Abstract
Background
The percentage of U.S. smokers who smoke <10 cigarettes per day has increased, yet it’s not known how often light parental smokers are offered and accept cessation assistance in pediatric offices.
Methods
A secondary analysis of parent interview data collected April-October 2017 at 10 pediatric practices participating in a cluster-randomized controlled trial of the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention.
Results
Forty percent of 725 usual care control (UCC) group smokers smoked lightly (<10 cigarettes per day); of these 58% smoked very lightly (<5 per day). Compared to heavier smokers in UCC practices, light and very light smokers in UCC practices were more likely to have made a recent quit attempt (p < .001), yet less likely to have used cessation medication (p = .001). In intervention practices, compared to heavier smokers, light (p = .04) and very light (p < .01) smokers were less likely to be asked if they smoke and very light smokers were less likely to be advised to quit (p = .02) and to receive a nicotine replacement therapy (NRT) prescription (p < .01). However, light smokers (p < .001), very light smokers (p < .001) and light smokers who use e-cigarettes (p = .01) were more likely to receive assistance (NRT or quitline enrollment) in intervention versus UCC practices.
Conclusions
The CEASE intervention increased assistance to light and very light smokers, yet heavier smokers received more assistance than light smokers. Improving cessation interventions for light and very light smokers is warranted.
Keywords: Smoking Cessation, Light Smoking, Nicotine Replacement Therapy, E-cigarette, Tobacco Control
Introduction
Adults who smoke less than half a pack of cigarettes (10) per day have been classified in previous assessments as light smokers.1–3 Smokers who consume even fewer cigarettes (≤ 5 cigarettes per day) have previously been referred to as very light smokers.3,4 Light smoking is responsible for increased risks of the same adverse health consequences experienced by people who smoke more heavily such as coronary heart disease, myocardial infarction, stroke, and all-cause mortality.5–8 A recent meta-analysis found that smoking just one cigarette per day is responsible for approximately half the risk for developing coronary heart disease and stroke as smoking 20 cigarettes per day.9 Compared to never smokers, smoking one cigarette per day increased the risk for heart disease by 74% for men and 119% for women when adjusted for confounders.9 The risk of stroke from one cigarette per day was found to be 30% and 46% higher than non-smokers for men and women, respectively, when adjusted for multiple factors.9 The proportion of U.S. adult daily smokers who smoke fewer than 10 cigarettes per day has increased dramatically from 16.4% in 2005 to 25.0% in 2016.10 Ensuring evidence-based treatment is provided to this growing segment of the smoking population should be a major component of comprehensive tobacco control programs. All smokers, including those who are light smokers, should be advised by healthcare clinicians to quit and offered supportive counseling, such as that provided by a tobacco quitline, to help them achieve cessation.1 Unfortunately, widely disseminated treatment guidelines do not contain specific recommendations for the use of NRT or other medications to treat tobacco dependence in light smokers.11 Instead existing recommendations have been written for moderate or heavy smokers since the large majority of existing evidence is from smoking cessation trials that have not historically included light smokers.1,12,13
The majority of smoking cessation research has been carried out with heavier smokers, which has resulted in a paucity of data about light smokers and how they utilize smoking cessation assistance.5,14 Specifically, we examined to what extent practices trained in the Clinical Effort Against Secondhand Smoke Exposure (CEASE) intervention were effective at screening light and very light parental smokers for smoking status, providing counseling to quit smoking, referring them to the quitline and prescribing NRT compared to usual care control practices.15 The usual care control practices did not receive training in the CEASE intervention from the research team, yet these practices were not precluded from screening or delivering smoking cessation treatments to parents as a condition of their participation in the study. We hypothesized that CEASE intervention practices would outperform usual care control practices in screening and delivery of smoking cessation treatments for light and very light smokers. This study also explored if light and very light smokers were treated differently at intervention practices when compared to heavy smokers by comparing the rates at which they were screened for smoking, received advice, and were provided tobacco cessation treatment. The CEASE training provided to intervention practices did not advise clinicians to prioritize delivery of tobacco control activities to heavier smokers. Therefore, we hypothesized that the rates of screening and delivery of smoking cessation treatment would not differ by the number of cigarettes smoked. Additionally, because substantial proportions of parental smokers are now dual using cigarettes and e-cigarettes,16 we explored how often light and very light smoking dual users received evidence-based cessation assistance at their child’s doctor’s office and the rate at which light and very light smoking dual users were using evidence-based cessation aids such as the quitline and NRT.
Methods
Study Procedure
Parents were interviewed by research assistants between April 2017 and October 2017 upon exiting 10 pediatric primary care practices that were participating in a cluster randomized controlled clinical trial testing the effectiveness of the CEASE intervention. One intervention and one usual care control practice participated from each of the following states: Virginia, Tennessee, Ohio, North Carolina, and Indiana. Intervention practices were trained by research staff to routinely distribute an electronic tablet-based screening survey to parents to identify households that had at least one smoker. The number of cigarettes smoked per day was not assessed on the electronic pre-visit screening survey. Staff at intervention practices were trained to hand parents who screened positive for tobacco use on the electronic tablet a CEASE Action Sheet for use during the visit with the clinician to guide the discussion about their tobacco use. The main components of the intervention involved counseling and offering evidence-based assistance to parents who smoke, offering enrollment for parent smokers in the state tobacco quitline, prescribing NRT and advising families to establish smoke-free homes and cars. Additional information about the design and conduct of the overall trial has been previously reported.15,17 The data for this analysis were collected two years after implementation of the intervention in both the intervention and usual care control group practices.
Participants
Research assistants approached all adults who exited the pediatric practices after their child’s visit and asked them if they would be willing to participate in a brief screening interview. Parents or legal guardians of the child seen that day who indicated on the screening interview they were current smokers (had smoked at least 100 cigarettes in their lifetime and had smoked a cigarette, even a puff, in the past 7 days) and who agreed to participate in an enrollment interview were included in the present study. Parents were required to be at least 18 years of age and able to speak English to participate. Parents signed a consent form prior to the enrollment interview and were provided with $5 for their participation. Institutional Review Board approval was obtained from Massachusetts General Hospital, the American Academy of Pediatrics, and from pediatric practices (when required).
Measures and Statistical Analysis
Parents who were current smokers were asked if they smoke every day or on some days. When parents responded that they smoke every day, they were asked to indicate how many cigarettes, on average, they smoke per day. If parents indicated that they smoke on some days, parents were asked on how many days within the past 30 days they smoked and on the days that they had smoked, how many cigarettes, on average, did they smoke. Based on each of the parent’s responses, we calculated an average number of cigarettes smoked per day for each parent smoker. Light smoking was defined as having smoked less than an average of 10 cigarettes per day and very light smoking was characterized as having smoked less than an average of 5 cigarettes per day. Light smokers were categorized as meaning light smokers versus all other smokers and very light smokers were similarly defined as very light smokers versus all other smokers. This paper reports a secondary analysis of the CEASE clinical trial dataset.15 Analyses were cross-sectional in nature and were not adjusted for multiple comparisons.
Bivariate analyses were conducted to compare light and very light smokers versus heavier smokers in usual care control group practices on demographic characteristics and cessation-related behaviors. Multivariable logistic regression analyses were conducted to examine if light and very light cigarette smoking among usual care control group parents was independently associated with use of a tobacco quitline or online quit smoking service in the past two years, the use of medication to help quit smoking in the past two years, the use of an electronic cigarette in the past 30 days, and the likelihood of making at least one quit attempt in the past three months. Parental characteristics that were significantly associated with the outcome in the bivariate analyses were included in the multivariable models as control variables.
Pearson’s chi-square analyses were used to calculate if light and very light smokers had a different likelihood of receiving tobacco control assistance at the visit if they were seen in intervention practices compared to usual care control practices and used to determine if light and very light smokers who had visited an intervention practice were less likely to receive tobacco control assistance than parents who smoke more heavily. Fisher’s exact tests calculated if light smokers who dual used e-cigarettes in the past 30 days had a different likelihood of receiving a prescription for NRT at the visit, enrolling in the tobacco quitline at the visit, using medication to help them quit within the past two years and using a quitline or an online program within the past two years if they were seen in intervention practices compared to usual care control practices. Analyses were performed using IBM SPSS Statistics, Version 24.
Results
Of the 725 enrolled parents who completed interviews at usual care control practices and who reported smoking cigarettes within the past seven days, 287 (39.6%) smoked less than ten cigarettes per day and of these parents 166 (57.8 %) smoked less than five cigarettes per day. Of the 800 parents who smoked and were interviewed at intervention practices, 280 (35.0%) reported smoking less than ten cigarettes per day and of these parents 148 (52.9 %) smoked less than five cigarettes per day.
Unadjusted odds ratios are presented in Table 1. Positive associations were detected between light smoking and identifying as non-Hispanic Black or African American (OR=3.36, 95% CI=2.03–5.69) and identifying as other or more than one race (OR=1.80, 95% CI=3.67–1.60). Very light smoking was positively associated with identifying as Non-Hispanic Black or African American (OR=2.73, 95% CI=1.63–4.53). College educated parents were more likely to be light (OR=1.48, 95% CI=1.09–2.01) and very light (OR=1.75, 95% CI=1.23–2.48) smokers than parents who did not attend college. Unadjusted analyses show parents who made a quit attempt within the past three months were significantly more likely to be light (OR=2.42, 95% CI=1.78–3.29) and very light (OR=2.26, 95% CI=1.58–3.25) smokers than parents who did not make a quit attempt. Light (OR=0.51, 95% CI=0.34–0.74) and very light (OR=0.43, 95% CI=0.25–0.69) smokers were less likely to have reported using a medication to help them with quitting smoking.
Table 1:
Unadjusted odds ratios and 95% confidence intervals for light and very light cigarette use among parents who smoke seen in usual care control practices. (N = 725)
| Light smoker | Very light smoker | ||||||
|---|---|---|---|---|---|---|---|
| No N = 438 |
Yes N = 287 |
No N=559 |
Yes N=166 |
||||
| Characteristics | n (%) | n (%) | OR (95% CI) | n (%) | n (%) | OR (95% CI) | |
| Parent Age | 18–24 years | 70 (16.0) | 45 (15.7) | 1.31 (0.72, 2.05) | 91 (16.3) | 24 (14.5) | 1.13 (0.55, 2.35) |
| 25–44 years | 315 (71.9) | 216 (75.3) | 1.40 (0.86, 2.34) | 404 (72.3) | 127 (76.5) | 1.34 (0.76, 2.52) | |
| 45 and over | 53 (12.1) | 26 (9.1) | Ref | 64 (11.4) | 15 (9.0) | ref | |
| Parent Sex | Male | 73 (16.7) | 50 (17.4) | 1.06 (0.71, 1.56) | 91 (16.3) | 32 (19.3) | 1.23 (0.78, 1.90) |
| Female | 365 (83.3) | 237 (82.6) | ref | 468 (83.7) | 134 (80.7) | ref | |
| Race/Ethnicity | Hispanic | 6 (1.4) | 5 (1.7) | 1.49 (0.43, 5.01) | 7 (1.3) | 4 (2.4) | 2.19 (0.57, 7.36) |
| Non-Hispanic Black or African American | 25 (5.7) | 47 (16.4) | 3.36 (2.03, 5.69) | 42 (7.5) | 30 (18.1) | 2.73 (1.63, 4.53) | |
| Other or > 1 race | 16 (3.7) | 16 (5.6) | 1.80 (3.67, 1.60) | 26 (4.7) | 6 (3.6) | 0.88 (0.32, 2.06) | |
| Non-Hispanic White | 390 (89.2) | 218 (76.2) | ref | 482 (86.5) | 126 (75.9) | ref | |
| Education | Some college or more | 155 (35.6) | 128 (44.9) | 1.48 (1.09, 2.01) | 201 (36.2) | 82 (49.7) | 1.75 (1.23, 2.48) |
| No college | 281 (64.4) | 157 (55.1) | ref | 355(63.8) | 83 (50.3) | ref | |
| Behaviors | |||||||
| Used quitline or online quit smoking service (past 2 years) | Yes | 23 (5.3) | 21 (7.3) | 1.42 (0.77, 2.63) | 33 (5.9) | 11 (6.7) | 1.13 (0.54, 2.23) |
| No | 413 (94.7) | 265 (92.7) | ref | 524 (94.1) | 154 (93.3) | ref | |
| Used medication to help with quitting smoking (past 2 years) | Yes | 118 (27.0) | 45 (15.7) | 0.51 (0.34, 0.74) | 142 (25.4) | 21 (12.7) | 0.43 (0.25, 0.69) |
| No | 319 (73.0) | 241 (84.3) | ref | 416 (74.6) | 144 (87.3) | ref | |
| E-cigarette use (past 30 days) | Yes | 47 (10.7) | 33 (11.5) | 1.08 (0.67, 1.73) | 67 (12.0) | 13 (7.8) | 0.62 (0.32, 1.13) |
| No | 391 (89.3) | 254 (88.5) | ref | 492 (88.0) | 153 (92.2) | ref | |
| Quit attempt in the last 3 months | Yes | 178 (40.9) | 179 (62.6) | 2.42 (1.78, 3.29) | 250 (45.0) | 107 (64.8) | 2.26 (1.58, 3.25) |
| No | 257 (59.1) | 107 (37.4) | ref | 306 (55.0) | 58 (35.2) | ref | |
Note: Logistic regression was applied.
Odds ratios presented in Table 2 that were adjusted for parent race and ethnicity and level of education show that light (aOR=2.33, 95% CI=1.70–3.20) and very light (aOR=2.24, 95% CI=1.55–3.27) smokers were more likely to have had made at least one quit attempt in the past three months compared to heavier smokers. However, parents who were light (aOR=0.52, 95% CI=0.35– 0.76) and very light (aOR=0.44, 95% CI=0.26–0.71) smokers were significantly less likely to have used medication within the past two years to help them quit smoking after adjusting for parent race and ethnicity and level of education.
Table 2:
Adjusted odds ratios and 95% confidence intervals for tobacco control behaviors in light and very light smokers versus heavier smokers in usual care control practices. N=714
| Light smoker | Very light smoker | |||||
|---|---|---|---|---|---|---|
| Characteristic | aOR | 95% CI | p-value | aOR | 95% CI | p-value |
| Used quitline or online quit smoking service (past 2 years) | 1.49 | (0.79, 2.77) | 0.21 | 1.16 | (0.54, 2.32) | 0.69 |
| Used medication to help with quitting smoking (past 2 years) | 0.52 | (0.35, 0.76) | .001 | 0.44 | (0.26, 0.71) | .001 |
| E-cigarette use (past 30 days) | 1.17 | (0.72, 1.90) | 0.52 | 0.64 | (0.33, 1.17) | 0.17 |
| Quit attempt in the last 3 months | 2.33 | (1.70, 3.29) | < .001 | 2.24 | (1.55, 3.27) | < .001 |
Note: Logistic regression was applied. All models were adjusted for parent education and Race/Ethnicity.
As displayed in Table 3, light and very light smokers at their child’s visit were significantly more likely to be asked if they smoked, advised to quit smoking, to have discussed medication to help them quit smoking, be given a prescription for NRT medication, to have discussed using a quitline or another smoking cessation program, and be enrolled in the quitline if they visited a CEASE intervention practice compared to a usual care control practice. No light smokers seen in control practices received cessation assistance (quitline enrollment or prescription for NRT), whereas 11.4% of light smokers and 7.4% of very light smokers who were seen at intervention practices reported being enrolled in the quitline or receiving a prescription for NRT at the visit.
Table 3:
Rates of light and very light smoking parents being asked about or advised to quit smoking and receipt of evidence-based assistance at the pediatric visit.
| Usual care control arm n (%) | Intervention arm n (%) | p-value | N | |
|---|---|---|---|---|
| Light Smokers | ||||
| Ask if you smoke cigarettes | 48 (16.8) | 121 (43.2) | < .001 | 565 |
| Advise you to quit smoking | 27 (9.5) | 97 (34.6) | < .001 | 565 |
| Discussed medication to help quit smoking | 4 (1.4) | 77 (27.5) | < .001 | 565 |
| Received prescription for NRT | 0 (0) | 28 (10.1) | < .001 | 563 |
| Discussed using a quitline or other program | 4 (1.4) | 51 (18.3) | < .001 | 563 |
| Enrolled in quitline | 0 (0) | 18 (6.4) | < .001 | 565 |
| Any Assistance (received prescription for NRT or enrolled in quitline or other program) | 0 (0) | 32 (11.4) | < .001 | 565 |
| Very Light Smokers | ||||
| Ask if you smoke cigarettes | 27 (16.4) | 55 (37.2) | < .001 | 313 |
| Advise you to quit smoking | 17 (10.4) | 45 (30.4) | < .001 | 312 |
| Discussed medication to help quit smoking | 3 (1.8) | 35 (23.6) | < .001 | 312 |
| Received prescription for NRT | 0 (0) | 9 (6.2) | .001 | 310 |
| Discussed using a quitline or other program | 3 (1.8) | 22 (15.0) | < .001 | 311 |
| Enrolled in quitline or other program | 0 (0) | 7 (4.7) | .005 | 312 |
| Any Assistance (received prescription for NRT or enrolled in quitline or other program) | 0 (0) | 11 (7.4) | < .001 | 312 |
Note: Pearson chi-square used for p-value.
As shown in Table 4, light (p = .04) and very light (p < .01) smokers who visited CEASE intervention practices were significantly less likely to be asked if they smoke cigarettes than parents who smoked more heavily. Very light smokers were significantly less likely to be advised to quit smoking (p = .02) and less likely to receive a prescription for NRT medication (p < .01) than parents who smoked more heavily.
Table 4:
Receipt of evidence-based cessation assistance in intervention practices according to light and very light smoking status among enrolled parents who smoke (N = 800)
| Light smoker | Very light smoker | |||||
|---|---|---|---|---|---|---|
| No N = 520 |
Yes N = 280 |
No N = 652 |
Yes N = 148 |
|||
| Evidence-based cessation assistance | n (%) | n (%) | p-value | n (%) | n (%) | p-value |
| Ask if you smoke cigarettes at visit | .04 | < .01 | ||||
| Yes | 264 (50.8) | 121 (43.2) | 330 (50.6) | 55 (37.2) | ||
| No | 256 (49.2) | 159 (56.8) | 332 (50.9) | 93 (62.8) | ||
| Advise you to quit smoking at visit | .06 | .02 | ||||
| Yes | 216 (41.5) | 97 (34.6) | 268 (41.1) | 45 (30.4) | ||
| No | 304 (58.5) | 183 (65.4) | 384 (58.9) | 103 (69.6) | ||
| Received prescription for NRT | .09 | < .01 | ||||
| Yes | 74 (14.3) | 28 (10.1) | 93 (14.3) | 9 (6.2) | ||
| No | 444 (85.7) | 250 (89.9) | 557 (85.7) | 137 (93.8) | ||
| Discussed using a quitline or other program | .34 | .08 | ||||
| Yes | 110 (21.2) | 51 (18.3) | 139 (21.4) | 22 (15.0) | ||
| No | 409 (78.8) | 227 (81.7) | 511 (78.6) | 125 (85.0) | ||
| Enrolled in quitline or other program | .16 | .08 | ||||
| Yes | 48 (9.3) | 18 (6.4) | 59 (9.1) | 7 (4.7) | ||
| No | 469 (90.7) | 262 (93.6) | 590 (90.9) | 141 (95.3) | ||
Note: Pearson chi-square used for p-value.
Light smokers who also used e-cigarettes (dual users) were significantly more likely to be enrolled in the tobacco quitline (p = .02) and to have received a prescription for NRT at their child’s visit (p = .049) in intervention vs. usual care control practices. Non-significant trends were detected in the direction of light smoking parents who were dual users of e-cigarettes being more likely to have used medication to help them quit smoking in the past two years and to have used a quitline or an online cessation program in the past two years if seen at an intervention practice. Results are presented in Table 5.
Table 5:
Evidence-based cessation assistance utilized by light smokers who also used e-cigarettes in the past 30 days (dual users)
| Usual care control arm n (%) |
Intervention arm n (%) |
p-value | N | |
|---|---|---|---|---|
| Received prescription for NRT at visit | 0 (0) | 4 (12.9) | < .05 | 62 |
| Enrolled in quitline or other program | 0 (0) | 5 (16.1) | .02 | 63 |
| Any Assistance (received prescription for NRT or enrolled in quitline) | 0 (0) | 6 (19.4) | .01 | 63 |
| Used medication to help with quitting smoking (past 2 years) | 8 (24.2) | 15 (48.4) | .07 | 64 |
| Used quitline or online quit smoking service (past 2 years) | 7 (21.2) | 11 (35.5) | .27 | 64 |
Note: Fisher’s exact test was applied for p-value calculation.
Discussion
In this study, almost 40% of parental smokers seen in pediatric primary care offices were light or very light smokers. The characteristics associated with light and very light smoking parents confirmed prior research findings on other adult populations.3,4,18–20 Light smokers are more likely than heavier smokers to have increased motivation to quit and to be actively planning to quit.3,18 Similar to studies conducted among the general adult population, we found that light parental smokers were also more likely to have attempted quitting.3,18,20
Paradoxically, a British study showed light smokers were less likely than heavier smokers to use NRT medication to quit smoking.18 A similar trend in medication use was observed in usual care control practices in the present study; light and very light smokers were much more likely to have made an attempt to quit smoking within the past three months, yet light and very light smokers were also much less likely to have reported using medication to help with quitting smoking at any time in the past two years. A potential reason for this finding may be that parents who are light smokers are less likely to believe medication will benefit them compared to smokers who smoke more heavily.20 Light smokers also express increased feelings of confidence in being able to quit smoking compared to heavy smokers.21
Light and very light smokers seen in CEASE intervention practices were asked about smoking, advised to quit smoking, enrolled in the quitline at the visit, and received prescriptions for NRT at significantly higher rates than parents seen in usual care control practices. These results show light and very light smokers who visited a practice in the CEASE intervention arm were more likely to benefit by receiving evidence-based tobacco control assistance compared to light and very light smokers seen at usual care control practices. However, the proportion of light and very light smokers seen in intervention practices who reported receiving any assistance in the form of a prescription for NRT or enrollment in the quitline or another cessation program were relatively low. Since only 11.4% of light smokers and 7.4% of very light smokers seen at intervention practices received any assistance at the visit for their smoking, future iterations of the CEASE intervention should aim to increase the rates of assistance for light and very light smokers.
While light smokers are typically less dependent on nicotine than heavier smokers,3,19,22,23 many light and very light smokers still have urges to smoke and report symptoms of nicotine dependence.18,24 Light smokers do not necessarily have a less difficult time quitting than heavier smokers.13,21,25,26 Even though CEASE practices were trained to provide assistance to every parent who smoked, data revealed that light and very light smokers seen in intervention practices were significantly less likely to be asked about smoking and very light smokers seen in intervention practices were significantly less likely to be advised to quit smoking and to have received a prescription for NRT compared to parents who smoked more heavily. These results show clinicians in the pediatric setting are less frequently adhering to components of the intervention when parents are light and very light smokers. Future research should aim to gain a better understanding of the interpersonal dynamics involved that could explain why light and very light smokers were less likely to be asked about their smoking status than parents who smoked more heavily.
In addition to not prescribing NRT, our findings also suggest that clinicians may be avoiding asking about and advising very light smokers about the importance of quitting. It may not be broadly recognized by healthcare professionals that very light smoking has been associated with about half of the risk for coronary heart disease and stroke as people who smoke 20 cigarettes per day.9 Education for clinicians about the relatively high cardiovascular disease risks from light and very light smoking is crucially important to accompany calls for higher rates of screening and advising of light and very light smokers. To mitigate the adverse health risks posed by light and very light smoking, it is essential these parents receive accurate information from their child’s doctor about the risks to their health and receive assistance to help them quit completely.
Several previous studies conducted in other clinical settings have found tobacco control assistance was less often delivered to non-daily or light smokers compared to those who smoke more often or more heavily. For instance, U.S. non-daily smokers were more likely to want to quit than daily smokers but were also less likely to be asked if they use tobacco or advised to quit by their doctor.27 Light smokers from the Netherlands and England were less likely to report being advised to quit by their doctor compared to moderate and heavy smokers.28 A study of smokers receiving cessation services in France showed they were less likely to be offered medication to help them quit smoking if they were light smokers compared to those who smoked heavily.29
There is a strong evidence base to support the use of NRT to increase the likelihood of successfully quitting smoking among moderate and heavy smokers.30 Several studies among light smokers have also found an increased likelihood of quitting smoking among those who used NRT compared to those who did not use NRT. Light smokers who used nicotine lozenges were more likely to quit smoking at 6 weeks and 1 year than light smokers assigned to the placebo control group.26 The use of a nicotine patch among light smokers increased the likelihood of abstinence after one month.29 In another study, light smokers who used the New York State Smokers’ Quitline were more likely to quit smoking at 7 and 30 days follow-up if they were provided with NRT.31 Other studies demonstrate varenicline when used with behavioral counseling helped light smokers quit11,32 and bupropion increased short-term cessation outcomes among light smokers.33,34 The lack of clinical guidance around the issue of pharmacotherapy for light and very light smokers is probably resulting in fewer parents receiving cessation medication. As pointed out in 2002 in a paper by Okuyemi et al., there remains a need of high-quality research to inform the development of treatment guidelines for light and very light tobacco users.35
An increasing number of U.S. parents who smoke are now dual using e-cigarettes and cigarettes.16 A French study analyzing data collected from 2007–10 suggested that NRT might have additional benefit for light smokers who were concerned about coping with withdrawal symptoms when quitting cigarettes.36 E-cigarettes may be used by some light smokers for similar reasons, but e-cigarettes are not FDA-approved for smoking cessation. Also, dual users are exposed to the toxic substances from both products, and as a result, dual users may have additional health risks compared to people who only smoke.37,38 No dual users who smoked lightly received any evidence-based assistance in the usual care control practices. Nearly two out of every ten light smoking dual users seen in intervention practices accepted prescriptions for FDA-approved NRT or enrollment to the tobacco quitline, though studies with larger samples of light smoking dual user parents will be necessary before drawing well-founded conclusions about how often they accept evidence-based cessation treatments compared to parents who do not use e-cigarettes. As e-cigarette use rates continue to grow, it’s important for clinicians to recognize that dual users who smoke lightly may be interested in receiving evidence-based cessation treatments.
Limitations
This study has several limitations. The statistics used were not specifically powered to answer the questions posed in this secondary analysis of the CEASE clinical trial dataset.15 Self-report data may not reflect the true incidence of the behaviors assessed in this study as they may be influenced by response and recall bias. The analyses did not account for the number of times a parent had visited the practice prior to the exit interview. It is possible that parents who had visited the practice more frequently may have been asked about smoking or had received assistance for their smoking at different rates than parents who had visited the practice less often. The analyses involving dual users of cigarettes of e-cigarettes were based on small sample sizes and should be interpreted as exploratory in nature, pending future studies with larger populations of light smoking dual users. Cross-sectional analyses preclude our ability to infer causality. Despite these limitations, the results of this study are promising and should be used to inform future research and development of smoking cessation interventions that involve light smokers.
Conclusions
This study showed light and very light smokers were more likely to have recently made a quit attempt than parents who smoked more heavily. Compared to the usual care control group, the CEASE intervention increased assistance provided to light smokers, very light smokers, and light smoking dual users of e-cigarettes. Identifying and providing evidence-based cessation assistance to light and very light smokers seen in the pediatric setting is necessary to ensure this growing segment of parent smokers are not omitted from the benefits of tobacco control interventions.15
What’s New?
Light smoking parents attempt to quit at higher rates than heavier smokers, yet they are less likely to use cessation medication when attempting to quit. The CEASE intervention improved delivery of cessation assistance, including prescriptions for medication, to light smokers.
Acknowledgements
We appreciate the efforts of the American Academy of Pediatrics practices and practitioners who participated in this study.
Funding: This work was supported by the National Institutes of Health NCI grant [grant number R01-CA127127]. The funder had no role in the design or conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, approval of the manuscript or the decision to submit the article for publication.
Footnotes
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Clinical Trial Registration: (ClinicalTrials.gov, Identifier: NCT01882348, https://clinicaltrials.gov/ct2/show/NCT01882348)
Declarations of interest: None
References
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