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. Author manuscript; available in PMC: 2020 Nov 1.
Published in final edited form as: Ethn Health. 2017 Oct 16;24(8):855–873. doi: 10.1080/13557858.2017.1390549

Intent to Quit, Quit Attempts, and Perceived Health Risk Reduction among African American, Latino, and White Nondaily and Daily Smokers in the United States

Taneisha S Scheuermann 1, Nicole L Nollen 1, Xianghua Luo 2, Lisa Sanderson Cox 1, Jasjit S Ahluwalia 3
PMCID: PMC6143426  NIHMSID: NIHMS1503841  PMID: 29035089

Abstract

Objective:

Ethnic and racial differences in smoking patterns and behaviors have been well documented and most African American and Latino smokers are nondaily or light smokers. However, differences within smoking levels are understudied. Our primary aim was to determine whether there are racial and ethnic differences among African American, Latino, and White nondaily, light daily, and moderate to heavy daily smokers on 1) perceived health risk reduction, 2) intentions to quit, and 3) past year quit attempts.

Design:

Smokers were recruited through an online research panel for a cross-sectional survey (n = 2,376). Sampling quotas were used to obtain equal numbers of African American, Latino, and White nondaily and daily smokers.

Results:

African American (59.6%) and Latino (54%) nondaily smokers were more likely than White nondaily smokers (45%) to currently limit their cigarettes per day (cpd) as a perceived health risk reduction strategy (p<0.05). African American nondaily smokers were more likely than Latino and White nondaily smokers (p<0.05) to limit their smoking in the past year as a perceived health risk reduction strategy (range: 0 “never” to 5 “always”; Means = 3.2, 2.9, 3.0, standard deviations [SD] = 1.1, 1.1, 1.2, respectively). African American nondaily smokers (15%) were more likely than either Latinos (7.8%) or Whites (8.5%) to intend to quit in the next 30 days (p<0.01). African American (61.6%) and Latino (60.3%) nondaily smokers were more likely than Whites (49%) to have made a quit attempt in the past year (p<0.01). Fewer racial and ethnic differences were found among daily smokers.

Conclusions:

Racial and ethnic group differences were more pronounced among nondaily smokers compared to light daily smoker and moderate to heavy daily smokers. Smoking level is an important consideration in understanding racial and ethnic variation in perceived health risk reduction and cessation-related behaviors.

Keywords: African American, Latino, White, perceived health risk reduction, smoking

INTRODUCTION

Tobacco control efforts in the United States have resulted in a reduction in smoking prevalence over the past five decades to 15.1% in 2015 (U. S. Department of Health and Human Services 2014, Jamal et al. 2016). Alongside this decrease in prevalence, there have been dramatic changes in smoker characteristics. The mean number of cigarettes smoked per day (cpd) by daily smokers continues to decrease, with the national average cpd being 14.2 in 2015 (Jamal et al. 2016). Twenty-four percent of U.S. current cigarette smokers do not smoke every day (i.e., nondaily smokers) and 25.1% of daily smokers are light smokers (1–9 cpd) (Jamal et al. 2016). Light and nondaily smoking are the predominant smoking patterns for racial and ethnic minorities such as African Americans and Latinos (Trinidad et al. 2009). Among African American and Latino current smokers, 23.8% and 35.7%, respectively, are nondaily smokers and 42.7% and 40.7%, respectively, are light daily smokers (1–10 cpd) (Trinidad et al. 2009). Efforts to further decrease U.S. smoking prevalence will require tools to address specific smoking cessation challenges across smoker demographics (Clark et al. 1999, Unger et al. 2001).

Disparities in smoking prevalence (Jamal et al. 2016), smoking patterns (Trinidad et al. 2009), and success in quitting are seen across racial and ethnic groups (Fu et al. 2008). Smoking prevalence is higher among non-Latino Whites (16.6%) and African Americans (16.7%) than Latinos (10.1%)(Jamal et al. 2016) and racial/ethnic minority smokers are more likely to be nondaily or light smokers compared to non-Latino Whites (Trinidad et al. 2009). Survey data suggest that Latinos and non-Latino Whites have similar rates of smoking cessation (Fu et al. 2008), but African Americans are less likely than Whites to successfully quit smoking (Fu et al. 2008, Sakuma et al. 2015). Differences in smoking-related behavior may be due to multiple factors including cultural norms (Clark et al. 1999, Unger et al. 2001), biological differences in nicotine metabolism (Benowitz et al. 2011), price sensitivity (Myers et al. 2013), and barriers to treatment (Cokkinides et al. 2008). Because most African American and Latino smokers are either nondaily or light smokers, examining racial/ethnic differences grouping all smokers together could potentially obscure important findings. Developing more detailed descriptions of smoking patterns, attitudes, and cessation-related behaviors will result in improved tobacco control efforts including effectively targeted smoking cessation messaging and interventions (Schane, Prochaska, and Glantz 2013).

Several factors, including nicotine dependence, have been found to increase or decrease the likelihood of successful quitting (Vangeli et al. 2011). Despite significantly lower dependence (Shiffman, Ferguson, et al. 2012), nondaily smokers are only marginally more likely to successfully quit than daily smokers (Tindle and Shiffman 2011). Several theories have been offered for predicting whether individuals will engage in health protective behaviors such as smoking cessation (Painter et al. 2008). One such theory is the Health Belief Model that posits that people are more likely to engage in health protective behaviors if they view themselves as at risk for developing a condition, if they perceive the condition as severe, if they perceive benefits of the health behavior, and if the perceived benefits of the health behavior outweigh any barriers (Becker 1974, Skinner, Tiro, and Champion 2015). Qualitative findings indicate that nondaily smokers may perceive themselves as being at lower risk for developing smoking-related illness than daily smokers (Scheuermann et al. 2014), potentially negatively impacting their cessation efforts. Arguably, nondaily and light smokers may smoke at these rates because of a perception that reduced consumption may limit the health impact of their smoking; although even low rate smoking substantially increases the risk of tobacco-related disease and mortality compared to nonsmokers (Schane, Ling, and Glantz 2010, Inoue-Choi et al. 2016). One study found that African American light smokers are more likely than African American heavier smokers to use perceived health risk reduction strategies such as limiting the number of cigarettes smoked in an attempt to reduce their risks from smoking (Okuyemi, Richter, et al. 2002). Within the Health Belief Model, sociodemographic characteristics are hypothesized to influence perceptions of health risk and behavior (Skinner, Tiro, and Champion 2015), but the extent to which racial and ethnic differences exist in perceived health risk reduction among smokers has not been studied. Few studies address perceived health risk reduction based on decreased cigarette consumption (Okuyemi, Richter, et al. 2002), even though smokers may use this strategy in hopes of reducing harm (Scheuermann et al. 2014). Further, the perception of health risk reduction for lower rate smokers could potentially serve as a barrier to quitting and may be more salient for racial and ethnic groups with higher prevalence of nondaily and light smoking.

While previous studies have identified racial and ethnic differences among smokers on demographics (e.g., income), tobacco use characteristics (e.g., smoking dependence, menthol cigarette use), and psychological variables such as depression that may impact quit attempts and cessation (Webb Hooper, Baker, and McNutt 2014, Trinidad et al. 2009, Trinidad et al. 2011, Keeler et al. 2016); perceived health risk reduction through reduced cigarette consumption has only been studied among African American smokers (Okuyemi, Richter, et al. 2002).

Given tobacco-related differences by race and ethnicity (Webb Hooper, Baker, and McNutt 2014, Trinidad et al. 2011) and nondaily vs. daily smoking (Shiffman, Tindle, et al. 2012, Tindle and Shiffman 2011), one may infer that there are also racial and ethnic differences within each smoking pattern. However, no previous studies have directly contrasted racial and ethnic groups within each category of widely adopted smoking categories or levels: nondaily, light daily, and moderate to heavy daily smoking (Kotz, Fidler, and West 2012, Reitzel et al. 2009, Businelle et al. 2009, Tong et al. 2009).Therefore, the first aim of this study was to identify racial and ethnic differences among non-Latino African American, Latino, and non-Latino White nondaily, light daily, and moderate to heavy daily smokers on 1) limiting cigarette consumption to reduce health risks, 2) intentions to quit, and 3) recent quit attempts. We extended the literature by comparing racial and ethnic groups on demographic and smoking-related variables within each smoking level (i.e., nondaily, light daily, and moderate to heavy daily smoking) and including perceived health risk reduction. Our second aim was to identify correlates of quit-related plans and behaviors, specifically 1) intent to quit in the next 30 days, and 2) having made at least one quit attempt in the past year. We examined whether race and ethnicity, smoking level, and the interaction of race and ethnicity with smoking level explained differences among smokers in intention to quit and recent quit attempts after controlling for other demographic and tobacco-use related correlates. Statistically significant race and ethnicity by smoking level interaction effects would indicate that the associations between smoking level and quit-related plans and behaviors differed by race and/or ethnicity.

METHODS

Participants

Daily and nondaily smokers were recruited into a cross-sectional study using an online panel survey company, Survey Sampling International (SSI). SSI provides access to a research panel consisting of 1.5 million individuals across the United States willing to complete online surveys. For this study, eligible participants self-identified as non-Latino African American, non-Latino White, or Latino (the three largest racial and ethnic groups in the United States) (Humes, Jones, and Ramirez 2011), were English-speaking, and were at least 25 years old. In addition, they reported having smoked at least 100 cigarettes in their lifetime, smoking for at least one year, and smoking at their current rate (i.e., daily or nondaily) for at least 6 months. Individuals who participated in any smoking cessation treatment in the past 30 days, or who were currently pregnant or breast-feeding were excluded from the study. Additional details on the participants and procedures are described elsewhere (Kendzor et al. 2014).

Sampling quotas were established to obtain approximately 1,200 daily smokers (further categorized into light and moderate/heavy) and 1,200 nondaily smokers with equal proportions of participants from each of the three racial/ethnic groups. The planned sample size would allow reasonable precision when making comparisons between the different racial/ethnic groups within the nondaily smokers group. With 400 nondaily smokers in each racial/ethnic group, our analyses would have > 90% power to detect differences between two groups using previous estimates of proportions with past year quit attempts across racial and ethnic groups ranging from 29%−43% (Trinidad et al. 2011). Nondaily smokers were defined as having smoked fewer than 25 days in the past 30 days; persons who smoked three or fewer days out of the past 30 days were excluded from the study to include only smokers who were smoking the equivalent of at least once per week (Shiffman, Ferguson, et al. 2012). Based on a commonly used criteria for smoking most days of the month (Ahluwalia et al. 2006, Cox et al. 2012), daily smokers were defined as having smoked on 25 to 30 of the past 30 days (Evans et al. 1992). Daily smokers were further subdivided into light daily smokers (≤10 cpd) (Okuyemi, Harris, et al. 2002) and moderate to heavy smokers (>10 cpd) (Businelle et al. 2009, Reitzel et al. 2009).

Procedures

The study was approved by the University of Minnesota Institutional Review Board. Potential participants were recruited through daily e-mail invitations sent to SSI panelists directing them to the study and targeted email invitations to panelists (e.g., by self-identified race and ethnicity). The first page of the survey presented information needed for informed consent to participate; participants then completed screening questions to determine eligibility. Eligible participants were enrolled in the study until each of the race and ethnic group by smoking level sampling quotas were met. Participants who did not meet study criteria or who matched criteria for a quota that was already filled were ineligible. There were 38,590 panelists who completed the screener and 4,125 panelists who began the screener but did not complete it. Of those who completed the screener, 13,775 did not meet study eligibility criteria and 21,891 were excluded from the study because their sampling quota was met. There were 2,924 eligible panelists and 2,468 of these completed the survey. Sixty surveys from individuals who had already responded and 32 surveys with inconsistent responses to items assessing the eligibility criteria were excluded from the study. This resulted in 2,376 participants, 82% of the 2,892 non-duplicated, eligible respondents. SSI provided their standard incentives for panelists who completed surveys that included entry into their quarterly drawing for $12,500 and points that could be redeemed for cash.

Measures

Demographics

Demographic questions assessed participants’ age, gender, highest level of education, employment status, and monthly household income. Race and ethnicity were assessed using a two-item measure from the U.S. Department of Health and Human Services Data Standards (Dorsey and Graham 2011). Latinos indicated that they were of one of the “Hispanic, Latino/a, or of Spanish origin” categories and were of any race. African Americans and Whites selected the corresponding category on the item assessing race (i.e., “African American or Black”, “White”) and indicated that they were not of Hispanic, Latino/a or Spanish origin.

Psychological Variables

Depression.

The Patient Health Questionnaire (PHQ-2) is a two item measure used to screen for depression (Kroenke, Spitzer, and Williams 2003). Scores for the two items are summed to create a total score ranging from 0 to 6. PHQ-2 scores of 3 or greater indicate depressive symptoms.

Tobacco Use and History

Participants reported the number of days they smoked in the past month (Al-Delaimy et al. 2009). Average cpd was assessed using a modified item from the Tobacco Use Supplement to the Current Population Survey, “on the days you smoke, on average, about how many cigarettes do you smoke each day?”(US Department of Commerce 2012). Participants who reported smoking on 24 or fewer days in the past 30 days were classified as nondaily smokers, and participants smoking 25 or more days in the past 30 were classified as daily smokers (Evans et al. 1992). Daily smokers who reported smoking an average of ≤10 cpd were classified as light smokers and >10 cpd (Okuyemi, Harris, et al. 2002) as moderate to heavy smokers (Businelle et al. 2009, Reitzel et al. 2009). Participants were asked to indicate the length of time they had been smoking cigarettes (“How long have you smoked cigarettes?”) reported in years and/or months. Current daily smokers were also asked, “how long have you been smoking daily?” and current nondaily smokers were asked, “how long have you been smoking on some days of the month?” Participants were also asked to indicate whether they typically smoked mentholated or non-mentholated cigarettes (US Department of Commerce 2012).

Social Smoking.

Social smoking was assessed by asking “In the past 30 days, did you smoke…”: “mainly when you were with people,” “mainly when you were alone,” and “as often by yourself as with others” (Moran, Wechsler, and Rigotti 2004). Social smokers were identified as those who smoked mainly with others.

Cigarette Dependence.

Time to first cigarette, an item from the Fagerström Test of Cigarette Dependence (Heatherton et al. 1991, Fagerstrom 2012), was used as an indicator of cigarette dependence (Baker et al. 2007). We dichotomized responses into smoking < 30 minutes after waking and smoking > 30 minutes; smoking within 30 minutes of waking denotes higher cigarette dependence (Baker et al. 2007).

Perceived Health Risk Reduction

Current and past year use of strategies perceived as health risk reducing was assessed using the following two questions (Okuyemi, Richter, et al. 2002): “Do you currently set a limit for how many cigarettes you smoke a day to decrease your health risks from smoking?” Response options were yes or no; and “In the last year, how often did you limit how much you smoke to decrease your health risks from smoking?” The five response options ranged from “Never” to “Always.”

Intention to Quit and Past Quit Attempts

Intention to quit was assessed using a single-item measure that asked participants “What describes your intention to stop smoking completely, not even a puff? Would you say you…” “Never expect to quit”, “may quit in the future, but not in the next 6 months,” “will quit in the next 6 months,” “will quit in the next 30 days”(Fava, Velicer, and Prochaska 1995). Participants also reported their number of quit attempts in the past year that lasted at least 24 hours, and the length of their longest quit attempt in the past year (US Department of Commerce 2012).

Data Analysis

Descriptive statistics were used to summarize the variables used in this study. Categorical variables were summarized by frequencies and percentages, and continuous variables were summarized by means and standard deviations. To accomplish our first aim, we examined racial and ethnic differences among nondaily smokers, light daily smokers, and moderate to heavy daily smokers using ANOVA F-tests and t-tests for continuous variables and chi-square tests for categorical variables in SPSS 22.0 (IBM Corp., Armonk, NY). Pairwise comparison p values among the three racial and ethnic groups were adjusted by Holm’s method (Holm 1979) to control the family-wise type-I error rate at 5%. For our second aim, to determine the set of correlates that explain whether smokers 1) intend to quit in the next 30 days, and 2) made at least one quit attempt in the past year, we performed stepwise logistic regressions using SAS 9.4 (SAS Institute, Inc., Cary, NC) and included demographic and smoking variables, where a significance level of 0.1 is required to allow a variable into the model, and a significance level of 0.05 is required for a variable to stay in the model. We also evaluated fully adjusted logistic regression models with race and ethnicity by smoking level interaction terms. There were no missing data, therefore, all multivariable analyses included the full sample.

RESULTS

Our final study sample size was 2,376, with 1,201 nondaily smokers and 1,175 daily smokers (including 578 light daily smokers and 597 moderate to heavy daily smokers). These groups were further stratified across three race/ethnicity groups – African American (n=794), Latino (n=786), and Whites (n=796) – the sample included a total of nine groups based on three levels of smoking and three racial/ethnic groups. Fifty-eight percent of the sample was female.

Nondaily Smokers

Descriptive statistics for nondaily smokers and bivariate analyses by race and ethnicity are presented in Table 1. Below, we describe the findings for aim 1 addressing racial and ethnic differences on 1) perceived health risk reduction, 2) quit intentions, and 3) past year quit attempts within each smoking level.

Table 1.

Demographic and Smoking Characteristics of Nondaily Smokers by Race and Ethnicity

African American
(n=401)		 Latino
(n=400)		 White
(n=400)		 Overall
p-value		 Adjusted p-value* for AA vs. Latino Adjusted p-value* for AA vs. White Adjusted p-value* for Latino vs. White
M (SD) or
n (%)		 M (SD) or
n (%)		 M (SD) or
n (%)
Demographics
Female 242 (60.3%) 184 (46.0%) 244 (61.0%) <0.0001 <0.001 0.850 <0.001
 Age 43.1 (11.8) 36.7 (9.4) 44.4 (14.1) <0.001 <0.001 0.148 <0.001
 ≤High school education 119 (29.7%) 79 (19.8%) 92 (23.0%) 0.004 0.004 0.003 0.064
 Income <$1800 184 (48.2%) 107 (28.5%) 128 (34.0%) <0.0001 <0.001 <0.001 <0.001
 Employed 190 (47.4%) 292 (73.0%) 210 (52.5%) <0.0001 <0.001 <0.001 0.148
Psychological Variables
 Depressive symptoms (PHQ-2 ≥ 3) 122 (30.4%) 169 (42.3%) 123 (30.8%) 0.0003 <0.001 0.0016 0.9202
Tobacco Use and History
 Days smoked/ past month 14.7 (5.7) 14.7 (5.9) 14.2 (6.2) 0.318 0.318 0.875 0.527
 CPD on days smoked 5.2 (4.3) 4.9 (5.4) 6.1 (5.9) 0.004 0.004 0.367 0.032
 Time to first cigarette <30 min 175 (43.6%) 174 (43.5%) 111 (27.8%) <0.001 <0.001 0.968 <0.001
 Former daily smoker 295 (73.6) 300 (75.0) 309 (77.3) 0.476 0.476 0.911 0.697
 Years smoking cigarettes 15.20 (10.6) 12.11 (10.8) 20.66 (13.7) <0.001 <0.001 <0.001 <0.001
 Years smoking nondaily 10.9 (9.8) 9.2 (10.0) 14.2 (13.0) <0.001 <0.001 0.029 <0.001
 Smoke Menthol 338 (84.3%) 237 (59.3%) 142 (35.5%) <0.001 <0.001 <0.001 <0.001
 Smoke Mainly with Others 129 (32.2%) 169 (42.3%) 160 (40.0%) 0.009 0.009 0.010 0.042
Perceived Harm Reduction
 Currently sets a limit on cpd to decrease health risks 239 (59.6%) 216 (54.0%) 180 (45.0%) <0.001 0.110 <0.001 0.022
 Past year frequency of limiting amount smoked to decrease health risks
 (0:Never; 5: Always)		 3.2 (1.1) 2.9 (1.1) 3.0 (1.2) <0.001 <0.001 0.021 0.098
Intention to Quit and Past Year Attempts
 Intend to Quit < 30 days 60 (15.0%) 31 (7.8%) 34 (8.5%) 0.001 0.004 0.009 0.698
 > 1 past year quit attempt 247 (61.6%) 241 (60.3%) 196 (49.0%) <0.001 0.696 0.001 0.003
 Longest Quit Attempt 87.1 (78.0) 77.4 (70.2) 58.6 (62.6) 0.004 0.178 <0.001 0.012
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*

Pairwise p-values were adjusted by Holm’s method.

Perceived Health Risk Reduction.

African American (59.6%) and Latino (54%) nondaily smokers were more likely than White nondaily smokers (45%) to report setting a limit on their cpd to reduce health risks (p<0.001 and p = 0.022, respectively). African Americans reported a higher frequency of limiting the amount they smoked in the past year to reduce their health risks (the scale ranged from 0 “never” to 5 “always”; Mean = 3.2, standard deviation [SD] = 1.1), than Latinos (Mean = 2.9, SD = 1.1; p< 0.001) and Whites (Mean = 3.0, SD = 1.2; p = 0.021).

Quit Intentions and Past Year Quit Attempts.

African American nondaily smokers (15%) were more likely than either Latino (7.8%; p = 0.004) or White (8.5%; p = 0.009) nondaily smokers to report intention to quit in the next 30 days. African American (61.6%) and Latino (60.3%) nondaily smokers were more likely than White nondaily smokers to have made a quit attempt in the past year (49%; p = 0.001 and p = 0.003, respectively). African American and Latino nondaily smokers reported longer quit attempts in the past year on average (87.1 days and 77.4 days, respectively), than White nondaily smokers (58.6 days; p<0.001 and p = 0.012, respectively).

Light Daily Smokers

Descriptive statistics and statistical significance for differences among African American, Latino, and White light daily smokers are presented in Table 2.

Table 2.

Demographic and Smoking Characteristics of Light Daily Smokers by Race and Ethnicity

African American
(n=193)		 Latino
(n=190)		 White
(=195)		 Overall
p-value		 Adjusted p-value* for AA vs. Latino Adjusted p-value* for AA vs. White Adjusted p-value* for Latino vs. White
M (SD) or
n (%)		 M (SD) or
n (%)		 M (SD) or
n (%)
Demographics
 Female 121 (62.7%) 228 (62.1%) 132 (67.7%) 0.452 0.905 0.603 0.501
 Age 44.1 (12.2) 40.8 (11.2) 46.3 (13.6) <0.001 0.094 0.094 <0.001
 ≤High school education 51 (26.4%) 58 (30.5%) 67 (34.4%) 0.2365 0.748 0.268 0.748
 Income <$1800 93 (50.3%) 70 (38.5%) 65 (34.4%) 0.0053 0.046 0.006 0.415
 Employed 96 (49.7%) 102 (53.7%) 99 (50.8%) 0.7260 1.000 1.000 1.000
Psychological Variables
 Depressive symptoms
 (PHQ-2 ≥ 3)		 60 (31.1%) 76 (40.0%) 49 (25.1%) 0.007 0.138 0.192 0.006
Tobacco Use and History
 Days smoked/ past month 29.6 (1.1) 29.2 (1.73) 29.5 (1.5) 0.014 0.012 0.233 0.233
 CPD on days smoked 7.7(2.6) 6.87 (2.9) 7.64 (2.6) 0.004 0.009 0.779 0.014
 Time to first cigarette <30 min 144 (74.6%) 105 (55.3%) 118 (60.5%) <0.001 <0.001 0.006 0.297
 Years smoking cigarettes 21.1(12.5) 19.1 (12.1) 23.20 (14.61) 0.010 0.234 0.234 0.009
 Years smoking daily 19.2 (12.7) 16.9 (12.4) 21.2 (14.7) 0.007 0.145 0.157 0.006
 Smoke Menthol 170(88.1%) 93 (48.9%) 68 (34.9%) <0.001 <0.001 <0.001 0.005
 Smoke Mainly with Others 24 (12.4%) 31 (16.3%) 27 (13.8%) 0.545 0.837 0.997 0.997
Perceived Harm Reduction
 Currently sets a limit on cpd to decrease health risks 93 (48.2%) 88 (46.3%) 107 (54.9%) 0.209 0.714 0.375 0.280
 Past year frequency of limiting amount smoked to decrease health risks
 (0:Never; 5: Always)		 2.8 (1.2) 2.8 (1.2) 3.1 (1.2) 0.028 0.747 0.064 0.052
Intention to Quit and Past Year Attempts
 Intend to Quit ≤ 30 days 11 (5.7%) 10 (5.3%) 14 (7.2%) 0.710 1.000 1.000 1.000
 ≥ 1 past year quit attempt 73 (37.8%) 86 (45.3%) 88 (45.1%) 0.240 0.419 0.419 0.979
 Longest Quit Attempt 79.3 (70.3) 79.0 (72.9) 80.4 (63.9) 0.992 1.000 1.000 1.000
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*

Pairwise p-values were adjusted by Holm’s method.

Perceived Health Risk Reduction.

There were no statistically significant differences in the proportion of African American, Latino, and White light daily smokers who reported currently limiting their cpd for the purpose of reducing their health risks from smoking, and who reported limiting the amount they smoked in the past year to reduce their health risk.

Quit Intentions and Past Year Quit Attempts.

The racial and ethnic groups did not differ on the proportion of smokers intending to quit in the next 30 days, having made a quit attempt in the past year, or on the average number of days for the longest quit attempt in the past year.

Moderate to Heavy Daily Smokers

Descriptive statistics for all variables reported for African American, Latino, and White moderate to heavy daily smokers are presented in Table 3.

Table 3.

Demographic and Smoking Characteristics of Moderate to Heavy Smokers by Race and Ethnicity

African American
(n=200)		 Latino
(n=196)		 White
(n=201)		 Overall
p-value 		Adjusted p-value* for AA vs. Latino Adjusted p-value* for AA vs. White Adjusted p-value* for Latino vs. White
M (SD) or
n (%)		 M (SD) or
n (%)		 M (SD) or
n (%)
Demographics
      Female 108 (54.0%) 120 (61.2%) 113 (56.2%) 0.331 0.438 0.655 0.622
 Age 44.9 (11.7) 42.9 (11.7) 48.5 (12.0) <0.001 0.078 0.005 <0.001
 ≤High school education 48 (24.0%) 57 (29.1%) 60 (29.9%) 0.364 0.560 0.560 0.867
 Income <$1800 75 (38.1%) 49 (26.1%) 70 (35.0%) 0.035 0.035 0.525 0.113
 Employed 101 (50.5%) 113 (57.7%) 93 (46.3%) 0.072 0.307 0.397 0.071
Psychological Variables
 Depressive symptoms
 (PHQ-2 ≥ 3)		 75 (37.5%) 62 (31.6%) 71 (35.3%) 0.465 0.661 0.872 0.872
Tobacco Use and History
 Days smoked/ past month 29.7 (1.1) 29.8 (0.8) 29.9 (0.7) 0.064 0.222 0.096 0.560
 CPD on days smoked 19.3 (8.2) 21.0 (8.9) 21.6 (8.2) 0.018 0.087 0.015 0.500
 Time to first cigarette <30 min 181 (90.5%) 161 (82.1%) 180 (89.6%) 0.023 0.051 0.752 0.072
 Years smoking cigarettes 22.9 (12.2) 21.7 (12.5) 28.9 (12.6) <0.001 0.340 <0.001 <0.001
 Years smoking daily 21.6 (12.2) 20.0 (12.7) 27.4 (12.7) <0.001 0.225 <0.001 <0.001
 Smoke Menthol 169 (84.5%) 93 (47.4%) 50 (24.9%) <0.001 <0.001 <0.001 <0.001
 Smoke Mainly with Others 14 (7.0%) 23 (11.7%) 11 (5.5%) 0.058 0.211 0.527 0.077
Perceived Harm Reduction
 Currently sets a limit on cpd to decrease health risks 61(30.5%) 64 (32.7%) 53 (26.4%) 0.379 0.718 0.718 0.509
 Past year frequency of limiting amount smoked to decrease health risks
 (0:Never; 5: Always)		 2.6 (1.1) 2.5 (1.2) 2.4 (1.2) 0.227 0.589 0.265 0.589
Intention to Quit and Past Year Attempts
 Intend to Quit ≤ 30 days 10 (5.0%) 7 (3.6%) 11 (5.5%) 0.648 1.000 1.000 1.000
 ≥ 1 past year quit attempt 67 (33.5%) 68 (34.7%) 61 (30.3%) 0.634 1.000 1.000 1.000
 Longest Quit Attempt (days) 81.52 (75.3) 90.37 (76.7) 70.18 (58.1) 0.305 0.731 0.731 0.331
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*

Pairwise p-values were adjusted by Holm’s method.

Perceived Health Risk Reduction.

There were no differences among African American, Latino, and White moderate to heavy daily smokers on use of perceived health risk reduction strategies.

Quit Intentions and Past Year Quit Attempts.

There were no differences among racial and ethnic groups on the proportion of smokers intending to quit smoking in the next 30 days, the proportion who made a quit attempt in the past year, or the longest quit attempt in the past year.

Multivariable analyses of the associations of race/ethnicity and smoking level with quit intention and past year quit attempt

Below we describe our findings from the multivariable analyses used to address aim 2. Specifically we report on the correlates of 1) intent to quit, and 2) past year quit attempts in models including the full sample of smokers.

Intent to Quit.

We conducted a multiple logistic regression analysis with intent to quit as the dependent variable. Independent variables entered into the analysis were demographic variables (gender, race, age, income, education, employment status), depressive symptoms (PHQ-2 scores), and tobacco-related behaviors and perceptions (time to first cigarette, years smoking, menthol use, social smoking, perceived health risk reduction [i.e., currently limiting cpd, past year limiting amount smoked], and smoking level). We excluded cpd and days smoked in the past month from the model because these variables were used to define smoking level which was included in the model. We also tested a model including race/ethnicity by smoking level interaction terms to determine whether the associations between smoking level and having a past year quit attempt differed by race and ethnicity, but this interaction was not statistically significant (p = 0.399) so the final regression model was fitted without the race and ethnicity by smoking level interactions. The following variables remained in the final model examining factors associated with intent to quit in the next 30 days, using step wise entry (see Table 4): gender, frequency of limiting the amount smoked in the past year, and smoking level. Men were less likely than women to intend to quit (OR = 0.67, 95% CI = 0.48, 0.93, p = 0.016); participants who more frequently limited the amount they smoked in the past year in hopes of reducing their health risks were more likely to intend to quit (OR = 1.46, 95% CI = 1.27, 1.69, p < 0.001); and nondaily smokers were almost twice as likely to intend to quit compared to moderate to heavy smokers (OR=1.93, 95% CI = 1.24, 2.99, p = 0.004). The difference between light daily and moderate to heavy smokers was non-significant (OR = 1.08, 95% CI = 0.64, 1.83, p = 0.781). Compared to light daily smokers, nondaily smokers had a 79% increase in the odds of intending to quit (OR= 1.79, 95% CI = 1.19, 2.68, p = 0.005; results not shown in the table).

Table 4.

Final Multiple Logistic Regression Models for Intentions to Quit within the Next 30 Days and ≥ 1 Past Year Quit Attempt (n = 2,376)

Intend to quit ≤ 30 days
Odds Ratio (95% CI) p-value
Gender
   Male 0.67 (0.48– 0.93) 0.016
   Female 1.00
Past year frequency of limiting amount smoked to decrease health risks 1.46 (1.27– 1.69) <0.001
Smoking Level
   Nondaily smoker 1.93 (1.24–2.99) 0.004
   Light daily smoker 1.08 (0.64–1.83) 0.781
   Moderate to heavy daily smoker 1.00
≥ 1 past year quit attempt
Odds Ratio (95% CI) p-value
Age 0.99 (0.98–1.00) 0.005
Depressive symptoms
   PHQ-2 ≥ 3(Depressive symptoms) 1.78 (1.47–2.17) <0.001
   PHQ-2< 3 1.00
Time for first cigarette ≤30 min
   Yes 1.47 (1.19 – 1.80) <0.001
   No 1.00
Years smoking cigarettes 0.99 (0.98 – 1.00) 0.013
Currently sets a limit on cpd to decrease health risks
   Yes 0.70 (0.57 – 0.87) 0.001
   No 1.00
Past year frequency of limiting amount smoked to decrease health risks 1.68 (1.53 – 1.85) <0.001
Smoking Level
   Nondaily smoker 2.20 (1.70 – 2.83) <0.001
   Light daily smoker 1.27 (0.97 – 1.65) 0.080
   Moderate to heavy daily smoker 1.00
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At Least One Past Year Quit Attempt.

The second multiple logistic regression analysis included having made at least one quit attempt in the past year as the dependent variable and the same independent variables listed for Model 1. We tested a model with race/ethnicity-by-smoking level interaction terms, however, the interaction was not statistically significant (p = 0.176) so the final model was fitted without the interaction term. The final model examining the factors associated with at least one quit attempt in the past year included the following variables (see Table 4): age (OR = 0.99, 95% CI = 0.98 , 1.00, p = 0.005); depressive symptoms (PHQ-2 scores; OR = 1.78, 95% CI = 1.47, 2.17, p<0.001); time to first cigarette (OR = 1.47, 95% CI = 1.19 , 1.80, p<0.001); years smoking cigarettes (OR = 0.99, 95% CI = 0.98, 1.00, p = 0.013); currently limiting cpd to reduce health risks (OR = 0.70, 95% CI = 0.57, 0.87, p = 0.001); frequency of limiting the amount smoked in the past year to reduce health risks (OR = 1.68, 95% CI = 1.53, 1.85, p < 0.001); nondaily smoking vs. moderate to heavy daily smoking (OR = 2.20, 95% CI = 1.70 , 2.83, p<0.001); and light daily vs. moderate to heavy daily smoking (OR = 1.27, 95% CI = 0.97 , 1.65, p = 0.080). Nondaily smokers had 73% greater odds of making a quit attempt in the past year compared to light daily smokers (OR= 1.73, 95% CI = 1.37, 2.18, p < 0.001; not shown in the table). Race/ethnicity was not statistically significant in the multivariable models with or without race/ethnicity by smoking level interaction terms and was not retained in either of the final models for intention to quit and past year quit attempt.

DISCUSSION

In this study, our primary aim was to identify racial and ethnic differences on use of perceived health risk reduction strategies, quit intentions, past year quit attempts, and our secondary aim was to identify correlates of quit-related behaviors and intentions. There were more pronounced racial and ethnic group differences among nondaily smokers than either light daily smoker or moderate to heavy daily smokers. The bivariate findings suggest greater heterogeneity among nondaily smoker racial and ethnic groups in terms of perceived health risk reduction and quit intentions and attempts, variables that may impact quit success. Multivariable analyses identified perceived health risk reduction and smoking level (particularly nondaily vs. daily smoking) as important correlates of both intention to quit in the next 30 days and having made at least one quit attempt in the past year.

Racial and ethnic differences were most evident among nondaily smokers, whereas, daily smokers had comparable reports of perceived health risk reduction, intention to quit, and quit attempts. Among all three racial and ethnic groups, the majority of nondaily smokers reported being former daily smokers. Despite this similarity in smoking history, African American and Latino nondaily smokers were more likely than White nondaily smokers to currently limit their cigarette use as a perceived health risk reduction strategy. Further, African American nondaily smokers were more likely to intend to quit than either Latino or White nondaily smokers. Similar proportions of African American and Latino nondaily smokers had made a past year quit attempt with White nondaily smokers being least likely to make an attempt.

Perceived health risk reduction (specifically, limiting cigarette consumption in the past year) was positively associated with intending to quit in the next 30 days and having made a past year quit attempt in our multivariable analyses. Men were less likely than women to intend to quit and nondaily smokers compared to daily smokers were more likely to intend to quit. Controlling for other variables, more dependent smokers (as indicated by time to first cigarette) were more likely to have attempted to quit in the past year than less dependent smokers. Nondaily smokers were more than twice as likely to have made a past year quit attempt compared to moderate to heavy daily smokers. Variables emerging as significantly negatively associated with making a quit attempt in the past year were age, years smoking, and currently setting a limit on cpd to reduce health risks. Participants who screened positive for depression were likely to have made a quit attempt in the past year, similar to findings from a survey cohort study conducted in four countries (Cooper et al. 2016). Notably, the cohort study found that although depressed participants were more likely to attempt to quit, they were also more likely to relapse than their peers (Cooper et al. 2016). One proposed model suggests that the link between depression and smoking occurs through both adverse effects of withdrawal (including contributing to negative affect and decreasing positive affect) and high perceived reward value of smoking (Mathew et al. 2017). Perhaps depressed smokers are more likely to attempt to quit in initial attempts to alleviate the adverse effects of cyclical withdrawal symptoms associated with nicotine dependence.

While many of the relationships among the demographic and smoking-related variables with intent to quit and quit attempts could be expected from previous research with young adults (Fagan et al. 2007), the strong associations with perceived health risk reduction is surprising given the scant attention to this construct in the literature. Only perceived health reduction and smoking level emerged as statistically significant correlates of both intent to quit and past year attempts to quit after adjusting for other demographic and smoking-related variables. Considering the larger magnitude of racial and ethnic differences in the proportions of nondaily smokers who intended to quit and who made past year quit attempts compared to the differences among daily smokers, our findings suggest that smoking patterns and perceived risk reduction may account for differences between African Americans, Latinos, and Whites on quit-related intentions and behavior.

Recall that we operationalized perceived risk reduction as limiting the amount smoked in hopes of reducing the health risks of smoking. Two issues relevant to our findings on the use of this health risk reduction strategy are whether limiting the amount smoked leads to smoking abstinence and whether it actually reduces smokers’ risks of tobacco-related disease. Previous findings show that many smokers reduce prior to a quit attempt but this reduction does not increase successful quitting (Hughes et al. 2004, Hughes, Cummings, and Hyland 1999). In fact, the lower rate of smoking may be maintained over prolonged periods of time. We found that limiting the amount smoked in the past year in order to reduce health risks was associated with increased odds of both intending to quit and having attempted to quit in the past year – suggesting that underlying this perceived health risk reduction strategy may be health concerns driving a desire to quit. Our data also indicate that smokers who report specifically limiting cpd to reduce health risks (as did significant proportions of nondaily and light smokers) are less likely to have made a quit attempt in the past year. The differences in the direction of the associations between currently limiting cigarettes per day and past year limiting the amount smoked to reduce health risk may point to potential nuances in assessing perceived health risk reduction. It is possible that some smokers who limit their daily cigarette consumption may assume that they are effectively reducing their risk of smoking-related disease and are therefore not motivated to engage in smoking cessation efforts. Alternatively, some smokers who are reducing the amount they smoke may actually be preparing to quit rather than cutting back for its own sake (West et al. 2001).

Most importantly, existing evidence on the health impact of reducing cigarette consumption shows only have a modest decrease in the risks for developing tobacco-related disease (Godtfredsen et al. 2003, Godtfredsen, Prescott, and Osler 2005). Population-based longitudinal data from Denmark indicates that smoking cessation, not reduction in cpd, decreases smokers’ risk of myocardial infarction (Godtfredsen et al. 2003). However, compared to individuals who continued to use 15 or more cpd, smokers reducing by at least 50% had a decreased risk of lung cancer, but the risk remained higher than for those who quit (Godtfredsen, Prescott, and Osler 2005). Therefore, the fact that many nondaily and daily smokers across racial and ethnic groups report restricting their cigarette use to reduce their risks does not ensure their transition to smoking abstinence and these smokers remain at risk for developing tobacco-related disease and premature mortality.

Our finding that a significant subset of smokers reported making efforts to reduce health risks from smoking reiterates that smokers are concerned about the negative health impact of smoking. As researchers and public health professionals address the changing landscape of tobacco use, this concern and use of intentional smoking reduction could be leveraged in smoking cessation messaging and intervention development. Specifically, messaging should encourage smokers who reduce to make total abstinence their goal for maximum health benefits. This approach may be applicable to all low-rate smokers, but this study indicates that it may be particularly relevant for African American and Latino nondaily smokers. Intervention studies have found that smokers who reduce prior to a nicotine replacement therapy (NRT)-assisted quit attempt or other cessation intervention (e.g., behavioral support) have higher rates of success than smokers in control groups, but no additional benefit was found compared to other intervention strategies (Lindson-Hawley, Aveyard, and Hughes 2012). Thus, based on these clinical trial data, reduction during the induction phase of a smoking cessation attempt has the potential to be an effective strategy for some smokers and may be applicable for low rate smokers who have already been successful at reducing their cigarette use.

In addition to our analyses on our primary variables of interest, we found several racial and ethnic differences in our bivariate analyses that could impact quitting. Consistent with previous research, we found that White smokers had higher cigarette consumption levels than their African American and Latino peers among nondaily smokers and moderate to heavy smokers (Trinidad et al. 2011). Patterns of racial and ethnic differences in smoking dependence differed by smoking level, but across levels Latinos and Whites had either the same or lower smoking dependence than African American smokers. Latino nondaily and light daily smokers reported higher rates of depressive symptoms than African Americans and Whites but no differences were observed among moderate to heavy smokers – our multivariable analyses showed increased odds of attempting to quit in the past year among smokers with more depressive symptoms. Similar to findings from previous studies, African Americans were most likely to smoke menthol cigarettes, followed by Latinos, and Whites were least likely (Keeler et al. 2016, Stahre et al. 2010). A large, national survey showed that African American menthol cigarette smokers were more likely to attempt to quit but no differences were found for other race and ethnicities, and menthol use had no association with successful quitting (Keeler et al. 2016). The current study’s findings are similar in that use of menthol cigarettes was not associated with quit intentions or past attempts.

This study builds on previous work describing racial and ethnic differences among smokers from large, population-based studies and clinical trials by examining differences in intentionally limiting cigarette consumption in an effort to lower the health risks from smoking, quit intentions, and past year quit attempts. The study sample included nondaily, light, and moderate to heavy smokers from the three largest racial and ethnic groups in the United States. Given our inclusion and exclusion criterion, our sample consisted of established, relatively stable smokers. Therefore, these findings should be interpreted within the context that these individuals may be at high-risk for continued smoking. Our sample was from an existing online panel with members from across the country. While this recruitment strategy allowed us to survey a large, ethnically diverse sample, there are limitations. As the participants were drawn from an online panel, this sample is one that uses the internet regularly and likely has their own computer, thus excluding smokers without computer access. Additionally, we oversampled two racial and ethnic minority groups, African Americans and Latinos, but we did not include other groups. Therefore, while our sample is racially and ethnically diverse, generalizability to other groups may be limited. Another limitation of this study is that the measures of perceived health risk reduction strategies consisted of two single-item measures with different response formats (i.e., Likert, dichotomous [yes/no]) and this may have impacted our results.

In conclusion, racial and ethnic minorities, particularly African American nondaily smokers were more likely to use perceived health risk reduction strategies, intend to quit, and have made a recent quit attempt; whereas, few differences were observed among daily smokers on these behaviors and quit plans. After accounting for differences on demographics and tobacco use characteristics, two important correlates of both intention to quit and making a past year quit attempt were smoking level and perceived health risk reduction. In these analyses, the contribution of nondaily smoking compared to daily smoking was statistically significant for both intent to quit and attempting to quit in the past year after examining other relevant variables. Our results suggest that patterns of tobacco use may help to explain racial and ethnic differences among smokers’ cessation-related behaviors. Perceived health risk reduction is understudied and warrants further attention as researchers continue to develop interventions for nondaily and light smokers. These smokers may incorrectly believe that limiting their cigarettes per day is an effective strategy for preventing smoking-related disease and continue to smoke as a result.

Acknowledgments

Funding

This project was funded by Pfizer’s Global Research Awards for Nicotine Dependence (Ahluwalia). This work was also supported by a National Institute of Drug Abuse (NIDA) Diversity Supplement (Scheuermann) to R01-DA031815 (Nollen). Dr. Luo was supported in part by the Biostatistics and Bioinformatics Core Shared Resource of the University of Minnesota Masonic Cancer Center, which is funded by the National Cancer Institute (NCI/NIH - P30CA77598).

Footnotes

Declaration of Interests

Authors have no conflicts of interest pertaining to this research.

References

  1. Ahluwalia JS, Okuyemi K, Nollen N, Choi WS, Kaur H, Pulvers K, and Mayo MS 2006. “The effects of nicotine gum and counseling among African American light smokers: a 2 × 2 factorial design.” Addiction 101 (6):883–91. doi: 10.1111/j.1360-0443.2006.01461.x. [DOI] [PubMed] [Google Scholar]
  2. Al-Delaimy WK., Edland S, Pierce JP, Mills AL, and White MM. 2009. Technical Report on Analytic Methods and Approaches Used in the 2008 California Tobacco Survey Analysis Vol 1: Data Collection Methodology. La Jolla, CA: University of California, San Diego. [Google Scholar]
  3. Baker TB, Piper ME, McCarthy DE, Bolt DM, Smith SS, Kim SY, Colby S, Conti D, Giovino GA, Hatsukami D, Hyland A, Krishnan-Sarin S, Niaura R, Perkins KA, and Toll BA 2007. “Time to first cigarette in the morning as an index of ability to quit smoking: implications for nicotine dependence.” Nicotine Tob Res 9 (Suppl 4):S555–70. doi: 10.1080/14622200701673480. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Becker Marshall H. 1974. The Health Belief Model and Personal Health Behavior. Thorofare, NJ: Slack. [Google Scholar]
  5. Benowitz NL, Dains KM, Dempsey D, Wilson M, and Jacob P 2011. “Racial differences in the relationship between number of cigarettes smoked and nicotine and carcinogen exposure.” Nicotine Tob Res 13 (9):772–83. doi: 10.1093/ntr/ntr072. [DOI] [PMC free article] [PubMed] [Google Scholar]
  6. Businelle MS, Kendzor DE, Costello TJ, Cofta-Woerpel L, Li Y, Mazas CA, Vidrine JI, Reitzel LR, Cinciripini PM, Ahluwalia JS, and Wetter DW 2009. “Light versus heavy smoking among African American men and women.” Addictive Behaviors 34 (2):197–203. doi: 10.1016/j.addbeh.2008.10.009. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Clark PI, Scarisbrick-Hauser A, Gautam SP, and Wirk SJ 1999. “Anti-tobacco socialization in homes of African-American and white parents, and smoking and nonsmoking parents.” J Adolesc Health 24 (5):329–39. doi: 10.1016/S1054-139X(98)00117-7. [DOI] [PubMed] [Google Scholar]
  8. Cokkinides VE, Halpern MT, Barbeau EM, Ward E, and Thun MJ 2008. “Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey.” Am J Prev Med 34 (5):404–12. doi: 10.1016/j.amepre.2008.02.003. [DOI] [PubMed] [Google Scholar]
  9. Cooper Jae, Borland Ron, Sherry A McKee Hua‐Hie Yong, and Pierre‐Antoine Dugué. 2016. “Depression motivates quit attempts but predicts relapse: differential findings for gender from the International Tobacco Control Study.” Addiction 111 (8):1438–47. doi: 10.1111/add.13290. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cox Lisa S., Nollen Nicole L., Mayo Matthew S., Choi Won S., Faseru Babalola, Benowitz Neal L., Tyndale Rachel F., Okuyemi Kolawole S., and Ahluwalia Jasjit S. 2012. “Bupropion for smoking cessation in African American light smokers: A randomized controlled trial.” Journal of the National Cancer Institute 104 (4):290–298. doi: 10.1093/jnci/djr513. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Dorsey R, and Graham G 2011. “New HHS data standards for race, ethnicity, sex, primary language, and disability status.” Jama 306 (21):2378–9. doi: 10.1001/jama.2011.1789. [DOI] [PubMed] [Google Scholar]
  12. Evans Nicola J., Gilpin Elizabeth, Pierce John P., Burns David M., Borland Ronald, Johnson Michael, and Bal Dileep. 1992. “Occasional smoking among adults: evidence from the California Tobacco Survey.” Tobacco Control 1 (3):169. doi: 10.1136/tc.1.3.169 [DOI] [Google Scholar]
  13. Fagan P, Augustson E, Backinger CL, O’Connell ME, Vollinger RE Jr., Kaufman A, and Gibson JT 2007. “Quit attempts and intention to quit cigarette smoking among young adults in the United States.” Am J Public Health 97 (8):1412–20. doi: 10.2105/AJPH.2006.103697. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Fagerstrom K 2012. “Determinants of tobacco use and renaming the FTND to the Fagerstrom Test for Cigarette Dependence.” Nicotine Tob Res 14 (1):75–8. doi: 10.1093/ntr/ntr137. [DOI] [PubMed] [Google Scholar]
  15. Fava JL, Velicer WF, and Prochaska JO 1995. “Applying the transtheoretical model to a representative sample of smokers.” Addict Behav 20 (2):189–203. doi: 10.1016/0306-4603(94)00062-X. [DOI] [PubMed] [Google Scholar]
  16. Fu SS, Kodl MM, Joseph AM, Hatsukami DK, Johnson EO, Breslau N, Wu B, and Bierut L 2008. “Racial/Ethnic disparities in the use of nicotine replacement therapy and quit ratios in lifetime smokers ages 25 to 44 years.” Cancer Epidemiol Biomarkers Prev 17 (7):1640–7. doi: 10.1158/1055-9965.EPI-07-2726. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Godtfredsen NS, Osler M, Vestbo J, Andersen I, and Prescott E 2003. “Smoking reduction, smoking cessation, and incidence of fatal and non-fatal myocardial infarction in Denmark 1976–1998: a pooled cohort study.” J Epidemiol Community Health 57 (6):412–6. doi: 10.1136/jech.57.6.412. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Godtfredsen NS, Prescott E, and Osler M 2005. “Effect of smoking reduction on lung cancer risk.” JAMA 294 (12):1505–10. doi: 10.1001/jama.294.12.1505. [DOI] [PubMed] [Google Scholar]
  19. Heatherton TF, Kozlowski LT, Frecker RC, and Fagerstrom KO 1991. “The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire.” Br J Addict 86 (9):1119–27. doi: 10.1111/j.1360-0443.1991.tb01879.x. [DOI] [PubMed] [Google Scholar]
  20. Holm S 1979. “A simple sequentially rejective multiple test procedure.” Scandinavian Journal of Statistics 6 (2):65–70. [Google Scholar]
  21. Hughes J, Lindgren P, Connett J, Nides M, and Study Lung Health. 2004. “Smoking reduction in the Lung Health Study.” Nicotine Tob Res 6 (2):275–80. doi: 10.1080/14622200410001676297. [DOI] [PubMed] [Google Scholar]
  22. Hughes JR, Cummings KM, and Hyland A 1999. “Ability of smokers to reduce their smoking and its association with future smoking cessation.” Addiction 94 (1):109–114. doi: 10.1046/j.1360-0443.1999.9411097.x. [DOI] [PubMed] [Google Scholar]
  23. Humes, KR, NA Jones, and RR Ramirez. 2011. “Overview of race and Hispanic origin: 2010. 2010 Census Briefs.” Last Modified March 2011. Retrieved from US Census Bureau website: http://www.census.gov/prod/cen2010/briefs/c2010br-02.pdf.
  24. Inoue-Choi M, Liao LM, Reyes-Guzman C, Hartge P, Caporaso N, and Freedman ND 2016. “Association of long-term, low-intensity smoking with all-cause and cause-specific mortality in the national institutes of health–aarp diet and health study.” JAMA Internal Medicine 177 (1):87–95. doi: 10.1001/jamainternmed.2016.7511. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Jamal A, King BA, Neff LJ, Whitmill J, Babb SD, and Graffunder CM 2016. “Current Cigarette Smoking Among Adults — United States, 2005–2015.” MMWR Morb Mortal Wkly Rep 65 (44):1205–1211. doi: 10.15585/mmwr.mm6544a2. [DOI] [PubMed] [Google Scholar]
  26. Keeler C, Max W, Yerger V, Yao T, Ong MK, and Sung HY 2016. “The Association of Menthol Cigarette Use With Quit Attempts, Successful Cessation, and Intention to Quit Across Racial/Ethnic Groups in the United States.” Nicotine Tob Res:Advance online publication. . doi: 10.1093/ntr/ntw215. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Kendzor DE, Businelle MS, Reitzel LR, Rios DM, Scheuermann TS, Pulvers K, and Ahluwalia JS 2014. “Everyday discrimination is associated with nicotine dependence among African American, Latino, and White smokers.” Nicotine Tob Res 16 (6):633–40. doi: 10.1093/ntr/ntt198. [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Kotz Daniel, Fidler Jennifer, and West Robert. 2012. “Very low rate and light smokers: smoking patterns and cessation-related behaviour in England, 2006–11.” Addiction 107 (5):995–1002. doi: 10.1111/j.1360-0443.2011.03739.x. [DOI] [PubMed] [Google Scholar]
  29. Kroenke K, Spitzer RL, and Williams JB 2003. “The Patient Health Questionnaire-2: validity of a two-item depression screener.” Med Care 41 (11):1284–92. doi: 10.1097/01.MLR.0000093487.78664.3C. [DOI] [PubMed] [Google Scholar]
  30. Lindson-Hawley N, Aveyard P, and Hughes JR 2012. “Reduction versus abrupt cessation in smokers who want to quit.” Cochrane Database Systematic Review 11:CD008033. doi: 10.1002/14651858.CD008033.pub3. [DOI] [PubMed] [Google Scholar]
  31. Mathew AR, Hogarth L, Leventhal AM, Cook JW, and Hitsman B 2017. “Cigarette smoking and depression comorbidity: systematic review and proposed theoretical model.” Addiction 112 (3):401–412. doi: 10.1111/add.13604. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Moran Susan, Wechsler Henry, and Rigotti Nancy. 2004. “Social Smoking Among US College Students.” Pediatrics 114 (4):1028–1034. doi: 10.1542/peds.2003-0558-L. [DOI] [PubMed] [Google Scholar]
  33. Myers MG, Edland SD, Hofstetter CR, and Al-Delaimy WK 2013. “Perceived price sensitivity by ethnicity and smoking frequency among California Hispanic and non-Hispanic white smokers.” Nicotine Tob Res 15 (6):1069–74. doi: 10.1093/ntr/nts240. [DOI] [PubMed] [Google Scholar]
  34. Okuyemi KS, Harris KJ, Scheibmeir M, Choi WS, Powell J, and Ahluwalia JS 2002. “Light smokers: issues and recommendations.” Nicotine Tob Res 4 (Suppl 2):S103–12. doi: 10.1080/1462220021000032726. [DOI] [PubMed] [Google Scholar]
  35. Okuyemi KS, Richter KP, Ahluwalia JS, Mosier MC, Nazir N, and Resnicow K 2002. “Smoking reduction practices among African American smokers.” Nicotine Tob Res 4 (Suppl 2):S167–73. doi: 10.1080/1462220021000032744. [DOI] [PubMed] [Google Scholar]
  36. Painter JE, Borba CPC, Hynes M, Mays D, and Glanz K 2008. “The use of theory in health behavior research from 2000 to 2005: A systematic review.” Annals of Behavioral Medicine 35 (3):358–362. doi: 10.1007/s12160-008-9042-y. [DOI] [PubMed] [Google Scholar]
  37. Reitzel LR, Costello TJ, Mazas CA, Vidrine JI, Businelle MS, Kendzor DE, Li Y, Cofta-Woerpel L, and Wetter DW 2009. “Low-level smoking among Spanish-speaking Latino smokers: relationships with demographics, tobacco dependence, withdrawal, and cessation.” Nicotine Tob Res 11 (2):178–84. doi: 10.1093/ntr/ntn021. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Sakuma KL, Felicitas J, Fagan P, Gruder CL, Blanco L, Cappelli C, and Trinidad DR 2015. “Smoking Trends and Disparities Among Black and Non-Hispanic Whites in California.” Nicotine Tob Res 17 (12):1491–8. doi: 10.1093/ntr/ntv032. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Schane RE, Ling PM, and Glantz SA 2010. “Health effects of light and intermittent smoking: a review.” Circulation 121 (13):1518–1522. doi: 10.1161/CIRCULATIONAHA.109.904235. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Schane RE, Prochaska JJ, and Glantz SA 2013. “Counseling nondaily smokers about secondhand smoke as a cessation message: a pilot randomized trial.” Nicotine Tob Res 15 (2):334–42. doi: 10.1093/ntr/nts126. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Scheuermann Taneisha S., Thomas Janet L., Hayes Rashelle B., Harwood Eileen M., Shanafelt Amy P., Wolff Emily R., Wolff Emily R., and Ahluwalia Jasjit S. 2014. “A Qualitative Exploration of Smoking Influences and Quit Attempts among Nondaily Smokers.” Health Behavior and Policy Review 1 (3):172–182. doi: 10.14485/hbpr.1.3.1. [DOI] [Google Scholar]
  42. Shiffman S, Ferguson SG, Dunbar MS, and Scholl SM 2012. “Tobacco dependence among intermittent smokers.” Nicotine Tob Res 14 (11):1372–81. doi: 10.1093/ntr/nts097. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Shiffman S, Tindle H, Li X, Scholl S, Dunbar M, and Mitchell-Miland C 2012. “Characteristics and smoking patterns of intermittent smokers.” Exp Clin Psychopharmacol 20 (4):264–77. doi: 10.1037/a0027546. [DOI] [PMC free article] [PubMed] [Google Scholar]
  44. Skinner Celette Sugg, Tiro Jasmin, and Champion Victoria L. 2015. “The health belief model” Health Behavior: Theory, Research, and Practice.John Wiley & Sons,San Francisco, CA:75–94. [Google Scholar]
  45. Stahre M, Okuyemi KS, Joseph AM, and Fu SS 2010. “Racial/ethnic differences in menthol cigarette smoking, population quit ratios and utilization of evidence-based tobacco cessation treatments.” Addiction 105 (Suppl 1):75–83. doi: 10.1111/j.1360-0443.2010.03200.x. [DOI] [PubMed] [Google Scholar]
  46. Tindle HA, and Shiffman S 2011. “Smoking cessation behavior among intermittent smokers versus daily smokers.” Am J Public Health 101 (7):e1–3. doi: 10.2105/AJPH.2011.300186. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Tong EK, Nguyen T, Vittinghoff E, and Perez-Stable EJ 2009. “Light and intermittent smoking among California’s Asian Americans.” Nicotine Tob Res 11 (2):197–202. doi: 10.1093/ntr/ntp013. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Trinidad DR, Perez-Stable EJ, Emery SL, White MM, Grana RA, and Messer KS 2009. “Intermittent and light daily smoking across racial/ethnic groups in the United States.” Nicotine Tob Res 11 (2):203–10. doi: 10.1093/ntr/ntn018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Trinidad DR, Perez-Stable EJ, White MM, Emery SL, and Messer K 2011. “A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors.” Am J Public Health 101 (4):699–706. doi: 10.2105/AJPH.2010.191668. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. U. S. Department of Health and Human Services. 2014. “The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General.” In. Atlanta, GA: U.S: Department of Health and Human Services, Centers for Diseasse Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. [Google Scholar]
  51. Unger JB, Rohrbach LA, Cruz TB, Baezconde-Garbanati L, Howard KA, Palmer PH, and Johnson CA 2001. “Ethnic variation in peer influences on adolescent smoking.” Nicotine Tob Res 3 (2):167–76. doi: 10.1080/14622200110043086. [DOI] [PubMed] [Google Scholar]
  52. US Department of Commerce, Census Bureau;. 2012. “National Cancer Institute-sponsored Tobacco Use Supplement to the Current Population Survey (2010–11). Technical documentation.” In. Technical documentation. http://www.census.gov/programs-surveys/cps/technical-documentation/complete.html.
  53. Vangeli Eleni, Stapleton John, Eline Suzanne Smit Ron Borland, and West Robert. 2011. “Predictors of attempts to stop smoking and their success in adult general population samples: a systematic review.” Addiction 106 (12):2110–2121. doi: 10.1111/j.1360-0443.2011.03565.x. [DOI] [PubMed] [Google Scholar]
  54. Webb Hooper M, Baker EA, and McNutt MD 2014. “Racial/Ethnic differences among smokers: revisited and expanded to help seekers.” Nicotine Tob Res 16 (5):621–5. doi: 10.1093/ntr/ntt206. [DOI] [PubMed] [Google Scholar]
  55. West R, McEwen A, Bolling K, and Owen L 2001. “Smoking cessation and smoking patterns in the general population: a 1-year follow-up.” Addiction 96 (6):891–902. doi: 10.1080/09652140020051013. [DOI] [PubMed] [Google Scholar]

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