Barbara A. Pizacani

Demonstrating the Importance and Feasibility of Including Sexual Orientation in Public Health Surveys: Health Disparities in the Pacific Northwest

OBJECTIVES We identified health disparities for a statewide population of lesbian, gay, and bisexual (LGB) men and women compared with their heterosexual counterparts. METHODS We used data from the 2003-2006 Washington State Behavioral Risk Factor Surveillance System to examine associations between sexual orientation and chronic health conditions, health risk behaviors, access to care, and preventive services. RESULTS Lesbian and bisexual women were more likely than were heterosexual women to have poor physical and mental health, asthma, and diabetes (bisexuals only), to be overweight, to smoke, and to drink excess alcohol. They were also less likely to have access to care and to use preventive services. Gay and bisexual men were more likely than were heterosexual men to have poor mental health, poor health-limited activities, and to smoke. Bisexuals of both genders had the greatest number and magnitude of disparities compared with heterosexuals. CONCLUSIONS Important health disparities exist for LGB adults. Sexual orientation can be effectively included as a standard demographic variable in public health surveillance systems to provide data that support planning interventions and progress toward improving LGB health.

A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change

Objective: To assess the degree to which smokers living with a full household ban on smoking change their cessation related behaviour. Design, setting, and participants: Prospective cohort study; follow up of a population based cohort of 1133 smokers, identified from a 1997 telephone survey of adult Oregonians. After a median of 21 months, 565 were located and reinterviewed. Main outcome measures: Quit attempts, time until relapse, and smoking cessation, defined as seven day and 90 day sustained abstinence at follow up. Results: A full ban at baseline was associated with a doubling of the odds of a subsequent quit attempt (odds ratio (OR)  =  2.0, 95% confidence interval (CI), 1.0 to 3.9). Among respondents in the preparation stage at baseline (intention to quit in the next month with a quit attempt in the previous year), a full ban was associated with a lower relapse rate (hazard ratio  =  0.5 (95% CI, 0.2 to 0.9)), while for those in precontemplation/contemplation (no intention to quit or intention to quit within the next six months, respectively), there was no significant association between full ban and relapse rate. For respondents in preparation, those with a full ban had over four times the odds of being in cessation for seven or more days before the follow up call (OR  =  4.4 (1.1 to 18.7)), but for those in precontemplation/contemplation, full bans were unrelated to cessation. Conclusions: Full household bans may facilitate cessation among smokers who are preparing to quit by increasing quit attempts. They may also prolong time to relapse among those smokers.

Does Tobacco Industry Marketing Excessively Impact Lesbian, Gay and Bisexual Communities?

Background: Tobacco industry documents have revealed marketing plans specifically to reach lesbian, gay and bisexual (LGB) populations. Research supports a causal linkage between receptivity and exposure to tobacco industry marketing and tobacco use uptake among adolescents. Pro-tobacco messages may diminish the effectiveness of tobacco control activities and contribute to the high smoking prevalence among LGB populations. Objective: To compare receptivity and exposure to tobacco industry marketing between LGB and heterosexual populations. Methods: Nearly 400 gay or bisexual men and more than 600 lesbian or bisexual women were identified in the 2003–2006 Washington State Behavioral Risk Factor Surveillance System (BRFSS), a state-wide, population-based telephone survey of adults. The BRFSS included questions measuring receptivity and exposure to tobacco industry marketing. Multiple logistic regression models stratified by gender were used to assess differences for lesbians, gays and bisexuals separately, in comparison to their heterosexual counterparts. Results: As expected, smoking prevalence was higher among LGB populations than among heterosexuals. After adjustment for demographic differences and smoking status, gay and bisexual men reported more exposure to tobacco industry marketing (free sample distribution) than straight men, but were equally receptive to it. Lesbian and bisexual women were more receptive to and reported more exposure to tobacco industry marketing than straight women. Conclusion: LGB communities, especially lesbian and bisexual women, appear to be effectively targeted by tobacco industry marketing activities. Strategies to limit tobacco industry marketing, and increase individuals’ resistance to marketing, may be critical to reducing smoking among LGB populations.

Smoking-related knowledge, attitudes and behaviors in the lesbian, gay and bisexual community: A population-based study from the U.S. Pacific Northwest ☆

OBJECTIVE Several studies have shown that lesbian, gay and bisexual (LGB) persons have higher smoking prevalence than heterosexuals. However, few population-based studies have explored whether smoking-related knowledge, attitudes and behaviors also differ between the communities. METHODS We used Behavioral Risk Factor Surveillance System data for 2003 to 2005 from two states (Washington and Oregon) to compare smoking-related indicators between the self-identified LGB population and their heterosexual counterparts. RESULTS Lesbians, gays and bisexuals were more likely to be current or ever smokers than their heterosexual counterparts. All except bisexual men and had lower quit ratios than heterosexuals. Among successful quitters, bisexual men were less likely to be long-term quitters than heterosexuals. For all groups, attitudes and behaviors regarding secondhand smoke (SHS) were similar to those of heterosexuals, except for bisexual women, who were more likely to be exposed to SHS. CONCLUSIONS Despite a disparity in smoking prevalence, the LGB population in these two states appeared to have similar levels of knowledge and attitudes toward tobacco control as their heterosexual counterparts. Nevertheless, tobacco control programs should continue to focus on this population to prevent smoking initiation, promote cessation, and reduce secondhand smoke exposure.

Implementation of a Smoke-free Policy in Subsidized Multiunit Housing: Effects on Smoking Cessation and Secondhand Smoke Exposure

INTRODUCTION We studied the impact of implementing a comprehensive smoke-free policy in multiunit housing in the Portland, Oregon metropolitan area. Among low-income tenants living in a subset of subsidized multiunit buildings, we evaluated cessation-related behaviors, policy knowledge and compliance, and secondhand smoke (SHS) exposure. METHODS We mailed a self-administered questionnaire to a random sample of 839 current tenants of 17 subsidized buildings 4 months after policy implementation in January 2008 and sent another questionnaire to participants 1 year later. Results are based on 440 tenants who completed both surveys. RESULTS We observed a self-reported annualized quit rate of 14.7% over the study period (95% CI = 7.9%-21.6%) compared with a historical quit rate in this population of 2.6% (95% CI = 0.6%-4.5%). Almost half of ongoing smokers reduced their cigarette consumption. More smokers correctly reported policy rules for indoor settings than for outdoor settings; self-reported indoor smoking decreased significantly from 59% to 17%. Among nonsmokers, frequent indoor SHS exposure (multiple times per week) decreased significantly from 41% prepolicy to 17% postpolicy. CONCLUSIONS The implementation of a smoke-free policy was associated with positive changes in cessation-related behaviors and reduced SHS exposure in this population of low-income adults.

Is a statewide tobacco quitline an appropriate service for specific populations

Objective: To assess whether smoking quit rates and satisfaction with the Washington State tobacco quitline (QL) services varied by race/ethnicity, socioeconomic status, area of residence (that is, urban versus non-urban), or sex of Washington QL callers. Methods: From October 2004 into October 2005, we conducted telephone surveys of Washington QL callers about three months after their initial call to the QL. Analyses compared 7-day quit rates and satisfaction measures by race/ethnicity, education level, area of residence and sex (using α = 0.05). Results: We surveyed half (n = 1312) of the 2638 adult smokers we attempted to contact. The 7-day quit rate among survey participants at the 3-month follow-up was 31% (CI: 27.1% to 34.2%), 92% (CI: 89.9% to 94.1%) were somewhat/very satisfied overall with the QL programme, 97% (CI: 95.5% to 98.2%) indicated that they would probably/for sure suggest the QL to others and 95% (CI: 92.9% to 96.4%) were somewhat/very satisfied with the QL specialist. Quit rate did not vary significantly by race/ethnicity, education level, area of residence or sex. Satisfaction levels were high across subpopulations. Almost all participants (99%) agreed that they were always treated respectfully during interactions with QL staff. Conclusions: The Washington QL appeared effective and well received by callers from the specific populations studied. States choosing to promote their QL more aggressively should feel confident that a tobacco QL can be an effective and well received cessation service for smokers who call from a broad range of communities.

The Impact of Clean Indoor Air Exemptions and Preemption Policies on the Prevalence of a Tobacco-Specific Lung Carcinogen Among Nonsmoking Bar and Restaurant Workers

OBJECTIVES We studied the impact of clean indoor air law exemptions and preemption policies on the prevalence of a tobacco-specific lung carcinogen-4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK)--among nonsmoking bar and restaurant workers. METHODS secondhand smoke were compared with results from participants who were exposed to it. RESULTS Participants exposed to workplace secondhand smoke were more likely to have any detectable level of NNAL (P=.005) and higher mean levels of NNAL (P < .001) compared with nonexposed participants. Increased levels of NNAL were also associated with hours of a single workplace exposure (P=.005). CONCLUSIONS Nonsmoking employees left unprotected from workplace secondhand smoke exposure had elevated levels of a tobacco-specific carcinogen in their bodies. All workers--including bar and restaurant workers--should be protected from indoor workplace exposure to cancer-causing secondhand smoke.

Are Latinos Really Less Likely to be Smokers? Lessons from Oregon

Our objective was to identify factors associated with current cigarette smoking among Latino adults in Oregon. We used data from 1,356 Latino participants and, for comparison, 18,593 non-Latino White participants in the 2000-2002 Oregon Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a random-digit-dialed, cross-sectional survey of noninstitutionalized, English- or Spanish-speaking adults who live in Oregon households with a telephone. We examined relationships between current smoking and gender, age, education, and survey language (a measure of acculturation) among Latinos and used the .05 level of significance. The prevalence of current smoking was significantly lower among Latinos (18.1%) than non-Latino Whites (20.8%). Latino men were significantly more likely than Latina women to be smokers (23.1% vs. 11.4%), and some evidence indicated that less education was associated with smoking among Latino men. Taking the survey in English was strongly and significantly associated with smoking among Latina women: Smoking prevalence was 20.5% among those taking the survey in English and 3.3% for those taking it in Spanish. Our results suggest that the lower smoking prevalence among Latinos was driven by Latina women taking the survey in Spanish. Hence, it is essential for tobacco control programs to examine their local Latino smoking prevalence by gender and acculturation to avoid incorrectly concluding that Latinos are at decreased risk. Although programs for Latinos should reinforce protective aspects of Latino culture, decreasing the smoking prevalence in the U.S. mainstream culture might mitigate the negative impact of acculturation on smoking behaviors.

Longitudinal study of household smoking ban adoption among households with at least one smoker: associated factors, barriers, and smoker support.

We conducted a longitudinal study among Oregon households with at least one smoker to assess smoking-related associations with ban adoption, to examine smoker support for bans, and to examine barriers to ban establishment. We followed a cohort of 1,604 baseline survey respondents for a median time of 21 months and re-interviewed 825 respondents (51.4% response rate). Of these, 512 did not have a full household ban in place at baseline. Thirty-two percent of the respondents without a ban at baseline adopted a full ban. Baseline smoking-related factors associated with ban adoption were: longer time until first cigarette, stage of change, and attitudes towards respondents smoking. Associated follow-up factors included cessation and reduced consumption. Ninety-one percent of respondents reported smoker support of a ban. Future work should focus on ban establishment in households with more highly addicted smokers.

Support for spirituality in smoking cessation: results of pilot survey.

Patient spiritual resources are increasingly included in the treatment of medical conditions such as cancers and alcohol and drug dependence, but use of spiritual resources is usually excluded from tobacco dependence treatment. We hypothesized that this omission may be linked to perceived resistance from smokers. To examine this hypothesis, we conducted a pilot survey to assess whether current smokers would consider spiritual, including religious, resources helpful if they were planning to quit. Smokers at least 18 years of age at Oregon Health & Science University in Portland, Oregon, (N=104) completed a brief survey of smoking behaviors and spiritual beliefs. None were attempting to quit. Of these individuals, 92 (88%) reported some history of spiritual resources (spiritual practice or belief in a Higher Power), and of those respondents, 78% reported that using spiritual resources to quit could be helpful, and 77% reported being open to having their providers encourage use of spiritual resources when quitting. Results of logistic regression analysis indicated that those aged 31-50 years (OR=3.3), those over age 50 years (OR=5.4), and women (OR=3.4) were significantly more likely to have used spiritual resources in the past. Of the 92 smokers with any history of spiritual resources, those smoking more than 15 cigarettes/day were significantly more receptive to provider encouragement of spiritual resources in a quit attempt (OR=5.4). Our data are consistent with overall beliefs in the United States about spirituality and recent trends to include spirituality in health care. We conclude that smokers, especially heavier smokers, may be receptive to using spiritual resources in a quit attempt and that spirituality in tobacco dependence treatment warrants additional investigation and program development.