Disability and Health Journal 8 (2015) 258e263 www.disabilityandhealthjnl.com
Multiple tobacco use and increased nicotine dependence among people with disabilities Eric K. Soule, M.P.H.*, Jamie L. Pomeranz, Ph.D., Michael D. Moorhouse, Ph.D., and Tracey E. Barnett, Ph.D. Department of Behavioral Science and Community Health, College of Public Health and Health Professions, University of Florida, USA
Abstract Background: People with disabilities (PWD) are at greatest risk for tobacco use compared to people without disabilities. However, little is known about the use of multiple types of tobacco by PWD. Objective/Hypothesis: The purpose of this study was to examine nicotine dependence among a sample of PWD who use multiple types tobacco products. We hypothesized that individuals who used multiple forms of tobacco would have higher levels of nicotine dependence. Methods: A tobacco survey was administered to clients who use tobacco and receive services from an organization that provides independent living services to PWD. The self-report brief survey included measures of nicotine dependence and items indicating the types of tobacco products participants used. A total of 113 male and female participants with disabilities (mean age 5 51.7, SD 5 10.1) participated in the study. Results: Multiple tobacco use was reported by 16.8% of the participants and was significantly associated with nicotine dependence. Compared to single tobacco product users, multiple tobacco users were more likely to use tobacco within the first 30 min of waking, believe tobacco the first thing in the morning would be the most difficult to give up, and find it hard to not use tobacco in prohibited locations. Conclusions: The use of multiple types of tobacco products among PWD disability is relatively common and is associated with greater nicotine dependence. Tobacco cessation interventions targeting PWD should consider the addressing unique challenges of preventing different types of tobacco products. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Tobacco; Multiple tobacco use; Fagerstrom Nicotine Dependence Test; Center for Independent Living
Tobacco use has steadily decreased in the United States for nearly half a century.1 However, among some populations, such as people with disabilities (PWD), tobacco use prevalence remains high. PWD are 50% more likely to smoke than people without disabilities.2,3 PWD also smoke more cigarettes per day and are more nicotine dependent than people without disabilities.3,4 The research documenting the risk of tobacco use among PWD highlights the need for tobacco cessation programs that take the unique challenges faced by PWD into consideration.5 The Centers for Disease Control and Prevention (CDC) estimate that approximately 22% or 50 million Americans experience some form of disability.6 Unfortunately, this number is expected to grow over the next 25 years as the U.S. baby-boom generation ages and becomes more prone This study was presented as a poster presentation at the Society for Research on Nicotine and Tobacco Conference in Boston, MA in 2013. * Corresponding author. 1112 E Clay Street, Suite B-01, P.O. Box 980205, Richmond, VA 23298-0205, USA. Tel.: þ1 313 400 1148. E-mail address: [email protected]
(E.K. Soule). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.09.004
to disabling injuries and illnesses.7 As PWD go through the aging process, they encounter the same health conditions as people without disabilities, but may acquire these conditions at an earlier age and often have additional health consequences.8 As PWD age, their narrow margins of health can even lead to life threatening complications, such as respiratory and urinary tract infections.8e10 Given the narrower margin of health experienced by PWD, tobacco cessation is particularly important for them because their medical conditions can be further exacerbated by tobacco use. When compared to people without disabilities, PWD are more likely to have ever smoked, be current smokers, have fewer quit attempts, smoke daily, smoke more cigarettes per day, smoke earlier upon waking, and have greater nicotine dependence.3,4 The higher incidence of tobacco use among PWD may stem from barriers to tobacco cessation treatment. PWD receive preventive smoking cessation counseling from their primary care physicians at lower rates compared to people without disabilities.3,11 The most common explanations for the disparities found in smoking cessation counseling lie with primary care and other
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clinicians. Physicians often report they are preoccupied with the underlying disabling condition, do not view smoking as an important enough issue to address in lieu of other health issues, are insufficiently trained to deal with disabled patients, and are not fully confident in their smoking cessation counseling abilities.1,3,10e12 These barriers to treatment contribute to the high level of tobacco use among individuals with physical and/or mental disabilities.2 Studies show that PWD face barriers to preventive health care and have less access to preventive health services than the general population.8,10,13 These barriers to preventive health services can exacerbate disabling conditions and increase the incidence of medical, social, emotional, family or community problems.8e10 In addition, PWD often have lower socioeconomic status, lack health insurance, and have poor health literacy. Low SES combined with cognitive, affective, or sensory impairments can render obtaining, understanding or remembering cessation materials extremely difficult.3,8,9,12 Despite evidence demonstrating greater nicotine dependence among PWD,3,4 there is a gap in the research literature on the tobacco use behaviors among PWD associated with greater levels of nicotine dependence. Previous research has shown multiple tobacco use is associated with greater levels of nicotine dependence in populations without disabilities,14 however, research has not examined if this relationship is also true among PWD. Therefore, the purpose of this study was to examine the types of tobacco products PWD use and examine if increased nicotine dependence is associated with the use of multiple tobacco products.
Methods This study was approved by the University of Florida Institutional Review Board. For this study, researchers collected data from consumers with disabilities receiving services from the Center for Independent Living (CIL). The mission of the CIL is to provide independent support services, and advocacy to PWD.15 Clients receiving services from the CIL commonly report having a physical disability, sensory disability, cognitive disability, mental disability, or a combination of multiple disabilities. Over a three month period, research staff invited consumers who applied for paratransit services and indicated that they used tobacco at the CIL facility to complete a brief tobacco survey. The research team provided additional assistance to participants who required help completing the survey. The survey instrument included items examining demographics, types of tobacco products used, and a nicotine dependence measure informed by the Fagerstrom Nicotine Dependence Test.16 Tobacco product use questions asked participants to indicate the frequency and types of tobacco products used. Three nicotine dependence items were analyzed for this study. The first question asked participants
to report how soon after waking they first used tobacco. The response options were ‘‘within the first 30 min of waking’’ or ‘‘more than 30 min after waking’’ with the former being an indication of greater nicotine dependence. The second question asked participants to indicate which tobacco use time would be the most difficult to give up. Participants could choose ‘‘the first use of the day’’ or ‘‘any other time during the day’’ with the former representing greater nicotine dependence. Finally, the last nicotine dependence measure asked participants if they found it hard to not use tobacco in places where it is not permitted (e.g., in a movie theater, a place of worship, in an airport or airplane, in a hospital, etc.). ‘‘Yes’’ responses indicated greater levels of nicotine dependence based on previous research on nicotine dependence.16e18 We conducted frequency analyses, chisquared tests, and Fisher’s exact tests to examine associations between tobacco use and nicotine dependence.
Results A total of 113 CIL of North Central Florida consumers (mean age 5 51.7, SD 5 10.1, 40.4% female) participated in the study. Table 1 describes the demographics of the sample. The majority of the participants identified their race as either white/Caucasian (49.5%) or black/African American (38.8%). Participants most commonly reported having a combination of physical, sensory, cognitive, or mental disability (40.5%), followed by physical disability (33.3%) or mental disability (19.8%) only. The participants had varying levels of education with the greatest percentage (34.5%) having graduated from high school or earned a general equivalency degree, 23.9% reported having some college or technical school experience, while 29.2% had less than a high school education. Table 1 Participant demographic characteristics Demographic characteristic Age (mean, SD) Race White/Caucasian Black/African American Latino(a) Asian/Asian American American Indian/Alaskan Native Other Education Less than high school diploma High school diploma or GED Some college/technical school College degree Graduate degree Disability type Physical Sensory Cognitive Mental Combination
% (N ) 51.7, 10.1 49.5 41.3 2.8 0.9 4.6 0.9
(54) (45) (3) (1) (5) (1)
29.2 34.5 23.9 10.6 1.8
(33) (39) (27) (12) (2)
33.3 4.5 1.8 19.8 40.5
(37) (5) (2) (22) (45)
E.K. Soule et al. / Disability and Health Journal 8 (2015) 258e263
Table 2 Tests of association between multiple tobacco use and nicotine dependence indicators among all participants Multiple tobacco users Non-multiple tobacco users % (N ) % (N ) Nicotine dependence measure 16.8% (19) 83.2% (94) First tobacco use Within 30 min of waking More than 30 min after waking Most difficult tobacco use to give up First use in the morning Any other time Hard to not use tobacco where prohibited Yes No
94.7 (18) 5.3 (1)
66.3 (59) 33.7 (30)
83.3 (15) 16.7 (3)
56.8 (50) 43.2 (38)
63.2 (7) 36.8 (7)
38.5 (35) 61.5 (56)
Analyses are based on participants who provided complete data for each nicotine dependence item.
With regard to tobacco products, cigarette smoking was the most common form of tobacco used (90.2%) among participants. More than one-quarter of the sample (27.4%) also reported using cigars, little cigars, or cigarillos. Multiple tobacco use was relatively common among participants with 16.8% indicating current use (use in the past 30 days) of two or more tobacco products. Multiple tobacco use was not significantly associated with disability type (c2(4) 5 2.99, p 5 0.559) indicating multiple tobacco use was not unique to a particular disability type. The multiple tobacco product users showed greater signs of nicotine dependence compared to single-product tobacco users. Table 2 displays tests of association between multiple tobacco use and nicotine dependence measures among the entire sample. Compared to single tobacco product users, multiple tobacco product users were significantly more likely to report using tobacco within 30 min of waking (c2(1) 5 6.19, p 5 0.013, Cramer’s V 5 0.24). This association had a medium effect size. Similarly, when participants were asked which time of day they would prefer not to give up tobacco products, multiple tobacco product users were more likely to prefer to not give up their first tobacco use in the morning compared to single tobacco product use (c2(1) 5 4.43, p 5 0.035, Cramer’s V 5 0.20). This association also had a medium effect size. Finally, multiple tobacco users also were significantly more likely to report it is hard to not use tobacco in places where it is prohibited compared to single tobacco product users (c2(1) 5 3.92, p 5 0.048, Cramer’s V 5 0.189). This association had a small to medium effect size. While the small number of participants who reported sensory, cognitive, or mental disabilities prevented tests of association between multiple tobacco use and the nicotine dependence measures, we were able to conduct tests of association between multiple tobacco use and nicotine dependence among participants who reported having a physical disability or having multiple disabilities separately (Table 3). However, theses samples remained small enough that some expected cell counts fell below five and therefore we used the Fisher’s exact test to determine significance. There was only one significant association between
multiple tobacco use and nicotine dependence among the specific physical disability and multiple disability groups. Among those who only reported having a physical disability, multiple tobacco users were significantly more likely to report it is hard to not use tobacco in locations where it is prohibited (c2(1) 5 9.12, p 5 0.005, Cramer’s V 5 0.50). This association had a strong effect size.
Discussion The findings from this study indicate multiple tobacco product use as an area of concern among PWD. In this study, PWD who reported multiple tobacco product use were significantly more likely to show signs of nicotine dependence than those who reported only using one tobacco product. Furthermore, multiple tobacco use was not uncommon in this sample: about one-sixth of the participants reported currently using multiple types of tobacco products. While research on the prevalence of multiple tobacco product use among people without disabilities remains limited, current evidence indicates multiple tobacco use is relatively uncommon among the general population, though still associated with greater nicotine dependence.19 PWD already face many challenges with regard to accessing appropriate tobacco cessation services. For instance, effective cessation strategies from tobacco cessation programs may be ineffective for PWD if they do not account for mobility limitations (e.g., recommending tobacco users to go for a run when feeling a craving). The findings from this study suggest multiple tobacco product use may add to the tobacco cessation challenges faced by PWD. Multiple tobacco product users also endorsed survey items indicative of greater nicotine dependence such as smoking within the first 30 min after waking, believing the first tobacco use in the morning would be the most difficult to give up, or finding it difficult to not use tobacco in locations where tobacco use is prohibited. Previous research has shown time to first cigarette of less than 30 min is associated with greater levels of nicotine dependence.16e18 The magnitudes of the effect sizes from the
E.K. Soule et al. / Disability and Health Journal 8 (2015) 258e263 Table 3 Tests of association between multiple tobacco use and nicotine dependence disabilities Multiple tobacco users % (N ) Nicotine dependence measure 16.8% (19) Participants with physical disability First tobacco use Within 30 min of waking More than 30 min after waking Most difficult tobacco use to give up First use in the morning Any other time Hard to not use tobacco where prohibited Yes No Participants with multiple disabilities First tobacco use Within 30 min of waking More than 30 min after waking Most difficult tobacco use to give up First use in the morning Any other time Hard to not use tobacco where prohibited Yes No a
indicators among participants with a physical disability or with multiple Non-multiple tobacco users % (N ) 83.2% (94)
100 (5) 0 (0)
51.6 (16) 48.4 (15)
100 (4) 0 (0)
51.6 (16) 48.4 (15)
100 (5) 0 (0)
29.0 (9) 71.0 (22)
87.5 (7) 12.5 (1)
69.4 (25) 30.6 (11)
87.5 (7) 12.5 (1)
58.3 (21) 41.7 (15)
25.0 (2) 75.0 (6)
37.8 (14) 62.2 (23)
Fisher’s exact test applied due to expected counts less than 5.
current study highlighted a non-trivial relationship between multiple tobacco product use and nicotine dependence. That is, PWD who reported multiple tobacco product use were likely to be at greater risk for nicotine dependence than those who did not engage in multiple tobacco product use. Additionally, the association between multiple tobacco use and nicotine dependence may vary across disability type as evidenced by participants with physical disabilities being more likely to report difficulty in not using tobacco in prohibited locations whereas this association did not exist among those with multiple disabilities. Similar research has found greater levels of nicotine dependence among PWD3,4 and among those who use multiple tobacco products,14 however, to the best of our knowledge this is the first study to examine nicotine dependence and multiple tobacco use among the PWD population. Almost all (89.5%) of the multiple tobacco product users reported cigar, cigarillo, or little cigar use in addition to cigarette use. Cigar, cigarillo, or little cigar sales increased more than threefold from 1995 to 2008,20 likely resulting from cigarette taxes being more than three times cigar taxes.21e23 Given that PWD often report lower household incomes than the general population,24 current cigarette smokers with disabilities may be attracted to cigars, cigarillos, or little cigars as a potential supplement or lower cost replacement. The combination of low income and deep dependence may drive those who are most dependent to seek out less expensive alternatives to cigarettes for greater access to nicotine. Therefore, tobacco cessation specialists should consider cigar, cigarillo, or little cigar use when working with PWD.
While the findings from this study indicated a significant association between multiple tobacco product use and greater nicotine dependence among PWD, many of the single-tobacco product using participants in this study also exhibited signs of nicotine dependence. This study did not examine the association between frequency or quantity of tobacco use, but rather compared nicotine dependence based on the number of types of tobacco products the participants used. PWD who only use one type of tobacco product are still at risk for nicotine dependence, however, the current findings suggest that greater nicotine dependence is associated with the use of multiple types of tobacco products. There were several limitations in this study. First, the small sample size limited our ability to extensively examine all of the populations separately based on disability type, however, we were able to assess several measures of nicotine dependence among a broad sample of PWD as well as among those with a physical disability only and those with more than one disability from the CIL. Participants were not randomly selected, however, data collection took place over multiple days over the course of three months which helped to capture a more representative sample than collecting data in a shorter time frame. The analyses conducted in this study did not control for other variables such as demographic characteristics which may also be associated with nicotine dependence. However, the findings from this study were consistent with previous research on tobacco use among people without disabilities.14 The study also had many strengths. Participants with multiple types of disabilities were included in the analysis
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improving the generalizability of the findings to people with multiple types of disabilities. This study also used a measure based off of the gold standard measure of nicotine dependence16 to examine the association between multiple tobacco use and nicotine dependence among PWD. This study was also the first known study to examine the association between multiple tobacco product use and nicotine dependence among PWD. Future studies should continue to examine the relationship between multiple tobacco product use and nicotine dependence among PWD. Studies that compare PWD and people without disabilities would allow researchers to determine if the association between multiple tobacco product use and greater nicotine dependence is stronger among PWD or if the association is similar across the entire population. Multivariate analyses that control for other participant characteristics such as sex, age, or tobacco use history would also help explain how disability status uniquely affects multiple tobacco product use and nicotine dependence. While the results from this study suggest multiple tobacco product use among PWD is associated with greater levels of nicotine dependence, further research is needed to confirm these findings.
Conclusions This study provides further evidence of the need to include people with disabilities in tobacco cessation interventions. Previous research has shown PWD have higher rates of tobacco use than people without disabilities, but this study shows that PWD may face greater challenges still regarding tobacco cessation due to increased levels of nicotine dependence. Given the increased rates of multiple tobacco product use among PWD and the association between multiple tobacco product use and nicotine dependence found in this study as well as previous research, PWD may have greater difficulties with tobacco cessation. PWD carry a disproportionate amount of the tobacco epidemic. Public health efforts should seek to eliminate these disparities in tobacco use between PWD and people without disabilities. Previous research has called for the development for novel tobacco cessation interventions which target PWD for two reasons: (1) the disproportionately high rates of smoking and (2) the lack of intervention programs that address the unique barriers among this population.4 Promoting public health interventions such as tobacco cessation for people with disabilities is consistent with the Healthy People 2020 objectives regarding PWD. A key objective of Healthy People 2020 is to prevent secondary conditions, and eliminate disparities between people with and without disabilities in the U.S.25 When developing tobacco cessation programs, counselors should consider multiple tobacco use as a potential barrier for clients to overcome. Additionally, multiple tobacco product use
may be a warning sign of greater nicotine dependence that counselors can use to determine who is at greatest need for tobacco cessation intervention. In either scenario, taking into account multiple tobacco use can provide a greater potential for successful outcomes for PWD participating in tailored cessation programs.
Acknowledgment We would like to thank the University of Florida Area Health Education Center for their support of this study. References 1. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed [cited 2013 Dec 2]. Available from: http://www.healthypeople.gov/2010/Document/ pdf/uih/2010uih.pdf; 2000. 2. Armour BS, Campbell VA, Crews JE, Malarcher A, Maurice E, Richard RA. State-level prevalence of cigarette smoking and treatment advice, by disability status, United States. Prev Chronic Dis. 2007;4:1e11. 3. Brawarsky P, Brooks DR, Wilber N, Gertz RE Jr, Klein Walker D. Tobacco use among adults with disabilities in Massachusetts. Tob Control. 2002;11:ii29eii33. 4. Jones GC, Bell K. Adverse health behaviors and chronic conditions in working-age women with disabilities. Fam Community Health. 2004;27:22e36. 5. 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;54:118e121. 6. Centers for Disease Control and Prevention. Disability and Health State Chartbook, 2006: Profiles of Health for Adults With Disabilities. Atlanta: Centers for Disease Control and Prevention [updated 2010 June 30; cited 2013 Dec 2]. Available from: http://www.cdc.gov/ ncbddd/disabilityandhealth/chartbook/; 2010. 7. Freedman VA, Martin LG, Schoeni RF. Disability in America. Popul Bull. 2004;59:3e32. 8. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Arch Phys Med Rehabil. 2004;85(5):749e757. 9. Iezzoni LI, McCarthy EP, Davis RB, Siebens H. Mobility impairments and use of screening and preventive services. Am J Public Health. 2000;90(6):955e961. 10. Kroll T, Jones GC, Kehn M, Neri MT. Barriers and strategies affecting the utilisation of primary preventive services for people with physical disabilities: a qualitative inquiry. Health Soc Care Community. 2006; 14(4):284e293. 11. Friend KB, Levy DT, Mernoff ST. The adoption of tobacco dependence treatment by rehabilitation clinicians. Disabil Rehabil. 2005;27(4):147e155. 12. Iezzoni LI, McCarthy EP, Davis RB, Harris-David L, O’Day B. Use of screening and preventive services among women with disabilities. Am J Med Qual. 2001;16(4):135e144. 13. Chan L, Doctor JN, MacLehose RF, et al. Do Medicare patients with disabilities receive preventive services? A population-based study. Arch Phys Med Rehabil. 1999;80(6):642e646. 14. Post A, Gilljam H, Rosendahl I, Bremberg S, Galanti MR. Symptoms of nicotine dependence in a cohort of Swedish youths: a comparison between smokers, smokeless tobacco users and dual tobacco users. Addiction. 2010;105:740e746. 15. Center for Independent Living. Center for Independent Living: People With Disabilities Creating Opportunities. updated 2012; cited 2013 Dec 2]. Available from: http://www.cilberkeley.org/mission/; 2005.
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