Associations between Health Literacy and Smoking

1. Associations between Health Literacy and Smoking Diana W. Stewart, Ph.D. Claire E. Adams, Ph.D., Miguel A. Cano, Ph.D., Virmarie Correa-Fernandez, Ph.D., Yumei Cao, M.A., Yisheng Li, Ph.D., Andrew J. Waters, Ph.D., David W. Wetter, Ph.D., & Jennifer Irvin Vidrine, Ph.D. American Public Health Association October 29, 2012

2. Presenter Disclosures • No relationships to disclose

3. Cigarette Smoking • Cigarette smoking is the leading preventable cause of US morbidity and mortality [Mokdad et al., 2004] • Responsible for one-third of all cancer-related deaths and 90% of lung cancer cases each year [USDHHS, 2004] • Nearly 20% of US adults smoke [CDC, 2012] • Certain populations have higher smoking prevalence and lower quit rates [CDC, 2002; Vidrine et al., 2009; Wetter et al., 2005] • Individuals with low income, education, employment • Racial/ethnic minorities

4. Predictors of Smoking Cessation • Research has identified numerous predictors of smoking cessation • Nicotine dependence [Kozlowski et al., 1994] • Smoking outcome expectancies [Copeland et al., 1995] • Smoking health risk knowledge and risk perceptions [Borelli et al., 2010; Gibbons et al., 1997] • Quitting self-efficacy [DiClemente, 1991] • Intentions to quit, cut back, or limit smoking [Peters and Hughes, 2009]

5. Health Literacy • Poor health literacy (HL) might also negatively affect cessation outcomes • Little research has investigated this • HL is the ability to obtain, understand, and use health information to make decisions about health and medical care [USDHHS, 2005] • Nearly half of US adults have poor HL [Kutner et al., 2006] • Racial/ethnic minorities and those with low education, income, and employment have highest rates [Kutner et al., 2005]

6. Health Literacy and Health Behavior Low HL is associated with poor overall health status and poor health outcomes [see Berkman et al., 2011 for a review] Higher incidence of chronic illness (e.g., diabetes) Limited access to prevention and treatment programs Unhealthy behaviors (e.g., poor medication adherence) Low illness-related knowledge Lower rates of cancer screening Diagnosis of advanced-stage cancer Premature mortality

7. Health Literacy and Smoking • Few studies have investigated relations between HL and smoking • Mixed results regarding HL and smoking status [Baker et al., 2007; Sudore et al, 2006; Arnold et al., 2001] • One study found that poor HL was associated with lower smoking risk knowledge and more positive smoking-related attitudes [Arnold et al., 2001] • Another study reported that HL was not associated with smoking cessation outcomes • Very small sample size, most participants had high HL [Varekojis et al., 2011]

8. Health Literacy and Smoking • Smoking is the leading behavioral risk factor contributing to social disparities in disease • Critical need to better understand how HL may be related to smoking prevalence and cessation among racial/ethnic minorities and those with low-SES • HL may be an essential, but overlooked factor in understanding tobacco-related health disparities

9. Purpose of the Present Study • This study investigated associations between HL and established predictors of smoking cessation in a sample of smokers • Hypothesized that lower HL would be related to: • Higher nicotine dependence • Greater positive and fewer negative smoking expectancies • Lower smoking health risk knowledge and risk perceptions • Lower self-efficacy • Fewer intentions to quit, reduce, or limit smoking

10. Method: Participants and Procedure • Data collected as part of a larger study evaluating smokers’ responses to smoking health risk messages • Participants recruited via media and outreach • Eligibility: • Ages 18-70 • Smoked >5 CPD for past year; CO > 10 ppm • Report no intention to quit within 30 days of enrollment • Eligible participants attended lab visit and completed baseline questionnaires before reviewing various smoking health risk messages

11. Method: Measures • Demographics • Heaviness of Smoking Index [HSI; Kozlowski et al., 1994] • Rapid Estimate of Adult Literacy in Medicine [REALM; Davis et al., 1991] • Scores based on reading level • HL was dichotomized based on a median split at the 9th grade level • Smoking Consequences Questionnaire-Adult [SCQ-A; Copeland et al., 1995] • Smoking risk knowledge • Smoking risk perceptions [see Weinstein et al., 2004] • 6 items assessing absolute risk and risk compared to others • Self-efficacy for quitting smoking • Intentions to change smoking behavior [see Gollwitzer & Sheeran 2006]

12. Data Analyses • Chi Square analyses and t-tests tested for demographic differences between those with high vs. low HL • Multiple linear regression analyses were conducted to assess associations between HL and smoking variables • Analyses controlled for demographic and SES-related variables (i.e., age, gender, race/ethnicity, education, income, relationship status)

13. Results: Participant Characteristics • N=402 • Mean age of 43.2 (+10.2) years • 66% male • 70% Black • 27% had less than a high school diploma or GED • 70% reported annual household income of <$10,000 • 43% had low HL; 57% had high HL • Low HL was significantly associated with being male and Black, and having lower income and education (ps < .05) Stewart, D. W., Adams, C. E., Cano, M., Correa-Fernandez, V., Li, Y., Waters, A. J., Wetter, D. W., & Vidrine, J. I. (in press). Associations between health literacy and established predictors of smoking cessation. American Journal of Public Health.

14. Results: HL and Smoking Characteristics • Smokers with low HL reported: • Higher levels of nicotine dependence (p = .003) • Fewer negative smoking outcome expectancies • Health Risks (p < .001) • Craving/Addiction (p = .07) • More positive smoking outcome expectancies • Stimulation/State Enhancement (p = .05) • Social Facilitation (p = .05) • Weight Control (p = .07)

15. Results: HL and Smoking Characteristics • Smokers with low HL reported: • Lower smoking risk knowledge (p < .001) • Lower smoking risk perceptions • “If you don’t quit smoking for good, what are chances of ever developing a smoking-related health problem?” (p = .03) • “Compared to other smokers, what are your chances of ever developing a smoking-related health problem if you quit smoking for good?” (p < .001) • “What is your perceived risk of developing at least one health consequence of smoking if you continue smoking?” (p < .001) • HL not associated with self-efficacy to quit smoking or intentions to limit, reduce, or quit smoking

16. Conclusions • Low HL is associated with certain known predictors of smoking cessation even after controlling for demographics and SES-related factors • First evidence that low HL may be a unique risk factor for poor cessation outcomes over and above well-established predictors of cessation in low-SES, racially/ethnically diverse smokers • Low-SES, racially/ethnically diverse smokers with low HL may be at higher risk for poor cessation outcomes

17. Limitations Cross-sectional analyses Results demonstrate associations rather than causality Longitudinal studies are needed to clarify temporal relations Participants were non-treatment seeking smokers Eligibility criteria required that smokers did not intend to quit within 30 days of study enrollment Research needed to replicate this research among smokers seeking treatment Self-report measures May be biased

18. Implications and Future Directions • First known study to investigate relations between HL and known predictors of smoking cessation • Current methods of teaching about the health risks of smoking may be inadequate • Improve providers’ training in clear communication • Improve visual education materials • Future research is needed to evaluate mechanisms underlying relations between HL and smoking • Findings might be used to develop prevention and cessation strategies tailored for those with low HL, thereby reducing tobacco-related health disparities for the underserved

19. Acknowledgements • Grant Support • National Institutes of Health/National Cancer Institute (R01CA125413; PI: Vidrine) • National Cancer Institute (R25T CA57730; PI: Chang) • National Cancer Institute Latinos Contra el Cancer Community Networks Program Center Grant (U54CA153505; MPIs: Wetter, Fernandez, Jones) • National Institutes of Health through MD Anderson Cancer Center Support Grant (CA016672)

20. Thank you!