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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: J Ethn Subst Abuse. 2019 Apr 22;20(2):171–186. doi: 10.1080/15332640.2019.1598906

Racial/Ethnic Differences in Perceived Risks and Benefits of Quitting Smoking in a Sample of African-American and Hispanic Adults Living with HIV/AIDS: A Preliminary Study.

Andrea H Weinberger a,b, Elizabeth K Seng a,b, Jonathan Shuter a,c
PMCID: PMC6946878  NIHMSID: NIHMS1063730  PMID: 31010385

Abstract

Persons living with HIV/AIDS (PLWH) report very high cigarette smoking prevalences, and there are racial/ethnic disparities in smoking consequences and quit outcomes. In this exploratory pilot study, we examined racial/ethnic differences in perceived risks and benefits of quitting cigarette smoking among 97 adult PLWH in the Bronx, New York (Hispanic, 53.6%; African-American, 46.4%). Compared to African-American PLWH, Hispanic PLWH reported greater endorsement of overall risks and benefits, and risks of negative affect, difficulty concentrating, social ostracism, loss of enjoyment, and cravings. It may be useful to incorporate risks and benefits of quitting into smoking treatment for African-American and Hispanic PLWH.

Keywords: HIV, smoking, perceived risks, race, ethnicity

Introduction

Tobacco is the leading cause of mortality and morbidity in the United States (US) (USDHHS, 2014), and a leading cause of global mortality (WHO, 2012). Persons living with HIV (PLWH) smoke cigarettes at prevalences that are two to four times higher than the general population in studies in the US (Park, Hernandez-Ramirez, Silverberg, Crothers, & Dubrow, 2016; Weinberger, Smith, Funk, Rabin, & Shuter, 2017) and other countries (e.g., Tron et al., 2014; Rasmussen et al., 2015). PLWH who smoke cigarettes experience greater mortality and increased rates of pulmonary and cardiovascular disease, cancers (HIV-related and non-HIV-related), and poorer health-related quality of life (e.g., Calvo, Laguno, Martinez, & Martinez, 2015; Helleberg et al., 2014; Helleberg et al., 2015; Pacek & Crum, 2015; Vidrine, 2009).

A number of reasons have been suggested for the higher cigarette smoking prevalence among PLWH (see Shuter & Weinberger, in press for review). For example, PLWH report high prevalences of psychiatric correlates of smoking such as mood, anxiety, and substance use disorders (e.g., Parhami et al., 2013; Pence et al., 2006). In addition, many individuals including PLWH report smoking cigarettes to reduce negative feelings like stress, depression, boredom, and pain (i.e., for negative reinforcement; e.g., Baker et al., 2004; Shuter et al., 2012). In a study that conducted focus groups with male PLWH in the US (Reynolds et al., 2004), some participants felt that the short-term benefits of cigarette smoking (e.g., reducing stress of living with HIV) were more important than the potential long-term consequences of smoking. Recent research also found a higher nicotine metabolite ratio for PLWH compared to persons without HIV/AIDS (Ashare et al., 2019), a factor associated with more intense smoking, greater nicotine dependence, greater reward from smoking, and poorer quit outcomes (e.g., Schnoll et al., 2009; Strasser et al., 2011; Sofuoglu, Herman, Nadim, & Jatlow, 2012; Chenoweth et al., 2016; Schnoll et al., 2019).

African-American and Hispanic persons are disproportionately impacted by HIV. African-American and Hispanic individuals account for approximately 44% and 25%, respectively, of new HIV diagnoses in the US (CDC, 2018a, 2018b). Further, African-American and Hispanic individuals experience significant disparities in smoking-related consequences such as cancer (Lortet-Tieulent et al., 2017; USDHHS, 1998). Racial/ethnic differences have been observed in smoking treatment outcomes among PLWH. Lower overall quit rates have been reported for African-American PLWH compared to White PLWH (Stanton et al., 2009; Mdodo et al., 2015), while Hispanic PLWH report better smoking abstinence outcomes than African-American and White PLWH (Lloyd-Richardson et al., 2009; Moadel et al., 2012). An important step in improving smoking cessation outcomes for PLWH, including African-American and Hispanic PLWH, is to identify key smoking-related variables that impact quitting behaviors and can be targeted through interventions.

Adult cigarette smokers endorse beliefs about the risks and benefits of quitting (e.g., cravings, difficulty managing negative affect, improved health; Hendricks, Wood, Baker, Delucchi, & Hall, 2011; McKee, O’Malley, Salovey, Krishnan-Sarin, & Mazure, 2005). Among community smokers, greater perceived risks of quitting are associated with lower motivation to quit, shorter time to smoking lapse, and worse quit outcomes, while perceived benefits of quitting are positively associated with motivation to quit (Hendricks & Leventhal, 2013; McKee et al., 2005; Toll, 2008; Weinberger, Krishnan-Sarin, Mazure, & McKee, 2008; Weinberger, Mazure, & McKee, 2010). Among a sample of PLWH who smoke cigarettes, we found that the most strongly endorsed risks of quitting were cravings and weight gain, and greater endorsement of the risk related to managing cravings after quitting was associated with lower confidence related to quitting smoking (Weinberger, Seng, Esan, & Shuter, 2017).

Little is known about racial/ethnic differences in beliefs about quitting smoking. In a study of 423 community cigarette smokers (Hendricks et al., 2014), African-American individuals who smoked cigarettes, compared to White individuals who smoked cigarettes, reported weaker beliefs that withdrawal symptoms would occur when quitting and greater beliefs that quitting smoking would not be difficult. In a second study of 439 community cigarette smokers (Parvanta, Gibson, Moldovan-Johnson, Mallya, & Hornik, 2013), fewer African-American than White individuals who smoked cigarettes reported that quitting would lead to intense cravings (67% versus 80%, p<0.05) while more African-American than White persons who smoked cigarettes reported that they would be able to breathe easier after quitting (60% versus 38%, p<0.001). A third study of 673 community cigarette smokers (Cropsey et al., 2014) found that African-American individuals had greater beliefs about the effectiveness of behavioral cessation treatments than did White individuals and this belief was positively related to motivation to quit smoking and self-efficacy related to quitting. These reported beliefs stand in contrast to racial/ethnic differences observed in quit rates and treatment outcomes among PLWH discussed above.

It is not yet clear why different racial/ethnic groups of PLWH differ in their smoking quit outcomes. Previous research has identified relationships between beliefs about quitting smoking and motivation to quit, confidence to quit, and quit outcomes in community samples (e.g., McKee et al., 2005; Toll, 2008), but these samples consisted primarily of White, Non-Hispanic participants (e.g., McKee et al., 2005) so little is known about beliefs about quitting smoking among African-American and Hispanic individuals. Further, racial/ethnic differences have been observed in response to different tobacco treatment strategies in PLWH. To our knowledge, no study has yet examined differences in perceived risks and benefits of quitting among African-American and Hispanic PLWH. The purpose of this preliminary pilot study was to begin to address these gaps in the literature by exploring racial/ethnic differences in perceived risks and benefits of quitting in a sample of African-American and Hispanic cigarette smoking PLWH. Examining perceptions of risks of quitting smoking for African-American and Hispanic PLWH may help to develop an understanding of the racial/ethnic differences in smoking quit outcomes for PLWH and inform smoking treatment interventions for African-American and Hispanic PLWH.

Methods

Participants

Participants were recruited from the Center for Positive Living at the Montefiore Medical Center in the Bronx, New York (US) between May 21, 2015 and September 21, 2015. Inclusion criteria for the main study were: (1) an HIV or AIDS diagnosis, (2) current cigarette smoking, (3) 18 years old or older, (4) ability to speak and read English, and (5) ability to provide oral informed consent. For the current analyses, self-identification as African-American (non-Hispanic) or Hispanic served as an additional inclusion criterion.

Procedures

All aspects of the study were approved by the Albert Einstein College of Medicine Institutional Review Board. Using a randomized list of patients with appointments, the research staff (i.e., psychology graduate students) approached each patient on the list in order while attempting to recruit an approximately equal number of men and women. Following oral informed consent, the participant completed the study measures listed below. Participants received a $20 gift card and list of resources for managing smoking behaviors. See Weinberger, Seng, Ditre, Willoughby, & Shuter, 2019 and Weinberger, Seng, Esan, & Shuter, 2017 for additional details about the study.

Measures

Demographics.

Participants self-reported demographics including age, gender (male, female, transgender, other), sexual orientation (heterosexual, homosexual/gay/lesbian, bisexual, other) and race/ethnicity. Race and ethnicity were assessed by two questions. Participants were asked to identify their ethnicity as Hispanic or Non-Hispanic and to identify their race as Black/African-American, White, American Indian/Alaskan Native, Asian, Native Hawaiian/Other Pacific Islander, or Other. The current analyses included persons who identified as either non-Hispanic Black/African-American or Hispanic.

HIV Status.

Participants were asked to report the year of their HIV diagnosis, whether they have a diagnosis of AIDS (yes/no), and use of antiretroviral medication (yes, currently; yes, in the past; no).

Current Smoking and Tobacco Use Behavior.

Frequency of current cigarette smoking was assessed using the question “How many days each week do you smoke right now?” Quantity of current cigarette smoking was assessed using the question “How many cigarettes each day do you smoke right now?” Participants were able to write in their responses for these two questions. For analyses, smoking frequency (i.e., smoking days) was dichotomized into daily (7 days per week) and less than daily (6 or fewer days per week) smoking categories similar to past research (e.g., Harrison & McKee, 2011; Yi, Mayorga, Hassmiller Lich, & Pearson, 2017). Quantity of current cigarette smoking was also dichotomized into two categories: 10 or more cigarettes per day (i.e., heavier smoking) and less than 10 cigarettes per day (i.e., lighter smoking) consistent with other studies (e.g., Yi et al. 2017). To assess the use of other tobacco products, participants were asked whether they currently use tobacco products other than cigarettes (yes/no) and then were asked to circle all products that they use from a list that included cigars, pipes, chew, snuff, and e-cigarettes. Current motivation to quit smoking (Quit Motivation; 1=no desire to quit to 10=extremely high desire to quit) and confidence in quitting smoking (Quit Confidence; 1=not confident to 10=extremely confident) were assessed using the Thoughts About Abstinence Scale (Hall, Havassy, & Wasserman, 1991).

Perceived Risks and Benefits of Quitting Smoking.

The 40-item Perceived Risks and Benefits Questionnaire (PRBQ; McKee et al., 2005) assessed beliefs about quitting smoking on a 7-point Likert Scale (1=no chance, 7=certain to happen). Six subscales assessed risks of quitting (alphas are for the current analytic sample): 1) Weight Gain (e.g., “I will gain weight.”, 3 items, α=0.61); 2) Negative Affect (e.g., “I will be more irritable.”, 3 items, α=0.62); 3) Difficulty Concentrating (e.g., “I will be less able to concentrate.”, 5 items, α=0.77); 4) Social Ostracism (e.g., “I will feel uncomfortable around smokers.”, 2 items, α=0.36); 5) Loss of Enjoyment (e.g., “I will miss the taste of cigarettes.”, 2 items, α=0.67); 6) Craving (“I will desire a cigarette.”, 3 items, α=0.77). An Overall Perceived Risks score was created by averaging all 18 risk items (α=0.87). Six subscales assessed benefits of quitting: (1) Health (e.g., “I will lower my chances of developing lung cancer.”, 5 items, α=0.83); (2) General Well-Being (e.g., “I will be healthier.”, 4 items, α=0.75); (3) Self-Esteem (e.g., “I will feel proud that I was able to quit.”, 4 items, α=0.23); (4) Finances (e.g., “I will be able to save more money.”, 2 items, α=0.72); (5) Physical Appeal (e.g., “I will smell cleaner.”, 3 items, α=0.74); (6) Social Approval (e.g., “The people who care most about me will approve.”, 4 items, α=0.72). An Overall Perceived Benefits score was created by averaging all 22 benefit items (α=0.86).

Nine investigator-written questions assessed additional perceived risks and benefits of quitting smoking that were not assessed in the PRBQ and that may be relevant to PLWH. These items are listed in the Table and assessed beliefs about quitting smoking related to HIV (5 items; e.g., “I will be more committed to my HIV care.”), mood (2 items, e.g., “I will feel more depressed.”), substance use (1 item, “I will be more likely to relapse to use of other substances or drugs.”), and pain (1 item, “I will have more trouble managing pain.”) using the same 7-point Likert scale described above for the PRBQ. The internal consistency for the investigator-written items in the current analytic sample was α=0.84 for all 9 items and α=0.82 for the 5 HIV-related items.

Table.

Demographics, HIV clinical characteristics, smoking characteristics, and perceived risks and benefits of quitting smoking by race/ethnicity in a sample of African-American and Hispanic adults living with HIV/AIDS who smoke cigarettes (n=97).

African-American
PLWH (n=45)		 Hispanic
PLWH (n=52)		 Significance
Demographics M (SD) or N (%) M (SD) or N (%)
Age 50.2 (8.6) 49.8 (8.7) p = 0.833
Gender p = 0.788
 Women 23 (51.1%) 28 (53.8%)
 Men 22 (48.9%) 24 (46.2%)
Sexual Orientationa
 Heterosexual 31 (73.9%) 35 (68.6%) p = 0.741
 Homosexual 8 (19.0%) 10 (19.6%)
 Bisexual/Other 3 (7.1%) 6 (11.8%)
Highest Grade Completeda
 1st–11th Grade 13 (30.2%) 22 (43.1%) p = 0.220
 High School Graduate/GED 19 (44.2%) 14 (27.5%)
 Some College or College Graduate 11 (25.6%) 15 (29.4%)
HIV Clinical Characteristics M (SD) or N (%) M (SD) or N (%)
Years Since HIV Diagnosisa 18.8 (6.4) 19.4 (7.5) p = 0.719
AIDS Diagnosisa
 Yes 16 (36.4%) 21 (42.9%) p = 0.534
 No 28 (63.6%) 28 (57.1%)
Antiretroviral Medicationa
 Yes, currently 24 (68.6%) 35 (83.3%) p = 0.104
 Yes, in the past 3 (8.6%) 0 (0%)
 No 8 (22.8%) 7 (16.7%)
Smoking Characteristics Mdn (IQR) or N (%) Mdn (IQR) or N (%)
Smoking Daysa
 Daily 30 (73.2%) 40 (83.3%) p = 0.303
 Less than daily 11 (26.8%) 8 (16.7%)
Cigarettes per Daya
 ≥ 10 15 (36.6%) 26 (51.0%) p = 0.207
 < 10 26 (63.4%) 25 (49.0%)
Other Tobacco use
 Cigar, E-Cigarette, or Pipe 6 (13.3%) 6 (11.5%) p = 0.999
 None 39 (86.7%) 46 (88.5%)
Quit Attempts
 Number of Attemptsa 1.0 (0.0–3.8) 1.0 (0.0–4.0) p = 0.807
 Days of Longest Attempta 180 (4.5–730) 30 (0.0–205) p = 0.029
Quit Motivation and Confidence M (SD) M (SD)
Quit Motivationb 7.2 (2.6) 6.8 (3.1) p = 0.499
Quit Confidenceb 6.2 (2.7) 5.9 (3.0) p = 0.636
Perceived Risks and Benefits of Quitting Smoking
Perceived Risk subscalesc M (SD) M (SD)
 Weight Gaina 3.7 (1.6) 3.9 (1.6) p = 0.607
 Negative Affect 3.2 (1.7) 3.9 (1.5) p = 0.033
 Attention/Difficulty Concentrating 2.6 (3.4) 3.4 (1.5) p = 0.021
 Social Ostracism 3.1 (1.7) 3.8 (1.7) p = 0.029
 Loss of Enjoyment 2.9 (1.8) 3.9 (1.8) p = 0.008
 Cravings 3.5 (1.6) 4.2 (1.5) p = 0.040
Overall Perceived Risksd 3.0 (1.2) 3.9 (1.1) p = 0.002
Perceived Benefit subscalesc Mdn (IQR) Mdn (IQR)
 Health 5.1 (3.7–6.0) 5.4 (4.6–6.0) p = 0.222
 General Well-Being 4.4 (3.6–5.2) 5.5 (4.4–6.0) p = 0.005
 Self-Esteem 4.8 (3.9–5.3) 5.3 (4.5–5.8) p = 0.176
 Finances 5.5 (4.0–6.0) 6.0 (4.5–6.0) p = 0.176
 Physical Appeal 5.0 (4.0–5.8) 5.7 (4.0–6.0) p = 0.126
 Social Approval 4.3 (3.0–5.3) 5.0 (4.0–5.8) p = 0.029
Overall Perceived Benefitse 4.8 (4.0–5.5) 5.2 (4.9–5.7) p = 0.021
HIV-related itemsf Mdn (IQR) Mdn (IQR)
T-cell count will go up. 3.5 (2.0–6.0) 5.0 (3.0–6.0) p = 0.103
My viral load will go down. 3.0 (1.0–5.0) 4.0 (1.0–6.0) p = 0.236
I will be less likely to get infections. 4.0 (2.0–6.0) 5.0 (2.0–6.0) p = 0.569
I will be more committed to my HIV care. 4.0 (2.5–6.0) 5.0 (2.0–6.0) p = 0.569
I will take my HIV medications more reliably. 4.5 (2.0–6.0) 5.0 (2.0–6.0) p = 0.974
Mood-related itemsf
I will feel more depressed. 2.0 (0.0–4.0) 3.5 (2.0–6.0) p = 0.011
I will feel more anxious. 3.0 (1.0–4.0) 3.0 (1.0–6.0) p = 0.216
Substance use-related itemf
I will be more likely to relapse to use of other substances or drugs. 1.0 (0.0–3.8) 1.0 (0.0–5.0) p = 0.956
Pain-related itemf
I will have more trouble managing pain. 2.0 (0.0–4.0) 2.0 (0.0–5.0) p = 0.597
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Key: IQR, interquartile range; M, mean; Mdn, median; PLWH, persons living with HIV/AIDS; SD, standard deviation

Note. Subtest p-values are Bonferroni corrected.

a

Due to missing data, sample sizes for these variables ranged from 29 to 42 for African-American participants and 43 to 51 for Hispanic participants

b

Range=1–10 with higher scores reflecting greater motivation to/confidence in quitting smoking; assessed using the Thoughts About Abstinence Scale (Hall, Havassy, & Wasserman, 1991)

c

Range=1–7 with higher scores indicating a greater likelihood that the risk/benefit would occur when quitting smoking; assessed using the Perceived Risks and Benefits Questionnaire (McKee et al., 2005)

d

Mean of 18 items measuring perceived risks of quitting

e

Mean of the 22 items measuring perceived benefits of quitting

f

Range of items=1–7 with higher scores indicating greater agreement with the item.

Statistical Analysis

Descriptive statistics were evaluated for all variables. To examine racial/ethnic differences in demographics, smoking characteristics, and perceived risks and benefits of quitting smoking, differences in proportions were evaluated using chi-squared or Fisher’s exact test and differences in means were evaluated using Student’s t-test or Mann-Whitney U test for ordinal variables or variables that violated equivalence of variance assumptions. The Bonferroni-Holm correction was used to account for family-wise error when making multiple comparisons within a scale across racial/ethnic groups; for example, the Perceived Risks scale has six subscales, therefore the p-values were adjusted for six comparisons. Effect sizes were computed using Cohen’s d. Two-tailed tests were conducted and two-tailed and significance was set at alphas<0.05. All analyses were conducted using SPSS v.24.

Results

Sample Characteristics

One-hundred thirteen participants completed consent procedures. Ten people identified as White, Non-Hispanic or other races/ethnicities, five people were not current cigarette smokers, and one person completed no survey questions which resulted in a final analytic sample of 97 participants (53.6% Hispanic and 46.4% African-American; 52.6% female). The sample was on average approximately 50 years old (M=49.7, SD=8.6), and was primarily heterosexual (71.0%), denied prior diagnosis of AIDS (60.2%), and reported use of antiretroviral medication (76.6%). Most participants smoked cigarettes on a daily basis (78.7%), did not use any tobacco products other than cigarettes (87.6%), and were divided among those smoking 10 cigarettes a day or more (44.6%) and fewer than 10 cigarettes a day (55.4%). On average, participants reported a moderately high level of motivation to quit smoking (M=7.01, SD=2.85) and a moderate level of confidence in their ability to quit (M=6.03, SD=2.82). African-American and Hispanic PLWH did not differ on other demographic parameters, HIV characteristics, smoking frequency, smoking quantity, other tobacco product use, number of lifetime quit attempts, quit motivation, or quit confidence. African-American PLWH reported a longer median number of days abstinent from cigarette smoking during past quit attempts than Hispanic PLWH (see Table).

Perceived Risks and Benefits of Quitting Smoking

See Table for the perceived risks and benefits of quitting by race/ethnicity. Compared to African-American PLWH, Hispanic PLWH reported greater endorsement of overall risks of quitting (Cohen’s d=0.66, medium effect), and risks related to managing negative affect (Cohen’s d=0.44, small-medium effect), attention or difficulty concentrating (Cohen’s d=0.30, small effect), social ostracism (Cohen’s d=0.41, small-medium effect), loss of enjoyment (Cohen’s d=0.56, medium effect), and cravings (Cohen’s d=0.45, small-medium effect). The only risk of quitting that did not differ by race/ethnicity was weight gain. Hispanic PLWH also reported greater endorsement than African-American PLWH of overall benefits of quitting and benefits related to general well-being and social approval.

With regard to HIV-, mood-, substance use-, and pain-related beliefs about quitting smoking (Table), on average, participants endorsed that it was likely that they would take their HIV medications more reliably if they quit smoking. Participants also endorsed on average that it was not likely that they would relapse to other drugs, have more trouble managing pain, or feel more depressed if they quit smoking. Hispanic PLWH were more likely to say that they would feel more depressed if they quit smoking than African-American PLWH. No other racial/ethnic differences were found among the belief variables.

Discussion

The current preliminary study examined perceived risks and benefits of quitting smoking in a sample of Hispanic versus African-American PLWH who reported current cigarette smoking. Hispanic PLWH more strongly endorsed a number of risks and benefits of quitting smoking. There was no difference in the endorsement of HIV-related risks of quitting by race/ethnicity.

As stated earlier, there are racial/ethnic differences in quit rates and response to smoking treatments for PLWH (e.g., Mdodo et al., 2015; Moadel et al., 2012) and racial/ethnic differences in perceived risks of quitting could be related to these different treatment outcomes. It may be useful for clinicians working with PLWH who smoke cigarettes to target risk perceptions, such as beliefs about cravings, when providing smoking cessation counseling. Targeting the specific beliefs about quitting smoking that are assessed in the PRBQ may be especially useful for Hispanic PLWH who more strongly endorsed overall risks, and nearly all of the specific risks of quitting, compared to African-American PLWH. While smoking cessation counseling frequently includes information about methods to cope with withdrawal symptoms and negative affect, and pharmacological treatments (e.g., nicotine replacement therapy, varenicline) can be prescribed to reduce cravings and withdrawal symptoms when quitting smoking, few treatments include a direct discussion with individuals about how concerned they are about specific potential risks (e.g., coping with cravings or negative affect, weight gain) and which risks are most concerning and may have the biggest impact on making a quit attempt or remaining abstinent after quitting smoking.

Information about perceived risks and benefits of quitting can be integrated into smoking cessation interventions provided by providers in a range of clinical care settings. Preliminary data suggest that it is feasible and acceptable to target perceived risks of quitting, measured using the PRBQ, as part of behavioral treatment for smoking cessation among women in the community who want to quit using cigarettes (Weinberger, Pittman, Mazure, & McKee, 2015). Further, Perkins and colleagues (2001) found that an intervention addressing concerns about cessation-related weight gain resulted in higher rates of smoking abstinence than weight control or standard cessation treatment. In addition to targeting perceived risks of quitting in general, treatments that are individualized may improve quit outcomes (e.g., Copeland, Martin, Geiselman, Rash, & Kendzor, 2006). Weinberger et al (2015) provided individualized treatment plans where risks that were most highly endorsed by participants on the PRBQ were covered earlier in treatment than risks that were less highly endorsed and this part of treatment was also feasible and acceptable. PLWH who want to quit smoking may benefit from individualized discussions about their concerns related to quitting smoking and ways to target these concerns. Studies are needed that examine the usefulness of targeting risks of quitting smoking for PLWH who want to quit smoking and the relationship of targeting quit risk perceptions and quit outcomes among different racial/ethnic groups of PLWH.

There are a number of findings from this study that would benefit from additional exploration. For example, PLWH reported that, on average, it was likely that they would take their HIV medications more reliably if they quit smoking and it would be useful to learn more about beliefs related to a link between smoking abstinence and better medication adherence. African-American PLWH were less likely to report perceived risks of quitting than Hispanic PLWH and African-American PLWH may have concerns that were not included in the measure or there may be other factors that are more strongly associated with quit behavior (e.g., menthol cigarette use which is associated with poorer cessation outcomes; e.g., Villanti et al., 2017; Foulds et al., 2010). There may also be racial/ethnic and/or cultural factors related to perceived risks of smoking for either racial/ethnic group that were not captured through the PRBQ. It would be useful to explore these aspects of smoking cessation; as well as other information about perceived risks of quitting and their relationship to motivation to quit, confidence in quitting, and quit behavior; in greater depth through interviews or focus groups with current cigarette smoking PLWH from different racial/ethnic groups.

A number of limitations must be noted. First, this was a preliminary investigation and sample sizes for the two racial/ethnic groups were comparatively small. These sample sizes limited our power to detect differences between the two racial/ethnic groups, especially for smaller effect sizes. Replication of this study in larger samples would help to identify differences in beliefs about quitting smoking that may be smaller effects. Due to our small sample sizes, we were not able to examine subgroups of African-American and Hispanic PLWH. There are differences in smoking and cessation behavior among Hispanic individuals by gender, country of origin (e.g., Puerto Rican, Cuban), and acculturation status (e.g., Kaplan et al., 2014; Pérez-Stable et al., 2001). Studies with larger samples should examine differences in perceived risks and benefits and smoking-related behavior among subgroups of Hispanic and African-American PLWH. There are a number of other analyses that could be explored in future, larger studies including the interaction of other demographics and race/ethnicity on quit perceptions (e.g., endorsement of risks and benefits by both gender and race/ethnicity) and racial/ethnic differences in the relationship of risks and benefits with motivation to quit or confidence in quitting smoking.

Two of the PRBQ subscales had low alphas: the risk subscale of Social Ostracism (α=0.36) and the benefits subscale of Self-Esteem (α=0.23). Both of these subscales included a small number of items (2 items for Social Ostracism and 4 items for Self-Esteem) although it is notable that these internal consistency reliability estimates were lower than those found in a community sample (Social Ostracism α=0.61; Self-Esteem α=0.75; McKee et al., 2005). It is possible that these subscales are operating differently in a sample of PLWH than a sample of people from the community. As mentioned above, more in-depth research would help elucidate the perceived risks and benefits of quitting among PLWH including those related to social ostracism and self-esteem. In addition, our sample included PLWH in New York who were English-speaking Hispanic and non-Hispanic African-American adults. Additional research would be needed to determine whether results apply to other samples of PLWH (e.g., Spanish-speaking PLWH, PLWH in other geographic areas) and to examine beliefs related to quitting for African-American and Hispanic PLWH compared to non-Hispanic White PLWH. Finally, as mentioned above, future research should also examine the relationship between risks and benefits of smoking and outcomes of quit attempts for African-American and Hispanic PLWH and how information about perceived risks and benefits of quitting can be used in smoking cessation counseling to best assist quit efforts for PLWH of different races and ethnicities.

Conclusions

In a sample of PLWH who currently smoke cigarettes, Hispanic PLWH reported greater endorsement than African-American PLWH of overall perceived risks of quitting smoking and risks related to managing negative affect, attention or difficulty concentrating, social ostracism, loss of enjoyment, and cravings as well as greater endorsement of overall perceived benefits of quitting smoking and benefits related to general well-being and social approval. It may be useful for health care professionals to incorporate information about perceived risks and benefits of quitting into treatment when working with African-American and Hispanic PLWH who smoke.

Acknowledgments:

The authors thank Alyssa Burns, Hannah Esan, and Christine Lee for their help with data collection and Melody Willoughby for her help with data management and entry.

Funding: This work was supported by the National Institutes of Health under grants R01-DA036445, R01-CA192954, R34-DA037042, and K23-NS096107.

Footnotes

Disclosure Statement: The authors have no conflicts of interest to report.

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