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. Author manuscript; available in PMC: 2021 Jan 12.
Published in final edited form as: Subst Use Misuse. 2019 Nov 15;55(3):424–428. doi: 10.1080/10826084.2019.1683200

The interacting effect of peer quitting norms and nicotine dependence on quit attempts: gender-stratified results from a study of low-income smokers in Baltimore, MD

Norah L Crossnohere 1,2, Melissa Davey-Rothwell 1, Carl Latkin 1, Tuo-Yen Tseng 1, Lauren Czaplicki 1, Amy Knowlton 1
PMCID: PMC7802369  NIHMSID: NIHMS1543940  PMID: 31729269

Abstract

Background:

Declines in smoking prevalence among low-income adults lag behind national samples. Understanding the influence of social context factors such as gender, and normative influence on smoking attitudes and behaviors can inform smoking cessation interventions.

Objective:

This study explored how gender, smoking dependence and cigarette-quitting norms influenced the likelihood of current quit attempts among urban, predominately African American adults.

Methods:

Participants answered questions about their current quit attempts, smoking dependence (heaviness of smoking index [HSI]) and cigarette-quitting norms (descriptive: having friends who quit smoking; injunctive: friends disapproving of smoking) as a part of a parent study exploring social and environmental factors in tobacco use. Logistic regression stratifying by gender and adjusting for demographics examined main and interaction effects of norms and HSI on odds of having a current quit attempt.

Results:

Among men, having a higher smoking dependence was associated with a reduced likelihood of trying to quit (AOR=0.30 [0.15–0.59]), but this effect was moderated by having friends who had quit smoking (AOR=2.40 [1.20–4.78]). When accounting for the effect of friends quitting smoking, men were not influenced by friends disapproving of smoking. Among women, currently attempting to quit was not predicted by smoking dependence nor norms.

Conclusions/Importance:

Cigarette-quitting norms were impactful on the cessation attempts of men, but not women, in this study. This highlights the importance of conducting gender stratification in socially-oriented smoking cessation research as well as to socially-tailor cessation interventions.

Keywords: smoking cessation, peer influence, vulnerable populations, social norms, African Americans, norms

1. INTRODUCTION

Smoking cessation initiatives have successfully reduced the prevalence of adult smoking in the US (Jamal, 2016). Unfortunately, positive outcomes for those of low-income, low-education, and of minority race have lagged behind national estimates, causing these groups to bear a disproportional burden of smoking’s health consequences (David, Esson, Perucic, & Fitzpatrick, 2010). Amidst national commitments to reduce nicotine consumption in the US (“Healthy People 2020,” 2010), there is a need to understand the social context of adult smoking so as to reduce social disparities across cessation outcomes.

Social conditions and environmental context create and reinforce smoking behaviors (Borland et al., 2010; Mason et al., 2017; Simons-Morton & Farhat, 2010). Smoking behaviors may “spread” throughout networks, resulting in pronounced relationships between adult’s own smoking status and the smoking behaviors of a spouse, siblings, and friends (Christakis & Fowler, 2008). Overcoming nicotine addiction (CDC, 2010), and modifying normative behaviors around smoking are two of the leading evidence-based mechanisms through which to improve smoking cessation (CDC, 2014). Social norms interventions around smoking stimulate quit behaviors by changing perceptions of these social contexts such as friendships (Phua, 2013). Such interventions utilize descriptive norms (perceptions of prevalence of a behavior within a group) and injunctive norms (perception of a specific group’s approval/disproval of actions) to change participant’s beliefs and actions (Rimal & Real, 2005).

Men and women have historically been subject to different social and cultural expectations around smoking. Examples of this include that smoking has been perceived as more acceptable for men than women, and that women may experience greater pressure to quit smoking as compared to men (Royce, Corbett, Sorensen, & Ockene, 1997; Smith, Bessette, Weinberger, Sheffer, & McKee, 2016). Social pressures result in real-world health outcomes, and are cited as a contributing factor to the historically lower prevalence of smoking among women (Westmaas, Wild, & Ferrence, 2002; WHO, 2008).

Men and women experience different social pressures around smoking and therefore may also be differently effected by social normative smoking cessation interventions. Prior research has demonstrated that subjective norms (the expectations of referent groups regarding how to behave) around quitting may have more influence on the quitting behaviors of men as compared to women (Westmaas et al., 2002). Both subjective and descriptive norms better predict quitting intention for men than women, and only when women have a strong descriptive norm does their subjective norm correlate with quitting intention (Dohnke, Weiss-Gerlach, & Spies, 2011). By examining the influence of norms on current quit attempts among men and women, separately, we will begin to identify what types of messages are salient to each subgroup. This approach follows calls to consider gender differences in cessation outcomes at large (CDC, 2014).

This study explored associations among trying to quit smoking, quitting norms, and nicotine dependence among low-income, predominately African American smokers in Baltimore, MD. Given that men and women may be differently influenced by norms, this study examines the impact of norms on smoking quit attempts by gender.

2. MATERIALS AND METHODS

This research used data from the Tobacco Use in Drug Environments study. Individuals were recruited in Baltimore, MD from September 2013–May 2015 and were eligible if they were 18 years or older, had self-reported smoking >100 cigarettes in a lifetime, and had smoked in the past week. Consenting individuals completed a cross-sectional survey for which they received $35. Protocols were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.

2.1. Measures

2.1.1. Outcome: Current quit attempt

Current quit attempt was assessed by asking Are you currently trying to quit smoking cigarettes? Participants were informed that quitting cigarettes meant not smoking for at least 24 hours straight. Response options included yes, no.

2.1.2. Quitting norms

Descriptive norms were assessed by asking How many of your friends used to smoke but have quit smoking? Injunctive norms were assessed by asking How many of your friends disapprove of your smoking? Response options included “none,” “a few,” “some,” “most,” or “all,” and were dichotomized into none vs. a few–all for analysis.

2.1.3. Heaviness of Smoking

The validated Heaviness of Smoking Index (HSI) assessed nicotine dependence on a scale of 0–6 (low-high dependence) (Heatherton, Kozlowski, Frecker, Rickert, & Robinson, 1989).

2.1.4. Covariates

Age, gender, race, income, heroine/cocaine use in past 6 months, and number of quit attempts in past year were assessed.

2.2. Analysis

Gender-stratified T-tests and chi-squared tests explored differences in measures across the outcome. Three sets of gender-stratified logistic regression models with “current quit attempt” as the outcome were built, adjusting for age, income, and race and including the following covariates:

  1. Descriptive norms model: friends quit norm, HSI, friends quit*HSI interaction

  2. Injunctive norms model: friends disapprove norm, HSI, friends disapprove*HSI interaction

  3. Descriptive and injunctive norms model: friends quit, friends disapprove, HSI, friends quit*HSI interaction, friends disapprove*HSI interaction.

Including interactions terms allowed us to explore how quitting norms differently influenced the cessation outcome across smokers with varying levels of nicotine dependence. Interactions were centered on mean HSI prior to running interactions. Centering on mean HSI improves the interpretability of the interaction term but does not have any effects on the model or the magnitude of associations. Running separate descriptive (model 1) and injunctive (model 2) models allowed us to assess the relationship of each of the norms and norm-HSI interactions on having a current quit attempt. Following these separate models with an aggregate model that including both the descriptive and injunctive norms and norm- HSI interactions (model 3) added to the information learned from models 1 and 2 by describing the relative influence of the norms and their norm-HSI interactions on the current quit outcome. This incremental modeling approach has been applied previously (Davey-Rothwell et al., 2018).

Model 3 results were transformed from adjusted odd rations to probability scores so as to visualize the relationship between current quit attempts and HSI as moderated by norms. T-tests were used to assess differences in probabilities of current quit attempts between those with and without friends who had quit smoking.

3. RESULTS

3.1. Sample characteristics

A total of 200 men and 335 women participated in the study, 90% of whom were African American. One third (33.7%) of men were currently attempting to quit smoking. Men currently trying to quit had tried to quit more times in the past year (3.6 attempts vs. 1.0, p<0.001), and had a lower HSI (2.4 vs. 3.0, p<0.001) than men not currently attempting to quit. Men were on average 46.7 years old (SD=10.5), almost half (46%) had an income less than $5000/year, and one-third (29%) had used heroine/cocaine in the past 6 months. Men trying to quit were more likely to have friends who had quit (86% vs. 71%, p=0.003) and friends who disapproved of smoking (60% vs. 47%, p=0.03).

One third of women (36%) were currently attempting to quit smoking. Women attempting to quit had tried to quit more times in the past year (3.2 attempts vs. 1.1, p=0.002) than women not attempting to quit. Women were on average 47.5 years (SD=8.6), and had an average HSI of 2.9 (SD=1.4), and one-third had used heroine/cocaine in the past six months. Almost half (44%) of women had an income of less than $5000/year, almost three-quarters (71%) had a friend who had quit smoking, and half (52%) had a friend who disapproved of smoking, none of which varied by currently attempting to quit.

3.2. Models

3.2.1. Models 1 & 2: Independent descriptive and injunctive norms

Men’s likelihood of a current quit attempt was inversely related to their dependence on nicotine; each point increase in HSI reduced the odds of a current quit attempt by 67% (AOR=0.33 [0.27–0.65]) in Model 1, and 39% (AOR=0.61 [0.46–0.80]) in Model 2 (Table 1). Men with friends who had quit smoking were 180% more likely to have a current quit attempt than those without friends who had quit (AOR=2.83 [1.36–5.90], Model 1). Men with friends who disapproved of smoking were 75% more likely to have a current quit attempt (AOR=1.75 [1.07–2.83], Model 2). Among men with friends who had quit smoking, higher HSI was associated with higher odds of a current quit attempt (Model 1: AOR=2.51 [1.26–4.99]). The same pattern was observed among men with friends who disapproved of smoking (Model 2: AOR=1.43 [1.00–2.05]).

Table 1.

Adjusted odds of currently attempting to quit based on norms

Model Predictor Men AOR (95% CI) n=335 Women AOR (95% CI) n=200
1. Descriptive norm Friends Quit 2.83 (1.36 – 5.90) ** 1.93 (0.97 – 3.87)
Heaviness Smoking Index 0.33 (0.27 – 0.65) ** 1.00 (0.54 – 1.84)
Friends quit × HIS 2.51 (1.26 – 4.99) ** 0.92 (0.56 – 1.50)
2. Injunctive norm Friends Disapprove 1.75 (1.07 – 2.83) * 1.49 (0.83 – 2.70)
Heaviness Smoking Index 0.61 (0.46 – 0.80) *** 0.90 (0.67 – 1.21)
Friends disapprove × HSI 1.43 (1.00 – 2.05) * 1.09 (0.71 – 1.67)
3. Descriptive and injunctive norms Friends Quit 2.53 (1.19 – 5.38) * 1.78 (0.86 – 3.73)
Friends Disapprove 1.47 (0.89 – 2.44) 1.25 (0.66 – 2.34)
Heaviness Smoking Index 0.30 (0.15 – 0.59) *** 0.96 (0.62 – 1.49)
Friends quit × HIS 2.40 (1.20 – 4.78) * 0.87 (0.51 – 1.48)
Friends disapprove × HSI 1.34 (0.93 – 1.93) 1.15 (0.72 – 1.82)
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AOR, Adjusted odds ratio

All models adjusted for age, income and race

*

p < 0.05;

**

p ≤ 0.01;

***

p < 0.001

None of the measures predicted a current quit attempt among women.

3.2.3. Model 3: Combined descriptive and injunctive norms

Among men, there was no association between a current quit attempt and the independent item of friends disapproving. Men with friends who had quit smoking were 150% more likely to have a current quit attempt (AOR=2.53 [1.19–5.38]). Each point increase in HSI reduced the odds of a current quit attempt by 70% (AOR=0.30 [0.15–0.59]). There was a significant interaction between HSI and having friends who quit smoking (AOR=2.40 [1.20–4.78]). There was no significant interaction effect between men’s HSI and having friends who disapproved of smoking on currently quitting.

Figure 1 displays the probabilities of having a current quit attempt for men with and without a friend who has quit smoking across different levels of nicotine dependence. Having friends who had quit smoking increased the probability of a current quit among men with HSIs 3–5 (between group p values < 0.05), but not among men with HSIs 0–2 or with HSI of 6.

Figure 1. Probability of a quit attempt by smoking dependence, n = 335 men.

Figure 1.

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Bars represent 95% confidence intervals

Asterisks represent statistical difference between groups

Note that only 11 participants total had HSI scores of 6

None of the measures predicted current quit attempts for women.

4. DISCUSSION

Among men from this sample of low-income predominantly African American adults, a higher nicotine dependence was associated with decreased odds of having a current quit attempt. This relationship was attenuated for men with moderate-high dependence if they had friends who had quit smoking. Neither smoking dependence nor norms were associated with a current quit attempt for women.

Women may not have been influenced by quitting norms in this study as they assume many social roles and responsibilities (Frankenhaeuser, Lundberg, & Chesney, 2012), which may lead to higher stress preventing them from quitting despite negative social cues. Quitting behaviors may also be influenced by relationships such as romantic partners (Dohnke et al., 2011), and this romantic influence may exert more influence on women than men in the smoking context (Walsh et al., 2007). As compared to men, women may also have different perceptions of their self-efficacy (Helgeson, 2016) and ability to quit smoking.

That HSI was not related to likelihood of a current quit attempt among women (even when unadjusted, data not shown) suggests that quit-behaviors are not derived from dependence on smoking for women in this sample. Cessation attempts may be better explained by other social exposures such as physical environment which were not considered in the current study (Mead, Rimal, Ferrence, & Cohen, 2014). That descriptive norms better predicted odds of a current quit than injunctive norms for men is consistent with earlier literature (Rise, Kovac, Kraft, & Moan, 2008), as observing other’s change their behavior may improve smoker’s perceived control, empowering them to quit.

The focus on low income, predominantly African American urban smokers is a strength given the dearth of smoking norms research within this population (Pennanen et al., 2014). That respondents were from a convenience sample limits generalizability. Respondents may have provided biased responses about their own smoking habits or about their normative influences due to social desirability bias. As single item measures were used to capture these factor there are limited opportunities to triangulate this data. The current research did not capture smoking behaviors or norms among romantic partners, which may be an important component of women’s motivations to quit. Given that the average person who smokes will try to quit numerous times before doing so successfully (with estimates ranging between 6 – 142 attempts in total, see Chaiton et al.), future work should consider the longitudinal effects of norms on quitting.

Evidence-based socially oriented smoking cessation programs for low-income adults are sparse. This study suggests the importance of examining gender differences and norms in smoking cessation outcomes, and in tailoring smoking cessation programs to meet differing social influences. It is important to consider the normative social environment of people who are ready to quit smoking as they are the consumers of smoking cessation programing.

Acknowledgements:

The authors wish to acknowledge and thank participants in this study from Baltimore, MD.

Funding: Research reported in this publication was supported by NIDA/NIH and FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

Footnotes

Data availability statement: The data that support the findings of this study are available upon reasonable request.

Disclosure statement:Authors have no conflicts of interest to declare.

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