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. Author manuscript; available in PMC: 2016 Aug 1.
Published in final edited form as: Addict Behav. 2015 Apr 3;47:66–69. doi: 10.1016/j.addbeh.2015.03.026

Financial Strain and Smoking Cessation among Men and Women within a Self-Guided Quit Attempt

Lorraine R Reitzel a, Kirsten J Langdon b, Nga T Nguyen c, Michael J Zvolensky d
PMCID: PMC4417440  NIHMSID: NIHMS677915  PMID: 25879712

Abstract

Financial strain, defined as an unfavorable asset-to-needs ratio, has been associated with reduced odds of smoking cessation in the context of a structured clinical study providing cessation assistance. This study reports on a secondary data analysis that assessed the association of financial strain and biochemically-verified smoking abstinence within a structured clinical study of smokers making a self-guided cessation attempt. Participants (N=58; 65.5% men) were enrolled in a study about anxiety sensitivity and smoking cessation whereby they were instructed to initiate a self-guided quit attempt. Relations between financial strain and biochemically-verified smoking abstinence on the quit day and at Days 3, 7, 14, 28, and 90 post-quit were assessed using generalized estimating equations controlling for age, sex, race, education, partner status, pre-quit cigarettes smoked per day, and time. Associations between financial strain and abstinence in the whole sample were marginal (aOR=.94, 95% CI=.87-1.01, observations=293; p=.07). However, sex was a significant moderator: greater financial strain was associated with lower odds of abstinence for men (aOR=.90, 95% CI= .80-1.00, observations=201; p=.05), but not women (aOR=1.05, 95% CI= .91-1.21, observations=92; p=.48). Results indicated that financial strain was associated with lower odds of cessation among men undergoing a self-guided quit attempt in the context of a structured clinical study. These data suggest financial strain may be an important socioeconomic determinant of smoking cessation and support its relevance for better understanding socioeconomic-based smoking-related health disparities. Future work may benefit by exploring sex-specific models of financial strain in the context of smoking cessation.

Keywords: financial strain, smoking cessation, self-guided quit attempt, sex differences, smoking disparities, socioeconomic status

1. Introduction

The prevalence of smoking in the U.S. is highest among individuals of lower socioeconomic status (SES; Agaku, King, & Dube, 2014). Financial strain, defined as an unfavorable asset-to-needs ratio, is a potentially overlapping construct with traditional indicators of low SES such as low income, low educational attainment, and unemployment (Szanton et al., 2008). However, financial strain represents not objective SES level, but rather income inadequacy relative to expenses and accumulated debt. In that way, financial strain is a construct that may be applicable to individuals of any SES strata who experience debt that exceeds their economic capacities and impacts their ability to afford food, clothing, housing, and other bills (Siahpush, Borland, & Scollo, 2003). Financial strain has been linked with both smoking prevalence and heaviness of smoking (Falba, Teng, Sindelar, & Gallo, 2005; Murayama et al., 2013; Nelson, Lust, Story, & Ehlinger, 2008). Moreover, studies indicate that the likelihood of experiencing financial stress was greater among households containing smokers relative to non-smokers, regardless of income (Siahpush et al., 2003) and that the odds of current smoking increase as financial strain increases (Shaw, Agahi, & Krause, 2011). Although financial strain has received less attention relative to the more traditional SES indicators, these and other studies support that financial strain represents a distinct construct and suggest that it may be an important social determinant of smoking behaviors in its own right. This is especially critical to investigate given that financial strain seems to be rising in the U.S. (Garcia & Draut, 2009; Rapoport & Wheary, 2013; Weller, 2012).

Individuals experiencing financial strain are more likely than their counterparts to report interest in quitting smoking (Siahpush, Yong, Borland, Reid, & Hammond, 2009). Notably, quitting smoking significantly reduces the likelihood of experiencing future financial stress (Siahpush, Spittal, & Singh, 2007a, 2007b). However, financial strain appears to hinder cessation. For example, financial strain was associated with lower quit rates and a greater likelihood of relapse among recent quitters one year later in an Australian cohort study (Siahpush & Carlin, 2006). A multi-country study indicated that financial strain was associated with lower odds of self-reported abstinence among individuals who tried to quit smoking (Siahpush et al., 2009). Similar results have been found within a structured clinical study where participants were provided with counseling and other cessation aids, even after accounting for the effects of SES (Kendzor et al., 2010). Thus, a growing literature appears to support the potential influence of financial strain on smoking relapse. Moreover, the consistency of results found between population-based studies of self-guided quitters and a clinical study of aided quitters suggests the robustness of these associations and their potential generalizability to diverse groups of intended-quitters. Better understanding the association between financial strain and cessation within self-guided quit attempts remains of interest because some quit attempts are undertaken without aid (Chapman & MacKenzie, 2010; Zhu, Melcer, Sun, Rosbrook, & Pierce, 2000), and no previous studies of self-guided quitters, to our knowledge, have benefitted from biochemical confirmation of abstinence status.

This study examined the association between financial strain and smoking abstinence during a self-guided quit attempt and extends the extant literature by examining these relations within the context of a structured clinical study utilizing biochemical-verification of abstinence status. In addition, sex was explored as a potential moderator of these relations given that women are more likely than men to experience financial strain [Wider Opportunities for Women (WOW), 2011], and the effects of financial strain on health and health outcomes may differ by sex [e.g., (Cambois & Jusot, 2011)].

2. Material and Methods

2.1 Participants and Procedures

This study was a secondary data analysis of a parent study focused on anxiety vulnerability and smoking cessation (N=64). All procedures were approved by the Institutional Review Boards at the Universities of Vermont and Houston. Participants were recruited via advertisements for a research study on “quitting smoking” and were initially screened via phone. Included participants were 18-65 years of age; a daily smoker for ≥1 years of ≥ 5 cigarettes per day (CPD); and interested in making a serious but unaided quit attempt. Exclusion criteria entailed evidence of limited mental competency (not oriented to person, place, or time); pregnancy; current nicotine replacement therapy use; current or past history of psychotic-spectrum symptoms/disorders; suicidality; and the “as needed” use of psychotropic medication. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Non-Patient Version (First, Spitzer, Gibbon, & Williams, 2002) and a modified version of the Medical History Form (Scheftner & Endicott, 1984) were used to assess the latter exclusionary criteria.

Eligible participants were scheduled for an in-person baseline visit, which included a final assessment of eligibility criteria, completion of written informed consent, verification of smoking status via expired breath carbon monoxide (CO) ≥8 ppm, and the completion of a structured clinical interview and study questionnaires. Participants were instructed to initiate a self-guided smoking quit attempt 14 days following the baseline session. Participants then attended in-person visits on their quit day, 3 days post-quit (Day 3), 7 days post-quit (Day 7), 14 days post-quit (Day 14), 28 days post-quit (Day 28), and 90 days post-quit (Day 90). Participants could be compensated up to $100, based procedural compliance.

2.2 Measures

Sociodemographic characteristics

Sociodemographic characteristics collected at baseline included age, sex, race (non-Hispanic White versus other race), education (high school degree/equivalent or less, Associates degree or some college, versus Bachelor's degree or greater), and partner status (married or living with partner versus not married).

Smoking-related variables

Smoking-related variables collected at baseline included the number of CPD self-reported at baseline and the time to the first cigarette of the day (<30 minutes versus ≥30 minutes after waking).

Financial strain

The Financial Strain Questionnaire was collected at baseline and consisted of 7 items adapted from an economic strain measure to assess the degree to which it was financially difficult for participants to afford food, clothing, housing, major items (e.g., car), furniture/household equipment, leisure activities, and bills at the present time (Pearlin, Lieberman, Menaghan, & Mullan, 1981). Response categories were: 1=no difficulty, 2=some difficulty, and 3=great difficulty. Total scores could range from 7 to 21, with higher scores indicative of greater financial strain. Cronbach's alpha in this sample was .84.

Smoking abstinence

Smoking abstinence was indicated by a self-report of no smoking since the previous in person assessment (not even a puff) and biochemically-verified using expired breath CO levels of <8 ppm. Smoking abstinence was assessed on the quit day and on Days 3, 7, 14, 28, and 90 post-quit. Missing smoking status data were maintained as missing.

2.3 Analysis

Participant characteristics were examined with descriptive statistics. Main analyses consisted of generalized linear regressions using a generalized estimating equation approach. The first examined whether financial strain predicted smoking abstinence while controlling for age, sex, race, education, partner status, CPD, and time. A follow-up adjusted analysis examined whether the effect of financial strain on abstinence varied over time by including an interaction term in the adjusted model. The next analysis examined potential moderation by sex with an interaction term. This was followed by fully adjusted sex-stratified analyses. Given the limited sample size, data from all abstinence assessments were used in analyses to increase the number of observations and enhance the ability to find effects. Analyses were conducted using SAS, version 9.3.

3. Results

The analyzable sample included 58 participants [Mean=34.9 years of age (±14.3); 65.5% men], with one participant excluded due to missing covariate data and five participants excluded due to the absence of smoking status data at any follow-up time point (i.e., dropouts). Dropouts did not significantly differ from included participants on any participant characteristics, including financial strain. See Table 1 for all participant characteristics. Financial strain did not differ significantly between men [M=14.53 (±3.80)] and women [M=13.80 (±3.79)] in this sample (p=.49).

Table 1. Participant Characteristics (N=58).

Participant characteristics Mean[SD]/n(%)
Age 34.91 [14.28]
Cigarettes per day 15.33 [5.52]
Sex
 Male 38 (65.5)
 Female 20 (34.5)
Race/Ethnicity
 Non-Hispanic White 50 (86.2)
 Other Race 8 (13.8)
Education
 High school or less 8 (13.8)
 Associate's degree/Some college 35 (60.3)
 Bachelor's degree or higher 15 (25.9)
Partner status
 Married or living with someone 17 (29.3)
 Not married or living with someone 41 (70.7)
Recruitment site
 University of Vermont 50 (86.2)
 University of Houston 8 (13.8)
Current SCID-NP diagnosis
 No current SCID-NP diagnosis 35 (60.3)
 Current SCID-NP diagnosis 23 (39.7)
Time to first cigarette of the day
 31 or more minutes after waking 17 (29.3)
 Within 30 minutes of waking 41 (70.7)
Financial Strain 14.28 [3.78]
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Note: SCID-NP = Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Non-Patient Version.

Abstinence rates among those who provided smoking status data at each respective follow-up (i.e., valid percent) were: 81% (quit day, n=0 missing), 37.3% (Day 3, n=7 missing), 27.5% (Day 7, n=7 missing), 22.4% (Day 14, n=9 missing), 20% (Day 28, n=13 missing) and 10.3% (Day 90, n=19 missing). Financial strain did not differ significantly between the 11 participants who were not abstinent on the quit day [M=15.18 (±3.52)] and the 47 abstinent participants [M=14.06 (±3.84), p=.38].

In fully adjusted analyses with all participants (N=58), financial strain was only marginally associated with smoking abstinence (p=.07). This marginally significant effect was consistent over time (financial strain × time; p=.42). In the next model, the interaction of financial strain and sex was significant (p=.05). Follow-up analyses stratified by gender indicated that greater financial strain was associated with lower odds of abstinence among men (p=.05), but not among women (p=.48). Specifically, every one unit increase in financial strain was associated with an 11.6% increase in the odds of being non-abstinent among men in the sample. See Table 2.

Table 2. Adjusted Relations of Financial Strain and Smoking Abstinence over Time for the Full Sample and by Sex.

Full Sample (N=58, observations=293)
Covariates and Predictor Beta (SE) p OR (95% CI)
Age .001 (.01) .92 1.00 (.97-1.03)
Cigarettes per day .018 (.03) .60 1.02 (.95-1.09)
Sex (Female) .027 (.04) .43 1.31 (.66-2.59)
Race/Ethnicity (Non-Hispanic White) 1.161 (.52) .03 3.19 (1.15-8.86)
Education
 Associate's degree/Some college .87 (.65) .18 2.39 (.67-8.57)
 Bachelor's degree or higher 1.109 (.69) .11 3.03 (.79-11.59)
Partner status (Married or LWS) .071 (.40) .08 2.03 (.93-4.45)
Time -.043 (.02) .01 .96 (.93-.99)
Financial Strain -.070 (.04) .07 .94 (.87-1.01)
Men only (n=38, observations=201)
Covariates and Predictor Beta (SE) p OR (95% CI)
Age -.018 (.02) .33 .98 (.94-1.02)
Cigarettes per day .048 (.05) .37 1.05 (.94-1.17)
Race/Ethnicity (Non-Hispanic White) 1.709 (.58) .003 5.52 (1.78-17.14)
Education
 Associate's degree/Some college 1.579 (1.12) .16 4.85 (.54-43.78)
 Bachelor's degree or higher 1.773 (1.10) .11 5.89 (.69-50.46)
Partner status (Married or LWS) 1.517 (.40) .08 4.56 (.92 – 22.55)
Time -.035 (.01) .004 .97 (.94-.99)
Financial Strain -.110 (.06) .05 .90 (.80-1.00)
Women only (n=20, observations=92)
Covariates and Predictor Beta (SE) p OR (95% CI)
Age -.018 (.03) .53 .98 (.93-1.04)
Cigarettes per day .066 (.07) .33 1.07 (.94-1.22)
Race/Ethnicity (Non-Hispanic White) 1.022 (1.31) .43 2.78 (.21-36.17)
Education
 Associate's degree/Some college -.52 (1.15) .65 .59 (.06-5.63)
 Bachelor's degree or higher .367 (1.25) .77 1.44 (.13-16.59)
Partner status (Married or LWS) .127 (.63) .84 1.13 (.33-3.92)
Time -.129 (.04) <.001 .88 (.81-.95)
Financial Strain .050 (.07) .57 1.05 (.91-1.21)
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Note: OR = Odds Ratio, CI=Confidence Interval, SE=Standard Error, LWS=Living With Someone.

4. Discussion

The current study links financial strain with lower odds of biochemically-verified smoking abstinence among male smokers undergoing a self-guided quit attempt in the context of a structured clinical study where no cessation treatment was provided. Taken together with results from population-based studies of self-guided quitters (Siahpush & Carlin, 2006; Siahpush et al., 2009) and a clinical study of aided quitters (Kendzor et al., 2010), these findings suggest that financial strain may be an important socioeconomic determinant of smoking cessation that is not commonly considered in conceptual models linking SES and smoking cessation [e.g., (Businelle et al., 2010)], but which may aid in better understanding socioeconomic-based smoking-related health disparities.

A notable difference between the current findings and those reported previously (e.g., Kendzor et al., 2010) was that significant effects did not extend to women in our sample; however, this finding should be interpreted with caution given sample characteristics that might limit generalizability. For example, previous studies report that women are more likely than men to experience financial strain (WOW, 2011); however, no sex differences in financial strain were observed among the participants in the current study. In addition, the current sample of women was small (n=20), with relatively limited abstinence rates at the final time point (n=0-3 on Days 14-90). However, the non-significant relation between financial strain and abstinence among women persisted with a slightly increased sample size (n=22, observations=138) that included drop-outs coded as non-abstinent. Women are known to relapse at higher rates than men (Ward, Klesges, Zbikowski, Bliss, & Garvey, 1997), and it may be that factors other than financial strain are more strongly associated with non-abstinence among self-guided female quitters relative to male counterparts (cf. Perkins, 2001; Westmaas & Langsam, 2005), although no previous studies have specifically addressed this point.

The current study was limited to variables collected within the parent project, and some potential variables of interest to the present work were not included (e.g., age of smoking initiation, income). Although the inability to control for income was a weakness of the current study, it should be noted that traditional SES indicators have not always been included as covariates in analyses involving financial strain (e.g., Puterman et al., 2013). In addition, education (a covariate in the current study) tends to be highly correlated with income (cf. U.S. Department of Labor, 2014) and is potentially more relevant as an indicator of SES for some participant subgroups (e.g., retired adults). An additional limitation of the current study is that the inclusion criteria may limit the generalizability of findings to some groups of smokers (e.g., smokers with psychotic disorders). However, the fact that smokers were not excluded from this study due to the lack of a valid phone number or home address was important, given the focus on financial strain. Finally, this study had a limited sample size; results should be replicated within larger samples and analyses should include all covariates of relevance, including potentially more comprehensive measures of tobacco dependence than cigarettes per day.

In summary, the inverse association between financial strain and smoking abstinence was supported among men engaging in a self-guided quit attempt in this sample. Results add to a growing body of literature suggesting the potentially unique role of financial strain in understanding socioeconomic-based smoking-related disparities and highlight the need to better understand underlying contributory mechanisms. The potential for sex-based variance in the relations of financial strain and cessation should be considered in future work.

Highlights.

  • Financial strain and smoking abstinence were examined among self-guided quitters.

  • Financial strain predicted lower odds of CO-confirmed abstinence among men only.

  • Financial strain may play a unique role in socioeconomic-based smoking disparities.

  • Studies should explore if sex-specific models aid in understanding these relations.

Acknowledgments

Funding: This work was supported by a National Research Service Award to Dr. Langdon by the National Institute on Drug Abuse (F31DA026634) and by institutional funds from the University of Houston provided to Dr. Reitzel. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the sponsoring organizations.

Footnotes

Declaration of Interests: Authors have no competing interests pertaining to this research.

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