INTRODUCTION

While tobacco smoking prevalence has declined in the US over the past fifty years, certain populations, including low-income and African American smokers, continue to face high morbidity and mortality rates from smoking-related diseases and significant barriers to smoking cessation^1,2. Further, African American smokers are less likely to successfully quit smoking compared to other groups despite making more attempts at cessation¹. African American communities are also disproportionately targeted by tobacco companies in advertising campaigns, which may inhibit cessation efforts³. In addition, normative high levels of smoking in some low-income communities may further compromise cessation efforts^4-6. Consequently, low-income African Americans experience multiple socio-environmental factors promoting smoking and impeding their smoking cessation despite having similar (or greater) intention to quit than other groups⁷. Given these racial and economic disparities, it is critical to have a greater understanding of factors that influence smoking behaviors among low-income minority populations.

Partner behavior and support have been shown to influence smoking behaviors and cessation^8,9. Specifically, partners’ supportive behaviors are associated with cessation, while negative behaviors, such as nagging the smoker and complaining about smoking, are predictive of relapse¹⁰. Some research has shown that partner support increases and wanes depending on whether or not the smoker makes small successes in their attempt to quit smoking⁸. Interventions that enhance partner support have potential to increase cessation efforts^10-12. However, these interventions have mixed effects for men and women¹³. Carlson et al.¹⁴ found that smoking cessation increases with social support. However, this association decreases over time for women¹⁴.

The majority of studies that focused on partner support and smoking cessation have focused on married or cohabitating couples^15-18. Less attention has been given to the influence of short-term or casual partnerships on smoking cessation. Type of partnerships may influence quitting attempts in different ways. Partners in committed or married relationships may be more invested in their partner quitting because they have a stronger interest in their partner’s health or want less exposure to secondhand smoke. Casual partners may be indifferent or not bothered by their partner’s smoking because they are not around this partner often. This study looks at the different ways partner support impacts smoking cessation among both committed and casual partnerships.

The current study focuses on a population with low rates of marriage and non-marital partners which may have a different impact on smoking behaviors compared to spouses. Specifically, we explored positive and negative aspects of social support, encouragement to quit, concerns about smoking, and not minding that the partner smokes. We hypothesized: 1) participants whose partner did not mind their smoking would be associated with decreased likelihood of quit attempt; 2) having a participant who was concerned about smoking would be associated with increased likelihood of current quit attempt; and 3) getting partner encouragement for cessation would be associated with increased quit attempt. We also conducted a supplementary analysis to compare the partner support/quit attempt relationships between participants in committed relationships to those in casual relationships. Understanding sex-partner attitudes regarding smoking and their relationship to smoking cessation activities may provide insights for future cessation interventions.

METHODS

RESULTS

There were 418 of participants who completed the social network survey, among which 140 individuals reporting no sex partners and 42 reporting multiple sex partners. These individuals were excluded from the study. There were 236 individuals who reported one sex partner in the past six months. Individuals missing data on the HSI were also removed (n=16) from this sample of people who had one sex partner. The total size of the final sample was 220 (134 men and 86 women). Variables that were significant in bivariate analyses and adjusted for in current modeling included: HSI, unemployment, alcohol consumption, and cocaine use.

As shown in Table 1, 33.6% (n=45) of men were trying to quit smoking. Unemployed men were more likely to report that they were not trying to quit smoking (91% vs 60%, p<0.01). Men who were currently trying to quit smoking had a lower HSI score (2.44 vs 2.98). There was no significant relationship between current quit attempt and partner support variables among men in the unadjusted analyses.

Twenty-nine percent (n=25) of women reported that they were trying to quit smoking. Women who used cocaine were more likely to report a current quit attempt (32.0% vs 11.5%, p<0.05). Women were more likely to report a current quit attempt if they had a partner who was concerned about their smoking (p<0.01), or if their partner encouraged them to quit smoking (p<0.01).

DISCUSSION

Through a review of studies examining gender differences in cessation, Smith et al.²⁰ posit that women have greater difficulty achieving longterm smoking cessation. This study attempted to understand how partner support, a recognized facilitator of smoking cessation, impacts current quit attempts among men and women. Social network members, including partners, impact health behaviors like smoking cessation, in a variety of ways these influences include social support, norms, and access to tangible and non-tangible resources²¹. Partners, both committed and casual, influence one’s decision to quit smoking. This study provides evidence that sex partner support is related to the likelihood of current quit attempt among a sample of low income, mostly African American smokers. Unlike previous research, this study looked at positive and negative aspects of social support/encouragement to quit, concern about smoking and not minding partner’s smoking.

Each of our hypotheses was supported, but differed by sex. Although the sample size was smaller for women, the relationship between partner support for cessation and current quit attempt was stronger for women than men in this population. Women were influenced by partner concerns about their smoking and encouragement to quit. Among men, sex partners’ permissive attitudes towards smoking (i.e. sex partner does not mind participant’s smoking) were associated with reduced likelihood of current quit attempt. Having a partner who is not bothered by one’s smoking means there is no motivation to decrease smoking. Our study also found that partner’s concerns and encouragement to quit did not have a significant influence on men’s current quit attempt.

In the supplemental analysis, we found that men and women smokers were influenced by both committed partner and casual partner support towards smoking cessation. Surprisingly, casual partners were more influential on men’s decision to quit. Men were less likely to quit if their committed partner did not mind their smoking but more likely to quit if they casual partner was concerned or encouraged them to quit.

Women were influenced by both committed and casual partners. Women in a causal partnership were less likely to have a current quit attempt if their partner did not mind their smoking. They were more likely to report quitting if their casual or committed partner encouraged them to quit or their committed partner was concerned about their smoking. In this sample with high levels of unemployment and moderate levels of drug use and homelessness, women may be dependent on both their committed and casual partner for money and other necessities²². This dependence may provoke women to follow their partner’s guidance to prevent disruption of their relationship.

In this sample, two-thirds of participants reported that their sex partner was also a smoker. Study findings are consistent with previous research that has shown smokers are more likely to have smoking partners compared to non-smokers²³. In populations where smoking is more a norm, including some lowincome communities, smokers are likely to have sexual partners who are also smokers. Prior research has indicated that partners who are former smokers or are currently quitting may particularly facilitate cessation, although these results are not consistent across studies¹¹. Thus, dyadic interventions that focus on creating a mutually supportive cessation effort may be a productive means of intervention for both smokers.

How partner support is expressed may also be important. In this study, supportive behaviors and attitudes (e.g. concern, encouragement) by sex partners were linked to making a quit attempt. Research has documented coercive behaviors of male partners towards their female smoking partners, particularly in the context of pregnancy²⁴. While sex partners’ supportive behaviors and attitudes may contribute to a quit attempt, it is also possible that individuals who are seeking to quit smoking may select social ties (including partners) who are supportive of cessation and have a longer history together.

CONCLUSIONS

Future research is needed to determine how to effectively foster partner support for smoking cessation since the limited existing research indicates a potential lack of efficacy in existing interventions. Bolstering interventions will be particularly important in populations that live in communities where tobacco use is a norm, and hence, partners are likely to be smokers. While the results of this study indicate that partner support is linked to a quit attempt, efforts to increase partner support may be more difficult in the context of communities with normative tobacco use and targeted advertising. Further, this study also suggests that smoking cessation programs should ask smokers about all types of sexual partnerships, not just if they are in a relationship, that may be sources of smoking cessation support.