Data regarding racial/ethnic variations in use of NRT among smokers aged 25-44 years, a critical age for intervention, are lacking. In this sample of lifetime smokers aged 25-44, African American smokers were significantly less likely than Caucasian smokers to have ever used NRT for smoking cessation. This disparity persisted even after controlling for sociodemographic factors and smoking history (e.g., nicotine dependence). Although Latino and Asian smokers were less likely to use NRT in unadjusted analyses, this finding did not persist after controlling for sociodemographic factors and smoking history.
Our findings provide further evidence of racial/ethnic disparities in tobacco treatment by being consistent with findings of previous population-based studies documenting disparities in the use of nicotine replacement therapy (9
). Our findings are also consistent with a study of veterans receiving care from the Veterans Health Administration, an equal access healthcare system (4
). This study consisted primarily of male smokers over the age of 50 and found that African American smokers were significantly less likely to use NRT than Caucasian smokers after adjusting for sociodemographic factors, smoking history, psychological factors, and health status (adjusted OR 0.53, 95% CI 0.34-0.83). Our study, however, did not replicate the findings of a study using data from the 2001 Colorado Tobacco Attitudes and Behaviors, which observed that Latino smokers were less likely than non-Latino smokers to use NRT (adjusted OR 0.31, 95% CI, 0.17-0.57) (5
). In our study, the number of Latinos was relatively small and the point estimate of the effect was in the same direction but not-statistically significant.
Compared to national samples (e.g., the national health interview survey), our study sample consisted primarily of individuals with health insurance with lower than national average rates of lifetime and current smoking. This may limit generalizeability of the study findings as individuals in this study likely have greater access to health care than national samples. Despite this, we still observed significant racial/ethnic disparities, suggesting that factors beyond access to care are responsible for the observed disparities in NRT utilization. Provider and system level factors are likely sources. Even though guidelines recommend that health care providers address tobacco use at every clinical visit, there is often a lack of skill, interest, and time to deliver quality tobacco cessation interventions. Time constraints also limit actual delivery of cessation services during busy clinic visits and providers may be less likely to intervene with racial/ethnic minority smokers who may have more competing demands and “more pressing” medical concerns. In addition, physicians’ interpersonal behaviors have a profound effect on patient utilization, adherence, and outcomes (14
). This is especially relevant for racial/ethnic minorities. Studies of disparities in quality of provider interpersonal behavior repeatedly demonstrate lower encounter quality when Caucasian physicians are interacting with non-Caucasian vs. Caucasian patients (15
). For example, low income and African American race are predictive of physicians adopting a “narrowly biomedical” communication pattern, characterized by low patient control of communication, high levels of physician biomedical information giving, and close-ended question-asking(16
). Interventions addressing provider and system barriers to delivery of smoking cessation treatments for racial/ethnic minority populations are sorely needed.
Recent findings suggest that patient beliefs, attitudes, and preferences may also be important determinants of decisions to use smoking cessation treatment. Audrain-McGovern et al. (17
) examined correlates of participation in a smoking cessation trial among younger adults (aged 18 to 30). Race was a significant predictor of participation in the trial and Caucasians, as compared to non-Caucasians, were six times more likely to participate in the behavioral smoking cessation interventions. Thus, even when smoking cessation care is available, minority smokers may be less likely to utilize it. Potential reasons that may contribute to minority smokers’ decisions to not use treatment include mistrust of physicians, negative attitudes towards treatment, skepticism about their effectiveness, lack of knowledge regarding the functional benefits of treatment (e.g., medications can be used to relieve withdrawal symptoms), and concerns about medication side effects (18
). More research is needed to understand the role of patient beliefs, attitudes, and preferences in decisions to utilize smoking cessation care and to identify effective strategies for increasing consumer demand for evidence-based cessation treatments.
Our study is also consistent with prior research that African American smokers are less likely to quit smoking (1
), independent of sociodemographic factors (3
), and adds to this research because we also controlled for smoking history (e.g., nicotine dependence and age of initiation). However, other studies indicate that controlling for population differences in age of smoking initiation (21
) or sociodemographic factors (22
) dramatically attenuates or eliminates observed differences between African Americans and Caucasians. For example, an analysis of the CARDIA study, a longitudinal study of young adults (18-35 years) observed markedly lower 10-year cessation rates among African Americans than Caucasians (25% vs 35%, crude OR 0.62 for women; 19% vs. 31%, crude OR 0.52 for men), but these differences were no longer significant after adjustment for socioeconomic factors (22
). A recent analysis of the National Health Interview Survey 1990-2000 found that in each year Caucasians were more likely to quit smoking than African Americans (23
). The differences between Caucasians and African Americans diminished after 1994 and were substantially attenuated after controlling for sociodemographic factors, though still significant with adjusted odds ratios near 1.5. It is possible that the racial/ethnic differences in our study findings are related to differences in sample size or in study design as we conducted a cross-sectional study while the CARDIA study was longitudinal and the King et al. study analyzed multiple years of cross-sectional data.
Possible explanations for the observed differences in the smoking cessation quit ratio between African Americans and Caucasians include differences in smoking patterns. African Americans are more likely to smoke menthol cigarettes that are higher in tar and nicotine and hence, may be more addictive and more difficult to quit smoking compared to plain cigarettes (24
). In the United States, 69% of African Americans smoke menthol cigarettes compared to 23% of Caucasians, 29% of Latinos, and 29% of Asians (25
). Further, menthol smoking rates are particularly high among younger smokers. It has been suggested that menthol cigarette smoking may contribute to the existing tobacco-related health disparities between African Americans and Caucasians (26
). However, only a few studies have examined the association between menthol cigarette smoking and cessation (24
). The findings from these studies are inconclusive. A recent secondary analysis of a randomized controlled trial of bupropion among 600 African Americans found that menthol smoking was associated with lower short-term (6 weeks) cessation, but not long-term (6 months) cessation (30
). Of note, the decreased short-term cessation rates for menthol smokers was only observed for participants who were less than 50 years of age and who had received bupropion.
Another possible explanation for the observed racial/ethnic differences in quit ratios is differences in access and utilization of smoking cessation care. In this study we observed significant racial/ethnic disparities in the use of NRT, which raises the question of whether lower rates of NRT use contribute to lower smoking cessation rates among African Americans. Our study, however, is not able to address this question. A clear temporal sequence cannot be established due to the cross-sectional nature of the study design. If we attempted to examine the association between prior use of NRT and quit ratios, we would not know whether we are examining the effect of using NRT on cessation versus the effect of continuing to smoke on likelihood of using NRT.
The strengths of this study include the size and diversity of the study sample, particularly for African Americans, as data regarding smoking cessation behaviors in racial/ethnic minority groups are sparse. However, the cell sizes for Latinos and Asians were relatively small and limit reaching firm conclusions about these latter two groups. Another strength of the study is that we controlled for smoking history (e.g., nicotine dependence level), as well as sociodemographic factors in our multivariate analysis. Our study, however, has several potential limitations. First, in regard to the use of race/ethnicity in this analysis, the operational definition allows racial comparisons (e.g., African American vs. White) to be disentangled from ethnicity. However, because Latino ethnicity is not exclusive to one particular race, for comparisons between Caucasians and Latinos, one is not able to separate out the independent contribution of Hispanic/Latino ethnicity from race. Second, we relied on self-reported assessment of use of NRT and smoking status, but previous studies indicate that misreporting rates are low in minimal intensity studies such as those involving surveys (31
). Third, the overall response rate for the screening survey was 40% and there is potential for non-response bias. However, we would expect non-respondents to be more disadvantaged than respondents, and if response bias was present, it would likely have a null effect on our findings. In other words, if bias is present, the observed racial/ethnic differences may be an underestimate.
An interesting observation was that education and use of NRT was inversely associated in unadjusted analyses but positively associated in multivariate analysis. We suspect that this association between education and NRT use in unadjusted analyses is confounded by nicotine dependence level. Education and nicotine dependence are strongly associated in that individuals with lower education have higher nicotine dependence levels (i.e., higher cigarettes per day and shorter time to first cigarette). After adjusting for nicotine dependence, education is positively associated with use of NRT. In previous research, higher education has been observed to be associated with greater likelihood of using NRT (32
In conclusion, further research is needed to assess the potential factors contributing to the observed racial/ethnic disparities in utilization of NRT and smoking cessation quit ratios. For example, research is needed examining the patient, provider, and system-level factors that contribute to racial/ethnic disparities in use of NRT. Future prospective studies are needed to assess whether lower utilization of cessation treatments such as NRT contribute to the observed disparity in quit ratios for African Americans. In addition, the role of menthol cigarette smoking and its effect on cessation should be examined in prospective studies. Environmental, social, cultural, and genetic factors may also be important. Current national smoking cessation guidelines recommend that all smokers be offered tobacco cessation treatment that includes pharmacotherapy. In particular, the 25-44 year age group should be a priority target population for cessation interventions because this age group has 1) high rates of smoking, and 2) stands to yield the greatest health benefits. However, due to being relatively young and healthy, this age group may have less frequent health care provider visits where most cessation interventions may occur. Therefore, alternative approaches for tobacco cessation intervention outside the health care setting should be considered. Finally, culturally appropriate interventions need to be developed to increase use of evidence-based pharmacologic and behavioral treatments during attempts to quit smoking by racial/ethnic minority smokers.