摘要：Objectives. We examined associations between health literacy and predictors of smoking cessation among 402 low-socioeconomic status (SES), racially/ethnically diverse smokers. Methods. Data were collected as part of a larger study evaluating smoking health risk messages. We conducted multiple linear regression analyses to examine relations between health literacy and predictors of smoking cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking risk perceptions and knowledge, self-efficacy, intentions to quit or reduce smoking). Results. Lower health literacy was associated with higher nicotine dependence, more positive and less negative smoking outcome expectancies, less knowledge about smoking health risks, and lower risk perceptions. Associations remained significant ( P < .05) after controlling for demographics and SES-related factors. Conclusions. These results provide the first evidence that low health literacy may serve as a critical and independent risk factor for poor cessation outcomes among low-socioeconomic status, racially/ethnically diverse smokers. Research is needed to investigate potential mechanisms underlying this relationship. Cigarette smoking is the leading preventable cause of morbidity and mortality in the United States. 1 Approximately one third of all US cancer-related deaths and 87% of lung cancer cases result from smoking, 2 and smoking contributes to 80% to 90% of lung cancer deaths each year. 3 Although smoking prevalence has declined in recent years, nearly 21% of US adults continue to smoke. 4 Distinct populations such as those with low education, income, and occupational status and racial/ethnic minorities have disproportionately high smoking rates. 5–8 Individuals from these populations are also less likely to successfully quit smoking because they have limited access to effective smoking cessation resources and are less likely to use such resources. 9–11 Thus, smoking has a striking impact on socioeconomic status (SES) and racial/ethnic disparities in cancer morbidity and mortality. 10–13 Numerous key predictors of smoking cessation and maintenance have been identified in previous research. One of the most robust predictors is nicotine dependence (i.e., average number of cigarettes smoked per day, time to first cigarette on waking). 14–16 Smokers with higher levels of dependence are less likely to quit smoking and less likely to maintain abstinence. 14–16 Smoking outcome expectancies, or the beliefs that smokers have about the consequences of smoking, also predict cessation. 17 Smoking expectancies can be positive (e.g., smoking facilitates social interactions, smoking reduces boredom or negative affect) or negative (e.g., smoking is harmful to health, others might disapprove of smoking). Stronger negative outcome expectancies are associated with greater intentions to quit and better cessation outcomes. 18 Smoking health risk knowledge and risk perceptions are also associated with smoking cessation such that lower perceived vulnerability and fewer perceived smoking risks are negatively associated with abstinence. 19,20 Moreover, quitting self-efficacy (i.e., the confidence in one’s ability to quit smoking) 21,22 and intention to quit smoking predict successful cessation outcomes. 15,23,24 Poor health literacy is one factor that may be negatively associated with cessation outcomes, particularly for low-SES racial/ethnic minority populations. However, very little research has examined health literacy as an independent predictor of smoking initiation or poor cessation outcomes. Health literacy is the ability to obtain, understand, and use health information to make important decisions regarding health and medical care. 25 Nearly half of US adults have poor health literacy. 26 Racial/ethnic minorities and those with lower educational attainment, income, and employment status are more likely to have difficulty with health literacy. 27–31 Specifically, two thirds of African American adults and three fourths of Latino adults have limited health literacy, compared with 32% of non-Latino Whites. 32 Poor health literacy is associated with higher incidence of chronic illness (e.g., diabetes, hypertension) and more limited access to prevention and treatment programs. 33 Those with poor health literacy tend to engage in harmful health behaviors (e.g., poor medication adherence, less preventive care utilization, less cancer screening) and are more likely to report poor health status. 34–36 They also have low levels of illness-related knowledge. 31,35,37,38 Furthermore, individuals with low health literacy are less likely to be screened for cancer and are more frequently diagnosed with advanced-stage cancers. 35,39 Low health literacy is also associated with higher overall mortality rates. 40–42 Whereas associations between low health literacy, negative health behaviors, and poor health outcomes have been well documented, 35 few studies have examined potential associations between health literacy and smoking. Sudore et al. 30 reported that elderly participants with lower health literacy were more likely to endorse current smoking status. However, Baker et al. 40 found no such association in a different sample of elderly persons. Another study found no relationship between health literacy and smoking status in a sample of low-income pregnant women; however, poor health literacy was found to be associated with lower smoking risk knowledge and fewer negative smoking-related attitudes. 43 A more recent study found that health literacy was not significantly associated with cessation outcomes after completion of an inpatient smoking cessation program. 44 Notably, this study had a very small sample size, and most participants had adequate health literacy. Thus, there is a critical need to better understand how health literacy may be linked with smoking prevalence and cessation, particularly in large samples of low-SES, racial/ethnic minority smokers, because health literacy may be an essential, but often overlooked, factor in understanding tobacco-related health disparities. We investigated associations between health literacy and established predictors of cessation (i.e., nicotine dependence, smoking outcome expectancies, smoking health risk knowledge and risk perceptions, self-efficacy to quit smoking, and intentions to quit or reduce smoking). The data were collected as part of a larger, single-visit laboratory study (Project INFORM) that evaluated responses to different types of smoking health risk messages among smokers with different levels of health literacy. On the basis of the existing literature, we hypothesized that smokers with lower (vs higher) health literacy would be more nicotine dependent, have more positive and fewer negative smoking outcome expectancies, have lower perceptions of smoking-related risk, be less knowledgeable about the health consequences of smoking, and have lower self-efficacy to quit smoking, and weaker intentions to change their smoking behavior.
