VOLUME 39 NUMBER 2 MARCH/APRIL 2015 Subjective Social Status and Readiness to Quit among Homeless Smokers Lorra Garey, Lorraine R. Reitzel, Jafar Bakhshaie, Darla E. Kendzor, Michael J. Zvolensky, Michael S. Businelle Predicting General Practice Attendance for Follow-up Cancer Care Irene Ngune, Moyez Jiwa, Alexandra McManus, Richard Parsons, Rupert Hodder Measurement Properties of the Sedentary Behavior Strategy Self-management Instrument in African-American Breast Cancer Survivors Raheem J. Paxton, Yong Gao, Stephen D. Herrmann, Gregory J. Norman Coping Mediates the Effects of Depressive Symptoms on Sleep Problems Selena T. Nguyen-Rodriquez, Nadra E. Lisha, Donna Spruijt-Metz, Ping Sun, Louise A. Rohrbach, Steve Sussman Social Spport, Stress, and Suicidal Ideation in Professional Firefighters Grace Stephanie J. Carpenter, Thomas P. Carpenter, Nathan A. Kimbrel, Elisa J. Flynn, Michelle L. Pennington, Claire Cammarata, Rose T. Zimering, Barbara W. Kamholz, Suzy B. Gulliver Getting Youth to Check it Out!® A New Approach to Teaching Self-screening Resa M. Jones, Ian J. Wallace, Alice Westerberg, Kristyn N. Hoy, John M. Quillin, Steven J. Danish HPV Awareness, Knowledge and Attitudes among Older African-American Women Kellie L. Watkins, Lorraine R. Reitzel, David W. Wetter, Lorna H. McNeill Men's Help-seeking Behavior with Regards to Lower Bowel Symptoms Devesh V. Oberoi, Moyez Jiwa, Alexandra McManus, Rupert Hodder Health Priorities among Women Recently Released from Jail Megha Ramaswamy, Satyasree Upadhyayula, Ka Yee Clara Chan, Kylie Rhodes, April Leonardo Social Contingencies and College Quit and Win Contest: A Qualitative Inquiry Janet L. Thomas, Jill E. Bengtson, Winta Ghidei, Meredith Schreier, Qi Wang, Xianghua Luo, Katherine Lust, Jasjit S. Ahluwalia Walk ScoreTM, Perceived Neighborhood Walkability, and Walking in the US Peter Tuckel, William Milczarski Health Behaviors and Perceptions of Cancer Survivors Harvesting at an Urban Garden Colleen K. Spees, Alexis Joseph, Amy Darragh, Felisha Lyons, Kay N. Wolf Adolescent Girls' Experiences in the Go Girls! Group-Based Lifestyle Mentoring Program A. Justine Dowd, Samantha M. Harden, Mark R. Beauchamp Dual Use of Smokeless Tobacco or E-cigarettes with Cigarettes and Cessation Sara Kalkhoran, Rachel A. Grana, Torsten B. Neilands, Pamela M. Ling Cultural Beliefs and Physical Activity among African-American Adolescents Herpreet Thind, TaShauna U. Goldsby, Akilah Dulin-Keita, Monica L. Baskin

Subjective Social Status and Readiness to Quit among Homeless Smokers Lorra Garey, BA; Lorraine R. Reitzel, PhD; Jafar Bakhshaie, MD; Darla E. Kendzor, PhD; Michael J. Zvolensky, PhD; Michael S. Businelle, PhD Objectives: To explore the predictive value of subjective social status (SSSUS and SSS-Community) on readiness to quit among 245 homeless smokers. Methods: Hierarchical multiple regression analyses were conducted (stratified by sex). Results: Higher SSS-US (p = .02) and SSS-Community (p < .001) predicted greater readiness to quit in the total sample. These relationships upheld for men (p’s .05), or readiness to quit (Men: M = 5.89; SD = 1.84; Women: M = 5.77; SD = 2.06; t[243] = 0.42, p > .05). Men (M = 44.45; SD = 10.93) were significantly older than women (M = 41.16; SD = 12.29; t[243] = 2.06, p = .04), men were significantly more likely to report no current partner (χ2[1] = 27.93, p < .001), and there were significantly more African-American men than any other race (χ2[1] = 6.17, p = .01). Men and women did not significantly differ on any other study variables (all p’s > .05). Zero-order correlations are presented in Table 2. SSS (US and Community) were significantly and positively associated with one another and readiness to quit. SSS (US and Community) and readiness to quit all significantly and negatively correlated with CPD. SSS-US also correlated significantly and positively with employment status and family income for past 12-months. Additionally, being female was related to being older and being partnered. Age also positively correlated with duration of lifetime homelessness.

for 13% of the variance in readiness to quit, with CPD (p = .002) and education (p = .05) as significant predictors; Step 2 accounted for 12% of the variance, with CPD as a significant predictor (p = .002), however, SSS-US was a non-significant predictor (p > .05; ΔR2= .004, p > .05; F(8, 61) = 2.16, p = .04). Model 6: Step 1 accounted for 13% of the variance, with CPD (p = .002) and education (p = .05) as significant predictors; Step 2 accounted for 19% of the variance, with education (p = .05) and SSS-Community (p = .02) as significant predictors (ΔR2= .07, p = .02; F(8, 61) = 2.99, p = .01). See Table 3.

Hierarchical Multiple Regression Models Analyses with total sample. Model 1: Step 1 accounted for 6% of the variance in readiness to quit, and CPD was a significant predictor (p < .001); Step 2 accounted for 8% of the variance with CPD (p < .001) and SSS-US (p = .02) as significant predictors (ΔR2 = .02, p = .02; F(9, 235) = 3.42, p = .001). Model 2: Step 1 accounted for 6% of the variance, and CPD was a significant predictor (p < .001); Step 2 accounted for 13% of the variance, with CPD (p = .001) and SSS-Community (p < .001) as significant predictors (ΔR2= .06, p < .001; F(9, 235) = 4.88, p < .001). See Table 3. Analyses for men. Model 3: Step 1 accounted for 4% of the variance in readiness to quit, and CPD was a significant predictor (p = .001); Step 2 accounted for 8% of the variance, with CPD (p = .001) and SSS-US (p = .003) as significant predictors (ΔR2= .05, p = .003; F(8,166) = 2.95, p =.004). Model 4: Step 1 accounted for 4% of the variance, and CPD was a significant predictor (p = .001); Step 2 accounted for 9% of the variance, with CPD (p = .01) and SSS-Community (p = .002) as significant predictors (ΔR2= .05, p = .002; F(8, 166) = 3.14, p = .002). See Table 3. Analyses for women. Model 5: Step 1 accounted

DISCUSSION The current study examined the association between US and community dimensions of SSS and readiness to quit among homeless smokers. As predicted, higher ratings on both dimensions of SSS were significantly associated with greater readiness to quit smoking. These relations emerged after controlling for factors believed to influence SSS and readiness to quit.16,18 Indeed, the additional variance explained by each SSS measure produced a small to medium effect size. Mixed findings emerged between each SSS ladder and readiness to quit when explored by sex, such that SSS (US and Community) predicted readiness to quit for men and only SSS-Community predicted readiness to quit for women. Findings broaden extant work exploring readiness to quit among homeless individuals by suggesting that, in addition to self-efficacy to quit smoking and social support,9 SSS also is related to readiness to quit, and that this effect is not attributable to other factors related to SSS and readiness to quit. The incremental predictive value of SSS above and beyond factors commonly associated with SES, including employment status, income, and educational achievement, suggests that SSS may be a more relevant predictor of readiness to quit. Drawing from the theory of planned action,38 perception of social standing may be more relevant to understanding processes of smoking (including one’s readiness to quit) than one’s actual standing. Indeed, research corroborates this finding by showing that subjective SES is a better predictor of health status than objective SES.24 In the longitudinal study, researchers observed that subjective SES, assessed by a 10-rung SSS ladder, was associated with changes in health over time; objective SES, as assessed by a civil service grade that was determined by salary, social status, and level of responsibility, lost significance when subjective SES was entered into the model. It should be noted that the measures of health included selfreport items pertaining to general health as well as psychological and mental health, but not smoking specifically. Further, it may be that a subjective measure of SES (as assessed by SSS) is a more suitable assessment of social standing than an objective measure given the restriction of range on

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Table 3 Hierarchical Regression Analyses Predicting Readiness to Quit from Subjective Social Status while Controlling for Covariates Full Sample (N = 245) Criterion Readiness to Quit

Readiness to Quit

Readiness to Quit

Predictor Step 1 for Models 1 and 2

Step 2 for Model 1

Step 2 for Model 2

Covariates

Covariates and SSS-US

Covariates and SSSCommunity

B

SE B

t

β

Sex

-0.06

0.28

-0.23

-0.02

Employment

0.04

0.42

0.11

0.01

Income

0.13

0.13

1.06

0.07

Education

-0.08

0.08

-0.93

-0.06

CPD

-0.08

0.02

-4.51

-0.29***

Age

0.01

0.01

1.21

0.08

Partner Status

0.28

0.27

1.04

0.07

Duration Homeless

-0.001

0.003

-0.40

-0.03

Sex

-0.13

0.28

-0.46

-0.03

Employment

-0.07

0.42

-0.17

-0.01

Income

0.09

0.13

0.71

0.05

Education

-0.09

0.08

-1.04

-0.07

CPD

-0.08

0.02

-4.16

-0.26***

Age

0.01

0.01

1.13

Partner Status

0.26

0.27

Duration Homeless

-0.002

0.003

SSS-US

0.13

0.05

2.36

0.15*

Sex

-0.10

0.27

-0.38

-0.03

Employment

0.06

0.40

0.15

0.01

Income

0.08

0.12

0.69

0.04

Education

-0.07

0.08

-0.86

-0.05

CPD

-0.06

0.02

-3.23

-0.21**

Age

0.02

0.01

1.45

0.09

Partner Status

0.36

0.26

1.35

0.09

Duration Homeless

-0.002

0.003

-0.51

-0.03

SSS-Community

0.21

0.05

4.17

0.26***

0.07

0.97

0 .06

-0.62

-0.04

Men Only (N = 175) Readiness to Quit

Readiness to Quit

Step 1 for Models 3 and 4

Step 2 for Model 3

Covariates

Covariates and SSS-US

Employment

0.14

0.51

0.27

0.02

Income

0.04

0.14

0.28

0.02

Education

0.04

0.10

0.36

0.03

CPD

-0.07

0.02

-3.34

-0.25**

Age

0.01

0.01

0.38

0.03

Partner Status

0.39

0.34

1.16

0.09

Duration Homeless

-0.001

0.004

-0.20

-0.02

Employment

-0.03

0.50

-0.06

-0.01

Income

-0.03

0.14

-0.20

-0.02

Education

0.02

0.10

0.23

0.02

CPD

-0.07

0.02

-3.35

-0.25**

Age

0.01

0.01

0.36

0.03

Partner Status

0.28

0.33

0.84

0.06

Duration Homeless

-0.002

0.004

-0.51

-0.04

SSS-US

0.19

0.06

2.98

0.23**

(continued on next page)

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Table 3 (continued) Hierarchical Regression Analyses Predicting Readiness to Quit from Subjective Social Status while Controlling for Covariates Criterion Readiness to Quit

Predictor Step 2 for Model 4

Covariates and SSSCommunity

SE B

t

Employment

B 0.11

0.50

0.22

β 0.02

Income

-0.01

0.14

-0.09

-0.01

Education

0.04

0.10

0.44

0.03

CPD

-0.06

0.02

-2.67

-0.20**

Age

0.01

0.01

0.67

0.05

Partner Status

0.36

0.33

1.09

0.08

Duration Homeless

-0.001

0.003

-0.42

-0.03

SSS-Community

0.19

0.06

3.21

0.24**

Employment

-0.35

0.73

-0.47

-0.05

Income

0.44

0.31

1.42

0.17

Education

-0.31

0.16

-1.99

-0.23*

CPD

-0.11

0.04

-3.27

-0.38**

Age

0.02

0.02

1.14

0.13

Partner Status

0.06

0.47

0.14

0.02

Duration Homeless

-0.002

0.01

-0.42

-0.05

Employment

-0.30

0.74

-0.41

-0.05

Income

0.47

0.32

1.47

0.18

Education

-0.30

0.16

-1.94

-0.22

CPD

-0.12

0.04

-3.20

-0.42**

Age

0.02

0.02

1.21

0.14

Partner Status

0.03

0.48

0.05

0.01

Duration Homeless

-0.002

0.01

-0.39

-0.05

SSS-US

-0.06

0.11

-0.59

-0.08

Employment

-0.12

0.72

-0.17

-0.02

Income

0.44

0.30

1.47

0.17

Education

-0.30

0.15

-2.02

-0.22*

CPD

-0.07

0.04

-1.72

-0.23

Age

0.02

0.02

0.89

0.10

Partner Status

0.41

0.48

0.86

0.10

-0.001

0.01

-0.23

-0.03

0.25

0.11

2.35

0.31*

Women Only (N = 70) Readiness to Quit

Readiness to Quit

Readiness to Quit

Step 1 for Models 5 and 6

Step 2 for Model 5

Step 2 for Model 6

Covariates

Covariates and SSS-US

Covariates and SSSCommunity

Duration Homeless SSS-Community

*** p < .001, ** p < .01, * p < .05 Note. Step 1 is only presented once for analyses with the full sample, men only, and women only because it was the same for subsequent models. CPD = Cigarettes per day; SSS = Subjective Social Status; US = United States.

traditional SES variables among homeless individuals. Additionally, models posit a relationship between SES and health disparities.28,29 The current study provides empirical support that SSS may be a more suitable construct for elucidating pathways related to tobacco-related health disparities. Specifically, lower SSS, after accounting for factors

traditionally associated with SES, is related to less readiness to quit, which in turn, has been shown to predict smoking cessation success.12 To this end, SSS may be a more comprehensive assessment of social standing than standard SES measures with regards to readiness to quit because it may encompass perceived financial and social comparisons that traditional SES indicators do not

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Subjective Social Status and Readiness to Quit among Homeless Smokers include. The additional considerations assessed by SSS may be underlying key influencers associated with tobacco-related health disparities through readiness to quit among homeless smokers. This point deserves consideration given that theory posits that readiness to quit predicts smoking cessation outcomes.12 These pathways, however, are complex and intricate. The current study supports continued research in this area with homeless smokers, and the extension to domiciled samples. Findings also underscore the importance for addressing SSS in smoking cessation with homeless smokers. Targeting underlying factors that may engender greater readiness and promote more successful quit outcomes is key when working with individuals who are less likely to be successful at quitting, such as homeless smokers.1 In addition to SSS, further exploration of targeted smoking cessation constructs is warranted with homeless smokers, especially given that causes of death among this vulnerable population are highly attributed to treatable and preventable illnesses;13,14 thus, providing tobacco-use cessation may contribute to a prolonged life and better quality of life. Broadening previous research,27 certain dimensions of one’s socioeconomic (or social) standing may differentially relate to tobacco-related disparities by sex. In contrast with extant work suggesting men tend to report higher SSS when considering full society comparisons and the greater US,23-25 men in the current sample reported lower SSS-US, although the difference was not statistically significant. As with prior research,39 men and women reported comparable ratings of SSS-Community. Similarly, men reported slightly greater readiness to quit; however, their ratings were statistically equivalent to women. Although men and women did not differ on SSS-US, SSS-Community, or readiness to quit, the relationship between the dimensions of SSS (eg, US and Community) and readiness to quit did differ by sex. Specifically, for homeless women, SSS-US was not significantly related to readiness to quit, but the relationship between SSS-Community and readiness to quit was statistically significant. For men, the relationships remained regardless of ladder administered such that higher perceived SSS relative to others in the US or community predicted greater readiness to quit. Therefore, SSS-Community may be a more relevant index of SSS, especially for women. To this end, the saliency and immediacy of the referent group appears to contribute to the relationship between SSS and readiness to quit among women. Future researchers examining sex differences in SSS (US and Community) ladders should examine factors participants consider when defining their comparison groups. Although not the primary study aims, 2 noteworthy findings emerged. First, the dimensions of SSS (eg, US and Community) were related, but distinct constructs. Indeed, these 2 constructs shared 25% of variance with one another. In conjunction with

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possible sex difference between these constructs observed in the current study, this observation lends further empirical support to the construct validity of these 2 subjective measures of social standing. Finally, greater CPD related to lower SSS (US and Community) and less readiness to quit. CPD also remained a significant predictor of readiness to quit for all models except Model 6. It may be that the increasing stigmatization and inconvenience of smoking due to smoking bans in shelter property may lend to lower perceptions of social status.40 Through this mechanism, readiness to quit may be impacted, as perceptions of acceptability of smoking relate to readiness to quit among domiciled smokers.11 Furthermore, smokers with higher nicotine dependence (ie, use more CPD) may perceive quitting smoking as more intimidating and difficult due to withdrawal symptoms. The problems they experienced with past quit attempts may lead to lower readiness to quit. Indeed, a study with domiciled smokers found a negative relationship between nicotine dependence indices and readiness to quit.11 Future studies might further explore the mechanisms that contribute to these findings. In addition, SSS rankings appear to be higher in the current sample of homeless smokers in comparison to other homeless samples. Specifically, the average SSS-US ranking was 4.0 (+2.3) in the current sample versus 3.3 (+2.3) in one study of 57 homeless smokers,18 with the SSS-Community ladder following suit [5.1 (+2.4) in the current sample versus 4.3 (+2.5) in a previous report]. However, SSS as reported by the current sample was only slightly less than that reported in at least one sample of low income domiciled smokers [SSS-US = 4.3 (+ 2.0); SSS-Community = 5.6 (+2.2)],41 but much less than those reported by other samples of relatively low income smokers [SSS-US = 5.8 – 6.016; SSS-Community = 6.4 (+2.2)21]. These differences may be attributable to study characteristics, as all of the previously mentioned studies were clinical trials that enrolled individuals who were willing to make a quit-smoking attempt, whereas the current study was not limited to motivated individuals and did not require as much time and effort from participants as a clinical trial. There are several limitations to the current study. First, the sample was disproportionately comprised of men, potentially affecting the generalizability of findings. Whereas men tend to comprise a larger percentage of homeless individuals,6 future studies should explore the relationships in a more balanced sample. Second, participants were recruited from a single shelter in Texas. This limitation also may impact the generalizability of study findings. Future studies should expand recruitment to enroll participants from more than one site. Third, the study employed a cross-sectional design. Future work is needed to examine possible mediating and moderating factors for the current findings, and aim to explicate directional

Garey et al effects prospectively for the observed associations and their relationship to smoking cessation outcomes. Finally, SSS also may be affected by other factors, such as depression or mental illness, especially among homeless individuals. However, post hoc analyses examining associations between SSS scales and the presence of severe mental illness (ie, depression, bipolar, schizophrenia or schizoaffective disorder) in the current sample were nonsignificant. Overall, the present study provides initial empirical support for the predictive value of different dimensions of SSS on readiness to quit among homeless adult smokers. Findings support additional research exploring the relationship between SSS and readiness to quit among homeless smoking adults. Better understanding the relationship between these variables may further our understanding of the long chain of variables that leads to continued smoking, disease, and health disparities in this understudied population. Future work should employ a longitudinal design to corroborate present findings.

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treatment: an ecological momentary assessment study. Nicotine Tob Res. In press.  3. Goldade K, Whembolua G-L, Thomas J, et al. Designing a smoking cessation intervention for the unique needs of homeless persons: a community-based randomized clinical trial. Clin Trials. 2011;8(6):744-754.  4. Okuyemi KS, Goldade K, Whembolua G-L, et al. Smoking characteristics and comorbidities in the power to quit randomized clinical trial for homeless smokers. Nicotine Tob Res. 2013;15(1):22-28.  5. Hwang SW. Homelessness and health. CMAJ. 2001;164(2):229-233.  6. SAMHSA. Current statistics on the prevalence and characteristics of people experiencing homelessness in the United States (online). Available at: http://homeless. samhsa.gov/ResourceFiles/hrc_factsheet.pdf. Accessed May 23, 2013.  7. Butler J, Okuyemi KS, Jean S, et al. Smoking characteristics of a homeless population. Subst Abus. 2002;23(4):223-231.  8. Okuyemi KS, Caldwell AR, Thomas JL, et al. Homelessness and smoking cessation: insights from focus groups. Nicotine Tob Res. 2006;8(2):287-296.  9. Arnsten JH, Reid K, Bierer M, et al. Smoking behavior and interest in quitting among homeless smokers. Addict Behav. 2004;29(6):1155-1161. 10. Connor SE, Cook RL, Herbert MI, et al. Smoking cessation in a homeless population. J Gen Intern Med. 2002;17(5):369-372. 11. Abrams DB, Biener L. Motivational characteristics of smokers at the workplace: a public health challenge. Prev Med. 1992;21(6):679-687. 12. DiClemente CC, Prochaska JO, Fairhurst SK, et al. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991;59(2):295-304. 13. Hwang SW, Orav EJ, O’Connell JJ, et al. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126(8):625-628. 14. Baggett TP, Hwang SW, O’Connell JJ, et al. Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period. JAMA Intern Med. 2013;173(3):189-195. 15. Reitzel LR, Vidrine JI, Li Y, et al. The influence of subjective social status on vulnerability to postpartum smoking among young pregnant women. Am J Public Health. 2007;97(8):1476-1482. 16. Reitzel LR, Businelle MS, Kendzor DE, et al. Subjective social status predicts long-term smoking abstinence. BMC Public Health. 2011;11(1):135. 17. Reitzel LR, Mazas CA, Cofta‐Woerpel L, et al. Subjective social status affects smoking abstinence during acute withdrawal through affective mediators. Addiction. 2010;105(5):928-936. 18. Reitzel LR, Kendzor DE, Cao Y, et al. Subjective social status predicts quit-day abstinence among homeless smokers. Am J Health Promot. 2014;29(1):43-45. 19. Reitzel LR, Buchanan TS, Nguyen N, et al. Associations of subjective social status with nondaily and daily smoking. Am J Health Behav. 2014;38(2):245-253. 20. Reitzel LR, Nguyen N, Strong LL, et al. Subjective social status and health behaviors among African Americans. Am J Health Behav. 2013;37(1):104-111. 21. Whembolua G-L, Davis JT, Reitzel LR, et al. Subjective social status predicts smoking abstinence among light smokers. Am J Health Behav. 2012;36(5):639-646. 22. Adler N. MacArthur Research Network on Socioeconomic Status and Health (online). Available at: http://www. macses.ucsf.edu/Research/Psychosocial/subjective. php. Accessed May 22, 2014. 23. Demakakos P, Nazroo J, Breeze E, et al. Socioeconomic status and health: the role of subjective social status.

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Human Subjects Statement All procedures were approved by the Institutional Review Boards at The University of Texas Health Science Center, The University of Texas MD Anderson Cancer Center, and the University of Houston. Informed consent was obtained from screened eligible participants prior to data collection. Conflict of Interest Statement The authors have no competing interests pertaining to this research. Acknowledgements This work was supported by institutional funding provided by the University of Texas Health Science Center, School of Public Health (to Businelle), the University of Texas MD Anderson Cancer Center, and the University of Houston (to Reitzel). Data analysis and manuscript preparation were additionally supported through grant MRSGT-10104-01-CPHPS (to Kendzor) and MRSGT-12-11401-CPPB (to Businelle) awarded by the American Cancer Society. The contents of the manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the sponsoring organizations. Authors are grateful to Dr. Mark A. Prince, NIAAA Postdoctoral Fellow at the Research Institute on Addictions at the University at Buffalo, State University of New York, for his statistical consult on the revision of this manuscript prior to publication. References

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Subjective social status and readiness to quit among homeless smokers.

To explore the predictive value of subjective social status (SSS-US and SSS-Community) on readiness to quit among 245 homeless smokers...
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