Executive Summary: Strengthening Psychology’s Role in Reducing Tobacco Health Disparities
The American Psychological Association (APA) convened a meeting Dec. 10 - 11, 2012, to identify and discuss recommendations the APA might undertake in development of a plan to strengthen, expand and enhance APA's efforts to prevent and treat tobacco use in health disparity populations. Twenty-four sessions were held that addressed the prevalence and determinants of tobacco use in health priority populations, emerging concerns and research needs, and prevention and treatment interventions, programs and resources. Approximately 80 invited speakers, students, federal and APA staff, and other guests participated in the meeting, generating 130 recommendations.
“Tobacco Use, Prevention, and Treatment Needs in Health Priority Populations,” H. Westley Clark, MD, JD, MPH, Director of the Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services Administration (SAMHSA). Clark presented an overview of smoking and other tobacco use in vulnerable and underserved populations and summarized SAMHSA’s initiatives to reduce tobacco use and increase cessation. He reported that more than 400,000 Americans die of tobacco-related illnesses each year. Risk factors associated with smoking include alcohol use; being lesbian, gay or transgender (LGBT—1.5 to 2.5 times more likely to smoke than heterosexuals); having a mental health condition (34 to 59 percent vs. 21 percent in the general population); and having a substance use disorder (77 to 92 percent). Moreover, smoking is often co-morbid with other conditions. For example, while 20.6 percent of the general population smokes, the percentage is much higher for people with mental illnesses: 59.1 percent of people with schizophrenia, 46.4 percent bipolar disorder, 38.1 percent serious psychological distress, 37.2 percent attention deficit disorder, 35.4 percent dementia and 34.3 percent phobias or fears.
Major SAMHSA tobacco initiatives began in 2010 with the release of the U.S. Department of Health and Human Services’ strategic action plan to achieve the 4 tobacco-related objectives of Healthy People 2020. They include Synar programs to reduce youth access to tobacco by requiring states and territories to enact and enforce laws prohibiting tobacco sales to young people; 100 Pioneers for Smoking Cessation Campaign, which gave grantees $1,000 incentive awards to address nicotine addiction and create smoke-free environments; an interagency agreement with the Food and Drug Administration (FDA) focused on tobacco prevention and cessation messaging; and expanding use of tobacco cessation activities among SAMHSA’s primary and behavioral health care integration grantees.
Clark observed that the tobacco industry spends nearly $10 billion a year to aggressively promote tobacco use and fuel addiction among consumer, but noted that research shows that, overall with effort and commitment, prevention works, treatment is effective and people recover.
“Determinants of Tobacco Use in Vulnerable Populations,” Moderator, Jacqueline Gray, PhD, University of North Dakota
“Tobacco Research and the Population Assessment of Tobacco and Health Study,” presented by Nicolette Borek, PhD, Food and Drug Administration (FDA), Center for Tobacco Products (CTP). FDA’s public health goals are to prevent Americans from starting to use tobacco, to encourage users to quit, and to decrease the harm of tobacco product use. To do this, FDA has specific authority: to restrict youth access to tobacco products; establish tobacco product standards, health warnings on cigarettes and smokeless tobacco product packages and ads, advertising and promotion, industry registration and ingredient listing; and conduct research to support tobacco product regulation.
“Environmental Affordances Theory for Understanding Population Differences,” presented by Jennifer Glass, PhD, University of Michigan. Neighborhood affordances are the interrelationships among environment, stressors, negative health behaviors and physical and mental health disorders. They are differential opportunities (e.g., food, services, jobs) that afford differential coping resources (e.g., fast food outlets, liquor stores). Glass discussed the self-regulation of health behaviors and how it relates to the interrelationships among physical and mental health disparities and the utilization of stress coping mechanisms. This psychological awareness motivates individuals to do something about their problem, e.g., eating comfort food, smoking, drinking alcohol and using drugs. Glass showed that African-Americans and other marginalized groups’ exhibit reduced rates of psychiatric disorders, but they at the same time have higher rates of physical morbidities, excess and early mortality, perhaps buying the former with the latter.
“Minors’ Access to Tobacco,” presented by Elizabeth Klonoff, PhD, University of California–San Diego and San Diego State University. Klonoff described research efforts to determine how minors acquired cigarettes. In California, minors’ access to cigarettes has decreased from commercial sources, but access has increased through social sources (people). Klonoff observed that many youth acquire cigarettes through internet sales and that attention must be paid to these current procurement methods.
“Lessons from Spider: Traditional Tobacco Medicine, American Indian/Alaska Natives, and Commercial Tobacco Abuse,” presented by Leah M. Rouse Arndt, PhD, University of Wisconsin–Milwaukee. Arndt discussed the meaning and use of tobacco in traditional American Indian/Alaska Native ceremonies. Recognizing that smoking and the resultant health consequences pose significant health disparities for American Indians, the Menominee Indian Tribe of Wisconsin, the University of Wisconsin-Madison, and Arndt (UW- Milwaukee) undertook a clinical trial that examined standard smoking cessation treatment against a culturally-tailored intervention. She explained that traditional, sacred “tobacco” belongs to a variety of plants, including various willows. Since there is no ceremonial relationship with commercial tobacco, use of commercial tobacco establishes a mutually abusive relationship, which results in addiction and adverse health outcomes. A traditional tobacco relationship is medicinal and spiritual.
“HIV, Smoking, and Tobacco-related Illness: Intersecting Epidemics,” presented by Jonathan Shuter, MD, Montefiore Medical Center, Albert Einstein College of Medicine. HIV and cigarette smoking are two intersecting epidemics. Tobacco use is epidemic among persons living with HIV/AIDS, but despite cessation being associated with major health benefits, there are few proven treatment options. Moreover, HIV care providers are poorly equipped to treat tobacco use.
“Tobacco Disparities Are Driven by Marketing: Industry Strategies Targeting Low-income Women,” presented by Cati Brown, PhD, University of California–San Francisco. Brown shared research on tobacco marketing strategies used to encourage smoking particularly in women. She showed that tobacco companies have exploited military and welfare women via direct mail and psychological appeals to low socioeconomic status women using price as a manipulator. Smoking rates for people below the poverty line are much higher than for the rest of the population (29 percent vs. 17 percent of women) and they are less likely to quit. She concluded that tobacco disparities are driven by predatory marketing practices.
“Evidence-based Interventions: A Primer for Health Priority Populations,” presented by Felipe González Castro, PhD, MSW, University of Texas-El Paso. Castro discussed factors important in developing and implementing culturally appropriate interventions. He described the four stages of formal intervention adaptation: information gathering, preliminary adaptation design, preliminary adaptation test and adaptation refinement. Five competing or conflicting imperatives were discussed: knowledge sources (scientific evidence-based vs. community-based participatory), design (specificity/standardization vs. adjustability/adaptability), implementation (fidelity vs. adaptation), engagement (motivating participation vs. building skills) and dissemination (adoption vs. adaptation). Abiding issues of cultural adaptation strategies were identified: maintain core components; increase cultural relevance and engagement; sustain intervention efficacy maintaining effect size on targeted outcomes or increase effect size. He used StopLite as an example of program adaptation. StopLite, adapted for Mexicans, is a light and intermittent smoking cessation intervention empirically and theoretically developed as a one- time brief intervention at the University of Texas–El Paso.
“Tobacco Use Presentation and Treatment with Health Priority Populations,” Moderator, Faye Belgrave, PhD, Virginia Commonwealth University
“Smoking Cessation Programs in Substance Abuse Treatment Facilities: A Closer Look,” presented by Jessica Muilenburg, PhD, University of Georgia. Evidence-based treatment for smoking in substance abuse treatment is hindered by lack of clinician knowledge and training, the belief that treating smoking behavior reduces the likelihood of sobriety and reimbursement limits. Nevertheless, research shows that patients seeking drug treatment are interested in quitting smoking, and that integrating smoking cessation into substance abuse treatment does not negatively affect treatment for the primary substance abuse and may increase treatment success. Nicotine replacement and psychological methods together are now the recommended approach.
“Who Smokes Today and What Kind of Cessation Assistance Do They Need?” presented by Dee Burton, PhD, State University of New York (SUNY) Downstate School of Public Health. Burton argued that stress is a high predictor of smoking and that highly stressed individuals are more likely to smoke. There is great need for cessation assistance that comes to them (outreach), provides long- term support (stays with them) and is tailored to the whole person’s lived experience.
“Acculturation and Tobacco Prevention in Latino Populations: Correcting Health Disparities,” presented by Lourdes Baezconde-Garbanati, PhD, MPH, University of Southern California. Men smoke more frequently and are more likely to be smokers. There is no moderating effect of age or gender. Social networks are likely to be influential, ostracism is a factor, and self-awareness and self-regulation are decreased in smokers. Country of origin is related to smoking among Latino men. More U.S.-born Latinos smoke than do those born in their country of origin.
“Racism/Ethnic Discrimination and Smoking,” presented by Elizabeth Brondolo, PhD, St. Johns University. Racism is a psychosocial stressor consistently associated with increased risk of cigarette smoking. In the presenter’s study of smoking in Black and Latino adults, racism was related to smoking status and frequency. Other contributing factors include socioeconomic status, level of education and negative mood. There are still significant gaps in knowledge about the relationship of racism to smoking, and filling these gaps is essential to developing effective programs for smoking prevention and cessation in populations at risk for exposure to racism and ethnic discrimination.
“New Concerns and Research Needs,” Moderator, James Sallis, PhD, University of California–San Diego
“Challenges and Emerging Trends in Tobacco Health Disparities: Implications for Mental Health Professionals,” presented by Amber Bullock, MPH, CHES, Legacy. Bullock described the work of Legacy, discussed tobacco use in vulnerable populations (e.g., LGBT, low socioeconomic, mentally ill), and described challenges to prevention and treatment. She noted that tobacco use among the mentally ill is a hidden epidemic with rates of 60 percent in comparison to rates of 21 percent among the general population. She further reported that people with serious mental illness die 25 years earlier than persons who are not mentally ill. Moreover, the seriously mentally ill often rely on fixed incomes — of which schizophrenics spend one-quarter on cigarettes. Effective strategies were discussed including involving the client in intervention planning. She emphasized the importance of not focusing exclusively on cessation, but to integrate smoking concerns with general medical issues and health care needs.
“Research Needs in Support of Effective Tobacco Interventions with Priority Populations,” presented by Bart Aoki, PhD, University of California.” Aoki described smoking among health priority populations in California and research efforts and continuing needs. Smoking has steadily declined in California, largely as a result of very aggressive control programs. However, the remaining 12 percent smoking rate masks disparities. African-Americans have the highest overall rate of the four ethnic groups (18 percent for men, 15 percent for women), while 41 percent of Korean men smoke. In addition, over a third (34 percent) of military personnel smoke. Changing context and research needs indicates that cessation efforts must also change to take into account: context of new harm reduction products; prevention in the context of new products targeted at priority populations; disparities in access to prevention and cessation services (Affordable Care Act); and new technology platforms and adoption by priority populations.
“National Programs,” Moderator, Vickie Mays, PhD, University of California–Los Angeles
“The Role of Tobacco Control Policies in Reducing Tobacco Use Disparities,” presented by Shane Davis, PhD, Centers for Disease Control and Prevention (CDC). Davis reported that tobacco is the leading preventable cause of death and disease in the United States responsible for $96 billion in medical costs and $97 billion in lost productivity. The Centers for Disease Control and Prevention (CDC), through their Office on Smoking and Health (OSH), is the lead federal agency for comprehensive tobacco prevention and control. Its goals are to prevent initiation of tobacco use, to promote cessation of tobacco use, to eliminate exposure to second-hand smoke and to identify and eliminate tobacco-related disparities. She shared a variety of strategies that have been successful in decreasing tobacco use including changing social norms, taxes, counseling, nicotine replacement and media campaigns. She stated that clinicians should treat tobacco users who come to a health care setting, encourage patients to quit, offer patients at least the brief treatments shown to be effective and use motivational techniques to increase future attempts to quit.
“The Potential of eHealth and mHealth Resources: Examples from the Smokefree.gov Initiative,” presented by Erik Augustson, PhD, MPH, National Cancer Institute. Augustson described the importance and promise of embracing new technologies to deliver health information and interventions. Close to 230 million have cell phones, and 90 percent of the world has cell signal access. Low-education and low-income people in the U.S. own smartphones. Text messaging for health information is becoming significant with 9 percent of Americans currently subscribing to health updates and alerts. New technologies can be used to get tobacco cessation interventions into the hands of those who need them. Text messaging for health information is becoming significant, and mHealth is a resource as an intervention (instead of dissemination) platform in which its features engage the audience, increase access to intervention, decrease barriers to participation, decrease space and time gaps between treatment and behavior, and integrate user interaction with treatment within their daily life.
“Addressing Tobacco Use in Mental Health Populations in the VA,” presented by Kim Hamlett-Berry, PhD, Veterans Health Administration. Hamlett-Berry described the VA’s efforts to address smoking in its patient populations. They include: increased access to evidence-based care, e.g., all smoking cessation medications can be prescribed to all veterans (attendance at a smoking cessation clinic is not required); no co-pay for outpatient smoking session counseling and co-pay for medications is applied for veterans who qualify for medication co-pay. She stated that smoking must continue to be de-normalized, and in fact the image of the smoker has changed to “asocial, irresponsible and self-destructive.” Tobacco treatment must address the physiological addiction to nicotine as well as the behavioral habit of using tobacco. The VA has developed models of smoking cessation care responsive to veterans post-deployment, about 50 percent of whom smoke.
“Organizations in Action,” Moderator, Martin Iguchi, PhD, Georgetown University
“Coalitions, a Vehicle for Community Change,” presented by Alicia D. Smith, MPH, Community Anti-Drug Coalitions of America/Community Anti-Drug Coalitions of America (CADCA). CADCA works with more than 5,000 community coalitions in the U.S. and internationally to build and strengthen the capacity of community coalitions to achieve population-level change and create and maintain safe, healthy and drug-free communities. CADCA provides public policy and advocacy, training and technical assistance, research dissemination and evaluation, membership and communications (including webinars), special events and conferences, international programs, and youth programs and uses a social networking site for coalitions to network with each other.
“Eliminating Tobacco Disparities through a National Network for Asian Americans, Native Hawaiians, and Pacific Islanders,” presented by Rod Lew, MPH, Asian Pacific Partners for Empowerment, Advocacy and Leadership.” Asian Pacific Partners for Empowerment, Advocacy and Leadership (APPEAL) champions for social justice, parity and empowerment for its constituents by supporting and mobilizing community-led movements through advocacy and leadership development on health issues including obesity and tobacco. Lew described the diverse constituencies and unique needs and challenges of addressing tobacco use within the Pacific Islander and Asian populations the organization represents. APPEAL provides a technical assistance network and resources with its CLEAN AIR program: capacity-building, leadership development, education, advocacy, and needs assessment; and appropriateness, impact and relationships.
“Towards Health Equity for Tobacco Users,” presented by Katherine Pruitt, American Lung Association. The American Lung Association was founded to combat tuberculosis, but began working on tobacco control in 1963. Its mission strategies are research, education and advocacy, and it provides information to disparately affected communities to raise community awareness. Their recent publication series includes, Smoking Out a Deadly Threat, and Cutting Tobacco’s Rural Roots.
“APA Programs,” Moderator, Gabe Twose, PhD, APA
“Public Interest Government Relations Office Overview,” presented by Diane Elmore, PhD, MPH, APA. The APA already has a robust relationship with government, including 20 to 25 lobbyists who focus on promoting psychology in the public interest. They are the primary liaison between APA and Congress, the White House and federal agencies, and enable APA to share psychological science with policy makers and provide constituents’ and experts’ voices to policy makers so that science and practice can translate into sound policy.
“Public Interest Directorate: Applying Psychological Science, Benefiting Society,” presented by Gwendolyn Keita, PhD, APA. APA’s Public Interest Directorate mission is to apply the science and practice of psychology to the fundamental problems of human welfare and social justice and the promotion of equitable and just treatments of all segments of society through education, training and public policy. Work done to address concerns of racial/ethnic populations, women, persons with disabilities and low socioeconomic populations was highlighted.
“The Behavioral and Social Science Volunteer Experience,” presented by Deborah Bowen, PhD, Boston University School of Public Health. Bowen described her experience working as a Behavioral and Social Science Volunteer (BSSV). The BSSV program matches APA members with local community groups who express a wide assortment of needs related to HIV/AIDs, cancer disparities, and other program development, implementation and evaluation concerns.
“Strengthening Psychology’s Role in Reducing Tobacco Health Disparities,” presented by Lula Beatty, PhD, APA. Beatty gave an overview of health disparities work in the country referencing the 1985 Heckler Report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (i.e., the Institute of Medicine’s 2003 report to Congress), and the Minority Health and Health Disparities Research and Education Act. She described APA’s Health Disparities Initiative. In 2011, a 3-year Health Disparities Initiative was approved as part of the advancing health goal of the association’s strategic plan. Based in the Public Interest Directorate, the Health Disparities Initiative will support dissemination and implementation projects in the areas of substance use (with a major focus on tobacco), stress and obesity.
“Best Practices Dissemination Network Action Planning,” Moderators, Gwendolyn P. Keita, PhD, APA, and Lula Beatty, PhD, APA. From the discussion and the ideas submitted on paper, the group put forth 130 recommendations and actions addressing most frequently, ideas for education and training, partnerships and collaborations, research, interventions and treatment, and policy.