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. Author manuscript; available in PMC: 2019 Nov 1.
Published in final edited form as: J Subst Abuse Treat. 2018 Aug 8;94:9–17. doi: 10.1016/j.jsat.2018.08.003

Differences in tobacco use prevalence, behaviors, and cessation services by race/ethnicity: a survey of persons in addiction treatment

Anna Pagano a, Noah R Gubner b, Thao Le b, Deborah Yip b, Denise Williams b, Delucchi Kevin c, Joseph Guydish b
PMCID: PMC6203319  NIHMSID: NIHMS1503467  PMID: 30243423

Abstract

Background:

Disparities in tobacco use prevalence, behaviors, and services have been identified among people of different racial and ethnic groups in the United States general population. Persons in addiction treatment have among the highest smoking prevalence of any population. However, little is known about racial and ethnic disparities in tobacco use prevalence, behaviors, and services among persons in addiction treatment.

Methods:

Survey data were used from 1,840 clients from 24 addiction treatment programs from the NIDA Clinical Trials Network. Multivariate regression analyses were conducted to assess associations between race/ethnicity (White, African American, Hispanic) and patterns of tobacco and other tobacco product use, as well as quitting behaviors and receipt of tobacco cessation services among current smokers (n=1,425) while in treatment.

Results:

There was no difference in cigarette smoking prevalence across racial/ethnic groups. In the multivariate models, Hispanics and African Americans, compared to Whites, were less likely to be daily smokers, use smokeless tobacco, or use ecigarettes. African Americans and Hispanics reported more past-year quit attempts and higher use of menthol compared to Whites. Hispanics were more interested in quitting while in treatment than Whites. Contrary to expectations, African Americans reported receiving more tobacco cessation advice and services while in treatment than Whites.

Conclusions:

Some findings reflected broader population patterns (e.g., tobacco use behaviors, other tobacco product use), while others did not (e.g., no difference in tobacco use prevalence by race/ethnicity). The reasons for greater receipt of cessation services among African Americans are unclear. Findings indicate the need for continued engagement of African Americans and Hispanics in cessation services while in addiction treatment, and for addressing heavier tobacco use and lack of interest in cessation during treatment among White clients.

Keywords: tobacco, cessation, race, ethnicity, disparities

1. INTRODUCTION

Persons in addiction treatment have among the highest smoking rates of any population, ranging from 65% to over 90% (Guydish, Passalacqua, et al., 2011). Persons with comorbid tobacco use and alcohol/other drug use disorders report increased nicotine dependence and lower quit rates as compared to smokers in the general population (Weinberger, Funk, & Goodwin, 2016). Additionally, tobaccorelated mortality is elevated for this population. Recent studies have identified tobacco-attributable mortality rates of 49% for persons with alcohol use disorder and 54% for persons with any substance use disorder (Bandiera, Anteneh, Le, Delucchi, & Guydish, 2015).

Disparities in tobacco use prevalence, behaviors, and cessation services have been identified among different racial and ethnic groups in the United States (U.S.) general population. For instance, smoking prevalence is lower among Hispanics/Latinos and African Americans as compared to Whites (Trinidad, Perez-Stable, White, Emery, & Messer, 2011); and among current smokers, Hispanics/Latinos and African Americans smoke fewer cigarettes per day (Trinidad et al., 2011), make more quit attempts (Babb, 2017), and are more often light and intermittent smokers (Trinidad et al., 2009) as compared to Whites. Nevertheless, African Americans have the highest tobacco-related cancer incidence and death rates of any U.S. racial/ethnic population (Henley et al., 2016). Further, African Americans and Hispanics/Latinos are less likely than Whites to receive nicotine replacement therapy (NRT), an evidence-based intervention for tobacco cessation (Fu et al., 2008; Trinidad et al., 2011) and are less likely to receive physician advice to quit smoking (Cokkinides, Halpern, Barbeau, Ward, & Thun, 2008).

Differences in tobacco product use have also been identified by race and ethnicity in the general population. African Americans, for example, report higher rates of menthol cigarette use than Whites. Recent data from the Current Population Survey show that 72% of African American smokers use menthol, compared to 22% of Whites and Asians, and 28% of Hispanics (Keeler et al., 2016). Among working adults who participated in the National Health Interview Survey (NHIS), Whites had higher rates of both electronic cigarette (e-cigarette) and smokeless tobacco use than other racial and ethnic groups (Syamlal, Jamal, King, & Mazurek, 2016; Syamlal, Jamal, & Mazurek, 2016).

While these data are available for the general population, little is known about racial and ethnic differences in smoking-related variables among subgroups with high smoking prevalence, such as persons in addiction treatment. Clinical practice guidelines recommend screening all individuals for tobacco use and treating all tobacco users within health care settings (Fiore et al., 2008). Racial and ethnic minorities in addiction treatment may face a compounded disparity of belonging to a tobaccovulnerable subgroup (addiction treatment clients) and being less likely to receive cessation services, as with racial and ethnic minorities in the general population (Cokkinides et al., 2008; Fu et al., 2008; Trinidad et al., 2011). Therefore, it is important to determine whether receipt of cessation services differs by racial/ethnic group among addiction treatment clients.

This study examined survey data from a nationwide sample of persons in addiction treatment to determine whether racial/ethnic disparities existed in tobacco use prevalence, behaviors, product use, and cessation services; and if so, how and the extent to which specific groups were affected. Based on review of the literature cited above, it was hypothesized that racial/ethnic differences in tobacco-related variables among this addiction treatment sample would resemble those documented for the general U.S. population. Specifically, it was expected that (1) African Americans and Hispanics would display lower smoking prevalence and cigarettes per day (CPD) (Trinidad et al., 2011), would more often be light and intermittent smokers (Trinidad et al., 2009), and would report more past-year quit attempts (Babb, 2017; Pagano, Gubner, Le, & Guydish, 2018) and less NRT use (Trinidad et al., 2011) as compared to Whites; (2) Whites would report higher rates of electronic cigarette and smokeless tobacco use (Syamlal, Jamal, King, et al., 2016; Syamlal, Jamal, & Mazurek, 2016), while African Americans and Hispanics would report higher rates of menthol cigarette use (Keeler et al., 2016); and (3) Hispanics and African Americans would have received fewer tobacco cessation services from their current treatment program (e.g., advice or counseling to quit, NRT) as compared to Whites (Cokkinides et al., 2008; Fu et al., 2008; Trinidad et al., 2011).

2. MATERIALS AND METHODS

2.1. Program selection, participant recruitment, and data collection procedures

Participating clinics were selected to be representative of the 166 addiction treatment centers in the National Institute on Drug Abuse (NIDA) Clinical Trial Network (CTN) as of 2013. Inclusion criteria were that programs: (a) were publicly funded, defined as receiving 51% of revenues from public sources; (b) had at least 60 active clients; and (c) the program director agreed to participate in the study and assigned a staff liaison to coordinate data collection with the study team. Exclusion criteria included: (a) privately funded programs; (b) Veterans Administration (VA) programs: (c) adolescent programs: and (d) criminal justice or hospital-based programs that would require local IRB approval in addition to approval from the lead university. Forty-eight programs met inclusion criteria. The data collection plan was for a sample of 25 programs and, to allow for refusals, a sample of 33 programs stratified by program type was drawn. Six programs were identified as ineligible after contact, two declined participation, and one program was not contacted when it became clear that recruitment goals could be met without it. The remaining 24 programs included outpatient (n=7), residential (n=10) and methadone (n=7) programs, and these programs were located in 14 U.S. states.

A two-person research team visited each program for 1 to 2 days in 2015 and 2016, with the goal of recruiting up to 50 clients per clinic. In residential programs, all clients present in the program on the site visit day were invited to participate in the survey. In outpatient programs, all clients who visited the program for therapy sessions were invited to participate. In methadone programs, all clients who visited the program during dosing hours were invited to participate. In residential programs this resulted in a census sample, while in outpatient and methadone programs this resulted in a convenience sample based on patients who attended the program on the day of the site visit.

The 2015 and 2016 surveys included 2278 individuals from a total estimated population of 13,602 clients serviced by these programs during the two-year period (approximately 16.7% of the total active clients treated in these 24 programs during the survey period; however, all active clients were not invited to participate in the study). The number of participants in 2015 recruited per clinic ranged from 31 to 55, with a median of 48. In 2016, the number of participants recruited per clinic ranged from 36 to 55, with a median of 50. No record was made of persons who declined the survey, but all those who began the consent procedure also completed the survey. Anonymous surveys were administered on iPads, each respondent received a $20 gift card following the survey, and each program received a $2,000 incentive following each site visit. Details of program selection and participant recruitment were reported previously (Guydish et al., 2016). Study procedures were approved by the Institutional Review Board of the University of California, San Francisco.

2.2. Measures

2.2.1. Demographics.

Survey items included demographics (age, gender, race/ethnicity, employment, education, marital status), and primary drug for which the client sought treatment as well as treatment program type (outpatient, residential, or methadone). Self-reported race categories were African American/Black; White; American Indian or Alaska Native; Native Hawaiian or Pacific Islander; Asian; or Other. The latter four categories (American Indian/Alaska Native; Native Hawaiian/Pacific Islander; Asian; Other) and multiracial individuals were excluded from the present analyses due to relatively low numbers of participants in each category, yielding a final sample size of 1,840. “Hispanic or Latino” ethnicity was assessed using a separate question. For analytic purposes, these items were combined into a single race/ethnicity variable including three groups: Hispanic or Latino (referred to as “Hispanic” in the text), non-Hispanic Black (referred to as “African American”), and non-Hispanic White (referred to as “White”).

2.2.2. Smoking status and behaviors.

Participants self-reported their smoking status as current, former, or never smoker. Current smoking was defined as having smoked more than 100 cigarettes in lifetime, and self-identification as a current smoker (Jamal et al., 2018). Current smokers reported the number of cigarettes smoked per day (CPD), smoking days/week, whether they had made a quit attempt in the past year lasting at least 24 hours (“In the past year, did you quit smoking voluntarily for at least 24 hours?”) (yes/no), and whether they had ever used NRT products such as nicotine patches, gum, or lozenges (“Have you ever used any of the following products to help you try to quit smoking?”) (yes/no). The survey assessed interest in quitting smoking by asking “Are you seriously thinking of quitting smoking?” to which current smokers could respond “yes, in the next 30 days;” “yes, within the next six months but not in the next 30 days;” or “no.” In the Transtheoretical model of behavior change, interest in quitting in the next 30 days is considered as the ‘preparation’ stage of change (DiClemente et al., 1991). Participants were also asked whether they had quit smoking while in their current treatment program.

2.2.3. Other tobacco product use.

All current smokers were classified as “users” of combustible cigarettes. With pictures of products embedded in the survey, respondents were asked whether they had ever used smokeless tobacco, standard cigars, little filtered cigars (LFCs), or e-cigarettes/vape pens. Current smokers were also asked whether their usual cigarette was menthol or non-menthol, as menthol use has been associated with cigarette dependence and difficulty in quitting among African American smokers (Foulds, Hooper, Pletcher, & Okuyemi, 2010; Keeler et al., 2016). For each product, those reporting lifetime use were asked whether they had used the product in the past 30 days. Tobacco product use items were adapted from the Population Assessment of Tobacco and Health (PATH) survey (Ambrose, Day, Rostron, & et al., 2015).

2.2.4. Smoking-related services.

Both current and former smokers were asked, “In the drug treatment program where you are now, did you want help with quitting smoking?”), to which they could respond “yes” or “no” (Guydish, Tajima, Chan, Delucchi, & Ziedonis, 2011).

The Program Service and Clinician Service scales were developed from questions drawn from prior research (Borrelli et al., 2001; Glynn & Manley, 1995; Goldstein et al., 1998; Joseph, Nichol, Willenbring, Korn, & Lysaght, 1990; Velasquez et al., 2000). The scales are based on factor analyses yielding the present scale configurations, and where Cronbach’s alpha = 0.82 for each of the two scales (Guydish, Tajima, et al., 2011). The Program Service scale included eight items asking whether, at the current program, (1) staff had discussed the risks of smoking and the benefits of quitting with the client; (2) the client had received advice on how to quit; (3) the client had received a referral to a smoking cessation clinic specialist; (4) the client had attended a group that provided education about smoking; (5) the client had attended a support group for people trying to quit smoking; (6) the client had received educational material about quitting smoking, such as pamphlets; (7) quitting smoking was a requirement of the program; and (8) the client had received NRT or other pharmaceutical aids to quit smoking.

The Clinician Service scale included four items asking how often, in the past month, the client’s own counselor had encouraged them to (1) quit smoking, (2) reduce smoking if the client stated they could not quit, (3) use NRT or any smoking cessation medications; or (4) arranged a follow-up appointment to discuss smoking. All items were scored from one to five, and a higher scale score (the mean of the item scores) reflected receipt of more tobacco cessation services from the program or from the counselor.

The items in these scales are supported by recent studies on the benefits of smoking cessation counseling and referrals from behavioral health and non-physician clinical staff (Lancaster & Stead, 2017; Wray, Funderburk, Acker, Wray, & Maisto, 2017); health education about the risks of smoking (Papadakis et al., 2010; West et al., 2015); smoking cessation support groups (Stead, Carroll, & Lancaster, 2017); tobacco-free policies in addiction treatment programs (Guydish et al., 2017); and the use of NRT to aid smoking cessation (Hartmann-Boyce, Stead, Cahill, & Lancaster, 2013; Stead et al., 2012). Consistent with clinical practice guidelines stating that all tobacco users seen in a health care setting should receive treatment (Fiore et al., 2008), the research team was interested in service receipt per se; that is, all current smokers were assumed to be in need of cessation services, regardless of motivation to quit at the time of the survey.

2.2.5. Best time to quit.

Finally, current smokers were asked “When is the best point to stop smoking in drug treatment?” Response options were: “as soon as treatment begins; after six months of treatment; after one year of treatment; never.” This question was included due to the widespread belief among clients that quitting smoking during treatment may increase the chances of alcohol or other drug use relapse, a belief which can affect motivation to quit (McHugh et al., 2017).

2.3. Data Analysis

Across all programs the total sample size was 1,125 in 2015 and 1,153 in 2016. In 2016, 145 cases reported having taken the survey previously. Because all responses were anonymous, it was not possible to use a model accounting for non-independence of some observations. Therefore, these cases were dropped from analysis. In addition, 293 persons self-identified as Other race/ethnicity, or identified in groups too small to permit subgroup analysis, and were removed from analyses. Former smokers (including 122 who had quit during the program, 57 of whom had wanted help quitting smoking) were also excluded from the analyses since their small number precluded analysis of racial/ethnic differences within this subgroup. The final sample included 1,840 respondents, of which 1,425 were smokers.

The goal of the analysis plan was to explore racial/ethnic differences in tobacco-related outcomes (smoking behaviors, tobacco product use, and smoking cessation services) in a sample of persons enrolled in addiction treatment. The research team did this in three analytic steps.

First, for all participants (N=1,840), key demographic characteristics were compared between Hispanic (n=220), African American (266), and White (n=939) participants. Demographic variables showing differences across the three groups would be used to adjust subsequent multivariate regression models. Using analysis of variance (ANOVA) for continuous and chi square for categorical variables, omnibus tests including all three groups were conducted. The research team was interested in the presence of any difference across three groups, so that such differences could be adjusted in subsequent multivariate analyses. For this step the research team was not interested in differences between specific groups, for example, between Hispanics and Whites, or between Whites and African Americans, so post hoc subgroup comparisons were not conducted.

Second, for the subgroup of current smokers (n=1,425), outcome measures (smoking behaviors, tobacco product use, and smoking cessation services) were compared across the three demographic groups prior to multivariate adjustment. Outcome variables significant at the 0.10 alpha level were included in the multivariate analyses. As with demographic characteristics, the research team was interested in whether any differences were observed across all groups and did not conduct post-hoc subgroup comparisons.

Last, multivariate regression analyses were used to assess racial/ethnic differences in tobaccorelated outcomes (smoking behaviors, tobacco product use, and smoking cessation services). The multivariate models controlled for demographic differences observed in step 1 and tested whether univariate differences in outcomes observed in step 2 remained in the presence of these statistical adjustments. Logistic regression models were used for dichotomous outcomes, linear regression models for continuous outcomes (Program Services, Clinician Services), and Poisson regression models for count outcomes (CPD). These analyses used race/ethnicity as the predictor, adjusting for demographic variables (age, gender, education, marital status, employment), primary drug of use, and program type, and also controlling for nesting of clients within programs. Missing data was low (≤1%). The multivariate regression models used complete case analysis.

3. RESULTS

3.1. Univariate comparisons of demographics by racial/ethnic group

Univariate comparison of demographic characteristics by racial/ethnic groups are shown in Table 1. There were significant differences for age (F(2,1837) = 65.57, p<0.0001), gender (χ2 (4, N = 1840) = 24.42, p<0.0001) educational attainment (χ2 (4, N = 1836) = 60.28, p<0.0001), marital status (χ2 (6, N = 1840) = 15.73, p=0.015), employment (χ2 (2, N = 1840) = 10.79, p=0.005), primary drug of use (χ2 (6, N = 1839) = 221.41, p<0.0001), and type of treatment program (χ2 (4, N = 1840) = 52.33, p<0.0001).

Table 1.

Demographics, Primary Drug, and Treatment Program among Clients in Addiction Treatment (N=1,840)

Mean (SD) or n (%)
 p value
Hispanic (n=282) Non-Hispanic Black (n=354) Non-Hispanic White (n=1,204)
Age 35.5 (10.77) 44.9 (12.54) 37.3 (11.41) <0.0001
Gender <0.0001
    Male 157 (55.7%) 211 (59.6%) 592 (49.2%)
    Female 120 (42.6%) 140 (39.6%) 609 (50.6%)
    Other 5 (1.8%) 3 (0.9%) 3 (0.3%)
Education <0.0001
    Less than high school 83 (29.6%) 103 (29.1%) 200 (16.6%)
    High School/General Equivalency Diploma 105 (37.5%) 136 (38.4%) 409 (34.0%)
    More than high school 92 (32.9%) 115 (32.5%) 593 (49.3%)
Marital status 0.015
    Married 28 (9.9%) 39 (11.0%) 173 (14.4%)
    Divorced/Separated/Widowed 67 (23.8%) 106 (29.9%) 336 (27.9%)
    Not married but in a long-term relationship 77 (27.3%) 63 (17.8%) 260 (21.6%)
    Never married 110 (39.0%) 146 (41.2%) 435 (36.1%)
Currently employed 82 (29.1%) 77 (21.8%) 370 (30.7%) 0.005
Primary drug of use <0.0001
    Alcohol 42 (15.0%) 77 (21.8%) 255 (21.2%)
    Stimulants 65 (23.1%) 110 (31.1%) 183 (15.2%)
    Opioids 110 (39.2%) 75 (21.2%) 683 (56.7%)
    Other 64 (22.8%) 92 (26.0%) 83 (6.9%)
Has health insurance 209 (74.1%) 236 (67.1%) 858 (71.4%) 0.130
Program type <0.0001
    Residential 112 (39.7%) 143 (40.4%) 424 (35.2%)
    Outpatient 100 (35.5%) 147 (41.5%) 342 (28.4%)
    Methadone 70 (24.8%) 64 (18.1%) 438 (36.4%)
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3.2. Univariate comparisons of tobacco use characteristics and cessation services by racial/ethnic group

Table 2 displays clients’ tobacco use prevalence and behaviors, as well as smoking cessation services received while in their treatment programs. Among all clients (N=1,840), there was no difference in smoking status by race/ethnicity. Among current smokers (N=1,425), racial/ethnic differences were observed for CPD (F(2,1422) = 77.95, p<0.0001), daily smoking (χ2 (2, N = 1422) = 29.23, p<0.0001), menthol cigarette use (χ2 (2, N = 1424) = 184.95, p<0.0001), past-year quit attempts (χ2 (2, N = 1425) = 21.48, p<0.0001), NRT use (χ2 (2, N = 1415) = 17.18, p<0.001); and thinking of quitting in the next 30 days (χ2 (2, N = 1424) = 15.03, p<0.001).

Table 2.

Tobacco Use & Behaviors and Smoking Cessation Services across Race/ethnicity Groups among Clients in Addiction Treatment

Mean (SD) or n (%)
 p value
Hispanic Non-Hispanic Black Non-Hispanic White
All clients (N=1,840) n=282 n=354 n=1,204
Smoking status 0.323
    Current smokers 220 (78.0%) 266 (75.1%) 939 (77.8%)
    Former smokers 43 (15.3%) 51 (14.4%) 179 (14.9%)
    Never smokers 19 (6.7%) 37 (10.5%) 86 (7.1%)
Current smokers (N=1,425) n=220 n=266 n=939
Smoking behaviors
    Cigarettes per day (CPD) 10.7 (7.32) 9.2 (6.41) 15.4 (8.65) <0.0001
    Daily smoker 179 (81.7%) 221 (83.1%) 862 (92.0%) <0.0001
    Menthol user 159 (72.3%) 224 (84.5%) 393 (41.9%) <0.0001
    Past year quit attempts 125 (56.8%) 137 (51.5%) 389 (41.4%) <0.0001
    Nicotine replacement therapy (NRT) use 96 (44.4%) 118 (44.9%) 527 (56.3%) <0.001
    Thinking of quitting in the next 30 days 65 (29.6%) 87 (32.7%) 207 (22.1%) <0.001
Past 30-day other tobacco product use
    Smokeless 14 (6.4%) 15 (5.7%) 138 (14.8%) <0.0001
    Cigarillos or Little Filtered Cigars 48 (21.8%) 45 (17.2%) 141 (15.2%) 0.054
    Cigars 22 (10.0%) 37 (14.0%) 81 (8.7%) 0.038
    E-cigarettes 49 (22.4%) 37 (14.1%) 304 (32.6%) <0.0001
Smoking cessation services
    Program services 2.6 (1.23) 2.6 (1.16) 2.2 (1.14) <0.0001
    Clinician services 1.9 (1.06) 2.0 (1.12) 1.7 (0.97) <0.0001
    In the drug treatment program where you are now, did you want help with quitting smoking? (yes) 100 (45.7%) 128 (48.1%) 331 (35.3%) <0.0001
    When is the best point to stop smoking in drug treatment? (smokers) <0.0001
        As soon as treatment begins 124 (56.7%) 169 (63.8%) 371 (39.6%)
        After 6 months of treatment 45 (20.6%) 50 (18.9%) 229 (24.4%)
        After 1 year of treatment 29 (13.3%) 21 (7.9%) 212 (22.6%)
        Never 20 (9.2%) 25 (9.4%) 126 (13.4%)
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Differences between racial/ethnic groups were also found for past 30-day use of smokeless tobacco (χ2 (2, N = 1417) = 23.62, p<0.0001), electronic cigarette use (χ2 (2, N = 1415) = 38.72, p<0.0001), and cigars (χ2 (2, N = 1416) = 6.55, p=0.038). African Americans had the lowest rates of past 30-day smokeless tobacco use (5.7%) and electronic cigarette use (14.1%). The highest rate of past 30-day electronic cigarette use was found among Whites (32.6%).

Further differences were identified for smoking cessation services received while in the current treatment program for Program Services score (F(2,1419) = 17.41, p<0.0001) and Clinician Services scores (F(2,1421) = 10.33, p<0.0001); wanting help with quitting smoking (χ2 (2, N = 1422) = 18.59, p<0.001); and the best point to stop smoking during drug treatment (χ2 (6, N = 1421) = 67.25, p<0.0001). The highest Program Service score (2.6) was reported by Hispanics and African Americans, with the lowest reported by Whites (2.2). A similar finding emerged for Clinician Services: African Americans reported the highest score (1.12) while Whites reported the lowest (0.97).

3.3. Tobacco use behaviors and tobacco cessation services (multivariate)

Table 3 shows the results of multivariate regression analyses adjusted for demographics (age, gender, education, marital status, employment status), primary drug, program type; and nesting of participants within clinics. The top third of the table shows odds ratios for most smoking behaviors, other product use, wanting help quitting, and the best time to quit. Ratios of means are presented in the middle third for CPD only. The bottom third shows mean differences for Program and Clinician Service scores.

Table 3.

Multivariate analysis of smoking behaviors across race/ethnicity groups among current smokers in addiction treatment1

Hispanic vs. Non-Hispanic White Non-Hispanic Black vs. Non-Hispanic White
OR (95%CI) p OR (95%CI) p
Smoking behaviors
    Daily smoker 0.41 (0.24, 0.70) 0.001 0.53 (0.34, 0.82) 0.005
    Menthol user 3.80 (2.35, 6.16) <0.0001 11.20 (5.98, 20.97) <0.0001
    Past year quit attempts 1.88 (1.39, 2.55) <0.0001 1.48 (1.14, 1.91) 0.003
    Nicotine replacement therapy (NRT) use 0.79 (0.55, 1.12) 0.181 0.71 (0.55, 0.93) 0.012
    Thinking of quitting in the next 30 days 1.35 (0.93, 1.96) 0.111 1.34 (0.97, 1.85) 0.078
Past 30-day tobacco product use
    Smokeless 0.29 (0.17, 0.49) <0.0001 0.33 (0.16, 0.68) 0.003
    Cigarillos or little filtered cigars 1.34 (0.94, 1.91) 0.110 1.10 (0.75, 1.61) 0.625
    Cigars 1.02 (0.62, 1.69) 0.932 1.78 (1.19, 2.69) 0.006
    E-cigarettes 0.58 (0.41, 0.82) 0.002 0.46 (0.31, 0.69) <0.001
Smoking cessation services
    In the drug treatment program where you are now, did you want help with quitting smoking? (yes) 1.40 (1.05, 1.86) 0.021 1.29 (0.94, 1.78) 0.120
    The best point to stop smoking in drug treatment is as soon as treatment begins (vs. all other responses) 1.84 (1.33, 2.52) <0.001 2.25 (1.46, 3.48) <0.001
Mean ratio (95% CI) p Mean ratio (95% CI) p
Cigarettes per day (CPD) 0.71 (0.66, 0.78) <0.0001 0.60 (0.55, 0.66) <0.0001
Mean Difference (95% CI) p Mean Difference (95% CI) p
Program services 0.14 (−0.03, 0.32) 0.105 0.36 (0.19, 0.53) <0.0001
Clinician services 0.06 (−0.09, 0.22) 0.427 0.24 (0.09, 0.39) 0.002
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1

adjusted for demographics (Age, gender, education, marital status, employment status), primary drug use & program type; also controlled for nesting of participants within clinics.

Following multivariate analyses, Hispanics were less likely than Whites to be daily smokers (OR = 0.41, 95% CI = 0.24, 0.70); menthol cigarette users (OR = 3.80, 95% CI = 2.35, 6.16); and more likely to report having made a past-year quit attempt (OR = 1.88, 95% CI = 1.39, 2.55). African Americans compared to Whites were also less likely to be daily smokers (OR = 0.53, 95% CI = 0.34, 0.82); more likely to be menthol cigarette users (OR = 11.20, 95% CI = 5.98, 20.97); more likely to report having made a past-year quit attempt (OR = 1.48, 95% CI = 1.14, 1.91); and were less likely to have ever used NRT (OR = 0.71, 95% CI = 0.55, 0.93). Shown toward the bottom of table 3, both Hispanics (MR =0.71, 95% CI = 0.66, 0.78) and African Americans (MR =0.60, 95% CI = 0.55, 0.66) smoked fewer CPD compared to Whites.

Racial/ethnic differences also persisted for past 30-day use of other (non-cigarette) tobacco products. Compared to Whites, Hispanics were less likely to have used smokeless tobacco (OR = 0.29, 95% CI = 0.17, 0.49) and e-cigarettes (OR = 0.58, 95% CI = 0.41, 0.82) in the past 30 days. African Americans compared to Whites were also less likely to have used smokeless tobacco (OR = 0.33, 95% CI =0.16, 0.68) and e-cigarettes (OR = 0.46, 95% CI =0.31, 0.69), but were more likely to have smoked cigars (OR = 1.78, 95% CI =1.19, 2.69) in the past 30 days.

In the multivariate analyses, Hispanics were more likely than Whites to have reported wanting help with quitting smoking in their current treatment program (OR=1.40, 95% CI=1.05, 1.86). Both Hispanics (OR=1.84, 95% CI=1.33, 2.52) and African Americans (OR=2.25, 95% CI=1.46, 3.48) were more likely than Whites to have endorsed the statement, “The best point to stop smoking in drug treatment is as soon as treatment begins.” African Americans reported higher receipt of smoking cessation services as compared to Whites. In an additional analysis (results not shown) that controlled for wanting to quit, thinking of quitting in the next 30 days, and affirming that the best point to stop smoking was immediately upon entering treatment, the finding that African Americans reported higher service scores relative to Whites remained significant. While these analyses of differences in tobaccorelated services controlled for type of treatment, doing so may not address whether racial/ ethnic differences in receipt of tobacco cessation services differ by treatment type. Accordingly, we tested for interactions between treatment type and racial/ethnic group for smoking cessation services, program services, and clinician services. No significant interactions were found (data not shown).

4. DISCUSSION

The study aimed to identify racial/ethnic differences in smoking prevalence, smoking behaviors, tobacco product use, and receipt of smoking cessation services reported by a sample of persons currently enrolled in U.S. addiction treatment programs.

Tobacco Use and Behaviors

There was no difference in smoking prevalence by race/ethnicity in this sample. This contrasts with general U.S. population studies reporting higher smoking prevalence among non-Hispanic Whites than among racial/ethnic minority groups (Jamal et al., 2016; Lariscy et al., 2013). Being in addiction treatment may be a stronger predictor of smoking prevalence than race or ethnicity.

White smokers reported significantly higher CPD and were more likely to be daily smokers than those from other racial/ethnic groups. These findings are consistent with U.S. population-level data showing that Hispanics and African Americans are more likely than Whites to be light and intermittent smokers (Trinidad et al., 2009) and report lower CPD (Trinidad et al., 2011).

Tobacco Cessation

The finding of fewer past-year quit attempts among Whites as compared to African Americans and Hispanics may reflect patterns in the broader U.S. population. While some studies have found more quit attempts among U.S. Hispanics than Whites (Levinson, Pérez-Stable, Espinoza, Flores, & Byers, 2004), others have found the opposite (Rafful et al., 2013). A recent review found evidence for more quit attempts among African Americans than Whites, although Whites had more successful quit attempts (Kulak, Cornelius, Fong, & Giovino, 2016). A survey of heavy-drinking smokers similarly found that African Americans reported more failed quit attempts than Whites, despite endorsing fewer motives to continue smoking (Bacio, Guzman, Shapiro, & Ray, 2014).

Whites in this sample reported the highest rates of lifetime NRT use, consistent with U.S. population-level analyses showing that Hispanic smokers are less likely than White smokers to use NRT (Levinson et al., 2004); African American and Hispanic smokers are less likely than Whites to have used tobacco-cessation aids during a past-year quit attempt (Cokkinides et al., 2008); and African American smokers are less likely to use NRT than other racial/ethnic groups (Fu et al., 2008). The reasons for these disparities are unclear, although in one qualitative study African American smokers attributed their low use to mistrust of doctors and insufficient information about NRT (Fu et al., 2007).

Other Tobacco Product Use

The findings regarding other tobacco product use aligned with broader U.S. population patterns. Lower odds of smokeless tobacco use among African Americans and Hispanics, and of e-cigarettes among African Americans as compared to Whites, mirror other product use by race/ethnicity among working adults in the U.S. (Syamlal, Jamal, King, et al., 2016; Syamlal, Jamal, & Mazurek, 2016). Higher likelihood of past 30-day cigar use among African Americans as compared to Whites in this analysis is consistent with a population-level study of U.S. young adults (ages 18–25) (Cullen et al., 2011).

Higher odds of menthol use among African Americans and Hispanics also echoes findings from previous studies of the general U.S. population (Keeler et al., 2016) as well as U.S. racial and ethnic minorities with psychological distress and serious mental illness (Hickman, Delucchi, & Prochaska, 2013; Young-Wolff, Hickman, Kim, Gali, & Prochaska, 2015). Menthol use has been linked to more difficulty quitting for African Americans and Hispanics in some studies (Gandhi, Foulds, Steinberg, Lu, & Williams, 2009; Trinidad, Perez-Stable, Messer, White, & Pierce, 2010), but not others (Keeler et al., 2016).

Receipt of Services

Findings on receipt of cessation service by race/ethnicity were unexpected, as African Americans reported greater receipt of such services as compared to Whites. Also unexpected was the lack of association between wanting to quit and reports of greater service receipt among both African Americans and Hispanics. Although Hispanics were more likely than Whites to report wanting help with quitting smoking, they were not more likely to report receiving more cessation services than Whites. African Americans were no more likely than Whites to endorse wanting help with quitting smoking or “thinking of quitting in the next 30 days.” Both African Americans and Hispanics were more likely than Whites to endorse the statement, “the best point to stop smoking in drug treatment is as soon as treatment begins,” which in theory could help to explain greater service receipt among African Americans if not among Hispanics; however, after controlling for this variable, results remained the same.

While there is no literature on receipt of smoking cessation services in addiction treatment by client race/ethnicity, racial and ethnic disparities in access to addiction treatment services more generally have been identified. Some studies report that racial and ethnic minorities have less access to addiction treatment in general (Chartier & Caetano, 2011; Schmidt, Ye, Greenfield, & Bond, 2007; Wells, Klap, Koike, & Sherbourne, 2001; Wu, Kouzis, & Schlenger, 2003; Zemore et al., 2014), and also to other health and social services (e.g., primary care, employment assistance, transportation, child care) within addiction treatment programs (Jerrell & Wilson, 1997; Marsh, Cao, Guerrero, & Shin, 2009).

In other analyses, however, non-Whites reported greater access to some types of addiction treatment services. For example, studies have found that African Americans were more likely than Whites to access (Hatzenbuehler, Keyes, Narrow, Grant, & Hasin, 2008; Keyes et al., 2008; MulvaneyDay, DeAngelo, Chen, Cook, & Alegría, 2012; Perron et al., 2009) and to engage with (Acevedo, Garnick, Ritter, Horgan, & Lundgren, 2015) addiction treatment programs. In one study, African Americans were more likely than both Whites and Hispanics to receive employment services from their treatment programs (Niv, Pham, & Hser, 2009).

Researchers have attributed such “reverse” access disparities to higher rates of criminal justice referrals to treatment and greater access to Medicaid insurance among African Americans and Hispanics compared to Whites (Cook & Alegria, 2011; Keyes et al., 2008). The present study did not collect data on referral source, so it was not possible to assess the relationship between court referral and receipt of smoking-related services. Participants were asked whether they had any insurance coverage, however there were no differences by race/ethnicity in univariate analyses and, on this basis, insurance status was not included in the adjusted analyses. To explore the issue of insurance further, the research team assessed whether African Americans in the present study were more likely than participants from other racial/ethnic groups to be recruited from states with Medicaid expansion, which could have increased access to cessation services (Brantley, Greene, Bruen, Steinmetz, & Ku, 2018). No difference was observed for this variable (data not shown).

It is plausible that African Americans and Hispanics are more likely than Whites to perceive addiction treatment as an ideal moment to quit smoking because they may have greater access to cessation resources while in the program. While there were no data on clients’ perceived access to cessation services outside the program, U.S. population-level studies showing Whites are more likely than African Americans and Hispanics to receive cessation resources, including NRT, support this hypothesis (Cokkinides et al., 2008).

Previous studies of cessation advice by race or ethnicity present mixed results. In some studies of non-addiction treatment populations, African Americans were less likely than Whites to be asked about tobacco use or advised to quit by their healthcare providers (Cokkinides et al., 2008; Danesh, Paskett, & Ferketich, 2014). However, the opposite was found for other non-addiction treatment groups such as pregnant women (Tran, Rosenberg, & Carlson, 2010) and adolescents (Clawson, Robinson, & Ali, 2016).

Higher rates of being asked about smoking status and receiving advice to quit reported by African Americans in this study may reflect clinicians’ distinct ways of engaging with racial/ethnic minority clients as opposed to Whites. A previous study of Veterans Affairs ambulatory patients found that African Americans and Hispanics were more likely than Whites to receive advice from clinicians about their alcohol use, regardless of patients’ reported level of consumption (Dobscha, Dickinson, Lasarev, & Lee, 2009).

Limitations

One limitation of the study is that it is a secondary data analysis. The parent study was focused on current tobacco use, so it employed a cross-sectional design which did not include retrospective questions about tobacco use at different points in treatment. A longitudinal design with recruitment at treatment entry would have allowed for assessment of tobacco use at intake and provided a more detailed picture of how participants’ tobacco use and service receipt may have varied over time. Additionally, findings may be biased due to the exclusion of 122 smokers who reported that they had quit smoking while in treatment. This subgroup represents 8% of all cases if these cases had been included in the analysis. Separate analyses of the 122 smokers who quit in treatment were deemed uninformative for comparisons between racial/ethnic groups due small sample size. Nevertheless, given that the original study design was cross-sectional and that no outcomes are available on the 122 former smokers, our results may underestimate receipt of tobacco cessation services.

Generalizability and representativeness are also limitations. The sample included only programs participating in the NIDA CTN, and prior research has shown that CTN programs differ in some ways from non-CTN addiction treatment programs (Susukida, Crum, Stuart, Ebnesajjad, & Mojtabai, 2016). Sampling within programs relied on census samples in residential programs and convenience samples in outpatient and methadone treatment programs. The pragmatic factors may restrict representativeness of the participating programs, and of clients recruited within each program. Comparison of the present sample with National Survey on Drug Use and Health (NSDUH) data suggest that that the present sample had higher proportions of women and African Americans, lower education levels, and lower employment rates as compared to NSDUH respondents who received any substance abuse treatment in 2015–2016 (Substance Abuse and Mental Health Services Administration, 2017). A previous study noted that participants in the present sample reported higher rates of opioids and lower rates of alcohol as their main drug of use as compared to NSDUH data (Gubner, Pagano, Tajima, & Guydish, 2018). Further, no information was collected on those who declined to participate in the study. Last, the small numbers of American Indian/Alaska Native, Native Hawaiian/Pacific Islanders, and Asian American participants prevented analyses with these racial/ethnic groups. Despite these limitations, this study is among the first to report racial and ethnic differences in tobacco use, cessation, and service receipt among persons in addiction treatment.

5. CONCLUSIONS

The investigation of racial/ethnic disparities in tobacco use and services may support tailored approaches to intervention among persons in addiction treatment. For instance, findings on racial/ethnic differences in CPD can be used to guide the design of tobacco interventions for light and intermittent versus heavy smokers. Information on racial/ethnic differences in other tobacco product use can be used to make the content of tobacco interventions more relevant to variation in use patterns. Higher motivation to quit among African Americans and Hispanics (i.e., more past-year quit attempts, wanting help quitting, and endorsing quitting immediately upon entering treatment) suggests that clients from these groups may be more readily engaged in cessation services while in treatment. Lower motivation to quit among Whites (i.e., fewer past-year quit attempts, not wanting help with quitting, endorsing quitting only one year after beginning treatment), coupled with heavier smoking in this group, implies that White clients who smoke may benefit from motivational approaches, and cessation-related advice and resources.

HIGHLIGHTS.

  • Tobacco use disparities exist by race/ethnicity in the general United States population.

  • Persons in addiction treatment have high tobacco use prevalence.

  • We surveyed 1,840 clients from 24 U.S. addiction treatment programs about tobacco use.

  • We found racial/ethnic differences in tobacco use behaviors and cessation services.

  • Our findings can inform cessation services for diverse in-treatment populations.

ACKNOWLEDGEMENTS

The authors would like to thank the NIDA (National Institutes on Drug Abuse) Clinical Trials Network for assistance with the sample, as well as the treatment programs that participated in this study.

FUNDING

This work was supported by the National Institute on Drug Abuse (P50 DA 009253), and by a joint grant from the National Institute on Drug Abuse and the Food and Drug Administration Center for Tobacco Products (R01 DA 036066). Dr. Gubner was also supported by a Postdoctoral Training Grant from the National Institute on Drug Abuse (T32 DA007250). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.

Footnotes

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