Nondaily Smoking Patterns
Treatment of tobacco dependence includes interventions for longstanding dependent cigarette users as well as therapy designed for individuals who consume tobacco products on a nondaily basis, smoking on some days but not every day. In the past, healthcare providers have viewed nondaily tobacco use as a transient smoking pattern associated with smoking initiation or stop smoking attempts.302-304 However, new research on nondaily smoking shows that this pattern of tobacco use may represent a stable form of chronic low-level (fewer than 10 cigarettes per day on the days that they smoke) consumption.305, 306 For example, longitudinal studies have shown that many nondaily smokers sustain their smoking patterns for 1 to 2 years, if not indefinitely.302, 303, 305 Studies have also shown that nondaily smokers differ from daily smokers in that they tend not to self identify as smokers when asked by family, friends, or healthcare providers, and they appear to avoid cigarettes for days, weeks, and even months without exhibiting physiologic nicotine withdrawal symptoms.307, 308 To date no formal trials have looked at the role of nicotine withdrawal among adult nondaily and social smokers once they stop using tobacco products. In a study of adolescent very light smokers (1-3 cigarettes per day), however, no evidence was found to suggest active signs of nicotine withdrawal, as measured by changes in heart rate and neuropsychological testing, after 24 hours of abstinence.309
Nondaily smoking is relevant to the practicing physician because its prevalence is increasing. In the United States, between 1996 and 2001, rates of nondaily smoking increased in 31 of the 50 states, going from 16% of current smokers in 1997 to 19% in 1999, and 24% in 2001.310 Rates of nondaily smoking are likely to continue to increase as more laws pass limiting tobacco use in workplaces and public places. There are data that show that implementation of workplace restrictions increase the odds of a smoker being a light or intermittent user (OR= 1.28, 95% CI = 1.18-1.38).311 Furthermore, smokers who enforce smoke-free policies at home are nearly three times as likely to be light or intermittent users (OR= 2.8, 95% CI = 2.60-3.04).311 Accordingly, healthcare professionals will probably encounter these patients more frequently, highlighting the need for clinician education and training programs that will help this growing group become tobacco free.
Nondaily smokers also differ from everyday smokers in their demographic profile. Nondaily smokers tend to be younger, female, better educated, wealthier, and from minority backgrounds (African American and Hispanic)303, 305, 306 when compared to everyday smokers. Hispanic/Latino smokers, for example, are more than three times as likely to smoke intermittently when compared to non-Hispanic Whites (OR = 3.2, 95% CI 2.75-3.74).312 Nondaily smoking has also been associated with excessive alcohol consumption on U.S. college campuses.313, 314
Health Risks Associated with Light and Nondaily Daily Smoking
Light smoking is defined as smoking fewer than 10 cigarettes per day, while nondaily smoking is defined as smoking on some days but not every day. Although there have been no formal trials that have looked at the dangers associated with social smoking, there are data that show that light and nondaily tobacco use are associated with increased risk of coronary artery disease (including ischemic heart disease and aortic aneurysm), cancer (esophageal, lung, gastric, and pancreatic), lower respiratory tract infections (increased frequency and prolonged symptoms), cataracts, compromised reproductive health (delayed time to conception in women), and poor bone mineral density leading to frequent ankle fractures in older women.315 Light smokers (fewer than 15 cigarettes per day) also report lower health-related quality of life as measured by the SF-36 health status questionnaire than nonsmokers.316 The risk of all-cause mortality in light or intermittent male smokers has been found to be 1.5 times that of nonsmoking men.317 No association has been found yet for women between all-cause mortality and light or nondaily smoking.318 It is pertinent to keep in mind, however, in this early stage of characterizing nondaily and light cigarette use, that initial research showed a relationship between regular cigarette smoking and lung cancer only in men, not in women.319
Social Smoking: An Example of A Nondaily Smoking Pattern
“Social smoking” — smoking that is limited to social situations — is one example of a nondaily smoking behavior. The healthcare community first became aware of social smoking in the mid 1990s when a limited number of studies reported high rates of social smoking patterns on college campuses (up to 50%).320-322 In these studies, social smokers are characterized as experimenting, affluent, Caucasian college students who only smoke socially to gain peer acceptance. Social smokers tend not to smoke alone and are described as restricting their tobacco use to parties, bars, or nightclubs.320-322 Possible biological factors that separate social smokers from other nondaily or regular daily smokers, such as their genetics or physiology, have not been studied. Rather, what has been identified is that social smoking is primarily a behavioral phenomenon; social smokers may consume a similar volume of cigarettes as other nondaily smokers (smoking on some days but not every day) but their smoking is primarily initiated and driven by social contexts.320-322
Social smokers, like other nondaily smokers, refuse to categorize themselves as “smokers” when asked by family, friends, or healthcare providers and tend not view their smoking as a marker of personal addiction.320-322 Social smokers often state that they could stop smoking anytime and under-recognize the health risks associated with their tobacco use.322 At the same time, it is important for clinicians to realize that there are no formal trials that have looked at risks for nicotine withdrawal among this group once social smokers stop using tobacco products.
Although social smoking is relatively new to the medical community, it has been a focus of tobacco company research for over 30 years.323 As early as the 1970s, confidential industry research found that social smokers represented as many as 20% to 25% of all smokers323, 324 and that social smokers were observed among people of varying socioeconomic backgrounds, levels of education, and ethnicities — not just college students.323 Social smokers purchased cigarettes primarily by the pack to limit consumption, smoking on average fewer than 10 cigarettes in a day, while commonly smoking more on weekends or at parties.323 Industry marketers used their research to design cigarettes and advertising campaigns to attract and sustain social smoking patterns.323 Tobacco companies further discovered that social smokers did not identify themselves as smokers and denied nicotine dependence.323
In contrast to the low sensitivity to personal risks associated with their own smoking, tobacco companies discovered that social smokers were particularly concerned about the impact their smoking had upon others. Social smokers would often avoid situations where smoking was discouraged or would ask permission prior to lighting a cigarette.323 Industry research showed that social smokers experiencing social pressure against smoking would either refrain from use in public or voluntarily relocate to minimize exposure to others. Social smokers supported smoking restrictions because these policies often designated areas that were acceptable to smoke without offending nonsmokers.
Implications for Treatment Strategies
Because nondaily smokers, including social smokers, deny nicotine dependence, refuse to label themselves as smokers, and often under-recognize the harm associated with intermittent smoking, they pose a serious challenge to healthcare professionals. Existing tobacco-dependence treatment programs have been developed for daily, dependent cigarette users. The strategies recommended in the Clinical Practice Guideline 2008 Update: Treating Tobacco Use and Dependence to identify tobacco use, the 5A’s (“Ask”, “Advise”, “Assess”, “Assist”, and “Arrange”), might not apply at all to either nondaily or to social smokers.325 For example, when clinicians “Ask” patients “Are you a smoker?” they run the risk of missing tobacco users who self-categorize as nonsmokers. A better approach would be to “Ask”, “Do you use tobacco products — ever?” If yes, “What products do you prefer to use?” And, finally, “Do you use cigarettes or any other tobacco product on a daily basis, intermittently, such as weekly or monthly, or do you smoke on a social basis, only when you are with friends or acquaintances who are smoking?” With focused, directed questions, healthcare professionals should be able to better identify the growing population of nondaily and social smokers. [Refer to box with suggested strategies]
Furthermore, treatment of tobacco dependence for the addicted daily smoker involves Advising patients about the personal health risk associated with their smoking.325 While the harm associated with light and intermittent smoking is significant, at least for males, and emphasizes the need for clinicians to encourage stopping smoking completely, the psychological profile of nondaily and social smokers suggests that communicating these risks may not be an effective way to encourage them to stop smoking. Tobacco industry research suggests that clinicians should “Advise” their patients about the dangers of secondhand smoke to friends and loved ones317, 326 and encourage personal smoke-free policies (such as smoke-free homes and cars). Although counseling nondaily and social smokers on the dangers of secondhand smoke as a treatment message has not been the subject of randomized clinical trials, concerns about the effects of secondhand smoke have been associated with intentions to quit and stopping smoking among young adult nondaily smokers.308
In conjunction with using an alternative counseling approach, healthcare professionals should also recognize that the pharmacotherapy options designed to treat tobacco dependence, such as nicotine medications, bupropion, and varenicline, were developed for regular, daily smokers who consume 10 or more cigarettes per day and suffer from nicotine addiction.325 Because nondaily and social smokers consume less and tend not to show signs of nicotine dependence, Assisting patients with pharmacotherapies that are designed to counter withdrawal symptoms may not be relevant. The doses of nicotine found in commercially available nicotine medications may exceed that which nondaily smokers receive from smoking cigarettes or would need during treatment. Understanding what potential therapeutic approaches might be appropriate and effective for both nondaily and social smoking populations, including behavioral interventions and medications, such as nicotine medications, bupropion, and varenicline, will be a productive, future research area.
Recent public health research indicates that nondaily smoking consists of a stable pattern of chronic low-level consumption and comprises about a quarter of all smokers (and growing) of varying age, ethnicity, socioeconomic status, and educational background. More importantly, public health research on nondaily smoking and internal, unpublished tobacco industry research on social smoking suggests that current tobacco-dependence treatment strategies based upon personal health risk and treatment of nicotine addiction may not be effective for this population of tobacco users. Both nondaily and social smokers may be more responsive to messages that focus on the harms their smoking poses to other nonsmoking friends or family members as a motivator to stop smoking.
Information on nondaily and social smoking patterns contained above in this Tool Kit will hopefully improve the way clinicians screen and identify these groups. Clinicians will recognize that taking detailed smoking histories of their patients with focused questions involving smoking frequency and volume of consumption will allow for better identification of nondaily and social smoking patterns. Once identified, clinicians should realize that social smokers may be motivated to stop smoking by messages stressing the harm of secondhand smoke and by encouragement to break associations between social activities and tobacco use, rather than by messages that only focus on personal health risk or with pharmacotherapy. Clinician training programs must recognize nondaily and social smoking patterns as examples of chronic tobacco use that require proper identification and most likely different treatment approaches as part of the healthcare community’s commitment to providing effective treatments to enable our patients to become tobacco-free.