Associations between health literacy and smoking
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Associations between Health Literacy and Smoking. 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.

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Associations between Health Literacy and Smoking

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Associations between health literacy and smoking

Associations between Health Literacy and Smoking

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 Association

October 29, 2012


Presenter disclosures

Presenter Disclosures

  • No relationships to disclose


Cigarette smoking

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

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

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

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

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 smoking1

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

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

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 outreach

  • Eligibility:

    • 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

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 level

  • Smoking 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 others

  • Self-efficacy for quitting smoking

  • Intentions to change smoking behavior [see Gollwitzer & Sheeran 2006]


Data analyses

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

Results: Participant Characteristics

  • N=402

  • Mean age of 43.2 (+10.2) years

  • 66% male

  • 70% Black

  • 27% had less than a high school diploma or GED

  • 70% reported annual household income of <$10,000

  • 43% 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

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 characteristics1

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

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

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 treatment

Self-report measures

May be biased


Implications and future directions

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

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

Thank you!


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