The purpose of the current study was to examine whether attitudes toward pharmacotherapy were attributed to differing rates of self-reported pharmacotherapy usage among Black and Caucasian American smokers living in South Carolina. We believe this is among the first studies to examine attitudinal barriers to using pharmacotherapy within a large population-based sample. The study design, a population-based survey of South Carolina current smokers, oversampled for Blacks, builds upon previous research and supports external validity. Our results confirm racial differences in usage of pharmacotherapy, attitudes toward pharmacotherapy, as well as the link between attitudes and usage.
Across studies of smoking cessation pharmacotherapy, measurement of past pharmacotherapy use is variable, with some studies examining usage during the most recent quit attempt, usage during the past year, or ever usage. Our study measured ever usage estimated at 23% among Blacks and 39% among non-Hispanic Whites. These rates appear lower compared with other recent reports, which found usage rates among adult smokers (across racial groups) who made a quit attempt in the past year to be 22% (Cokkinides et al., 2005
), 32% (any pharmacologic or behavioral cessation aid; Stahre et al., 2010
), and 32% (Shiffman, Brockwell, et al., 2008
). The low usage rates found in our study likely reflect the unique population of smokers in South Carolina as well as the state tobacco control climate. South Carolina incurs a disproportionate burden of tobacco-related disease (Alberg et al., 2006
) and historically has had weak tobacco control legislation. For example, in fiscal year 2009, South Carolina was ranked 51st in the nation on tobacco control spending, allocating $0 and $1 million of state and federal funds, respectively, or less than 2% of Centers for Disease Control recommendations (Campaign for Tobacco Free Kids, 2009
Our findings demonstrate that Black smokers differ from non-Hispanic White smokers on several attitudes toward pharmacotherapy, including beliefs about its efficacy and addiction potential. They rate medications as being more harmful than do White smokers and generally discount the need for treatment to quit. This is consistent with the findings from a prior population-based study, which demonstrated greater concerns about the safety and efficacy of NRT among non-White smokers (Shiffman, Ferguson, et al., 2008
), and consistent with the previous findings of qualitative studies, which have identified greater concerns about pharmacotherapy products among non-White smokers on themes of safety and addiction likelihood (Cummings et al., 2004
; Fu et al., 2005
; Yerger et al., 2008
). The finding that Black smokers discount the need for cessation treatment of any kind suggests that they hold different views on nicotine dependence, including the value of comprehensive treatment for it. Thus, there seems to be an overall dismissal of any treatment need not just medication alone. This underscores a clear need for increased education on the challenges of quitting and the role of pharmacotherapy in that process. The need for heightened education is more apparent, given prior research that shows lower rates of health literacy among Blacks (Willey, Williams, & Boden-Albala, 2009
) as well as the link between low health literacy and negative health outcomes (Williams, Davis, Parker, & Weiss, 2002
). Importantly, there is support for the efficacy of educational efforts to improve health care literacy among Blacks (Mabiso, Williams, Todem, & Templin, 2010
; Yang et al., 2010
Contrary to our hypothesis, however, we did not find significant Race × Attitude interactions as being predictive of pharmacotherapy use. That is, associations between use and attitudes were consistent across (not moderated by) racial group. This suggests that the attitudes that undermine pharmacotherapy usage are universal across race and possibly other demographics. Conversely, this may reflect limitations in power, incomplete assessment of attitudinal beliefs about pharmacotherapy, or both. Our data collection instrument was limited in its scope of pharmacotherapy attitudes. We conceptualized attitudinal barriers as consisting primarily of safety concerns and doubts of efficacy, an approach based on prior research (Cummings et al., 2004
; Fu et al., 2005
; Shiffman, Ferguson, et al., 2008
; Yerger et al., 2008
). Other more detailed attitudes certainly exist, such as the comparative harm of pharmacotherapy to smoking.
Nonetheless, the lack of significant Race × Attitude interactions suggests that factors other than attitudes may undermine pharmacotherapy use among Blacks. Prior studies have documented a history of negative health care experiences among Black smokers (Browning, Ferketich, Salsberry, & Wewers, 2008
; Chase, McMenamin, & Halpin, 2007
; Franks, Fiscella, & Meldrum, 2005
; Fu et al., 2007
; Houston, Scarinci, Person, & Greene, 2005
) and strong negative attitudes (i.e., mistrust) toward doctors (Fu et al., 2007
). Perceptions of discrimination and inequity within the health care system are related to medical care delays and nonadherence (Casagrande, Gary, LaVeist, Gaskin, & Cooper, 2007
). Also, a number of studies have shown that Blacks are routinely less likely to receive adequate quit advice from health care providers than Whites (Browning et al., 2008
; Chase et al., 2007
; Franks et al., 2005
; Houston et al., 2005
). Whether it is negative expectations about the health care system in general or an absence of clear cessation advice, it does appear that systemic influences have dissuaded Blacks from seeking treatment, following through with treatment recommendations or even believing treatment is necessary.
Another potential systems-level influence on misperceptions about pharmacotherapy relates to how it is regulated and marketed. Many products are often considered as “drugs,” labeled with implicit (and often explicit) suggestion that they are dangerous (Foulds, 2008
). Black smokers have voiced strong concerns about foreign ingredients within products and the effects these unfamiliar ingredients might have on the body (Yerger et al., 2008
). Lack of familiarization and trust in how products are developed and tested (Carpenter, Ford, Cartmell, & Alberg, in press
) may account for this apprehension.
This study was subject to some limitations. The sampling for the survey consisted exclusively of landlines, which biases against inclusion of households that are wireless only. The role of socioeconomic status may be an important factor in pharmacotherapy use. While we did not collect this information directly, our reliance on educational status may be a proxy. As noted previously, the survey assessed a limited number of attitudes toward pharmacotherapy, leaving the possibility that we did not assess significant attitudes related to pharmacotherapy use. The survey only assessed a crude measure of pharmacotherapy usage (yes/no) and neither assessed duration or context of use. Our estimates were of ever usage, which allows for indirect comparisons with other studies that assess usage in past year or during the most recent quit attempt. Finally, the temporal relationship between attitude and usage is impossible to disentangle in a cross-sectional survey.
Within this sample of current smokers in a southeastern state with weak tobacco control, overall ever usage of pharmacotherapy was 23% among Blacks and 39% among non-Hispanic Whites. Misconceptions about these products exist regardless of racial group, and both Black and non-Hispanic Whites are using pharmacotherapy at rates that fall well below best practice, given the support for their efficacy. The findings highlight a clear need to better educate individuals, particularly non-Whites, about the benefits and limited risks of pharmacological treatments to improve utilization and have an impact on smoking cessation.