RESEARCH AND PRACTICE
Smoking Cessation Among African American and White Smokers in the Veterans Affairs Health Care System Diana J. Burgess, PhD, Michelle van Ryn, PhD, MPH, Siamak Noorbaloochi, PhD, Barbara Clothier, MS, MA, Brent C. Taylor, PhD, Scott Sherman, MD, MPH, Anne M. Joseph, MD, MPH, and Steven S. Fu, MD, MSCE
Numerous studies have found that African American smokers are less likely than White smokers to quit successfully.1---8 These disparities in quit rates exist despite the fact that African American smokers report stronger motivation and readiness to quit, are more likely to believe they will be able to quit successfully,9---11 and are more likely to make quit attempts than Whites.12,13 Evidence has suggested that an important contributor to racial differences in cessation rates is African Americans’ lower use of evidence-based cessation treatment. Specifically, African Americans are less likely to be screened for nicotine use, to receive cessation advice, and to be prescribed nicotine replacement treatment (NRT) than Whites.3,6,8,13---17 African Americans are also less likely to believe that NRT and formal smoking cessation treatment are effective and have less favorable attitudes toward pharmacotherapy than Whites.10,17 Taken together, this research has suggested that increasing the use of evidencebased cessation treatment among African Americans may be a promising way to reduce racial disparities in cessation. The Veterans Victory over Tobacco (Victory) study, a pragmatic randomized controlled trial, assessed the effects of a proactive-care smoking cessation intervention, designed to increase the reach of evidence-based cessation treatment, on smoking abstinence rates among a diverse population of smokers enrolled in the Veterans Health Administration.18 In this intervention, smokers were identified through electronic medical records and offered the choice of telephone or face-to-face care for treatment of tobacco dependence. Main effects of this study, which have already been published, revealed a significant 2.6% absolute increase in population-level smoking cessation rates in the proactive-care condition over usual care.19 This study is a secondary analysis of data from the Victory study to determine
Objectives. We examined whether a proactive care smoking cessation intervention designed to overcome barriers to treatment would be especially effective at increasing cessation among African Americans receiving care in the Veterans Health Administration. Methods. We analyzed data from a randomized controlled trial, the Veterans Victory over Tobacco study, involving a population-based electronic registry of current smokers (702 African Americans, 1569 Whites) and assessed 6-month prolonged smoking abstinence at 1 year via a follow-up survey of all current smokers. We also examined candidate risk adjustors for the race effect on smoking abstinence. Results. The interaction between patient race and intervention condition (proactive care vs usual care) was not significant. Overall, African Americans had higher quit rates than Whites (13% vs 9%; P < .006) regardless of condition. Conclusions. African Americans quit at higher rates than Whites. These findings may be a result of the large number of veterans receiving smoking cessation services and the lack of racial differences in receipt of these services as well as racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans. (Am J Public Health. 2014;104:S580–S587. doi:10. 2105/AJPH.2014.302023)
whether the effects of treatment differ by race and, secondarily, to explore baseline factors that might account for the association between race and smoking cessation. Our hypothesis was that a proactive, population-based tobacco cessation care model, with low barriers to access, would have greater benefit among African American smokers than White smokers because the former are less likely to have received prior pharmacotherapy or counseling.3,6,8,13---17
METHODS The Victory study was a pragmatic randomized controlled trial. Details of the design and methods have previously been described.18,19 The 4 participating sites were the James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G. V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN, the coordinating site). The study sites were selected
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to ensure adequate inclusion of racial/ethnic minorities. Participants were recruited from October 2009 to September 2010, and followup was completed in November 2011. Current smokers (aged 18---80 years) were identified using the US Department of Veterans Affairs’ (VA’s) electronic medical record health factor data set and, separately at each site, were randomized to either proactive care or usual care. Therefore, our sample was a stratified sample (stratified by site), and the clinical trial was a completely randomized repeatedmeasures block design. The proactive-care condition consisted of proactive outreach (mail followed by telephone outreach) combined with an offer of the choice of telephone or in-person smoking cessation services. Participants interested in in-person services were connected with their local VA hospital’s smoking cessation program. Telephone services combined proactive phonebased counseling delivered by counselors at the Minneapolis VA with increased access to smoking cessation medications from the VA.
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TABLE 1—Characteristics of White and African American Participants: Veterans Victory Over Tobacco Study, United States, 2009–2011 Characteristic
White (n = 1569), No. (%) or Mean 6SE
African American (n = 702), No. (%) or Mean 6SE
P
Control variables Male
1491 (95)
653 (93)
.04
Age, y Smoking-related cardiovascular disease
59.5 60.3 518 (33)
56.9 60.3 140 (20)
£ .001 £ .001
Smoking-related respiratory disease
377 (24)
91 (13)
£ .001
Audit-C Score
3.0 60.1
3.5 60.1
.002
Social network Married or living with significant other
832 (53)
309 (44)
£ .001
Living with other smoker
675 (43)
253 (36)
£ .001
Not allowed anywhere Allowed in some places or some times
659 (42) 314 (20)
229 (33) 174 (25)
Allowed anywhere
596 (38)
299 (43)
266 (17)
113 (16)
£ .001
Home smoking rules
Friends who smoke None
.208
< half
435 (28)
225 (32)
About half
355 (23)
140 (20)
> half
311 (20)
126 (18)
202 (13)
98 (14)
Strongly disagree to neutral
361 (23)
134 (19)
Somewhat agree
377 (24)
140 (20)
Strongly agree
831 (53)
428 (61)
465 (30)
257 (37)
544 (35)
217 (31)
560 (36) Socioeconomic status
228 (32)
All Supportive others
.006
Smoking stigma Low Middle High
.01
Education 130 (8)
63 (9)
High school graduate or GED
647 (41)
288 (41)
Some college
600 (38)
295 (42)
‡ bachelor’s degree
192 (12)
56 (8)
467 (30) 169 (11)
218 (31) 111 (16)
£ .001
Employment status Employed Unemployed Retired
482 (31)
137 (20)
Unable to work
451 (29)
236 (34)
192 (12)
183 (26)
£ .001
Income, $ < 10 000
Data Collection
.053
£ 11th grade
10 000–20 000
475 (30)
239 (34)
20,001–40 000
522 (33)
182 (26)
‡ 40,001
380 (24)
98 (14)
Data collection occurred at baseline and 1 year after randomization. We obtained VA administrative and health care utilization data from the VA National Patient Care Databases. Survey data were collected at baseline and at 1-year follow-up. The baseline and follow-up survey procedures used a modified Dillman protocol (mail + postcard reminder + mail + mail) and included a $10 cash incentive with the first survey mailing. The follow-up survey protocol was similar to the baseline survey protocol but included an additional letter before the first survey mailing and telephone contact of those who did not respond to the mailed survey.
Measures Continued
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Those in the usual-care condition did not receive proactive outreach and did not have access to the telephone smoking cessation services offered by the counselors at the Minneapolis VA; this group did have access to tobacco treatment services from their local VA hospital and their state telephone quit line. National VA guidelines mandate screening for tobacco use, advising tobacco users to quit, and offering tobacco treatment (i.e., pharmacotherapy and counseling), and VA hospitals are held accountable through the use of performance measures determined by external audit of medical records. The primary analytical sample for the parent study included 5123 participants who were both randomized and fully eligible. Within this primary analytical sample, 2519 participants received the proactive-care intervention, and 2604 participants received usual care. Analyses examining the race · treatment effect were based on the 2271 participants who identified themselves as either White (1569) or African American (702) and who returned the baseline survey, which contained all of the questions assessing factors that might contribute to racial differences in cessation (except for perceived discrimination, which was assessed at followup) and who had complete 6-month prolonged abstinence data.
We included a number of potential factors that might account for racial differences in cessation and the interaction between race and the intervention. We included prior
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TABLE 1—Continued Smoking history Longest quit length
.008
Never quit
137 (9)
73 (10)
< 1 mo
373 (24)
214 (30)
1 mo to < 6 mo
435 (28)
183 (26)
624 (40)
232 (33)
> 30
361 (23)
239 (34)
6–30
879 (56)
337 (48)
£5
329 (21)
126 (18)
Smokes menthol cigarettes
251 (16)
548 (78)
£ .001
Quit in past y
785 (50)
456 (65)
£ .001
361 (23) 754 (48)
393 (56) 267 (38)
‡ 6 mo Time to first cigarette, min
£ .001
£ .001
Cigarettes per d £ 10 11–20 ‡ 21 Age at smoking initiation, y
454 (29)
42 (6)
16.7 60.1
18.7 60.2
£ .001
SC treatment history SC treatment used in previous y at baseline
.006
None
922 (59)
404 (58)
Meds only
481 (31)
187 (27)
Counseling only Meds and counseling
45 (3) 121 (8)
35 (5) 76 (11)
518 (33)
232 (33)
Very satisfied with VA help with SC Satisfaction with VA process of obtaining SC meds Very satisfied
412 (26)
Somewhat satisfied
161 (10)
67 (10)
Very dissatisfied to neutral
396 (25)
148 (21)
Never received help
600 (38)
281 (40)
Self-efficacy scores Globalb Emotional
.939 .18
206 (29)
2.1 60.0
2.8 60.1
£ .001
–0.14 60.08
–0.53 60.05
£ .001
Social subscale
0.07 60.04
0.31 60.07
.005
Skill subscale
–0.24 60.05
–0.10 60.08
.137
20.8 60.1
21.6 60.2
£ .001
Readiness to quitc
5.5 60.1
6.2 60.1
£ .001
Perceived discriminationd
6.2 60.1
8.1 60.2
£ .001
Mastery
Attitudes toward nicotine replacement therapy Advantages Drawbacks (reverse scored)
3.57 60.02
3.50 60.03
.082
3.07 60.02
2.74 60.03
£ .001
Note. Audit-C = Alcohol Use Disorders Identification Test; SC = smoking cessation; VA = Veterans Affairs. Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN) a Median score for Whites, 1.4; for African Americans, 2.5. b Median score for Whites, 1.6; for African Americans, 2.4 c Median score for Whites, 4.7; for African Americans, 5.6 d Median score for Whites, 5.3; for African Americans, 7.6.
utilization of smoking cessation treatment because it might plausibly contribute to greater effectiveness of the intervention with African
Americans than with Whites; the intervention might have a stronger effect among smokers who had not previously received
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pharmacotherapy or counseling (and who were more likely to be African American).3,6,8,13---17 Similarly, we also explored whether the intervention would be especially effective among smokers with baseline negative attitudes toward NRT, who were also more likely to be African American.10,17 In addition, we included factors that were likely to contribute to lower quit rates among African Americans, such as use of menthol cigarettes,3,20,21 social network characteristics (e.g., the presence of home smoking bans),3,22 and prior experiences of discrimination, which African Americans experience at a greater rate and has been associated with increased smoking.23---28 We also included facilitators to quitting that have been shown to be more prevalent among African Americans, such as self-efficacy and motivation related to quitting,9---11 and factors related to prior smoking and cessation, such as having made a prior quit attempt,12,13 being a light smoker,3 and longer time to first cigarette.3 Six-month smoking abstinence. The primary outcome was a 6-month period of smoking abstinence 1 year after randomization.29 To assess population-level cessation, we assessed 6-month smoking abstinence with the 1-year follow-up survey among all current smokers irrespective of treatment use or interest in quitting. Race. We obtained race from the baseline survey unless it was missing. We then populated missing self-reported race with race obtained from the National Patient Care Databases. Gender, age, and smoking-related health conditions were also obtained from the databases. We assessed alcohol use with the Alcohol Use Disorders Identification Test score30 obtained from the baseline survey. Candidate risk adjustors. We examined measures for each of the 7 blocks of candidate risk adjustors that might account for racial differences in smoking cessation: (1) smoking history, (2) smoking cessation treatment history, (3) smoking cessation self-efficacy and motivation to quit, (4) attitudes toward NRT, (5) social network characteristics related to smoking, (6) perceived discrimination, and (7) socioeconomic status. All of these potential risk adjustors were measured at baseline, with the exception of perceived discrimination, which was measured at follow-up.
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TABLE 2—Adjusted Odds Ratios and 95% Confidence Intervals From Logistic Regressions Relating 6-Month Abstinence to Measure: Veterans Victory Over Tobacco Study, United States, 2009–2011 Measure
OR (95% CI)
Proactive outreach (vs usual care)
1.64* (1.23, 2.18)
African American (vs White)
1.59* (1.13, 2.24) Control variables
Male (vs female) Age (per point increase in years)
0.93 (0.49, 1.76) 1.01 (0.99, 1.02)
Smoking-related CHD (vs not)
1.13 (0.82, 1.55)
Smoking-related respiratory (vs not)
0.81 (0.55, 1.17)
Audit-C Score (per unit increase)
0.96 (0.92, 1.01) Social network characteristics
Married or living with significant other (vs not)
1.13 (0.85, 1.50)
Living with other smoker (vs not)
0.62* (0.46, 0.84)
Home smoking rules Not allowed anywhere
2.02* (1.45, 2.82)
Allowed in some places or some times
1.16 (0.77, 1.76)
Allowed anywhere (Ref)
1.00
Friends who smoke None
1.94* (1.09, 3.44)
< half
1.99* (1.17, 3.38)
About half
1.27 (0.71, 2.26)
> half All (Ref)
1.27 (0.70, 2.28) 1.00
Supportive others Strongly agree
1.49* (1.01, 2.19)
Somewhat agree
0.97 (0.60, 1.57)
Strongly disagree to neutral (Ref)
1.00
Smoking stigma Low
1.04 (0.73, 1.48)
Middle High (Ref)
1.01 (0.71, 1.44) 1.00 Socioeconomic status
Education ‡ bachelor’s degree
1.92 (0.97, 3.79)
Some college
1.23 (0.67, 2.26)
High school graduate or GED
1.56 (0.86, 2.82)
£ 11th grade (Ref)
1.00
Employment status Employed (Ref) Unemployed
1.00 0.97 (0.59, 1.59)
Retired
1.41 (0.92, 2.16)
Unable to work
0.92 (0.63, 1.36)
Income, $ < 10 000 (ref)
1.00
10 000–20 000
0.81 (0.52, 1.25)
20 000–40 000 ‡ 40 000
1.01 (0.66, 1.55) 0.94 (0.58, 1.52) Continued
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We collected information regarding smoking history, such as age of initiation, longest quit attempt, previous quit attempts, and prior use of tobacco treatment using standard questions from the California Tobacco Survey31 and the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey.32 We assessed nicotine dependence with the 2-question Heaviness of Smoking Index (cigarettes per day and time to first cigarette after waking).33 We also ascertained use of menthol cigarettes and satisfaction in regard to prior smoking cessation help from the VA. Standard tobacco performance measures assessed participants’ receipt of smoking cessation advice, counseling, and treatment from their VA primary care provider.34 We used questions from the Commonwealth Fund Survey to assess patients’ satisfaction with help received from their VA provider to quit smoking and with the process of obtaining smoking cessation medications from the VA.35 We assessed self-efficacy and motivation to quit with a global measure of self-efficacy to quit36 and 3 self-efficacy subscales (emotional, social, and skill self-efficacy),37 a Mastery scale (measured using a standard 7-item questionnaire assessing the control one feels over one’s life),28 and the readiness to quit ladder.27 Attitudes toward smoking cessation medication were assessed using the 12-item Attitudes toward Nicotine Replacement Therapy scale.26 On the follow-up survey, we assessed perceived discrimination with 9 questions asking about the frequency of exposure to experiences of discrimination, such as being treated with less courtesy or less respect or being harassed.38 Social network characteristics included questions assessing subjective norms related to smoking, smoking habits of friends and family, and home smoking rules. Questions concerning smoking stigma, the concept that one feels stigmatized because of one’s smoking behavior, were adapted from the Mental Health Consumers’ Experience of Stigma.39 We also included marital status (obtained from the baseline survey and National Patient Care Databases). We assessed socioeconomic status by income, education, and employment, obtained from the baseline survey.
Statistical Analysis For the primary analysis, we used logistic regression (SAS version 9.2, SAS Institute Inc.,
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TABLE 2—Continued Smoking history Longest quit length Never quit (Ref)
1.00
< 1 mo
1.24 (0.62, 2.48)
1 mo to < 6 mo
1.69 (0.86, 3.32)
‡ 6 mo Time to first cigarette
2.75* (1.44, 5.24)
> 30 min
3.25* (2.06, 5.13)
6–30 min
1.33, (0.84, 2.10)
£ 5 min (Ref)
1.00
Smokes menthol cigarettes (vs not)
1.01 (0.70, 1.47)
Quit in past y (vs not)
2.48* (1.79, 3.44)
Cigarettes per d £ 10 11–20
3.45* (2.14, 5.58) 1.41 (0.87, 2.27)
‡ 21 (Ref)
Cary, NC) to measure the effect of race on the primary outcome, 6-month abstinence. The initial model included race, treatment, site, and the treatment · race interaction. We used the weighted stratified Wald v2 test to assess categorical characteristics by race. Continuous covariates by race were assessed using a weighted stratified Wald F test. The weights were the inverses of the sampling proportion from each site. Because we wanted to see whether blocks of candidate risk adjustors helped explain the race effect, we ran a model to obtain the race effect odds ratio before and after adjusting for the 7 blocks of candidate risk adjustors.
RESULTS
1.00
Age at smoking initiation (per unit increase)
1.01 (0.99, 1.04) SC treatment history
SC treatment used in previous year at baseline None (Ref)
1.00
Meds only
0.85 (0.61, 1.18)
Counseling only Meds and counseling
1.39 (0.70, 2.72) 0.99 (0.61, 1.61)
Very satisfied with VA help with SC (vs not)
1.59* (1.18, 2.13)
Satisfaction with VA process of obtaining SC meds Very satisfied
1.02 (0.71, 1.46)
Somewhat satisfied
1.10 (0.68, 1.80)
Very dissatisfied to neutral
0.72 (0.47, 1.09)
Never received help (Ref)
1.00
Self-efficacy, per-unit increase Global
1.38* (1.24, 1.52)
Emotional subscale
1.30* (1.19, 1.41)
Social subscale
1.28* (1.18, 1.39)
Skill subscale
1.38* (1.25, 1.52)
Mastery
1.04* (1.00, 1.08)
Readiness to quit
1.34* (1.23, 1.46)
Perceived discrimination Attitudes toward NRT, per-unit increase Advantages Drawbacks (reverse scored)
0.97 (0.94, 1.00) 1.30* (1.06, 1.60) 1.11 (0.93, 1.31)
Note. CHD = coronary heart disease; CI = confidence interval; NRT = nicotine replacement treatment; OR = odds ratio; SC = smoking cessation; VA = Veterans Affairs. Values are based on the 1569 Whites and 702 African Americans who returned the baseline and follow-up surveys. Some measures have missing values. NRT drawbacks and NRT advantages were missing the most often, 249 (11%) and 272 (12%), respectively. ORs are adjusted for facility, experimental condition, race, and control variables (gender, age, smoking-related cardiovascular disease, smoking-related respiratory disease, and Audit-C score). Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN) *P < .05.
The interaction between patient race (African American vs White) and intervention condition (proactive treatment vs usual care) on population-level 6-month prolonged smoking abstinence was not significant (P = .823). However, we found a main effect of race; African Americans had higher 6-month prolonged abstinence rates than Whites (13% vs 9%; P = .006; odds ratio [OR] = 1.57; 95% confidence interval [CI] = 1.14, 2.15).
Candidate Risk Adjustors We performed secondary analyses aimed at understanding which block or blocks of candidate risk adjustors might explain this main effect of race on 6-month abstinence, irrespective of experimental condition. We did not examine the potential factors that contributed to the effect of treatment. We investigated candidate risk adjustors, comparing the race-effect ORs from larger models that included a specific set of candidate risk adjustors with odds ratios obtained from a simpler model that contained only the study design variables (site and treatment), race, demographics (gender and age), and health characteristics (smoking-related cardiovascular or respiratory disorders and Alcohol Use Disorders Identification Test score). We used multiple imputation methods to account for missingness with the candidate risk adjustors.
Baseline Characteristics by Race Baseline characteristics did not differ between the usual-care and intervention
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TABLE 3—Risk-Adjusted Race Effect Odds Ratios and 95% Confidence Intervals From Logistic Regressions Relating 6-Month Abstinence to Race Controlling for Risk Adjustor Block: Veterans Victory Over Tobacco Study, United States, 2009–2011 Risk Adjustor Block
Race Effect Using All Available Cases, OR (95% CI)
Race Effect Using Multiple Imputation Methods, OR (95% CI)
Smoking history
1.00 (0.64, 1.57)
1.17 (0.78, 1.76)
Smoking cessation treatment history Smoking cessation self-efficacy
1.51 (1.05, 2.17) 1.17 (0.78, 1.76)
1.62 (1.16, 2.25) 1.25 (0.89, 1.77)
Perceived discrimination
1.56 (1.08, 2.24)
1.70 (1.22, 2.36)
Attitudes toward nicotine replacement therapy
1.69 (1.17, 2.45)
1.66 (1.19, 2.32)
Social network characteristics related to smoking
1.45 (1.00, 2.09)
1.56 (1.11, 2.18)
Socioeconomic status
1.61 (1.12, 2.32)
1.65 (1.18, 2.31)
All blocks
1.14 (0.59, 2.18)
1.26 (0.81, 1.95)
DISCUSSION
Note. CI = confidence interval; OR = odds ratio. Each model contained the following independent variables: facility, experimental condition, race, gender, age, smoking-related cardiovascular disease, smoking-related respiratory disease, Audit-C score, and risk-adjustor block. Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN)
groups.40 However, we found several differences in baseline characteristics between African American and White participants (Table 1). Compared with Whites, African Americans were younger, less likely to have smokingrelated coronary heart disease or respiratory disorders, and had greater alcohol use. They had lower income, were less likely to be retired, and were more likely to be unemployed or unable to work. African Americans were more likely to smoke menthol cigarettes, had a shorter time to 1st cigarette, were more likely to be light smokers (smoking £ 10 cigarettes per day), and were more likely to have made a quit attempt in the past year but less likely to have quit for 6 months or more. African Americans were more likely to report receiving both pharmacotherapy and counseling or counseling only, whereas Whites were more likely to report using pharmacotherapy only (both inside and outside the VA). African Americans reported higher levels of mastery, social, and global self-efficacy and greater readiness to quit but reported lower emotional self-efficacy and perceived more disadvantages of nicotine replacement therapy. African Americans also reported higher levels of perceived discrimination (assessed at follow-up). African Americans were less likely to live with another smoker and were more likely to have important others who supported their quitting; however, they were less likely to have stringent home smoking rules.
Table 2 presents the association of each characteristics with 6-month abstinence, controlling for study design, race, and other controlling covariates. Smoking abstinence was more likely among patients in the proactive outreach condition and among African American patients. Smoking abstinence was less likely among those who lived with another smoker and more likely among those who had a complete nonsmoking ban and fewer friends who smoked and others who supported their quitting. Smoking abstinence was also associated with having previously quit for 6 months or longer, having quit in the past year, having a time to first cigarette of less than 30 minutes, and being a light smoker. Higher scores on global self-efficacy, the self-efficacy subscales, mastery, and readiness to quit all were associated with smoking abstinence, as was greater satisfaction with VA help with cessation and more positive beliefs in the advantages of NRT. Table 3 presents the results of the model to obtain the race effect odds ratio, in which each model used all of the available cases for that specific model. Because 42% of the 2271 participants were missing at least 1 of the covariates being considered, we used multiple imputation methods to obtain 9 complete versions of the data set and reimplemented the analyses. Those results are also provided in Table 3. The difference in the proportion of
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6-month prolonged abstinence rates between the 2 race groups seems to be largely the result of the differences in smoking history, and self-efficacy and motivation to quit between the 2 race groups, because the race effect odds ratio was greatly reduced after adjusting for each of these blocks of candidate risk adjustors. The 95% confidence intervals for the race effect odds ratio contain 1, after adjusting for each of these blocks (Table 3).
We examined whether a proactive-care smoking cessation intervention, designed to overcome barriers to use of tobacco treatment, would be especially effective at increasing prolonged smoking abstinence among African American smokers. This analysis did not reveal racial differences in the effectiveness of this intervention. However, we found higher rates of smoking abstinence among African American smokers than among White smokers. This finding contrasts with much of the existing research documenting lower rates of smoking cessation among African Americans. Several factors potentially explain the reverse racial disparity we found. First, unlike other populations that have been studied, African American VA patients in our sample did not use smoking cessation treatment less relative to Whites and, in fact, were more likely than Whites to use the combination of pharmacotherapy and counseling, which has been shown to be the most effective treatment of smoking. This is likely the result of the VA’s extensive efforts to deliver cessation services to all smokers, which includes holding facilities accountable through the use of performance measures. At the same time, and consistent with previous research, African Americans possessed more of the factors associated with successful smoking cessation, including those related to greater cessation self-efficacy and motivation and to smoking history: lower dependence on nicotine, smoking fewer than 10 cigarettes per day, and greater likelihood of having made a quit attempt in the past year. Indeed, subsequent analyses revealed that both of these contributed to greater cessation among African American smokers. It is also possible that African American and White VA patients differ in important ways (e.g., in terms of health
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and demographic characteristics, employment, and socioeconomic status) from those outside the VA and that those differences explain the differences between our finding and those of other investigations. Also, income differences between VA and non-VA users may be larger among Whites than among African Americans. Although we controlled for many factors known to contribute to quitting, unmeasured factors that differ between African Americans and Whites could explain the higher cessation rate among African Americans. Our finding that the proactive treatment intervention was not more effective among African Americans than Whites could be the result of the VA’s widespread efforts to provide smoking cessation services. It is important to note that the cessation rates among African American and White VA patients in our study (13% and 9%) are higher than the 6.2% population-level cessation rate in the total US population.41 In addition, many African American and White participants (42% and 41%) reported receiving some type of smoking cessation treatment in the year before the intervention. It may be that a proactive treatment intervention would be effective in reducing racial disparities in smoking cessation in other settings in which the likelihood of receiving smoking cessation treatment is lower, particularly for African Americans. It is also possible that if smoking cessation services were delivered more effectively, with fewer barriers to access, then smoking cessation rates among African American smokers would be higher and racial disparities in cessation rates would be reduced or nonexistent.
Limitations This study has several limitations. Because smoking abstinence was measured by selfreport and not biochemically verified, it is possible that demand characteristics could have led to underreporting of smoking status. Nonetheless, our use of self-reported smoking status is consistent with recommendations for population-based interventions,42 and the validity of self-reported smoking status has been supported by research showing very low rates of underreported smoking.43 Biochemical verification of 6-month abstinence, the study’s primary outcome, was also not possible. Although our findings could be the result of more
underreporting of smoking among African Americans (found in 1 previous study),44 the fact that African Americans in our sample had higher rates of many factors predictive of cessation argues against this explanation.
Human Participant Protection
Conclusions In contrast with previous studies conducted outside the VA, African Americans in the VA health care system quit at higher rates than Whites. These findings may be attributable, in part, to racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans as well as the large number of veterans receiving smoking cessation services and racial equity in receipt of these services. j
The Veterans Victory over Tobacco Study received approval from the participating sites’ institutional review boards: James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN; coordinating site).
References 1. King G, Polednak A, Bendel RB, Vilsaint MC, Nahata SB. Disparities in smoking cessation between African Americans and Whites: 1990---2000. Am J Public Health. 2004;94(11):1965---1971. 2. Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007;97(8):1503---1509.
About the Authors Diana J. Burgess, Siamak Noorbaloochi, Barbara Clothier, Brent C. Taylor, and Steven S. Fu are with the Center for Chronic Disease Outcomes Research, a VA Health Services Research and Development Center of Innovation, Minneapolis VA Health Care System, Minneapolis, MN. Michelle van Ryn is with Health Services Research, Mayo Clinic College of Medicine, Rochester, MN. Scott Sherman is with VA New York, Harbor Healthcare System and the Department of Population Health, New York University School of Medicine, New York, NY. Anne M. Joseph is with the Department of Medicine, University of Minnesota Medical School, Minneapolis. Correspondence should be sent to Diana J. Burgess, Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 25, 2014.
Contributors S. Sherman, A. M. Joseph, and S. S. Fu conceptualized the parent study design, drafted the study protocol, and contributed to the development of the study concept, design, and interpretation of the data. D. J. Burgess, M. van Ryn, S. Noorbaloochi, B. Clothier, and B. C. Taylor contributed to the development of the study concept, design, and conduct of the data analysis and interpretation of the data. D. J. Burgess led the preparation of the article, and all authors contributed to the revision of the article for important intellectual content and approved the final version of the article.
Acknowledgments This study was funded by the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and Health Services Research and Development (IAB-05-303) and registered in clinicaltrials.gov (NCT00608426). Note. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. S. S. Fu had full access to all of
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the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The funding agency had no role in the design and conduct of the study, collection, management, analysis and interpretation of the data; and preparation, review or approval of the article.
3. Trinidad DR, Perez-Stable EJ, White MM, Emery SL, Messer K. A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors. Am J Public Health. 2011;101 (4):699---706. 4. Trinidad DR, Gilpin EA, White MM, Pierce JP. Why does adult African-American smoking prevalence in California remain higher than for non-Hispanic Whites? Ethn Dis. 2005;15(3):505---511. 5. Lawrence D, Graber JE, Mills SL, Meissner HI, Warnecke R. Smoking cessation interventions in US racial/ethnic minority populations: an assessment of the literature. Prev Med. 2003;36(2):204---216. 6. Cokkinides VE, Halpern MT, Barbeau EM, Ward E, Thun MJ. Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey. Am J Prev Med. 2008;34(5):404---412. 7. Piper ME, Cook JW, Schlam TR, et al. Gender, race, and education differences in abstinence rates among participants in two randomized smoking cessation trials. Nicotine Tob Res. 2010;12(6):647---657. 8. Fu SS, Kodl MM, Joseph AM, et al. Racial/ethnic disparities in the use of nicotine replacement therapy and quit ratios in lifetime smokers ages 25 to 44 years. Cancer Epidemiol Biomarkers Prev. 2008;17(7):1640---1647. 9. Daza P, Cofta-Woerpel L, Mazas C, et al. Racial and ethnic differences in predictors of smoking cessation. Subst Use Misuse. 2006;41(3):317---339. 10. Hendricks PS, Westmaas JL, Ta Park VM, et al. Smoking abstinence-related expectancies among American Indians, African Americans, and women: potential mechanisms of tobacco-related disparities. Psychol Addict Behav. 2014; 28(1):193---205. 11. Rayens MK, Hahn EJ, Fernander A, Okoli CT. Racially classified social group differences in cigarette smoking, nicotine dependence, and readiness to quit. J Addict Nurs. 2013;24(2):71---81. 12. Kahende JW, Malarcher AM, Teplinskaya A, Asman KJ. Quit attempt correlates among smokers by race/ ethnicity. Int J Environ Res Public Health. 2011;8(10): 3871---3888.
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13. Fu SS, Sherman SE, Yano EM, van Ryn M, Lanto AB, Joseph AM. Ethnic disparities in the use of nicotine replacement therapy for smoking cessation in an equal access health care system. Am J Health Promot. 2005; 20(2):108---116. 14. Franks P, Fiscella K, Meldrum S. Racial disparities in the content of primary care office visits. J Gen Intern Med. 2005;20(7):599---603. 15. Houston TK, Scarinci IC, Person SD, Greene PG. Patient smoking cessation advice by health care providers: the role of ethnicity, socioeconomic status, and health. Am J Public Health. 2005;95(6):1056---1061. 16. Hymowitz N, Jackson J, Carter R, Eckholdt H. Past quit smoking assistance and doctors’ advice for White and African-American smokers. J Natl Med Assoc. 1996;88(4):249---252. 17. Ryan KK, Garrett-Mayer E, Alberg AJ, Cartmell KB, Carpenter MJ. Predictors of cessation pharmacotherapy use among Black and non-Hispanic White smokers. Nicotine Tob Res. 2011;13(8):646---652. 18. Fu SS, van Ryn M, Sherman SE, et al. Populationbased tobacco treatment: study design of a randomized controlled trial. BMC Public Health. 2012;12:159. 19. Fu SS, van Ryn M, Sherman SE, et al. Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial. JAMA Intern Med. 2014;174(5):671---677. 20. Robles GI, Singh-Franco D, Ghin HL. A review of the efficacy of smoking-cessation pharmacotherapies in nonwhite populations. Clin Ther. 2008;30(5):800--812. 21. Delnevo CD, Gundersen DA, Hrywna M, Echeverria SE, Steinberg MB. Smoking-cessation prevalence among US smokers of menthol versus non-menthol cigarettes. Am J Prev Med. 2011;41(4):357---365. 22. Moritsugu KP. The 2006 Report of the Surgeon General: the health consequences of involuntary exposure to tobacco smoke. Am J Prev Med. 2007;32(6): 542---543. 23. Slopen N, Dutra LM, Williams DR, et al. Psychosocial stressors and cigarette smoking among African American adults in midlife. Nicotine Tob Res. 2012;14 (10):1161---1169. 24. Nguyen KH, Subramanian SV, Sorensen G, Tsang K, Wright RJ. Influence of experiences of racial discrimination and ethnic identity on prenatal smoking among urban Black and Hispanic women. J Epidemiol Community Health. 2012;66(4):315---321. 25. Corral I, Landrine H. Racial discrimination and health-promoting vs damaging behaviors among African-American adults. J Health Psychol. 2012;17(8): 1176---1182. 26. Etter JF, Perneger TV. Attitudes toward nicotine replacement therapy in smokers and ex-smokers in the general public. Clin Pharmacol Ther. 2001;69(3):175--183. 27. Biener L, Abrams DB. The contemplation ladder: validation of a measure of readiness to consider smoking cessation. Health Psychol. 1991;10(5):360---365. 28. Pearlin LI, Schooler C. The structure of coping. J Health Soc Behav. 1978;19(1):2---21. 29. Hughes JR, Keely JP, Niaura RS, Ossip-Klein DJ, Richmond RL, Swan GE. Measures of abstinence in clinical trials: issues and recommendations. Nicotine Tob Res. 2003;5(1):13---25.
30. Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA, Ambulatory Care Quality Improvement Project (ACQUIP). The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Arch Intern Med. 1998;158 (16):1789---1795. 31. California Adult Tobacco Survey: 2008 Questionnaire. California Department of Public Health. December 3, 2007. Available at: http:// www.cdph.ca.gov/programs/tobacco/Documents/ CTCPCaliforniaAdultTobaccoSurvey2008.pdf. Accessed July 7, 2014. 32. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2006. Available at: http://www.cdc.gov/brfss/ annual_data/pdf-ques/2007BRFSS.pdf. Accessed July 7, 2014. 33. Heatherton TF, Kozlowski LT, Frecker RC, Rickert W, Robinson J. Measuring the heaviness of smoking: using self-reported time to the first cigarette of the day and number of cigarettes smoked per day. Br J Addict. 1989;84(7):791---799. 34. Davis RM. Healthcare report cards and tobacco measures. Tob Control. 1997;6(suppl 1):S70---S77. 35. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. 2004;19(2):101---110. 36. Baldwin AS, Rothman AJ, Hertel AW, et al. Specifying the determinants of the initiation and maintenance of behavior change: an examination of self-efficacy, satisfaction, and smoking cessation. Health Psychol. 2006;25(5):626---634. 37. Dijkstra A, De Vries H. Self-efficacy expectations with regard to different tasks in smoking cessation. Psychol Health. 2000;15(4):501---511. 38. Kessler RC, Mickelson KD, Williams DR. The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. J Health Soc Behav. 1999;40(3):208---230. 39. Wahl OF. Mental health consumers’ experience of stigma. Schizophr Bull. 1999;25(3):467---478. 40. Fu SS, van Ryn M, Sherman SE, et al. Proactive tobacco treatment and population-level cessation: a pragmatic randomized controlled trial. JAMA Intern Med. 2014;174(5):671---677. 41. Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001---2010. MMWR Morb Mortal Wkly Rep. 2011;60(44):1513--1519. 42. SRNT Subcommittee on Biochemical Verification. Biochemical verification of tobacco use and cessation. Nicotine Tob Res. 2002;4(2):149---159. 43. Yeager DS, Krosnick JA. The validity of self-reported nicotine product use in the 2001---2008 National Health and Nutrition Examination Survey. Med Care. 2010; 48(12):1128---1132. 44. Wagenknecht LE, Burke GL, Perkins LL, Haley NJ, Friedman GD. Misclassification of smoking status in the CARDIA study: a comparison of self-report with serum cotinine levels. Am J Public Health. 1992;82(1):33---36.
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Smoking Cessation Among African American and White Smokers in the Veterans Affairs Health Care System Diana J. Burgess, PhD, Michelle van Ryn, PhD, MPH, Siamak Noorbaloochi, PhD, Barbara Clothier, MS, MA, Brent C. Taylor, PhD, Scott Sherman, MD, MPH, Anne M. Joseph, MD, MPH, and Steven S. Fu, MD, MSCE
Numerous studies have found that African American smokers are less likely than White smokers to quit successfully.1---8 These disparities in quit rates exist despite the fact that African American smokers report stronger motivation and readiness to quit, are more likely to believe they will be able to quit successfully,9---11 and are more likely to make quit attempts than Whites.12,13 Evidence has suggested that an important contributor to racial differences in cessation rates is African Americans’ lower use of evidence-based cessation treatment. Specifically, African Americans are less likely to be screened for nicotine use, to receive cessation advice, and to be prescribed nicotine replacement treatment (NRT) than Whites.3,6,8,13---17 African Americans are also less likely to believe that NRT and formal smoking cessation treatment are effective and have less favorable attitudes toward pharmacotherapy than Whites.10,17 Taken together, this research has suggested that increasing the use of evidencebased cessation treatment among African Americans may be a promising way to reduce racial disparities in cessation. The Veterans Victory over Tobacco (Victory) study, a pragmatic randomized controlled trial, assessed the effects of a proactive-care smoking cessation intervention, designed to increase the reach of evidence-based cessation treatment, on smoking abstinence rates among a diverse population of smokers enrolled in the Veterans Health Administration.18 In this intervention, smokers were identified through electronic medical records and offered the choice of telephone or face-to-face care for treatment of tobacco dependence. Main effects of this study, which have already been published, revealed a significant 2.6% absolute increase in population-level smoking cessation rates in the proactive-care condition over usual care.19 This study is a secondary analysis of data from the Victory study to determine
Objectives. We examined whether a proactive care smoking cessation intervention designed to overcome barriers to treatment would be especially effective at increasing cessation among African Americans receiving care in the Veterans Health Administration. Methods. We analyzed data from a randomized controlled trial, the Veterans Victory over Tobacco study, involving a population-based electronic registry of current smokers (702 African Americans, 1569 Whites) and assessed 6-month prolonged smoking abstinence at 1 year via a follow-up survey of all current smokers. We also examined candidate risk adjustors for the race effect on smoking abstinence. Results. The interaction between patient race and intervention condition (proactive care vs usual care) was not significant. Overall, African Americans had higher quit rates than Whites (13% vs 9%; P < .006) regardless of condition. Conclusions. African Americans quit at higher rates than Whites. These findings may be a result of the large number of veterans receiving smoking cessation services and the lack of racial differences in receipt of these services as well as racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans. (Am J Public Health. 2014;104:S580–S587. doi:10. 2105/AJPH.2014.302023)
whether the effects of treatment differ by race and, secondarily, to explore baseline factors that might account for the association between race and smoking cessation. Our hypothesis was that a proactive, population-based tobacco cessation care model, with low barriers to access, would have greater benefit among African American smokers than White smokers because the former are less likely to have received prior pharmacotherapy or counseling.3,6,8,13---17
METHODS The Victory study was a pragmatic randomized controlled trial. Details of the design and methods have previously been described.18,19 The 4 participating sites were the James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G. V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN, the coordinating site). The study sites were selected
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to ensure adequate inclusion of racial/ethnic minorities. Participants were recruited from October 2009 to September 2010, and followup was completed in November 2011. Current smokers (aged 18---80 years) were identified using the US Department of Veterans Affairs’ (VA’s) electronic medical record health factor data set and, separately at each site, were randomized to either proactive care or usual care. Therefore, our sample was a stratified sample (stratified by site), and the clinical trial was a completely randomized repeatedmeasures block design. The proactive-care condition consisted of proactive outreach (mail followed by telephone outreach) combined with an offer of the choice of telephone or in-person smoking cessation services. Participants interested in in-person services were connected with their local VA hospital’s smoking cessation program. Telephone services combined proactive phonebased counseling delivered by counselors at the Minneapolis VA with increased access to smoking cessation medications from the VA.
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TABLE 1—Characteristics of White and African American Participants: Veterans Victory Over Tobacco Study, United States, 2009–2011 Characteristic
White (n = 1569), No. (%) or Mean 6SE
African American (n = 702), No. (%) or Mean 6SE
P
Control variables Male
1491 (95)
653 (93)
.04
Age, y Smoking-related cardiovascular disease
59.5 60.3 518 (33)
56.9 60.3 140 (20)
£ .001 £ .001
Smoking-related respiratory disease
377 (24)
91 (13)
£ .001
Audit-C Score
3.0 60.1
3.5 60.1
.002
Social network Married or living with significant other
832 (53)
309 (44)
£ .001
Living with other smoker
675 (43)
253 (36)
£ .001
Not allowed anywhere Allowed in some places or some times
659 (42) 314 (20)
229 (33) 174 (25)
Allowed anywhere
596 (38)
299 (43)
266 (17)
113 (16)
£ .001
Home smoking rules
Friends who smoke None
.208
< half
435 (28)
225 (32)
About half
355 (23)
140 (20)
> half
311 (20)
126 (18)
202 (13)
98 (14)
Strongly disagree to neutral
361 (23)
134 (19)
Somewhat agree
377 (24)
140 (20)
Strongly agree
831 (53)
428 (61)
465 (30)
257 (37)
544 (35)
217 (31)
560 (36) Socioeconomic status
228 (32)
All Supportive others
.006
Smoking stigma Low Middle High
.01
Education 130 (8)
63 (9)
High school graduate or GED
647 (41)
288 (41)
Some college
600 (38)
295 (42)
‡ bachelor’s degree
192 (12)
56 (8)
467 (30) 169 (11)
218 (31) 111 (16)
£ .001
Employment status Employed Unemployed Retired
482 (31)
137 (20)
Unable to work
451 (29)
236 (34)
192 (12)
183 (26)
£ .001
Income, $ < 10 000
Data Collection
.053
£ 11th grade
10 000–20 000
475 (30)
239 (34)
20,001–40 000
522 (33)
182 (26)
‡ 40,001
380 (24)
98 (14)
Data collection occurred at baseline and 1 year after randomization. We obtained VA administrative and health care utilization data from the VA National Patient Care Databases. Survey data were collected at baseline and at 1-year follow-up. The baseline and follow-up survey procedures used a modified Dillman protocol (mail + postcard reminder + mail + mail) and included a $10 cash incentive with the first survey mailing. The follow-up survey protocol was similar to the baseline survey protocol but included an additional letter before the first survey mailing and telephone contact of those who did not respond to the mailed survey.
Measures Continued
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Those in the usual-care condition did not receive proactive outreach and did not have access to the telephone smoking cessation services offered by the counselors at the Minneapolis VA; this group did have access to tobacco treatment services from their local VA hospital and their state telephone quit line. National VA guidelines mandate screening for tobacco use, advising tobacco users to quit, and offering tobacco treatment (i.e., pharmacotherapy and counseling), and VA hospitals are held accountable through the use of performance measures determined by external audit of medical records. The primary analytical sample for the parent study included 5123 participants who were both randomized and fully eligible. Within this primary analytical sample, 2519 participants received the proactive-care intervention, and 2604 participants received usual care. Analyses examining the race · treatment effect were based on the 2271 participants who identified themselves as either White (1569) or African American (702) and who returned the baseline survey, which contained all of the questions assessing factors that might contribute to racial differences in cessation (except for perceived discrimination, which was assessed at followup) and who had complete 6-month prolonged abstinence data.
We included a number of potential factors that might account for racial differences in cessation and the interaction between race and the intervention. We included prior
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TABLE 1—Continued Smoking history Longest quit length
.008
Never quit
137 (9)
73 (10)
< 1 mo
373 (24)
214 (30)
1 mo to < 6 mo
435 (28)
183 (26)
624 (40)
232 (33)
> 30
361 (23)
239 (34)
6–30
879 (56)
337 (48)
£5
329 (21)
126 (18)
Smokes menthol cigarettes
251 (16)
548 (78)
£ .001
Quit in past y
785 (50)
456 (65)
£ .001
361 (23) 754 (48)
393 (56) 267 (38)
‡ 6 mo Time to first cigarette, min
£ .001
£ .001
Cigarettes per d £ 10 11–20 ‡ 21 Age at smoking initiation, y
454 (29)
42 (6)
16.7 60.1
18.7 60.2
£ .001
SC treatment history SC treatment used in previous y at baseline
.006
None
922 (59)
404 (58)
Meds only
481 (31)
187 (27)
Counseling only Meds and counseling
45 (3) 121 (8)
35 (5) 76 (11)
518 (33)
232 (33)
Very satisfied with VA help with SC Satisfaction with VA process of obtaining SC meds Very satisfied
412 (26)
Somewhat satisfied
161 (10)
67 (10)
Very dissatisfied to neutral
396 (25)
148 (21)
Never received help
600 (38)
281 (40)
Self-efficacy scores Globalb Emotional
.939 .18
206 (29)
2.1 60.0
2.8 60.1
£ .001
–0.14 60.08
–0.53 60.05
£ .001
Social subscale
0.07 60.04
0.31 60.07
.005
Skill subscale
–0.24 60.05
–0.10 60.08
.137
20.8 60.1
21.6 60.2
£ .001
Readiness to quitc
5.5 60.1
6.2 60.1
£ .001
Perceived discriminationd
6.2 60.1
8.1 60.2
£ .001
Mastery
Attitudes toward nicotine replacement therapy Advantages Drawbacks (reverse scored)
3.57 60.02
3.50 60.03
.082
3.07 60.02
2.74 60.03
£ .001
Note. Audit-C = Alcohol Use Disorders Identification Test; SC = smoking cessation; VA = Veterans Affairs. Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN) a Median score for Whites, 1.4; for African Americans, 2.5. b Median score for Whites, 1.6; for African Americans, 2.4 c Median score for Whites, 4.7; for African Americans, 5.6 d Median score for Whites, 5.3; for African Americans, 7.6.
utilization of smoking cessation treatment because it might plausibly contribute to greater effectiveness of the intervention with African
Americans than with Whites; the intervention might have a stronger effect among smokers who had not previously received
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pharmacotherapy or counseling (and who were more likely to be African American).3,6,8,13---17 Similarly, we also explored whether the intervention would be especially effective among smokers with baseline negative attitudes toward NRT, who were also more likely to be African American.10,17 In addition, we included factors that were likely to contribute to lower quit rates among African Americans, such as use of menthol cigarettes,3,20,21 social network characteristics (e.g., the presence of home smoking bans),3,22 and prior experiences of discrimination, which African Americans experience at a greater rate and has been associated with increased smoking.23---28 We also included facilitators to quitting that have been shown to be more prevalent among African Americans, such as self-efficacy and motivation related to quitting,9---11 and factors related to prior smoking and cessation, such as having made a prior quit attempt,12,13 being a light smoker,3 and longer time to first cigarette.3 Six-month smoking abstinence. The primary outcome was a 6-month period of smoking abstinence 1 year after randomization.29 To assess population-level cessation, we assessed 6-month smoking abstinence with the 1-year follow-up survey among all current smokers irrespective of treatment use or interest in quitting. Race. We obtained race from the baseline survey unless it was missing. We then populated missing self-reported race with race obtained from the National Patient Care Databases. Gender, age, and smoking-related health conditions were also obtained from the databases. We assessed alcohol use with the Alcohol Use Disorders Identification Test score30 obtained from the baseline survey. Candidate risk adjustors. We examined measures for each of the 7 blocks of candidate risk adjustors that might account for racial differences in smoking cessation: (1) smoking history, (2) smoking cessation treatment history, (3) smoking cessation self-efficacy and motivation to quit, (4) attitudes toward NRT, (5) social network characteristics related to smoking, (6) perceived discrimination, and (7) socioeconomic status. All of these potential risk adjustors were measured at baseline, with the exception of perceived discrimination, which was measured at follow-up.
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TABLE 2—Adjusted Odds Ratios and 95% Confidence Intervals From Logistic Regressions Relating 6-Month Abstinence to Measure: Veterans Victory Over Tobacco Study, United States, 2009–2011 Measure
OR (95% CI)
Proactive outreach (vs usual care)
1.64* (1.23, 2.18)
African American (vs White)
1.59* (1.13, 2.24) Control variables
Male (vs female) Age (per point increase in years)
0.93 (0.49, 1.76) 1.01 (0.99, 1.02)
Smoking-related CHD (vs not)
1.13 (0.82, 1.55)
Smoking-related respiratory (vs not)
0.81 (0.55, 1.17)
Audit-C Score (per unit increase)
0.96 (0.92, 1.01) Social network characteristics
Married or living with significant other (vs not)
1.13 (0.85, 1.50)
Living with other smoker (vs not)
0.62* (0.46, 0.84)
Home smoking rules Not allowed anywhere
2.02* (1.45, 2.82)
Allowed in some places or some times
1.16 (0.77, 1.76)
Allowed anywhere (Ref)
1.00
Friends who smoke None
1.94* (1.09, 3.44)
< half
1.99* (1.17, 3.38)
About half
1.27 (0.71, 2.26)
> half All (Ref)
1.27 (0.70, 2.28) 1.00
Supportive others Strongly agree
1.49* (1.01, 2.19)
Somewhat agree
0.97 (0.60, 1.57)
Strongly disagree to neutral (Ref)
1.00
Smoking stigma Low
1.04 (0.73, 1.48)
Middle High (Ref)
1.01 (0.71, 1.44) 1.00 Socioeconomic status
Education ‡ bachelor’s degree
1.92 (0.97, 3.79)
Some college
1.23 (0.67, 2.26)
High school graduate or GED
1.56 (0.86, 2.82)
£ 11th grade (Ref)
1.00
Employment status Employed (Ref) Unemployed
1.00 0.97 (0.59, 1.59)
Retired
1.41 (0.92, 2.16)
Unable to work
0.92 (0.63, 1.36)
Income, $ < 10 000 (ref)
1.00
10 000–20 000
0.81 (0.52, 1.25)
20 000–40 000 ‡ 40 000
1.01 (0.66, 1.55) 0.94 (0.58, 1.52) Continued
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We collected information regarding smoking history, such as age of initiation, longest quit attempt, previous quit attempts, and prior use of tobacco treatment using standard questions from the California Tobacco Survey31 and the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance Survey.32 We assessed nicotine dependence with the 2-question Heaviness of Smoking Index (cigarettes per day and time to first cigarette after waking).33 We also ascertained use of menthol cigarettes and satisfaction in regard to prior smoking cessation help from the VA. Standard tobacco performance measures assessed participants’ receipt of smoking cessation advice, counseling, and treatment from their VA primary care provider.34 We used questions from the Commonwealth Fund Survey to assess patients’ satisfaction with help received from their VA provider to quit smoking and with the process of obtaining smoking cessation medications from the VA.35 We assessed self-efficacy and motivation to quit with a global measure of self-efficacy to quit36 and 3 self-efficacy subscales (emotional, social, and skill self-efficacy),37 a Mastery scale (measured using a standard 7-item questionnaire assessing the control one feels over one’s life),28 and the readiness to quit ladder.27 Attitudes toward smoking cessation medication were assessed using the 12-item Attitudes toward Nicotine Replacement Therapy scale.26 On the follow-up survey, we assessed perceived discrimination with 9 questions asking about the frequency of exposure to experiences of discrimination, such as being treated with less courtesy or less respect or being harassed.38 Social network characteristics included questions assessing subjective norms related to smoking, smoking habits of friends and family, and home smoking rules. Questions concerning smoking stigma, the concept that one feels stigmatized because of one’s smoking behavior, were adapted from the Mental Health Consumers’ Experience of Stigma.39 We also included marital status (obtained from the baseline survey and National Patient Care Databases). We assessed socioeconomic status by income, education, and employment, obtained from the baseline survey.
Statistical Analysis For the primary analysis, we used logistic regression (SAS version 9.2, SAS Institute Inc.,
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TABLE 2—Continued Smoking history Longest quit length Never quit (Ref)
1.00
< 1 mo
1.24 (0.62, 2.48)
1 mo to < 6 mo
1.69 (0.86, 3.32)
‡ 6 mo Time to first cigarette
2.75* (1.44, 5.24)
> 30 min
3.25* (2.06, 5.13)
6–30 min
1.33, (0.84, 2.10)
£ 5 min (Ref)
1.00
Smokes menthol cigarettes (vs not)
1.01 (0.70, 1.47)
Quit in past y (vs not)
2.48* (1.79, 3.44)
Cigarettes per d £ 10 11–20
3.45* (2.14, 5.58) 1.41 (0.87, 2.27)
‡ 21 (Ref)
Cary, NC) to measure the effect of race on the primary outcome, 6-month abstinence. The initial model included race, treatment, site, and the treatment · race interaction. We used the weighted stratified Wald v2 test to assess categorical characteristics by race. Continuous covariates by race were assessed using a weighted stratified Wald F test. The weights were the inverses of the sampling proportion from each site. Because we wanted to see whether blocks of candidate risk adjustors helped explain the race effect, we ran a model to obtain the race effect odds ratio before and after adjusting for the 7 blocks of candidate risk adjustors.
RESULTS
1.00
Age at smoking initiation (per unit increase)
1.01 (0.99, 1.04) SC treatment history
SC treatment used in previous year at baseline None (Ref)
1.00
Meds only
0.85 (0.61, 1.18)
Counseling only Meds and counseling
1.39 (0.70, 2.72) 0.99 (0.61, 1.61)
Very satisfied with VA help with SC (vs not)
1.59* (1.18, 2.13)
Satisfaction with VA process of obtaining SC meds Very satisfied
1.02 (0.71, 1.46)
Somewhat satisfied
1.10 (0.68, 1.80)
Very dissatisfied to neutral
0.72 (0.47, 1.09)
Never received help (Ref)
1.00
Self-efficacy, per-unit increase Global
1.38* (1.24, 1.52)
Emotional subscale
1.30* (1.19, 1.41)
Social subscale
1.28* (1.18, 1.39)
Skill subscale
1.38* (1.25, 1.52)
Mastery
1.04* (1.00, 1.08)
Readiness to quit
1.34* (1.23, 1.46)
Perceived discrimination Attitudes toward NRT, per-unit increase Advantages Drawbacks (reverse scored)
0.97 (0.94, 1.00) 1.30* (1.06, 1.60) 1.11 (0.93, 1.31)
Note. CHD = coronary heart disease; CI = confidence interval; NRT = nicotine replacement treatment; OR = odds ratio; SC = smoking cessation; VA = Veterans Affairs. Values are based on the 1569 Whites and 702 African Americans who returned the baseline and follow-up surveys. Some measures have missing values. NRT drawbacks and NRT advantages were missing the most often, 249 (11%) and 272 (12%), respectively. ORs are adjusted for facility, experimental condition, race, and control variables (gender, age, smoking-related cardiovascular disease, smoking-related respiratory disease, and Audit-C score). Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN) *P < .05.
The interaction between patient race (African American vs White) and intervention condition (proactive treatment vs usual care) on population-level 6-month prolonged smoking abstinence was not significant (P = .823). However, we found a main effect of race; African Americans had higher 6-month prolonged abstinence rates than Whites (13% vs 9%; P = .006; odds ratio [OR] = 1.57; 95% confidence interval [CI] = 1.14, 2.15).
Candidate Risk Adjustors We performed secondary analyses aimed at understanding which block or blocks of candidate risk adjustors might explain this main effect of race on 6-month abstinence, irrespective of experimental condition. We did not examine the potential factors that contributed to the effect of treatment. We investigated candidate risk adjustors, comparing the race-effect ORs from larger models that included a specific set of candidate risk adjustors with odds ratios obtained from a simpler model that contained only the study design variables (site and treatment), race, demographics (gender and age), and health characteristics (smoking-related cardiovascular or respiratory disorders and Alcohol Use Disorders Identification Test score). We used multiple imputation methods to account for missingness with the candidate risk adjustors.
Baseline Characteristics by Race Baseline characteristics did not differ between the usual-care and intervention
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TABLE 3—Risk-Adjusted Race Effect Odds Ratios and 95% Confidence Intervals From Logistic Regressions Relating 6-Month Abstinence to Race Controlling for Risk Adjustor Block: Veterans Victory Over Tobacco Study, United States, 2009–2011 Risk Adjustor Block
Race Effect Using All Available Cases, OR (95% CI)
Race Effect Using Multiple Imputation Methods, OR (95% CI)
Smoking history
1.00 (0.64, 1.57)
1.17 (0.78, 1.76)
Smoking cessation treatment history Smoking cessation self-efficacy
1.51 (1.05, 2.17) 1.17 (0.78, 1.76)
1.62 (1.16, 2.25) 1.25 (0.89, 1.77)
Perceived discrimination
1.56 (1.08, 2.24)
1.70 (1.22, 2.36)
Attitudes toward nicotine replacement therapy
1.69 (1.17, 2.45)
1.66 (1.19, 2.32)
Social network characteristics related to smoking
1.45 (1.00, 2.09)
1.56 (1.11, 2.18)
Socioeconomic status
1.61 (1.12, 2.32)
1.65 (1.18, 2.31)
All blocks
1.14 (0.59, 2.18)
1.26 (0.81, 1.95)
DISCUSSION
Note. CI = confidence interval; OR = odds ratio. Each model contained the following independent variables: facility, experimental condition, race, gender, age, smoking-related cardiovascular disease, smoking-related respiratory disease, Audit-C score, and risk-adjustor block. Veterans Victory Over Tobacco Study locations were James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN)
groups.40 However, we found several differences in baseline characteristics between African American and White participants (Table 1). Compared with Whites, African Americans were younger, less likely to have smokingrelated coronary heart disease or respiratory disorders, and had greater alcohol use. They had lower income, were less likely to be retired, and were more likely to be unemployed or unable to work. African Americans were more likely to smoke menthol cigarettes, had a shorter time to 1st cigarette, were more likely to be light smokers (smoking £ 10 cigarettes per day), and were more likely to have made a quit attempt in the past year but less likely to have quit for 6 months or more. African Americans were more likely to report receiving both pharmacotherapy and counseling or counseling only, whereas Whites were more likely to report using pharmacotherapy only (both inside and outside the VA). African Americans reported higher levels of mastery, social, and global self-efficacy and greater readiness to quit but reported lower emotional self-efficacy and perceived more disadvantages of nicotine replacement therapy. African Americans also reported higher levels of perceived discrimination (assessed at follow-up). African Americans were less likely to live with another smoker and were more likely to have important others who supported their quitting; however, they were less likely to have stringent home smoking rules.
Table 2 presents the association of each characteristics with 6-month abstinence, controlling for study design, race, and other controlling covariates. Smoking abstinence was more likely among patients in the proactive outreach condition and among African American patients. Smoking abstinence was less likely among those who lived with another smoker and more likely among those who had a complete nonsmoking ban and fewer friends who smoked and others who supported their quitting. Smoking abstinence was also associated with having previously quit for 6 months or longer, having quit in the past year, having a time to first cigarette of less than 30 minutes, and being a light smoker. Higher scores on global self-efficacy, the self-efficacy subscales, mastery, and readiness to quit all were associated with smoking abstinence, as was greater satisfaction with VA help with cessation and more positive beliefs in the advantages of NRT. Table 3 presents the results of the model to obtain the race effect odds ratio, in which each model used all of the available cases for that specific model. Because 42% of the 2271 participants were missing at least 1 of the covariates being considered, we used multiple imputation methods to obtain 9 complete versions of the data set and reimplemented the analyses. Those results are also provided in Table 3. The difference in the proportion of
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6-month prolonged abstinence rates between the 2 race groups seems to be largely the result of the differences in smoking history, and self-efficacy and motivation to quit between the 2 race groups, because the race effect odds ratio was greatly reduced after adjusting for each of these blocks of candidate risk adjustors. The 95% confidence intervals for the race effect odds ratio contain 1, after adjusting for each of these blocks (Table 3).
We examined whether a proactive-care smoking cessation intervention, designed to overcome barriers to use of tobacco treatment, would be especially effective at increasing prolonged smoking abstinence among African American smokers. This analysis did not reveal racial differences in the effectiveness of this intervention. However, we found higher rates of smoking abstinence among African American smokers than among White smokers. This finding contrasts with much of the existing research documenting lower rates of smoking cessation among African Americans. Several factors potentially explain the reverse racial disparity we found. First, unlike other populations that have been studied, African American VA patients in our sample did not use smoking cessation treatment less relative to Whites and, in fact, were more likely than Whites to use the combination of pharmacotherapy and counseling, which has been shown to be the most effective treatment of smoking. This is likely the result of the VA’s extensive efforts to deliver cessation services to all smokers, which includes holding facilities accountable through the use of performance measures. At the same time, and consistent with previous research, African Americans possessed more of the factors associated with successful smoking cessation, including those related to greater cessation self-efficacy and motivation and to smoking history: lower dependence on nicotine, smoking fewer than 10 cigarettes per day, and greater likelihood of having made a quit attempt in the past year. Indeed, subsequent analyses revealed that both of these contributed to greater cessation among African American smokers. It is also possible that African American and White VA patients differ in important ways (e.g., in terms of health
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and demographic characteristics, employment, and socioeconomic status) from those outside the VA and that those differences explain the differences between our finding and those of other investigations. Also, income differences between VA and non-VA users may be larger among Whites than among African Americans. Although we controlled for many factors known to contribute to quitting, unmeasured factors that differ between African Americans and Whites could explain the higher cessation rate among African Americans. Our finding that the proactive treatment intervention was not more effective among African Americans than Whites could be the result of the VA’s widespread efforts to provide smoking cessation services. It is important to note that the cessation rates among African American and White VA patients in our study (13% and 9%) are higher than the 6.2% population-level cessation rate in the total US population.41 In addition, many African American and White participants (42% and 41%) reported receiving some type of smoking cessation treatment in the year before the intervention. It may be that a proactive treatment intervention would be effective in reducing racial disparities in smoking cessation in other settings in which the likelihood of receiving smoking cessation treatment is lower, particularly for African Americans. It is also possible that if smoking cessation services were delivered more effectively, with fewer barriers to access, then smoking cessation rates among African American smokers would be higher and racial disparities in cessation rates would be reduced or nonexistent.
Limitations This study has several limitations. Because smoking abstinence was measured by selfreport and not biochemically verified, it is possible that demand characteristics could have led to underreporting of smoking status. Nonetheless, our use of self-reported smoking status is consistent with recommendations for population-based interventions,42 and the validity of self-reported smoking status has been supported by research showing very low rates of underreported smoking.43 Biochemical verification of 6-month abstinence, the study’s primary outcome, was also not possible. Although our findings could be the result of more
underreporting of smoking among African Americans (found in 1 previous study),44 the fact that African Americans in our sample had higher rates of many factors predictive of cessation argues against this explanation.
Human Participant Protection
Conclusions In contrast with previous studies conducted outside the VA, African Americans in the VA health care system quit at higher rates than Whites. These findings may be attributable, in part, to racial differences in smoking history, self-efficacy, and motivation to quit that favor African Americans as well as the large number of veterans receiving smoking cessation services and racial equity in receipt of these services. j
The Veterans Victory over Tobacco Study received approval from the participating sites’ institutional review boards: James A. Haley VA Medical Center (Tampa, FL), New York Harbor VA Medical Center (New York, NY), G.V. (Sonny) Montgomery VA Medical Center (Jackson, MS), and Minneapolis VA Medical Center (Minneapolis, MN; coordinating site).
References 1. King G, Polednak A, Bendel RB, Vilsaint MC, Nahata SB. Disparities in smoking cessation between African Americans and Whites: 1990---2000. Am J Public Health. 2004;94(11):1965---1971. 2. Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007;97(8):1503---1509.
About the Authors Diana J. Burgess, Siamak Noorbaloochi, Barbara Clothier, Brent C. Taylor, and Steven S. Fu are with the Center for Chronic Disease Outcomes Research, a VA Health Services Research and Development Center of Innovation, Minneapolis VA Health Care System, Minneapolis, MN. Michelle van Ryn is with Health Services Research, Mayo Clinic College of Medicine, Rochester, MN. Scott Sherman is with VA New York, Harbor Healthcare System and the Department of Population Health, New York University School of Medicine, New York, NY. Anne M. Joseph is with the Department of Medicine, University of Minnesota Medical School, Minneapolis. Correspondence should be sent to Diana J. Burgess, Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, One Veterans Drive, Minneapolis, MN 55417 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted March 25, 2014.
Contributors S. Sherman, A. M. Joseph, and S. S. Fu conceptualized the parent study design, drafted the study protocol, and contributed to the development of the study concept, design, and interpretation of the data. D. J. Burgess, M. van Ryn, S. Noorbaloochi, B. Clothier, and B. C. Taylor contributed to the development of the study concept, design, and conduct of the data analysis and interpretation of the data. D. J. Burgess led the preparation of the article, and all authors contributed to the revision of the article for important intellectual content and approved the final version of the article.
Acknowledgments This study was funded by the US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and Health Services Research and Development (IAB-05-303) and registered in clinicaltrials.gov (NCT00608426). Note. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. S. S. Fu had full access to all of
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the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The funding agency had no role in the design and conduct of the study, collection, management, analysis and interpretation of the data; and preparation, review or approval of the article.
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