Nicotine dependence and intentions to quit among a communitybased sample of African American menthol and non-menthol smokers in Los Angeles

Transcription

1 Nicotine dependence and intentions to quit among a communitybased sample of African American menthol and non-menthol smokers in Los Angeles Final Report Submitted to RTI International and the Food and Drug Administration Jennifer B. Unger, Ph.D., University of Southern California Tess Boley Cruz, Ph.D., University of Southern California Bruce Allen, Jr., Dr.PH., Charles Drew University of Medicine and Science November 8, 2010 November 8,

2 Summary of Results Project Title, Investigators, and Institutional Affiliation Title Nicotine dependence and intentions to quit among a community-based sample of African American menthol and non-menthol smokers in Los Angeles Investigators and Institutional Affiliations Jennifer B. Unger, Ph.D., University of Southern California Tess Boley Cruz, Ph.D., University of Southern California Bruce Allen, Jr., Dr.PH., Charles Drew University of Medicine and Science Background and Analysis Objectives Background Although the prevalence of smoking among African Americans is similar to that among Whites, African Americans bear a larger burden of the health consequences of smoking. Over 70% of African American smokers prefer menthol cigarettes, compared with 30% of White smokers. Most studies of menthol smoking have been conducted in clinical samples of smokers who are seeking assistance with smoking cessation. Smokers who are not ready to quit and smokers who have failed to quit and have given up are not represented in these studies. Little is known about the differences between menthol smokers and non-menthol smokers in community-based samples. This analysis used a large community-based survey of African American smokers to compare menthol and non-menthol smokers on nicotine dependence and intentions to quit. Study Questions and Hypotheses 1. Are menthol smokers more nicotine-dependent (more likely to smoke within 30 minutes of waking) than non-menthol smokers? a. Does this association vary across genders, age groups, level of education, or number of cigarettes smoked per day? 2. Do menthol smokers have lower intentions to quit (in the next month and in the next 6 months) than non-menthol smokers? a. Does this association vary across genders, age groups, level of education, or number of cigarettes smoked per day? Methods and Approach Study Population and Data Source Study Population. 720 African American adult smokers surveyed in Los Angeles County in Data Source. The sample was designed to be representative of African American smokers in Los Angeles County. A three-stage sampling method was used to recruit adult African American smokers. In the first stage, U.S. Census data were used to locate all census tracts in Los Angeles County with 5% African American residents. These census tracks were stratified by population density and median income. 32 census tracts were randomly selected within 4 strata. Respondents were approached at community intercept sites in each selected tract and interviewed by telephone in November 8,

3 Measures Operational measures of tobacco use, nicotine dependence, cessation Number of cigarettes per day Nicotine dependence: smoking within 30 minutes of waking Intention to quit smoking: within next 30 days and within next 6 months Operational measures of menthol cigarette use Menthol smoking status (3 categories: Menthol only, Non-menthol only, and Combined menthol/non-menthol) Operational measures of covariates Demographics: age, gender, education, income Psychosocial variables: perceived stress, depression, smokers in current social network Model Specification and Analysis Logistic regression models were used to identify the significant correlates of the outcome variables: nicotine dependence and intention to quit. Interaction terms were evaluated to determine whether the predictors of nicotine dependence and intentions to quit vary across age groups, genders, number of cigarettes per day, education level, and menthol status. Predictors of nicotine dependence and intention to quit were analyzed separately across menthol status groups and compared. Findings This analysis revealed several differences across the three groups of smokers (mentholonly smokers, non-menthol-only smokers, and combined smokers). Although there were no significant differences across the three groups in the proportion of respondents who smoked within 30 minutes of waking, planned to quit in the next month, or contemplated quitting in the next 6 months, there were differences across the three groups in the variables that were significantly associated with these outcomes: Among menthol smokers, those who had other menthol smokers in their social networks were more likely to smoke within 30 minutes of waking. Among non-menthol-only smokers and combined smokers, lighter smokers were more likely to contemplate quitting within the next 6 months than heavier smokers. However, among menthol smokers, lighter smokers were not more likely to contemplate quitting in the next 6 months. Among smokers with a high school education (but not among those with higher or lower levels of education), combined smokers were significantly less likely to contemplate quitting within the next 6 months, relative to non-menthol-only smokers. Conclusions Findings suggest that among certain groups of African American smokers (i.e., light smokers and those with a high school education), menthol smokers may be less likely than nonmenthol smokers to express intentions to quit. Targeted smoking cessation interventions are needed to help African American menthol smokers quit. Funding Source for the Collection of Primary Data Source The data collection was supported by the California Tobacco-Related Disease Research Program (TRDRP), grant #15RT-0044H, Determinants of Menthol Smoking Among Blacks (Bruce Allen, PI). November 8,

4 Nicotine dependence and intentions to quit among a communitybased sample of African American menthol and non-menthol smokers in Los Angeles Background and Analysis Objectives: Background. Menthol cigarette smoking is an important public health issue in the African American community. Although the prevalence of smoking among African Americans is similar to that among Whites, African Americans bear a larger burden of the health consequences of smoking. Over 70% of African American smokers prefer menthol cigarettes, compared with 30% of White smokers (Gardiner, 2004; Giovino et al., 2004). Menthol in cigarettes may cause respiratory depression and longer inhalations, resulting in greater exposure to the nicotine and particulate matter in tobacco smoke (Ahijevych & Garrett, 2004; Garten & Falkner, 2004). Menthol also slows the rate of nicotine metabolism to cotinine, resulting in a longer duration of nicotine exposure in the body (Benowitz, Herrera, & Jacob, 2004). In addition, menthol smokers smoke sooner after waking (Collins & Moolchan, 2005), experience stronger cravings (Wackowski & Delnevo, 2007), are less successful in quitting smoking than non-menthol smokers (Gandhi, Foulds, Steinberg, Lu, & Williams, 2009; Gunderson, Delnevo, & Wackowski, 2009; Okuyemi, Ebersole-Robinson, Nazir, & Ahluwalia, 2004; Okuyemi, Faseru, Sanderson-Cox, Bronars, & Ahluwalia, 2007), and have a higher rate of relapse (Pletcher et al., 2006). Because of their smoother, milder taste, menthol cigarettes have been implicated as a starter tobacco product for youth (Hersey et al., 2006; Klein et al., 2008). Most studies of menthol smoking have been conducted in clinical samples of smokers who are seeking assistance with smoking cessation. These samples are limited to smokers who are actively attempting to quit. Smokers who are not ready to quit and smokers who have failed to quit and have given up are not represented in these studies. Little is known about the differences between menthol smokers and non-menthol smokers in community-based samples. For example, in the general population of smokers, it is not known whether menthol smokers are more nicotine-dependent or less ready to quit. This analysis used a large community-based survey of African American smokers to compare menthol and non-menthol smokers on nicotine dependence and intentions to quit. The large sample size also made it possible to conduct analyses stratified by gender, age group, level of education, and number of cigarettes smoked per day. Study Questions and Hypothesis 1. Are menthol smokers more nicotine-dependent (more likely to smoke within 30 minutes of waking) than non-menthol smokers? a. Does this association vary across genders, age groups, level of education, or number of cigarettes smoked per day? 2. Do menthol smokers have lower intentions to quit (in the next month and in the next 6 months) than non-menthol smokers? a. Does this association vary across genders, age groups, level of education, or number of cigarettes smoked per day? November 8,

5 Methods and Approach: Study Population. The sample included 720 African American adult smokers, who responded to a telephone survey in The sample was designed to be representative of African American smokers in Los Angeles County. Data Source. The study design is described in detail by Unger et al., (2010). A threestage sampling method was used in 2006 to recruit adult African American smokers for the telephone survey. In the first stage, U.S. Census data from 2000 were analyzed to locate all census tracts in Los Angeles County with 5% or more African American residents. These census tracks were coded as having high or low population density (above or below the median), and high or low median household income, resulting in four strata: (1) census tracks with higher income and higher population density; (2) higher income and lower population density; (3) lower income and higher population density; and (4) lower income and lower population density. Eight census tracts were randomly selected from each of these four strata for a total of 32 census tracts. In the second stage, community intercept sites were selected within each of these randomly selected census tracts. Six types of sites were selected: banks, check cashing services, retail outlets, food and beverage serving outlets, gas stations, and grocery and/or liquor stores. All existing sites within each census tract were identified using the yellow pages and called to confirm that they were still in business. A total of 522 community intercepts were randomly selected from this list. The recruiters attempted to recruit 112 smokers in each census tract, evenly distributed across the six types of sites. However, if a census tract did not have a particular type of intercept, the number of smokers to be recruited was redistributed among the remaining intercepts in that census tract. Five teams of two trained recruiters were sent to these intercept locations to recruit participants in July and August, Recruiters asked all people who appeared to be adult African Americans if they could talk to them about a study. Those who consented were screened for eligibility. Individuals were eligible to participate if they self-reported as African American, were current smokers, smoked at least 5 cigarettes a day for the past year, were willing to participate in a 30-minute telephone interview for which they would receive a $25.00 gift certificate, and had access to a working telephone. Eligible individuals were asked their name, home address, home and cell phone numbers, date of birth, average number of cigarettes smoked per day, and whether they usually smoked menthol cigarettes. The brief study description and screening interview lasted approximately 5 minutes. This pre-qualified group was given an imprinted pen as a token of appreciation and as a reminder about the study. After recruiting the predetermined number of smokers, or after two hours, whichever came first, the interviewers moved to the next pre-selected site. After six weeks, these intercept interviews resulted in the recruitment of 2,852 adult smokers who were available for further contact. In the third stage, a professional survey research firm attempted to contact these recruits between October 2006 and January 2007, with repeat calls until the desired sample of 720 adult smokers completed the telephone survey. Disconnected telephone numbers were redialed after several weeks to determine if the number had only been temporarily disconnected and then returned to service. Most of the participants (58%) were reached on the first call; 94% were reached within the first 10 calls. The number of calls needed to reach the recruits ranged from 1 to 41 (mean=5.04). November 8,

6 Individuals who initially refused to participate in the telephone interview were called again later in an attempt to persuade them to participate. They were reminded that they had signed up to participate, and that they would receive a $25 gift card for completing the survey. Those who could not be reached were mailed a personalized letter encouraging them to respond, with a $1 bill in the letter. These follow-up strategies resulted in 39 additional smokers completing the telephone survey. Measures Outcome variables Nicotine dependence: smoking within 30 minutes of waking Intention to quit smoking: within next 30 days and within next 6 months Predictor variables Menthol smoking status (3 categories: Menthol only, Non-menthol only, and Combined menthol/non-menthol) When you smoked during the past 30 days, did you smoke. 1. Only menthol 2. Mostly menthol 3. Half and half 4. Mostly non-menthol 5. Only non-menthol Demographics: age, gender, education, income Number of cigarettes per day Psychosocial variables Perceived stress Perceived Stress Scale (Cohen et al., 1983) Depression Centers for Epidemiologic Studies Depression (CES-D) Scale (Radloff, 1977) Smokers in current social network Does your spouse/partner smoke menthols? (yes/no) Among your close African American friends who smoke, how many of them currently smoke menthols? (all/most/a few/none) How many other African American smokers around you currently smoke menthols? (all/most/a few/none) Model Specification and Analysis. The distributions of the outcome variables (nicotine dependence and intentions to quit) were compared across the three menthol smoking groups (menthol-only, non-menthol-only, and people who smoked both types of cigarettes) with chisquare tests. Logistic regression models were used to identify the significant correlates of the outcome variables: nicotine dependence and intention to quit. Interaction terms were included to determine whether the predictors of nicotine dependence and intentions to quit vary across age groups, genders, education level, number of cigarettes per day, and menthol status. Psychosocial and demographic correlates of nicotine dependence and intentions to quit were analyzed separately by menthol status group with logistic regression models, and patterns of results were compared. Bonferroni adjustments were used to correct for the likelihood of Type I errors due to multiple tests. November 8,

7 Findings: Table 1 shows the demographic characteristics of the sample. As required by the selection criteria, all participants were African American and reported smoking at least 5 cigarettes per day. Their mean age was 44.2 years (SD=12.4, range=18-81), 52% were female, and they smoked a mean of 12.3 cigarettes per day (SD=7.6, range=5-100). Over one-half of the respondents (57%) smoked menthols exclusively; 15% smoked non-menthols exclusively, and 28% smoked a combination of menthols and non-menthols. Table 1. Demographic characteristics of sample N % Age Gender Female Male Education Less than high school High school graduate Some college College degree Refused 1 0 Income Less than $10, $10,000-$20, $20,000-$35, $35,000-$50, Over $50, Don t know/refused 22 3 Type of cigarette smoked Non-menthol only Mostly non-menthol 48 7 Half and half 59 8 Mostly menthol Menthol only Cigarettes per day Missing 1 0 November 8,

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9 As shown in Table 2, there were no significant differences across the three groups (mentholonly smokers, combined smokers, and non-menthol-only smokers) on nicotine dependence or intentions to quit. Table 2. Frequencies of the outcome variables across menthol smoking groups Smoke within 30 minutes of waking Plan to quit within next month Contemplate quitting within 6 months Menthol-only smokers (N=410) Combined menthol / non-menthol smokers (N=204) Non-menthol only smokers (N=106) Chisquare 64% 61% 67% % 44% 42% % 80% 82% 0.81 After correcting for multiple tests, none of the interactions with gender, age group, or number of cigarettes were significant. However, the interaction between education and menthol smoking was significant (p<.001). Among respondents with a high school education, combined smokers (those who smoked both menthols and non-menthols) were significantly less likely to contemplate quitting within the next 6 months, relative to those who smoked non-menthols only (OR= 0.116, 95% CI=0.015, 0.922). This was not the case for respondents with less than a high school education or respondents with more than a high school education. Next, we compared the significant predictors of nicotine dependence and intentions to quit among menthol-only smokers, non-menthol-only smokers, and combined smokers. The predictor variables examined were age, gender, education, income, number of cigarettes smoked per day, stress, depression, and menthol smokers in the social network. As shown in Table 3, number of cigarettes smoked per day was significantly associated with smoking within 30 minutes of waking across all three groups. Among menthol-only smokers, those who had menthol smokers in their social networks were 1.43 times more likely to smoke within 30 minutes of waking, relative to those without menthol smokers in their social networks. Number of cigarettes smoked per day was inversely associated with planning to quit in the next month among menthol-only smokers and non-menthol-only smokers, but not among combined smokers. Number of cigarettes smoked per day was inversely associated with contemplating quitting in the next 6 months among non-menthol-only smokers and combined smokers, but not among menthol-only smokers. November 8,

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11 Table 3. Variables significantly associated with nicotine dependence and intentions to quit across the three menthol status groups Nicotine dependence (smoking within 30 minutes of waking) Menthol Only (N=410) Combined menthol / nonmenthol (N=204) Non-Menthol Only (N=106) Predictor OR 95% CI OR 95% CI OR 95% CI Age group (18-39 vs 40+) 1.35 (0.84, 2.17) 1.24 (0.59, 2.61) 0.72 (0.23, 2.25) Gender (male vs. female) 0.67 (0.41, 1.07) 1.23 (0.64, 2.35) 0.70 (0.24, 2.04) Education (<HS vs HS+) 1.05 (0.56, 1.97) 1.74 (0.64, 4.73) 0.66 (0.15, 2.94) Education (HS vs HS+) 0.83 (0.48, 1.42) 0.87 (0.43, 1.76) 0.68 (0.21, 2.20) Income 0.97 (0.87, 1.08) 1.05 (0.91, 1.22) 0.84 (0.66, 1.06) Cigarettes per day (5-9 vs. 15+) 0.13 (0.07, 0.25) 0.18 (0.08, 0.40) 0.15 (0.05, 0.49) Cigarettes per day (10-14 vs. 15+) 0.30 (0.16, 0.59) 0.47 (0.20, 1.10) 1.14 (0.31, 4.28) Stress 0.91 (0.70, 1.17) 1.00 (0.67, 1.47) 0.55 (0.29, 1.04) Depression 0.98 (0.75, 1.27) 1.02 (0.71, 1.47) 1.03 (0.52, 2.02) Menthol smokers in social network 1.43 (1.13, 1.80) 1.24 (0.87, 1.76) 1.42 (0.84, 2.40) November 8,

12 Table 3 (continued) Plan to quit in next month Menthol Only (N=410) Combined menthol / non-menthol (N=204) Non-Menthol Only (N=106) Predictor OR 95% CI OR 95% CI OR 95% CI Age group (18-39 vs 40+) 0.85 (0.55, 1.31) 0.58 (0.29, 1.19) 0.81 (0.29, 2.26) Gender (male vs. female) 1.25 (0.81, 1.94) 1.40 (0.76, 2.59) 1.07 (0.42, 2.72) Education (<HS vs HS+) 1.87 (1.05, 3.33) 1.31 (0.53, 3.26) 1.16 (0.33, 4.07) Education (HS vs HS+) 1.09 (0.66, 1.78) 1.04 (0.53, 2.03) 1.14 (0.40, 3.28) Income 1.00 (0.91, 1.11) 0.97 (0.84, 1.12) 1.06 (0.86, 1.31) Cigarettes per day (5-9 vs. 15+) 1.71 (1.02, 2.86) 1.72 (0.83, 3.59) 2.19 (0.74, 6.55) Cigarettes per day (10-14 vs. 15+) 1.77 (1.02, 3.05) 1.85 (0.87, 3.97) 4.91 (1.60, 15.02) Stress 0.94 (0.74, 1.19) 1.05 (0.73, 1.52) 1.03 (0.61, 1.76) Depression 1.16 (0.91, 1.48) 1.08 (0.78, 1.50) 1.29 (0.71, 2.35) Menthol smokers in social network 1.03 (0.83, 1.28) 0.80 (0.57, 1.11) 0.82 (0.52, 1.28) November 8,

13 Table 3 (continued) Contemplate quitting in next 6 months Menthol Only (N=410) Combined menthol / non-menthol (N=204) Non-Menthol Only (N=106) Predictor OR 95% CI OR 95% CI OR 95% CI Age group (18-39 vs 40+) 1.45 (0.82, 2.58) 0.96 (0.41, 2.27) 0.78 (0.16, 3.71) Gender (male vs. female) 1.23 (0.69, 2.20) 1.45 (0.67, 3.14) 0.33 (0.08, 1.38) Education (<HS vs HS+) 0.59 (0.28, 1.23) 1.22 (0.34, 4.40) 0.42 (0.09, 1.93) Education (HS vs HS+) 0.60 (0.31, 1.16) 0.57 (0.25, 1.34) 8.89 (0.87, 91.12) Income 1.02 (0.89, 1.16) 1.06 (0.87, 1.28) 0.89 (0.67, 1.19) Cigarettes per day (5-9 vs. 15+) 1.15 (0.60, 2.21) 1.76 (0.76, 4.09) 3.87 (0.89, 16.84) Cigarettes per day (10-14 vs. 15+) 1.03 (0.52, 2.04) 5.05 (1.66, 15.30) 5.39 (1.16, 25.09) Stress 1.02 (0.75, 1.38) 0.68 (0.42, 1.11) 1.70 (0.80, 3.59) Depression 1.06 (0.77, 1.44) 1.53 (0.94, 2.50) 0.80 (0.39, 1.64) Menthol smokers in social network 0.93 (0.70, 1.22) 0.96 (0.62, 1.48) 0.68 (0.35, 1.35) November 8,

14 Conclusions: This analysis revealed several differences across the three groups of smokers: mentholonly smokers, non-menthol-only smokers, and combined smokers (smokers of both types of cigarettes). Although there were no significant differences across the three groups in the proportion of respondents who smoked within 30 minutes of waking, planned to quit in the next month, or contemplated quitting in the next 6 months, there were differences across the three groups in the variables that were significantly associated with these outcomes: Among menthol smokers, those who had other menthol smokers in their social networks were more likely to smoke within 30 minutes of waking. Among non-menthol-only smokers and combined smokers, lighter smokers were more likely to contemplate quitting within the next 6 months than heavier smokers. However, among menthol smokers, lighter smokers were not more likely to contemplate quitting in the next 6 months. Among smokers with a high school education (but not among those with higher or lower levels of education), combined smokers were significantly less likely to contemplate quitting within the next 6 months, relative to non-menthol-only smokers. These findings suggest that culturally appropriate, targeted smoking cessation programs may be needed for certain subgroups of African American menthol smokers. Among those with just a high school degree, who represent nearly one-third of the African American population, combined smokers (those who smoke both menthol and non-menthol cigarettes) are least likely to contemplate quitting within the next 6 months. This group may represent heavily nicotinedependent smokers who switch cigarette brands based on price or availability and/or social smokers who are not motivated to quit. Programs are needed to educate these smokers about the dangers of all types of cigarettes and help them develop the motivation and self-efficacy to quit. Smoking cessation interventions are also needed for light menthol smokers, those who smoke fewer than 10 cigarettes per day. These smokers may be less motivated to quit because they mistakenly believe that light menthol smoking is not harmful or that they could actually quit if they wanted to. They also may continue to smoke menthol cigarettes for the menthol taste or sensation, even if they are not very nicotine-dependent. Health education messages are needed to motivate these light menthol smokers to quit completely. Social network members may encourage menthol smokers to keep smoking or discourage them from quitting. Group-based interventions may be useful to help menthol smokers quit together, or to help menthol smokers form new social networks of nonsmokers. To quit smoking successfully, menthol smokers who have other menthol smokers in their social networks may need to learn to resist the social influences of their smoking friends and family members. It also could be helpful for them to learn to avoid situations where others are smoking. Limitations: These findings are based on self-reports. Biochemical validation of the respondents smoking status was beyond the means of the current study. It is possible that respondents November 8,

15 might have misrepresented their smoking status to gain access to the study or the incentives. These results were also limited to people who appeared to be African American, were in Los Angeles County, and were intercepted in public places. People who do not go to public places (e.g., those with severe physical disabilities) and multiracial people who do not appear African American may have been underrepresented. This convenience sample also does not include people who refused to participate in the initial intercept screening or the telephone survey, people who gave the interviewer incorrect telephone numbers, or people who had changed telephone numbers before they were contacted. Response rates to telephone surveys have declined dramatically in recent years, due to the widespread adoption of Caller ID, the national Do Not Call registry, and households with cellular phones only (Fahimi, Link, Mokdad, Schwartz, & Levy, 2008; Link, Mokdad, Stackhouse, & Flowers, 2006). We attempted to increase participation by personally engaging potential respondents at community intercept locations before requesting their participation in the telephone survey. However, it appears that many potential respondents were still reluctant to give their correct telephone numbers to a stranger. Our participation rate was comparable to those reported by other recent telephone surveys (Fahimi et al., 2008; Link et al., 2006). Nevertheless, a higher response rate would have improved the generalizability of the results. Funding Source for the Collection of Primary Data Source The data collection was supported by the California Tobacco-Related Disease Research Program (TRDRP), grant #15RT-0044H, Determinants of Menthol Smoking Among Blacks (Bruce Allen, PI). November 8,

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