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Abstract

Introduction

Nondaily smoking has become increasingly common among cigarette smokers. Our objective was to determine whether current daily versus nondaily smoking differed by tobacco-related risk perceptions (TRRPs), demographic factors, and cancer history.

Methods

Participants were all adults in Waves 1–3 of the longitudinal cohort Population Assessment of Tobacco and Health Study who were current smokers at Wave 3 (N = 8307). The primary analysis was weighted logistic regression of daily versus nondaily smoking at Wave 3. TRRP measures were cigarette harm perception, worry that tobacco products will damage one’s health, belief that smoking cigarettes causes [lung/bladder/mouth/liver] cancer, and nondaily cigarette harm perception (Likert-type scale). Other measures included demographic factors, other tobacco product use, minor at time of first cigarette, and cancer survivor status (yes/no).

Results

Among current smokers, daily versus nondaily smoking was significantly associated with being a minor at time of first cigarette (OR = 1.54, p < .001), TRRPs (OR = 0.83, p < .001; OR = 1.40, p < .001; and OR = 1.17, p = .009 [harm perception, worry, and nondaily cigarette harm perception, respectively]), and interaction between cancer survivor status and belief that smoking causes cancer (p < .001). TRRPs among current smokers did not differ significantly between cancer survivors and respondents without a cancer history.

Conclusions

Respondents with lower harm perception, higher worry, and higher nondaily cigarette harm perception were more likely to be daily versus nondaily smokers. Respondents with higher belief that smoking causes cancer or who were cancer survivors were less likely to be daily (versus nondaily) smokers compared to respondents with low belief and no cancer history.

Implications

This study is unique in that it examined associations of smoking cigarettes daily versus nondaily with tobacco-related risk perceptions and cancer survivorship—comparing cancer survivors to those without a cancer history. Given the increasing prevalence of nondaily smoking as compared with daily smoking in the general population, and the prognostic significance of smoking after cancer diagnosis, these findings fill a clinically important gap in the literature and provide a foundation for further research.

Introduction

Nondaily smokers (those who smoke some days but not every day) account for a notable proportion of cigarette smokers. In the general population, nondaily smoking has been on the rise over the past several decades; data from the National Health Interview Survey indicate that nondaily smokers comprised 25.4% of all smokers in 2018 compared with 19.2% in 2005.1,2 Among participants in the third wave (2010–2011) of the American Cancer Society’s Study of Cancer Survivors, an estimated 18% of current smokers were nondaily smokers who smoked 11 days per month on average; these nondaily smokers also tended to be light smokers.3 Definitions of light smoking vary; one definition is ≤10 cigarettes per day.4

Tobacco-related risk perceptions are thoughts and feelings about the harm associated with cigarette smoking.5 Perceptions of tobacco-related risks may be important to understanding smoking frequency. Risk perceptions have been shown to affect behavior,6 and furthermore, tobacco-related risk perceptions have been associated with quitting behavior7,8 and intentions to quit.9 A growing body of literature has found that affective risk perceptions, or those that are emotional reactions to a potential harm such as worry, are distinct from thinking about the perceived likelihood of harm.5,10–12

At the time of cancer diagnosis, approximately 20%–30% of patients report current cigarette smoking.13 There is evidence that continued smoking among cancer survivors (i.e., individuals who have received a cancer diagnosis) may interfere with cancer treatments, increase the risk of recurrence of cancer and the incidence of a second tobacco-related cancer, and increase the risk of all-cause mortality and cancer-specific mortality.14,15 For example, continued smoking versus stopping after diagnosis was associated with a 76% increased overall mortality among male cancer survivors.16 In a study of early-stage, nonsmall cell lung cancer patients in Russia, the adjusted median overall survival time was 21.6 months higher among patients who had quit smoking than among those who continued to smoke.17 Fortunately, a recent diagnosis of cancer is associated with an increased likelihood of smoking cessation compared to smokers who are not diagnosed with cancer.18 However, up to 64% of smokers who smoked prior to being diagnosed with cancer continue to smoke after their diagnosis.19–21 Previous studies have described tobacco-related risk perceptions of smokers who are cancer survivors.7–9,22,23 Some studies have shown that cancer survivors may not be aware that continuing to smoke has a negative impact on cancer outcomes.22,23 Smoking prevalence among cancer survivors ranges from 12% to 20% in nationally representative studies, although prevalence estimates vary over a wider range, depending on the type of cancer, sociodemographic characteristics, and time since diagnosis.20,24–33

The question that motivated the current research is whether cancer survivors who continue to smoke after diagnosis are more likely to be daily versus nondaily smokers when compared to individuals without a cancer history, and if so, do individuals’ risk perceptions help explain the associations between cancer survivor status and daily versus nondaily smoking? Plausible hypotheses would hold that cancer survivors who smoke are either more or less likely to smoke daily than other individuals. To wit, cancer survivors might be hypothesized to have greater tobacco-related risk perceptions and to be less likely to smoke daily, due to the salient experience of having cancer. On the other hand, cancer survivors who continue to smoke may be those whose tobacco-related risk perceptions are lower. No recent research has used a nationally representative U.S. sample to examine the associations of daily versus nondaily smoking with tobacco-related risk perceptions, and the potential role of cancer history in those associations. Our primary aim was to examine the associations of tobacco-related risk perceptions with daily versus nondaily smoking and to determine whether those associations are different for individuals who are cancer survivors as compared to current smokers without a cancer history. We used data from the nationally representative Population Assessment of Tobacco and Health (PATH) Study34 to examine daily and nondaily smoking patterns and tobacco-related risk perceptions among cancer survivors and adults without cancer.

Methods

Participants

The PATH study is a longitudinal cohort study of adults (ages 18 or older) and youths (ages 12–17) in the United States. The study records tobacco use behaviors and related health outcomes. PATH collects data using audio computer-assisted self-interviews available in English and Spanish. Wave 1 recruitment used a stratified, address-based, area-probability sampling design that oversampled tobacco users, young adults (ages 18–24), and Black adults. PATH study design and methods, including survey interview procedures, questionnaires, sampling, weighting, and information on accessing the data, are published elsewhere.34,35 The present analyses included adult (ages 18 or older) public use data from all respondents who participated in each of Waves 1 through 3 (collected from 2013 to 2016) and who were current cigarette smokers at Wave 3. The analyses in this report are essentially cross-sectional at Wave 3; however, Wave 1 participant characteristics are included and data from Waves 1 to 3 are necessary to distinguish individuals who have received a cancer diagnosis from those who have not. Longitudinal analyses are the subject of a separate manuscript.

Measures

Demographics (Wave 1)

Demographic variables age, sex, education, household income, employment status, and geographic region were categorical variables as in the PATH public use data. Race and ethnicity were combined to create a single categorical race/ethnicity variable. Detailed descriptions of these variables are found elsewhere.34

Tobacco-Related Risk Perception (Wave 3)

Four measures of tobacco-related risk perception, all with Likert-type scales, were used: (1) Cigarette harm perception (“How harmful do you think cigarettes are to health?” 1 = Not at all harmful, 2 = Slightly harmful, 3 = Somewhat harmful, 4 = Very harmful, 5 = Extremely harmful); (2) Worry that tobacco products will damage one’s health (“To what extent, if at all, are you worried that using tobacco products will damage your health in the future?” 1 = Not at all worried, 2 = A little worried, 3 = Moderately worried, 4 = Very worried); (3) Belief that smoking causes cancer was measured with the mean level of agreement with four items (Cronbach’s alpha 0.85) capturing beliefs for four cancer sites (“Based on what you believe, how much do you agree or disagree with the following statements? Smoking can cause [lung/bladder/mouth/liver] cancer in smokers.” 1 = Strongly agree, 2 = Agree, 3 = Neither agree nor disagree, 4 = Disagree, 5 = Strongly disagree), reverse-coded so that high scores indicate agreement; and (4) Nondaily cigarette harm perception (“How much do you think people harm themselves when they smoke cigarettes some days but not every day?” 1 = No harm, 2 = A little harm, 3 = Some harm, 4 = A lot of harm). Tobacco-related risk perceptions were analyzed as continuous variables.

Cancer Survivor Status (Waves 1–3)

The binary variable cancer survivor status indicates that participants reported a history of cancer at Wave 1 (“Have you ever been told by a doctor or other health professional that you had cancer?” 1 = Yes, 2 = No) or a cancer diagnosis within 12 months at Waves 2–3 (“In the past 12 months, have you been told by a doctor, nurse, or other health professional that you had cancer?” 1 = Yes, 2 = No). Missing responses at Waves 2–3 of respondents were imputed as “no” if the respondents reported that they had not seen a doctor within 12 months.

Cigarette Smoking

Current cigarette smoking at Wave 3 was determined by PATH-derived variables that indicated current smoking every day or some days. (See the codebook for the adult questionnaire: https://www.icpsr.umich.edu/web/NAHDAP/studies/36498/datadocumentation.) Those respondents were further defined as daily or nondaily smokers if they reported currently smoking every day or some days, respectively. Respondents were defined as minors at the time of their first cigarette if they reported being younger than age 18 in response to this question at Wave 1: “How old were you the first time you smoked part or all of a cigarette?”

Other Tobacco Use (Wave 1)

Other tobacco product use was defined as current every day or some days use of e-cigarettes, pipes, hookahs, dissolvable tobacco, traditional cigars, filtered cigars, cigarillos, or smokeless tobacco products. For example, for e-cigarettes, participants were asked, “Do you now use e-cigarettes …” (1) Every day, (2) Some days, or (3) Not at all? Other tobacco use was a dichotomous variable in the analyses.

Statistical Analysis

Descriptive statistics are provided for categorical variables with unweighted counts and with percentages calculated using “all-wave” longitudinal survey weights. For numerical variables, medians and ranges are provided. The analyses included respondents who reported current cigarette smoking at Wave 3. TRRPs were compared between cancer survivors and respondents without cancer with weighted linear regression, adjusted for demographic variables. Weighted logistic regression was the primary analysis. The outcome was daily versus nondaily smoking rather than the reverse because daily smoking has more severe health implications than nondaily smoking. The full model included all demographics listed above, tobacco-related risk perceptions, minor at time of first cigarette, other tobacco product use, and interactions between cancer survivor status and tobacco-related risk perceptions. No continuous variables were categorized for the present study. To select the final minimally adjusted logistic regression model, backward elimination was used with p > .5 as the criterion.36 To account for the complex survey design in all linear and logistic regressions, we used the balanced repeated replication variance estimation method, with Fay’s adjustment set to 0.3.37,38 PATH survey weights account for selection bias due to loss to follow-up. The logistic regressions exclude participants with missing data for a covariate. Characteristics of respondents with complete data (N = 7776) and respondents who were not included in the final logistic regression model due to missing data (N = 531) are shown in Supplementary Table S1.

Effects were considered statistically significant for p < .05. For variables involved in interactions that were statistically significant, the effects for combinations of interacting variables are reported. Estimates are produced for specific exemplar values of continuous variables in significant interactions. For variables for which the interaction was nonsignificant, main effects are reported. The analyses were conducted with SAS version 9 (Cary, NC) and SUDAAN version 11.0.1 (RTI, Research Triangle Park, NC).

Results

Table 1 provides the distribution of characteristics of the analytic sample (N = 8307 adult current smokers who completed surveys at Waves 1–3)—54% were male, 14% non-Hispanic Black, and 12% Hispanic; 33% had received some college education but not a bachelor’s degree; 26% had a household income of at least $10,000 and under $25,000; 45% worked full time; and 41% resided in the South. A total of 6,436 participants (77%) were minors (younger than age 18) at the time of their first cigarette, and 3,525 (42%) used other tobacco products in addition to cigarettes; 1,787 (23%) and 6,520 (77%) smoked nondaily and daily, respectively; 537 (7%) had received a cancer diagnosis.

Table 1.
Open in new tab

Participant Characteristics and Association of Daily Versus Nondaily Smoking With Sociodemographics, Tobacco Use, Cancer Survivor Status, and Tobacco-Related Risk Perceptions

CharacteristicDaily smokers 
(N = 6520)Nondaily smokers (N = 1787)Analytic sample (N = 8307)Daily smoking vs. nondaily smokinga
No. (Weighted %)No. (Weighted %)No. (Weighted %)Odds Ratio (95% CI)P Value
Age
 18–241192 (12.0)586 (22.5)1778 (14.4)1.08 (0.29, 4.01)<.001
 25–341361 (22.3)444 (28.2)1805 (23.7)1.62 (0.43, 6.12)
 35–441205 (19.3)286 (18.5)1491 (19.1)2.25 (0.59, 8.51)
 45–541335 (21.6)232 (14.6)1567 (20.0)2.60 (0.67, 10.06)
 55–641010 (17.1)164 (10.2)1174 (15.5)3.13 (0.77, 12.72)
 65–74337 (6.2)65 (4.7)402 (5.9)2.19 (0.50, 9.70)
 ≥7579 (1.4)10 (1.4)89 (1.4)1 [Reference]
Sex
 Male3129 (52.9)988 (57.2)4117 (53.9)0.91 (0.79, 1.04).17
 Female3389 (47.1)799 (42.8)4188 (46.1)1 [Reference]
Race/ethnicity
 White, non-Hispanic4293 (71.1)952 (58.4)5245 (68.2)2.56 (2.07, 3.16)<.001
 Black, non-Hispanic967 (13.9)271 (14.3)1238 (14.0)1.86 (1.42, 2.43)
 Other, non-Hispanic437 (5.2)129 (7.0)566 (5.6)2.08 (1.46, 2.97)
 Hispanic701 (9.8)403 (20.3)1104 (12.2)1 [Reference]
Educational attainment
 <High school1253 (18.1)270 (14.9)1523 (17.4)3.40 (2.19, 5.27)<.001
 GED805 (11.8)148 (7.6)953 (10.8)3.84 (2.35, 6.26)
 High school graduate1713 (30.0)400 (22.9)2113 (28.4)3.38 (2.22, 5.15)
 Some college (no degree) or associates degree2212 (31.7)681 (37.2)2893 (32.9)2.31 (1.56, 3.41)
 Bachelor’s degree393 (6.8)210 (13.8)603 (8.4)1.30 (0.85, 2.00)
 Advanced degree119 (1.5)73 (3.7)192 (2.0)1 [Reference]
Household income ($)
 <10,0001556 (21.4)407 (19.7)1963 (21.0)1.64 (1.16, 2.30)<.001
 10,000–24,9991812 (26.8)429 (22.5)2241 (25.8)1.68 (1.20, 2.35)
 25,000–49,9991483 (23.2)373 (21.4)1856 (22.8)1.58 (1.14, 2.19)
 50,000–99,999894 (15.0)307 (20.2)1201 (16.2)1.02 (0.76, 1.38)
 ≥100,000285 (5.0)136 (8.6)421 (5.8)1 [Reference]
 Missing490 (8.5)135 (7.6)625 (8.3)1.62 (1.07, 2.45)
Employment status
 Works full time at least 35 hours per week2635 (43.4)800 (49.3)3435 (44.7)0.89 (0.75, 1.06).36
 Works part time at least 15 to 34 hours per week744 (10.9)264 (13.2)1008 (11.4)0.82 (0.65, 1.05)
 Works part time less than 15 hours per week312 (4.6)106 (5.1)418 (4.7)0.85 (0.62, 1.17)
 Does not currently work for pay2787 (41.1)603 (32.4)3390 (39.2)1 [Reference]
Census region
 Northeast946 (16.9)267 (18.3)1213 (17.2)1.07 (0.82, 1.39).04
 Midwest1906 (25.2)411 (19.7)2317 (24.0)1.34 (1.08, 1.67)
 South2562 (40.9)708 (39.7)3270 (40.6)1.16 (0.94, 1.44)
 West1106 (17.1)401 (22.4)1507 (18.3)1 [Reference]
Minor at time of first cigarette
 Minor (age<18 years)5183 (79.4)1253 (70.4)6436 (77.4)1.54 (1.30, 1.82)<0.001
 Adult (age≥18 years)1306 (20.6)501 (29.6)1807 (22.6)1 [Reference]
Current use of other tobacco products
 Yes2665 (40.8)860 (43.7)3525 (41.5)N/Ab
 No3616 (59.2)878 (56.3)4494 (58.5)N/Ab
Cancer diagnosis
 No cancer history6027 (92.7)1700 (94.6)7727 (93.1)N/Ac
 Cancer survivor456 (7.3)81 (5.4)537 (6.9)N/Ac
Tobacco-related risk perceptionsMedian (Range)Odds ratio (95% CI)P Value
Cigarette harm perception3.5 (1.0–5.0)3.7 (1.0–5.0)3.6 (1.0–5.0)0.83 (0.75, 0.92)<.001
Worry that tobacco products will damage one’s health2.1 (1.0–4.0)1.8 (1.0–4.0)2.0 (1.0–4.0)1.40 (1.29, 1.52)<.001
Belief that smoking causes cancer3.9 (1.0–5.0)4.0 (1.0–5.0)3.9 (1.0–5.0)N/Ac.009
Nondaily cigarette harm perception2.6 (1.0–4.0)2.6 (1.0–4.0)2.6 (1.0–4.0)1.17 (1.04, 1.31)
Interaction of cancer survivor status with belief that smoking causes cancercLeast squares mean Log-Odds (95% CI)
 Non-cancer, belief = 1N/AN/AN/A1.81 (1.41, 2.21)<.001
 Cancer, belief = 1N/AN/AN/A−0.42 (−1.87, 1.03)
 Non-cancer, belief = 5N/AN/AN/A0.38 (0.14, 0.61)
 Cancer, belief = 5N/AN/AN/A1.08 (0.64, 1.52)
CharacteristicDaily smokers 
(N = 6520)Nondaily smokers (N = 1787)Analytic sample (N = 8307)Daily smoking vs. nondaily smokinga
No. (Weighted %)No. (Weighted %)No. (Weighted %)Odds Ratio (95% CI)P Value
Age
 18–241192 (12.0)586 (22.5)1778 (14.4)1.08 (0.29, 4.01)<.001
 25–341361 (22.3)444 (28.2)1805 (23.7)1.62 (0.43, 6.12)
 35–441205 (19.3)286 (18.5)1491 (19.1)2.25 (0.59, 8.51)
 45–541335 (21.6)232 (14.6)1567 (20.0)2.60 (0.67, 10.06)
 55–641010 (17.1)164 (10.2)1174 (15.5)3.13 (0.77, 12.72)
 65–74337 (6.2)65 (4.7)402 (5.9)2.19 (0.50, 9.70)
 ≥7579 (1.4)10 (1.4)89 (1.4)1 [Reference]
Sex
 Male3129 (52.9)988 (57.2)4117 (53.9)0.91 (0.79, 1.04).17
 Female3389 (47.1)799 (42.8)4188 (46.1)1 [Reference]
Race/ethnicity
 White, non-Hispanic4293 (71.1)952 (58.4)5245 (68.2)2.56 (2.07, 3.16)<.001
 Black, non-Hispanic967 (13.9)271 (14.3)1238 (14.0)1.86 (1.42, 2.43)
 Other, non-Hispanic437 (5.2)129 (7.0)566 (5.6)2.08 (1.46, 2.97)
 Hispanic701 (9.8)403 (20.3)1104 (12.2)1 [Reference]
Educational attainment
 <High school1253 (18.1)270 (14.9)1523 (17.4)3.40 (2.19, 5.27)<.001
 GED805 (11.8)148 (7.6)953 (10.8)3.84 (2.35, 6.26)
 High school graduate1713 (30.0)400 (22.9)2113 (28.4)3.38 (2.22, 5.15)
 Some college (no degree) or associates degree2212 (31.7)681 (37.2)2893 (32.9)2.31 (1.56, 3.41)
 Bachelor’s degree393 (6.8)210 (13.8)603 (8.4)1.30 (0.85, 2.00)
 Advanced degree119 (1.5)73 (3.7)192 (2.0)1 [Reference]
Household income ($)
 <10,0001556 (21.4)407 (19.7)1963 (21.0)1.64 (1.16, 2.30)<.001
 10,000–24,9991812 (26.8)429 (22.5)2241 (25.8)1.68 (1.20, 2.35)
 25,000–49,9991483 (23.2)373 (21.4)1856 (22.8)1.58 (1.14, 2.19)
 50,000–99,999894 (15.0)307 (20.2)1201 (16.2)1.02 (0.76, 1.38)
 ≥100,000285 (5.0)136 (8.6)421 (5.8)1 [Reference]
 Missing490 (8.5)135 (7.6)625 (8.3)1.62 (1.07, 2.45)
Employment status
 Works full time at least 35 hours per week2635 (43.4)800 (49.3)3435 (44.7)0.89 (0.75, 1.06).36
 Works part time at least 15 to 34 hours per week744 (10.9)264 (13.2)1008 (11.4)0.82 (0.65, 1.05)
 Works part time less than 15 hours per week312 (4.6)106 (5.1)418 (4.7)0.85 (0.62, 1.17)
 Does not currently work for pay2787 (41.1)603 (32.4)3390 (39.2)1 [Reference]
Census region
 Northeast946 (16.9)267 (18.3)1213 (17.2)1.07 (0.82, 1.39).04
 Midwest1906 (25.2)411 (19.7)2317 (24.0)1.34 (1.08, 1.67)
 South2562 (40.9)708 (39.7)3270 (40.6)1.16 (0.94, 1.44)
 West1106 (17.1)401 (22.4)1507 (18.3)1 [Reference]
Minor at time of first cigarette
 Minor (age<18 years)5183 (79.4)1253 (70.4)6436 (77.4)1.54 (1.30, 1.82)<0.001
 Adult (age≥18 years)1306 (20.6)501 (29.6)1807 (22.6)1 [Reference]
Current use of other tobacco products
 Yes2665 (40.8)860 (43.7)3525 (41.5)N/Ab
 No3616 (59.2)878 (56.3)4494 (58.5)N/Ab
Cancer diagnosis
 No cancer history6027 (92.7)1700 (94.6)7727 (93.1)N/Ac
 Cancer survivor456 (7.3)81 (5.4)537 (6.9)N/Ac
Tobacco-related risk perceptionsMedian (Range)Odds ratio (95% CI)P Value
Cigarette harm perception3.5 (1.0–5.0)3.7 (1.0–5.0)3.6 (1.0–5.0)0.83 (0.75, 0.92)<.001
Worry that tobacco products will damage one’s health2.1 (1.0–4.0)1.8 (1.0–4.0)2.0 (1.0–4.0)1.40 (1.29, 1.52)<.001
Belief that smoking causes cancer3.9 (1.0–5.0)4.0 (1.0–5.0)3.9 (1.0–5.0)N/Ac.009
Nondaily cigarette harm perception2.6 (1.0–4.0)2.6 (1.0–4.0)2.6 (1.0–4.0)1.17 (1.04, 1.31)
Interaction of cancer survivor status with belief that smoking causes cancercLeast squares mean Log-Odds (95% CI)
 Non-cancer, belief = 1N/AN/AN/A1.81 (1.41, 2.21)<.001
 Cancer, belief = 1N/AN/AN/A−0.42 (−1.87, 1.03)
 Non-cancer, belief = 5N/AN/AN/A0.38 (0.14, 0.61)
 Cancer, belief = 5N/AN/AN/A1.08 (0.64, 1.52)

Estimates and p-values are based on weighted logistic regression.

Current use of other tobacco products was nonsignificant with p = .81 in the full model and was, therefore, excluded from the final model.

For variables involved in interactions that were statistically significant, the effects for combinations of interacting variables are reported.

Table 1.
Open in new tab

Participant Characteristics and Association of Daily Versus Nondaily Smoking With Sociodemographics, Tobacco Use, Cancer Survivor Status, and Tobacco-Related Risk Perceptions

CharacteristicDaily smokers 
(N = 6520)Nondaily smokers (N = 1787)Analytic sample (N = 8307)Daily smoking vs. nondaily smokinga
No. (Weighted %)No. (Weighted %)No. (Weighted %)Odds Ratio (95% CI)P Value
Age
 18–241192 (12.0)586 (22.5)1778 (14.4)1.08 (0.29, 4.01)<.001
 25–341361 (22.3)444 (28.2)1805 (23.7)1.62 (0.43, 6.12)
 35–441205 (19.3)286 (18.5)1491 (19.1)2.25 (0.59, 8.51)
 45–541335 (21.6)232 (14.6)1567 (20.0)2.60 (0.67, 10.06)
 55–641010 (17.1)164 (10.2)1174 (15.5)3.13 (0.77, 12.72)
 65–74337 (6.2)65 (4.7)402 (5.9)2.19 (0.50, 9.70)
 ≥7579 (1.4)10 (1.4)89 (1.4)1 [Reference]
Sex
 Male3129 (52.9)988 (57.2)4117 (53.9)0.91 (0.79, 1.04).17
 Female3389 (47.1)799 (42.8)4188 (46.1)1 [Reference]
Race/ethnicity
 White, non-Hispanic4293 (71.1)952 (58.4)5245 (68.2)2.56 (2.07, 3.16)<.001
 Black, non-Hispanic967 (13.9)271 (14.3)1238 (14.0)1.86 (1.42, 2.43)
 Other, non-Hispanic437 (5.2)129 (7.0)566 (5.6)2.08 (1.46, 2.97)
 Hispanic701 (9.8)403 (20.3)1104 (12.2)1 [Reference]
Educational attainment
 <High school1253 (18.1)270 (14.9)1523 (17.4)3.40 (2.19, 5.27)<.001
 GED805 (11.8)148 (7.6)953 (10.8)3.84 (2.35, 6.26)
 High school graduate1713 (30.0)400 (22.9)2113 (28.4)3.38 (2.22, 5.15)
 Some college (no degree) or associates degree2212 (31.7)681 (37.2)2893 (32.9)2.31 (1.56, 3.41)
 Bachelor’s degree393 (6.8)210 (13.8)603 (8.4)1.30 (0.85, 2.00)
 Advanced degree119 (1.5)73 (3.7)192 (2.0)1 [Reference]
Household income ($)
 <10,0001556 (21.4)407 (19.7)1963 (21.0)1.64 (1.16, 2.30)<.001
 10,000–24,9991812 (26.8)429 (22.5)2241 (25.8)1.68 (1.20, 2.35)
 25,000–49,9991483 (23.2)373 (21.4)1856 (22.8)1.58 (1.14, 2.19)
 50,000–99,999894 (15.0)307 (20.2)1201 (16.2)1.02 (0.76, 1.38)
 ≥100,000285 (5.0)136 (8.6)421 (5.8)1 [Reference]
 Missing490 (8.5)135 (7.6)625 (8.3)1.62 (1.07, 2.45)
Employment status
 Works full time at least 35 hours per week2635 (43.4)800 (49.3)3435 (44.7)0.89 (0.75, 1.06).36
 Works part time at least 15 to 34 hours per week744 (10.9)264 (13.2)1008 (11.4)0.82 (0.65, 1.05)
 Works part time less than 15 hours per week312 (4.6)106 (5.1)418 (4.7)0.85 (0.62, 1.17)
 Does not currently work for pay2787 (41.1)603 (32.4)3390 (39.2)1 [Reference]
Census region
 Northeast946 (16.9)267 (18.3)1213 (17.2)1.07 (0.82, 1.39).04
 Midwest1906 (25.2)411 (19.7)2317 (24.0)1.34 (1.08, 1.67)
 South2562 (40.9)708 (39.7)3270 (40.6)1.16 (0.94, 1.44)
 West1106 (17.1)401 (22.4)1507 (18.3)1 [Reference]
Minor at time of first cigarette
 Minor (age<18 years)5183 (79.4)1253 (70.4)6436 (77.4)1.54 (1.30, 1.82)<0.001
 Adult (age≥18 years)1306 (20.6)501 (29.6)1807 (22.6)1 [Reference]
Current use of other tobacco products
 Yes2665 (40.8)860 (43.7)3525 (41.5)N/Ab
 No3616 (59.2)878 (56.3)4494 (58.5)N/Ab
Cancer diagnosis
 No cancer history6027 (92.7)1700 (94.6)7727 (93.1)N/Ac
 Cancer survivor456 (7.3)81 (5.4)537 (6.9)N/Ac
Tobacco-related risk perceptionsMedian (Range)Odds ratio (95% CI)P Value
Cigarette harm perception3.5 (1.0–5.0)3.7 (1.0–5.0)3.6 (1.0–5.0)0.83 (0.75, 0.92)<.001
Worry that tobacco products will damage one’s health2.1 (1.0–4.0)1.8 (1.0–4.0)2.0 (1.0–4.0)1.40 (1.29, 1.52)<.001
Belief that smoking causes cancer3.9 (1.0–5.0)4.0 (1.0–5.0)3.9 (1.0–5.0)N/Ac.009
Nondaily cigarette harm perception2.6 (1.0–4.0)2.6 (1.0–4.0)2.6 (1.0–4.0)1.17 (1.04, 1.31)
Interaction of cancer survivor status with belief that smoking causes cancercLeast squares mean Log-Odds (95% CI)
 Non-cancer, belief = 1N/AN/AN/A1.81 (1.41, 2.21)<.001
 Cancer, belief = 1N/AN/AN/A−0.42 (−1.87, 1.03)
 Non-cancer, belief = 5N/AN/AN/A0.38 (0.14, 0.61)
 Cancer, belief = 5N/AN/AN/A1.08 (0.64, 1.52)
CharacteristicDaily smokers 
(N = 6520)Nondaily smokers (N = 1787)Analytic sample (N = 8307)Daily smoking vs. nondaily smokinga
No. (Weighted %)No. (Weighted %)No. (Weighted %)Odds Ratio (95% CI)P Value
Age
 18–241192 (12.0)586 (22.5)1778 (14.4)1.08 (0.29, 4.01)<.001
 25–341361 (22.3)444 (28.2)1805 (23.7)1.62 (0.43, 6.12)
 35–441205 (19.3)286 (18.5)1491 (19.1)2.25 (0.59, 8.51)
 45–541335 (21.6)232 (14.6)1567 (20.0)2.60 (0.67, 10.06)
 55–641010 (17.1)164 (10.2)1174 (15.5)3.13 (0.77, 12.72)
 65–74337 (6.2)65 (4.7)402 (5.9)2.19 (0.50, 9.70)
 ≥7579 (1.4)10 (1.4)89 (1.4)1 [Reference]
Sex
 Male3129 (52.9)988 (57.2)4117 (53.9)0.91 (0.79, 1.04).17
 Female3389 (47.1)799 (42.8)4188 (46.1)1 [Reference]
Race/ethnicity
 White, non-Hispanic4293 (71.1)952 (58.4)5245 (68.2)2.56 (2.07, 3.16)<.001
 Black, non-Hispanic967 (13.9)271 (14.3)1238 (14.0)1.86 (1.42, 2.43)
 Other, non-Hispanic437 (5.2)129 (7.0)566 (5.6)2.08 (1.46, 2.97)
 Hispanic701 (9.8)403 (20.3)1104 (12.2)1 [Reference]
Educational attainment
 <High school1253 (18.1)270 (14.9)1523 (17.4)3.40 (2.19, 5.27)<.001
 GED805 (11.8)148 (7.6)953 (10.8)3.84 (2.35, 6.26)
 High school graduate1713 (30.0)400 (22.9)2113 (28.4)3.38 (2.22, 5.15)
 Some college (no degree) or associates degree2212 (31.7)681 (37.2)2893 (32.9)2.31 (1.56, 3.41)
 Bachelor’s degree393 (6.8)210 (13.8)603 (8.4)1.30 (0.85, 2.00)
 Advanced degree119 (1.5)73 (3.7)192 (2.0)1 [Reference]
Household income ($)
 <10,0001556 (21.4)407 (19.7)1963 (21.0)1.64 (1.16, 2.30)<.001
 10,000–24,9991812 (26.8)429 (22.5)2241 (25.8)1.68 (1.20, 2.35)
 25,000–49,9991483 (23.2)373 (21.4)1856 (22.8)1.58 (1.14, 2.19)
 50,000–99,999894 (15.0)307 (20.2)1201 (16.2)1.02 (0.76, 1.38)
 ≥100,000285 (5.0)136 (8.6)421 (5.8)1 [Reference]
 Missing490 (8.5)135 (7.6)625 (8.3)1.62 (1.07, 2.45)
Employment status
 Works full time at least 35 hours per week2635 (43.4)800 (49.3)3435 (44.7)0.89 (0.75, 1.06).36
 Works part time at least 15 to 34 hours per week744 (10.9)264 (13.2)1008 (11.4)0.82 (0.65, 1.05)
 Works part time less than 15 hours per week312 (4.6)106 (5.1)418 (4.7)0.85 (0.62, 1.17)
 Does not currently work for pay2787 (41.1)603 (32.4)3390 (39.2)1 [Reference]
Census region
 Northeast946 (16.9)267 (18.3)1213 (17.2)1.07 (0.82, 1.39).04
 Midwest1906 (25.2)411 (19.7)2317 (24.0)1.34 (1.08, 1.67)
 South2562 (40.9)708 (39.7)3270 (40.6)1.16 (0.94, 1.44)
 West1106 (17.1)401 (22.4)1507 (18.3)1 [Reference]
Minor at time of first cigarette
 Minor (age<18 years)5183 (79.4)1253 (70.4)6436 (77.4)1.54 (1.30, 1.82)<0.001
 Adult (age≥18 years)1306 (20.6)501 (29.6)1807 (22.6)1 [Reference]
Current use of other tobacco products
 Yes2665 (40.8)860 (43.7)3525 (41.5)N/Ab
 No3616 (59.2)878 (56.3)4494 (58.5)N/Ab
Cancer diagnosis
 No cancer history6027 (92.7)1700 (94.6)7727 (93.1)N/Ac
 Cancer survivor456 (7.3)81 (5.4)537 (6.9)N/Ac
Tobacco-related risk perceptionsMedian (Range)Odds ratio (95% CI)P Value
Cigarette harm perception3.5 (1.0–5.0)3.7 (1.0–5.0)3.6 (1.0–5.0)0.83 (0.75, 0.92)<.001
Worry that tobacco products will damage one’s health2.1 (1.0–4.0)1.8 (1.0–4.0)2.0 (1.0–4.0)1.40 (1.29, 1.52)<.001
Belief that smoking causes cancer3.9 (1.0–5.0)4.0 (1.0–5.0)3.9 (1.0–5.0)N/Ac.009
Nondaily cigarette harm perception2.6 (1.0–4.0)2.6 (1.0–4.0)2.6 (1.0–4.0)1.17 (1.04, 1.31)
Interaction of cancer survivor status with belief that smoking causes cancercLeast squares mean Log-Odds (95% CI)
 Non-cancer, belief = 1N/AN/AN/A1.81 (1.41, 2.21)<.001
 Cancer, belief = 1N/AN/AN/A−0.42 (−1.87, 1.03)
 Non-cancer, belief = 5N/AN/AN/A0.38 (0.14, 0.61)
 Cancer, belief = 5N/AN/AN/A1.08 (0.64, 1.52)

Estimates and p-values are based on weighted logistic regression.

Current use of other tobacco products was nonsignificant with p = .81 in the full model and was, therefore, excluded from the final model.

For variables involved in interactions that were statistically significant, the effects for combinations of interacting variables are reported.

Cancer survivors did not have significantly different tobacco-related risk perceptions from other respondents (Figure 1, Supplementary Table S2). The estimated median tobacco-related risk perceptions were as follows: cigarette harm perception, 3.6 (mean 4.0); worry that tobacco products will damage one’s health, 2.0 (mean 2.6); belief that smoking causes cancer, 3.9 (mean 4.0); and nondaily cigarette harm perception, 2.6 (mean 3.1).

Tobacco-related risk perceptions by cancer survivor status among current smokers (Medians and 95% confidence intervals, survey-weighted, unadjusted for other factors).
Figure 1.

Tobacco-related risk perceptions by cancer survivor status among current smokers (Medians and 95% confidence intervals, survey-weighted, unadjusted for other factors).

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Logistic regression was used to estimate the association of daily versus nondaily smoking with demographic characteristics, tobacco-related risk perceptions, cancer survivor status, and other explanatory variables. Individuals of non-Hispanic ethnicity, less education, and lower income were significantly more likely to smoke daily (versus nondaily) (Table 1). Having been a minor at the time of first cigarette was also associated with smoking daily (odds ratio [OR] = 1.54, 95% confidence interval [CI] [1.30, 1.82]). The use of other tobacco products was nonsignificant with p = .81 in the full model and was, therefore, excluded from the final model. Sex and employment status were nonsignificant in the final model. Age demonstrated a concave association, with increasing odds through the 55–64 age range (OR = 3.13, 95% CI [0.77, 12.72] vs. those ages 75 and older) and then decreasing, and every age group was more likely to smoke daily as compared with those ages 75 and older.

The logistic regression also demonstrated that respondents with lower cigarette harm perception (OR = 0.83, 95% CI [0.75, 0.92]), with greater worry that tobacco products will damage one’s health (OR = 1.40, 95% CI [1.29, 1.52]), and with greater nondaily cigarette harm perception (OR = 1.17, 95% CI [1.04, 1.31]) were more likely to smoke daily (vs. nondaily). Belief that smoking causes cancer and cancer survivor status significantly interacted (p < .001). For example, among respondents who strongly endorsed the belief that smoking causes cancer, cancer survivors were more likely to be daily smokers versus those without a cancer history (OR = 2.0), whereas among those with a low level of belief that smoking causes cancer, cancer survivors were less likely to be daily smokers (OR = 0.11). Table 1 and Figure 2 provide the parameter estimates with confidence intervals for this example. (Analogous examples could be constructed for any values of the continuous belief variable; the example comparing values 1 [low] and 4 [high] was selected to illustrate the effect.) The figure also shows that individuals without cancer who had lower belief that smoking causes cancer had higher odds of daily smoking than other respondents.

Daily vs. nondaily smoking interaction of cancer survivor status and belief that smoking causes cancer (Least-squares means of log-odds of daily versus nondaily smoking, from final weighted logistic regression model).
Figure 2.

Daily vs. nondaily smoking interaction of cancer survivor status and belief that smoking causes cancer (Least-squares means of log-odds of daily versus nondaily smoking, from final weighted logistic regression model).

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Discussion

We found that among current smokers, respondents with greater worry that tobacco products will damage one’s health, lower cigarette harm perception, and greater nondaily cigarette harm perception were more likely to be daily (vs. nondaily) smokers. For example, a one-point increase in worry (e.g., the difference between “a little worried” and “moderately worried”) corresponded to a 40% increase in the odds of being a daily versus nondaily smoker. The association with worry that tobacco products will damage one’s health may be the result of reverse causation; daily smoking may cause greater worry that tobacco products will damage one’s health as compared with nondaily smoking. We also found that those ages 55–64 (relative to older and younger respondents), with lower income, with less education, and of non-Hispanic ethnicity were significantly associated with smoking daily, which is consistent with other research conducted in the general U.S. population.4

We found that cigarette harm perception was associated with a higher likelihood of nondaily smoking. For example, a difference of one point (e.g., the difference between “somewhat harmful” and “very harmful”) corresponded to a 17% decrease in the odds of being a daily versus nondaily smoker. This may indicate that individuals who perceived greater harm from smoking were motivated to smoke nondaily rather than daily. This interpretation is consistent with literature indicating that nondaily smokers tend to perceive their smoking behavior as posing fewer health harms than daily smoking, and they do not always regard themselves as smokers.39–42 Research conducted in Norway, for example, found that a moderate proportion (one-third) of nondaily smokers do not believe that their smoking harms their health.41 Research has suggested that among cigarette smokers, nondaily smokers have the lowest perceived risk of developing smoking-related diseases (e.g., lung cancer, lung disease, heart disease), followed by light daily smokers and moderate-to-heavy daily smokers.43 Some smokers who struggle with quitting may attempt to mitigate health risks by smoking nondaily or by reducing the number of cigarettes smoked per day.44,45 However, nondaily smoking is associated with increased morbidity and mortality compared with former smokers and never-smokers,46,47 and lifelong nondaily smokers have a 72% elevated mortality risk—even at very low levels of smoking—compared to never-smokers.48 Providing information about the risks of nondaily smoking must be done with care, given our finding that participants with a higher perception of the risks of nondaily smoking were more likely to be daily smokers.

Our study found that cancer survivors did not have significantly different risk perceptions than respondents without a cancer history. That finding is consistent with a study of 430 participants in the National Lung Screening Trial, which found that perceptions of risk for lung cancer and other smoking-related diseases at 1-year follow-up did not significantly differ by positive or negative screening test result, although no participants in this study had a confirmed lung cancer diagnosis at follow-up.49 Our finding may be due to the selection of current smokers and to the heterogeneity of the survivors; the analytic sample included survivors of any cancer site and those who had survived any length of time since diagnosis. A study of medically ill smokers found a difference in tobacco-related risk perceptions between lung cancer survivors and individuals without a lung cancer history.50

Cancer survivor status interacted with the belief that smoking causes cancer (Smoking can cause [lung/bladder/mouth/liver] cancer in smokers; the only tobacco-related risk perception item specifically about cancer) in predicting daily smoking. That is, cancer survivor status moderated the effect of that belief on daily smoking. Examining that interaction, the highest odds of being a daily smoker were seen in respondents who had not had cancer and who had a low belief that smoking causes cancer. It might be expected that the lowest odds of being a daily (vs. nondaily) smoker would be among those who had a high belief that smoking causes cancer and who, themselves, had experienced cancer. However, we found that among those with high belief, cancer survivors were more likely to be daily smokers than respondents without a cancer history. It may be that because individuals are more likely to quit smoking altogether after a cancer diagnosis, those cancer survivors who do continue are more dependent and are, therefore, daily smokers.18 A cancer diagnosis frequently motivates cigarette smokers to attempt to quit; more heavily dependent smokers, who are more likely to be daily smokers, are less likely to succeed. This observation may help explain why our study found that among those with high belief, cancer survivors were more likely to be daily smokers than respondents without a cancer history.

Limitations

The PATH study is the only nationally representative longitudinal study that assesses tobacco use with a comprehensive battery of tobacco-related constructs. However, the tobacco-related risk perception items are limited in number and scope, and the only one that asked about the participant’s personal risk was worry that tobacco products will damage one’s health. The other tobacco-related risk perception items asked about general perceptions of harm. Future research should include more items to assess tobacco-related risk perceptions in a more comprehensive way. Cancer diagnoses included all organ sites; it is conceivable that different results would be found with specific cancers. Finally, we used PATH data collected through October 2016. We elected not to use more recent data because we determined that the number of individuals diagnosed with cancer, who had participated in all included waves, would be diminished by attrition, reducing the statistical power and generalizability and outweighing the benefit of recency.

Conclusions

Individuals with a lower perception of cigarette harm and a higher perception of nondaily cigarette harm were more likely to be daily (vs. nondaily) smokers. Worry that tobacco products would harm one’s health was also associated with daily smoking. Respondents with higher belief that smoking causes cancer or who were cancer survivors were less likely to be daily (vs. nondaily) smokers.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This project was supported in whole or in part with Federal funds from the National Cancer Institute, National Institutes of Health, U.S. Department of Health and Human Services, under contract number HHSN261201700004I.

Declaration of Interests

None declared.

Acknowledgments

Rebecca Ferrer, Ph.D. (National Cancer Institute), and Laura Wagstaff, M.P.H. (NORC at the University of Chicago), participated in discussions regarding the foundations of this project. The views and opinions expressed in this paper are those of the authors only and do not necessarily represent the views, official policy, or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies nor of the U.S. Department of Housing and Urban Development. CMR-G and ARK contributed equally to this work.

Data and Code Availability

The PATH data are publicly available at https://www.icpsr.umich.edu/web/NAHDAP/studies/36231. The code is available here.

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Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco 2022.
This work is written by (a) US Government employee(s) and is in the public domain in the US.
Topic:
Issue Section:
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