Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure

The co-use of nicotine and prescription psychostimulants: A review of their behavioral and neuropharmacological interactions

BACKGROUND

Nicotine is commonly co-used with other psychostimulants. These high co-use rates have prompted much research on interactions between nicotine and psychostimulant drugs. These studies range from examination of illicitly used psychostimulants such as cocaine and methamphetamine to prescription psychostimulants used to treat attention deficit hyperactivity disorder (ADHD) such as methylphenidate (Ritalin™) and d-amphetamine (active ingredient of Adderall™). However, previous reviews largely focus on nicotine interactions with illicitly used psychostimulants with sparse mention of prescription psychostimulants. The currently available epidemiological and laboratory research, however, suggests high co-use between nicotine and prescription psychostimulants, and that these drugs interact to modulate use liability of either drug. The present review synthesizes epidemiological and experimental human and pre-clinical research assessing the behavioral and neuropharmacological interactions between nicotine and prescription psychostimulants that may contribute to high nicotine-prescription psychostimulant co-use.

METHODS

We searched databases for literature investigating acute and chronic nicotine and prescription psychostimulant interactions. Inclusion criteria were that participants/subjects had to experience nicotine and a prescription psychostimulant compound at least once in the study, in addition to assessment of their interaction.

RESULTS AND CONCLUSIONS

Nicotine clearly interacts with d-amphetamine and methylphenidate in a variety of behavioral tasks and neurochemical assays assessing co-use liability across preclinical, clinical, and epidemiological research. The currently available research suggests research gaps examining these interactions in women/female rodents, in consideration of ADHD symptoms, and how prescription psychostimulant exposure influences later nicotine-related outcomes. Nicotine has been less widely studied with alternative ADHD pharmacotherapy bupropion, but we also discuss this research.

Child marriage and risky health behaviors: an analysis of tobacco use among early adult and early middle-aged women in India

BACKGROUND

Though the harmful impacts of child marriage have been evaluated across several domains, evidence on the relationship between child marriage and health behaviors over the life course is limited. In this paper, we examined whether getting married as a child is associated with one of the most common risky health behaviors, tobacco use, in adulthood.

METHODS

Using nationally representative data from India, we compared the odds in favor of tobacco use among early adult (age 22-34) and early middle-aged (age 35-44) women who were married before age 18 with that of those who were married as youths (age 18-21). We estimated univariate and multivariable logistic regressions to obtain odds ratios in favor of any tobacco-use and relative risk ratios in favor of mutually exclusive types of tobacco use (smoking-only, smokeless-only, and dual-use). We also explored the intensive margin of the relationship by assessing if the odds of tobacco use in adulthood were affected by how early (13 or less, 14-15, or 16-17) a child bride was married.

RESULTS

We find that the adjusted odds of tobacco use for those who were married as a child were 1.3 and 1.2 times that of those who were married as a youth among early adult and early middle-aged women, respectively. The younger was the child bride when married, the higher were the odds of tobacco use as an adult. The relative risks of different types of tobacco use were also higher for child brides than their peers.

CONCLUSIONS

These results are the first evidence of the association between child marriage and a major risky health behavior, tobacco use, over the life course. These findings will inform policies to strengthen child marriage prevention efforts and targeted tobacco control initiatives in the low-and-middle income countries.

Prevalence and socio-structural determinants of tobacco exposure in young women: Data from the Healthy Trajectories Initiative (HeLTI) study in urban Soweto, South Africa

BACKGROUND

Tobacco use is a major public health risk worldwide, which has increased on the African continent over the past 40 years. Socio-economic factors impact tobacco use and exposure, but little is known about the scope of this problem in young women living in an urban, historically disadvantaged township in contemporary South Africa. This study aimed to identify the prevalence of tobacco use in a cohort of young South African women using serum cotinine, and to assess the association between a number of socio-economic and social factors and tobacco use in this setting.

METHODS

Secondary analysis was conducted on cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Serum cotinine was measured and a cut-off of ≥ 10 ng/mL was classified as tobacco use. Household socio-economic, socio-demographic and health information were collected by an interviewer-administered questionnaire.

RESULTS

Cotinine data was available for 1508 participants, of whom 29.2% (n = 441) had cotinine levels indicative of tobacco use. In regression analyses, moderate to severe socio-economic vulnerability (score 2-3 OR 1.66, p = 0.008; score ≥4: OR 1.63, p = 0.026) and multiparity (OR 1.74, p = 0.013) were associated with tobacco use. In addition, alcohol dependence (OR 3.07, p < 0.001) and drug use (OR 4.84, p < 0.001) were associated with tobacco use.

CONCLUSION

Young women with multiple children, moderate to severe socio-economic vulnerability, and alcohol and drug use were identified as more likely to use tobacco, indicating the need for targeted anti-tobacco interventions to curb the impact of tobacco on the growing burden of noncommunicable diseases in this setting.

Gender, Tobacco Control Policies, and Persistent Smoking Among Older Adults: A Longitudinal Analysis of 11 European Countries

INTRODUCTION

Little is known about sociodemographic and macro-level predictors of persistent smoking when one has developed a health condition that is likely caused by smoking.

AIMS AND METHODS

We investigate the impact of gender, education, and tobacco control policies (TCPs) on persistent smoking among older Europeans. Respondents (aged 50 +) with a smoking history and at least one smoking-related health condition were pooled from the Survey of Health, Aging and Retirement in Europe (SHARE) and the English Longitudinal Study of Ageing (ELSA) from four waves from 2004 to 2013. We fitted gender-specific logistic regression models with two-way fixed effects (country and year) and tested interaction terms between gender, education, and TCPs.

RESULTS

Although women are less likely to smoke than men, they were more likely to smoke persistently. The effects of education and general TCPs on persistent smoking were significant for women only. Compared to women with low levels of education, those with moderate education (odds ratio [OR] = .63; .49-.82) and high education (OR = .57; .34-.98) are less likely to be persistent smokers. TCPs are associated with a reduced risk of women's persistent smoking (OR = .70; .51-.95) and the association is stronger for those having less education.

CONCLUSIONS

Older women, particularly those with low levels of education, are vulnerable to persistent smoking. TCPs might be effective in reducing persistent smoking for older women, with greater effects for less-educated women. Future studies are needed to understand mechanisms that explain gender differences in responsiveness to TCPs.

IMPLICATIONS

Persistent smoking is a particularly harmful smoking behavior as it is associated with greater risks of comorbidity and mortality. By employing the framework of the multilevel social determinants of health, this study examined the behavior of persistent smoking among older adults in European countries. Women, especially women with low levels of education are vulnerable to persistent smoking. Moreover, TCPs, in general, are significantly related to a reduction in persistent smoking among older women only and the negative association is stronger for those having less education, indicating gender and socioeconomic differences in responsiveness to TCPs.

Social Determinants of Cigarette Smoking among American Women during Pregnancy

Educational attainment is among the most substantial protective factors against cigarette smoking, including during pregnancy. Although Minorities’ Diminished Returns (MDRs) of educational attainment, defined as weaker protective effect of education for racial and ethnic minority groups compared to Non-Hispanic Whites, has been demonstrated in previous studies; such MDRs are not tested for cigarette smoking during pregnancy. To better understand the relevance of MDRs to tobacco use during pregnancy, this study had three aims: firstly, to investigate the association between educational attainment and cigarette smoking in pregnant women; secondly, to compare racial and ethnic groups for the association between educational attainment and cigarette smoking; and thirdly, to explore the mediating effect of poverty status on such MDRs, among American adults during pregnancy. This cross-sectional study explored a nationally representative sample of pregnant American women (n = 338), which was taken from the Population Assessment of Tobacco and Health (PATH; 2013). Current smoking was the outcome. Educational attainment was the independent variable. Region and age were the covariates. Poverty status was the mediator. Race and ethnicity were the effect modifiers. Overall, a higher level of educational attainment (OR = 0.54, p < 0.05) was associated with lower odds of current smoking among pregnant women. Race (OR = 2.04, p < 0.05) and ethnicity (OR = 2.12, p < 0.05) both showed significant interactions with educational attainment on smoking, suggesting that the protective effect of educational attainment against smoking during pregnancy is smaller for Blacks and Hispanics than Non-Hispanic Whites. Poverty status fully mediated the above interactions. In the United States, highly educated pregnant Black and Hispanic women remain at higher risk of smoking cigarettes, possibly because they are more likely to live in poverty, compared to their White counterparts. The results suggest the role that labor market discrimination has in explaining lower returns of educational attainment in terms of less cigarette smoking by racial and ethnic minority pregnant women.

Intersectional analysis of cannabis use, stigma and health among marginalized Nigerian women

Cannabis use by women has been under-researched, particularly use by marginalized women in developing societies. This article draws on qualitative research in Uyo, Nigeria, to explore how intersecting stigmas around social identity categories (e.g. gender, sex work) shapes cannabis use and contributes to health harms for marginalized women. Qualitative data were collected via in-depth interviews with street-involved female cannabis users, and transcribed, coded and analysed thematically. Initiation of cannabis use was influenced by social networks and sexual relationships. Heavy cannabis use enabled some women to perform alternative femininity thereby challenging the boundaries of appropriate gendered behaviour, while others were pressured by normative expectations to enact moderation according to traditional femininity. Recreational cannabis use overlapped with marginalized forms of use, including using heavily to cope with the mental health sequalae of gender-based discriminations and structural inequities. Cannabis use attracted heightened stigma, operating as part of intersecting stigmatizing identities that adversely impacted mental health and wellbeing. Cannabis stigma does not exist in isolation from other social identity categories that shape women's lives. There exists a need to combat stigma through interventions that seek to mediate changes in gender relations, improve living conditions and access to health-care services for marginalized women.

Intersectionality and Smoking Cessation: Exploring Various Approaches for Understanding Health Inequities

OBJECTIVE

Many marginalized groups smoke at higher rates and have greater difficulty quitting than less marginalized groups. Most research on smoking cessation inequities has focused on a single sociodemographic attribute (eg, race or socioeconomic status), yet individuals possess multiple attributes that may increase risk. The current study used an intersectionality framework to examine how the interplay between multiple marginalized attributes may impact smoking cessation outcomes.

METHODS

A diverse sample of 344 adults enrolled in a smoking cessation program and reported on sociodemographic attributes (eg, race/ethnicity, gender, income) and continuous smoking abstinence on their quit date and at 1, 2, and 4 weeks postquit date. A Cox proportional hazard regression model was used to estimate whether intersectional links among race/ethnicity, gender, and income were related to smoking cessation outcomes.

RESULTS

Lower household income may be related to higher risk of smoking cessation failure. There were no significant interactions among race/ethnicity, gender, and income in predicting relapse. Pairwise intersectional group differences suggested some groups may be at higher risk of relapse. Number of marginalized sociodemographic attributes did not predict relapse.

CONCLUSIONS

Intersectionality may be a promising framework for addressing health inequities, and may help elucidate how to best design and target intervention efforts for individuals characterized by sociodemographic intersections that concur particularly high risk for poor tobacco cessation outcomes.

IMPLICATIONS

Despite an overall decline in smoking rates, socioeconomic inequities in smoking prevalence and cancer mortality are widening. Efforts targeting tobacco cessation should incorporate new theory to capture the complex set of factors that may account for tobacco cessation inequities (eg, multiple aspects of identity that may influence access to tobacco cessation treatment and exposure to certain stressors that impede cessation efforts). Intersectionality may be a promising framework for addressing health inequities in tobacco use and cessation and may help elucidate how to best design and target intervention efforts for individuals that concur particularly high risk for poor tobacco cessation outcomes.

Effects of social network diversity in the disablement process: a comparison of causal inference methods and an outcome-wide approach to the Indonesian Family Life Surveys, 2007-2015

BACKGROUND

Social networks (SN) have been proven to be instrumental for healthy aging and function as important safety nets, particular for older adults in low and middle-income countries (LMICs). Despite the importance of interpreting health outcomes in terms of SN, in many LMICs - including Indonesia - epidemiological studies and policy responses on the health effects of SN for aging populations are still uncommon. Using outcome-wide multi-method approaches to longitudinal panel data, this study aims to outline more clearly the role of SN diversity in the aging process in Indonesia. We explore whether and to what degree there is an association of SN diversity with adult health outcomes and investigate potential gender differences, heterogeneous treatment effects, and effect gradients along disablement processes.

METHODS

Data came from the fourth and fifth waves of the Indonesian Family Life Survey fielded in 2007-08 and 2014-15. The analytic sample consisted of 3060 adults aged 50+ years. The primary exposure variable was the diversity of respondents' SN at baseline. This was measured through a social network index (SNI), conjoining information about household size together with a range of social ties with whom respondents had active contact across six different types of role relationships. Guided by the disablement process model, a battery of 19 outcomes (8 pathologies, 5 impairments, 4 functional limitations, 2 disabilities) were included into analyses. Evidence for causal effects of SN diversity on health was evaluated using outcome-wide multivariable regression adjustment (RA), propensity score matching (PSM), and instrumental variable (IV) analyses.

RESULTS

At baseline, 60% of respondents had a low SNI. Results from the RA and PSM models showed greatest concordance and that among women a diverse SN was positively associated with pulmonary outcomes and upper and lower body functions. Both men and women with a high SNI reported less limitations in performing activities of daily living (ADL) and instrumental ADL (IADL) tasks. A high SNI was negatively associated with C-reactive protein levels in women. The IV analyses yielded positive associations with cognitive functions for both men and women.

CONCLUSIONS

Diverse SN confer a wide range of strong and heterogeneous long-term health effects, particularly for older women. In settings with limited formal welfare protection, intervening in the SN of older adults and safeguarding their access to diverse networks can be an investment in population health, with manifold implications for health and public policy.

Gender, women, and the future of tobacco control

Purpose

This paper aims to provide a gendered analysis of the WHO Framework Convention on Tobacco Control (FCTC) benchmarked upon the global commitments to women’s health and well-being in the UN Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) and the Beijing Declaration and Platform for Action. It reviews evidence of the global consequences of neglecting women’s tobacco use and health, as well as analyzes persistent issues related to sex and gender that compromise the efficacy of tobacco control and science. Actionable recommendations are made to the Conference of the Parties to the FCTC and other key stakeholders.

Design/methodology/approach

This paper draws upon empirical studies, literature reviews and global health data at the varying intersections of gender, sex, tobacco and global health.

Findings

The global tobacco control framework and its implementation by state governments have been largely gender blind to date with dire health and economic consequences, including inequitable positive outcomes for men compared to women, and an increase in women’s smoking with associated morbidity and mortality. Gender equitable progress in combatting the tobacco epidemic will not be possible without resolving the gender bias, stigmatization, sexism and lack of intersectionality that plague tobacco control policy, research and interventions for cessation and harm reduction.

Originality/value

This paper provides an updated global overview of current trends in women’s tobacco use and comprehensively details the persistent structural barriers in tobacco control and science that limit their capacity to effectively analyze and address tobacco use and its impact on women.

Protective Effects of Parental Education Against Youth Cigarette Smoking: Diminished Returns of Blacks and Hispanics

Background

High parental educational attainment is protective against youth health risk behaviors such as tobacco use. According to the Marginalization-related Diminished Returns (MDRs) theory, however, higher parental education is less protective for marginalized groups relative to non-Hispanic Whites.

Objective

To explore race/ethnic differences in the effects of parental educational attainment on cigarette smoking in a national sample of American adolescents.

Methods

In a cross-sectional study, we used baseline data of 10,878 American youth who had participated in the Population Assessment of Tobacco and Health (PATH 2013). The independent variable was parental educational attainment. The dependent variables were lifetime cigarette smoking, current (past 30-day) cigarette moking, and daily cigarette smoking. Youth age, youth gender, and parental marital status were the covariates. Race/ethnicity was the moderating variable. Logistic regression model was used for data analysis.

Results

Overall, a higher parental educational attainment was associated with a lower lifetime cigarette smoking, current (past 30-day) cigarette smoking, and daily cigarette smoking. Parental educational attainment showed significant interaction with race/ethnicity suggesting smaller protective effects of parental educational attainment on youth tobacco outcomes for Black and Hispanic than for non-Hispanic White youth.

Conclusion

For American youth, race/ethnicity limits the health gains that are expected to follow parental educational attainment. While high parental educational attainment is protective against smoking overall, non-Hispanic Whites (the most socially privileged group) gain most and Blacks and Hispanics (the least socially privileged groups) gain least from such resource. In addition to addressing low SES, researchers and policymakers should identify and address mechanisms by which high SES minority youth remain at risk of tobacco use.

Parental educational attainment and relatives' substance use of American youth: Hispanics Diminished Returns

OBJECTIVES

Research on Minorities' Diminished Returns (MDRs) has shown higher than expected substance use (tobacco and alcohol use) in middle-class Hispanic and Black youth and adults. In theory, some of this more than expected risk might be due to the high substance use problem of the social network. To better understand the role of social network as an explanatory mechanism behind higher than expected substance use of middle-class Hispanic and Black youth, this study tested MDRs of parental educational attainment on substance use involvement of biological relatives in Hispanic and Black middle-class youth, we compared ethnic groups for effects of parental educational attainment on the substance use involvement of biological relatives among American youth.

METHODS

Current longitudinal study used waves 1 and wave 4 data of the Population Assessment of Tobacco and Health- Adolescents (PATH; 2013-2018) study. The sample included 4264 nationally representative American youth who were followed for 4 years. The independent variable was parental educational attainment. The dependent variable was substance use involvement of biological relatives. Age, gender, and marital status of the family were the covariates. Ethnicity was the moderator. Linear regression was used to analyze the data.

RESULTS

Parental educational attainment was inversely associated with substance use involvement of biological relatives in the pooled sample (OR = 1.36, 95% CI = 1.13 -1.63 for high school graduation and OR = 0.65, 95% CI = 0.53- 0.80 for college graduation). Hispanic ethnicity showed statistically significant interactions with parental educational attainment (OR = 2.26, 95% CI = 1.49 -3.44 for high school graduation and OR = 2.98, 95% CI =1.80 - 4.93 for college graduation), suggesting that the protective effect of parental educational attainment against substance use involvement of biological relatives is smaller for Hispanic youth than for non-Hispanic youth.

CONCLUSIONS

While high parental educational attainment reduces substance use involvement of biological relatives, this protective effect is weaker for Hispanic than non-Hispanic youth. That means, substance use involvement of biological relatives is still high in middle-class Hispanic youth, which increases their risk of substance use. Future research should explore societal and contextual factors that cayuse MDRs of parental educational attainment on substance use of middle-class Hispanic families.

Social Determinants of Hookah Smoking in the United States

Background

Educational attainment and income are two socioeconomic status indicators with strong protective effects against cigarette smoking. Marginalization-related Diminished Returns, however, refer to less than expected protective effects of socioeconomic status indicators for the members of the racial and ethnic minority groups, particularly Blacks and Hispanics, compared to non-Hispanic Whites.

Aim

Borrowing data from a nationally representative study in the US, this study tested whether racial and ethnic differences exist in the effects of educational attainment and poverty status on cigarette smoking of American adults.

Methods

This cross-sectional study entered 28,329 adult participants of the Population Assessment of Tobacco and Health (PATH; 2013). Both educational attainment and poverty status were the independent variables. The dependent variable was current hookah smoking. Age, gender, and region were the covariates. Race and ethnicity were the effect modifiers (moderators).

Results

Overall, individuals with higher educational attainment were more likely to smoke a hookah. Individuals who lived out of poverty, however, had lower odds of current hookah smoking. Race and ethnicity both showed statistical interactions with both socioeconomic indicators suggesting that Blacks and Hispanics with high educational attainment and those who live out of poverty have disproportionately high odds of hookah smoking, compared to non-Hispanic Whites with high socioeconomic status.

Conclusions

In the United States, middle-class racial and ethnic minority people remain at higher risk of smoking hookah. As a result, we should expect a high tobacco burden in middle-class Black and Hispanic adults. We suggest that policymakers should not take an over-simplistic way and reduce the problem of race/ethnic inequalities in tobacco use to gaps in socioeconomic status between groups. Marginalization-related diminished returns generate tobacco disparities in higher socioeconomic status levels. Middle-class racial and ethnic minority people need extra support to stay healthy.

Association of Educational Attainment and Race/Ethnicity With Exposure to Tobacco Advertisement Among US Young Adults

Importance

Associations of educational attainment with improved health outcomes have been found to be weaker among racial/ethnic minority groups compared with those among the racial/ethnic majority group. Recent research has also documented higher than expected prevalence of smoking in highly educated African American and Hispanic adults.

Objective

To compare the association of educational attainment with exposure to tobacco advertisements among racial/ethnic groups of US young adults.

Design, Setting, and Participants

This cross-sectional study included data from 6700 young adults who participated in wave 1 of the Population Assessment of Tobacco and Health Study, a nationally representative survey of US adults in 2013. Educational attainment was classified as less than high school diploma, high school graduate, or college graduate. Analysis was conducted between September 20 and October 4, 2019.

Main Outcomes and Measures

The independent variable was educational attainment (less than high school diploma, high school graduate, and college graduate). The dependent variable was any exposure to tobacco advertisements in the past 12 months. Race/ethnicity, age, sex, poverty status, unemployment, and region were the covariates. Binary logistic and Poisson regression were used to analyze the data.

Results

The study included 6700 participants (3366 [50.2%] men) between ages 18 and 24 years. Most participants were non-Hispanic (5257 participants [78.9%]) and white (5394 participants [80.5%]), while 1443 participants (21.5%) were Hispanic. Educational levels included 1167 participants (17.4%) with less than a high school diploma, 4812 participants (71.8%) who were high school graduates, and 4812 participants (10.8%) who were college graduates. A total of 4728 participants (70.6%) reported exposure to tobacco advertisements in the past 12 months. Exposure to tobacco advertising was reported by 383 participants (53.1%) who were college graduates, 3453 participants (71.8%) who were high school graduates, and 892 participants (76.4%) with less than high school educational attainment. In regression analysis, high school graduation (odds ratio, 0.79; 95% CI, 0.68-0.92) and college graduation (odds ratio, 0.46; 95% CI, 0.39-0.54) were associated with lower odds of exposure to tobacco advertisements compared with young adults with lower educational attainment. Compared with non-Hispanic participants, high school education had a weaker protective association for tobacco advertisement exposure among Hispanic participants (odds ratio, 1.44; 95% CI, 1.03-2.01; P = .03), suggesting that the association of high school graduation with lower exposure to tobacco advertisement is weaker among Hispanic young adults than non-Hispanic young adults.

Conclusions and Relevance

This study found that high school graduation had a weaker inverse association with tobacco advertisement exposure among Hispanic than non-Hispanic young adults. Future research should explore the role of targeted marketing strategies of the tobacco industry that largely advertise tobacco in areas with high concentrations of racial/ethnic minority groups. Future research should also evaluate the efficacy of more restrictive marketing policies on racial/ethnic disparities in tobacco use.

Second-Hand Smoke Exposure at Home in the United States; Minorities' Diminished Returns

Introduction

Educational attainment and poverty status are two strong socioeconomic status (SES) indicators that protect individuals against exposure to second-hand smoke. Minorities' Diminished Returns (MDRs), however, refer to smaller protective effects of SES indicators among ethnic minority groups such as Hispanics and Blacks, compared to non-Hispanic Whites. This study explored ethnic differences in the effects of educational attainment and poverty status on second-hand smoke exposure in the homes of American adults.

Methods

This cross-sectional study included 18,274 non-smoking adults who had participated in the Population Assessment of Tobacco and Health (PATH; 2013). The independent variables were educational attainment and poverty status. The dependent variable was second-hand smoke exposure at home. Age and region of residence were the covariates. Ethnicity was the moderator.

Results

Overall, individuals with a higher educational attainment (odds ratio [OR] = 0.76, 95% CI = 0.74-0.79) and those who lived out of poverty (OR = 0.56, 95% CI =0.51-0.62) had lower odds of second-hand smoke exposure at home. Hispanic ethnicity showed significant interactions with both SES indicators, suggesting that the protective effects of education and poverty on second-hand smoke exposure at home are smaller for Hispanics (ORs for interaction with education and poverty status = 1.30 and 1.26, P < 0.05) than for Non-Hispanics.

Conclusion

In the US, high SES Hispanics remain at high risk of exposure to second-hand smoke at home despite a high education and income. High SES better reduces environmental exposures for non-Hispanic than for Hispanic individuals.

Education Level and Cigarette Smoking: Diminished Returns of Lesbian, Gay and Bisexual Individuals

Background: Education level is one of the strongest protective factors against high-risk behaviors such as cigarette smoking. Minorities' Diminished Returns (MDRs), however, suggest that the protective effects of education level tend to be weaker for racial and ethnic minority groups relative to non-Hispanic White people. Only two previous studies have shown that MDRs may also apply to lesbian, gay, and bisexual (LGB) individuals; however, these studies have focused on outcomes other than tobacco use. Aims: To compare LGB and non-LGB American adults for the effects of education level on cigarette-smoking status. Methods: Population Assessment of Tobacco and Health (PATH; 2013) entered 31,480 American adults who were either non-LGB (n = 29,303, 93.1%) or LGB (n = 2,177; 6.9%). The independent variable was education level. The dependent variable was current established cigarette smoking. Race, ethnicity, age, gender, poverty status, employment, and region were the covariates. LGB status was the moderator. Results: Overall, individuals with higher education level (odds ratio (OR) = 0.69) had lower odds of current established smoking. We found a significant interaction between LGB status and education level suggesting that the protective effect of education level on smoking status is systemically smaller for LGB people than non-LGB individuals (OR for interaction = 1.19). Conclusions: Similar to the patterns that are shown for racial and ethnic minorities, MDRs can be observed for the effects of education level among sexual minorities. In the United States, highly educated LGB adults remain at high risk of smoking cigarettes, a risk which is disproportionate to their education level. In other terms, high education level better helps non-LGB than LGB individuals to avoid cigarette smoking. The result is a relatively high burden of tobacco use in highly educated LGB individuals.

Smoking and Tobacco-Free Policies in Women's Residential Substance Use Disorder Treatment Facilities: A Community-Engaged Approach

Introduction

The purpose of this study was to (1) describe the role of smoking in the lives of women in residential substance use disorder (SUD) treatment and (2) explore perceptions of the facilitators and barriers to tobacco-free policy among women in residential SUD treatment.

Methods

This was a community-engaged study using qualitative descriptive methods. We first recruited women in a residential SUD treatment facility to participate on a community research team. Interviews with staff (N = 10) and focus groups with clients (N = 42) were conducted using guides informed by the community research team. Interviews and focus groups were analyzed using content analysis.

Results

There were two themes related to the role of smoking in the women's lives: (1) smoking facilitates socialization and (2) smoking as a coping mechanism. There were three themes related to the benefits of tobacco-free policy: (1) improved health, (2) support for continued abstinence from a previous tobacco-free placement (eg, prison), and (3) less grounds up-keep. Barriers to tobacco-free policy included (1) lack of an alternative coping mechanism to smoking, (2) fear that a tobacco-free policy would drive clients away, and (3) anticipation of implementation challenges.

Conclusions

Many women in residential SUD treatment smoke, which they attribute to the fact that smoking is used to facilitate socialization and cope with stress. Future research is needed to develop and test messages to counter the misperception that smoking is an effective method to cope with stress. Ultimately, evidence-based tobacco-free policies are needed to reduce tobacco-related disease among women with SUDs.

Implications

To promote smoking cessation among women with substance use disorders through evidence-based tobacco policy, it is necessary to first understand the role of smoking in their lives as well as facilitators and barriers to tobacco-free policy in residential treatment facilities. Participants reported that smoking facilitated socialization and served as a coping mechanism. Tobacco-free policies have many benefits, including improved health, support for continued abstinence from a previous tobacco-free placement (eg, prison), and less grounds up-keep. Barriers include the lack of an alternative coping mechanism, fear that a tobacco-free policy would drive away clients and anticipation of implementation challenges. To reduce the burden of tobacco-related morbidity and mortality among women and their children, it is necessary to catalyze a culture change in behavioral health settings to prioritize the treatment of tobacco alongside treatment of other addictions.

Unequal Effects of Educational Attainment on Workplace Exposure to Second-Hand Smoke by Race and Ethnicity; Minorities' Diminished Returns in the National Health Interview Survey (NHIS)

BACKGROUND

One of the mechanisms by which high educational attainment promotes populations' health is through reducing exposure to environmental risk factors such as second-hand smoke. Minorities' Diminished Returns theory, however, posits that the protective effect of educational attainment may be smaller for racial and ethnic minority individuals particularly Blacks and Hispanics compared to Whites.

AIMS

To explore racial and ethnic differences in the association between educational attainment and second-hand smoke exposure at work in a national sample of American adults.

METHODS

Data came from the National Health Interview Survey (NHIS 2015), a cross-sectional study that included 15,726 employed adults. The independent variable was educational attainment, the dependent variables were any and daily second-hand smoke exposure at workplace, age and gender were covariates, and race and ethnicity were the moderators.

RESULTS

Overall, higher educational attainment was associated with lower odds of any and daily second-hand smoke exposure at work. Race and ethnicity both interacted with educational attainment suggesting that the protective effects of educational attainment on reducing the odds of any and daily second-hand smoke exposure at work are systemically smaller for Blacks and Hispanics than Whites.

CONCLUSIONS

In the United States, race and ethnicity bound the health gains that follow educational attainment. While educational attainment helps individuals avoid environmental risk factors such as second-hand smoke, this is more valid for Whites than Blacks and Hispanics. The result is additional risk of cancer and tobacco related disease in highly educated Blacks and Hispanics. The results are important given racial and ethnic minorities are the largest growing section of the US population. We should not assume that educational attainment is similarly protective across all racial and ethnic groups. In this context, educational attainment may increase, rather than reduce, health disparities.

Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers

This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.

Protective Effects of Educational Attainment Against Cigarette Smoking; Diminished Returns of American Indians and Alaska Natives in the National Health Interview Survey

BACKGROUND

Although educational attainment is protective against health risk behaviors such as smoking, Minorities' Diminished Returns theory posits that these protective effects are smaller for ethnic minority than the majority groups.

AIMS

compare the effects of educational attainment on smoking status of American Indian Alaska Native (AIAN) and White adults.

METHODS

Data came from the National Health Interview Survey (NHIS - 2015). A total number of 21114 individuals entered our analysis. The independent variable was years of schooling. The dependent variable was current smoking status. Age, gender, region, marital status, and employment were covariates. Ethnicity was the moderator.

RESULTS

Overall, educational attainment was inversely associated with current smoking. Ethnicity showed a significant interaction with educational attainment that was suggestive that the protective effects of educational attainment against smoking is smaller for AIAN than Whites.

CONCLUSIONS

In the United States, while educational attainment helps individuals stay healthy by avoiding high risk behaviors such as smoking, this effect is smaller for AIANs than Whites. The result is additional risk of smoking in highly educated AIANs. To reduce ethnic disparities I tobacco use, it is important to go beyond SES inequalities and investigate why high SES ethnic minorities remain at high risk of tobacco use.

The Role of Multiple Social Identities in Discrimination and Perceived Smoking-Related Stigma among Sexual and Gender Minority Current or Former Smokers

AIMS

We investigated how intersections of being a racial minority (i.e. being African American) and economically-disadvantaged (i.e. housing insecurity) may influence experiences with discrimination and perceptions of smoking-related stigma among sexual and gender minority (SGM) current and former smokers. Methods: Survey data were collected from 227 SGM current and former smokers in California (19-65 years old), oversampling African American participants. Participants reported their race, ethnicity, past month housing insecurity, number of lifetime experiences with SGM discrimination, and perceptions of smoking-related stigma.

FINDINGS

Using univariate General Linear Models and controlling for age, ethnicity, and SGM visibility, we found a significant interaction between being African American and facing housing insecurity on experiences with SGM discrimination [F(1,220)=7.21, p=0.01], perceived smoker stigma [F(1,220)=5.48, p=0.02], perceived differential treatment due to smoking [F(1,220)=10.03, p=0.00], and social withdrawal from non-smokers [F(1,220)=6.18, p=0.01]. These interactions suggest that economically-disadvantaged African American SGM current or former smokers experience increased levels of discrimination and perceive more smoking-related stigma compared to other SGM current and former smokers. Conclusions: Results suggest that people's multiple identities intersect to intensify oppression and inequities for some people and raise questions about the unintended consequences of stigmatizing smokers for reducing smoking among SGM adults.

A social-contextual investigation of smoking among rural women: multi-level factors associated with smoking status and considerations for cessation

INTRODUCTION

The social-contextual model of tobacco control and the potential mechanisms of the maintenance or cessation of smoking behavior among disadvantaged women, including rural residents, have yet to be comprehensively studied. The purpose of this study was to determine the association between selected individual, interpersonal, workplace, and neighborhood characteristics and smoking status among women in Appalachia, a US region whose residents experience a disproportionate prevalence of tobacco-related health disparities. These findings may assist in efforts to design and test scientifically valid tobacco control interventions for this and other disadvantaged populations.

METHODS

Women, 18 years of age and older, residing in three rural Ohio Appalachian counties, were recruited using a two-phase address-based sampling methodology for a cross-sectional interview-administered survey between August 2012 and October 2013 (N=408). Multinomial logistic regression was employed to determine associations between select multilevel factors (independent variables) and smoking status (dependent variable). The sample included 82 (20.1%) current smokers, 92 (22.5%) former smokers, and 234 (57.4%) women reporting never smoking (mean age 51.7 years).

RESULTS

In the final multivariable multinomial logistic regression model, controlling for all other significant associations, constructs at multiple social-contextual levels were associated with current versus either former or never smoking. At the individual level, for every additional year in age, the odds of being a former or never smoker increased by 7% and 6% (odds ratio (OR) (95% confidence interval(CI)): 1.07 (1.0-1.11) and 1.06 (1.02-1.09)), respectively, as compared to the odds of being a current smoker. With regard to depression, for each one unit increase in the Center for Epidemiologic Studies Depression Scale score, the odds of being a former or never smoker were 5% and 7% lower (OR(95%CI): 0.95(0.91-0.999) and 0.93(0.88-0.98)), respectively. Five interpersonal factors were associated with smoking status. As the social influence injunctive norm score increased by one unit, indicating perception of smoking to be more acceptable, the odds of being a former or never smoker decreased by 23% and 30%, respectively. For every one unit increase in the social participation score, indicating past-year engagement in one additional activity type, the odds of being a former or never smoker increased by 17% and 36%, respectively. For every 10% increase in the percentage of social ties in the participant's advice network who smoked, the odds of being a former or never smoker were 24% and 28% less, respectively. For every 0.1 unit increase in the E/I index, indicating increasing homophily on smoking in one's social network, the odds of being a former or never smoker were 20% and 24% less, respectively, in the time network, and 18% and 20% less, respectively, in the advice network. At the neighborhood level, for every one unit increase in neighborhood cohesion score, indicating increasing cohesion, the odds of being a former smoker or never smoker were 12% and 14% less, respectively.

CONCLUSIONS

These findings indicate that a social-contextual approach to tobacco control may be useful for narrowing a widening trajectory of smoking disparity for rural women. Interpersonal context, in particular, must be considered in the development of culturally targeted cessation interventions for Ohio Appalachian women.

Reasons for quitting smoking in young adult cigarette smokers

BACKGROUND

Although most young adult smokers want to quit smoking, few can do so successfully. Increased understanding of reasons to quit in this age group could help tailor interventions, but few studies document reasons to quit in young adults or examine reasons to quit by smoker characteristics.

METHODS

In 2011-12, 311 current smokers (age 22-28, M=24.1; 48.9% male, 51.1% female; 50.4% daily smokers) from the Nicotine Dependence in Teens Study completed the Adolescent Reasons for Quitting scale. We assessed differences in the importance of 15 reasons to quit by sex, education, smoking frequency, quit attempt in the past year, perceived difficulty in quitting, and motivation to quit. We also examined differences between participants who discounted the importance of long-term health risks and those who acknowledged such risks.

RESULTS

Concerns about getting sick or still smoking when older were considered very important by >70% of participants. Median scores were higher among daily smokers, those who had tried to quit or who expressed difficulty quitting, and those with strong motivation to quit. Discounters (14.5% of participants) were primarily nondaily, low-consumption smokers. Their Fagerström Test for Nicotine Dependence scores did not differ from non-discounters', and 11% (vs. 35.7% of non-discounters) were ICD-10 tobacco dependent.

CONCLUSIONS

Novel smoking cessation interventions are needed to help young adult smokers quit by capitalizing on their health concerns. Discounters may need educational intervention to better understand the impact of even "light" smoking on their health before or in conjunction with quit interventions.

Family-focussed interventions to reduce harm from smoking in primary school-aged children: A systematic review of evaluative studies

Children living in families where adults smoke are exposed to harmful effects of tobacco smoke and risk a predisposition to smoking initiation. Interventions to support families to reduce risk of harm from smoking have been developed and tested. The purpose of this review is to identify effective family-based interventions used to promote smoke-free home environments in families with primary school age children (aged 5-12years). A systematic search of MEDLINE, Cochrane and CINAHL electronic databases was conducted. Narrative synthesis of included articles was completed. Guidelines for reporting behaviour change interventions were used to summarise and compare intervention timing, content, intensity and delivery. Quality of included studies was critiqued using United States Preventative Services Taskforce (USPST) procedures for internal and external validity. Narrative synthesis was based on methods described by Popay and colleagues. Nineteen articles that evaluated 14 intervention studies focussed on child smoking prevention (n=5), parent smoking cessation (n=4) and environmental tobacco smoke reduction (n=6). Interventions and outcomes were heterogeneous, and were rarely informed by theoretical frameworks relating to family, parenting or child development. Family based interventions may be an important strategy to reduce the effects of smoking for children. There is a need for interventions to be informed by theory relevant to children, parenting and families.

Social determinants of tobacco use: towards an equity lens approach

Tobacco is the only commercial product that eventually kills nearly half of all long-term users. The prevalence of tobacco use is disproportionately high in lower socioeconomic strata and vulnerable groups (such as adolescents) within and across countries. Given its highly addictive nature, tobacco use perpetuates poverty and loss of opportunities, thus undermining the UN Sustainable Development Goals. Moreover, by shaping the national and international context, globalization and governance impact on the tobacco epidemic and underlying disparities. Therefore, socio-economic gradients, which influence predisposition to tobacco uptake and cessation, must be confronted. Here I argue that tobacco prevention and control must be addressed through a lifelong, equity lens approach. This approach describes the essential need for every individual to have equal access to informative prevention and cessation services independent of income, occupational status, social stratum, or residence. I also contend that rather than being occupied with "research on research", the focus should shift to how to practically implement the existing accumulated, cogent body of scientific evidence in a societally equitable manner. Finally, in line with the core dilemma of "who really governs the policies that shape our health?" raised by the WHO's Director General, it is time for civil society either on its own or in partnership with local authorities to formulate policies that implement the "health for all" imperative rather than the currently dominant "wealth for some".

The Gendered Experience of Smoking Stigma: Implications for Tobacco Control

Tobacco denormalization is a widely accepted tobacco control strategy, shaping policies and programs throughout the United States as well as globally. In spite of widespread beliefs about the effectiveness of tobacco denormalization approaches, concerns about their emphasis on stigmatization have emerged. Social science research on smoking stigma raises questions about the potential iatrogenic consequences of tobacco denormalization approaches. Few studies have considered how smoking stigma may be internalized differently by different people, particularly those who experience stigmatization because of other socially-ascribed makers of inequity (e.g. race, ethnicity, gender, sexuality). The intersection of multiple stigmas may work to intensify the "social isolation and marginalization" that some people already experience (Greaves & Hemsing 2009; pg S127). This paper presents results from a pattern-level analysis of focus group and interview data from a study investigating smoking-related stigma and perceptions of tobacco denormalization approaches among 15 low income Black women who smoke in the San Francisco Bay Area. Our analysis revealed a cycle where Black women's experiences with structural oppression resulted in stress and the use of cigarettes to cope with that stress. Though the connection between smoking and stress is well documented in previous research, our analysis further revealed the additional contribution of the stigmatization of smoking and how it intensifies inequity for Black women who smoke. Implications of these findings for tobacco control and prevention are discussed.

Interventions to reduce harm from smoking with families in infancy and early childhood: a systematic review

Exposure to adult smoking can have deleterious effects on children. Interventions that assist families with smoking cessation/reduction and environmental tobacco smoke (ETS) avoidance can improve child health outcomes and reduce the risk of smoking initiation. The purpose of this review was to describe the state of the science of interventions with families to promote smoke-free home environments for infants and young children, including parent smoking reduction and cessation interventions, ETS reduction, and anti-smoking socialisation interventions, using the socio-ecological framework as a guide. A systematic review of peer-reviewed articles identified from journal databases from 2000 to 2014 was undertaken. Of 921 articles identified, 28 were included in the review. Considerable heterogeneity characterised target populations, intervention types, complexity and intensity, precluding meta-analysis. Few studies used socio-ecological approaches, such as family theories or concepts. Studies in early parenthood (child age newborn to one year) tended to focus on parent smoking cessation, where studies of families with children aged 1-5 years were more likely to target household SHSe reduction. Results suggest that interventions for reduction in ETS may be more successful than for smoking cessation and relapse prevention in families of children aged less than 5 years. There is a need for a range of interventions to support families in creating a smoke free home environment that are both tailored and targeted to specific populations. Interventions that target the social and psychodynamics of the family should be considered further, particularly in reaching vulnerable populations. Consideration is also required for approaches to interventions that may further stigmatise families containing smokers. Further research is required to identify successful elements of interventions and the contexts in which they are most effective.

The meanings of smoking to women and their implications for cessation

Smoking cigarettes is a gendered activity with sex- and gender-specific uptake trends and cessation patterns. While global male smoking rates have peaked, female rates are set to escalate in the 21st century, especially in low and middle income countries. Hence, smoking cessation for women will be an ongoing issue and requires refreshed attention. Public health and health promotion messages are being challenged to be increasingly tailored, taking gender into account. Women-centred approaches that include harm-reduction, motivational interviewing and trauma-informed elements are the new frontiers in interventions to encourage smoking cessation for women. Such approaches are linked to the meanings of smoking to women, the adaptive function of, and the overall role of smoking cigarettes in the context of women’s lives. These approaches respect gender and sex-related factors that affect smoking and smoking cessation and respond to these issues, not by reinforcing destructive or negative gender norms, but with insight. This article discusses a women-centred approach to smoking cessation that could underpin initiatives in clinical, community or public health settings and could inform campaigns and messaging.

Gender, smoking and tobacco reduction and cessation: a scoping review

Considerations of how gender-related factors influence smoking first appeared over 20 years ago in the work of critical and feminist scholars. This scholarship highlighted the need to consider the social and cultural context of women's tobacco use and the relationships between smoking and gender inequity. Parallel research on men's smoking and masculinities has only recently emerged with some attention being given to gender influences on men's tobacco use. Since that time, a multidisciplinary literature addressing women and men's tobacco use has spanned the social, psychological and medical sciences. To incorporate these gender-related factors into tobacco reduction and cessation interventions, our research team identified the need to clarify the current theoretical and methodological interpretations of gender within the context of tobacco research. To address this need a scoping review of the published literature was conducted focussing on tobacco reduction and cessation from the perspective of three aspects of gender: gender roles, gender identities, and gender relations. Findings of the review indicate that there is a need for greater clarity on how researchers define and conceptualize gender and its significance for tobacco control. Patterns and anomalies in the literature are described to guide the future development of interventions that are gender-sensitive and gender-specific. Three principles for including gender-related factors in tobacco reduction and cessation interventions were identified: a) the need to build upon solid conceptualizations of gender, b) the importance of including components that comprehensively address gender-related influences, and c) the importance of promoting gender equity and healthy gender norms, roles and relations.

Tobacco and alcohol use in the context of adolescent pregnancy and postpartum: a scoping review of the literature

Adolescent girls are more likely than women of other ages to smoke tobacco or drink alcohol during pregnancy. The health impacts of smoking and drinking for girls and the interconnections between alcohol and tobacco use with adolescent pregnancy underscore the urgent need for integrated approaches to prevent and reduce alcohol and tobacco use among pregnant girls/young women. This article reports on the results of a scoping review of the literature focused on adolescents' use of tobacco and alcohol during pregnancy and postpartum. A search of CINAHL, Medline, Social Science Index and Web of Science identified 40 articles published in the two decades between 1990 and 2012 that met our inclusion criteria related to this age group, pregnancy/motherhood status, and use of both alcohol and tobacco. The review points to compelling gaps in our knowledge and our responsiveness to adolescents aged 19 and under who use alcohol and tobacco during pregnancy and the postpartum period. Research has been primarily descriptive, with separate, parallel streams of investigation to identify trends and predictors of alcohol and tobacco use, prior to, during and following pregnancy. There is a marked lack of effective interventions described in the literature that are designed to prevent or reduce alcohol and tobacco use during pregnancy among adolescent girls; and there are few examples of gender-informed prevention or treatment programmes for this population. Research is needed on interventions that attend to the context of adolescent girls' substance use as well as their preferences and developmental needs for support that encourage sustained behaviour change throughout pregnancy and the postpartum period and that effectively address the influence of partners and friends on use.

Exploring promising gender-sensitive tobacco and alcohol use interventions: results of a scoping review

This review examined the breadth of gender-sensitive tobacco and alcohol interventions that target girls and women. A comprehensive review of databases and websites was conducted in 2011/2012 for interventions that focused on girls and women health, incorporated an understanding of sex and/or gender, engaged with the determinants of women's health, and sought to reduce gender-related social and health inequities. Results of the review suggest that interventions designed with an understanding of the effect of gender roles, norms, and behaviors on women's health are limited and that much work remains to encourage practitioners to use a gender-sensitive approach when designing interventions.

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.

Personal and social determinants sustaining smoking practices in rural China: a qualitative study

Introduction

Tobacco use in China is disproportionally distributed among rural and urban populations with rural people smoking more. While there is a wealth of evidence on the association between tobacco use among rural people and their lower socio-economic status (SES), how social structural factors contribute to rural smoking is not well understood. Guided by a socio-ecological model, the objective of this study was to explore the personal and social determinants that play a key role in sustaining smoking practices among Chinese rural people.

Methods

An ethnographic study was conducted in a rural area of Central Jiangsu, China. Participants (n = 29) were recruited from families where there was at least one smoking resident and there were young children. In-depth interviews and unstructured observations were used to collect data, which were then analyzed with an interpretive lens.

Results

Although individuals had limited knowledge about the risks of smoking and lack of motivation to quit, social factors were in effect the main barriers to quitting smoking. Cigarette exchange and cigarette gifting permeated every aspect of rural family life, from economic activities to leisure pastimes, in family and wider social interactions. Traditional familism and collectivism interplayed with the pro-smoking environment and supported rural people’s smoking practices at the community level. Living in the rural area was also a barrier to quitting smoking because of the lack of information on smoking cessation and the influence of courtyard-based leisure activities that facilitated smoking.

Conclusion

Development of comprehensive smoking cessation interventions in rural China needs to extend beyond an individual level to take into account the social determinants influencing smoking practices.

The many faces of tobacco use among women

Smoking is still considered to be mainly a male problem. However, it is estimated that there are approximately 250 million women worldwide who smoke cigarettes and millions more women who use smokeless tobacco products. This article addresses the many facets of tobacco use among women. The aim of the paper is to increase recognition among clinicians and researchers of the specific characteristics of female tobacco use. Together with providing epidemiological data on the distribution of tobacco use among women and data from population-based analyses on sociocultural factors that influence it, the article presents tobacco use during pregnancy as a particularly important public health problem. Further, the article points out sex-related differences (ie, physiological, psychological, or behavioral) between male and female tobacco use. A special focus is on the important role of ovarian hormones. Adverse effects of tobacco use to women and their children as well as tobacco-related morbidities and comorbidities are presented, and women's greater susceptibility to tobacco constituents as compared to men is stressed. Awareness of these differences can contribute to improvement of the effectiveness of smoking cessation programs addressed both to the specific female population and to an individual smoking woman.

The effect of psychosocial stress on single mothers' smoking

Background

Evidence suggests an increased risk of smoking among single mothers as compared to their cohabitating counterparts. This article examines the role of psychosocial stress in mediating the relationship between single motherhood and smoking.

Methods

Data were derived from a cross-sectional population based sample of German women (n = 3129) with underage children (0–18 years of age). Perceived stress was measured with 13 items covering socioeconomic as well as family- and parenting-related stressors. According to Baron and Kenny (1986) a series of logistic regression models was applied to investigate the role of psychosocial stress as a mediator on the relationship between single motherhood and smoking.

Results

About 44.0% of single mothers smoked daily, whereas only 26.2% of cohabitating mothers did. Single mothers reported more stress related to their economic situation, occupation and family than partnered mothers. Out of the original 13 stressors only 'conflicts with the partner or ex-partner’ and 'financial worries’ remained significant in explaining single mothers’ higher risk of smoking. Against expectation, stress due to household requirements and family demands was associated with lower odds of single mothers’ smoking. After controlling for psychosocial stress, the odds ratio of single mothers’ moderate smoking (< 20 cig./day) decreased slightly from 1.75 to 1.66 (explained fraction XF = 12.0%) and with respect to heavy smoking (≥ 20 cig./day) more pronounced from 2.56 to 2.01 (XF = 35.3%).

Conclusions

It can be stated that single mothers’ heavy more than moderate smoking appeared to be mediated by perceived psychosocial stress. Out of all stressors considered, financial worries were of paramount significance in explaining single mothers’ heavy smoking while some family-related stressors rather appeared to keep single mothers from smoking. Overall, a higher stress exposure explains partly but not sufficiently single mothers’ increased smoking rates.

Predictors of Voluntary Home-Smoking Restrictions and Associations with an Objective Measure of In-Home Smoking among Subsidized Housing Tenants

Purpose.

Examine predictors of voluntary home-smoking restrictions (HSRs) and associations with an objective measure of in-home smoking.

Design.

Cross-sectional.

Setting.

Publicly subsidized multiunit housing units managed by private company in Columbus, Ohio, without a smoke-free housing policy.

Subjects.

Probability sample of primary leaseholders (N = 301, 64% response rate).

Measures.

Self-reported knowledge, attitudes, and behaviors collected during face-to-face survey in fall 2011, including individual (e.g., knowledge of health effects), social (e.g., number of friends who smoke), and environmental (e.g., safety) factors hypothesized to be related to having HSRs. Surface nicotine concentration (μg/m2) based on samples collected from wood surface in respondents' living rooms (n = 279).

Analysis.

Multiple linear and logistic regression were used to identify factors associated with having HSRs and with indoor surface nicotine concentrations.

Results.

Fewer than one-third (29.2%) of tenants had complete HSRs, while more than half (55.8%) had partial restrictions. Several individual and social factors, but no environmental/community factors, were associated with having HSRs. Type of HSRs (p < .001) and smoking status (p < .001) were independently associated with mean surface nicotine concentrations.

Conclusion.

Few subsidized housing tenants voluntarily limit in-home smoking. Partial restrictions could be considered as a harm reduction strategy but may be less effective among smokers. Strategies to change social norms are also needed to modify in-home smoking behavior among subsidized housing tenants.

The gender-specific association between asthma and the need to smoke tobacco

OBJECTIVES

To examine the associations between multidimensional tobacco dependence and youths' asthma status with gender as an effect modifier.

BACKGROUND

Despite the adverse respiratory effects, some adolescents with asthma smoke tobacco. Girls and boys have been shown to have different motivations for tobacco use.

METHODS

Secondary analyses were conducted of data obtained from 1248 adolescents who completed the British Columbia Youth Survey of Smoking and Health II. The sample was limited to youth who reported current or experimental tobacco use and who provided asthma status information. Tobacco dependence was assessed with the modified-Fagerström Tolerance Questionnaire and four-dimension Adolescents' Need for Smoking Scale (ANSS), which assesses social dependence, physical dependence, emotional dependence, and sensory dependence on tobacco. All analyses were stratified by gender.

RESULTS

The sample was 535 boys and 713 girls who were 15.9 years of age (SD = 1.5), on average. Gender was associated with both self-reported asthma status and the physical dependence dimension of the ANSS. Multiple linear regression analyses revealed that girls with asthma, compared with girls without asthma, had higher physical tobacco dependence scores, after adjusting for demographic and other factors. None of the tobacco dependence dimensions was associated with the asthma status of boys.

CONCLUSIONS

Asthmatic girls who report smoking may be doing so because they develop physical dependence relatively quickly and lose their autonomy with respect to tobacco use. They may require significant support for smoking cessation, including cognitive behavioral therapy and nicotine replacement therapy.

Space and power: young mothers' management of smoking in extended families in China

Multigenerational co-residence is a widespread phenomenon in China but there is little knowledge about the impact of power dynamics on smoking behaviors among extended family residents. Using a gender lens, this ethnographic study explored how young mothers in extended families in mainland China managed the smoking of their husbands and other family members. Analysis of data resulted in a model of 'two units-three domains' to reflect gendered relationships between young mothers and other family members, and young mothers' participation in family management. Exploration of the mothers' efforts to deal with household smoking using the model provided an explanation for why the young mothers had limited control over household space and could only impose partial restrictions on home smoking in the extended family.

Individual, social, and environmental factors associated with support for smoke-free housing policies among subsidized multiunit housing tenants

INTRODUCTION

Mandatory smoke-free policies in subsidized, multiunit housing (MUH) may decrease secondhand smoke exposure in households with the highest rates of exposure. Ideally, policies should be based on a strong understanding of factors affecting support for smoke-free policies in the target population to maximize effectiveness.

METHODS

A face-to-face survey was conducted from August to October 2011 using a stratified random sample of private subsidized housing units in Columbus, OH, without an existing smoke-free policy (n = 301, 64% response rate). Lease holders were asked to report individual, social, and environmental factors hypothesized to be related to support for smoke-free policies. Multiple logistic regression models were used to identify factors independently associated with policy support.

RESULTS

Most tenants supported smoke-free policies in common areas (82.7%), half supported policies inside units (54.5%), and one third supported a ban outside the building (36.3%). Support for smoke-free policies in units and outdoors was more common among nonsmokers than smokers (71.5% vs. 35.7%, p < .001 and 46.2% vs. 25.4%, p < .001, respectively). Several individual and social, but no environmental, factors were independently associated with policy support. Smokers who intended to quit within 6 months or less were more likely than other smokers to support in-unit policies (45.3% vs. 21.1%; p = .003).

CONCLUSIONS

More than half of subsidized MUH tenants supported smoke-free policies inside their units. Strategies to address individual- and social-level barriers to behavior change should be implemented in parallel with smoke-free policies. Policies should be evaluated with objective measures to determine their effectiveness.

Sex differences in nicotine dependence among addictions clients accessing a smoking cessation programme in Vancouver, British Columbia, Canada

Most individuals in drug treatment programmes use tobacco and are dependent on nicotine. For 323 participants (65% men, mean age = 49.3 years) with a history of substance use disorder (SUD) and/or psychiatric disorders (PD) enrolled in a tobacco dependence clinic programme, we compared baseline characteristics among women and men and examined factors associated with nicotine dependence (ND). Individuals with mood, anxiety and psychotic disorders were more likely to be female, whereas men were more likely to be characterized by alcohol, cocaine and marijuana use, older age, older age at smoking initiation and higher confidence in quitting smoking scores. In stratified multivariate analyses, among women, history of an anxiety disorder and a greater number of cigarettes smoked per day were associated with higher ND scores; among men, a greater number of cigarettes smoked per day and higher confidence in quitting scores were associated with higher ND scores. Given the differences in smoking, SUD and PD histories between women and men accessing addiction treatment, and differential associations with ND, it is important to further explore factors that may enhance tailored treatments and inform future studies examining biological and psychosocial factors for tobacco use in SUD and PD treatment populations.

Smoking and behavioral health of women

BACKGROUND

Using data from a study of reliability and validity of a screening tool for co-occurring substance abuse and mental health problems, our objective was to compare behavioral health issues of female smokers and nonsmokers and explore correlates of smoking.

METHODS

Using a convenience sample (n=1021), we recruited participants to complete an online survey conducted in substance abuse treatment, primary care, mental health services, senior, and public settings. The survey included demographic questions, smoking status, the co-occurring disorders screening tool, the Global Appraisal of Individual Needs-Short Screener (GAIN-SS) and the Postraumatic Stress Disorder Checklist (PCL)-Civilian.

RESULTS

One third of participants self-identified as smokers, and African American, American Indian, and bisexual women reported the highest rates of smoking. Seventy-two percent of women reported at least one mental health problem in the past year; 29% had a past year substance abuse problem, and 26% reported a past year co-occurring disorder of both. Smokers had significantly higher rates of posttraumatic stress disorder (PTSD), past year depression and anxiety, suicidality, past year substance abuse, and co-occurring disorders. Smokers also had significantly higher rates of lifetime intimate partner violence (IPV) and childhood abuse.

CONCLUSIONS

Smoking in women was associated with significantly higher rates of mental health and substance abuse problems. Substance abuse, being in a treatment setting, IPV, African American and mixed ethnicity, Medicaid insurance status, reduced income, and no home ownership were identified as predictors of smoking. Screening and evaluation of smoking status, mental health, substance use disorders, and the presence and impact of violence are essential for women's health.

The role of worksite and home smoking bans in smoking cessation among U.S. employed adult female smokers

PURPOSE

Examine the association of work and home smoking bans with quitting behaviors among employed female smokers in the United States.

DESIGN

Secondary analyses using cross-sectional data from the 2006/2007 Tobacco Use Supplement to the Current Population Survey.

SUBJECTS

Nationally representative sample of 7610 U.S. employed female smokers, aged 18 to 64 years, who reported working indoors. Setting . N/A.

METHODS

Multivariate logistic regression analyses were conducted to examine the association of smoking ban policies (complete work and home bans, complete work ban only, complete home ban only, and no complete work or home ban) with intention to quit in the next 30 days, at least one quit attempt in the past year, and sustained abstinence of at least 3 months in the past year.

RESULTS

Twenty-nine percent of women reported complete work and home smoking bans. Smoking bans were not associated with intention to quit and were marginally associated with sustained abstinence. Regardless of intention to quit, women with complete work and home bans were significantly more likely than those without complete work and home bans to report quit attempts. Among women with no intention to quit, the odds of having a quit attempt were significantly higher among women who had a complete home ban only compared with women without complete work and home bans.

CONCLUSIONS

Efforts to promote quitting behaviors among employed female smokers may be facilitated by increasing rates of complete smoking bans at both work and home settings.

Will cardiovascular disease prevention widen health inequalities?

Simon Capewell and Hilary Graham review different population strategies for preventing cardiovascular disease and conclude that screening and treating high-risk individuals may be ineffective and widen social inequalities.

The role of social support and social networks in smoking behavior among middle and older aged people in rural areas of South Korea: a cross-sectional study

Background

Although the number of studies on anti-smoking interventions has increased, studies focused on identifying social contextual factors in rural areas are scarce. The purpose of this study was to explore the role of social support and social networks in smoking behavior among middle and older aged people living in rural areas of South Korea.

Methods

The study employed a cross-sectional design. Participants included 1,057 adults, with a mean age of 60.7 years, residing in rural areas. Information on participants' tobacco use, stress, social support, and social networks was collected using structured questionnaires. The chi-square test, the t-test, ANOVA, and logistic regression were used for data analysis.

Results

The overall smoking prevalence in the study was 17.4% (men, 38.8%; women, 5.1%). Overall, stress was high among women, and social support was high among men. Smokers had high levels of social support (t = -2.90, p = .0038) and social networks (t = -2.22, p = .0271), as compared to non- and former smokers. Those in the high social support group were likely to be smokers (AOR = 2.21, 95% CI 1.15-4.26). Women with moderate social ties were less likely to smoke (AOR = 0.18, 95% CI 0.05-0.61).

Conclusion

There was a protective role of a moderate social network level among women, and a high level of social support was associated with smoking behaviors in rural areas. Findings suggest the need for a comprehensive understanding of the functions and characteristics of social contextual factors including social support and social networks in order to conduct more effective anti-smoking interventions in rural areas.

Educational disadvantage and cigarette smoking during pregnancy

This study examined the influence of education on smoking status in a cohort (n=316) of pregnant women who were smokers at the time they learned of the current pregnancy. Subjects were participants in clinical trials examining the efficacy of monetary-based incentives for smoking-cessation and relapse prevention. In multivariate analyses, educational achievement was a robust predictor of smoking status upon entering prenatal care, of achieving abstinence antepartum among those still smoking at entry into prenatal care, and of smoking status at 6-month postpartum in the entire cohort and the subsample who received smoking-cessation treatment. In addition to educational attainment, other predictors of smoking status included smoking-related characteristics (e.g., number of cigarettes/day smoked pre-pregnancy), treatment, maternal age, and stress ratings. We suggest that strategies to increase educational attainment be included with more conventional tobacco-control policies in efforts to reduce smoking among girls and young women.