Addressing Tobacco-Associated Health Disparities through Behavioral Science
By Monica S. Webb
Monica S. Webb, PhD, is an Assistant Professor of Psychology at the University of Miami, where she is also a member of the Biobehavioral Oncology and the Cancer Epidemiology and Prevention programs of the Sylvester Comprehensive Cancer Center at the Miller School of Medicine. She received her PhD from the University of South Florida in 2005 and has been a faculty member at Syracuse University (2005-2008). Dr. Webb’s program of research includes aspects of clinical health psychology, biobehavioral medicine, public health, and social psychology. Through the integration of these areas, Dr. Webb’s research contributes to our understanding of methods to address (1) health behavior change and (2) cancer health disparities in the general population and among African American smokers. This research includes theoretical, behavioral, experimental, and applied investigations of tobacco use, cessation, and relapse prevention. Findings from Dr. Webb’s program of research have been published in the Journal of Consulting and Clinical Psychology, Health Psychology, Psychology of Addictive Behaviors, and the Journal of Clinical Psychology.
Tobacco smoking is the leading cause of preventable morbidity and mortality in the United States. Smoking claims the lives of over 400,000 Americans yearly, including 30% of all cancer deaths and 87% of lung cancer deaths (US Department of Health and Human Services [USDHHS], 2004). As of 2007, 43 million Americans, 19.8% of the population, were current smokers (Centers for Disease Control and Prevention [CDC], 2008). The overall prevalence of smoking is the same for African Americans and Caucasians (20%; CDC, 2008); however, smoking rates among low socioeconomic status (SES) African Americans are at least double the national average (41%-60%; Delva et al., 2005). Moreover, the African American community is at the highest risk of tobacco-associated disease and death compared to other racial/ethnic communities.
African Americans have disproportionate rates of tobacco-associated illnesses, including several cancers, cardiovascular disease, and cerebrovascular disease (American Cancer Society, 2007; USDHHS, 1998). Research has examined contributory factors to racial/ethnic health disparities, with the goal of informing theory and developing effective intervention methods. Evidence has converged on key differences in smoking patterns between African American and Caucasians that can potentially be incorporated into intervention strategies. First, in adolescence, African Americans have significantly lower smoking rates than Caucasians (Tucker, Ellickson, & Klein, 2003), yet, the prevalence of smoking among African American adults approximates or exceeds that among Caucasians. Second, African American smokers consistently report fewer cigarettes per day compared to Caucasians (Caraballo et al., 1998). Third, over 70% of African Americans smokers use menthol cigarette brands, compared to less than 33% of Caucasian smokers (Substance Abuse and Mental Health Services Administration, 2005). Menthol cigarettes are particularly problematic because they inhibit smoking cessation (Okuyemi, Faseru, Cox, Bronars, & Ahluwalia, 2007). Moreover, smoking menthol cigarettes may confer a greater mental health risk (Webb et al., in press). Fourth, African American smokers may be more nicotine dependent, as evidenced by greater levels of serum cotinine (the primary nicotine metabolite) per cigarette (Ahijevych & Parsley, 1999) and earlier time to first cigarette in the morning (Muscat et al., 2009).
The importance of reducing tobacco-associated health disparities between African Americans and Caucasians cannot be understated. However, there is some good news. First, African American smokers are motivated to quit, and are more likely to have attempted cessation during the past 12 months compared to Caucasians (Burns & Pierce, 1992; Royce, Hymowitz, Corbett, Hartwell, & Orlandi, 1993). However, African Americans are less successful in quitting compared to Caucasians smokers (Novotny, Warner, Kendrick, & Remington, 1988; USDHHS, 1998). Second, there are several effective smoking cessation methods (Fiore et al., 2008), including various forms of behavioral counseling (e.g., brief physician advice, group and individual counseling, and telephone counseling), individually tailored self-help materials, and seven first-line Federal Drug Administration (FDA)-approved products (e.g., nicotine replacement therapy, bupropion, and varenicline). However, African Americans have less access to smoking cessation services and are less likely to be advised to quit by physicians (Ahluwalia, 1996; Anda, Remington, Sienko, & Davis, 1987). Moreover, the extent to which evidence-based intervention approaches can be generalized to the African American community remains unclear.
Resnicow, Baranowski, Ahluwalia, & Braithwaite (1999) developed a theoretical model for culturally specific intervention development that can be applied to African Americans. The model has two primary dimensions: surface structure and deep structure. Surface structure refers to the face validity of the intervention. That is, the intervention “looks like” it was designed for the target group (e.g., pictures of African American smokers only). Surface structure is thought to enhance people’s receptivity to the intervention. Deep structure refers to the incorporation of meaningful socio-cultural, historical, environmental, and psychological factors into the intervention (such as those related to African American families and communities, racism, smoking patterns among African Americans, and racially targeted tobacco marketing). Deep structure is hypothesized to increase intervention efficacy. Culturally specific interventions are thought to enhance the effectiveness of established methods by placing the intervention within a community and cultural context (Resnicow, Soler, Braithwaite, Ahluwalia, & Butler, 2000). However, little empirical research has tested the incremental efficacy of culturally specific interventions. When it has, methodological limitations (e.g., uncontrolled intervention intensity, contacts, and quality, and failure to include standard comparison conditions; Nollen, Ahluwalia, Mayo, Richter, Choi, Okuyemi et al., 2007; Orleans, Boyd, Bingler, Sutton, Fairclough, Heller et al., 1998) preclude our understanding of whether these interventions are more effective.
Thus, the important question of whether smoking cessation interventions need to be targeted to specific racial/ethnic groups remains largely unanswered. Is attending to cultural and racial factors a precondition to intervention success? Recent research has aimed to test the efficacy of culturally specific tobacco interventions in a randomized controlled trial, called the Free Yourself study (Webb, 2009). The study used dismantling (or component control) methodology to evaluate specific causal relationships involving intervention components (Behar & Borkovec, 2003).
In this study, adult African American smokers (final N = 183) were randomly assigned to receive two variations of a written smoking cessation intervention: a culturally specific guide versus a standard (i.e., non-culturally specific) guide. The two interventions were matched on all dimensions (e.g., content, length, design, and format) except for cultural specificity. The culturally specific intervention was Pathways to Freedom (PTF), an established CDC-sponsored smoking cessation guide developed for African Americans. PTF includes both surface and deep structure elements related to African Americans, including: reference to known smoking patterns of African Americans, pictures of African Americans exclusively, religious/spiritual quotations, discussion of targeted tobacco advertising, and an emphasis on family and community. The challenge in this study was to create a matched, standardized (i.e., generic) version of PTF, that maintained its essential content and structure, while removing the culturally specific aspects. Participants in the standard condition received Free Yourself, a ‘de-culturally specified’ version of PTF. Examples of how PTF was modified to create its standardized counterpart are shown in Table 1.
Table 1. Comparison of the Culturally Specific and Standard booklets
The primary outcome measures included evaluations of the intervention (e.g., “The quit smoking booklet was interesting;” “The quit smoking booklet was trustworthy; I believed what I read;” and “The information in the quit smoking booklet caught my attention.”), readiness to quit smoking (using the Contemplation Ladder—a 10-point continuous measure; Biener & Abrams, 1991), reduction in daily smoking, and 24-hour quit attempts. A 4-item (0-7 scale) manipulation check assessed perceptions of cultural specificity (e.g., “The information in the quit smoking booklet talked about parts of African American culture”). Based on the equivocal findings from previous research, it was unclear which intervention would produce the greatest effects on the outcome measures. Results indicated that (a) there were no differences in intervention quality or utilization; (b) the manipulation was successful (p < .05), such that participants in the culturally specific group (M = 22.45, SD = 4.97) were significantly more convinced that the intervention was designed specifically for African Americans than were those in the standard group (M = 18.91, SD = 4.97); and (c) participants preferred the culturally specific intervention (M = 71.47, SD =11.05) compared to the standard version (M = 67.39, SD = 13.39). However, results also indicated that (a) readiness to quit smoking was greater among participants who received the standard intervention (M = 8.22, SD = 2.38) compared to the culturally specific guide (M = 7.24, SD = 2.55); and (b) quit attempts were more likely among participants in the standard condition. There was no difference in smoking reduction between conditions.
This was one of the first well-controlled trials to examine the incremental efficacy of cultural specificity in smoking cessation interventions targeting African Americans. The finding that participants preferred culturally specific (versus standard) materials was consistent with theoretical models of cultural sensitivity. However, that the standard intervention led to greater readiness to quit smoking and quit attempts would not be predicted from the Resincow et al. (1999) model. From this study, we learned that a high quality standard (without ethno-cultural adaptations) intervention can facilitate behavior change among African American smokers. However, given the cultural heterogeneity in this population, the question of whether culturally specific approaches are more effective might best be determined at a more fine-grained level.
Individual difference factors may account for some of the variance in responses to culturally specific intervention approaches. One such variable, level of acculturation, refers to the adoption of the attitudes, values, beliefs, practices, and/or behaviors of the dominant (in this case, Caucasian) ethno-cultural group. Less acculturated African Americans are more likely to engage in traditional cultural practices; thus, these individuals may be more likely to appreciate efforts to incorporate ethno-cultural factors into interventions. In contrast, acculturated African Americans are less connected to the traditional culture and might not derive additional benefit from a cultural focus. Previous research examining culturally specific tobacco interventions had not considered individual differences in levels of acculturation.
In a separate analysis of the Free Yourself data, acculturation was considered as a moderator of culturally specific intervention effects (Webb, 2008). It was hypothesized that culturally specific tobacco interventions would be most effective among less acculturated African Americans, and may be ineffective (or result in negative effects) for those who are more acculturated. Indeed, results demonstrated that level of acculturation moderated intervention efficacy such that (a) the culturally specific intervention was evaluated more favorably by less acculturated smokers compared to those who were more acculturated (Figure 1a); and (b) readiness to quit was increased among less acculturated smokers who received the culturally specific guide compared to the standard guide (Figure 1b). This was the first study to suggest that level of acculturation is an individual difference factor that influences culturally specific intervention outcomes. This research indicates that one size does not fit all members of an ethno-cultural group, and that inter-group variation needs to be considered.
Figure 1. Regression lines by condition, illustrating interaction between intervention condition (standard versus culturally specific) and level of acculturation. (a) Illustrates the moderating effect of acculturation on content evaluations; (b) illustrates the moderating effect of acculturation on Contemplation Ladder (Biener & Abrams, 1991) scores. Interactions are statistically significant at p < .05. On the African American Acculturation Scale-Revised (Klonoff & Landrine, 1999), low scores indicate greater acculturation; high scores indicate less acculturation/more traditional African American culture.
In summary, reducing ethnic/racial disparities in tobacco-related medical conditions is a national public health priority. Continued research aiming to reduce health disparities through understanding and addressing tobacco use among African Americans is warranted. Future research is needed to answer the questions of (a) whether culturally specific interventions lead to greater long-term smoking abstinence compared to their traditional counterparts; and (b) for whom culturally specific approaches are most beneficial. The answers will inform theories related to ‘cultural sensitivity’ and best practices for tobacco intervention among African Americans.
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