Faculty Mentor: Teresa DeAtley (Family & Preventative Medicine, University of Utah)

Introduction

In the United States (U.S.) smoking continues to be a major public health concern, where approximately, 1 in 5 deaths are due to tobacco related disease.¹ While combustible tobacco use has decreased over the last two decades, population data demonstrates that tobacco use remains high in specific subpopulations of tobacco users, such as racial and ethnic minorities. ^1,2Evidence based practices for smoking cessation are successful in helping tobacco users quit.^3,4,5 For example, cigarette users who use counseling and smoking cessation support have been able to successfully quit smoking.⁵ However, barriers exist for racial and ethnic minorities when accessing these resources.² The socioecological model examines how racial and ethnic minority status interacts with healthcare mistrust influencing smoking behavior, specifically quit attempts. Limited evidence has considered how health care distrust is associated with smoking behaviors. The general literature on race and trust in the healthcare system shows that healthcare distrust influences healthcare utilization, and smoking outcomes.^6,7 Specific racial and ethnic groups such as African Americans and those of Latin American descent, report higher levels of medical mistrust compared to non-minority groups. Contributing factors for mistrust include public perceptions, and discriminatory experiences within healthcare settings.⁸ Johanna Birhauer et al. highlight that trust in healthcare professionals is needed for effective patient care and positive health outcomes, emphasizing the need to build trust to improve quit attempts among tobacco users.⁴This summer research examined the association between health-related trust in commercial and governmental health systems and quit attempts among a diverse sample of adult cigarette users hypothesizing that racial and ethnic minorities would be less likely to attempt quitting due to higher levels of mistrust. Understanding their association is essential to contribute to more effective smoking cessation strategies for racially and ethnically diverse populations.

Methods

We conducted a preliminary secondary analysis of data gathered from adults between the ages of 21 and 65 years, who resided in the United States, using Prolific crowdsourcing web panels. This analysis focused on cigarette users only, we used data from participants with a smoking status of “current”, and “recent”. Given the nature of our research question our study team excluded non-smokers from this analysis. We conducted univariate and bivariate analysis and logistic regressions (not controlling for covariates) to examine the effect of governmental and commercial health-related trust on two outcomes: 1) a serious attempt to quit smoking in that last year that lasted at least 24 hours and 2) an intentional attempt to quit smoking in the last 30 days. To examine governmental and commercial health related trust we used three measures: 1) a general health system trust scale scored from 1 (no trust) to 50 (most trust)9, and two questions, 2) how much trust do you have in the U.S. Surgeon General and 3) how much trust do you have in the tobacco industry?

Results

Across a sample of 542 cigarette users the majority were men 55.9%. Our sample was comprised of 44.8% Non-Latinx White, 24.7% Non-Latinx Black, 21.6 Latinx, and 8.9% Non-Latinx Asian individuals. Analysis of the Health Trust Scale revealed an overall mean score of 30.33. Bivariate analyses found significant differences between race and ethnicity and our two outcomes as well as trust in the U.S. surgeon general and trust in the tobacco industry. We found that there were no significant differences between race and ethnicity and the health trust scale. Regarding outcome one, logistic regressions revealed that the odds of making a quit attempt in the last year over 24 hours was lower among participants that had a “fair amount of trust” in the U.S. surgeon general compared to those who had a great deal and that Non-Latinx Black individuals were more likely to make a quit attempt in the last year compared to all of the other racial and ethnic groups. In terms of outcome two, the logistic regressions revealed that Non-Latinx White individuals were more likely to have made a quit attempt in the last 30 days compared to Non-Latinx Black individuals.

Discussion

We hypothesized that racial and ethnic minorities would be less likely to attempt quitting smoking due to higher levels of mistrust. However, our findings revealed that Non-Latinx Black individuals were more likely to make a quit attempt in the last year compared to all other racial and ethnic groups, including Non-Latinx White individuals. Additionally, Non-Latinx-White individuals were less likely to have made a quit attempt in the last 30 days compared to Non-Latinx Black individuals, contradicting the hypothesis, and suggesting that we might want to investigate the complex relationship between our existing variables and possible confounders. Interestingly, trust was lower than expected for both the tobacco industry and the U.S surgeon general, reflecting skepticism in commercial and governmental entities regardless of race and ethnicity. The association between healthcare mistrust and quit attempts varied, suggesting that trust in different entities, such as governmental and commercial health systems, may influence smoking cessation behavior differently across racial and ethnic groups. Overall, our initial hypothesis testing indicated that there are associations between our three variables of interest, 1) race/ethnicity, 2) commercial and governmental healthcare entity trust, and 3) quit attempts.

Conclusion

In conclusion, our study emphasizes the complexity of factors influencing smoking behavior, specifically quit attempts, among racial and ethnic minorities. Next steps include further analyses to better understand these associations, such as controlling for relevant covariates (e.g. socioeconomic factors) and running interaction terms. This approach will help us understand the reasons behind quit attempts for racial and ethnic minorities.

Personal Reflection

From this experience I was able to learn a lot about tobacco-related health inequities, interpreting statistical models, survey design and data management in SPSS. I was also able to attend online seminars through the Society for Research on Nicotine and Tobacco that supplied me with information aiding me in creating my project. As someone who has not had the opportunity to be closely guided by a mentor in research, working with Dr. Deatley helped me realize how much you can accomplish and learn when given guidance. As we end the summer, I feel much more prepared to adapt to the trial and errors that I will encounter in future research projects. I have learned the importance of being able to look at research from several perspectives. Also, I made significant progress in my public speaking skills through practice and encouragement by my mentor. I am extremely grateful to have been selected for this program and believe that I will be able to use these skills when presenting and creating research projects in the future.

Footnotes

1. Centers for Disease Control and Prevention. (2023, May 4). “Current cigarette smoking among adults in the United States. Centers for Disease Control and Prevention. https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm

2. Choi, Kelvin et al. “Trends in Education-Related Smoking Disparities Among U.S. Black or African American and White Adults: Intersections of Race, Sex, and Region.” Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco vol. 25,4 (2023): 718-728. doi:10.1093/ntr/ntac238

3. Bazargan, Mohsen, et al. “Preparedness for Serious Illnesses: Impact of Ethnicity, Mistrust, Perceived Discrimination, and Health Communication.” American Journal of Hospice and Palliative Medicine®, vol. 39, no. 4, Apr. 2022, pp. 461–71. DOI.org (Crossref), https://doi.org/10.1177/10499091211036885.

4. Birkhäuer, Johanna et al. “Trust in the health care professional and health outcome: A meta-analysis.” PloS one vol. 12,2 e0170988. 7 Feb. 2017, doi: 10.1371/journal.pone.0170988

5. Varghese, Jerin, and Pramita Muntode Gharde. “A Comprehensive Review on the Impacts of Smoking on the Health of an Individual.” Cureus vol. 15,10 e46532. 5 Oct. 2023, doi:10.7759/cureus.46532

6. LaVeist, Thomas A et al. “Mistrust of health care organizations is associated with underutilization of health services.” Health services research vol. 44,6 (2009): 2093-105. doi:10.1111/j.1475-6773.2009.01017

7. Cuevas, Adolfo G, and Kerth O’Brien. “Racial centrality may be linked to mistrust in healthcare institutions for African Americans.” Journal of health psychology vol. 24,14 (2019): 2022-2030. doi:10.1177/1359105317715092

8. Senn, Siena A., et al. “Health Care Discrimination and Psychological Health by the Intersection of Ethnicity and Income.” Stigma and Health, Mar. 2023. DOI.org (Crossref), https://doi.org/10.1037/sah0000448.

9. Rose, Abigail et al. “Development and testing of the health care system distrust scale.” Journal of general internal medicine vol. 19,1 (2004): 57-63. doi:10.1111/j.1525-1497.2004.21146.x