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Zvolensky MJ, Shepherd JM, Clausen BK, Redmond BY, De Dios M, Cano MÁ. Combustible cigarette smokers versus dual combustible and electronic users: Evaluation of differences in anxiety, depression, and transdiagnostic constructs among Latinx adults. J Ethn Subst Abuse 2024:1-18. [PMID: 39145994 DOI: 10.1080/15332640.2024.2391309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
Research on dual combustible and electronic nicotine use among Latinx persons is needed to better understand patterns of use because this group is an established tobacco disparities population. Negative emotional symptoms and related processes (e.g., reactive transdiagnostic vulnerabilities) have been among the most prominent factors linked to the onset, maintenance, and relapse of smoking. As such, the current study sought to compare levels of mental health symptoms among combustible users compared to dual combustible and electronic users among Latinx persons who smoke. The current sample consisted of 297 adult Latinx daily cigarette smokers (Mage = 35.90 years; SD = 8.87; age range 18-61; 36.4% female), of which 92 reported current dual use of an e-cigarette (Mage = 33.34 years; SD = 7.75; age range 19-60; 28.3% female). Differences in anxiety, depression, anxiety sensitivity, emotion dysregulation, and distress tolerance were examined, and we hypothesized that dual users would showcase higher mental health problems. Results indicated that adult Latinx dual users evidenced greater levels of anxiety, depression, emotional dysregulation, anxiety sensitivity, and lower levels of distress tolerance compared to combustible users. The current study sheds light on the clinical importance of affective differences among dual versus combustible Latinx smokers.
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Affiliation(s)
- Michael J Zvolensky
- Department of Psychology, University of Houston, Houston, Texas, USA
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- HEALTH Institute, University of Houston, Houston, Texas, USA
| | - Justin M Shepherd
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Bryce K Clausen
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Brooke Y Redmond
- Department of Psychology, University of Houston, Houston, Texas, USA
| | - Marcel De Dios
- Department of Psychological, Health, and Learning Sciences, University of Houston, Houston, Texas, USA
| | - Miguel Ángel Cano
- Peter O'Donnell Jr. School of Public Health, The University of Texas Southwestern Medical Center, Houston, Texas, USA
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2
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Santiago-Torres M, Kwon DM, Mull KE, Sullivan BM, Ahluwalia JS, Alexander AC, Nollen NL, Bricker JB. Efficacy of Web-Delivered Acceptance and Commitment Therapy (ACT) for Helping Black Adults Quit Smoking. J Racial Ethn Health Disparities 2023; 10:2816-2825. [PMID: 36414931 DOI: 10.1007/s40615-022-01458-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Digital smoking cessation interventions may reduce racial disparities in cessation because they are low cost, scalable, and can provide support at any place or time. Despite their promise, whether Black adults engage with and benefit from these tools is largely unknown. In a secondary analysis of a randomized trial, we explored the efficacy of an acceptance and commitment therapy (ACT)-based website (WebQuit) for smoking cessation compared to a US clinical practice guidelines-based website (Smokefree.gov) among Black adults. METHODS A total of 316 Black adult smokers were enrolled in the trial between May 2017 and September 2018 and received access to WebQuit or Smokefree for 12 months. Participants self-reported on 30-day and 7-day abstinence from cigarette smoking at 3, 6, and 12-months. Treatment engagement was objectively measured and compared between arms. Participants also reported on their willingness to accept cues to smoke without smoking. RESULTS WebQuit versus Smokefree participants engaged more with their website (higher number of logins, Incidence Rate Ratio (IRR) = 2.21; 95% CI: 1.70, 2.89). Complete-case 30-day point prevalence abstinence (PPA) at 12-months was 34% for WebQuit vs. 29% for Smokefree (OR = 1.22 95% CI: 0.73, 2.04). Increases in participants' willingness to accept cues to smoke mediated the intervention effect on abstinence from cigarette smoking at 12 months. CONCLUSIONS This study addressed the lack of research on the utilization and efficacy of digital interventions for helping Black adults quit smoking. WebQuit participants engaged more with their website and quit smoking at a somewhat higher rate relative to Smokefree participants, albeit nonsignificant. Findings suggest high acceptability of ACT-based digital interventions to enable Black adult smokers to engage and sustain behavior changes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01812278.
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Affiliation(s)
- Margarita Santiago-Torres
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Center, 1100 Fairview Avenue North, Seattle, WA, 98109, USA.
| | - Diana M Kwon
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Center, 1100 Fairview Avenue North, Seattle, WA, 98109, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Kristin E Mull
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Center, 1100 Fairview Avenue North, Seattle, WA, 98109, USA
| | - Brianna M Sullivan
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Center, 1100 Fairview Avenue North, Seattle, WA, 98109, USA
| | - Jasjit S Ahluwalia
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, 02912, USA
| | - Adam C Alexander
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Nicole L Nollen
- Department of Population Health, University of Kansas School of Medicine, 3901 Rainbow Boulevard Mail Stop 1008, Kansas City, KS, 66160, USA
| | - Jonathan B Bricker
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Center, 1100 Fairview Avenue North, Seattle, WA, 98109, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
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3
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Cwalina SN, Ihenacho U, Barker J, Smiley SL, Pentz MA, Wipfli H. Advancing racial equity and social justice for Black communities in US tobacco control policy. Tob Control 2023; 32:381-384. [PMID: 34526408 PMCID: PMC8920941 DOI: 10.1136/tobaccocontrol-2021-056704] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/02/2021] [Indexed: 11/03/2022]
Abstract
The US Food and Drug Administration (FDA) applies the Population Health Standard in tobacco product review processes by weighing anticipated health benefits against risks associated with a given commercial tobacco product at the population level. However, systemic racism (ie, discriminatory policies and practices) contributes to an inequitable distribution of tobacco-related health benefits and risks between white and Black/African Americans at the population level. Therefore, Black-centered, antiracist data standards for tobacco product review processes are needed to achieve racial equity and social justice in US tobacco control policy. Regardless of whether FDA implements such data standards, non-industry tobacco scientists should prioritise producing and disseminating Black-centred data relevant to FDA's regulatory authority. We describe how systemic racism contributes to disparities in tobacco-related outcomes and why these disparities are relevant for population-level risk assessments, then discuss four possible options for Black-centred data standards relevant to tobacco product review processes.
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Affiliation(s)
- Sam N Cwalina
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Ugonna Ihenacho
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Joshua Barker
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Sabrina L Smiley
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Mary Ann Pentz
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
| | - Heather Wipfli
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
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4
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Barroso-Hurtado M, Suárez-Castro D, Martínez-Vispo C, Becoña E, López-Durán A. Perceived Stress and Smoking Cessation: The Role of Smoking Urges. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1257. [PMID: 36674019 PMCID: PMC9859085 DOI: 10.3390/ijerph20021257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/28/2022] [Accepted: 01/06/2023] [Indexed: 06/17/2023]
Abstract
Despite the fact that perceived stress is related to abstinence smoking outcomes, no studies have investigated the mediational effect of specific tobacco-related variables on this relationship. This study aimed to explore the indirect effect of perceived stress on abstinence at the end of treatment through smoking urges. The sample comprised 260 treatment-seeking smokers (58.5% female; Mage = 46.00; SD = 11.1) who underwent psychological smoking cessation treatment. The brief version of the Questionnaire of Smoking Urges (QSU) and the Perceived Stress Scale (PSS14) were used. Mediation analyses were conducted in which smoking urges and their dimensions were potential mediators in the relationship between perceived stress and abstinence at the end of treatment. The results showed a non-significant direct effect of perceived stress on abstinence. However, a significant indirect effect was found through smoking urges (QSU-total) and, specifically, through smoking urges associated with the expectation of negative affect relief (QSU-Factor 2). A non-significant indirect effect through smoking urges related to the expectation of tobacco use as a pleasurable experience (QSU-Factor 1) was also found. Analyzing possible mediator variables could contribute to understanding previous conflicting data. These findings point to potential interest in including treatment components targeting perceived stress and smoking urges to improve the effectiveness of smoking cessation treatments.
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Affiliation(s)
- María Barroso-Hurtado
- Smoking and Addictive Disorders Unit, Department of Clinical Psychology and Psychobiology, University of Santiago de Compostela, 15782 Santiago de Compostela, Spain
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Shpigel DM, Gittleman JM, Estey D, Birchwale JT, Rosensweig SR, Sullivan D, Lalani S, De La Fuente A, Mercedes E, Weinberger AH. Psychosocial and psychiatric-related stress and cigarette smoking among Black and Latinx adults with psychiatric disorders. J Ethn Subst Abuse 2023; 22:260-284. [PMID: 34139960 DOI: 10.1080/15332640.2021.1938328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
While the cigarette smoking prevalence in the United States has decreased, smoking disparities persist for individuals with psychiatric disorders and individuals who identify as racial/ethnic minorities. These groups also experience higher levels of psychosocial stress. This study was the first to examine the relationship between psychosocial and psychiatric-related stressors and cigarette smoking status in a sample of Black and Latinx adults with psychiatric illness. Stress associated with friend strain, lifetime discrimination, and attending appointments for psychotropic medication management were associated with cigarette smoking. The present results have implications for integrating smoking cessation interventions into mental health treatment settings.
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Affiliation(s)
- Danielle M Shpigel
- Ferkauf Graduate School of Psychology, Bronx, New York.,Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - David Estey
- Ferkauf Graduate School of Psychology, Bronx, New York
| | | | - Shayna Rabin Rosensweig
- Ferkauf Graduate School of Psychology, Bronx, New York.,Fairleigh Dickinson University, Teaneck, New Jersey
| | | | - Shama Lalani
- Lincoln Hospital, Bronx, New York.,BronxCare Health System, Bronx, New York
| | - Angelica De La Fuente
- Lincoln Hospital, Bronx, New York.,New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Enmanuel Mercedes
- Lincoln Hospital, Bronx, New York.,Zufall Health Center, West Orange, New Jersey
| | - Andrea H Weinberger
- Ferkauf Graduate School of Psychology, Bronx, New York.,Albert Einstein College of Medicine, Bronx, New York
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Avila JC, Sokolovsky AW, Nollen NL, Lee J, Schmid CH, Ahluwalia JS. The effect of race/ethnicity and adversities on smoking cessation among U.S. adult smokers. Addict Behav 2022; 131:107332. [PMID: 35436698 PMCID: PMC9870094 DOI: 10.1016/j.addbeh.2022.107332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 03/31/2022] [Accepted: 04/06/2022] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Black and Hispanic individuals in the US experience more socioeconomic adversities that are associated with disparities in tobacco use and cessation than White individuals. This study examined if racial/ethnic differences in smoking abstinence were mediated by socioeconomic (SES) adversities. METHODS Data from 7,101 established smokers were identified in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) and followed to Wave 4 (2016-2018). The study outcome was cigarette abstinence at Wave 4. The main independent variable was race/ethnicity (Non-Hispanic White [White], Non-Hispanic Black [Black] and Hispanic). The mediators were five measures of SES adversities (unemployment, poverty, difficulty with money, lower education level, lack of health insurance). A weighted Generalized Structural Equation Model (GSEM) was used to estimate the total, direct, and indirect effect of race/ethnicity on the odds of quitting mediated by the five SES adversities. This model was adjusted by study covariates, including health and smoking characteristics. RESULTS The indirect effect of race/ethnicity on cessation showed that differences in quitting between Black and White individuals as well as Hispanic and White individuals were mediated by SES adversities. However, the differences in quitting between Hispanic and Black individuals were not mediated by SES adversities. Black and Hispanic individuals were less likely to quit than White individuals, but Hispanic individuals were more likely to quit than Black individuals. There were no direct effects between Black or Hispanic individuals compared to White individuals. Those with higher SES were more likely to quit compared to those with lower SES. DISCUSSION Smoking abstinence is higher in White individuals compared to Black and Hispanic individuals and is mediated by SES adversities. However, smoking abstinence is higher among Hispanic individuals compared to Black individuals and it is not mediated by SES adversities. Future studies should consider the role of other factors, such as psychosocial support, racism, discrimination, and stress over the life course in explaining differences in smoking abstinence between Black and Hispanic individuals.
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Affiliation(s)
- Jaqueline C. Avila
- Department of Behavioral and Social Sciences and Center for Alcohol and Addiction Studies, School of Public Health, Brown University, United States,Corresponding author at: 121 S Main street, Box G-S121-4, Providence, RI 02912, United States. (J.C. Avila)
| | - Alexander W. Sokolovsky
- Department of Behavioral and Social Sciences and Center for Alcohol and Addiction Studies, School of Public Health, Brown University, United States
| | - Nicole L. Nollen
- Department of Population Health, School of Medicine, University of Kansas Medical Center, United States
| | - Juhan Lee
- Department of Psychiatry, School of Medicine, Yale University, United States
| | - Christopher H. Schmid
- Department of Biostatistics, School of Public Health, Brown University, United States
| | - Jasjit S. Ahluwalia
- Department of Behavioral and Social Sciences and Center for Alcohol and Addiction Studies, School of Public Health, Brown University, United States,Department of Medicine, Alpert School of Medicine, Brown University, United States
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7
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Santiago-Torres M, Mull KE, Sullivan BM, Kwon D, Nollen NL, Zvolensky MJ, Bricker JB. Efficacy and utilization of an acceptance and commitment therapy-based smartphone application for smoking cessation among Black adults: secondary analysis of the iCanQuit randomized trial. Addiction 2022; 117:760-771. [PMID: 34890104 PMCID: PMC9798432 DOI: 10.1111/add.15721] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 10/11/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Black adults who smoke are less likely to seek treatment and to succeed in quitting compared with other racial groups. The lack of efficacious and engaging trials for smoking cessation further contributes to this disparity. This study explored whether an acceptance and commitment therapy (ACT)-based smartphone application (iCanQuit) was more efficacious for smoking cessation than a United States Clinical Practice Guidelines (USCPG)-based smartphone application (QuitGuide) among Black adults. DESIGN Secondary analysis of a two-arm randomized trial with 12-month follow-up. SETTING United States (US). PARTICIPANTS A total of 554 Black adults who smoke daily were recruited from 34 US states and enrolled between May 2017 and September 2018. INTERVENTIONS Participants were randomized to receive iCanQuit (n = 274) or QuitGuide (n = 280) for 12 months. MEASUREMENTS Smoking cessation outcomes were measured at 3, 6, and 12 months. The primary outcome was self-reported complete-case 30-day point prevalence abstinence (PPA) at 12 months. Secondary outcomes were 7-day PPA, missing-as-smoking imputation, multiple imputation, prolonged abstinence, and cessation of all tobacco products at 12 months. Study retention, treatment engagement, and change in ACT-based processes were also compared between arms. FINDINGS Study retention was 89% at 12 months and did not differ by arm (P > 0.05). The complete-case 30-day PPA was 28% for iCanQuit versus 20% for QuitGuide at 12 months (odds ratio [OR] = 1.60; 95% confidence interval [CI] = 1.03, 2.46). Similar associations were observed for the missing-as-smoking imputation, although non-significant (25% iCanQuit vs 18% QuitGuide; OR = 1.50; 95% CI = 0.98, 2.30). iCanQuit vs QuitGuide participants were significantly more engaged with iCanQuit application as measured by the number of logins from baseline to 6 months (incidence rate ratio = 3.26; 95% CI = 2.58, 4.13). Increased acceptance of cues to smoke mediated the effect of treatment on cessation (indirect effect: OR = 0.20; 95% CI = 0.05, 0.29). CONCLUSIONS Among Black adults, an acceptance and commitment therapy-based smartphone application appeared to be more efficacious and engaging for smoking cessation than the United States Clinical Practice Guidelines-based QuitGuide application.
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Affiliation(s)
- Margarita Santiago-Torres
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kristin E. Mull
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Brianna M. Sullivan
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Diana Kwon
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
| | - Nicolle L. Nollen
- Department of Preventive Medicine, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Michael J. Zvolensky
- Department of Psychology, University of Houston, Houston, TX, USA
- HEALTH Institutive, University of Houston, Houston, TX, USA
- MD Anderson Cancer Center, University of Texas, Houston, TX, USA
| | - Jonathan B. Bricker
- Division of Public Health Sciences, Cancer Prevention Program, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Department of Psychology, University of Washington, Seattle, WA, USA
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8
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Webb Hooper M, Calixte-Civil P, Verzijl C, Brandon KO, Asfar T, Koru-Sengul T, Antoni MH, Lee DJ, Simmons VN, Brandon TH. Associations between Perceived Racial Discrimination and Tobacco Cessation among Diverse Treatment Seekers. Ethn Dis 2020; 30:411-420. [PMID: 32742143 PMCID: PMC7360180 DOI: 10.18865/ed.30.3.411] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Objectives This study investigated a) racial/ethnic differences in past-year discrimination experiences and b) associations between discrimination and smoking abstinence. Design Prospective, longitudinal analysis of smoking status. Perceived past-year discrimination was assessed at baseline. ANCOVAs and intent-to-treat hierarchical logistic regressions were conducted. Setting Dual-site (Tampa, FL and Miami, FL) randomized controlled trial testing the effects of a group cessation intervention plus pharmacotherapy. Participants Treatment-seeking adult smokers (N=347; non-Hispanic White, non-Hispanic African American/Black, or Hispanic). Main Outcome Measures Biochemically verified 7-day point prevalence abstinence (7-day ppa) was assessed immediately post-intervention and at 6-month follow-up. Results After controlling for covariates, African Americans/Blacks reported greater perceived discrimination compared with non-Hispanic Whites (P=.02), and Hispanics (P=.06). Non-Hispanic Whites and Hispanics did not differ in perceived racial/ethnic discrimination experiences over the past year. Irrespective of race/ethnicity, past-year perceived discrimination was inversely associated with 7-day ppa, both post-intervention (AOR=.97, CI: .95-.99) and at 6-months (AOR=.98, CI: .96-.99). Among African Americans/Blacks, past-year perceived discrimination was inversely associated with 7-day ppa, both post-intervention (AOR=.95, CI: .92-.97) and at 6-months (AOR=.97, CI: .94-.99). Perceived discrimination was unrelated to 7-day ppa among Hispanics. Among non-Hispanic Whites, past-year perceived discrimination was inversely associated with post-intervention 7-day ppa (AOR=.95, CI: .91-.99), but not 6-months. Conclusions Perceived racial/ethnic discrimination was greater among African American/Black smokers compared with non-Hispanic Whites. Perceived discrimination was negatively associated with tobacco cessation in the full sample, and for African Americans at 6-months post-intervention. These data have implications for intervention delivery and health disparities.
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Affiliation(s)
- Monica Webb Hooper
- National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD (former affiliation when study was conducted: Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, Cleveland, OH)
| | | | | | | | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | | | - David J. Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Vani N. Simmons
- Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
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Thomas DP, Davey M, Sterren AE, Panaretto KS, Lyons L. Do stress, life satisfaction, depression and alcohol use predict quitting among Aboriginal and Torres Strait Islander smokers? Aust N Z J Public Health 2020; 44:186-192. [DOI: 10.1111/1753-6405.12993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 02/01/2020] [Accepted: 03/01/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- David P. Thomas
- Menzies School of Health ResearchCharles Darwin University Northern Territory
| | | | - Anke E. Sterren
- Alcohol Tobacco and Other Drug Association ACT Australian Capital Territory
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Vinci C. Cognitive Behavioral and Mindfulness-Based Interventions for Smoking Cessation: a Review of the Recent Literature. Curr Oncol Rep 2020; 22:58. [PMID: 32415381 PMCID: PMC7874528 DOI: 10.1007/s11912-020-00915-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Cigarette smoking is the primary cause of cancer and is the leading preventable cause of morbidity and mortality. Cognitive behavioral therapy (CBT) is one of the most well-established and efficacious interventions for smoking cessation. The study of mindfulness-based interventions (MBIs) has increased exponentially in recent years, showing efficacy for smoking cessation as well. This review highlights research from the past 5 years examining CBT and MBIs for smoking cessation. RECENT FINDINGS Both CBT and MBIs are efficacious for special populations (e.g., low SES; pregnant smokers) and have shown initial efficacy when delivered via mhealth/ehealth. CBT has shown efficacy when combined with another behavioral treatment (e.g., ACT). Continued research is needed on CBT and MBIs that have high potential for scalability. Understanding whether they are beneficial for certain populations (e.g., cancer survivors), along with determining for whom CBT vs MBIs are most effective, is also needed.
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Affiliation(s)
- Christine Vinci
- Moffitt Cancer Center, Health Outcomes and Behavior, 4115 E Fowler Ave, Tampa, FL, 33617, USA.
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11
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Bazargan M, Cobb S, Castro Sandoval J, Assari S. Smoking Status and Well-Being of Underserved African American Older Adults. Behav Sci (Basel) 2020; 10:bs10040078. [PMID: 32326442 PMCID: PMC7226211 DOI: 10.3390/bs10040078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/12/2020] [Accepted: 04/13/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose: This study investigated the association between current and past cigarette smoking, with four domains of well-being, namely, physical quality of life, mental quality of life, depressive symptoms, and self-rated health status (SRH), among older African American adults who lived in economically impoverished areas of South Los Angles. Methods: This community-based cross-sectional study included a convenience sample of economically-disadvantaged African Americans adults (n = 740) who were 55 years old and older residing in South Los Angeles. We conducted in-depth face-to-face interviews to collect data on the socioeconomic status (level of education and fiscal pressures), demographic factors (age and gender), physical health (number of chronic medical conditions), smoking (never smokers (reference group), past smokers, and current smokers), and well-being (quality of life, depressive symptoms, and self-rated health). Linear regressions were used to analyze the data. Results: Over 21% reported that they are current smokers, compared with 31% who identified as former smokers. Almost 40% perceived the quality of their health status to be fair or poor. Compared with non-smokers, current cigarette smokers reported a worse physical quality of life, depressive symptoms, and self-rated health. Current smokers also reported a marginally worse mental quality of life. Past smoker status was inconsistently associated with worse well-being in some, but not all, indicators. The association between smoking status and worse well-being was independent of gender, socioeconomic status, and physical health status. Conclusion: Current smoking is associated with worse well-being of older African American adults in economically constrained urban settings. As the same pattern could not be found for former smokers, quitting smoking may be a strategy for economically-disadvantaged African American individuals to enhance their well-being. This provides additional support for programs that help African American individuals who are smokers to quit smoking, particularly in economically-disadvantaged urban areas.
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Affiliation(s)
- Mohsen Bazargan
- Departments of Family Medicine, College of Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA;
- Departments of Family Medicine, University of California, Los Angeles (UCLA), Los Angeles, CA 90095, USA
| | - Sharon Cobb
- School of Nursing, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA;
| | - Jessica Castro Sandoval
- Department of Public Health, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA;
| | - Shervin Assari
- Departments of Family Medicine, College of Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA 90059, USA;
- Correspondence:
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12
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Webb Hooper M. Racial/Ethnic Differences in Physiological Stress and Relapse among Treatment Seeking Tobacco Smokers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3090. [PMID: 31450707 PMCID: PMC6747351 DOI: 10.3390/ijerph16173090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/16/2019] [Accepted: 08/18/2019] [Indexed: 11/16/2022]
Abstract
Stress is robustly associated with tobacco smoking and relapse. African Americans experience greater difficulty quitting compared to whites, yet no studies have examined race differences in physiological stress biomarkers during a quit attempt. This pilot study compared cortisol levels among treatment-seeking African American and white smokers, and relapse rates. Adult smokers (N = 115; n = 72 African American, n = 43 White) received eight sessions of group cognitive behavioral therapy plus transdermal nicotine patches. Assessments included demographics, salivary cortisol (collected at session 1, the end-of-therapy [EOT], and one-month post-therapy), and carbon monoxide-verified smoking relapse. Overall, cortisol levels declined over the course of the day at baseline, the EOT, and the one-month follow-up. African Americans exhibited lower cortisol levels compared to Whites at baseline and the EOT, but not at the one-month follow-up. In addition, African American smokers exhibited flatter slopes compared to Whites at each time point. Relapse rates were greater among African Americans at the EOT and one-month follow-up. The attenuated cortisol pattern observed in African Americans may indicate hypothalamic-pituitary-adrenal axis (HPA) exhaustion and aid our understanding of tobacco-related disparities. There is a need to focus on stress mechanisms and specific intervention approaches in order to eliminate racial/ethnic differences.
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Affiliation(s)
- Monica Webb Hooper
- Case Comprehensive Cancer Center, Case Western Reserve University Cleveland, OH 44106, USA.
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Patten CA, Koller KR, Flanagan CA, Hiratsuka V, Merritt ZT, Sapp F, Meade CD, Hughes CA, Decker PA, Murphy N, Thomas TK. Postpartum Tobacco Use and Perceived Stress among Alaska Native Women: MAW Phase 4 Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E3024. [PMID: 31438550 PMCID: PMC6747207 DOI: 10.3390/ijerph16173024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/16/2019] [Accepted: 08/17/2019] [Indexed: 01/29/2023]
Abstract
Prior research explored reasons for tobacco use among pregnant Alaska Native (AN) women but did not address the postpartum period. This study followed up with AN women one to three years postpartum who had participated in a prenatal smoking cessation intervention study (Motivate Alaska Women (MAW) Phase 3) and had consented to be re-contacted for future studies. Of 47 eligible women, 32 (68%) participated. A semi-structured phone interview was conducted a mean of 2.0 years after delivery (range 1.6-2.8). Measures assessed self-reported tobacco use status in the 12 months after delivery, at 12 months postpartum, and at the time of the interview; reasons for maintaining abstinence, continued use, or relapse; and included the Perceived Stress Scale (PSS) and Negative Affect (NA) scale. Content analysis was used to generate themes from open-ended response items. Tobacco use was reported by 23 women (72%) at delivery, 30 (94%) within the 12 months after delivery, 27 (84%) at 12 months postpartum, and 29 (91%) at the time of the interview. Among nine women not using tobacco at delivery, seven (78%) relapsed during the 12 months after delivery. Of the 29 current tobacco users, 28 (97%) smoked cigarettes. Twenty-seven participants (84%) reported stress and 15 (52%) indicated addiction as reasons for continuing, starting, or resuming tobacco use. Types of stressors were related to parenting and traumatic experiences. Among current tobacco users, mean NA score (18.7) was significantly higher (p = 0.01) than the normative mean (14.8), but no differences were detected for PSS score. In this sample of AN women, postpartum tobacco use was highly prevalent, and stress was a primary reason that women endorsed for using tobacco. These preliminary results have several practice and research implications for exploring ways to support non-tobacco use among postpartum AN women.
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Affiliation(s)
- Christi A Patten
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA.
| | - Kathryn R Koller
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
| | - Christie A Flanagan
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
| | - Vanessa Hiratsuka
- Southcentral Foundation, Department of Obstetrics and Gynecology, Alaska Native Medical Center, 4320 Diplomacy Dr., Ste. 1800, Anchorage, AK 99508, USA
| | - Zoe T Merritt
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
| | - Flora Sapp
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
| | - Crystal D Meade
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
| | - Christine A Hughes
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Paul A Decker
- Department of Health Sciences Research, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
| | - Neil Murphy
- Southcentral Foundation, Department of Obstetrics and Gynecology, Alaska Native Medical Center, 4320 Diplomacy Dr., Ste. 1800, Anchorage, AK 99508, USA
| | - Timothy K Thomas
- Clinical and Research Services, Division of Community Health Services, Alaska Native Tribal Health Consortium, 4000 Ambassador Dr., Anchorage, AK 99508, USA
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Use of the Fagerström test to assess differences in the degree of nicotine dependence in smokers from five ethnic groups: The HELIUS study. Drug Alcohol Depend 2019; 194:197-204. [PMID: 30447512 DOI: 10.1016/j.drugalcdep.2018.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/03/2018] [Accepted: 10/09/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND The prevalence of smoking varies across ethnic groups in developed countries, but little is known about ethnic variations in specific aspects of nicotine dependence (ND). We conducted item-response analyses in current smokers to compare ND factors across five ethnic groups. METHODS Data were obtained from a population-based, multi-ethnic cohort study conducted in the Netherlands. The Fagerström Test for Nicotine Dependence (FTND) was assessed in 1147 Dutch, 991 South-Asian Surinamese, 1408 African Surinamese, 1396 Turkish, and 584 Moroccan smokers (N = 5526). We tested whether the factorial structure of the FTND was invariant across ethnic groups using a multi-group confirmatory factor analysis. FTND item and total scores and factor means were compared across groups. RESULTS The two-factor model representing "morning smoking" and "smoking patterns" provided an adequate fit. The items "Cigarettes smoked daily" and "Time until first cigarette" showed differential item functioning (DIF) as a function of ethnicity. Three out of four ethnic minority groups scored significantly higher on both factors compared to the Dutch origin group (all p < 0.001) before and after taking DIF into account, while the African Surinamese scored higher only on "morning smoking" when DIF was accounted for. DISCUSSION The factor structure of the FTND is not measurement invariant across ethnic groups in this population-based sample. Accounting for DIF affecting the nicotine dependence factor scores, although South-Asian Surinamese, Turkish, and Moroccan groups showed higher levels of dependence than the Dutch origin group, genetic as well as environmental factors may account for the observed differences.
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Webb Hooper M, Lee DJ, Simmons VN, Brandon KO, Antoni MH, Unrod M, Asfar T, Correa JB, Koru-Sengul T, Brandon TH. Reducing racial/ethnic tobacco cessation disparities via cognitive behavioral therapy: Design of a dualsite randomized controlled trial. Contemp Clin Trials 2018; 68:127-132. [PMID: 29617633 DOI: 10.1016/j.cct.2018.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 03/28/2018] [Accepted: 03/31/2018] [Indexed: 11/27/2022]
Abstract
Racial/ethnic disparities in tobacco cessation are such that U.S. minorities have greater difficulty quitting compared to White non-Hispanics. Group differences in distress (i.e., perceived stress and depressive symptoms) may contribute to cessation disparities. The allostasis model of health suggests that the toll of chronic stress experienced by racial/ethnic minorities may lead to dysregulation of the physiological stress system and drug use. Previous research suggests that group cognitive behavioral therapy (CBT) for tobacco cessation addresses distress as a modifiable mechanism and has the potential to reduce/eliminate disparities. The present study is a dualsite randomized controlled trial aimed at evaluating the efficacy of group CBT in eliminating racial/ethnic differences in smoking cessation and distress. The study utilizes a [2 (intervention: group CBT or group general health education [GHE]) × 3 (race/ethnicity: African American/Black, Hispanic, White)] factorial design by randomizing 225 adult smokers from the community. Both interventions provide eight counseling sessions and eight weeks of nicotine patch therapy. Assessments occur at the end-of-therapy, and at 3-, 6-, and 12-months. Generalized longitudinal mixed modeling will be used to test our primary abstinence outcome, biochemically-confirmed 7-day point prevalence abstinence at 12-months. We hypothesize that group CBT will reduce or eliminate racial/ethnic differences in perceived stress, depressive symptoms, and smoking cessation compared to group GHE. We also hypothesize that reductions in physiological distress, assessed by salivary cortisol, will mediate racial/ethnic group differences in smoking cessation, particularly among racial/ethnic minorities. This study has implications for eliminating disparities in psychosocial factors related to tobacco use and cessation. TRIAL REGISTRATION Clinicaltrials.govNCT02511236. Registered on July 27, 2015.
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Affiliation(s)
- Monica Webb Hooper
- Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, 10900 Euclid Ave, Cleveland, OH 44106, United States.
| | - David J Lee
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL 33136, United States; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, United States
| | - Vani N Simmons
- Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States
| | - Karen O Brandon
- Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States
| | - Michael H Antoni
- Department of Psychology, University of Miami College of Arts and Sciences, PO Box 248185, Coral Gables, FL 33124, United States; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, United States
| | - Marina Unrod
- Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States
| | - Taghrid Asfar
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL 33136, United States; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, United States
| | - John B Correa
- Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States
| | - Tulay Koru-Sengul
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL 33136, United States; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Miami, FL 33136, United States
| | - Thomas H Brandon
- Health Outcomes and Behavior, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612, United States
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Giovino GA, Gardiner PS. Understanding Tobacco Use Behaviors Among African Americans: Progress, Critical Gaps, and Opportunities. Nicotine Tob Res 2016; 18 Suppl 1:S1-6. [PMID: 26980859 DOI: 10.1093/ntr/ntv234] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Although multiple factors likely influence the differences between African Americans (AAs) and whites in cardiovascular disease and lung cancer mortality rates, historical patterns of tobacco use, particularly cigarette smoking, are the major contributors. This issue of Nicotine & Tobacco Research presents original research, a review, and commentaries that will serve to advance our understanding of several relevant behavioral similarities and differences between AAs and whites. BEHAVIORAL ANALYSIS Here, we illustrate how the diverging trends in cigarette smoking between AA and white high school seniors observed since the mid-1970s were influenced by patterns of ever use and current use among ever users. During 1977 to 2014, the percentage of current users among ever users was higher, but less variable, among whites than AAs. Among adults, trends in self-reported cigarette smoking among non-Hispanic AAs and non-Hispanic whites are available since 1978. The trends observed were likely due in part to the maturation of the high school senior cohorts from the 1970s and 1980s when AA smoking rates declined sharply relative to whites. Later age of initiation among AAs and less quitting among older AAs, relative to whites, also contribute. CONCLUSIONS Further research on multiple topics, including the continuation of use among ever users, use of multiple combusted and noncombusted products, provision of cessation support services, influence of discrimination, and validity of self-report would expand the science base. Strategies to reduce the marketing and availability of menthol and other characterizing flavorings and to enrich environments would promote the public's health.
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Affiliation(s)
- Gary A Giovino
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, SUNY, Buffalo, NY;
| | - Phillip S Gardiner
- Tobacco-Related Disease Research Program, University of California, Office of the President, Oakland, CA
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Simmons VN, Pineiro B, Hooper MW, Gray JE, Brandon TH. Tobacco-Related Health Disparities Across the Cancer Care Continuum. Cancer Control 2016; 23:434-441. [PMID: 27842333 PMCID: PMC5972388 DOI: 10.1177/107327481602300415] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Use of tobacco is the leading preventable cause of death in the United States. Racial/ethnic minorities and individuals of low socioeconomic status disproportionately experience tobacco-related disease and illness. Unique challenges and circumstances exist at each point in the cancer care continuum that may contribute to the greater cancer burden experienced by these groups. METHODS We reviewed tobacco-related disparities from cancer prevention to cancer survivorship. We also describe research that seeks to reduce tobacco-related disparities. RESULTS Racial/ethnic minorities and low-income individuals experience unique social and environmental contextual challenges such as greater environmental cues to smoke and greater levels of perceived stress and social discrimination. Clinical practice guidelines support the effectiveness of pharmacotherapy and behavioral counseling for racial and ethnic minorities, yet smoking cessation rates are lower in this group when compared with non-Hispanic whites. Superior efficacy for culturally adapted interventions has not yet been established. CONCLUSIONS To reduce health disparities in this population, a comprehensive strategy is needed with efforts directed at each point along the cancer care continuum. Strategies are needed to reduce the impact of contextual factors such as targeted tobacco marketing and social discrimination on smoking initiation and maintenance. Future efforts should focus on increasing the use of evidence-based cessation treatment methods and studying its effectiveness in these populations. Attention must also be focused on improving treatment outcomes by reducing smoking in diverse racial and ethnic patient populations.
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Affiliation(s)
- Vani Nath Simmons
- Health Outcomes and Behavior Program, Moffitt Cancer Center, Tampa, FL, USA.
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Kulak JA, Cornelius ME, Fong GT, Giovino GA. Differences in Quit Attempts and Cigarette Smoking Abstinence Between Whites and African Americans in the United States: Literature Review and Results From the International Tobacco Control US Survey. Nicotine Tob Res 2016; 18 Suppl 1:S79-87. [PMID: 26980868 PMCID: PMC5009448 DOI: 10.1093/ntr/ntv228] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 09/30/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION While cigarette smoking prevalence is declining among US adults, quit rates may differ between white and African American smokers. Here, we summarize the literature on smoking cessation behaviors in whites and African Americans across four study designs and report the findings of new analyses of International Tobacco Control (ITC) US Survey cohort data. METHODS We reviewed 32 publications containing 39 relevant analyses that compared quit attempts and abstinence between US whites and African Americans. Two additional longitudinal analyses were conducted on 821 white and 76 African American cigarette smokers from Waves 7 and 8 of the ITC US Survey (mean follow-up = 19 months). RESULTS Of 17 total analyses of quit attempts, nine (including the ITC US Survey) observed that African American smokers were more likely than whites to attempt to quit during a given year; seven found no differences. Whites were more likely than African Americans to be abstinent in five of six retrospective cohort analyses and in two of five considered community- and population-based cohort studies. Four of these 11 analyses, including one from the ITC US Survey, found no differences. CONCLUSIONS Of 11 population- or community-based analyses, all seven that found significant differences indicated that whites were more likely to quit than African Americans. These findings, combined with the similar results from population-based birth cohort analyses, support the conclusion that white smokers are more likely to quit than African American smokers. Efforts to encourage and support quitting among all tobacco users remain a priority. IMPLICATIONS This article provides a review of the literature on smoking cessation among African American and white smokers, and adds new analyses that compare quit attempts and abstinence between US African Americans and whites. Results demonstrate a clear distinction between the findings of cross-sectional and retrospective cohort studies with those of cohort studies. Reasons for these differences merit further study.
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Affiliation(s)
- Jessica A Kulak
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY;
| | - Monica E Cornelius
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC
| | - Geoffrey T Fong
- Department of Psychology and School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada; Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Gary A Giovino
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY
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