April 26, 2010 Seminar: Health Disparities Interest Group

Tobacco Use and Cessation Among Ohio Appalachian Residents

Introduction

• Antoinette Percy-Laurry, co-chair of this year's HDIG seminar series, led introductions of all meeting attendees and introduced this month's speaker, Dr. Mary Ellen Wewers.
  • Presenter: Mary Ellen Wewers, Ph.D., MPH
    • Professor, The Ohio State University College of Public Health
    • Co-Leader, Cancer Control Program, OSU Comprehensive Cancer Center
  • Presentation Title: Tobacco Use and Cessation among Ohio Appalachian Residents

Background Information

• Underlying framework: a social-contextual model considering upstream factors such as social conditions and policies as well as downstream factors such as individual physiological processes
• Appalachia
  • Includes parts of 12 states, plus all of West Virginia
  • Includes 29 counties in Ohio, which are mostly rural
• Ohio Appalachian residents, in general, have:
  • Low SES
  • High unemployment
  • Low-paying jobs
  • Deficits in education
  • Less access to health services, especially health promotion and prevention
  • High incidence and mortality from cervical cancer
  • High rates of human papillomavirus (HPV)
• Cervical cancer
  • Risk factors include smoking, being HIV positive, lack of screening, and lack of follow-up to an unusual pap smear result
  • Smoking can increase cervical cancer rates by 2-4 times, and can increase the persistence of HPV
• Smoking environment in Appalachian Ohio
  • Unlike the U.S. and Ohio in general, Appalachian Ohio has not experienced a significant drop in smoking rates between 2004 and 2008
  • Ohio enacted a smokefree law in 2006, but these laws are not well-enforced in Appalachian Ohio
  • The environment is rural and farm-based, and tobacco is grown in the area

Project: Tobacco Use and Cessation among Ohio Appalachian Women

• A clinic-based study of the 22 clinics in 14 Appalachian Ohio counties that conduct >200 cervical cancer screenings per year
  • 14 of these 22 clinics provided complete lists of all female patients seen in the past two years
  • Some of these women were randomly selected each month to determine eligibility for the baseline survey, which aimed to describe the social and behavioral factors related to tobacco use among Appalachian women
  • Of the approximately 4,500 women who were randomly selected, 2,903 were initially deemed eligible, and 570 of these were eventually interviewed
• Baseline survey results – compared to never-smokers, current smokers were
  • Less likely to be professionally employed
  • Less likely to have health insurance
  • Less likely to ban smoking in the home
  • At a lower socioeconomic position (SEP), both as a child and as an adult
  • More likely to binge-drink
  • More likely to have depressive symptomatology
  • More likely to have experienced a pregnancy or live birth as a teenager
  • More likely to be a single mother
• After baseline, 556 women who smoked daily and had no medical contraindications to nicotine-replacement therapy (NRT) were found to be eligible for the intervention, and 302 were enrolled
  • Intervention: a nurse-managed protocol administered by lay health workers, including eight weeks of counseling and eight weeks of NRT. This intervention was based on the 2000 US Public Health Service Clinical Practice Guidelines for Tobacco Cessation
  • Control: mailed participants a personalized letter, and print materials encouraging recipients to make an appointment with a physician and to bring up smoking cessation at the appointment
  • Participants were randomized to the two groups, which were stratified to control for differences in demographics, occupation, depressive symptoms, alcohol use, perceived stress, and smoking behavior characteristics

• Results
  • The 12-month quit rate among intervention arm participants was 17%
  • The intervention resulted in significantly higher quit rates at 3 and 6 months, but the difference was non-significant at 12 months
    • Interestingly, the control group had modest increases in the quit rate between 3 and 12 months post-intervention
    • The researchers found that on their own, about 30% of the control group had accessed cessation resources and about 25% had purchased NRT
• Discussion and future research
  • Cotinine validation was essential in determining smoking status
  • Extending or increasing the intensity of the intervention may boost quit rates
  • Depression symptoms were found throughout, and future interventions may want to address them
  • Future research should explore the control group's use of NRT
• Next Steps
  • A group randomized trial in 12 Appalachian Ohio counties, including both men and women, and comparing the intervention from this study to the Ohio quitline
  • This new study will build in multilevel modeling, taking into account geographic patterning and social and contextual variables

Research on Social Networks

• Because of their uneven enforcement, smokefree legislation is not changing social norms around smoking the way it is in other states, increasing the relative importance of social networks in changing these norms
• Previous studies suggest that:
  • Smokers tend to quit in groups
  • Smokers have fewer social ties, and their ties tend to be to other smokers
  • Smokers are often on the periphery of social networks, making them more difficult to reach
• This research aims to:
  • Characterize the social networks of current, former, and never smokers in Appalachian Ohio
  • Examine individual, interpersonal, and community characteristics such as social cohesion
  • Test a social network-based intervention among Appalachian smokers

Discussion Topics

• Dual use of smokeless tobacco along with cigarette smoking
• Targeting the peer influencer of a social network in order to affect the smoking habits of the whole network
• How to measure social networks
• Uniformity of smokefree legislation and cigarette taxes across Ohio
• Other tobacco prevention and cessation programs in Ohio, such as media campaigns and the state quitline
• Role of medical providers, their training in smoking cessation, and their own smoking status

Announcements

• Next HDIG Meeting: Monday, May 24, 2010. Dr. Paul Sorlie will discuss the National Longitudinal Mortality Study (NLMS).

For more information, please contact Antoinette Percy-Laurry, Co-Chair of the HDIG Seminar Series, at 301-594-8421 or percyl@mail.nih.gov.

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