Diana W. Stewart, Ph.D.Claire E. Adams, Ph.D., Miguel A. Cano, Ph.D., Virmarie Correa-Fernandez, Ph.D., Yumei Cao, M.A., Yisheng Li, Ph.D., Andrew J. Waters, Ph.D., David W. Wetter, Ph.D., & Jennifer Irvin Vidrine,

Ph.D.

American Public Health AssociationOctober 29, 2012

Associations between Health Literacy and Smoking

Presenter Disclosures

No relationships to disclose

Cigarette Smoking

Cigarette smoking is the leading preventable cause of US morbidity and mortality [Mokdad et al., 2004]

Responsible for one-third of all cancer-related deaths and 90% of lung cancer cases each year [USDHHS, 2004]

Nearly 20% of US adults smoke [CDC, 2012] Certain populations have higher smoking

prevalence and lower quit rates [CDC, 2002; Vidrine et al., 2009; Wetter et al., 2005]

Individuals with low income, education, employment Racial/ethnic minorities

Predictors of Smoking Cessation

Research has identified numerous predictors of smoking cessation

Nicotine dependence [Kozlowski et al., 1994] Smoking outcome expectancies [Copeland et al.,

1995] Smoking health risk knowledge and risk

perceptions [Borelli et al., 2010; Gibbons et al., 1997] Quitting self-efficacy [DiClemente, 1991] Intentions to quit, cut back, or limit smoking

[Peters and Hughes, 2009]

Health Literacy

Poor health literacy (HL) might also negatively affect cessation outcomes

Little research has investigated this HL is the ability to obtain, understand, and

use health information to make decisions about health and medical care [USDHHS, 2005]

Nearly half of US adults have poor HL [Kutner et al., 2006]

Racial/ethnic minorities and those with low education, income, and employment have highest rates [Kutner et al., 2005]

Health Literacy and Health Behavior

Low HL is associated with poor overall health status and poor health outcomes [see Berkman et al., 2011 for a review] Higher incidence of chronic illness (e.g., diabetes) Limited access to prevention and treatment programs Unhealthy behaviors (e.g., poor medication

adherence) Low illness-related knowledge Lower rates of cancer screening Diagnosis of advanced-stage cancer Premature mortality

Health Literacy and Smoking

Few studies have investigated relations between HL and smoking Mixed results regarding HL and smoking status

[Baker et al., 2007; Sudore et al, 2006; Arnold et al., 2001] One study found that poor HL was associated with

lower smoking risk knowledge and more positive smoking-related attitudes [Arnold et al., 2001]

Another study reported that HL was not associated with smoking cessation outcomes Very small sample size, most participants had high HL

[Varekojis et al., 2011]

Health Literacy and Smoking

Smoking is the leading behavioral risk factor contributing to social disparities in disease

Critical need to better understand how HL may be related to smoking prevalence and cessation among racial/ethnic minorities and those with low-SES HL may be an essential, but overlooked factor in

understanding tobacco-related health disparities

Purpose of the Present Study

This study investigated associations between HL and established predictors of smoking cessation in a sample of smokers

Hypothesized that lower HL would be related to: Higher nicotine dependence Greater positive and fewer negative smoking

expectancies Lower smoking health risk knowledge and risk

perceptions Lower self-efficacy Fewer intentions to quit, reduce, or limit smoking

Method: Participants and Procedure

Data collected as part of a larger study evaluating smokers’ responses to smoking health risk messages

Participants recruited via media and outreachEligibility:

Ages 18-70 Smoked >5 CPD for past year; CO > 10 ppm Report no intention to quit within 30 days of enrollment

Eligible participants attended lab visit and completed baseline questionnaires before reviewing various smoking health risk messages

Method: Measures Demographics Heaviness of Smoking Index [HSI; Kozlowski et al., 1994]

Rapid Estimate of Adult Literacy in Medicine [REALM; Davis et al., 1991] Scores based on reading level HL was dichotomized based on a median split at the 9th grade

levelSmoking Consequences Questionnaire-Adult [SCQ-A; Copeland et

al., 1995]

Smoking risk knowledge Smoking risk perceptions [see Weinstein et al., 2004]

6 items assessing absolute risk and risk compared to othersSelf-efficacy for quitting smokingIntentions to change smoking behavior [see Gollwitzer & Sheeran

2006]

Data Analyses

Chi Square analyses and t-tests tested for demographic differences between those with high vs. low HL

Multiple linear regression analyses were conducted to assess associations between HL and smoking variables Analyses controlled for demographic and SES-related variables

(i.e., age, gender, race/ethnicity, education, income, relationship status)

Results: Participant Characteristics

N=402Mean age of 43.2 (+10.2) years66% male70% Black27% had less than a high school diploma or GED70% reported annual household income of <$10,00043% had low HL; 57% had high HL Low HL was significantly associated with being male and

Black, and having lower income and education (ps < .05)

Stewart, D. W., Adams, C. E., Cano, M., Correa-Fernandez, V., Li, Y., Waters, A. J., Wetter, D. W., & Vidrine, J. I. (in press). Associations between health literacy and established predictors of smoking cessation. American Journal of Public Health.

Results: HL and Smoking Characteristics

Smokers with low HL reported: Higher levels of nicotine dependence (p = .003) Fewer negative smoking outcome expectancies

Health Risks (p < .001) Craving/Addiction (p = .07)

More positive smoking outcome expectancies Stimulation/State Enhancement (p = .05) Social Facilitation (p = .05) Weight Control (p = .07)

Results: HL and Smoking Characteristics

Smokers with low HL reported: Lower smoking risk knowledge (p < .001) Lower smoking risk perceptions

“If you don’t quit smoking for good, what are chances of ever developing a smoking-related health problem?” (p = .03)

“Compared to other smokers, what are your chances of ever developing a smoking-related health problem if you quit smoking for good?” (p < .001)

“What is your perceived risk of developing at least one health consequence of smoking if you continue smoking?” (p < .001)

HL not associated with self-efficacy to quit smoking or intentions to limit, reduce, or quit smoking

Conclusions

Low HL is associated with certain known predictors of smoking cessation even after controlling for demographics and SES-related factors

First evidence that low HL may be a unique risk factor for poor cessation outcomes over and above well-established predictors of cessation in low-SES, racially/ethnically diverse smokers

Low-SES, racially/ethnically diverse smokers with low HL may be at higher risk for poor cessation outcomes

Limitations

Cross-sectional analyses Results demonstrate associations rather than causality Longitudinal studies are needed to clarify temporal

relations

Participants were non-treatment seeking smokers Eligibility criteria required that smokers did not intend

to quit within 30 days of study enrollment Research needed to replicate this research among

smokers seeking treatmentSelf-report measures

May be biased

Implications and Future Directions

First known study to investigate relations between HL and known predictors of smoking cessation

Current methods of teaching about the health risks of smoking may be inadequate Improve providers’ training in clear communication Improve visual education materials

Future research is needed to evaluate mechanisms underlying relations between HL and smoking Findings might be used to develop prevention and

cessation strategies tailored for those with low HL, thereby reducing tobacco-related health disparities for the underserved

Acknowledgements

Grant Support National Institutes of Health/National Cancer

Institute (R01CA125413; PI: Vidrine) National Cancer Institute (R25T CA57730; PI:

Chang) National Cancer Institute Latinos Contra el Cancer

Community Networks Program Center Grant (U54CA153505; MPIs: Wetter, Fernandez, Jones)

National Institutes of Health through MD Anderson Cancer Center Support Grant (CA016672)

Thank you!