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The association between having a first-degree family history of cancer and smoking status
YPMED-03954; No. of pages: 5; 4C: Preventive Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
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Hermine Poghosyan a,⁎, Janice F. Bell b, Jill G. Joseph b, Mary E. Cooley c a
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Available online xxxx
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Keywords: Smoking status Family cancer history Smoking cessation
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College of Nursing Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA 02125, USA Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA 95817, USA Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
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Objective. A diagnosis of cancer within the family provides an opportunity for smokers to adopt a healthpromoting behavior. This study examines the associations between having a first-degree family history of cancer and smoking status using population-based data with a large and diverse sample. Method. Cross-sectional data from the 2009 California Health Interview Survey (CHIS) on 47,331 adults were analyzed. Sample weights were applied to account for the survey design with results generalizable to non-institutionalized adults in California (27.4 million). Results. In 2009, 3.7 million (13.6%) adults were current-smokers, 6.3 million (23.0%) were former smokers and 17.4 million (63.4%) were never-smokers. Nine-million-six-hundred-thousand (35%) had a first-degree family history of cancer. Controlling for all covariates, first-degree family history of cancer was significantly associated with being a current smoker (OR = 1.16; 95% CI = 1.01–1.35) and to being a former smoker (OR = 1.17; 95% CI = 1.05–1.30). Conclusion. In California, although many adults with a first-degree family history of cancer quit smoking, a significant subset still smoke which places them at higher risk for poor health outcomes. This subset represents an important target population for smoking cessation interventions. © 2014 Published by Elsevier Inc.
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The association between having a first-degree family history of cancer and smoking status
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Introduction
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Tobacco smoking continues to be a major public health issue in the United States, as the leading cause of preventable death for more than three decades. More than 16 million Americans suffer from a disease caused by smoking. Each year approximately 443,000 individuals die from cigarette smoking or exposure to second-hand smoke in the United States (Schiller et al., 2012; U.S. Department of Health and Human Services, 2014). Tobacco use also generates significant economic costs to society, with the total annual economic burden associated with tobacco use estimated at $193 billion in the United States (Centers for Disease Control and Prevention (CDC), 2008). In 2011, 19% of adults aged 18 years and older were current cigarette smokers, which represents approximately 43.8 million current adult smokers (Schiller et al., 2012). Although adult smoking prevalence is lower in California compared with the overall US prevalence rate, the prevalence remains unacceptably high (Centers for Disease Control and Prevention (CDC), 2012). California has the largest population (38.3 million in
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⁎ Corresponding author. E-mail addresses: [email protected] (H. Poghosyan), [email protected] (J.F. Bell), [email protected] (J.G. Joseph), [email protected] (M.E. Cooley).
2013) in the United States, and even lower percentage still represents many current smokers (U.S. Census Bureau, 2014). Prior research has reported that cigarette smoking and family history of cancer are risk factors for developing various types of cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2001; Peto and Houlston, 2001; Rosenberg et al., 2013; Sasco et al., 2004; Schairer et al., 2013; Turati et al., 2013). However, having both risk factors further increases cancer risk. For example, Suzuki and colleagues evaluated the effect of familial history and smoking on risks of fourteen common cancers (breast, lung, colorectum, prostate, head and neck, esophagus, stomach, liver, pancreas, uterus, ovary, bladder, thyroid, lymphoma). They found that among participants with a family history of cancer, the risks of cancer were found to be higher in smokers compared with nonsmokers (Suzuki et al., 2007). Another study conducted by Cote and colleagues found that smokers with a family history of lung cancer had a higher risk of developing lung cancer themselves than smokers without a family history of lung cancer (Cote et al., 2005). Information about a family history of cancer may provide an opportunity for smokers to adopt a health-promoting behavior. Patterson and colleagues showed that smokers with a family history of cancer were significantly more likely to report that they intended to quit (66%) than smokers without a family history of cancer (58%, X2 = 7.08, p b .01), using the National Cancer Institute's Health Information Trends Survey
http://dx.doi.org/10.1016/j.ypmed.2014.05.013 0091-7435/© 2014 Published by Elsevier Inc.
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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Methods
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Sample
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Cross-sectional data from the 2009 California Health Interview Survey (CHIS) of 47,331 adults were used in this study. The 2009 data were the latest available data that includes information about family history of cancer. The total sample of adults was 47,614 excluded proxy interviews (n = 283) for frail and ill persons who were unable to complete the extended adult interview. CHIS is a population-based telephone survey of non-institutionalized population in California that uses a multi-stage stratified random-digit-dial sampling design. Every other year since 2001, CHIS has collected information on health status, health conditions, health-related behaviors, health insurance coverage, access to healthcare services, and other health and health related issues for all age groups. Interviews were conducted in five languages: English, Spanish, Chinese (Mandarin and Cantonese dialects), Vietnamese, and Korean. Separate questionnaires are used for adults (ages 18 and older), adolescents (ages 12–17 years) and children (ages 0–11) years (Ponce et al., 2004). The adult sample data was used in this analyses and the response rate was 49% for the CHIS 2009 survey (California Health Interview Survey (CHIS), 2012).
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Variables
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The outcome variable, smoking status, was classified as current-smokers (smoked at least 100 cigarettes in entire life with reported current tobacco use), former-smokers (smoked at least 100 cigarettes in entire life and does not smoke at all now), or never-smoker (smoked less than 100 cigarettes in entire life). The main independent variable, first-degree family history of cancer, was defined as blood relatives (biological father or mother, full brothers or sisters, and biological sons or daughters) with a history of cancer or not. Demographic characteristics included age, gender, race/ethnicity, marital status, federal poverty level (FPL), education level and health insurance coverage. General health status, physical activity, body weight status and binge drinking status were also included. General health status was assessed using a single item question “Would you say that in general your health is excellent, very good, good, fair, or poor?” on a 5-point response format with 1 being excellent and 5 being poor. Then we reclassified as excellent/very good, good and fair/ poor. Physical activity was defined as regular physical, some physical activity and sedentary (no physical activity). Body weight status was defined by body mass index as underweight b 18.5 kg/m2, normal = 18.5–24.9 kg/m2, overweight = 25.0–29.9 kg/m2, and obesity ≥ 30.0 kg/m2. Binge-drinking status was defined as ≥5 alcoholic drinks for males or ≥4 alcoholic drinks for females in a single episode in the past year.
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Statistical analyses
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Sample weights were applied to account for the complex survey design with results generalizable to non-institutionalized adults in California. Descriptive statistics, both percentages and 95% confidence intervals (CI), were used to describe the sample characteristics. Prevalence of current, former, and never smoking status by characteristics of study population was computed. Then, we used multinomial logistic regression controlled for demographic characteristics, FPL, health insurance coverage, general health status, physical activity, body weight status and binge drinking status to analyze the association between first-degree family history of cancer (yes/no) and smoking status (current smoker and former smoker). Results were considered statistically significant if two-sided p-values were b 0.05. All analyses were performed using STATA version 12.
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A total of 47,331 adults were included in the sample, corresponding to a population estimate of 27.4 million in California with characteristics as presented in Table 1. In 2009, 13.6% (3.7 million) of the 27.4 million adults were current-smokers, 23.0% (6.3 million) former-smokers and 63.4% (17.4 million) never-smokers. Thirty-five percent (9.6 million) had a first-degree family history of cancer. Non-Hispanic Whites and Hispanics comprised 46.4% and 32.5% of the sample, respectively. Greater than half of the participants (52.2%) reported having an income ≥300% of the FPL. The majority of participants had health insurance coverage (82%). Table 2 presents the prevalence of current, former, and never smoking by characteristics of study population. In California, 13.5% (1.3 million) of the 9.6 million adults with a first-degree family history
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Characteristics
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Smoking status Current-smokers Former-smokers Never-smokers Family cancer history Yes No Age 18–25 26–34 35–49 50+ Gender Male Female Race/ethnicity Hispanic Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Non-Hispanic Other Marital status Married Not-married Federal poverty level (FPL) b100% FPL 100–199% FPL 200–299% FPL ≥300% FPL Education level High-school or less Some college College or more Health insurance Currently insured Not insured General health Excellent/very good Good Fair/poor Body weight status Underweight Normal Overweight Obese Physical activity Sedentary Some activity Regular activity Binge drinking status Yes No
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Table 1 Characteristics of California Health Interview Survey participants, 2009.
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Results
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(Patterson et al., 2010). Research into the association of family history of cancer on smoking status is limited. Therefore, this study examines the associations between having a first-degree family history of cancer and smoking status using population-based data with a large and diverse sample. This information may help identify whether family members of those diagnosed with cancer represent a target population for smoking cessation interventions. Given that 30% of all cancer deaths in the United States can be prevented by avoiding exposure to tobacco (Kushi et al., 2012) identifying and providing smoking cessation interventions to individuals with increased risk of developing cancer are essential.
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H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx
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Unweighted sample size
Weighted %
95% CI
5528 14,486 27,317
13.6 23.0 63.4
12.8–14.4 22.1–23.8 62.5–64.3
22,286 25,045
35.0 65.0
34.1–35.8 64.1–65.8
2826 3446 10,484 30,575
16.0 15.6 30.2 38.2
15.6–16.4 15.0–16.0 29.7–30.5 38.1–38.2
19,280 28,051
49.0 51.0
49.0–49.1 50.0–51.0
8281 30,951 1839 4833 1427
32.5 46.4 5.6 12.8 2.6
32.4–32.5 46.4–46.5 5.6–5.7 12.8–13.0 2.5–2.6
27,079 20,252
61.3 38.6
60.5–62.2 37.8–39.5
5747 7950 6478 27,156
16.0 18.0 13.7 52.2
15.3–16.8 17.2–18.7 13.0–14.5 51.3–53.1
15,140 12,858 19,333
42.2 23.7 34.0
42.0–42.4 23.0–24.5 33.3–34.7
42,186 5145
82.0 18.0
81.0–82.8 17.1–19.0
24,554 13,588 9189
52.0 29.8 18.2
51.0–52.8 28.4–30.8 17.4–19.0
1051 19,689 16,078 10,513
2.2 41.3 33.7 22.7
2.0–2.5 40.4–42.3 32.8–34.5 21.8–23.5
16,936 20,838 9557
34.6 43.4 21.8
33.6–35.7 42.3–44.5 21.0–22.7
11,049 36,282
31.4 68.5
30.5–32.3 67.6–69.4
Note: Percentages were computed accounting for the complex survey design of the 2009 CHIS.
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
t1:3 t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20 t1:21 t1:22 t1:23 t1:24 t1:25 t1:26 t1:27 t1:28 t1:29 t1:30 t1:31 t1:32 t1:33 t1:34 t1:35 t1:36 t1:37 t1:38 t1:39 t1:40 t1:41 t1:42 t1:43 t1:44 t1:45 t1:46 t1:47 t1:48 t1:49 t1:50 t1:51 t1:52 t1:53 t1:54 t1:55 t1:56 t1:57
H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx Table 2 Prevalence of smoking by characteristics of study population, California Health Interview Survey, 2009.
13.5 (12.3–14.6) 13.7 (12.7–14.7)
29.7 (28.5–31.0) 19.3 (18.0–20.4)
56.8 (55.4–58.2) 67.0 (65.7–68.3)
14.1 (12.0–16.3) 18.5 (15.8–21.5) 13.8 (12.7–15.0) 11.2 (10.3–12.2)
10.1 (8.0–12.7) 14.0 (12.0–16.2) 18.3 (17.0–19.8) 35.7 (34.5–36.8)
75.8 (73.0–78.5) 67.5 (64.7–70.0) 67.9 (66.0–69.7) 53.1 (51.7–54.4)
17.2 (16.0–18.5) 10.1 (9.3–11.0)
26.8 (25.6–28.0) 19.2 (18.2–20.3)
56.0 (54.5–57.3) 70.7 (69.4–71.8)
12.7 (11.2–14.3) 14.2 (13.3–15.2) 16.6 (13.8–19.7) 10.3 (8.0–12.8) 23.6 (19.5–28.2)
17.7 (16.0–19.5) 30.0 (28.8–31.0) 20.0 (17.0–23.3) 12.2 (10.2–14.6) 22.0 (18.7–25.7)
11.9 (11.0–13.0) 16.3 (15.2–17.7)
25.7 (24.5–26.8) 18.6 (17.2–20.0)
62.4 (61.2–63.6) 65.1 (63.2–66.8)
16.9 (15.0–19.0) 17.1 (15.1–18.7) 16.2 (13.8–18.8) 10.8 (9.9–11.6)
16.8 (14.4–19.4) 20.7 (18.7–22.8) 23.2 (20.6–25.8) 25.5 (24.4–26.6)
66.3 (63.2–69.2) 62.2 (59.7–64.5) 60.6 (57.6–63.6) 63.7 (62.4–64.9)
22.9 (21.6–24.3) 24.5 (22.7–26.4) 21.8 (20.5–23.1)
59.5 (57.9–61.0) 60.1 (58.0–61.9) 70.8 (69.2–72.2)
24.0 (23.1–24.8) 18.3 (15.9–20.9)
63.7 (62.6–64.6) 62.4 (59.5–65.1)
22.1 (20.9–23.2) 23.5 (22.0–24.9) 24.6 (22.4–26.8)
66.4 (65.0–67.7) 63.0 (61.4–64.5) 55.6 (53.2–57.9)
9.4 (7.2–12.0) 19.1 (17.9–20.3) 26.2 (24.7–27.7) 26.4 (24.6–28.2)
73.1 (67.6–78.0) 67.4 (65.8–68.8) 60.1 (58.3–61.7) 60.3 (58.5–62.0)
25.4 (23.8–27.0) 21.2 (20.0–22.4) 22.5 (20.7–24.3)
60.6 (58.9–62.2) 65.4 (63.7–66.9) 64.2 (61.8–66.5)
24.0 (22.3–25.6) 22.5 (21.6–23.3)
53.7 (51.8–55.5) 67.9 (66.8–69.0)
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12.3 (11.5–13.2) 19.3 (17.4–21.3)
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17.5 (13.0–23.0) 13.5 (12.2–14.7) 13.7 (12.5–14.9) 13.3 (11.8– 14.9) 14.0 (12.8–15.3) 13.4 (12.2–14.7) 13.3 (11.6–15.0) 22.3 (20.6–24.1) 9.6 (8.8–10.4)
Note: Percentages were computed accounting for the complex survey design of the 2009 CHIS.
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of cancer were current-smokers, 29.7% (2.8 million) former-smokers and 56.8% (5.4 million) never smokers. Table 3 presents the results of multivariate multinomial logistic regression models. After controlling for the covariates, having a first-degree family history of cancer was significantly related to being a current smoker (AOR = 1.16, 95% CI = 1.01–1.35). Current smoking status was also greater among men, those of older age, poorer, individuals who were not married, had lower education, had poor health, and were binge drinkers. Having a first-degree family history of cancer was significantly related to being a former-smoker (OR = 1.17; 95% CI = 1.05–1.30), controlling for all covariates. Former smoking status was greater among those of older age, men, individuals with lower education, and binge drinkers.
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Discussion
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The result of this study demonstrated that first-degree family history of cancer was associated with being a current smoker and to being a
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D
17.6 (16.3–18.8) 15.4 (13.9–17.1) 7.4 (6.5–8.3)
11.5 (10.5–12.5) 13.5 (12.3–14.7) 19.8 (17.9–21.8)
F
Never smokers % (95% CI)
R
Family cancer history Yes No Age 18–25 26–34 35–49 50+ Gender Male Female Race/ethnicity Hispanic Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Non-Hispanic Other Marital status Married Not-married Federal poverty level (FPL) b100% FPL 100–199% FPL 200–299% FPL ≥300% FPL Education level High-school or less Some college College or more Health insurance Currently insured Not insured General health Excellent/very good Good Fair/poor Body weight status Underweight Normal Overweight Obese Physical activity Sedentary Some activity Regular activity Binge drinking status Yes No
Former smokers % (95% CI)
N C O
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20 t2:21 t2:22 t2:23 t2:24 t2:25 t2:26 t2:27 t2:28 t2:29 t2:30 t2:31 t2:32 t2:33 t2:34 t2:35 t2:36 t2:37 t2:38 t2:39 t2:40 t2:41 t2:42 t2:43 t2:44 t2:45 t2:46 t2:47 t2:48 t2:49 t2:50 t2:51
Current smokers % (95% CI)
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Characteristics t2:3
T
t2:1 t2:2
3
69.6 (67.7–71.3) 55.8 (54.6–57.0) 63.4 (59.0–67.4) 77.5 (74.4–80.2) 54.4 (49.5–59.0)
former smoker. These findings are consistent with several other studies, however, this is the first study that used population-based data with a large and diverse sample. One cross-sectional study (n = 657) conducted in Australia found that 36% of smokers with a friend or relative diagnosed with cancer reported quitting smoking (Humpel et al., 2007). Another study (n = 1145) found that smokers with a family history of cancer were significantly more likely to report that they intended to quit than those without a family cancer history (Patterson et al., 2010). Further, our results indicated that nearly 1.3 million adults with a first-degree family history of cancer smoke in California, which places them at higher risk for poor health outcomes. A diagnosis of cancer in the family may provide an opportunity for relatives of patients to quit smoking and may also motivate them to enroll in smoking cessation programs. A recent study by Schnoll et al. (2013) showed that smokers (n = 113) with a family member who received a cancer diagnosis were more likely to enroll in the smoking cessation programs versus smokers of orthopedic patients (n = 121) (Schnoll et al., 2013). Another study found that 88% of patients (n = 37) diagnosed with lung cancer and 91% of family members of these patients indicated readiness to quit
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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Cancer family history No (reference) Yes Age 18–25 (reference) 26–34 35–49 50+ Gender Female (reference) Male Race/ethnicity NH White (reference) Hispanic NH Black NH Asian NH Other Marital status Not-married (reference) Married Poverty level ≥300% FPL (reference) 200–299% FPL 100–199% FPL b100% FPL Education level High-school or less (reference) Some college College or more General health Fair/poor (reference) Good Excellent/very good Body weight status Normal (reference) Underweight Overweight Obese Physical activity Sedentary (reference) Some activity Regular activity Binge drinking status No (reference) Yes Health insurance Not insured (reference) Currently insured
Former smokers vs. never smokers Adjusted odds ratio (95% CI)
1.00 1.16 (1.01–1.35)
1.00 1.17 (1.05–1.30)
1.00 2.37 (1.80–3.11) 1.81 (1.43–2.29) 2.05 (1.59–2.65)
1.00 1.71 (1.23–2.38) 2.09 (1.55–2.81) 5.17 (3.90–6.85)
1.00 2.06 (1.80–2.36)
1.00 1.82 (1.64–2.03)
R O
O
1.00 0.41 (0.33–0.51) 0.89 (0.68–1.15) 0.57 (0.42–0.78) 1.51 (1.06–2.13) 1.00 0.81 (0.68–0.96)
P
1.00 1.38 (1.10–1.73) 1.39 (1.15–1.67) 1.26 (1.01–1.60) 1.00 0.81 (0.70–0.93) 0.32 (0.26–0.38)
T
1.00 0.58 (0.48–0.72) 0.49 (0.40–0.60)
R
R
E
C
1.00 1.44 (0.97–2.15) 0.85 (0.72–1.00) 0.74 (0.61–0.89)
O
t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18 t3:19 t3:20 t3:21 t3:22 t3:23 t3:24 t3:25 t3:26 t3:27 t3:28 t3:29 t3:30 t3:31 t3:32 t3:33 t3:34 t3:35 t3:36 t3:37 t3:38 t3:39 t3:40 t3:41 t3:42 t3:43 t3:44 t3:45 t3:46 t3:47 t3:48 t3:49 t3:50 t3:51 t3:52
Current smokers vs. never smokers Adjusted odds ratio (95% CI)
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Variables
t3:4
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Table 3 Multivariate multinomial logistic models for smoking status, California Health Interview Survey, 2009.
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t3:1 t3:2
H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx
1.00 0.51 (0.44–0.59) 0.65 (0.51–0.82) 0.39 (0.31–0.50) 0.89 (0.68–1.15) 1.00 1.11 (0.96–1.27)
1.00 1.02 (0.83–1.25) 0.95 (0.80–1.14) 0.85 (0.66–1.09) 1.00 0.91 (0.78–1.06) 0.58 (0.49–0.68) 1.00 0.90 (0.77–1.05) 0.81 (0.70–0.95) 1.00 0.59 (0.44–0.79) 1.09 (0.97–1.24) 1.07 (0.93–1.24)
1.00 0.87 (0.73–1.03) 0.84 (0.67–1.04)
1.00 0.74 (0.66–0.83) 0.85 (0.73–0.98)
1.00 3.29 (2.81–3.86)
1.00 1.83 (1.64–2.05)
1.00 0.82 (0.70–0.95)
1.00 0.95 (0.78–1.16)
Note: All estimates are on weighted analyses accounting for the complex survey design of the 2009 CHIS. FPL, federal poverty level; NH, non-Hispanic.
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smoking within the next 6 months (Cooley et al., 2013). Therefore, smoking cessation interventions are needed for this high-risk population group. The present study has some limitations. Family history of cancer and smoking status data were based on self-report that may be inaccurate due to recall. Using biochemical verification of smoking status is usually recommended in tobacco control studies to minimize the risk of underestimating smoking prevalence (Benowitz et al., 2002). Also, only respondents who spoke one of the five survey languages were included. There may be other variables, such as family member smoking status, which may modify the association between family history of cancer and smoking status, but were not captured in CHIS. The absence of information about family member smoking status is a major limitation, because it has been known for decades that having a close relative (e.g., parent or sibling) who smokes increases the likelihood of becoming a smoker (Bricker et al., 2006; Wilkinson et al., 2008). We were not able to measure the intention to quit smoking with the CHIS data, therefore, further studies are needed to evaluate the intention to quit smoking among individuals with a first-degree family history of cancer.
193 194 195 196 197 198 199 200 201 202 203 204 205
N
191 192
U
189 190
C
t3:53
Other variables that might be missing are time since they quit smoking for former smokers, information about participant's quitting smoking in response to the family member's cancer diagnosis, as well as information about which first-degree relative(s) (parent, sibling, or child) had cancer and information about whether first-degree relatives had a smoking-related cancer. Despite these limitations, this study is strengthened by its population-based methodology that has a large representative sample. This information may be used to support public health interventions by identifying individuals at risk for poor health due to cigarette smoking. Future research investigating smoking behaviors among individuals with a first-degree family history of cancer is warranted given the limited literature on this topic. In summary, many adults in California with a first-degree family history of cancer still smoke, which places them at increased risk for developing cancer (Suzuki et al., 2007). The evidence regarding the effectiveness of smoking cessation is well established (Dresler and Gritz, 2001; Fiore et al., 2008; Rodu and Godshall, 2006). Evidence-based smoking cessation interventions increase the quit rate and are critical to reduce tobacco-related death and disease burden (Fiore et al.,
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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Conflict of interest statement
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The authors declare that there are no conflicts of interest.
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2008). Given the potential increased risk for developing cancer based on smoking status and family history of cancer, it is important to identify the group of individuals who are at increased risk of developing cancer so that preventive interventions such as smoking cessation can be implemented. All smokers should be targeted for smoking cessation interventions, however, individuals with increased risk of developing cancer should be considered as the primary target population. Thus, smokers with a first-degree family history of cancer represent an important target population for smoking cessation interventions. Also, young adults who smoke and have a first-degree family history of cancer could be targeted for smoking prevention.
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Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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Contents lists available at ScienceDirect
Preventive Medicine journal homepage: www.elsevier.com/locate/ypmed
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Hermine Poghosyan a,⁎, Janice F. Bell b, Jill G. Joseph b, Mary E. Cooley c a
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Keywords: Smoking status Family cancer history Smoking cessation
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College of Nursing Health Sciences, University of Massachusetts Boston, 100 Morrissey Boulevard, Boston, MA 02125, USA Betty Irene Moore School of Nursing, University of California Davis, 4610 X Street, Sacramento, CA 95817, USA Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA
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Objective. A diagnosis of cancer within the family provides an opportunity for smokers to adopt a healthpromoting behavior. This study examines the associations between having a first-degree family history of cancer and smoking status using population-based data with a large and diverse sample. Method. Cross-sectional data from the 2009 California Health Interview Survey (CHIS) on 47,331 adults were analyzed. Sample weights were applied to account for the survey design with results generalizable to non-institutionalized adults in California (27.4 million). Results. In 2009, 3.7 million (13.6%) adults were current-smokers, 6.3 million (23.0%) were former smokers and 17.4 million (63.4%) were never-smokers. Nine-million-six-hundred-thousand (35%) had a first-degree family history of cancer. Controlling for all covariates, first-degree family history of cancer was significantly associated with being a current smoker (OR = 1.16; 95% CI = 1.01–1.35) and to being a former smoker (OR = 1.17; 95% CI = 1.05–1.30). Conclusion. In California, although many adults with a first-degree family history of cancer quit smoking, a significant subset still smoke which places them at higher risk for poor health outcomes. This subset represents an important target population for smoking cessation interventions. © 2014 Published by Elsevier Inc.
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The association between having a first-degree family history of cancer and smoking status
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Introduction
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Tobacco smoking continues to be a major public health issue in the United States, as the leading cause of preventable death for more than three decades. More than 16 million Americans suffer from a disease caused by smoking. Each year approximately 443,000 individuals die from cigarette smoking or exposure to second-hand smoke in the United States (Schiller et al., 2012; U.S. Department of Health and Human Services, 2014). Tobacco use also generates significant economic costs to society, with the total annual economic burden associated with tobacco use estimated at $193 billion in the United States (Centers for Disease Control and Prevention (CDC), 2008). In 2011, 19% of adults aged 18 years and older were current cigarette smokers, which represents approximately 43.8 million current adult smokers (Schiller et al., 2012). Although adult smoking prevalence is lower in California compared with the overall US prevalence rate, the prevalence remains unacceptably high (Centers for Disease Control and Prevention (CDC), 2012). California has the largest population (38.3 million in
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⁎ Corresponding author. E-mail addresses: [email protected] (H. Poghosyan), [email protected] (J.F. Bell), [email protected] (J.G. Joseph), [email protected] (M.E. Cooley).
2013) in the United States, and even lower percentage still represents many current smokers (U.S. Census Bureau, 2014). Prior research has reported that cigarette smoking and family history of cancer are risk factors for developing various types of cancer (Collaborative Group on Hormonal Factors in Breast Cancer, 2001; Peto and Houlston, 2001; Rosenberg et al., 2013; Sasco et al., 2004; Schairer et al., 2013; Turati et al., 2013). However, having both risk factors further increases cancer risk. For example, Suzuki and colleagues evaluated the effect of familial history and smoking on risks of fourteen common cancers (breast, lung, colorectum, prostate, head and neck, esophagus, stomach, liver, pancreas, uterus, ovary, bladder, thyroid, lymphoma). They found that among participants with a family history of cancer, the risks of cancer were found to be higher in smokers compared with nonsmokers (Suzuki et al., 2007). Another study conducted by Cote and colleagues found that smokers with a family history of lung cancer had a higher risk of developing lung cancer themselves than smokers without a family history of lung cancer (Cote et al., 2005). Information about a family history of cancer may provide an opportunity for smokers to adopt a health-promoting behavior. Patterson and colleagues showed that smokers with a family history of cancer were significantly more likely to report that they intended to quit (66%) than smokers without a family history of cancer (58%, X2 = 7.08, p b .01), using the National Cancer Institute's Health Information Trends Survey
http://dx.doi.org/10.1016/j.ypmed.2014.05.013 0091-7435/© 2014 Published by Elsevier Inc.
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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Methods
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Sample
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Cross-sectional data from the 2009 California Health Interview Survey (CHIS) of 47,331 adults were used in this study. The 2009 data were the latest available data that includes information about family history of cancer. The total sample of adults was 47,614 excluded proxy interviews (n = 283) for frail and ill persons who were unable to complete the extended adult interview. CHIS is a population-based telephone survey of non-institutionalized population in California that uses a multi-stage stratified random-digit-dial sampling design. Every other year since 2001, CHIS has collected information on health status, health conditions, health-related behaviors, health insurance coverage, access to healthcare services, and other health and health related issues for all age groups. Interviews were conducted in five languages: English, Spanish, Chinese (Mandarin and Cantonese dialects), Vietnamese, and Korean. Separate questionnaires are used for adults (ages 18 and older), adolescents (ages 12–17 years) and children (ages 0–11) years (Ponce et al., 2004). The adult sample data was used in this analyses and the response rate was 49% for the CHIS 2009 survey (California Health Interview Survey (CHIS), 2012).
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Variables
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The outcome variable, smoking status, was classified as current-smokers (smoked at least 100 cigarettes in entire life with reported current tobacco use), former-smokers (smoked at least 100 cigarettes in entire life and does not smoke at all now), or never-smoker (smoked less than 100 cigarettes in entire life). The main independent variable, first-degree family history of cancer, was defined as blood relatives (biological father or mother, full brothers or sisters, and biological sons or daughters) with a history of cancer or not. Demographic characteristics included age, gender, race/ethnicity, marital status, federal poverty level (FPL), education level and health insurance coverage. General health status, physical activity, body weight status and binge drinking status were also included. General health status was assessed using a single item question “Would you say that in general your health is excellent, very good, good, fair, or poor?” on a 5-point response format with 1 being excellent and 5 being poor. Then we reclassified as excellent/very good, good and fair/ poor. Physical activity was defined as regular physical, some physical activity and sedentary (no physical activity). Body weight status was defined by body mass index as underweight b 18.5 kg/m2, normal = 18.5–24.9 kg/m2, overweight = 25.0–29.9 kg/m2, and obesity ≥ 30.0 kg/m2. Binge-drinking status was defined as ≥5 alcoholic drinks for males or ≥4 alcoholic drinks for females in a single episode in the past year.
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Statistical analyses
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Sample weights were applied to account for the complex survey design with results generalizable to non-institutionalized adults in California. Descriptive statistics, both percentages and 95% confidence intervals (CI), were used to describe the sample characteristics. Prevalence of current, former, and never smoking status by characteristics of study population was computed. Then, we used multinomial logistic regression controlled for demographic characteristics, FPL, health insurance coverage, general health status, physical activity, body weight status and binge drinking status to analyze the association between first-degree family history of cancer (yes/no) and smoking status (current smoker and former smoker). Results were considered statistically significant if two-sided p-values were b 0.05. All analyses were performed using STATA version 12.
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A total of 47,331 adults were included in the sample, corresponding to a population estimate of 27.4 million in California with characteristics as presented in Table 1. In 2009, 13.6% (3.7 million) of the 27.4 million adults were current-smokers, 23.0% (6.3 million) former-smokers and 63.4% (17.4 million) never-smokers. Thirty-five percent (9.6 million) had a first-degree family history of cancer. Non-Hispanic Whites and Hispanics comprised 46.4% and 32.5% of the sample, respectively. Greater than half of the participants (52.2%) reported having an income ≥300% of the FPL. The majority of participants had health insurance coverage (82%). Table 2 presents the prevalence of current, former, and never smoking by characteristics of study population. In California, 13.5% (1.3 million) of the 9.6 million adults with a first-degree family history
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Smoking status Current-smokers Former-smokers Never-smokers Family cancer history Yes No Age 18–25 26–34 35–49 50+ Gender Male Female Race/ethnicity Hispanic Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Non-Hispanic Other Marital status Married Not-married Federal poverty level (FPL) b100% FPL 100–199% FPL 200–299% FPL ≥300% FPL Education level High-school or less Some college College or more Health insurance Currently insured Not insured General health Excellent/very good Good Fair/poor Body weight status Underweight Normal Overweight Obese Physical activity Sedentary Some activity Regular activity Binge drinking status Yes No
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Table 1 Characteristics of California Health Interview Survey participants, 2009.
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(Patterson et al., 2010). Research into the association of family history of cancer on smoking status is limited. Therefore, this study examines the associations between having a first-degree family history of cancer and smoking status using population-based data with a large and diverse sample. This information may help identify whether family members of those diagnosed with cancer represent a target population for smoking cessation interventions. Given that 30% of all cancer deaths in the United States can be prevented by avoiding exposure to tobacco (Kushi et al., 2012) identifying and providing smoking cessation interventions to individuals with increased risk of developing cancer are essential.
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Unweighted sample size
Weighted %
95% CI
5528 14,486 27,317
13.6 23.0 63.4
12.8–14.4 22.1–23.8 62.5–64.3
22,286 25,045
35.0 65.0
34.1–35.8 64.1–65.8
2826 3446 10,484 30,575
16.0 15.6 30.2 38.2
15.6–16.4 15.0–16.0 29.7–30.5 38.1–38.2
19,280 28,051
49.0 51.0
49.0–49.1 50.0–51.0
8281 30,951 1839 4833 1427
32.5 46.4 5.6 12.8 2.6
32.4–32.5 46.4–46.5 5.6–5.7 12.8–13.0 2.5–2.6
27,079 20,252
61.3 38.6
60.5–62.2 37.8–39.5
5747 7950 6478 27,156
16.0 18.0 13.7 52.2
15.3–16.8 17.2–18.7 13.0–14.5 51.3–53.1
15,140 12,858 19,333
42.2 23.7 34.0
42.0–42.4 23.0–24.5 33.3–34.7
42,186 5145
82.0 18.0
81.0–82.8 17.1–19.0
24,554 13,588 9189
52.0 29.8 18.2
51.0–52.8 28.4–30.8 17.4–19.0
1051 19,689 16,078 10,513
2.2 41.3 33.7 22.7
2.0–2.5 40.4–42.3 32.8–34.5 21.8–23.5
16,936 20,838 9557
34.6 43.4 21.8
33.6–35.7 42.3–44.5 21.0–22.7
11,049 36,282
31.4 68.5
30.5–32.3 67.6–69.4
Note: Percentages were computed accounting for the complex survey design of the 2009 CHIS.
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
t1:3 t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20 t1:21 t1:22 t1:23 t1:24 t1:25 t1:26 t1:27 t1:28 t1:29 t1:30 t1:31 t1:32 t1:33 t1:34 t1:35 t1:36 t1:37 t1:38 t1:39 t1:40 t1:41 t1:42 t1:43 t1:44 t1:45 t1:46 t1:47 t1:48 t1:49 t1:50 t1:51 t1:52 t1:53 t1:54 t1:55 t1:56 t1:57
H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx Table 2 Prevalence of smoking by characteristics of study population, California Health Interview Survey, 2009.
13.5 (12.3–14.6) 13.7 (12.7–14.7)
29.7 (28.5–31.0) 19.3 (18.0–20.4)
56.8 (55.4–58.2) 67.0 (65.7–68.3)
14.1 (12.0–16.3) 18.5 (15.8–21.5) 13.8 (12.7–15.0) 11.2 (10.3–12.2)
10.1 (8.0–12.7) 14.0 (12.0–16.2) 18.3 (17.0–19.8) 35.7 (34.5–36.8)
75.8 (73.0–78.5) 67.5 (64.7–70.0) 67.9 (66.0–69.7) 53.1 (51.7–54.4)
17.2 (16.0–18.5) 10.1 (9.3–11.0)
26.8 (25.6–28.0) 19.2 (18.2–20.3)
56.0 (54.5–57.3) 70.7 (69.4–71.8)
12.7 (11.2–14.3) 14.2 (13.3–15.2) 16.6 (13.8–19.7) 10.3 (8.0–12.8) 23.6 (19.5–28.2)
17.7 (16.0–19.5) 30.0 (28.8–31.0) 20.0 (17.0–23.3) 12.2 (10.2–14.6) 22.0 (18.7–25.7)
11.9 (11.0–13.0) 16.3 (15.2–17.7)
25.7 (24.5–26.8) 18.6 (17.2–20.0)
62.4 (61.2–63.6) 65.1 (63.2–66.8)
16.9 (15.0–19.0) 17.1 (15.1–18.7) 16.2 (13.8–18.8) 10.8 (9.9–11.6)
16.8 (14.4–19.4) 20.7 (18.7–22.8) 23.2 (20.6–25.8) 25.5 (24.4–26.6)
66.3 (63.2–69.2) 62.2 (59.7–64.5) 60.6 (57.6–63.6) 63.7 (62.4–64.9)
22.9 (21.6–24.3) 24.5 (22.7–26.4) 21.8 (20.5–23.1)
59.5 (57.9–61.0) 60.1 (58.0–61.9) 70.8 (69.2–72.2)
24.0 (23.1–24.8) 18.3 (15.9–20.9)
63.7 (62.6–64.6) 62.4 (59.5–65.1)
22.1 (20.9–23.2) 23.5 (22.0–24.9) 24.6 (22.4–26.8)
66.4 (65.0–67.7) 63.0 (61.4–64.5) 55.6 (53.2–57.9)
9.4 (7.2–12.0) 19.1 (17.9–20.3) 26.2 (24.7–27.7) 26.4 (24.6–28.2)
73.1 (67.6–78.0) 67.4 (65.8–68.8) 60.1 (58.3–61.7) 60.3 (58.5–62.0)
25.4 (23.8–27.0) 21.2 (20.0–22.4) 22.5 (20.7–24.3)
60.6 (58.9–62.2) 65.4 (63.7–66.9) 64.2 (61.8–66.5)
24.0 (22.3–25.6) 22.5 (21.6–23.3)
53.7 (51.8–55.5) 67.9 (66.8–69.0)
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Note: Percentages were computed accounting for the complex survey design of the 2009 CHIS.
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of cancer were current-smokers, 29.7% (2.8 million) former-smokers and 56.8% (5.4 million) never smokers. Table 3 presents the results of multivariate multinomial logistic regression models. After controlling for the covariates, having a first-degree family history of cancer was significantly related to being a current smoker (AOR = 1.16, 95% CI = 1.01–1.35). Current smoking status was also greater among men, those of older age, poorer, individuals who were not married, had lower education, had poor health, and were binge drinkers. Having a first-degree family history of cancer was significantly related to being a former-smoker (OR = 1.17; 95% CI = 1.05–1.30), controlling for all covariates. Former smoking status was greater among those of older age, men, individuals with lower education, and binge drinkers.
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The result of this study demonstrated that first-degree family history of cancer was associated with being a current smoker and to being a
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17.6 (16.3–18.8) 15.4 (13.9–17.1) 7.4 (6.5–8.3)
11.5 (10.5–12.5) 13.5 (12.3–14.7) 19.8 (17.9–21.8)
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Family cancer history Yes No Age 18–25 26–34 35–49 50+ Gender Male Female Race/ethnicity Hispanic Non-Hispanic White Non-Hispanic Black Non-Hispanic Asian Non-Hispanic Other Marital status Married Not-married Federal poverty level (FPL) b100% FPL 100–199% FPL 200–299% FPL ≥300% FPL Education level High-school or less Some college College or more Health insurance Currently insured Not insured General health Excellent/very good Good Fair/poor Body weight status Underweight Normal Overweight Obese Physical activity Sedentary Some activity Regular activity Binge drinking status Yes No
Former smokers % (95% CI)
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Current smokers % (95% CI)
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t2:1 t2:2
3
69.6 (67.7–71.3) 55.8 (54.6–57.0) 63.4 (59.0–67.4) 77.5 (74.4–80.2) 54.4 (49.5–59.0)
former smoker. These findings are consistent with several other studies, however, this is the first study that used population-based data with a large and diverse sample. One cross-sectional study (n = 657) conducted in Australia found that 36% of smokers with a friend or relative diagnosed with cancer reported quitting smoking (Humpel et al., 2007). Another study (n = 1145) found that smokers with a family history of cancer were significantly more likely to report that they intended to quit than those without a family cancer history (Patterson et al., 2010). Further, our results indicated that nearly 1.3 million adults with a first-degree family history of cancer smoke in California, which places them at higher risk for poor health outcomes. A diagnosis of cancer in the family may provide an opportunity for relatives of patients to quit smoking and may also motivate them to enroll in smoking cessation programs. A recent study by Schnoll et al. (2013) showed that smokers (n = 113) with a family member who received a cancer diagnosis were more likely to enroll in the smoking cessation programs versus smokers of orthopedic patients (n = 121) (Schnoll et al., 2013). Another study found that 88% of patients (n = 37) diagnosed with lung cancer and 91% of family members of these patients indicated readiness to quit
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
168 169 170 171 172 173 Q10 174 175 176 177 178 179 180 181 182 183 184 185 186
4
Cancer family history No (reference) Yes Age 18–25 (reference) 26–34 35–49 50+ Gender Female (reference) Male Race/ethnicity NH White (reference) Hispanic NH Black NH Asian NH Other Marital status Not-married (reference) Married Poverty level ≥300% FPL (reference) 200–299% FPL 100–199% FPL b100% FPL Education level High-school or less (reference) Some college College or more General health Fair/poor (reference) Good Excellent/very good Body weight status Normal (reference) Underweight Overweight Obese Physical activity Sedentary (reference) Some activity Regular activity Binge drinking status No (reference) Yes Health insurance Not insured (reference) Currently insured
Former smokers vs. never smokers Adjusted odds ratio (95% CI)
1.00 1.16 (1.01–1.35)
1.00 1.17 (1.05–1.30)
1.00 2.37 (1.80–3.11) 1.81 (1.43–2.29) 2.05 (1.59–2.65)
1.00 1.71 (1.23–2.38) 2.09 (1.55–2.81) 5.17 (3.90–6.85)
1.00 2.06 (1.80–2.36)
1.00 1.82 (1.64–2.03)
R O
O
1.00 0.41 (0.33–0.51) 0.89 (0.68–1.15) 0.57 (0.42–0.78) 1.51 (1.06–2.13) 1.00 0.81 (0.68–0.96)
P
1.00 1.38 (1.10–1.73) 1.39 (1.15–1.67) 1.26 (1.01–1.60) 1.00 0.81 (0.70–0.93) 0.32 (0.26–0.38)
T
1.00 0.58 (0.48–0.72) 0.49 (0.40–0.60)
R
R
E
C
1.00 1.44 (0.97–2.15) 0.85 (0.72–1.00) 0.74 (0.61–0.89)
O
t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18 t3:19 t3:20 t3:21 t3:22 t3:23 t3:24 t3:25 t3:26 t3:27 t3:28 t3:29 t3:30 t3:31 t3:32 t3:33 t3:34 t3:35 t3:36 t3:37 t3:38 t3:39 t3:40 t3:41 t3:42 t3:43 t3:44 t3:45 t3:46 t3:47 t3:48 t3:49 t3:50 t3:51 t3:52
Current smokers vs. never smokers Adjusted odds ratio (95% CI)
F
Variables
t3:4
D
t3:3
Table 3 Multivariate multinomial logistic models for smoking status, California Health Interview Survey, 2009.
E
t3:1 t3:2
H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx
1.00 0.51 (0.44–0.59) 0.65 (0.51–0.82) 0.39 (0.31–0.50) 0.89 (0.68–1.15) 1.00 1.11 (0.96–1.27)
1.00 1.02 (0.83–1.25) 0.95 (0.80–1.14) 0.85 (0.66–1.09) 1.00 0.91 (0.78–1.06) 0.58 (0.49–0.68) 1.00 0.90 (0.77–1.05) 0.81 (0.70–0.95) 1.00 0.59 (0.44–0.79) 1.09 (0.97–1.24) 1.07 (0.93–1.24)
1.00 0.87 (0.73–1.03) 0.84 (0.67–1.04)
1.00 0.74 (0.66–0.83) 0.85 (0.73–0.98)
1.00 3.29 (2.81–3.86)
1.00 1.83 (1.64–2.05)
1.00 0.82 (0.70–0.95)
1.00 0.95 (0.78–1.16)
Note: All estimates are on weighted analyses accounting for the complex survey design of the 2009 CHIS. FPL, federal poverty level; NH, non-Hispanic.
187 188
smoking within the next 6 months (Cooley et al., 2013). Therefore, smoking cessation interventions are needed for this high-risk population group. The present study has some limitations. Family history of cancer and smoking status data were based on self-report that may be inaccurate due to recall. Using biochemical verification of smoking status is usually recommended in tobacco control studies to minimize the risk of underestimating smoking prevalence (Benowitz et al., 2002). Also, only respondents who spoke one of the five survey languages were included. There may be other variables, such as family member smoking status, which may modify the association between family history of cancer and smoking status, but were not captured in CHIS. The absence of information about family member smoking status is a major limitation, because it has been known for decades that having a close relative (e.g., parent or sibling) who smokes increases the likelihood of becoming a smoker (Bricker et al., 2006; Wilkinson et al., 2008). We were not able to measure the intention to quit smoking with the CHIS data, therefore, further studies are needed to evaluate the intention to quit smoking among individuals with a first-degree family history of cancer.
193 194 195 196 197 198 199 200 201 202 203 204 205
N
191 192
U
189 190
C
t3:53
Other variables that might be missing are time since they quit smoking for former smokers, information about participant's quitting smoking in response to the family member's cancer diagnosis, as well as information about which first-degree relative(s) (parent, sibling, or child) had cancer and information about whether first-degree relatives had a smoking-related cancer. Despite these limitations, this study is strengthened by its population-based methodology that has a large representative sample. This information may be used to support public health interventions by identifying individuals at risk for poor health due to cigarette smoking. Future research investigating smoking behaviors among individuals with a first-degree family history of cancer is warranted given the limited literature on this topic. In summary, many adults in California with a first-degree family history of cancer still smoke, which places them at increased risk for developing cancer (Suzuki et al., 2007). The evidence regarding the effectiveness of smoking cessation is well established (Dresler and Gritz, 2001; Fiore et al., 2008; Rodu and Godshall, 2006). Evidence-based smoking cessation interventions increase the quit rate and are critical to reduce tobacco-related death and disease burden (Fiore et al.,
Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
206 Q11 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
H. Poghosyan et al. / Preventive Medicine xxx (2014) xxx–xxx
236
Conflict of interest statement
237
The authors declare that there are no conflicts of interest.
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2008). Given the potential increased risk for developing cancer based on smoking status and family history of cancer, it is important to identify the group of individuals who are at increased risk of developing cancer so that preventive interventions such as smoking cessation can be implemented. All smokers should be targeted for smoking cessation interventions, however, individuals with increased risk of developing cancer should be considered as the primary target population. Thus, smokers with a first-degree family history of cancer represent an important target population for smoking cessation interventions. Also, young adults who smoke and have a first-degree family history of cancer could be targeted for smoking prevention.
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Please cite this article as: Poghosyan, H., et al., The association between having a first-degree family history of cancer and smoking status, Prev. Med. (2014), http://dx.doi.org/10.1016/j.ypmed.2014.05.013
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