Abstract
Introduction:
People with disabilities report a higher prevalence of cigarette use than people without disabilities. However, evidence is limited on the relationships between disability type, degree of functional difficulty, and other tobacco product use.
Methods:
Data from the 2019 U.S. National Health Interview Survey were used to estimate the prevalence and odds of tobacco product use for 6 disability types and degree of functional difficulty. Bivariate and multivariable analyses conducted in 2021 examined the associations between tobacco product use and disability type.
Results:
Compared to adults who reported no difficulty, current cigarette use prevalence was higher for adults who reported a lot of difficulty/cannot do at all to vision (21.5% vs 13.1%), hearing (19.6% vs 13.6%), mobility (20.0% vs 12.9%), and cognitive (25.4% vs 12.9%) disability questions. The odds of current cigarette (AOR=1.32), pipe (AOR=1.85), and smokeless tobacco (AOR=1.57) use were significantly higher for adults who reported a lot of difficulty/cannot do at all to any disability question and significantly higher for current cigarette (AOR=1.24), e-cigarette (AOR=1.33), pipe (AOR=1.45), and smokeless tobacco (AOR=1.29) use for adults who reported some difficulty to any disability question than those who reported no difficulty. Pipe use was correlated with mobility difficulty (AOR=1.68), and smokeless tobacco use was correlated with hearing difficulty (AOR=1.95).
Conclusions:
People who reported difficulty with vision, hearing, mobility, or cognition had a higher cigarette use prevalence than people without disabilities. Other tobacco use differed by disability type. Future research should tailor tobacco interventions to reduce these disparities.
INTRODUCTION
Tobacco use—the leading cause of preventable death in the U.S.1 is disproportionately higher in various population subgroups, including American Indian or Alaskan Natives, people of low SES, and sexual and gender minorities.2,3 People with disabilities, who comprise approximately 25% of the adult population4 but are frequently excluded from health research,5 also have a higher prevalence of using some tobacco products than people without a disability.6–8 National data indicate that people with disabilities report a higher prevalence of current cigarette use (20.1%) than people without a disability (13.3%), although the use of other tobacco products (i.e., e-cigarettes, pipes, cigars, and smokeless tobacco) is similar between people with and without disabilities.6 Other studies that use state-level data or analyze subpopulations of people with disabilities (e.g., age group, disability type) have found a higher prevalence of e-cigarette use among adults with a cognitive, independent living, vision, self-care, and 2 or more disabilities than in those who report no disability8,9; higher prevalence of cigarette, cigar, pipe, and smokeless tobacco use in college students with a disability than in college-aged students without a disability10; and higher prevalence of cigarette, little cigar, hookah, and e-cigarette use in high-school students with a disability than in students without a disability.11 Adolescents with physical disabilities are also more likely to use tobacco than adolescents without a physical disability.12 Consistent findings across samples show higher tobacco use in persons reporting a range of disabilities, but evidence is currently limited to describe the associations between the type of disability and tobacco use, which may inform intervention approaches.
Estimates of the relationship between disability and tobacco use may vary owing to differing definitions of disability and data sources used. Frequently, disability is identified through either the Washington Group Short Set on Functioning (WG-SS)13 or the American Community Survey (ACS) Disability Questions.14,15 Both question sets conceptualize disability using the social model of disability and as outlined by the WHO’s International Classification of Functioning, Disability, and Health.16 However, the 2 question sets diverge on the functional domains measured, with both sets assessing 5 functional domains (i.e., seeing, hearing, mobility, cognition, and self-care), the ACS assessing independence, and the WG-SS measuring functional difficulties in communication. The ACS questions require a dichotomous yes/no answer about each domain, whereas the WG-SS measures a range of functioning by asking respondents to respond with no difficulty, some difficulty, a lot of difficulty, or cannot do at all to each domain. Because of these differences, the prevalence of disability can vary depending on the survey questions used. For example, in data from the 2011–2012 National Health Interview Survey (NHIS), the ACS identified 2.1 times the percentage of adults with disabilities as the WG-SS (20.5% vs 9.7%).17
Previous research on the relationship between disability and tobacco use has included only 1 or a few types of tobacco use,9 measured tobacco use by either disability or no disability,10,11 examined 1 domain of functioning,12,18,19 or focused on 1 geographic region.20 This narrow approach, along with the use of different survey measures, limits comparability in tobacco use across various products among people who report different functional difficulties and may also obscure important differences in tobacco prevalence across different domains of function. These differences in study design and purpose may also contribute to the wide range of estimates of the prevalence of tobacco use by people with a disability. For example, in studies with surveys administered in 2017 or later, current prevalence of cigarette smoking among people with a disability ranged from 12.3% to 21.2%,6,11 and the prevalence of current e-cigarette use among people with any disability ranged from 4.2% to 18.3%,6,9,11 depending on whether the data are nationally, statewide, or certain age-group representative samples of people with disabilities. In addition, no study provides information on tobacco product use by the degree of functional difficulty within each disability domain. The most recent publication on tobacco use among adults from the NHIS only reports tobacco product use by either disability or no disability, although the use of WG-SS questions on the NHIS allows for a more detailed analysis of each functional domain and by difficulty level.6 The purpose of this study was to present the national prevalence of tobacco product use by disability type and the degree of functional difficulty as well as to describe the associations between tobacco product use and disability while controlling for various factors that are known to influence tobacco use.
METHODS
Study Sample
Data were from the 2019 NHIS, an annual household survey that provides information on the health status of the non-institutionalized U.S. civilian population. This population-based surveillance system, which is administered by the Centers for Disease Control and Prevention, uses a multistage stratified sampling design to ensure a nationally representative sample. A detailed description of the survey is reported elsewhere.21 A total of 31,977 adults aged ≥18 years responded to the survey in 2019, with a response rate of 59.1%. The University of Vermont IRB determined the study to be not human subjects research.
Measures
Disability type and degree of functional difficulty were determined by how respondents answered the following 6 WG-SS questions: (1) Do you have difficulty seeing, even when wearing glasses? (vision); (2) Do you have difficulty hearing, even when using a hearing aid? (hearing); (3) Do you have any difficulty walking or climbing steps? (mobility); (4) Using your usual language, do you have difficulty communicating, for example, understanding or being understood? (communication); (5) Do you have difficulty remembering or concentrating? (cognition); and (6) Do you have difficulty with self-care, such as washing all over or dressing? (self-care). Respondents answered no difficulty, some difficulty, a lot of difficulty, or cannot do at all to each of these items. Respondents were categorized as having a disability if they reported a lot of difficulty or cannot do at all to any of the 6 questions mentioned earlier.22 These 2 categories were combined owing to small sample size and to aid in comparison with previous research.6 Comparison categories were some difficulty and no difficulty, with the latter categorized as no disability and serving as the reference category.
The use of 5 tobacco products (i.e., cigarettes, e-cigarettes, cigars / cigarillos / filtered little cigars, regular pipe / water pipe / hookah, smokeless tobacco) were coded on the basis of measures available for each product. Cigarette smoking status was defined as current, former, and never. Current and former cigarette smokers reported smoking > 100-lifetime cigarettes. Current smokers also reported now smoking every day or some days, whereas former smokers reported now smoking not at all. Never cigarette smokers were those who did not meet the 100-cigarette threshold. For the remaining tobacco products, current users were defined among people who reported using the product even 1 time (ever users) and now using it every day or some days, and noncurrent users reported ever using the product but now using the product not at all. For e-cigarettes, cigars, regular pipe / water pipe / hookah, and smokeless tobacco, the resulting categories were current use, noncurrent use (ever use but not using every day or some days), and never use.
Variables included as covariates were sex, age, sexual orientation, race / ethnicity, education level, annual household income, marital status, health insurance, and mental health, operationalized using the Generalized Anxiety Disorder-7 (GAD-7) scoring. These variables are consistent with previous analyses.6,7
Statistical Analysis
All analyses used SVY procedures in Stata/Standard edition, version 17 (StataCorp LP, College Station, TX), using survey weights to account for complex survey design,23 with a Taylor series linearization method used to provide a variance estimation. Missing data, refused, and I don’t know responses were removed from analyses using list-wise deletion, per Stata’s default procedures owing to the small percentage of missing for each variable and in the multivariable models (range=0%–6%) (Appendix Figure 1, available online). Descriptive statistics were run for each of the sociodemographic variables, and each of these categorical variables was tested for differences in distribution using chi-square tests. Prevalence with 95% CIs was estimated by each of the 5 tobacco products (cigarettes, e-cigarettes, cigars, pipe, and smokeless tobacco) for each disability type by functional difficulty. Estimates with a relative SE >30% were suppressed owing to being considered statistically unreliable.24
Logistic regression models examined the association between tobacco product use and disability type and functional difficulty. These models generated crude ORs and AORs for product-specific tobacco use by disability type and functional difficulty. The first model only included disability variables to produce unadjusted ORs; the second multivariable model controlled for age, sex, race/ethnicity, sexual orientation, education, income, marital status, health insurance, and mental health because these variables have previously shown an association with increased odds of cigarette smoking25,26 and are similar to those variables used in previous research on disability and tobacco use.7 An α value at the level of 0.05 was used to evaluate statistical significance.
RESULTS
Table 1 shows the descriptive statistics for people with any disability. There were differences in the sociodemographic characteristics of people across the range of functionality, with people who reported having a lot of difficulty / cannot do at all to any of the disability questions more likely to be older, to be female, to be of lower income, to have lower levels of education, and to score severe on the GAD-7. The Appendix (available online) presents the sociodemographic characteristics by disability type (Appendix Tables 1–6, available online).
Table 1.
Study Population Characteristics, National Health Interview Survey, 2019
| Characteristics | Any disability | p-value | ||
|---|---|---|---|---|
| Degree of difficulty | ||||
| No, %a (95% CI) | Some, %a (95% CI) | A lot / cannot do, %a (95% CI) | ||
| Sex | <0.0001 | |||
| Male | 49.3 (48.3, 50.2) | 48.0 (46.8, 49.2) | 43.1 (41.0, 45.3) | |
| Female | 50.7 (49.8, 51.7) | 52 (50.8, 53.2) | 56.9 (54.7, 59.0) | |
| Age group, years | <0.0001 | |||
| 18–24 | 14.3 (13.4, 15.1) | 9.0 (8.2, 9.9) | 5.0 (3.8, 6.4) | |
| 25–44 | 42.7 (41.7, 43.7) | 23.8 (22.7, 24.9) | 14.9 (13.3, 16.7) | |
| 45–64 | 30.7 (29.8, 31.5) | 36.3 (35.2, 37.4) | 35.1 (33.0, 37.3) | |
| ≥65 | 12.4 (11.9, 12.9) | 30.8 (29.8, 31.9) | 45.0 (42.8, 47.1) | |
| Sexual orientation | 0.014 | |||
| Lesbian or gay | 1.4 (1.2, 1.7) | 1.2 (1.0, 1.5) | 1.2 (0.8, 1.7) | |
| Straight or heterosexual | 97 (96.6, 97.3) | 96.5 (96.0, 97.0) | 96.6 (95.7, 97.4) | |
| Bisexual | 1.3 (1.1, 1.5) | 1.7 (1.5, 2.1) | 1.6 (1.1, 2.4) | |
| Something else | 0.3 (0.2, 0.4) | 0.5 (0.4, 0.8) | 0.6 (0.3, 1.1) | |
| Race / ethnicity | <0.0001 | |||
| Hispanic | 18.9 (17.5, 20.3) | 12.9 (11.7, 14.3) | 14.4 (12.2, 16.9) | |
| Non-Hispanic White | 59.5 (57.9, 61.2) | 68.7 (66.9, 70.4) | 68.0 (65.2, 70.6) | |
| Non-Hispanic Black / African American | 11.9 (11.0, 12.9) | 11.4 (10.3, 12.7) | 11.7 (10.2, 13.4) | |
| Non-Hispanic other race | 9.7 (8.9, 10.6) | 6.9 (6.1, 7.9) | 6.0 (4.8, 7.3) | |
| Education completed | <0.0001 | |||
| Less than high school | 9.3 (8.5, 10.1) | 14.8 (13.7, 15.9) | 24.7 (22.6, 27.0) | |
| High-school diploma / GED | 25.8 (24.9, 26.7) | 28.6 (27.5, 29.7) | 34.3 (32.3, 36.3) | |
| Some college / associate degree | 31.2 (30.2, 32.1) | 32.2 (31.0, 33.4) | 27.1 (25.2, 29.0) | |
| Bachelor’s degree or more | 33.8 (32.6, 34.9) | 24.4 (23.3, 25.5) | 13.9 (12.6, 15.4) | |
| Annual household income ($) | <0.0001 | |||
| <35,000 | 19.2 (18.3, 20.1) | 29.7 (28.5, 31.0) | 48.8 (46.5, 51.0) | |
| 35,000–74,999 | 30.7 (29.8, 31.7) | 33.0 (31.9, 34.1) | 30.6 (28.6, 32.6) | |
| 75,000–99,999 | 14.6 (13.9, 15.4) | 12.3 (11.5, 13.1) | 8.6 (7.3, 10.0) | |
| ≥100,000 | 35.4 (34.3, 36.6) | 25.0 (23.7, 26.2) | 12.1 (10.7, 13.6) | |
| Marital status | <0.0001 | |||
| Married / living with partner | 63.1 (62.2, 64.1) | 61.8 (60.6, 63.0) | 47.8 (45.5, 50.1) | |
| Divorced / separated / widowed | 11.2 (10.7, 11.7) | 20.2 (19.3, 21.1) | 34.3 (32.4, 36.3) | |
| Never married | 25.7 (24.8, 26.6) | 18.0 (17.0, 19.1) | 17.9 (16.0, 20.0) | |
| Health insurance | <0.0001 | |||
| Yes | 87.2 (86.3, 88.0) | 89.1 (88.1, 90.0) | 93.1 (91.8, 94.2) | |
| No | 12.8 (12.0, 13.7) | 10.9 (10.0, 11.9) | 6.9 (5.8, 8.2) | |
| Generalized anxiety disorder | <0.0001 | |||
| None / minimal | 91.2 (90.6, 91.7) | 78.3 (77.2, 79.4) | 61.6 (59.3, 63.8) | |
| Mild | 6.5 (6.0, 6.9) | 13.1 (12.3, 14.0) | 16.5 (15.0, 18.1) | |
| Moderate | 1.4 (1.2, 1.7) | 5.0 (4.5, 5.5) | 10.3 (9.0, 11.8) | |
| Severe | 0.9 (0.8, 1.2) | 3.5 (3.1, 4.0) | 11.6 (10.2, 13.2) | |
Note: Boldface indicates statistical significance (p<0.05).
Percentages are weighted.
Tables 2 and 3 shows the overall prevalence with associated 95% CIs of each tobacco product use for people who reported any disability and by the difficulty of each disability type. The prevalence of current cigarette smoking was higher for any disability (21.2% vs 11.5%) and for adults who reported a lot of difficulty / cannot do at all to the vision (21.5% vs 13.1%), hearing (19.6% vs 13.6%), mobility (20.0% vs 12.9%), and cognitive (25.4% vs 12.9%) questions than for those who reported no difficulty. Current cigarette smoking was also higher for those reporting some difficulty in all functional domains than for those who report no difficulty. Current e-cigarette use was higher for those who reported some (6.2%) and a lot of difficulty / cannot do at all (7.6%) to the cognitive question than for adults who reported no difficulty (4.1%). Current pipe use was higher for those who reported a lot of difficulty / cannot do at all (1.4% vs 0.8%) to any disability question and those who reported some difficulty (1.4% vs 0.9%) to the cognitive question than for those who reported no difficulty. Current smokeless tobacco product use was higher for those who reported a lot of difficulty / cannot do at all (4.7%) and some difficulty (3.2%) to the hearing question than for those who reported no difficulty (2.2%). Current cigar use prevalence was similar across all disability types and degrees of functional difficulty.
Table 2.
Prevalence of Tobacco Product Use by Disability Type and Difficulty, National Health Interview Survey, 2019
| Tobacco product types | Disability type | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Any disability | Vision | Hearing | Mobility | |||||||||
| Degree of difficulty | Degree of difficulty | Degree of difficulty | Degree of difficulty | |||||||||
| No (na=17,690), %b (95% CI) |
Some (na=10,897), %b (95% CI) |
A lot / Cannot do at all (na=3,349), %b (95% CI) |
No (na = 26,475), %b (95% CI) |
Some (na=4,944), %b (95% CI) |
A lot / Cannot do at all (na=547), %b (95% CI) |
No (na=26,547), %b (95% CI) |
Some (na=4,832), %b (95% CI) |
A lot / Cannot do at all (na=587), %b (95% CI) |
No (na=24,987), %b (95% CI) |
Some (na=4,783), %b (95% CI) |
A lot / Cannot do at all (na=2,203), %b (95% CI) |
|
| Cigarettes | ||||||||||||
| Current | 11.5 (10.9, 12.2) |
16.5
(15.6, 17.4) |
21.2
(19.4, 23.0) |
13.1 (12.5, 13.6) |
18.5
(17.0, 20.0) |
21.5
(17.3, 26.4) |
13.6 (13.0, 14.2) |
15.8
(14.5, 17.2) |
19.6
(16.0, 23.8) |
12.9 (12.3, 13.5) |
18.3
(16.9, 19.7) |
20.0
(17.8, 22.4) |
| Former | 18.3 (17.6, 19.0) |
27.8
(26.7, 28.9) |
31.7
(29.8, 33.6) |
21.9 (21.2, 22.5) |
25.3
(23.8, 26.8) |
31.8
(27.0, 37) |
20.6 (20.0, 21.2) |
33.7
(32.1, 35.4) |
34.8
(30.7, 39.2) |
20.2 (19.6, 20.9) |
32.7
(31.0, 34.5) |
32.6
(30.2, 35.1) |
| Never | 70.2 (69.3, 71.1) |
55.7
(54.4, 57.0) |
47.2
(45.0, 49.4) |
65.1 (64.2, 65.9) |
56.3
(54.4, 58.2) |
46.7
(41.2, 52.3) |
65.8 (65.0, 66.6) |
50.5
(48.6, 52.4) |
45.6
(40.8, 50.5) |
66.9 (66.1, 67.7) |
49
(47.1, 50.9) |
47.4
(44.6, 50.2) |
| E-cigarettes | ||||||||||||
| Current | 4.2 (3.8, 4.6) |
5.0 (4.5, 5.6) |
4.2 (3.4, 5.3) |
4.4 (4.1, 4.7) |
4.9 (4.1, 5.8) |
3.3 (1.9, 5.8) |
4.5 (4.2, 4.9) |
4.3 (3.6, 5.2) |
3.6 (2.1, 6.1) |
4.7 (4.3, 5.0) |
3.7 (3.0, 4.6) |
3.1
(2.3, 4.1) |
| Noncurrent | 12 (11.4, 12.7) |
13.6
(12.7, 14.6) |
11.3 (10.0, 12.8) |
12.2 (11.6, 12.7) |
14.5
(13.2, 15.9) |
11.1 (7.8, 15.5) |
12.6 (12.0, 13.2) |
12 (10.9, 13.3) |
10.2 (7.6, 13.6) |
12.9 (12.3, 13.6) |
11.1
(10.0, 12.3) |
9.2
(7.7, 10.9) |
| Never | 83.8 (83.0, 84.5) |
81.4 (80.4, 82.4) |
84.4 (82.7, 86.0) |
83.4 (82.8, 84.1) |
80.7
(79.1, 82.1) |
85.6 (81.0, 89.2) |
82.9 (82.2, 83.6) |
83.7 (82.2, 85.0) |
86.2 (82.3, 89.3) |
82.4 (81.7, 83.1) |
85.2
(83.7, 86.5) |
87.8
(85.9, 89.4) |
| Cigars / cigarillos / filtered little cigars | ||||||||||||
| Current | 3.4 (3.1, 3.8) |
3.8 (3.3, 4.4) |
3.7 (2.9, 4.7) |
3.5 (3.2, 3.8) |
3.9 (3.2, 4.7) |
4.3 (2.6, 7.0) |
3.5 (3.2, 3.8) |
4.0 (3.3, 4.8) |
4.0 (2.4, 6.5) |
3.6 (3.3, 3.9) |
3.5 (2.9, 4.3) |
3.5 (2.5, 4.8) |
| Noncurrent | 25.8 (24.8, 26.8) |
31.8
(30.5, 33.0) |
28.2 (26.3, 30.2) |
27.4 (26.5, 28.3) |
30.9
(29.2, 32.7) |
25.3 (21.0, 30.1) |
26.4 (25.5, 27.3) |
37.3
(35.5, 39.1) |
32.3
(28.2, 36.7) |
28.1 (27.2, 29.1) |
27.5 (25.8, 29.3) |
25.6 (23.3, 28.1) |
| Never | 74.2 (73.2, 75.2) |
68.2
(67.0, 69.5) |
71.8 (69.8, 73.7) |
72.6 (71.7, 73.5) |
69.1
(67.3, 70.8) |
74.7 (69.9, 79.0) |
73.6 (72.7, 74.5) |
62.7
(60.9, 64.5) |
67.7
(63.3, 71.8) |
71.9 (70.9, 72.8) |
72.5 (70.7, 74.2) |
74.4 (71.9, 76.7) |
| Regular pipe / water pipe / hookah | ||||||||||||
| Current | 0.8 (0.7, 1.0) |
1.1 (0.9, 1.4) |
1.4
(1.0, 2.1) |
1.0 (0.8, 1.1) |
1.0 (0.7, 1.3) |
c | 1.0 (0.8, 1.1) |
1.0 (0.7, 1.4) |
c | 1.0 (0.8, 1.1) |
0.8 (0.5, 1.3) |
1.4 (0.9, 2.3) |
| Noncurrent | 11.5 (10.8, 12.2) |
16.6
(15.7, 17.5) |
14.6
(13.2, 16.1) |
13.0 (12.4, 13.6) |
15.7
(14.5, 17.0) |
14.8 (11.5, 19.0) |
12.4 (11.8, 13.0) |
19.4
(18.0, 20.8) |
19.2
(15.9, 22.9) |
13.3 (12.7, 13.9) |
13.9 (12.6, 15.2) |
13.6 (11.9, 15.4) |
| Never | 88.5 (87.8, 89.2) |
83.4
(82.5, 84.3) |
85.4
(83.9, 86.8) |
87.0 (86.4, 87.6) |
84.3
(83.0, 85.5) |
85.2 (81.0, 88.5) |
87.6 (87.0, 88.2) |
80.6
(79.2, 82.0) |
80.8
(77.1, 84.1) |
86.7 (86.1, 87.3) |
86.1 (84.8, 87.4) |
86.4 (84.6, 88.1) |
| Smokeless tobacco | ||||||||||||
| Current | 2.2 (1.9, 2.5) |
2.7 (2.3, 3.2) |
2.8 (2.2, 3.6) |
2.4 (2.1, 2.7) |
2.6 (2.1, 3.2) |
c | 2.2 (2.0, 2.5) |
3.2
(2.6, 4.0) |
4.7
(3.1, 7.1) |
2.5 (2.2, 2.8) |
2.0 (1.6, 2.6) |
2.5 (1.8, 3.6) |
| Noncurrent | 9.8 (9.1, 10.4) |
12.6
(11.7, 13.4) |
10.8 (9.6, 12.2) |
10.6 (10.0, 11.1) |
11.9 (10.8, 13.2) |
10.2 (7.6, 13.4) |
9.8 (9.3, 10.3) |
16.2
(15.0, 17.6 |
18.4
(15.0, 22.4) |
11.0 (10.5, 11.6) |
9.7 (8.7, 10.9) |
9.0 (7.7, 10.6) |
| Never | 90.2 (89.6, 90.9) |
87.4
(86.6, 88.3) |
89.2 (87.8, 90.4) |
89.4 (88.9, 90.0) |
88.1 (86.8, 89.2) |
89.8 (86.6, 92.4 |
90.2 (89.7, 90.7) |
83.8
(82.4, 85.0) |
81.6
(77.6, 85.0) |
89 (88.4, 89.5) |
90.3 (89.1, 91.3) |
91.0 (89.4, 92.3) |
Note: Boldface indicates statistical significance (p<0.05).
The no-difficulty category serves as the reference group.
Number reflects the unweighted sample size.
Percentages are weighted.
Suppressed.
Table 3.
Prevalence of Tobacco Product Use by Disability Type and Difficulty, National Health Interview Survey, 2019
| Tobacco product types | Disability type | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Communication | Cognitive | Self-care | |||||||
| Degree of difficulty | Degree of difficulty | Degree of difficulty | |||||||
| No (na=30,423), %b (95% CI) |
Some (na=1,309), %b (95% CI) |
A lot / Cannot do at all (na=243), %b (95% CI) |
No (na=26,312), %b (95% CI) |
Some (na=4,943), %b (95% CI) |
A lot / Cannot do at all (na=715), %b (95% CI) |
No (na=30,538), %b (95% CI) |
Some (na=1,077), %b (95% CI) |
A lot / Cannot do at all (na=363), %b (95% CI) |
|
| Cigarettes | |||||||||
| Current | 13.7 (13.2, 14.3) |
20.2
(17.6, 23.0) |
15.5 (11.1, 21.2) |
12.9 (12.3, 13.4) |
18.8
(17.4, 20.3) |
25.4
(21.6, 29.7) |
13.8 (13.2, 14.3) |
21.7
(18.2, 25.6) |
11.2 (8.0, 15.4) |
| Former | 22.3 (21.7, 23.0) |
26.6
(23.9, 29.5) |
23.5 (17.7, 30.4) |
21.2 (20.6, 21.9) |
29.4
(27.8, 31.1) |
27.2
(23.7, 31.1) |
22.2 (21.6, 22.9) |
29.3
(26.1, 32.7) |
29.0
(23.8, 34.8) |
| Never | 64.0 (63.1, 64.8) |
53.2
(49.9, 56.5) |
61.0 (53.6, 68.0) |
65.9 (65.1, 66.7) |
51.8
(50.0, 53.6) |
47.3
(42.8, 51.9) |
64.0 (63.2, 64.8) |
49.0
(45.1, 52.9) |
59.8 (53.3, 66.0) |
| E-cigarettes | |||||||||
| Current | 4.4 (4.1, 4.8) |
5.1 (3.8, 6.8) |
c | 4.1 (3.8, 4.4) |
6.2
(5.3, 7.2) |
7.6
(5.2, 10.9) |
4.5 (4.2, 4.8) |
5.0 (3.3, 7.6) |
c |
| Noncurrent | 12.5 (11.9, 13.0) |
13.7 (11.4, 16.3) |
8.7 (5.2, 14.0) |
11.8 (11.3, 12.4) |
15.6 (14.1, 17.1) |
16.6 (13.4, 20.2) |
12.6 (12.0, 13.2) |
10.6 (8.5, 13.2) |
5.7
(3.4, 9.4) |
| Never | 83.1 (82.5, 83.7) |
81.2 (78.4, 83.8) |
88.3 (82.8, 92.3) |
84.1 (83.4, 84.7) |
78.2 (76.5, 79.8) |
75.8 (71.5, 79.7) |
82.9 (82.3, 83.5) |
84.3 (81.2, 87.0) |
92.1
(88.1, 94.8) |
| Cigars / cigarillos / filtered little cigars | |||||||||
| Current | 3.6 (3.3, 3.9) |
4.1 (3.0, 5.5) |
c | 3.6 (3.3, 3.9) |
3.6 (2.9, 4.4) |
4.5 (2.8, 7.0) |
3.5 (3.3, 3.8) |
4.9 (3.1, 7.5) |
c |
| Noncurrent | 27.8 (26.9, 28.7) |
30.9 (28.1, 34.0) |
20.9 (15.5, 27.6) |
27.1 (26.2, 28.0) |
31.8
(30.1, 33.6) |
32.5
(28.2, 37.1) |
28.0 (27.1, 28.9) |
27.9 (24.6, 31.6) |
18.6
(14.2, 23.8) |
| Never | 72.2 (71.3, 73.1) |
69.1 (66.0, 71.9) |
79.1 (72.4, 84.5) |
72.9 (72.0, 73.8) |
68.2
(66.4, 69.9) |
67.5
(62.9, 71.8) |
72.0 (71.1, 72.9) |
72.1 (68.4, 75.4) |
81.4
(76.2, 85.8) |
| Regular pipe / water pipe / hookah | |||||||||
| Current | 1.0 (0.8, 1.1) |
c | c | 0.9 (0.8, 1.0) |
1.4
(1.1, 1.9) |
c | 1.0 (0.8, 1.1) |
c | c |
| Noncurrent | 13.2 (12.6, 13.8) |
18.8
(16.5, 21.4) |
8.1
(5.2, 12.3) |
12.5 (11.9, 13.1) |
18.4
(17.0, 19.8) |
15.7 (12.9, 18.9) |
13.4 (12.8, 14.0) |
15.0 (12.6, 17.8) |
8.9
(6.2, 12.4) |
| Never | 86.8 (86.2, 87.4) |
81.2
(78.6, 83.5) |
91.9
(87.7, 94.8) |
87.5 (86.9, 88.1) |
81.6
(80.2, 83.0) |
84.3 (81.1, 87.1) |
86.6 (86.0, 87.2) |
85.0 (82.2, 87.4) |
91.1
(87.6, 93.8) |
| Smokeless tobacco | |||||||||
| Current | 2.4 (2.2, 2.7) |
2.1 (1.4, 3.0) |
c | 2.3 (2.1, 2.6) |
2.8 (2.3, 3.4) |
3.0 (1.9, 4.8) |
2.4 (2.2, 2.7) |
1.5 (0.9, 2.6) |
c |
| Noncurrent | 10.7 (10.2, 11.3) |
12.2 (10.2, 14.5) |
6.0 (3.4, 10.5) |
10.5 (10.0, 11.1) |
12.0 (10.8, 13.3) |
11.8 (9.3, 15.0) |
10.9 (10.4, 11.5) |
7.0
(5.3, 9.1) |
6.8
(4.4, 10.4) |
| Never | 89.3 (88.7, 89.8) |
87.8 (85.5, 89.8) |
94.0 (89.5, 96.6) |
89.5 (88.9, 90.0) |
88.0 (86.7, 89.2) |
88.2 (85.0, 90.7) |
89.1 (88.5, 89.6) |
93.0
(90.9, 94.7) |
93.2
(89.6, 95.6) |
Note: Boldface indicates statistical significance (p<0.05).
The no-difficulty category serves as the reference group.
Number reflects the unweighted sample size.
Percentages are weighted.
Suppressed.
Table 4 and Appendix Figure 2 (available online) present the ORs for the association between tobacco product use and people with disabilities. After adjusting for covariates, the odds of currently using cigarettes (AOR=1.32, 95% CI=1.14, 1.54), pipe (AOR=1.85, 95% CI=1.15, 2.99), and smokeless tobacco products (AOR=1.57, 95% CI=1.11, 2.23) were significantly higher for adults who reported a lot of difficulty / cannot do at all to any disability than for those who reported no difficulty. Controlling for potential confounders in the multivariable model attenuated the relationship between any disability and current cigarette use but increased the magnitude of the association between any disability and current pipe and smokeless tobacco use. The OR of current cigarette use was significantly lower for those who reported a lot of difficulty / cannot do at all to the self-care question (AOR=0.57; 95% CI=0.38, 0.87). The odds of current pipe use were higher for adults who reported a lot of difficulty / cannot do at all to the mobility (AOR=1.68; 95% CI=1.00, 2.81) item, and the odds of current smokeless tobacco use were higher for those who reported a lot of difficulty / cannot do at all to the hearing (AOR=1.95; 95% CI=1.18, 3.23) question.
Table 4.
Association of Current Tobacco Product Use and Disability Type and Difficulty, National Health Interview Survey, 2019
| Variables | Cigarettes | E-cigarettes | Cigar | Pipe | Smokeless | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| Crude OR (95% CI) |
AORa (95% CI) |
Crude OR (95% CI) |
AORa (95% CI) |
Crude OR (95% CI) |
AORa (95% CI) |
Crude OR (95% CI) |
AORa (95% CI) |
Crude OR (95% CI) |
AORa (95% CI) |
|
| Any disability | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.51
(1.38, 1.65) ** |
1.24
(1.12, 1.37) ** |
1.21
(1.04, 1.41) * |
1.33
(1.11, 1.60) ** |
1.12 (0.93, 1.3) |
1.22 (1.00, 1.50) |
1.36
(1.00, 1.83) * |
1.45
(1.04, 2.03) * |
1.24
(1.02, 1.51) * |
1.29
(1.04, 1.61) * |
| A lot/Cannot do at all |
2.06
(1.83, 2.32) ** |
1.32
(1.14, 1.54) ** |
1.01 (0.79, 1.29) |
1.20 (0.89, 1.61) |
1.08 (0.83, 1.41) |
1.28 (0.92, 1.78) |
1.74
(1.14, 2.65) * |
1.85
(1.15, 2.99) ** |
1.28 (0.94, 1.74) |
1.57
(1.11, 2.23) ** |
| Vision | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.51
(1.35, 1.68) ** |
1.15
(1.03, 1.30) * |
1.12 (0.93, 1.34) |
1.10 (0.89, 1.35) |
1.12 (0.90, 1.38) |
1.25 (0.99, 1.58) |
1.00 (0.69, 1.44) |
0.88 (0.61, 1.27) |
1.08 (0.85, 1.37) |
1.14 (0.88, 1.47) |
| A lot / Cannot do at all |
1.82
(1.40, 2.38) ** |
1.33 (0.97, 1.82) |
0.75 (0.42, 1.35) |
1.06 (0.57, 1.97) |
1.24 (0.74, 2.07) |
1.45 (0.84, 2.50) |
b | b | b | b |
| Hearing | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.19
(1.06, 1.33) ** |
1.06 (0.94, 1.20) |
0.95 (0.77, 1.17) |
1.13 (0.90, 1.43) |
1.15 (0.94, 1.41) |
1.14 (0.91, 1.41) |
1.04 (0.71, 1.53) |
1.08 (0.70, 1.65) |
1.46
(1.16, 1.84) ** |
1.26 (0.97, 1.63) |
| A lot / Cannot do at all |
1.55
(1.20, 1.99) ** |
1.12 (0.83, 1.51) |
0.79 (0.45, 1.37) |
1.04 (0.59, 1.84) |
1.15 (0.68, 1.95) |
1.15 (0.68, 1.95) |
b | b |
2.17
(1.39, 3.38) ** |
1.95
(1.18, 3.23) ** |
| Mobility | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.51
(1.36, 1.68) ** |
1.19
(1.04, 1.35) ** |
0.79
(0.63, 0.99) b |
1.07 (0.84, 1.35) |
0.98 (0.78, 1.23) |
1.23 (0.95, 1.58) |
0.84 (0.51, 1.39) |
1.08 (0.60, 1.92) |
0.81 (0.63, 1.05) |
1.04 (0.78, 1.39) |
| A lot / Cannot do at all |
1.69
(1.45, 1.96) ** |
1.16 (0.96, 1.40) |
0.65
(0.48, 0.87) ** |
0.88 (0.62, 1.26) |
0.97 (0.69, 1.37) |
1.32 (0.89, 1.95) |
1.49 (0.92, 2.41) |
1.68
(1.00, 2.81) * |
1.03 (0.71, 1.49) |
1.34 (0.89, 2.02) |
| Communication | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.59
(1.34, 1.89) ** |
1.09 (0.90, 1.33) |
1.15 (0.84, 1.58) |
0.98 (0.68, 1.41) |
1.16 (0.84, 1.60) |
1.11 (0.78, 1.58) |
b | b | 0.84 (0.56, 1.26) |
0.77 (0.49, 1.21) |
| A lot / Cannot do at all | 1.15 (0.78, 1.70) |
0.74 (0.47, 1.17) |
b | b | b | b | b | b | b | b |
| Cognition | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.57
(1.41, 1.75) ** |
1.10 (0.97, 1.25) |
1.56
(1.29, 1.88) ** |
1.42
(1.13, 1.79) ** |
1.00 (0.79, 1.27) |
1.03 (0.79, 1.34) |
1.63
(1.17, 2.26) ** |
1.48
(1.04, 2.09) * |
1.20 (0.96, 1.50) |
1.29 (0.99, 1.69) |
| A lot / Cannot do at all |
2.31
(1.86, 2.88) ** |
1.16 (0.90, 1.49) |
1.94
(1.30, 2.89) ** |
1.41 (0.89, 2.22) |
1.28 (0.79, 2.06) |
1.07 (0.61, 1.85) |
b | b | 1.30 (0.80, 2.12) |
1.37 (0.73, 2.58) |
| Self-care | ||||||||||
| None | 1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
1.00 (ref) |
| Some |
1.73
(1.39, 2.16) ** |
1.05 (0.82, 1.36) |
1.13 (0.73, 1.77) |
1.11 (0.71, 1.75) |
1.39 (0.87, 2.22) |
1.46 (0.88, 2.41) |
b | b | 0.63 (0.37, 1.06) |
0.59 (0.32, 1.09) |
| A lot / Cannot do at all | 0.79 (0.54, 1.14) |
0.57
(0.38, 0.87) ** |
b | b | b | b | b | b | b | b |
Note: Boldface indicates statistical significance
p<0.05,
p<0.01.
AOR controlling for sex, age, sexual orientation, race/ethnicity, education level, annual household income, marital status, health insurance, and mental health.
Suppressed.
Adults who reported some difficulty to any disability also had higher odds of current cigarette (AOR=1.24; 95% CI=1.12, 1.37), e-cigarette (AOR=1.33; 95% CI=1.11, 1.60), pipe (AOR=1.45; 95% CI=1.04, 2.03), and smokeless tobacco product (AOR=1.29; 95% CI=1.04, 1.61) use. In addition, for specific products and disabilities, those reporting some difficulty had higher odds of some tobacco product use than those without difficulty despite no significant difference in the use of the product between those reporting a lot of difficulty / cannot do at all and those reporting no difficulty. These relationships included higher odds of cigarette use in those with some vision difficulty (AOR=1.15; 95% CI=1.03, 1.30) and some mobility difficulty (AOR=1.19; 95% CI=1.04, 1.35) and higher odds of e-cigarette use in those with some cognitive difficulties (AOR=1.42; 95% CI=1.13, 1.79).
DISCUSSION
Similar to previous studies, the prevalence of current cigarette smoking was higher in people with any disability,6,10‒12 although this study highlights that this disparity largely reflects those with vision, hearing, mobility, and cognitive disabilities. People with any disability also had higher odds of currently using cigarettes, pipe, and smokeless tobacco. Novel findings of this study include information on tobacco use by people who report some difficulty to the various disability types. These results provide important information on various tobacco product use by disability status—specifically, that adults with disabilities disproportionately use pipe and smokeless tobacco products in addition to cigarettes compared with adults without disabilities.
The results of this study extend the current understanding of disability and tobacco use using large-scale national data. Previous NHIS data indicated that a higher proportion of people with any disability are current cigarette users; however, by combining all disability types, these results obscured that only 4 types of disability functional domains (vision, hearing, mobility, cognitive) (Tables 2 and 3) showed a higher prevalence of cigarette use.6 In addition, previous NHIS data analyses indicated that people with any disability use e-cigarettes at a rate similar to that of those without disabilities,6 which the present data support. Although other research suggests that adults with some types of disabilities (e.g., cognitive, visual, self-care) may be more likely to be current e-cigarette users than people without a disability,9,27 the current data only suggest that people who report some difficulty with cognition have higher odds of using e-cigarettes. Addressing other tobacco product use (i.e., cigars, pipe, smokeless) in adults with differing types of disability highlights opportunities to target interventions by product to different subgroups of adults with disabilities.
The use of multiple levels of functioning difficulty in this study allowed for the data to be analyzed across these levels, thus providing a more complete picture of tobacco use among people with disabilities. Functioning exists on a continuum, and disability is defined in relation to a person’s environment; the degree of functional difficulty one may have in a domain may or may not lead to disability, depending on one’s support system and the broader environment. Stratifying the data by some is important to understand whether differences exist between this category and the category of those with no difficulty.22 Adults who reported some difficulty, who had lower income, had less education, were older, and scored higher on the GAD-7 than those without a disability but had higher income, had more education, were younger, and scored lower on the GAD-7 than those who reported more difficulties disproportionately used some tobacco products compared with those who report no difficulty. These stratified results also show that certain product use (e.g., e-cigarette) in some domains are higher in the some difficulty category than in the a lot of difficulty / cannot do at all category. This information is important because it indicates that future research should explore why people with some difficulties show this disparity.
LIMITATIONS
This study has several limitations. First, the study is cross-sectional; therefore, the directionality of the relationships cannot be inferred. Next, NHIS uses self-reported data; however, self-reported tobacco use data are valid.28 In addition, WG-SS limitations include that the questions fail to identify approximately half of people with psychosocial disabilities,22 thereby potentially missing a population with a high prevalence of cigarette use (e.g., anxiety, depression),6,29,30 and the some difficulty category may produce an underestimation of people with some difficulty.13 Further limitations include a small sample size for some tobacco products; examining only 5 tobacco products; the inability to explore tobacco use among youth with a disability; and the lack of adjustment for past alcohol or drug dependence given no proxy measures in the 2019 NHIS, even though drug and alcohol use have shown an increased risk for smoking.25 Finally, the NHIS surveys the non-institutionalized population and thus is not generalizable to the institutionalized population. Approximately 2.1 million people in institutions in the U.S. are living with a disability31; therefore, research is needed to explore tobacco product use among this population.
CONCLUSIONS
Future research should investigate the needs of people who report some difficulty to better understand the characteristics of this population and environmental barriers to tobacco cessation treatment and prevention policies they face. Understanding who is using what tobacco products may be especially important because adapting tobacco cessation and prevention policies and programs to best serve people with disabilities may be different depending on disability type and functioning level. Although people with disabilities disproportionately use tobacco products, interventions tailored to this population remain scarce. A survey of directors at Centers for Independent Living—community-based, non-profit organizations providing independent living support, which are planned and managed by people with disabilities32—indicates that tobacco cessation programs are a priority for this population but that services at Centers for Independent Living are not adequate.33 In addition, a systematic review identifying tobacco cessation programs for people with mild/moderate intellectual disabilities found only 6 studies internationally that focused on tobacco-related interventions for this population.34 Although a recent intervention—Living Independent From Tobacco—has been developed to address tobacco cessation for people with disabilities and has shown initial decreases in tobacco use for participants, more research is needed.35–37 Given the harms associated with the use of various tobacco products1,38–41 and higher odds of death among smokers with disabilities,42 future research is needed to develop and tailor tobacco cessation interventions and prevention efforts by product, addressing the specific needs of people with disabilities.
Supplementary Material
ACKNOWLEDGMENTS
The content of this study is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
JAS was supported by the National Institute on Drug Abuse of the NIH under Award Number U54 DA036114.
No financial disclosures were reported by the authors of this paper.
Footnotes
CREDIT AUTHOR STATEMENT
Jonathan A. Schulz: Conceptualization, Formal analysis, Methodology, Visualization, Writing – original draft. Andrea C. Villanti: Conceptualization, Methodology, Validation, Writing – review and editing. Julia C. West: Validation, Writing – review and editing. Jean P. Hall: Writing – review and editing.
SUPPLEMENTAL MATERIAL
Supplemental materials associated with this article can be found in the online version at https://doi.org/10.1016/j.amepre.2022.05.004.
REFERENCES
- 1.U.S. Department of Health and Human Services. The Health Consequences of Smoking-50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. https://www.ncbi.nlm.nih.gov/books/n/surgsmoke50/pdf/. Published 2014. Accessed August 18, 2021. [Google Scholar]
- 2.Drope J, Liber AC, Cahn Z, et al. Disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin. 2018;68(2):106–115. 10.3322/caac.21444. [DOI] [PubMed] [Google Scholar]
- 3.Marbin J, Balk SJ, Gribben V, Groner J. Section on Tobacco Control. Health disparities in tobacco use and exposure: a structural competency approach. Pediatrics. 2021;147(1):e2020040253. 10.1542/peds.2020-040253. [DOI] [PubMed] [Google Scholar]
- 4.Okoro CA, Hollis ND, Cyrus AC, Griffin-Blake S. Prevalence of disability and health care access by disability status and type among adults–United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67 (32):882–887. 10.15585/mmwr.mm6732a3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rios D, Magasi S, Novak C, Harniss M. Conducting accessible research: including people with disabilities in public health, epidemiological, and outcomes studies. Am J Public Health. 2016;106 (12):2137–2144. 10.2105/AJPH.2016.303448. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco product use among adults - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(46):1736–1742. 10.15585/mmwr.mm6946a4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Courtney-Long E, Stevens A, Caraballo R, Ramon I, Armour BS. Disparities in current cigarette smoking prevalence by type of disability, 2009–2011. Public Health Rep. 2014;129(3):252–260. 10.1177/003335491412900307. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Gimm G, Parekh T, Rossheim ME. Prevalence and risk factors of e-cigarette use among working-age adults with and without disabilities in 2017–2018. Disabil Health J. 2021;14(2):101048. 10.1016/j.dhjo.2020.101048. [DOI] [PubMed] [Google Scholar]
- 9.Atuegwu NC, Litt MD, Krishnan-Sarin S, Laubenbacher RC, Perez MF, Mortensen EM. E-cigarette use in young adult never cigarette smokers with disabilities: results from the Behavioral Risk Factor Surveillance System Survey. Int J Environ Res Public Health. 2021;18 (10):5476. 10.3390/ijerph18105476. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Casseus M, Graber JM, West B, Wackowski O. Tobacco use disparities and disability among U.S. college students. J Am Coll Health. 2020:1–6. 10.1080/07448481.2020.1842425. [DOI] [PubMed] [Google Scholar]
- 11.Senders A, Horner-Johnson W. Disparities in e-cigarette and tobacco use among adolescents with disabilities. Prev Chronic Dis. 2020;17: E135. 10.5888/pcd17.200161. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Nagarajan VD, Okoli CT. A systematic review of tobacco use among adolescents with physical disabilities. Public Health. 2016;133:107–115. 10.1016/j.puhe.2016.01.005. [DOI] [PubMed] [Google Scholar]
- 13.Miller K, Mont D, Maitland A, Altman B, Madans J. Results of a cross-national structured cognitive interviewing protocol to test measures of disability. Qual Quant. 2011;45(4):801–815. 10.1007/s11135-010-9370-4. [DOI] [Google Scholar]
- 14.Brault MW. Review of changes to the measurement of disability in the 2008 American Community Survey. Washington, DC: United States Census Bureau. https://www.census.gov/content/dam/Census/library/working-papers/2009/demo/2008acs-disability.pdf. Published September 22, 2009. Accessed September 10, 2021. [Google Scholar]
- 15.How disability data are collected from the American Community Survey. United States Census Bureau. https://www.census.gov/topics/health/disability/guidance/data-collection-acs.html#:»:text=shopping%20(DOUT).-,Respondents%20who%20report%20anyone%20of%20the%20six%20disability%20types%20are,populations%20of%2065%2C000%20or%20more. Updated November 21, 2021. Accessed August 19, 2021. [Google Scholar]
- 16.World Health Organization. International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: World Health Organization. http://whqlibdoc.who.int/publications/2001/9241545429.pdf. Published 2001. Accessed August 19, 2021. [Google Scholar]
- 17.Weeks JD, Dahlhamer JM, Madans JH, Maitland A. Measuring disability: an examination of differences between the Washington Group Short Set on Functioning and the American Community Survey disability questions. Natl Health Stat Report. 2021(161):1–9. 10.15620/cdc:107202. [DOI] [PubMed] [Google Scholar]
- 18.Eisenbaum E Tobacco product use and smoking frequency among U. S. adults with intellectual and developmental disabilities. J Intellect Disabil Res. 2018;62(8):709–718. 10.1111/jir.12507. [DOI] [PubMed] [Google Scholar]
- 19.Pacoricona Alfaro DL, Ehlinger V, Spilka S, Ross J, Sentenac M, Godeau E. Alcohol, tobacco and cannabis use: do students with mild-intellectual disability mimic students in the general population? Res Dev Disabil. 2017;63:118–131. 10.1016/j.ridd.2016.10.009. [DOI] [PubMed] [Google Scholar]
- 20.Hall AG, Schumacher JR, Cannell MB, Berry JB, Schiaffino M, Park S. Tobacco use in Florida: comparisons between adults living with and without disabilities. Disabil Health J. 2013;6(3):213–219. 10.1016/j.dhjo.2013.01.008. [DOI] [PubMed] [Google Scholar]
- 21.National Health Interview Survey: survey description. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/nhis/index.htm. Updated June 6, 2022. Accessed August 19, 2021.
- 22.Washington Group on Disability Statistics. An introduction to the Washington Group on Disability Statistics question sets. Hyattsville, MD: Washington Group on Disability Statistics. https://www.washing-tongroup-disability.com/fileadmin/uploads/wg/Documents/An_Introduction_to_the_WG_Questions_Sets__2_June_2020_.pdf. Published 2020. Accessed September 22, 2021. [Google Scholar]
- 23.Bramlett MD, Dahlhamer JM, Bose J, Blumberg SJ. New procedures for nonresponse adjustments to the 2019 National Health Interview Survey sampling weights. Atlanta, GA: Centers for Disease Control and Prevention, HHS, 2020. https://nhis.ipums.org/nhis/resources/nonresponse-report-508.pdf. Published 2020. Accessed August 19, 2021. [Google Scholar]
- 24.Parker JD, Talih M, Malec DJ, et al. National Center for Health Statistics data presentation standards for proportions. Vital Health Stat 2. 2017;175:1–22. https://www.cdc.gov/nchs/data/series/sr_02/sr02_175.pdf. Accessed September 30, 2019. [PubMed] [Google Scholar]
- 25.Higgins ST, Kurti AN, Redner R, et al. Co-occurring risk factors for current cigarette smoking in a U.S. nationally representative sample. Prev Med. 2016;92:110–117. 10.1016/j.ypmed.2016.02.025. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Li J, Haardörfer R, Vu M, Windle M, Berg CJ. Sex and sexual orientation in relation to tobacco use among young adult college students in the U.S.: a cross-sectional study. BMC Public Health. 2018;18(1):1244. 10.1186/s12889-018-6150-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Zhang QC, Courtney-Long EA, Sinclair LB, Reese S, Armour BS, Shapira SK. State-specific prevalence of current e-cigarette use by disability status and disability type-United States, BRFSS 2016–2018. Disabil Health J. 2022;15(1):101182. 10.1016/j.dhjo.2021.101182. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Patrick DL, Cheadle A, Thompson DC, Diehr P, Koepsell T, Kinne S. The validity of self-reported smoking: a review and meta-analysis. Am J Public Health. 1994;84(7):1086–1093. 10.2105/ajph.84.7.1086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Weinberger AH, Chaiton MO, Zhu J, Wall MM, Hasin DS, Goodwin RD. Trends in the prevalence of current, daily, and nondaily cigarette smoking and quit ratios by depression status in the U.S.: 2005–2017. Am J Prev Med. 2020;58(5):691–698. 10.1016/j.amepre.2019.12.023. [DOI] [PubMed] [Google Scholar]
- 30.Fluharty M, Taylor AE, Grabski M, Munafò MR. The association of cigarette smoking with depression and anxiety: a systematic review. Nicotine Tob Res. 2017;19(1):3–13. 10.1093/ntr/ntw140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Understanding disability statistics. ADA National Network https://adata.org/factsheet/understanding-disability-statistics. Updated June 2022. Accessed December 23, 2021.
- 32.ILRU directory of centers for independent living (CILs) and associations. Independent Living Research Utilization. https://www.ilru.org/projects/cil-net/cil-center-and-association-directory. Updated June 2022. Accessed September 22, 2021.
- 33.Moorhouse MD, Pomeranz JL, Barnett TE, Yu NS, Curbow BA. Tobacco cessation intervention for people with disabilities: survey of Center for Independent Living Directors. Rehabil Couns Bull. 2011;54(2):118–121. 10.1177/0034355210-380750. [DOI] [Google Scholar]
- 34.Kerr S, Lawrence M, Darbyshire C, Middleton AR, Fitzsimmons L. Tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a systematic review of the literature. J Intellect Disabil Res. 2013;57(5):393–408. 10.1111/j.1365-2788.2012.01543.x. [DOI] [PubMed] [Google Scholar]
- 35.Barnhart WR, Whalen Smith CN, Coleman E, Riddle IK, Havercamp SM. Living independent from tobacco reduces cigarette smoking and improves general health status among long-term tobacco users with disabilities. Disabil Health J. 2020;13(3):100882. 10.1016/j.dhjo.2019.100882. [DOI] [PubMed] [Google Scholar]
- 36.Havercamp SM, Barnhart WR, Ellsworth D, et al. Evidence for the fidelity and effectiveness of Living Independent From Tobacco for people with disabilities and their caregivers. Tob Use Insights. 2019;12: 1179173X18825075. 10.1177/1179173X18825075. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Pomeranz JL, Moorhouse MD, King J, et al. Creating a tobacco cessation program for people with disabilities: a community based participatory research approach. J Addict Res Ther. 2014;5 (4):1000204. 10.4172/2155-6105.1000204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.National Cancer Institute. Cigars: health effects and trends. Tobacco control monograph. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Cancer Institute. https://onesearch.nihlibrary.ors.nih.gov/discovery/fulldisplay?vid=01NIH_INST%3ANIH&docid=alma991001242433704686&lang=en&context=L&adaptor=Local%20Search%20Engine. Published 1998. Accessed January 19, 2022. [Google Scholar]
- 39.National Cancer Institute, Centers for Disease Control and Prevention. Smokeless tobacco and public health: a global perspective. Bethesda, MD: U.S. Department of Health and Human Services. Centers for Disease Control and Prevention and National Institutes of Health, National Cancer Institute. https://cancercontrol.cancer.gov/sites/default/files/2020-06/smokelesstobaccoandpublichealth.pdf. Published 2020. Accessed January 19, 2022. [Google Scholar]
- 40.National Academies of Sciences, Engineering, and Medicine. Public Health Consequences of E-Cigarettes. Washington, DC: The National Academies Press, 2018. 10.17226/24952. [DOI] [PubMed] [Google Scholar]
- 41.Waziry R, Jawad M, Ballout RA, Al Akel M, Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. Int J Epidemiol. 2017;46(1):32–43. 10.1093/ije/dyw021. [DOI] [PubMed] [Google Scholar]
- 42.Christensen AI, Ekholm O, Gray L, Glümer C, Juel K. What is wrong with non-respondents? Alcohol-, drug- and smoking-related mortality and morbidity in a 12-year follow-up study of respondents and non-respondents in the Danish Health and Morbidity Survey. Addiction. 2015;110(9):1505–1512. 10.1111/add.12939. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.