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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

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)
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