Black Americans attempt to quit smoking more often than their White counterparts but are less likely to succeed, and they pay the health consequences.
Dr Kevin Choi
This knowledge has driven Kevin Choi, MD, acting scientific director of the National Institute on Minority Health and Health Disparities in Bethesda, Maryland, to dedicate his career to studying the patterns and disparities of smoking among these patients.
Choi wants primary care clinicians to know they have the potential to not just educate patients on the harms of smoking ― most patients already know smoking is unhealthy ― but that aiding them will likely necessitate more assertive follow-up.
To do so, “We need to understand the bigger backdrop of racial and sociologic stress experienced by the Black population, which stems from both interpersonal and structural racism,” Choi said.
Not only are Black smokers more likely to try to quit, but they also tend to smoke fewer cigarettes per day than other racial groups. Yet they experience higher rates of smoking-related mortality.
The Reasons Behind the Attempts
Multiple factors play into Black smokers’ lower rates of successful quit attempts than Asian, Hispanic, White, and Native American individuals.
One reason: An estimated 85% of Black smokers smoke highly addictive menthol cigarettes. According to Choi and other experts, the tobacco industry engages in targeted marketing of menthols by sponsoring community events in predominantly Black neighborhoods and colleges with historically Black populations and by using Black culture in advertising.
Dr Daniel Kortsch
“The built environment really drives a change in behavior, and we have seen that chronically in the African American population being overly targeted and now being overly addicted to nicotine,” said Daniel Kortsch, MD, a family medicine physician and chair of the Tobacco Cessation Workgroup at Denver Health in Colorado.
Menthol cigarettes are more addictive than traditional cigarettes, in part because they provide a less harsh feeling in the respiratory system, owing to antitussive, anti-irritant, and cooling properties that act as a cough suppressant and mask irritation and pain.
Dr Julia Adamian
“You do not feel like you’re smoking that much or that it’s dangerous, and that’s exactly the reason why it’s harder to quit,” said Julia Adamian, MD, section chief of general internal medicine and clinical innovation at NYU Langone Tisch Hospital in New York City.
In addition, menthol cigarettes interact with the body in complex ways that make quitting harder, according to a 2019 study. Menthol increases the amount of nicotine that the body absorbs and thus increases the risk of dependence on the drug.
According to Choi, rates of cigar and cigarillo use are higher among Black Americans compared to other races, and these products are often left out of cessation programs. Smokers, regardless of race, may have a misguided belief that cigars and cigarillos are less harmful than cigarettes.
Research published in 2021 found that Black cigar smokers who were interested in cessation had not been asked by their healthcare provider if they smoked cigars, and those who were asked reported a lack of support for cessation.
Primary care providers should work to remove any misconceptions a patient has regarding the safety of cigarillos and cigars, Choi said.
These smokers are also at a disadvantage regarding cessation success because of the neighborhoods they may live in, according to Choi. Black Americans are more likely to earn less and to live in neighborhoods with lower housing values than other racial groups. Areas with more low-income households tend to have a higher density of tobacco outlets.
“If you’re trying to quit smoking, but you walk by three, four, or five gas stations, convenience stores, and other tobacco outlets with signs that advertise sales, it’s not going to make quitting easy,” Choi said.
Tailoring Treatment to Black Smokers
Considering the unique challenges Black patients may face in quitting, clinicians should provide more follow-up and consistent support, according to Adamian. The higher risk of tobacco-related death among Black smokers means clinicians need to be more aggressive in recommending every treatment possible if one treatment fails.
Pharmacotherapy, nicotine replacement therapy, and counseling are evidence-based options to help patients stop smoking.
Kortsch considers pharmacotherapy to be the most effective and evidence-based treatment for nicotine addiction. However, Black Americans are less likely than White smokers to try smoking cessation medications, and they express more suspicion about efficacy and potential addiction to the tools.
“African American populations simply do not use pharmacotherapy to the extent that other populations do to help them quit smoking; this is a problem,” Kortsch said.
Kortsch recommends the use of varenicline for all patients with nicotine addiction. He recommends varenicline in combination with tobacco replacement products such as lozenges, patches, gums, or inhalers if the patient is a heavy smoker as opposed to someone who has a few cigarettes on the weekends.
If a patient has anxiety or depression, Adamian advises initiating a pharmacologic treatment such as bupropion or varenicline more quickly because mood disorders can hinder cessation.
Cessation counseling is another option, but clinicians may need to more thoroughly explain what it entails. According to Choi, Black patients may be more reluctant to try cessation counseling because of the negative stigma associated with the term “counseling.” But this treatment is not therapy — it involves identifying and coming up with strategies to manage smoking triggers and providing encouragement. Clinicians can eliminate any confusion patients may have between psychological therapy and cessation counseling.
“‘Counseling’ tends to have a somewhat negative connotation among racial minority populations, like you go to counseling because you’re crazy,” Choi said. “That needs to change.”
Clinicians also must clarify how each cessation tool works. For example, some patients may not realize that the nicotine patch isn’t an instant fix for a craving and that hours may pass before the user feels its effects, according to Choi.
Move Past the “Advise” Stage
While recommending to patients various forms of cessation, clinicians should be mindful of the US Preventive Services Task Force’s guidelines for providers who treat patients who smoke. Those guidelines include a five-step process: Ask, Advise, Assess, Assist, and Arrange.
Choi said most providers stop at the “Advise” stage. In steps one and two, providers ask patients whether they smoke, then advise them to quit. Stage three involves asking whether or not a patient is ready to quit and where they are in their journey.
Clinicians shouldn’t give up when patients say they do not currently plan to quit. Instead, they can use the conversation to create an ongoing dialogue about the patient’s readiness to quit in future visits. Follow-up phone calls or text messages should be made 2 to 4 weeks after a patient makes an attempt to quit and at the same interval thereafter, Adamian advised.
“It takes a concerted effort on behalf of all people to be successful, and it is really uncommon for someone to be successful with only one attempt,” Kortsch said.
In a recent study published in the Journal of the American Medical Association, researchers identified three key factors that influence a Black smoker’s ability to stop smoking in early attempts. These factors have been shown to increase the chances of long-term cessation: fewer cigarettes per day, nonuse of other tobacco products, and lower levels of cotinine (a nicotine metabolite) at baseline.
“Using these predictors of early treatment response could allow providers to anticipate which smokers may benefit from a minimal, low-cost intervention and who may benefit from more intensive treatment,” said Eleanor Leavens, PhD, assistant professor in the Department of Population Health at the University of Kansas School of Medicine in Kansas City, who led the study.
Leavens’ research also confirmed that early abstinence predicts long-term cessation success. Smokers who were able to forgo cigarettes within 2 weeks of their quit date were almost four times more likely to remain abstinent over the long term.
A quick phone call or message from the clinician or a staff member can help patients achieve early progress, enable changes in approach to quitting, and build a relationship with the patient, Adamian said.
“Have more empathy for what Black patients are going through,” Choi said. “Continue to cheer them on and to be a supporter of their smoking cessation journey.”
Brittany Vargas is a medicine, mental health, and wellness journalist.
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