette Consumption, Cigarette Dependence, and Intention to Quit among Norwegian Smokers

BACKGROUND

The study aim was to examine the influence of education and income on multiple measures of risk of smoking continuation.

METHODS

Three logistic regression models were run on cigarette consumption, dependence, and intention to quit based on nationally representative samples (2007-2012) of approximately 1 200 current smokers aged 30-66 years in Norway.

RESULTS

The relative risk ratio for current versus never smokers was RRR 5.37, 95% CI [4.26-6.77] among individuals with low educational level versus high and RRR 1.53, 95% CI [1.14-2.06] in the low-income group versus high (adjusted model). Low educational level was associated with high cigarette consumption, high cigarette dependence, and no intention to quit. The difference in predicted probability for having high cigarette consumption, high cigarette dependence, and no intention to quit were in the range of 10-20 percentage points between smokers with low versus those with high educational level. A significant difference between low- and high-income levels was observed for intention to quit. The effect of education on high consumption and dependence was mainly found in smokers with high income.

CONCLUSION

Increased effort to combat social differences in smoking behaviour is needed. Implementation of smoking cessation programmes with high reach among low socioeconomic groups is recommended.

The Process of Adapting the Evidence-Based Treatment for Tobacco Dependence for Smokers of Lower Socioeconomic Status

INTRODUCTION

Tobacco use is the leading cause of preventable death and disease and contributes significantly to socioeconomic health disparities. The prevalence of smoking among individuals of lower socioeconomic status (SES) in the US, many of whom are African American (AA), is three to four times greater than the prevalence of smoking among individuals of higher SES. The disparity in tobacco dependence treatment outcomes between lower and higher SES smokers contributes to tobacco-related health disparities and calls for adapting evidence-based treatment to more fully meet the needs of lower SES smokers.

AIMS

We sought to adapt the evidence-based treatment for tobacco dependence using recommended frameworks for adapting evidence-based treatments.

METHODS

We systematically applied the recommended steps for adapting evidence-based treatments described by Barrera and Castro and Lau. The steps included information gathering, preliminary adaptation design, preliminary adaptation tests, and adaptation refinement. We also applied the PEN-3 Model for incorporating AA values and experiences into treatment approaches and a community-engaged approach.

RESULTS/FINDINGS

Findings from each step in the process contributed to the results. The final results were incorporated into a revised treatment called the RITCh Study Tobacco Dependence Treatment Manual and Toolkit.

CONCLUSIONS

To our knowledge, this is the first adaptation of evidence-based treatment for tobacco dependence that has systematically applied these recommended frameworks. The efficacy of the treatment to reduce treatment outcome disparities is now being examined in a randomized controlled trial in which the revised treatment is being compared with a standard, individualized cognitive-behavioral approach.

Socioeconomic differentials in smoking duration among adult male smokers in China: result from the 2006 China Health and Nutrition Survey

BACKGROUND

A smoker's risk of diseases and death from smoking is closely related to his/her smoking duration. But little is known about the average length of smoking and the association between smoking duration and socio-economic status (SES) among Chinese smokers.

METHODS

A sample of male ever smokers (N = 2,637) aged 18+ years was drawn from the 2006 China Health and Nutrition Survey to examine the average length of smoking and socioeconomic differentials in smoking duration. Kaplan-Meier analysis was used to obtain median smoking duration. Log-logistic regression models were employed to estimate the relative duration of smoking, adjusted for demographic characteristics, smoking history, and health status.

RESULTS

Results showed that Chinese male ever smokers aged 18 years and older had a median duration of smoking of 58 years (95% CI: 56-61). Male ever smokers with a lower status job (i.e. farmers, manual and skilled workers, service workers, and office staff) had a significantly longer duration of smoking than those with a professional or administrative job after adjusted for demographic characteristics, smoking history, and health status. Individuals who earned the lowest income and who had no education or were being illiterate smoked for 11% and 14% longer, respectively, relative to those who had the highest income or who had college or above education.

CONCLUSION

The findings demonstrated the problem of long smoking duration and a pattern of social disparities in smoking duration among Chinese male smokers. Social disparities in smoking behavior may exacerbate the already existing social inequalities in health. Thus, policies and interventions to promote smoking cessation should pay more attention to disadvantaged social groups.

Psychological, social and familial factors associated with tobacco cessation among young adults

BACKGROUND/AIMS

The younger individuals quit smoking, the greater the health benefits. We studied the role of adolescent and concurrent psychological, social and familial factors in successful tobacco cessation in a general population sample of French young adults.

METHODS

Our data came from participants of the TEMPO cohort study and their parents (members of the GAZEL cohort study) in France. Among regular smokers (n = 678), Cox proportional hazards models were used to estimate hazard ratios of self-reported tobacco cessation of at least 12 months in relation to individual and socioenvironmental variables.

RESULTS

On average, participants (mean: 28.9 years) smoked for 10.51 years (SD = 5.9); the majority had attempted to quit smoking at least once (59.5%). In multiple regression analyses, cannabis use in the preceding year and recent financial difficulties were both negatively associated with successful smoking cessation. Conversely, living with a partner and, for women only, recent pregnancy or childbirth were associated with an increased likelihood of tobacco cessation.

CONCLUSIONS

This study highlights the importance of young adults' cannabis use, family situation and socioeconomic context with regard to their smoking behavior. Physicians and public health decision makers aiming to decrease the burden of tobacco smoking should take into consideration these social and behavioral factors.

Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers

Objectives. We determined cigarette smoking prevalence, desire to quit, and tobacco-related counseling among a national sample of patients at health centers. Methods. Data came from the 2009 Health Center Patient Survey and the 2009 National Health Interview Survey. The analytic sample included 3949 adult patients at health centers and 27 731 US adults. Results. Thirty-one percent of health center patients were current smokers, compared with 21% of US adults in general. Among currently smoking health center patients, 83% desired to quit and 68% received tobacco counseling. In multivariable models, patients had higher adjusted odds of wanting to quit if they had indications of severe mental illness (adjusted odds ratio [AOR] = 3.26; 95% confidence interval [CI] = 1.19, 8.97) and lower odds if they had health insurance (AOR = 0.43; 95% CI = 0.22, 0.86). Patients had higher odds of receiving counseling if they had 2 or more chronic conditions (AOR = 2.05; 95% CI = 1.11, 3.78) and lower odds if they were Hispanic (AOR = 0.57; 95% CI = 0.34, 0.96). Conclusions. Cigarette smoking prevalence is substantially higher among patients at health centers than US adults in general. However, most smokers at health centers desire to quit. Continued efforts are warranted to reduce tobacco use in this vulnerable group.

A randomized clinical trial of a financial education intervention with nicotine replacement therapy (NRT) for low socio-economic status Australian smokers: a study protocol

BACKGROUND AND AIMS

Reducing smoking prevalence among smokers from low socio-economic status (SES) is a preventative health priority. Financial stress (e.g. shortage of money or inability to pay bills) may be a major barrier to quitting smoking. This study evaluates the efficacy of a financial education and support programme coupled with pharmacotherapy at improving cessation rates at 8-month follow-up among Australian low SES smokers (people receiving a government pension or allowance).

DESIGN

A two-group parallel block randomized (ratio 1 : 1) open-label clinical trial (RCT) with allocation concealment will be conducted. Allocation will be concealed to interviewers at data collection-points.

SETTING

The study will be conducted primarily by telephone with baseline, follow-up interviews and telephone-based support sessions. Nicotine replacement therapy (NRT) delivery will be mail-based.

PARTICIPANTS

Daily smokers who are interested in quitting smoking and are currently in receipt of government benefits (n = 1046) will be recruited through study advertisements placed in newspapers, posters placed in government social assistance agencies and Quitline telephone-based cessation support services. After completion of a baseline computer-assisted telephone interview, participants will be allocated randomly to control or intervention group using a permuted block approach.

INTERVENTION AND COMPARATOR

Participants in both groups will receive 8 weeks of free combination NRT plus Quitline support. Participants in the intervention group will also receive four telephone-delivered financial education and support sessions.

MEASUREMENTS

The primary outcome measure will be prolonged abstinence (at 8-month follow-up) assessed using Russell Standard criteria and biochemically verified (urine cotinine).

COMMENTS

This is the first intervention study to evaluate the potential of co-managing financial stress as a means of enhancing smokers' capacity to quit smoking. Such an intervention may provide a scalable intervention to help low SES smokers to quit.

Correlates of cessation success among Romanian adults

BACKGROUND

Tobacco smoking and its consequences are a serious public health problem in Romania. Evidence-based data on factors associated with successful smoking cessation are crucial to optimize tobacco control. The aim of the study was to determine the sociodemographic and other factors associated with smoking cessation success among adults.

MATERIALS AND METHODS

Data was from a sample of 4,517 individuals derived from the Global Adult Tobacco Survey (GATS). GATS is a cross-sectional, nationally representative household survey implemented in Romania in 2011. Data was analyzed with logistic regression.

RESULTS

Among females, the quit rate was 26.3% compared with 33.1% in males (P < 0.02). We found disparities in cessation success among the analyzed groups of respondents. Being economically active, being aged 40 and above, and having an awareness of smoking health consequences were associated with long-term quitting smoking among men, while initiating smoking at a later age increased the odds of quitting smoking among women. However, cohabitation with nonsmokers was the strongest predictor of successful cessation among both genders.

CONCLUSION

Programs increasing quit rates and encourage cessation among groups less likely to quit, adopting voluntary smoke-free homes, and increasing the awareness of smoking and tobacco pollution risks are needed.

Women’s longitudinal smoking patterns from preconception through child’s kindergarten entry: profiles of biological mothers of a 2001 US birth cohort

To identify longitudinal patterns of women’s smoking during the pre-conception, perinatal, and early parenting period and describe risk factors distinguishing the different profiles. We conducted longitudinal latent class analysis of maternal smoking status over a 6–7 year period in a sample of 8,650 biological mothers of the Early Childhood Longitudinal Study-Birth Cohort, nationally representative of US births in 2001. Five latent classes were identified: pregnancy-inspired quitters (4.3 %), delayed initiators (5.1 %), persistent smokers (8.5 %), temporary quitters (10.4 %), and nonsmokers (71.7 %). These classes were distinguished by age, race/ethnicity, education, poverty status, marital status, parity, drinking behavior, and depression. For example, when compared to those with college degrees, those with less than a high school degree were at least five times as likely to be in the delayed initiator, temporary quitter, or persistent smoker classes (vs. the nonsmoker class). Heterogeneous longitudinal smoking patterns indicate the need for both prevention messages and cessation treatment continuing past parturition, tailored to fit individual profiles in order to achieve better health outcomes for both mothers and children.

Characteristics of smokers who have never tried to quit: evidence from the British Opinions and Lifestyle Survey

Background

An understanding of the characteristics of smokers who have never tried to quit may be useful to help identify and target these individuals and encourage them to attempt to give up smoking. Using national survey data we investigated variables associated with smokers reporting never having tried to quit.

Methods

Using data from the 2007 and 2009 UK Office for National Statistics Opinions and Lifestyle Survey we identified all self-reported current smokers aged 16+. The primary outcome was response to the question ‘have you ever tried to quit smoking?’ Univariable and multivariable logistic regression quantified the association between this outcome and several potential explanatory variables, including age, sex, socioeconomic status, health status, smoking behaviour, and knowledge of the dangers of smoking.

Results

Desire to quit was the most significant independent predictor of whether a smoker reported never having tried to quit. Smokers who reported that their health was good or very good were more likely to report never having tried to quit than those whose health was fair, bad or very bad (OR 1.59, 95% CI 1.05-2.41). Smokers who reported that no family members, friends or colleagues had been trying to get them to quit smoking in the last year were more likely to report never having tried to quit than those who reported that someone was trying to persuade them (OR 1.57, 95% CI 1.09-2.28). Smokers who hadn’t received any cessation advice from a health professional in the last five years which they considered to be helpful were also more likely to report never having tried to quit.

Conclusions

Smokers who do not want to quit, who are in good health, whose friends and family are not trying to get them to quit, and who do not report receiving helpful advice to quit from a health professional, are more likely to report never having tried to quit.

[Smoking cessation and social deprivation]

Smoking is a major of public health policy issue; one in two lifelong smokers will die from a disease related to tobacco use. In France, smoking is responsible for more than 70,000 deaths every year. The benefits linked to stopping smoking include reduced mortality and morbidity related to the use of tobacco. Recent data show an increase in the prevalence of smoking in the lowest socioeconomic population. Tobacco control needs a better understanding of the determinants of smoking in this population, which are also factors in the failure of cessation attempts. Based on international literature, this review specifies the educational and socioeconomic factors involved in tobacco smoking and in the result of an attempt to quit. Its aim is to propose ways to improve the management of smoking cessation in a socially deprived population.

Prolonged financial stress predicts subsequent obesity: results from a prospective study of an Australian national sample

OBJECTIVE

The aim of this research was to assess the association of prolonged financial stress (FS) with subsequent obesity.

DESIGN AND METHODS

Data were from Waves 8 (2008), 9 (2009), and 10 (2010) of Household Income and Labor Dynamics in Australia (HILDA) survey. The outcome was obesity measured in 2010. Prolonged FS was defined as having experienced FS in both 2008 and 2009. FS was measured in each year using seven questionnaire items. Analyses adjusted for health, physical activity, income, education, baseline obesity, and other covariates.

RESULTS

Prolonged FS was a strong predictor of subsequent obesity. The adjusted risk of being obese in 2010 were 20% higher (RR: 1.20; 95% CI: 1.10-1.30) among individuals who experienced FS in both 2008 and 2009 than those who did not experience FS in either year. The association of FS with obesity was independent of income and constant across income categories.

CONCLUSIONS

Obesity prevention research should pay more attention to FS as an important dimension of economic deprivation, a concept that is distinct from common indicators of socioeconomic status such as income. Future research can examine the effect of financial education and counseling programs that help individuals with such skills as money management, budgeting, and saving on a reduction in FS and obesity.

Paying the price: a cross-sectional survey of Australian socioeconomically disadvantaged smokers' responses to hypothetical cigarette price rises

INTRODUCTION AND AIMS

Increases in tobacco taxation can lead to reductions in tobacco consumption and prevalence of use across social groups. However, use of price-minimisation strategies to manage current and future tobacco use and the role of financial stress is less understood. This study aimed to measure the effect of cigarette price increases on price-minimisation strategy endorsement and financial stress among socioeconomically disadvantaged smokers.

DESIGN AND METHODS

Community service organisation welfare recipients in NSW, Australia completed a touchscreen survey. Smoking history, financial stress, highest price to quit and responses to hypothetical cigarette price increases were assessed.

RESULTS

Participants were 354 smokers (response rate = 79%). Most participants received income from a government pension (95%), earned <A$300/week (55%), had not completed secondary schooling (64%), were moderately or heavily nicotine-dependent (60%), reported high financial stress (66%) and spent A$56/week on tobacco. In response to 10% and 20% hypothetical price rises, significantly more participants endorsed trying to quit in response to the larger increase scenario (P < 0.001), and fewer selected no change to their smoking (P < 0.001). Numerous price-minimisation strategies (e.g. switching to cheaper brands/products) were endorsed, but remained constant across hypothetical scenarios; level of financial stress appeared to have little influence. Smokers indicating they would not change their smoking in response to price rises had higher levels of nicotine dependence.

DISCUSSION AND CONCLUSIONS

Socially disadvantaged smokers endorsed numerous price-minimising strategies to maintain smoking at hypothetically increased costs. Larger cigarette price rises motivated more smokers to consider quitting, while price-resistant smokers appeared to have a more entrenched smoker status.

Does Social Support Buffer the Effect of Financial Strain on the Trajectory of Smoking in Older Japanese? A 19-Year Longitudinal Study

OBJECTIVES

Although there is extensive research on the stress-buffering effects of social support on health, there is little understanding of this effect on health behaviors such as smoking, particularly during old age. This study aimed to estimate the effect of financial strain and the stress-buffering effect of social support, on the trajectory of smoking over an extended period of time among older Japanese.

METHOD

Data came from a national sample of more than 4,800 adults, aged 60 and older in Japan, with up to 7 repeated observations between 1987 and 2006 (16,669 observations). Hierarchical linear modeling was used to analyze the intrapersonal and interpersonal differences in smoking.

RESULTS

Higher financial strain at baseline was associated with greater amount of smoking, and a slower rate of decline, after adjusting for sociodemographic attributes. Greater instrumental support partially offset the deleterious effect of financial strain on the rate of decline in smoking.

DISCUSSION

Our findings add a dynamic dimension to understanding the relationship among financial strain, social support, and smoking in old age. This knowledge is significant when designing health policies and interventions regarding health behaviors in late life.

Effects of the economic crisis on smoking prevalence and number of smokers in the USA

OBJECTIVE

Scanty and controversial information is available on the impact of macroeconomic fluctuations on smoking behaviour. No study has quantified the effects of fiscal crises on smoking prevalence. This study aimed to investigate the effects of the 2007-2008 economic crisis on smoking prevalence and number of smokers in the USA.

METHODS

Using data from the repeated Behavioural Risk Factor Surveillance System (BRFSS) surveys in pre-crisis (2005-2007) and post-crisis (2009-2010) periods on a total of 1,981,607 US adults, we separated the expected (after allowance for the demographic growth of the US population, secular smoking prevalence trends and changes in sociodemographic characteristics) from the unexpected (assumed attributable to the economic crisis) changes in the number of smokers across different employment statuses.

RESULTS

Joinpoint regression analysis revealed no significant changes in smoking prevalence trends over the period 2005-2010. The crisis resulted in an increase in the number of smokers in the US by 0.6 million. This is largely due to an unexpected decrease of 1.7 million smokers among employed and an increase of 2.4 million smokers among unemployed individuals, whose smoking prevalence also remains extremely high in the post-crisis period (32.6%).

CONCLUSIONS

The 2008 financial crisis had a weak effect on smoking prevalence. The pro-cyclical relationship (ie, the crisis results in a lower number of smokers) found among the employed is offset by the counter-cyclical relationship (ie, the crisis results in a higher number of smokers) found among unemployed individuals. Public health interventions should specifically target those in unemployment, particularly in hard times.

The association of lone-motherhood with smoking cessation and relapse: prospective results from an Australian national study

The aims were to examine the association of lone-motherhood with smoking cessation and relapse, and to investigate the extent to which this association was accounted for by socioeconomic status (education, occupation, and income), social support, and mental health. We used data from 10 yearly waves (2001 to 2010) of the Household Income and Labour Dynamics in Australia (HILDA) survey. Response rate in the first wave was 66%. Logistic regression was used to examine the effect of lone-motherhood and other covariates on smoking cessation (n = 2,878) and relapse (n = 3,242). Results showed that the age-adjusted odds of smoking cessation were 32% smaller among lone mothers than partnered mothers (p = 0.004). The age-adjusted odds of relapse was 172% greater among lone mothers than partnered mothers (p < 0.001). We found that socioeconomic status, social support, and mental health account for some of the association of lone motherhood and cessation and relapse. While efforts to reduce the smoking prevalence among lone mothers should focus on their material deprivation, availability of social support, and addressing mental health issues, other factors unique to the lives of lone mothers also need to be taken into account. More research is needed to discover other factors that can explain the association of lone-motherhood and smoking behavior.

Smoking behaviors and cessation interests among multiunit subsidized housing tenants, Columbus, Ohio, 2011

Introduction

Cessation services have been recommended to complement smoke-free policies in subsidized multiunit housing, but little is known about smoking- and cessation-related characteristics among subsidized housing tenants. This study examined smoking behaviors and cessation-related interests in a population of subsidized housing tenants.

Methods

A face-to-face survey was conducted in August to October 2011 with a probability sample of private subsidized housing lease holders in Columbus, Ohio (N = 301, 64% response rate).

Results

Almost half (47.5%) of respondents were current smokers, including smokers of cigarettes or small cigars. Smokers were less likely than nonsmokers to have health insurance and more likely to be at risk for food insecurity. Among smokers, 20.3% did not smoke daily and 35.0% smoked 5 or fewer cigarettes per day. More than half (61.3%) purchased single cigarettes in the past month, with higher rates among nondaily smokers. Most smokers intended to quit within 6 months or less (60.1%) and were interested in using nicotine replacement therapy (NRT) (65.0%). Most respondents had Medicaid but only 30.4% knew Medicaid covered cessation medications.

Conclusions

This population of subsidized housing tenants had high rates of smoking, including light smoking. Interest in NRT was high and access can be improved by increasing awareness of Medicaid coverage among clients and health care providers. However, more research is needed about scalable, evidence-based cessation strategies for low-socioeconomic status and light smokers. Strategies to address environmental factors such as availability of single cigarettes should also be considered in parallel with smoke-free policies.

Different patterns by age-group and gender of socioeconomic inequalities in smoking in Colombia

INTRODUCTION

Evidence on socioeconomic inequalities in smoking from low- and middle-income countries has shown some inconsistency between countries. We have studied the socioeconomic inequalities in current smoking, ever smoking, and smoking cessation in Colombia by age-group and gender.

METHODS

Sixty thousand, three hundred and forty-nine Colombian men and women aged 12-69 years were selected at random from the results of a national survey. We used Pearson's chi-square and Robust Poisson regression analyses to estimate adjusted prevalence ratios between smoking behaviors and 2 indicators of socioeconomic position; individuals' educational level and household socioeconomic stratum.

RESULTS

In men aged 45-69 years, higher socioeconomic stratum and higher education were associated with a lower rate of current smoking (PR = 0.49 [95% CI, 0.32-0.73] and PR = 0.64 [95% CI, 0.47-0.86], respectively), a history of smoking (PR = 0.67 [95% CI, 0.53-0.85] and PR = 0.75 [95% CI, 0.63-0.90], respectively), or a higher rate of smoking cessation (PR = 1.37 [95% CI, 1.09-1.72] and PR = 0.18 [95% CI, 0.99-1.72], respectively). In men aged 18-44 years, higher education was associated with lower odds of current and history of smoking (PR = 0.75 [95% CI, 0.61-0.92 and PR = 0.81 [95% CI, 0.67-0.98], respectively). Results in women and adolescents were mixed.

CONCLUSIONS

In Colombia, the overall declining prevalence of smoking in men seems to be accompanied by a narrowing of smoking inequalities in successive birth cohorts, suggesting a favorable evolution of the tobacco epidemic. Further research will be required to identify factors that have contributed these optimal circumstances in tobacco control.

Factors associated with self-assessed increase in tobacco consumption among over-indebted individuals in Germany: a cross-sectional study

Background

Over-indebtedness is an increasing phenomenon in industrialised nations causing individual hardship and societal problems. Nonetheless, few studies have explored smoking among over-indebted individuals.

Methods

A cross-sectional survey (n=949) on retrospectively assessed changes in tobacco consumption was carried out in 2006 and 2007 among clients of 84 officially approved debt and insolvency counselling centres in Germany (response rate 39.7%). Logistic regressions were performed to explore factors associated with reports of increased smoking after onset of over-indebtedness.

Results

63% of all respondents stated daily or occasional tobacco consumption. Almost one fifth reported an increase in smoking after becoming over-indebted. Females were less likely to report increased smoking than men (aOR 0.66, 95% CI 0.44-0.99) whereas respondents who had been over-indebted for more than 10 years were more likely to report increased smoking than those who had been over-indebted for less than five years (aOR 1.66; 95%-CI 1.00-2.76). The odds of increased smoking were also elevated among those who reported that their families and friends had withdrawn from them as a consequence of their over-indebtedness (aOR 1.82; 95%-CI 1.06-3.14).

Conclusions

The study identifies over-indebted individuals and particularly over-indebted men as a high-risk group of smokers. Low levels of social embeddedness/support were associated with a further increase in smoking after becoming over-indebted. Given recent increases of over-indebtedness, the findings highlight the need to develop appropriate public health policies.

Targeting cessation: understanding barriers and motivations to quitting among urban adult daily tobacco smokers

INTRODUCTION

Many people continue to smoke tobacco products despite known negative health consequences, including increased risk of chronic disease and death. Disparities exist in rates of smoking and chronic disease, underscoring the importance of understanding the barriers and motivations to smoking cessation among vulnerable populations, such as socioeconomically disadvantaged people of color.

METHODS

This study uses data from a cross-sectional randomized household survey conducted in six low-income neighborhoods in New Haven, Connecticut, USA (N=1205). The objectives were to examine barriers and motivations to quitting smoking among daily tobacco smokers (31.6% of respondents) and sociodemographic differences in endorsement of barriers and motivations.

RESULTS

The two most common barriers to quitting were perceiving it to be too difficult and not wanting to quit. Financial costs, social support, and social influence were themes endorsed highly across both barriers and motivations to quitting. Sociodemographic differences were found, such as women and Black participants being more likely to be interested in a free quitline or quit website; women and Latinos being more likely to be afraid of gaining weight; and women, participants with less education, and older participants being more likely to be concerned about the cost of cessation products.

CONCLUSIONS

Understanding barriers and motivations to quitting among disadvantaged populations is crucial. Financial issues, social support, and social norms should be targeted in promoting cessation among disadvantaged, urban populations. Programs, interventions, and policies can also use research about specific barriers and motivations for sociodemographic sub-groups to be tailored, targeted, and more effective.

Impact and perceptions of tobacco tax increase in remote Australian Aboriginal communities

INTRODUCTION

We sought to assess the impact of a 25% tax excise rise on tobacco sales in Aboriginal communities in remote Australia and to explore local perceptions about tobacco tax rises and their impact.

METHODS

Tobacco sales data were collected from 18 stores in small remote Aboriginal communities from October 2009 to December 2010. Sales in the 7 months before and after the tax increase were compared. Interviews were conducted with 54 informants in 6 communities.

RESULTS

There was a nonsignificant 2.2% average reduction (95% CI = -5 to 10) in total tobacco sold in a store in the 7 months after the price increase compared with the 7 months before the price increase, with a large variation across the 18 stores. The magnitude of this apparent impact may have been reduced by seasonal effects. There were increased demands to share cigarettes, with a perception that there was increased reliance on those with more disposable income to purchase cigarettes for other smokers. The main reasons given for not quitting or reducing smoking were dependence, the normative nature of smoking, and the lack of support to quit. All Aboriginal interviewees supported price increases as important in reducing smoking.

CONCLUSIONS

The wide confidence interval around our estimated reduction in consumption means that the tax increase could have either been associated or not with a reduction in consumption. Future excise rises are supported but should be carefully monitored in Australian Indigenous populations.

A longitudinal study on the impact of income change and poverty on smoking cessation

OBJECTIVES

Research on the association between income and smoking cessation has examined income as a static phenomenon, either cross-sectionally or as a predictor variable in longitudinal studies. This study recognizes income as a dynamic entity and examines the relationship between a change in income and subsequent smoking behaviour.

METHOD

Longitudinal data from the National Population Health Survey (1994/5 to 2008/9) were used to examine the impact of (1) change in income and (2) change in poverty status, on the probability of being a former or current smoker among a sample of Canadians identified as having ever smoked. Covariates include socio-demographic characteristics, number of cigarettes smoked per day, and smoking in the home.

RESULTS

Smoking behaviour was not associated with a change in household income but was associated with a change in household income that moved an individual across the poverty threshold. Canadians whose income increased to above the poverty threshold were less likely to continue smoking than someone who remained in poverty (OR = 0.72, 95% CI: 0.62-0.84). Those who remained out of poverty were also less likely to continue smoking than someone who remained in poverty (OR = 0.66, 95% CI: 0.57-0.75). There was no significant difference between those who remained in poverty and those whose income decreased to below the poverty level.

CONCLUSION

This study strengthens the link between smoking and poverty and supports strategies that address income as a socio-economic determinant of health. Policies that increase household incomes above the poverty line may lead to improvements in smoking cessation rates.

Struggling to make ends meet: exploring pathways to understand why smokers in financial difficulties are less likely to quit successfully

BACKGROUND

In high-income countries, those with low-to-middle incomes have been observing stagnating median wages and marginal improvements in their living standards. Smokers in financial difficulties appear to be less likely to quit smoking. Understanding the reasons for this is essential to intervening to improve cessation outcomes in this population, and reduce smoking-related health inequalities.

METHODS

We used longitudinal data from Waves 4 to 7 of the ITC Four Country Survey (ITC-4), and included those with data from at least two consecutive waves. Associations between financial difficulties and making a quit attempt, and quit success were analysed using generalised estimating equations, with adjustment for confounders. Mediation analysis was conducted to identify potential mediators of the observed effects of financial difficulties on cessation outcomes.

RESULTS

Having financial difficulties had little impact on making quit attempts (adjusted OR 0.84, 95% CI 0.70-1.01). Smokers with financial difficulties were substantially less likely to succeed at quitting (adjusted OR 0.55, 95% CI 0.39-0.76); an effect which was consistent over the survey years. Among the potential mediators examined, those relating to cognition of health-related and quality of life-related consequences of smoking were the most important mediators, though the proportion of the effect mediated by the largest mediator was small (6.8%).

CONCLUSION

Having financial difficulties remains an important barrier to smokers achieving quit success. This effect does not appear to be due to anticipated factors such as reduced use of cessation services or treatment. Further research is required to determine strong mediators of the financial difficulties effect on quit success and to tailor more effective cessation programmes.

Menthol smoking in relation to time to first cigarette and cotinine: results from a community-based study

Smokers who have their first cigarette shortly after waking, an indicator of nicotine dependence, have substantially higher cotinine levels. There is controversy regarding the role of menthol in nicotine dependence. We hypothesized that menthol smokers have a shorter time to first cigarette (TTFC), and tested whether any statistical association actually reflects increased dependence by measuring nicotine uptake (e.g. cotinine) in the same group of smokers. A cross-sectional community-based study was conducted that included 495 black and white daily cigarette smokers. Results showed a trend between menthol smoking and a shorter TTFC (P < 0.04 in blacks). Menthol was not an independent predictor of cotinine or an effect modifier with TTFC on cotinine levels in blacks and whites. These results show that while menthol in tobacco is associated with an indicator of nicotine dependence in blacks, menthol was not associated with biological uptake of nicotine in black and white smokers.

Tobacco expenditure, smoking-induced deprivation and financial stress: results from the International Tobacco Control (ITC) Four-Country Survey

INTRODUCTION AND AIMS

While higher tobacco prices lead to a reduction in smoking prevalence, there is a concern that paying more for cigarettes can lead to excess financial burden. Our primary aim was to examine the association of daily cigarette expenditure with smoking-induced deprivation (SID) and financial stress (FS).

DESIGN AND METHODS

We used data from wave 7 (2008-2009) of the International Tobacco Control (ITC) Four-Country Survey which is a survey of smokers in Canada, the USA, the UK and Australia (n = 5887). Logistic regressions were used to assess the association of daily cigarette expenditure with SID and FS.

RESULTS

In multivariate analyses, a one standard deviation increase in daily cigarette expenditure was associated with an increase of 24% (P = 0.004) in the probability of experiencing SID. While we found no association between daily cigarette expenditure and FS, we found that SID is a strong predictor of FS (odds ratio 6.25; P < 0.001). This suggests that cigarette expenditure indirectly affects FS through SID. Results showed no evidence of an interaction between cigarette expenditure and income or education in their effect on SID or FS.

CONCLUSIONS

Our results imply that spending more on tobacco may result in SID but surprisingly has no direct effect on FS. While most smokers may be adjusting their incomes and consumption to minimise FS, some fail to do so occasionally as indexed by the SID measure. Future studies need to prospectively examine the effect of increased tobacco expenditure on financial burden of smokers.

Socio-economic disadvantage at the area level poses few direct barriers to smoking cessation for Australian smokers: findings from the International Tobacco Control Australian cohort survey

INTRODUCTION

Area-level indicators of socio-economic variation are frequently included in models of individual health outcomes. Area disadvantage is linearly related to smoking prevalence, but its relation to cessation outcomes is less well understood.

AIMS

To explore the relationship between area-level disadvantage and prospective data on smoking cessation.

DESIGN AND METHODS

The Australian cohort of the International Tobacco Control Four-Country Survey (N = 3503) was used to prospectively examine the contribution of area-level socio-economic disadvantage to predicting three important smoking-cessation outcomes: making a quit attempt, achieving 1 month abstinence and achieving 6 month abstinence from smoking, while controlling for individual-level socio-economic indicators and other individual-level covariates related to smoking cessation.

RESULTS

Only two independent associations were observed between socio-economic disadvantage and cessation outcomes. Area-level disadvantage was related to 1 month abstinence in a non-linear fashion, and the individual experience of smoking-induced deprivation was associated with a lower likelihood of making quit attempts.

DISCUSSION

Despite the documented higher prevalence of smoking among the more disadvantaged and in more disadvantaged areas, socio-economic disadvantage was not consistently related to making quit attempts, nor to medium-term success. Nevertheless, indirect effects of disadvantage, like its impact on psychological distress, cannot be ruled out, and considering smokers' individual psychosocial circumstances is likely to aid cessation efforts.

CONCLUSION

Socio-economic disadvantage, particularly at the area level, poses few direct barriers to smoking cessation.

Psychosocial stressors and cigarette smoking among African American adults in midlife

INTRODUCTION

Psychosocial stress is a significant risk factor for smoking, and Blacks experience higher levels of psychosocial stress relative to other racial/ethnic groups. Limited research has comprehensively examined psychosocial stressors in relation to smoking among Blacks.

METHODS

We examined psychosocial stressors in relation to smoking status (current, previous, and never) in middle-aged Blacks (34-85 years, n = 592) from Milwaukee, Wisconsin, a subset of the Midlife in the United States Study II (2004-2006). Eleven stressor domains were assessed, including psychological and physical work stress, work-family conflict, perceived inequality, relationship stress, neighborhood stress, discrimination, financial stress, recent problems, stressful events, and childhood adversity. We also calculated a cumulative score. Multinomial models were adjusted for age, gender, education, and income.

RESULTS

Seven of the 11 stressors and the cumulative score were associated with higher odds of being a current smoker compared with a never-smoker: neighborhood, financial, relationship, and psychological work stress, perceived inequality, stressful events, childhood adversity (p values <.05; ORs ranged from 1.28 to 1.77). Three stressors and the cumulative score were associated with higher odds of being a previous smoker versus a never-smoker (p < .05). Individuals who scored in the top quartile on 5 or more stressors were 3.74 (95% CI = 2.09-6.71) times as likely to be current smokers, and more than twice as likely to be previous smokers, compared with individuals with no high stressors.

CONCLUSIONS

These results demonstrate a strong relationship between stress and smoking among urban middle-aged Blacks and suggest that cessation programs should address modifiable individual and community-level stressors.

Are changes in financial strain associated with changes in alcohol use and smoking among older adults?

OBJECTIVE

This study aimed to assess whether changes in levels of financial strain are associated with changes in alcohol use and smoking among older adults.

METHOD

Multilevel analyses were conducted using longitudinal data from a randomly selected national sample of older adults (N = 2,352; 60% female). The data were collected in six waves during the period of 1992-2006. We estimated associations between within-person changes in levels of financial strain and the odds of engaging in heavy drinking and smoking, while also testing for the moderating effects of gender, education, and age.

RESULTS

A direct association was observed between changes in levels of financial strain and the odds of heavy drinking, particularly among elderly men (odds ratio [OR] = 1.31) and those with low levels of education (OR = 1.27). A direct association between changes in levels of financial strain and the odds of smoking was also evident, particularly among the young-old (i.e., age 65 at baseline; OR = 1.44).

CONCLUSIONS

Exposure to financial strain places some groups of older adults at increased risk for unhealthy drinking and smoking. If the current global financial crisis leads to increases in experiences of financial strain among older adults, alcohol and smoking problems can also be expected to increase in this population.

Identifying Barriers to Entering Smoking Cessation Treatment Among Socioeconomically Disadvantaged Smokers

Background:Efficacious smoking cessation interventions exist, yet few smokers utilise available resources such as psychosocial treatment programs and pharmacotherapy. The goals of the present study were to (1) identify perceived barriers to entering smoking cessation treatment programs among socioeconomically disadvantaged smokers, who are presently underrepresented in smoking cessation interventions; (2) determine what variables are most important in predicting the barriers identified (i.e., age, gender, ethnicity, income, nicotine dependence level, smoking rate, years smoking, stage of change, presence of smoking-related illness and medical insurance status).Methods:Responses from socioeconomically disadvantaged smokers (N= 343) were collected in 2004–2005 and analysed to develop the Treatment Barriers Questionnaire, a 40-item measure of reasons for not entering smoking cessation programs. Study methods were approved by the Institutional Review Board of Louisiana State University; informed consent procedures were employed.Results:Principal components analysis yielded seven scales named for their theme: (1) Preparedness to Quit Smoking; (2) Work and Time Constraints; (3) Smokers Can or Should Quit on Own; (4) Opinions about Professional Assistance; (5) Mobility Limitations; (6) Insurance Limitations and (7) Misinformation about Professional Assistance. Gender, ethnicity, daily smoking rate, nicotine dependence and stage of change were significant predictors in regression analyses for scales 1,F(10, 201) = 7.83,p< .001,R2= .29, 2F(10, 201) = 2.30,p< .05,R2= .11, and 3,F(10, 201) = 3.58,p< .001,R2= .16. Conclusions: Results can inform efforts to facilitate entry and retention of smokers in cessation programs.

The relation between media promotions and service volume for a statewide tobacco quitline and a web-based cessation program

BACKGROUND

This observational study assessed the relation between mass media campaigns and service volume for a statewide tobacco cessation quitline and stand-alone web-based cessation program.

METHODS

Multivariate regression analysis was used to identify how weekly calls to a cessation quitline and weekly registrations to a web-based cessation program are related to levels of broadcast media, media campaigns, and media types, controlling for the impact of external and earned media events.

RESULTS

There was a positive relation between weekly broadcast targeted rating points and the number of weekly calls to a cessation quitline and the number of weekly registrations to a web-based cessation program. Additionally, print secondhand smoke ads and online cessation ads were positively related to weekly quitline calls. Television and radio cessation ads and radio smoke-free law ads were positively related to web program registration levels. There was a positive relation between the number of web registrations and the number of calls to the cessation quitline, with increases in registrations to the web in 1 week corresponding to increases in calls to the quitline in the subsequent week. Web program registration levels were more highly influenced by earned media and other external events than were quitline call volumes.

CONCLUSION

Overall, broadcast advertising had a greater impact on registrations for the web program than calls to the quitline. Furthermore, registrations for the web program influenced calls to the quitline. These two findings suggest the evolving roles of web-based cessation programs and Internet-use practices should be considered when creating cessation programs and media campaigns to promote them. Additionally, because different types of media and campaigns were positively associated with calls to the quitline and web registrations, developing mass media campaigns that offer a variety of messages and communicate through different types of media to motivate tobacco users to seek services appears important to reach tobacco users. Further research is needed to better understand the complexities and opportunities involved in simultaneous promotion of quitline and web-based cessation services.

Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review

AIMS

To identify the predictors of attempts to stop smoking and the predictors of quit attempt success in adult general population samples.

METHODS

We performed an electronic search of EMBASE, Pubmed, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group specialized register for articles that examined, in prospective adult general population samples, predictors of quit attempts and the success of quit attempts. Experts were contacted for knowledge of other relevant studies. Eight studies met the inclusion criteria and results were extracted independently by two researchers.

RESULTS

There was considerable methodological heterogeneity between studies. Motivational factors dominated the prediction of quit attempts, whereas only cigarette dependence consistently predicted success after an attempt had been made. Social grade also appeared to predict success but was only examined in two studies. None of the other socio-demographic factors consistently predicted making a quit attempt or success.

CONCLUSIONS

Population-level studies from a number of countries show that past quit attempts and measures of motivation to stop are highly predictive of quit attempts, whereas only measures of dependence are consistently predictive of success of those attempts. Gender, age and marital status and educational level are not related consistently to quit attempts or quit success across countries.

Australian smokers' and recent quitters' responses to the increasing price of cigarettes in the context of a tobacco tax increase

AIMS

To track smokers' responses to the increasing price of cigarettes after a tax increase, and assess socio-demographic differences in responses.

DESIGN

The Cancer Institute NSW's Tobacco Tracking Survey (CITTS) is a continuous tracking telephone survey. Weekly data were collected between May and September 2010.

SETTINGS

New South Wales, Australia.

PARTICIPANTS

A total of 834 smokers and 163 recent quitters (quit in last 12 months).

MEASUREMENTS

Responses to the price increase included smoking-related changes (tried to quit, cut down) and product-related changes (changed to lower priced brands, started using loose tobacco, bought in bulk). Recent quitters were asked how much the increasing price of cigarettes influenced them to quit.

FINDINGS

Overall, 47.5% of smokers made smoking-related changes and 11.4% made product-related changes without making smoking-related changes. Multinomial logistic regressions showed that younger smokers (versus older) were more likely to make product-related changes and smoking-related changes in comparison to no changes. Low- or moderate-income smokers (versus high-income) were more likely to make smoking-related changes compared to no changes. Highly addicted smokers (versus low addicted) were more likely to make product-related changes and less likely to make smoking-related changes. The proportion of smokers making only product-related changes decreased with time, while smoking-related changes increased. Recent quitters who quit after the tax increase (versus before) were more likely to report that price influenced them.

CONCLUSIONS

The effect of increasing cigarette prices on smoking does not appear to be mitigated by using cheaper cigarette products or sources. These results support the use of higher cigarette prices to encourage smoking cessation.