THE
C I E N C E
O F
L I F E S T Y L E
C H A N G E
Applied Research Brief: Tobacco Control
Subjective Social Status Predicts Quit-Day Abstinence Among Homeless Smokers Lorraine R. Reitzel, PhD; Darla E. Kendzor, PhD; Yumei Cao, MS; Michael S. Businelle, PhD
Abstract Purpose. Smoking prevalence is alarmingly high among the homeless. Few studies have focused on predictors o f smoking abstinence in this population. Subjective social status, a person’s ranking o f their own social standing relative to others in the United States or in their own self-defined communities, has predicted smoking cessation among domiciled smokers in analyses adjusted fo r objective socioeconomic status and other demographic variables. This study examined i f subjective social status predicted quit-day abstinence among homeless smokers m aking a quit attempt. Design. Longitudinal study using self-reported survey data. Setting. Transitional homeless shelter in Dallas, Texas. Subjects. A total of 5 7 homeless smokers enrolled in a cessation program. Measures. Predictors were the Subjective Social Status-U.S (SSS-U.S.) and the Subjective Social Status-Community (SSS-Community) ladders measured 1 week pre quit. Covariates were sociodemographics and tobacco dependence measured 1 week pre quit. The outcome was selfreported and biochemically verified smoking abstinence on the quit day. Analysis. Covariate-adjusted logistic regression models. Results. Higher rankings on the SSS-U.S. ladder, but not the SSS-Community ladder, predicted abstinence on the quit day (p = .005). Conclusion. Lower rankings on the SSS-U.S. ladder predicted increased risk o f relapse on the quit day or the inability to quit at all. The SSS-U.S. ladder might be useful in identifying homeless smokers needing additional preparation and intervention before initiating a quit attempt. (Am J Health Promot 2014;29[l]:43-45.) Key Words: Subjective Social Status, Homeless, Smoking Abstinence, Prevention
Research. M anuscript format: research; Research purpose: m odeling/relationship testing; Study design: nonexperim ental; O utcom e measure: behavioral; Setting: local community; H ealth focus: sm oking control; Strategy: skill building/behavior change; Target population: adults; Target population circumstances: ed u catio n / incom e level, race/ethnicity
PURPOSE C igarette sm oking am ong the hom eless is a m ajor public health issue.1 W hereas the cu rren t sm oking prevalence in the U nited States is about 19%,2 sm oking prevalence am ong the hom eless is about 73%.3 U nfortunately, lifetim e quit rates am ong the hom eless are quite low, at approxim ately 9% .3 Very few studies have focused on predictors o f smok ing cessation am ong the hom eless in the context of a specific quit attem pt. Consequently, m ore research is n eed ed to b etter und erstan d the factors th at influence sm oking cessation and relapse am ong the homeless. Subjective social status (SSS) repre sents a person’s perception of his or her position in the social hierarchy, relative to others in the U nited States (the SSS-U.S. ladder) or others in their self-defined com m unities (the SSSCommunity ladder) .4 H igher SSS-U.S. ladder and SSS-Community ladder rankings have predicted smoking ab stinence am ong dom iciled smokers in previous studies.5-' To date, no studies have evaluated relations of SSS and smoking abstinence during a quit attem pt am ong the homeless, or the
Lorraine R. Reitzel, PhD, is with the Department of Educational Psychology, College of Education, University of Houston, Houston, Texas. This work was completed when she was affiliated with the Department of Health Disparities Research, University o f Texas MD Anderson Cancer Center, Houston, Texas. Yumei Cao, MS, is with the Department of Health Disparities Research, University o f Texas MD Anderson Cancer Center, Houston, Texas. Darla E. Kendzor, PhD, and Michael S. Businelle, PhD, are with the Division o f Health Promotion and Behavioral Sciences, University of Texas School o f Public Health, Dallas, Texas, and The University of Texas Southwestern Harold C. Simmons Comprehensive Cancer, Dallas, Texas. Send re p rin t requests to L o rrain e R. Reitzel, PhD , 214 Farish H all, D ep artm en t o f E ducational Psychology, C ollege o f E ducation, University o f H o u sto n , H o u sto n , TX 77204-5023; reitzel_at_U H @ com cast.net. This m anuscript was submitted February 28, 2013; revisions were requested A pril 18, 2013; the m anuscript was accepted fo r publication J u n e 5, 2013. Copyright © 2 0 1 4 by American Journal o f H ealth Promotion, Inc. 0890-11 7 1 /1 4 /S 5 .0 0 + 0 DOT. 1 0 .4 2 78/ajhp. 130228-ARB-88
American Journal of Health Promotion
September/October 2014, Vol. 29, No. 1
43
relative predictive ability of the ladders. The purpose of the current study was to redress that gap. METHODS Design
Data were from a parent study conducted to identify barriers to smoking cessation among homeless smokers in Dallas, Texas. Data relevant to the current study were sociodemo graphics, tobacco dependence, and subjective social status (collected 1 week pre quit) and smoking status (collected on the quit day). Sample
Participants (N = 57) resided in a transitional shelter and were required to be >18 years old, English-speaking, and literate at a seventh-grade level, be willing to quit smoking a week follow ing their initial visit, have an expired carbon monoxide level of >8 parts per million (ppm), self-report current smoking of >5 cigarettes per day, and be willing to attend the required assessment visits. All participants were able to attend >6 weekly group cessation counseling sessions beginning 1 week pre quit and were offered pharmacologic interven tions. Measures Sociodemographics. Sociodemographics
were self-reported age, gender, race (“How would you best describe your race?” [black vs. white/other]), part ner status (“Do you have a spouse or partner?” [yes vs. no]), income (“What was your total income from all sources last month?” [no income, $20 to $500 vs. >$500]), education (“How many years of education have you complet ed?” [12 years]), and lifetime duration of homelessness (“What is the total amount of time you have been homeless in your life time?”). Tobacco Dependence. Prequit tobacco dependence was assessed by using the Heaviness of Smoking Index (HSI), which comprises two items: “How many cigarettes do you typically smoke per day?” and “On the days that you smoke, how soon after you wake up do you have your first cigarette?” The HSI
44
American Journal of Health Promotion
is a valid and reliable measure of tobacco dependence.8 Subjective Social Status. SSS was as sessed with two ladders. The SSS-U.S. ladder consists of a 10-rung ladder with higher rungs indicating higher status (i.e., more money, more education, and better jobs). Participants select the rung that best represents where they think they stand relative to others in the United States, resulting in a ranked indicator variable with 10 pos sible levels. The SSS-Community lad der is similar but asks participants to select the rung that best represents where they think they stand relative to others in their (self-defined) commu nity. These ladders have demonstrated adequate reliability and validity.4 The correlation between the ladders in this sample was .33 (p = .01). Smoking Status. Quit-day smoking abstinence was defined as a self-report of no cigarettes smoked since quitting the previous evening (not even a puff) and an expired carbon monoxide level of =.005]). The average SSS-U.S. ladder ranking among those who were abstinent was 5.0, versus 2.9 among those who were not abstinent. Where as 70% of participants who were abstinent endorsed >5 on the SSSU.S. ladder, only 15% of those who were not abstinent ranked themselves that highly. The SSS-Community lad der was not a significant predictor of quit-day abstinence (p= .77). The average SSS-Community ladder rank ing among those who were abstinent was 3.8, versus 4.4 among those who relapsed. DISCUSSION Summary
This study was the first to examine the utility of SSS in predicting smoking cessation among homeless smokers undergoing an aided quit attempt. Prior research among domiciled pop ulations has linked SSS with smoking abstinence during a specific quit at tempt.5_/ Consequently, we expected that SSS would be associated with smoking abstinence in the current sample. Results indicated that the SSSU.S. ladder, but not the SSS-Commu nity ladder, predicted biochemically verified abstinence on the quit day in analyses adjusted for several covariates including objective indicators of socio economic status. Limitations
This study benefited from a focus on an understudied and underserved population at exceedingly high risk of smoking-related health disparities, the ability to control for numerous covar iates, and the biochemical verification of smoking abstinence. Limitations include the small sample size and recruitment from a single transitional
September/October 2014, Vol. 29, No. 1
hom eless sh elter in the South. Results may n o t generalize to o th e r hom eless populations, an d should be replicated in o th e r settings. A dditional lim ita tions include th e sole focus on absti n ence on the quit day. U nfortunately, very low rates o f sm oking abstinence at weeks 1 to 4 post quit (n < 2) p recluded analyses exam ining the relations betw een th e SSS scales and sm oking abstinence beyond the quit date. Future studies should exam ine the relative utility o f the SSS ladders in predicting sm oking cessation beyond the quit day am ong larger populations o f hom eless sm okers with g reater variability in short- an d long-term cessation outcom es. Significance Results suggest th at h ig h er rankings on the SSS-U.S. lad d er are associated with the ability to m ake an initial sm oking quit attem pt. Prior research am ong hom eless sm okers suggests that previous q u it attem pts are associ ated with a g reater readiness to quit sm oking in th e fu tu re.9 T herefore, cessation even for a single day may provide a success experience th a t can be capitalized u p o n to extend cessa tion d u rin g a futu re attem pt. O n the o th e r h and, lower rankings on the SSS-U.S. lad d er suggest increased risk o f relapse on the q u it day o r p o ten tially the inability to initiate a sm oking q uit attem p t at all. T herefore, the SSSU.S. lad d er may have potential utility as a p retreatm en t screener to identify sm okers who may n eed additional p req u it preparation, such as addi tional counseling sessions an d p h ar
American Journal of Health Promotion
m acotherapy, before initiating a quit attem pt.
SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic?
Although several studies indicate that SSS predicts smoking abstinence among domiciled smokers who are trying to quit, no prior studies have examined these relations among homeless smokers. What does this article add?
The current study extends previous research linking SSS and smoking abstinence to homeless smokers. Findings indicated that homeless smokers endorsing lower SSS on the U.S. ladder are at increased risk of relapse on the quit day or potentially lack the ability to initiate a quit attem pt at all. The community ladder was unrelated to smoking abstinence in this sample. What are the implications for health promotion practice or research?
Results suggest that the SSS-U.S. ladder may be a helpful screener to identify homeless smokers who may need additional preparation and intervention before initiating a smoking quit attempt.
Acknowledgments Funding fo r this research was provided by the University of Texas Health Science Center, School o f Public Health in the form o f a PILO T grant (Dr. Businelle) and start-up funds (Drs. Businelle and Kendzor). Data analysis and manu script preparation were additionally supported through grants MRSGT-10-104-01-CPHPS (Dr. Kendzor) and
MRSGT-12-114-01-CPPB (Dr. Businelle) awarded by the American Cancer Society, the National Institutes of Health through MD Anderson’s Cancer Center Support Grant (CA016672), as well as by start-up fun d s (Dr. Reitzel) as provided by The University o f Texas MD Anderson Cancer Center. Its contents are solely the responsibility o f the authors and do not necessarily represent the official views of the sponsoring organizations.
References 1. Baggett TP, Anderson R, Freyder PJ, et al. Addressing tobacco use in homeless populations: a survey of health care professionals. J Health Care Poor Underserved. 2012;23:1650-1659. 2. CDC. Current cigarette smoking among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:889-894. 3. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med. 2010;39: 164-172. 4. Adler N. Social status ladder. John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health. Available at: http://www.macses.ucsf.edu/ Research/Psychosocial/subjective.php. Accessed February 28, 2013. 5. Reitzel LR, Mazas CA, Cofta-Woerpel L, et al. Subjective social status affects smoking abstinence during acute withdrawal through affective mediators. Addiction. 2010;105:928-936. 6. Reitzel LR, Businelle MS, Kendzor DE, et al. Subjective social status predicts long-term smoking abstinence. BMC Public Health. 2011;11:135. 7. Whembolua GL, Davis JT, Reitzel LR, et al. Subjective social status predicts smoking abstinence among light smokers. Am J Health Behav. 2012;36:639-646. 8. Borland R, Yong HH, O ’Connor RJ, et al. The reliability and predictive validity of the Heaviness of Smoking Index and its two components: findings from the International Tobacco Control Four Country study. Nicotine Tob Res. 2010; 12 (suppl) :S45-S50. 9. Connor SE, Cook RL, H erbert MI, et al. Smoking cessation in a homeless population: there is a will, but is there a way? J Gen Intern Med. 2002;17:369-372.
September/October 2014, Vol. 29, No. 1
45
Copyright of American Journal of Health Promotion is the property of American Journal of Health Promotion and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C I E N C E
O F
L I F E S T Y L E
C H A N G E
Applied Research Brief: Tobacco Control
Subjective Social Status Predicts Quit-Day Abstinence Among Homeless Smokers Lorraine R. Reitzel, PhD; Darla E. Kendzor, PhD; Yumei Cao, MS; Michael S. Businelle, PhD
Abstract Purpose. Smoking prevalence is alarmingly high among the homeless. Few studies have focused on predictors o f smoking abstinence in this population. Subjective social status, a person’s ranking o f their own social standing relative to others in the United States or in their own self-defined communities, has predicted smoking cessation among domiciled smokers in analyses adjusted fo r objective socioeconomic status and other demographic variables. This study examined i f subjective social status predicted quit-day abstinence among homeless smokers m aking a quit attempt. Design. Longitudinal study using self-reported survey data. Setting. Transitional homeless shelter in Dallas, Texas. Subjects. A total of 5 7 homeless smokers enrolled in a cessation program. Measures. Predictors were the Subjective Social Status-U.S (SSS-U.S.) and the Subjective Social Status-Community (SSS-Community) ladders measured 1 week pre quit. Covariates were sociodemographics and tobacco dependence measured 1 week pre quit. The outcome was selfreported and biochemically verified smoking abstinence on the quit day. Analysis. Covariate-adjusted logistic regression models. Results. Higher rankings on the SSS-U.S. ladder, but not the SSS-Community ladder, predicted abstinence on the quit day (p = .005). Conclusion. Lower rankings on the SSS-U.S. ladder predicted increased risk o f relapse on the quit day or the inability to quit at all. The SSS-U.S. ladder might be useful in identifying homeless smokers needing additional preparation and intervention before initiating a quit attempt. (Am J Health Promot 2014;29[l]:43-45.) Key Words: Subjective Social Status, Homeless, Smoking Abstinence, Prevention
Research. M anuscript format: research; Research purpose: m odeling/relationship testing; Study design: nonexperim ental; O utcom e measure: behavioral; Setting: local community; H ealth focus: sm oking control; Strategy: skill building/behavior change; Target population: adults; Target population circumstances: ed u catio n / incom e level, race/ethnicity
PURPOSE C igarette sm oking am ong the hom eless is a m ajor public health issue.1 W hereas the cu rren t sm oking prevalence in the U nited States is about 19%,2 sm oking prevalence am ong the hom eless is about 73%.3 U nfortunately, lifetim e quit rates am ong the hom eless are quite low, at approxim ately 9% .3 Very few studies have focused on predictors o f smok ing cessation am ong the hom eless in the context of a specific quit attem pt. Consequently, m ore research is n eed ed to b etter und erstan d the factors th at influence sm oking cessation and relapse am ong the homeless. Subjective social status (SSS) repre sents a person’s perception of his or her position in the social hierarchy, relative to others in the U nited States (the SSS-U.S. ladder) or others in their self-defined com m unities (the SSSCommunity ladder) .4 H igher SSS-U.S. ladder and SSS-Community ladder rankings have predicted smoking ab stinence am ong dom iciled smokers in previous studies.5-' To date, no studies have evaluated relations of SSS and smoking abstinence during a quit attem pt am ong the homeless, or the
Lorraine R. Reitzel, PhD, is with the Department of Educational Psychology, College of Education, University of Houston, Houston, Texas. This work was completed when she was affiliated with the Department of Health Disparities Research, University o f Texas MD Anderson Cancer Center, Houston, Texas. Yumei Cao, MS, is with the Department of Health Disparities Research, University o f Texas MD Anderson Cancer Center, Houston, Texas. Darla E. Kendzor, PhD, and Michael S. Businelle, PhD, are with the Division o f Health Promotion and Behavioral Sciences, University of Texas School o f Public Health, Dallas, Texas, and The University of Texas Southwestern Harold C. Simmons Comprehensive Cancer, Dallas, Texas. Send re p rin t requests to L o rrain e R. Reitzel, PhD , 214 Farish H all, D ep artm en t o f E ducational Psychology, C ollege o f E ducation, University o f H o u sto n , H o u sto n , TX 77204-5023; reitzel_at_U H @ com cast.net. This m anuscript was submitted February 28, 2013; revisions were requested A pril 18, 2013; the m anuscript was accepted fo r publication J u n e 5, 2013. Copyright © 2 0 1 4 by American Journal o f H ealth Promotion, Inc. 0890-11 7 1 /1 4 /S 5 .0 0 + 0 DOT. 1 0 .4 2 78/ajhp. 130228-ARB-88
American Journal of Health Promotion
September/October 2014, Vol. 29, No. 1
43
relative predictive ability of the ladders. The purpose of the current study was to redress that gap. METHODS Design
Data were from a parent study conducted to identify barriers to smoking cessation among homeless smokers in Dallas, Texas. Data relevant to the current study were sociodemo graphics, tobacco dependence, and subjective social status (collected 1 week pre quit) and smoking status (collected on the quit day). Sample
Participants (N = 57) resided in a transitional shelter and were required to be >18 years old, English-speaking, and literate at a seventh-grade level, be willing to quit smoking a week follow ing their initial visit, have an expired carbon monoxide level of >8 parts per million (ppm), self-report current smoking of >5 cigarettes per day, and be willing to attend the required assessment visits. All participants were able to attend >6 weekly group cessation counseling sessions beginning 1 week pre quit and were offered pharmacologic interven tions. Measures Sociodemographics. Sociodemographics
were self-reported age, gender, race (“How would you best describe your race?” [black vs. white/other]), part ner status (“Do you have a spouse or partner?” [yes vs. no]), income (“What was your total income from all sources last month?” [no income, $20 to $500 vs. >$500]), education (“How many years of education have you complet ed?” [12 years]), and lifetime duration of homelessness (“What is the total amount of time you have been homeless in your life time?”). Tobacco Dependence. Prequit tobacco dependence was assessed by using the Heaviness of Smoking Index (HSI), which comprises two items: “How many cigarettes do you typically smoke per day?” and “On the days that you smoke, how soon after you wake up do you have your first cigarette?” The HSI
44
American Journal of Health Promotion
is a valid and reliable measure of tobacco dependence.8 Subjective Social Status. SSS was as sessed with two ladders. The SSS-U.S. ladder consists of a 10-rung ladder with higher rungs indicating higher status (i.e., more money, more education, and better jobs). Participants select the rung that best represents where they think they stand relative to others in the United States, resulting in a ranked indicator variable with 10 pos sible levels. The SSS-Community lad der is similar but asks participants to select the rung that best represents where they think they stand relative to others in their (self-defined) commu nity. These ladders have demonstrated adequate reliability and validity.4 The correlation between the ladders in this sample was .33 (p = .01). Smoking Status. Quit-day smoking abstinence was defined as a self-report of no cigarettes smoked since quitting the previous evening (not even a puff) and an expired carbon monoxide level of =.005]). The average SSS-U.S. ladder ranking among those who were abstinent was 5.0, versus 2.9 among those who were not abstinent. Where as 70% of participants who were abstinent endorsed >5 on the SSSU.S. ladder, only 15% of those who were not abstinent ranked themselves that highly. The SSS-Community lad der was not a significant predictor of quit-day abstinence (p= .77). The average SSS-Community ladder rank ing among those who were abstinent was 3.8, versus 4.4 among those who relapsed. DISCUSSION Summary
This study was the first to examine the utility of SSS in predicting smoking cessation among homeless smokers undergoing an aided quit attempt. Prior research among domiciled pop ulations has linked SSS with smoking abstinence during a specific quit at tempt.5_/ Consequently, we expected that SSS would be associated with smoking abstinence in the current sample. Results indicated that the SSSU.S. ladder, but not the SSS-Commu nity ladder, predicted biochemically verified abstinence on the quit day in analyses adjusted for several covariates including objective indicators of socio economic status. Limitations
This study benefited from a focus on an understudied and underserved population at exceedingly high risk of smoking-related health disparities, the ability to control for numerous covar iates, and the biochemical verification of smoking abstinence. Limitations include the small sample size and recruitment from a single transitional
September/October 2014, Vol. 29, No. 1
hom eless sh elter in the South. Results may n o t generalize to o th e r hom eless populations, an d should be replicated in o th e r settings. A dditional lim ita tions include th e sole focus on absti n ence on the quit day. U nfortunately, very low rates o f sm oking abstinence at weeks 1 to 4 post quit (n < 2) p recluded analyses exam ining the relations betw een th e SSS scales and sm oking abstinence beyond the quit date. Future studies should exam ine the relative utility o f the SSS ladders in predicting sm oking cessation beyond the quit day am ong larger populations o f hom eless sm okers with g reater variability in short- an d long-term cessation outcom es. Significance Results suggest th at h ig h er rankings on the SSS-U.S. lad d er are associated with the ability to m ake an initial sm oking quit attem pt. Prior research am ong hom eless sm okers suggests that previous q u it attem pts are associ ated with a g reater readiness to quit sm oking in th e fu tu re.9 T herefore, cessation even for a single day may provide a success experience th a t can be capitalized u p o n to extend cessa tion d u rin g a futu re attem pt. O n the o th e r h and, lower rankings on the SSS-U.S. lad d er suggest increased risk o f relapse on the q u it day o r p o ten tially the inability to initiate a sm oking q uit attem p t at all. T herefore, the SSSU.S. lad d er may have potential utility as a p retreatm en t screener to identify sm okers who may n eed additional p req u it preparation, such as addi tional counseling sessions an d p h ar
American Journal of Health Promotion
m acotherapy, before initiating a quit attem pt.
SO WHAT? Implications for Health Promotion Practitioners and Researchers What is already known on this topic?
Although several studies indicate that SSS predicts smoking abstinence among domiciled smokers who are trying to quit, no prior studies have examined these relations among homeless smokers. What does this article add?
The current study extends previous research linking SSS and smoking abstinence to homeless smokers. Findings indicated that homeless smokers endorsing lower SSS on the U.S. ladder are at increased risk of relapse on the quit day or potentially lack the ability to initiate a quit attem pt at all. The community ladder was unrelated to smoking abstinence in this sample. What are the implications for health promotion practice or research?
Results suggest that the SSS-U.S. ladder may be a helpful screener to identify homeless smokers who may need additional preparation and intervention before initiating a smoking quit attempt.
Acknowledgments Funding fo r this research was provided by the University of Texas Health Science Center, School o f Public Health in the form o f a PILO T grant (Dr. Businelle) and start-up funds (Drs. Businelle and Kendzor). Data analysis and manu script preparation were additionally supported through grants MRSGT-10-104-01-CPHPS (Dr. Kendzor) and
MRSGT-12-114-01-CPPB (Dr. Businelle) awarded by the American Cancer Society, the National Institutes of Health through MD Anderson’s Cancer Center Support Grant (CA016672), as well as by start-up fun d s (Dr. Reitzel) as provided by The University o f Texas MD Anderson Cancer Center. Its contents are solely the responsibility o f the authors and do not necessarily represent the official views of the sponsoring organizations.
References 1. Baggett TP, Anderson R, Freyder PJ, et al. Addressing tobacco use in homeless populations: a survey of health care professionals. J Health Care Poor Underserved. 2012;23:1650-1659. 2. CDC. Current cigarette smoking among adults—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61:889-894. 3. Baggett TP, Rigotti NA. Cigarette smoking and advice to quit in a national sample of homeless adults. Am J Prev Med. 2010;39: 164-172. 4. Adler N. Social status ladder. John D. and Catherine T. MacArthur Research Network on Socioeconomic Status and Health. Available at: http://www.macses.ucsf.edu/ Research/Psychosocial/subjective.php. Accessed February 28, 2013. 5. Reitzel LR, Mazas CA, Cofta-Woerpel L, et al. Subjective social status affects smoking abstinence during acute withdrawal through affective mediators. Addiction. 2010;105:928-936. 6. Reitzel LR, Businelle MS, Kendzor DE, et al. Subjective social status predicts long-term smoking abstinence. BMC Public Health. 2011;11:135. 7. Whembolua GL, Davis JT, Reitzel LR, et al. Subjective social status predicts smoking abstinence among light smokers. Am J Health Behav. 2012;36:639-646. 8. Borland R, Yong HH, O ’Connor RJ, et al. The reliability and predictive validity of the Heaviness of Smoking Index and its two components: findings from the International Tobacco Control Four Country study. Nicotine Tob Res. 2010; 12 (suppl) :S45-S50. 9. Connor SE, Cook RL, H erbert MI, et al. Smoking cessation in a homeless population: there is a will, but is there a way? J Gen Intern Med. 2002;17:369-372.
September/October 2014, Vol. 29, No. 1
45
Copyright of American Journal of Health Promotion is the property of American Journal of Health Promotion and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
