Disparities in Cancer Risk Factors and Cancer Screening in the United States Part 2

Individual-Level Interventions in Reducing Disparities in Tobacco Smoking

Current Smoking Cessation Treatments

As noted earlier, whereas population-level interventions are instrumental in preventing the uptake of smoking or in motivating smokers to consider quitting, individual-level interventions for cessation provide smokers with the tools to successfully quit. By definition, individual-level interventions are characterized by increased contact between the provider and recipient, and currently there are several treatments that a smoker can use to help him or her quit. The extent to which these are also effective for members of groups that have experienced disparities is now receiving greater research attention. Moreover, standard behavioral treatments are now more commonly subjected to cultural tailoring, with the aim of enhancing cessation rates and ultimately reducing prevalence in, and disparities resulting from, tobacco use. Groups that have been the target of cultural tailoring of smoking cessation treatments include African Americans, members of the gay/lesbian/ bisexual community, and psychiatric populations.

Interventions to reduce disparities in prevalence by facilitating cessation are based on principles outlined in the updated (2008) Clinical Practice Guideline: Treating Tobacco Use and Dependence by the U.S. Department of Health and Human Services (Fiore et al., 2008). The guideline states that "Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit" and that "Effective treatments exist that can significantly increase rates of long-term abstinence." In addition to recommending first-line medications such as NRT (nicotine replacement therapy), bupropion (Zyban), and varenicline (Chantix), the guideline panel concluded that, based on results of their meta-analyses, "Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity." As described in the guideline, counseling consists of helping smokers "recognize danger situations" (that increase the risk of relapse), "develop coping skills" (to learn how to handle danger situations), and to "provide basic information about smoking and successful quitting." The guideline panel also recommended that smokers receive intra-treatment support from their provider that entails encouraging a quit attempt, communicating caring and concern, and facilitating dialogue with the smoker about the quitting process. These basic principles of tobacco treatment represent the protocol used in behavioral treatments found to be most effective in helping smokers quit. In addition to forming the basis of individual counseling by health professionals, they are incorporated into group programs for cessation and in telephone counseling protocols.


Recently, the format of delivery of tobacco cessation treatment has been expanded to include the Internet as well as mobile phones. Using automated algorithms, Internet programs for smoking cessation attempt to replicate the activities, information, and social support that smokers typically receive from in-person behavioral treatments. They also overcome some of the practical issues that smokers might have with using telephone counseling or attending group meetings (e.g., cost, or distance from treatment location). Reviews and meta-analyses of Internet-based treatments for tobacco use or other health behaviors have concluded that these programs are effective compared to minimal or no treatments (Portnoy, Scott-Sheldon, Johnson, & Carey, 2008; Webb, Joseph, Yardley, & Michie, 2010). There is, however, room for improvement; for example, by capitalizing on the interactive capabilities of the Internet and providing adequate follow-up contact or treatment (Bock et al., 2004).

In addition to the above treatments, the Clinical Practice Guideline also found that less intense interventions, such as being asked about one’s smoking status, or being advised to quit by a doctor, are associated with higher odds of quitting compared to controls. Individuals from ethnic-minority groups are less likely to be the recipients of these interventions (Cokkinides, Halpern, Barbeau, Ward, & Thun, 2008); however, a difference that studies have shown is related to socioeconomic factors such as lack of access to health insurance or to health systems (Koh et al., 2010). The remainder of this section will focus on the effectiveness of multisession behavioral treatments, which offer smokers the greatest chance of quitting, in reducing disparities in smoking prevalence.

Adapting Current Tobacco Treatments to Reduce Disparities in Special Populations

One reason for the relative paucity of research on the effectiveness of standard cessation treatments for special populations has been their underrepresentation in these studies, a case that is particularly true for African American smokers (Webb, 2008). Reduced participation unfortunately precludes analyses of a treatment’s effect as a function of minority or racial/ ethnic categories. Research is also needed on whether cultural tailoring of standard treatments to special populations increases the reach of treatments in these populations, or produces higher quit rates. Fortunately, research on cultural tailoring of cessation treatments is increasing, as evidenced by the number of presentations at the first pre-conference workshop on reducing disparities in smoking cessation at the 2010 annual meeting of the Society for Nicotine and Tobacco Research (Fagan, 2010).

Cultural adaptation, according to Borrelli, "involves any modification of an EBT’s [evidence-based treatment's] design, treatment components, approach to delivery, or nature of the therapeutic relationship, in order to accommodate the cultural beliefs, values, attitudes, and behaviors of the target population" (Borrelli, 2010). In the process of adapting an intervention to a particular group, researchers attend to its members’ common historical, environmental, and social influences. Borrelli proposed four phases of cultural adaptation. Phase 1 consists of information gathering from the community, focus groups, and archival historical data to best determine how the intervention can be made culturally specific. Phase 2 consists of modifying the intervention both at the surface level (i.e., so that intervention materials and messages are pertinent to "the observable social and behavioral characteristics of the group e.g., people, places, language, music, foods, brand names, locations, and clothing") (Resnicow, Braithwaite, Ahluwalia, & Butler, 2000), and at a deeper level (by incorporating the shared cultural values of the group) (Resnicow et al., 2000). Phases 3 and 4 consist of pilot-testing the culturally adapted intervention and measuring outcomes, respectively. An example of applying these principles in a group program for urban African American smokers would be to use images of African Americans in written materials, quotes from smokers who have quit using a vernacular that may be more common to members of this group, and addressing the types of stressors faced by the African American community as a factor in smoking (e.g., racial discrimination).

African American and Other Racial/Minority Smokers

To examine whether standard current cessation treatments are effective among African American smokers, and whether cultural tailoring can increase cessation rates, Webb conducted a meta-analysis of interventions in which approximately 50% of the participants were African Americans. Treatments that were ethno-culturally tailored were also included. Results of her analyses indicated that standard treatments were indeed effective for this population in increasing long-term quitting. Culturally tailored interventions, however, were superior only in facilitating short-term quitting. In addition, Church-based treatments were significantly better than others in producing short-term quitting, a finding that confirmed the importance of the Church as a socially supportive and socially cohesive institution that can facilitate positive health behavior change among African Americans (Pederson, Ahluwalia, Harris, & McGrady, 2000). The meta-analysis also found that group counseling programs were of particular benefit. Taken together, these findings indicate that social support during the quitting process may need to be an important component of tobacco treatment for African American smokers, and that cultural tailoring may demonstrate its greatest benefit in the early stages of the quitting process. Specifically, at least for African American smokers, cultural tailoring may increase the appeal of the program and its ability to recruit and retain smokers.

Several studies have documented higher rates of tobacco use among American Indian/Alaska Native populations, but lacking are interventions that are targeted or culturally tailored to members of this ethnic group. Although initial attempts to treat tobacco dependence in this population showed moderate success (Johnson, Lando, Schmid, & Solberg, 1997), subsequent tobacco control efforts recognized the ultimate importance of understanding cultural factors that could impact the success of treatments. These include ascribing an important role for elders (Varcoe, Bottorff, Carey, Sullivan, & Williams, 2010) and gaining a thorough understanding of other traditions, taboos, and religious beliefs and practices that could impact the success of tobacco treatment (Oberly & Macedo, 2004).

Low-SES Smokers

At the current time, we could find no published studies that examined whether standard cognitive-behavioral counseling used in in-person, group, or quit-line counseling programs are equally effective for low-income individuals, or those with lower levels of educational attainment, as compared with higher-income groups. Moreover, descriptions of cessation treatments adapted for this group are lacking. Nevertheless, attention to barriers that low-SES individuals face would likely result in greater use of treatments, improved motivation to quit, and possibly an equivalent or greater rate of quitting as compared with higher-SES individuals. Increasing health insurance coverage, particularly for cessation treatments, would remove several important barriers. Overall, offering free cessation counseling, in addition to NRT or other cessation medications, dispelling myths about the effects of NRT (Shiffman, Ferguson, Rohay, & Gitchell, 2008), making treatments more convenient, such as providing them at the workplace, and addressing coping with peer smoking, are likely to result in great uptake of treatments and cessation among low-SES smokers. Other forms of tobacco use (e.g., chewing tobacco) are also more prevalent among some groups of low-SES individuals and would thus need to be addressed in treatments.

Gay and Lesbian Smokers

Although, to date, national surveys have not asked respondents about their sexual orientation, extant studies have found a greater prevalence of smoking among gay men, and lesbian and bisexual women, compared with the general population. For example, in the California Health Interview Survey, a population-based sample of men and women, the prevalence of smoking among gay men was 33.2%, a rate that was 55.9% higher than that for heterosexual men (Tang et al., 2004). These results were consistent with those of another large-scale probability study of lesbian, gay, and bisexual (LGB) individuals (Gruskin, Greenwood, Matevia, Pollack, & Bye, 2007) in which the prevalence of daily smoking among gay men was 27.3%, as compared to 19.7% for heterosexual men. Similar findings have been obtained in samples from other large urban centers (Greenwood et al., 2005). These surveys also found elevated rates of smoking among lesbians and bisexual women, but the discussion below focuses on gay men due to the lack of reports of cessation interventions for, or attended by, lesbian and bisexual women.

The literature is sparse on reports investigating the success of standard smoking cessation interventions for gay men, or whether interventions tailored to this population can achieve comparable or higher quit rates. Only recently have steps been taken to understand disparities in smoking between gay and heterosexual men, and to incorporate these into culturally tailored interventions. Cultural tailoring of cessation interventions for gay men involves acknowledging the unique stressors that gay men face related to their sexual orientation that may explain their higher smoking rates, and their possibly greater difficulty quitting. These include internalized homophobia, expectations of stigma, and experiences with prejudice and rejection over their sexual orientation (Meyer, 2003). For example, in one study of LGB (lesbian, gay, and bisexual) youth, the experience of rejection after disclosing sexual orientation predicted subsequent smoking levels (Rosario, Schrimshaw, & Hunter, 2009). Recent data also suggests that young gay men may smoke when attempting to conceal their sexual orientation (Pachankis, Westmaas, & Dougherty, 2010). Other factors implicated in gay men’s higher smoking rates include the strong presence of tobacco promotional campaigns in gay venues (Dilley, Spigner, Boysun, Dent, & Pizacani, 2008; Smith, Offen, & Malone, 2005) and the centrality of places in the LGB community where smoking is more tolerated, such as bars (Trocki, Drabble, & Midanik, 2009).

Although there are many ways in which a standard intervention can be adapted to the experiences, values, and beliefs of a particular population, research on efforts to culturally tailor cessation interventions to gay men is sparse. Interventions that have done so have found promising results, however. In one study conducted in the U.K., a group cessation program that was facilitated by gay men for gay men, and that included "group discussion and processes" and "culturally specific contexts" for gay men, found quit rates comparable to those of the national population (Harding, Bensley, & Corrigan, 2004). Also tested have been Internet-based interventions tailored for gay men (e.g., www.iquit.medschool.ucsf.edu).

Although gay men appear to prefer interventions specifically tailored for them (Schwappach, 2008, 2009), comparisons between standard and tailored treatments will be needed to determine whether tailored treatments are indeed the best strategy for reducing disparities in this population. Treatments tailored or targeted to lesbian and bisexual women should also be a priority in efforts to reduce disparities in the prevalence of smoking among LGB individuals.

Psychiatric Populations

Population-based studies of smoking prevalence have typically not included assessments of mental illness diagnoses. The rate of smoking among individuals with a history of mental illness (lifetime or past-month), however, is almost double that compared with those who report no history of mental illness (Lasser et al., 2000). Moreover, individuals with mental illness are estimated to consume about 44.3% of cigarettes sold in the United States (Lasser et al., 2000). Reasons for psychiatric populations’ greater prevalence are varied, and include the perception that smoking alleviates psychiatric symptoms or side effects of medications, genetic susceptibility, the reluctance of addictions counselors to treat tobacco dependence for fear of diminishing the success of treatment for co-occurring disorders, use of cigarettes in token economies in psychiatric settings, and special promotional efforts by the tobacco industry (Hall & Prochaska, 2009; Winterer, 2010). There has also been an implicit assumption by health care providers that depression-prone smokers will not be successful in quitting. According to a recent meta-analysis, however, a lifetime history of major depressive disorder does not decrease the likelihood of cessation using standard behavioral treatments for cessation (Hitsman, Borrelli, McChargue, Spring, & Niaura, 2003). Still, this may not be the case for individuals with recurring depression, or those who report depressive symptoms at the beginning of treatment (Brown et al., 2001; Glassman et al., 1993; Seidman et al., 2010). In any event, smoking cessation interventions have been adapted to address these smokers’ depressed mood, or diminished positive affect. These activities include identifying life goals and values, monitoring and incorporating enjoyable activities consistent with these goals and values into daily activities, strategies to increase positive thoughts and decrease negative ones, and social skills and assertiveness training. Interventions with such tailoring improve cessation rates compared to those that do not (Brown et al., 2001; MacPherson et al., 2010).

Schizophrenic patients also smoke at substantially higher rates compared with controls (Leonard & Adams, 2006). While bupropion seems to be clearly superior to placebo in helping schizophrenic patients achieve abstinence (Tsoi, Porwal, & Webster, 2010a), very few studies have reported on the effectiveness of standard behavioral treatments in this population, as is also the case for treatments specifically tailored to this group (Tsoi, Porwal, & Webster, 2010b). Of the studies that have done so, adaptations have included the use of contingency reinforcement with money, deeper emphasis on motivating smokers, or more intense social skills training. These have not shown to be superior to standard treatments in producing short- and long-term quitting rates, however (Tsoi et al., 2010b). Still, the small number of studies in this area, and their inherent methodological problems, preclude conclusions about whether adapting current cessation treatments for schizophrenic patients can reduce disparities in tobacco prevalence (Tsoi et al., 2010b). Data is also lacking on cessation interventions for smokers who have co-occurring substance use disorders, such as alcohol or other drug dependence (Hall & Prochaska, 2009).

The Future of Disparities in Tobacco Use

Recent attention to the problem of disparities in tobacco consumption, and in its effects, has led to a greater focus on whether interventions reduce tobacco prevalence to the same degree among members of special populations, particularly ethnic-minority groups, as compared to the general population. Results for population- and community-level interventions thus far have been encouraging. Moreover, cultural tailoring of individual-level interventions, though in its nascent stages, shows promise in attracting smokers to treatments, and in helping them quit, at least in the short term. Research on the development and testing of culturally tailored interventions, and on understanding the causes of disparities, remains a priority for the American Cancer Society (ACS) and for other funding agencies, as this knowledge will lead to better strategies to reduce disparities. For example, research funded by the ACS has examined how the tobacco industry has targeted young African American adults of low socioeconomic status. This research is important in helping develop effective counter-strategies to discourage tobacco use in this and other vulnerable populations, such as LGB smokers and psychiatric patients. Prevention programs to reduce initiation of tobacco use in special populations, and in the general public, should also be a strong component of public health initiatives. Public health policies that also include improving access to care for tobacco-related diseases, as well as psychosocial and medical treatments for tobacco dependence, will effect the greatest reduction in tobacco prevalence and hopefully the elimination of disparities.

OBESITY, PHYSICAL ACTIVITY, AND NUTRITION

Obesity, physical inactivity, and poor nutrition are major risk factors for cancer, second only to tobacco use (World Cancer Research Fund/American Institute for Cancer Research, 2007). In the United States and in many developed nations, the prevalence of overweight (defined as a body mass index [BMI] greater or equal to 25 kg/m2 and less than 30 kg/m2) and obesity (BMI greater or equal to 30 kg/m2) has increased dramatically in recent decades, and much of the increase has been attributed to changes in diet and physical activity in Westernized societies (Hedley et al., 2004; Kumanyika et al., 2008; Ogden, Carroll, McDowell, & Flegal, 2007). In the United States, overweight and obesity contribute to 14-20% of all cancer-related mortality (Calle, Rodriguez, Walker-Thurmond, & Thun, 2003). Overweight and obesity are clearly associated with increased risk for developing cancers of the breast (in postmenopausal women), colon, endometrium, kidney, gallbladder, liver, and adenocarcinoma of the esophagous (World Cancer Research Fund/American Institute for Cancer Research, 2007); (Calle et al., 2003). In addition, excess body weight is an independent risk factor for cardiovascular disease and type 2 diabetes (Eyre et al., 2004).

Excessive weight gain is a direct function of an imbalance between the amount of calories consumed and the amount of calories expended by an individual; therefore, physical inactivity and poor nutrition play important roles in maintaining a healthy weight (Kushi et al., 2006; World Cancer Research Fund/American Institute for Cancer Research, 2007). The increasing trends in unhealthy eating and physical inactivity and resultant increases in overweight and obesity have largely been influenced by the environments in which people live, learn, work, and play (Kumanyika et al., 2008). For example, unhealthy eating trends have been driven by the greater availability and marketing of pre-packaged processed foods, low-cost/big-portion restaurant meals, and soft drinks, all of which may be high in sugar, calories, and/or fat; this is compounded by fewer opportunities to be regularly active as a result of our modes of transportation, sedentary jobs, and forms of entertainment during leisure time. Hence, to more effectively control overweight and obesity, experts recommend a public health approach that promotes environmental changes for healthy eating and increased physical activity, in addition to targeted behavioral and medical interventions (Eyre et al., 2004; Kumanyika et al., 2008; Kushi et al., 2006).

Physical activity has numerous mental and physical health benefits, including reductions in the risk of premature mortality, cardiovascular disease, hypertension, diabetes, and osteoporosis (Haskell et al., 2007; International Agency for Research on Cancer, 2002). Physical inactivity is an important risk factor for many chronic diseases and plays an important role in certain cancers (breast and colorectal cancer) (International Agency for Research on Cancer, 2002). Epidemiologic evidence shows that the risk of breast and colon cancers is reduced by physical activity (International Agency for Research on Cancer, 2002), and an active rather than sedentary lifestyle might also reduce the risk of other types of cancer, such as prostate, lung, and endometrial cancers, as well as the risk of dying from cancer (Calle et al., 2003). Physical activity contributes to the reduction in cancer risk through a range of pathways; supporting evidence continues to accumulate that physical activity reduces chronic disease risk both directly through its impact on hormones and indirectly through its impact on weight control (International Agency for Research on Cancer, 2002; Kushi et al., 2006). Although much remains to be learned about the role of specific nutrients—or the combination of nutrients—in decreasing the risk of chronic disease, however, dietary patterns are emerging as an important consideration. A balanced eating pattern emphasizing whole-grain foods, legumes, vegetables, and fruits, and limiting the intake of saturated fats, trans fats, cholesterol, and added sugars and salt, is associated with decreased risk of a variety of chronic diseases (Kushi et al., 2006). Population studies have shown that people who have a high intake of vegetables and fruits and a lower intake of animal fat, meat, or calories have a reduced risk of some of the most common types of cancer (International Agency for Research on Cancer, 2002; Kushi et al., 2006). Diets high in fruits and vegetables may have a protective effect against many cancers (International Agency for Research on Cancer, 2002). Conversely, excess consumption of red and processed meat may be associated with an increased risk of colorectal cancer (International Agency for Research on Cancer, 2002).

Based upon a comprehensive review of the evidence, the ACS has published guidelines on nutrition and physical activity for cancer prevention (Kushi et al., 2006). To all individuals seeking to reduce their cancer risk, it recommends the following individual choices: maintaining a healthy weight throughout life, adopting a physically active lifestyle, following a healthy diet, and limiting consumption of alcoholic beverages.

Racial/Ethnic and Socioeconomic Disparities in Obesity and Related Risk Factors

During the past decade, based on the National Health and Nutrition Examination Survey, which has collected objectively measured height and weight information from participants, the obesity (BMI > 30 kg/m2) trends in women have increased nonsignificantly, from 33.4% in 1999-2000 to 36.1% in 2007-2008; among men, the prevalence rose from 27.5% to 32.6% in this period. Compared to White men and women, African American and Hispanic men and women have higher rates of obesity (over 34%) (see Table 3.2). The prevalence of obesity varies slightly with the level of education in men, and strongly with the level of education in women. Prevalence ranges from 23.4% in women with more than 16 years of education to 44.0% in women with 8 or fewer years of education. Variations in obesity prevalence by income are also greater among women than for men (see Table 3.2).

TABLE 3.2 Prevalence of Obesity and Related Risk Factors by Race/Ethnicity, Education Level, and Income Level, Adults 18 and Older, United States

% No LeisureTime Physical Activitya

% Obeseb

% Five or More Fruit or Vegetable Servings a Day

Characteristic

Males

Females

Males

Females

Males

Females

Race/ethnicity

Hispanic

40.5

47.6

34.8

43.3

17.2

24.1

White

27.4

29.5

32.6

33.6

18.2

26.7

African American

34.7

44.8

37.6

49.9

18.3

23.6

Asian American

32.1

39.9

23.9

30.6

American Indian and Alaska Native’

36.3

36.4

-

16.4

27.8

Income

Below poverty level

46.2

52.8

28.9

42.1

16.0

22.6

100-200% above poverty level

42.4

45.5

35.1

40.0

17.5

25.1

> 200% of poverty level

24.9

27.6

33.0

32.8

20.7

30.3

Education (years)d


8 or fewer

57.0

61.6

31.7

44.0

15.0

22.3

9-11

47.7

53.7

32.2

46.3

1 4.0

19.3

12 or GED

39.4

45.2

33.4

40.3

14.3

21.0

13-15

27.9

31.1

37.8

38.1

17.4

26.3

16*i

20.2

21.5

26.7

23.4

22.7

34.5

More than 16

15.1

17.1

Total

30.4

34.6

32.6

36.1

18.4

26.2

Percentages are age adjusted to the 2000 U.S. standard population.

aNo leisure time physical activity is defined as not engaging in any regular leisure time physical activities.

bObese is defined as Body Mass Index (BMI) >30 kg.m2.

cThe estimate should be interpreted with caution because of the small sample sizes.

dPrevalence by education level is for those >25 years.

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