Do Health Care Providers Differentiate between Daily and Nondaily Smokers when Counseling for Smoking Cessation? Analysis by Race/Ethnicity

Special Article – Tobacco and Smoking Cessation

J Fam Med. 2015; 2(6): 1041.

Do Health Care Providers Differentiate between Daily and Nondaily Smokers when Counseling for Smoking Cessation? Analysis by Race/Ethnicity

Khariwala SS1,4*, Scheuermann TS², Luo X3,4, Nollen NL5, Pulvers K6, Siddiqi K7, Sherman S8 and Ahluwalia JS9

¹Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, USA

²Preventive Medicine and Public Health, University of Kansas School of Medicine, USA

³Division of Biostatistics, School of Public Health, University of Minnesota, USA

4Masonic Cancer Center, University of Minnesota, USA

5Department of Preventive Medicine and Public Health, University of Kansas, USA

6Department of Psychology, California State University San Marcos, USA

7Department of Health Sciences, University of York, UK

8Department of Population Health, New York University School of Medicine, USA

9School of Public Health, Rutgers University, USA

*Corresponding author: Samir S Khariwala, Department of Otolaryngology-Head, Neck Surgery and Masonic Cancer Center University of Minnesota, Minneapolis, MN55455, USA

Received: November 10, 2015; Accepted: December 16, 2015; Published: December 18, 2015


Objective: Nondaily smokers (NDS) may not receive cessation counseling due to perceptions that nondaily smoking is less hazardous and that NDS can quit unassisted. We investigated differences in provision of guideline-based cessation services -- i.e., ask, advise, assist, arrange follow-up (“4 A’s”)– by smoker type (NDS and DS) and race/ethnicity as well as the interaction between race and smoker type.

Methods: Participants were NDS (smoked 4-24 days in the last 30) and DS (smoked >25 days in the past month) recruited using an online panel. An online questionnaire gathered self-reported data from smokers regarding health care professional-provided tobacco treatment over the last 12 months. The 1587 participants who had at least one doctor visit in the past 12 month included native NDS, converted NDS, light DS, and heavy DS.

Results: Multivariable analysis showed that, there were no statistically significant differences on the odds of being asked about smoking between different types of smokers. However, compared to native nondaily smokers, Latino and White converted nondaily smokers (Latinos, AOR = 2.02, 95% CI 1.09, 3.74 and Whites, AOR= 2.33, 95% CI 1.27, 4.29), light daily smokers (AOR = 2.82, 95% CI 1.41, 5.63, and AOR= 3.72, 95% CI, 1.92, 7.22, respectively) and heavy daily smokers (AOR = 4.11, 95% CI 2.01, 8.43 and AOR = 6.85, 95% CI 3.39, 13.81, respectively) had increasing odds of reporting being advised to quit by their health care providers. Among African American smokers, converted nondaily smokers (AOR = 2.11, 95% CI 1.01, 4.44) and heavy daily smokers (AOR = 2.92, 95% CI 1.35, 6.28) were more likely to receive assistance in quitting than native nondaily smokers.

Among African Americans, heavy daily smokers’ had greater odds of having follow-up arranged compared to native nondaily smokers (AOR=3.06, 95% CI 1.08, 8.70) and among Latinos, these rates were only statistically significant for converted nondaily smokers compared to native nondaily smokers (AOR= 2.80, 95% CI 1.25, 6.26). Among Whites, light daily smokers had the greatest odds of having their health care provider arrange follow-up (AOR= 10.81, 95% CI 1.37, 85.12) compared to native nondaily smokers.

Conclusions: Daily smokers report greater engagement by health care providers compared to NDS with regard to smoking cessation. These findings such suggest the primary care providers are ascribing less risk to NDS than DS. Educational efforts are needed to change this tendency among primary care providers. In addition, the patterns identified were similar across the three ethnic groups studied here.

Keywords: Nondaily smoking; Tobacco use; Counseling; Smoking cessation


Cigarette smoking continues to be the leading cause of preventable disease and death in the U.S., accounting for over 480,000 preventable deaths per year [1]. Approximately 42 million Americans currently smoke regularly [2]. Anti-smoking legislation and public health efforts have led to lower overall rates of cigarette use and changes in the way that smokers use cigarettes. These shifts in tobacco consumption include an increase over the last 20 years in the prevalence of nondaily smoking (smoking on some days but not every day) among current smokers [2], such that roughly 23% of smoking adults now report nondaily smoking. Despite lower-levels of cigarette use relative to daily smokers, nondaily smokers are, on average, exposed to significant levels of nicotine and carcinogenic nitrosamines [3,4]. Nondaily smoking occurs at greater rates among Hispanics (30% of current smokers) and African Americans (19% of current smokers) compared to Caucasians (14% of current smokers) [5].

Clinical Practice Guidelines for the Treatment of Tobacco Dependence recommend that clinicians approach tobacco users through a brief intervention in the primary care setting. This includes asking about tobacco use, advising them to quit, assessing their willingness to quit, assisting with quit attempts and arranging for follow-up regarding tobacco cessation (“5 A’s”) [6]. Despite literature urging healthcare providers to advise nondaily smokers to quit [7], it is possible that this growing subgroup may not experience health care provider-led smoking interventions due to misperceptions that nondaily smoking is not associated with significant health risks [8], and beliefs that nondaily smokers are not addicted/ can quit on their own [9]. Prior data suggests that health care providers may be less aggressive in counseling nondaily smokers to quit [7]. Further review of the literature suggests that nondaily smokers engage in cessation at rates that are similar or slightly higher than their daily smoking counterparts [10-12].

Racial and ethnic disparities in the delivery of tobacco cessation services further complicate this issue. Specifically, tobacco screening and counseling are less common for Hispanic compared to non- Hispanic White smokers [13] and this difference does not appear to be related to proficiency in English [14]. Similar findings have been reported for African-American smokers even after controlling for social, economic, and healthcare-related factors [15]. These findings are problematic because light smoking and nondaily smoking are common practices in ethnic minorities [16-18]. Provision of the 5A’s to smokers across the smoking spectrum (i.e., nondaily, light daily, heavy daily) has not been studied, despite the fact that physician advice to quit is known to be effective in promoting smoking cessation [19]. Therefore, we conducted a study of nondaily and daily smokers to determine their experience with healthcare providers and the components of guidelines-based tobacco treatment received. Our goal was to understand how commonly health care providers addressed the issue of smoking across the full range of smoking spectrum. We examined differences in provision of 4 of the 5 A’s – i.e., ask, advise, assist, arrange follow-up – by smoker type (NDS and DS) and race/ethnicity (African American, Latino, White).Clinician assessment of readiness to quit was not queried but we included participants’ readiness to quit as a covariate in our analyses. We further categorized nondaily smokers by whether or not they had a previous history of daily smoking. Lastly, we examined interaction between smoker type and race/ethnicity to determine the presence or absence of any significance. We feel the latter consideration is an important one because, given the higher rate of nondaily smoking among minorities, there is a possibility that nondaily smoking minorities may be subject to greater bias (and resulting disparities in counseling) than nondaily smoking Caucasians. We hypothesized that the likelihood of being asked, advised, assisted, and having follow-up arranged would be greatest for daily heavy smokers and non-Hispanic Whites and lowest for native nondaily smokers (i.e., nondaily smokers who never smoked daily), African Americans, and Latinos.



Participants completed a cross-sectional survey administered through an online panel survey service. Eligible participants selfidentified as African American, White, or Latino (of any race), were at least 25 years old, and were English-speaking. These participants were current smokers (i.e., smoked at least one cigarette in the past 30 days), had smoked at least 100 cigarettes in their lifetime, smoked for at least one year, smoked at their current rate (i.e., daily or nondaily) for at least 6 months, and had not participated in any smoking cessation treatment in the past 30 days. Women who were currently pregnant or breast-feeding were excluded from the study.

The sample was stratified to obtain equal samples of each of the three race/ethnicity groups and for daily vs. nondaily smoking frequency levels (daily smokers were evenly divided between light daily and moderate to heavy daily smokers). Nondaily smokers smoked at least one cigarette on 4 to 24 days in the past 30 days; consistent with previous studies nondaily smokers who smoked fewer than 4 days were excluded in order to recruit individuals smoking the equivalent of at least once a week [20]. Daily smokers smoked 25 to 30 days in the past 30 days and were further stratified into light daily smokers (< 10 cigarettes per day; CPD) [21] and moderate to heavy daily smokers (> 10 CPD). Out of 2,376 total respondents, 1,587 had visited a health care provider in the last 12 months and were included in the study.


All study materials and procedures were approved by the University of Minnesota Institutional Review Board. The online panel survey company, SSI, provides access to a panel of 1.5 million participants in the United States; panelists are recruited through a variety of non-probability sampling strategies including websites and social networks [22]. SSI directed members of their panel to the survey using preliminary screening questions (e.g., smoking frequency) and participant profile information (e.g., race/ethnicity, age). Potential participants reviewed an informed consent page before proceeding to the eligibility screening questions. Quotas were set for nine subgroups (three race/ethnicity groups and three smoking levels based on our sampling stratification), and once respective quotas were met, no further participants were recruited. All participants who completed the survey received SSI’s standard incentives, which included entry into a quarterly drawing for $12,500 (available to the entire panel of 1.5 million active SSI panelists) and points redeemable for cash. A more detailed description of the survey procedures is available elsewhere [23].


Social demographics: Social demographic questions assessed participants’ age, race and ethnicity, gender, income, and education.

Cigarette use: Participants reported the number of days they smoked in the past month, average number of cigarettes smoked per day (CPD) on the days smoked in the past 7 days, and whether they had ever smoked daily for six months or longer (response options: yes or no). These items were used to classify smokers into the smoker types. Participants who smoked on 24 or fewer days in the past 30 days were categorized as nondaily smokers [24-26]. Nondaily smokers who reported that they had not smoked daily for at least 6 months were classified as native nondaily smokers and those who indicated that they had were classified as converted nondaily smokers [11].

Nicotine dependence: Time to first cigarette, an item from the Fagerström Test for Nicotine Dependence [27], was used as an indicator of nicotine dependence. Time to first cigarette was dichotomized (smoking <30 minutes after waking and smoking > 30 minutes); smoking within 30 minutes of waking denotes nicotine dependence [28].

Health status: Perceived health status was assessed using a single item from the 36-Item Short Form Health , Survey (SF-36), “In general, would you say your health is…” with response options “Excellent”, “Very Good”, “Good”, “Fair”, and “Poor” [29].

Intention to quit: Intention to quit was assessed using a singleitem measure that asked participants “What describes your intention to stop smoking completely, not even a puff? Would you say you…” response options were “Never expect to quit”, “may quit in the future, but not in the next 6 months,” “will quit in the next 6 months,” “will quit in the next 30 days” [30].

Health care visits and quitting assistance: Participants were asked to report their number of doctor’s office visits in the past 12 months. Those who reported no visits during the last 12 months were excluded from this analysis. We asked a series of four questions relating to health care providers’ assessment of smoking and provision of quit assistance (response options were yes or no): “In the last 12 months, did a doctor or other health professional ask if you smoked cigarettes?”; “In the last 12 months, did a doctor or other health professional advise you to stop smoking cigarettes?”; “In the last 12 months, did a doctor or other health professional give you assistance in quitting smoking, such as give you specific advice on how to quit smoking or prescribe medication?”; and “In the last 12 months, did a doctor or other health professional arrange follow-up with their office about quitting smoking or refer you to a smoking cessation program?” Items were adapted from the 2008 California Tobacco Survey [31].

Data analysis

Participants’ demographic and smoking-related variables were summarized, stratified by smoker type and race, the two sampling stratification factors of the study. Continuous variables were summarized using mean and standard deviation (SD). Categorical variables were summarized using frequencies and percentages. For comparisons between smoker type groups and comparisons between race/ethnicity groups, t-test test and Chi-square test were used for continuous and categorical variables, respectively. We examined the association between participants’ receipt of each of 4 A’s (ask, advise, assist, arrange follow-up) from their health care providers with smoker type (native nondaily, converted nondaily, light daily, and moderate to heavy daily) within each race/ethnicity group. We conducted multivariable logistic regressions for each race/ethnicity group with each of the 4 A’s as the dependent variable and smoker type as the primary covariate, adjusting for social-demographic variables (age, gender, education, and income), intention to quit, health status (excellent/very good/good vs. fair/poor) and the frequency a person visited doctors’ offices during the past 12 months (1 visit vs. =2 visits). The interaction of smoker type and race/ethnicity was formally tested in multivariable regressions adjusting for the same covariates as above with a likelihood ratio test (LRT) and the Chi-square statistic and p-value were reported. All tests were two-sided. P-values < 0.05 were considered statistically significant. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary, NC).


The 1587 subjects in this study included native nondaily smokers (N=186) and converted nondaily smokers (N=616), in addition to daily smokers that were categorized as light (N=378) or moderate to heavy (N=407). Subject demographics are described in Table 1. The average age of the sample was 44 years (standard deviation [SD] = 13), among Latinos and Whites heavier smokers were older and Latinos were younger than African Americans and Whites overall. Thirty-seven percent of participants had completed a college degree or higher; African Americans had the lowest percentage of college graduates and Latinos had the highest. Among Latinos and Whites, nondaily smokers were more likely to report completing at least a college degree than daily smokers. Approximately one-third of the sample had household incomes below $1,800 per month with Latinos being the least to report this income level and African Americans being most likely.