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Abstract
Background Heightened stigma surrounding the action of smoking may decrease the likelihood that individuals who engage in smoking identify with the label ‘smoker’. Non-identifying smokers (NIS) may undermine accurate smoking prevalence estimates and can be overlooked by tobacco control efforts.
Objective We sought to characterise NIS in a cross-sectional study using a sample representative of the population of adults (>18 years) in California who reported smoking at least 100 cigarettes in their lifetime, smoking at least some days and at least once in the last 30 days (n=1698). Individuals were considered NIS if they met the above criteria and answered ‘no’ when asked if they ‘considered themselves a smoker’.
Results We estimate that 395 928 (SD=54 126) NIS were living in California in 2011 (a prevalence of 12.3% of all smokers in California). The odds of being NIS were higher among non-daily smokers who were previously daily smokers (adjusted OR (AOR)=7.63, 95% CI 2.67 to 21.8) or were never previously daily smokers (AOR=7.14, CI 2.78 to 18.3) compared with daily smokers. The odds of being an NIS were also higher among those who did not believe they were addicted to cigarettes (AOR=3.84, CI 1.68 to 9.22), were older than 65 years (vs less than 45 years) (AOR=3.35, CI 1.16 to 9.75) or were from ethnic minorities including Black and Asian (vs non-Hispanic white) (AOR=3.16, CI 1.19 to 8.49).
Conclusions Smoking surveillance should restructure selection criteria to more accurately account for NIS in areas with high stigma toward smokers. Targeted interventions may be needed for NIS including educating healthcare providers to enquire more deeply into smoking habits.
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Introduction
Labels such as ‘phantom smokers’ and ‘deniers’ have been used to describe individuals who report smoking behaviour (typically smoking at least 1 day in the past 30 days), but do not label themselves ‘smokers’.1–6 These individuals, whom we refer to as non-identifying smokers (NIS), have been primarily characterised among young adults (18–25 years) and particularly college students1–3 ,5–10 where the estimated prevalence ranges from 5.5% to 56.3% among college students in the USA.1–3 ,8
NIS may present a public health challenge because they can be less motivated to quit smoking7 ,9 ,10 and less likely to make quit attempts,3 ,4 although more recent population level reports from England suggest the opposite may be true.11 What is most concerning about NIS, however, is that smoking prevalence studies or other tobacco control efforts may overlook NIS unless appropriate methods are used to correctly classify smoking status and understand their characteristics of not identifying as a smoker.12–14
In this brief report, we characterise NIS using data representative of the population of adults (>18 years) in California who admit to smoking at least 100 cigarettes in their lifetime, with a goal of aiding future surveillance studies and tobacco control programmes seeking to account for this type of smoker.
Methods
Sample characteristics
Our secondary cross-sectional analysis of the 2011 California Longitudinal Smokers Survey (CLSS) included participants who had smoked at least 100 cigarettes in their lifetime, reported smoking at least 1 day in the 30 days prior to their interview and reported currently smoking at least ‘some days’ (n=1698). CLSS is a survey of a population-based sample of smokers in California. Data collection lasted from 8 July 2011 to 8 December 2011 and included landline and cell phone interviews of known California residents who had reported smoking in the 2009 California Health Interview Survey;15 1961 of 4717 interviews attempted were completed (a response rate of 41.6%).
Statistical analysis
In analyses, we define NIS as individuals who reported smoking at least 100 cigarettes in their lifetime, at least ‘some days’, had smoked at least 1 day in the 30 days prior to interview and when asked ‘Do you consider yourself a smoker?’1–3 answered ‘No’.
All parameter estimates reported were weighted to be representative of the population of adult smokers in California. Weighted frequencies, SDs and SEs were calculated by the paired unit jackknife method (JK2), using 80 jackknife samples.16 Further documentation on weighting and sample methodology is available in the CLSS technical report.16 ,17 Crude ORs, adjusted ORs (AORs) and their 95% CIs were calculated using weighted logistic regression with ‘Do you consider yourself a smoker?’ (No vs Yes) set as the outcome variable.
All covariates were selected based on previous literature2–7 ,9 ,11 ,13 and as outlined in table 1 included: age, gender, ethnicity, level of education, frequency of smoking, any quit attempt in the last 12 months and addiction. Multivariate models simultaneously adjusted for all covariates. Three separate multivariate models were used to assess the influence of defining addiction in the three ways: Self-perceived level of addiction, less or greater than 30 min to first cigarette, and certainty of restraining from smoking. Less than 3% of data were missing in any category.
Characteristics of NIS among adult smokers in California, 2011 (n=1698)
All analyses were performed using SAS software, V.9.3 of the SAS System for Windows 7, SAS Institute Inc.
Results
Using the weighted analyses for the population of California, we estimate that there were 395 928 (SD=54 126) NIS in California in 2011, a prevalence of 12.3% of smokers in California (table 1). NIS were young (64.7%), male smokers (65.8%), former daily smokers (46.9%), believed they were not addicted to cigarettes (62.3%) and were from ethnic groups other than Hispanic and non-Hispanic white, including Black, Asian and all others (49.5%).
In multivariate analyses, smoking status was the strongest predictor of being NIS. Compared with daily smokers, the odds of being NIS were higher for non-daily smokers who were previously daily smokers (AOR=7.63, CI 2.67 to 21.8) or never daily smokers (AOR=7.14, CI 2.78 to 18.3). Additionally, the odds of being NIS were higher among those older than 65 years (vs 18–44 years) (AOR=3.35, CI 1.16 to 9.75), among those originating from ethnic minorities other than Hispanic, including Black, Asian and all others (vs non-Hispanic white) (AOR=4.76, CI 1.53 to 14.8), and among those believing they were not addicted to cigarettes (AOR=4.09, CI 1.65 to 10.1). When using other definitions of addiction (ie, smoking more than 30 min after waking vs within 30 min or self-reported certainty of restraining from smoking) in separate multivariate models, all associations remained in the same direction but failed to reach significance with the exception of non-daily smoking status (analyses not shown).
Discussion
Our study demonstrated that a large number of NIS were present in the population of individuals who smoked cigarettes in California in 2011. NIS tended to be non-daily smokers, although approximately 22% or an estimated 87 516 in California were daily smokers. This association is consistent with previous studies that only included college students.1–3 ,5–10 Future control efforts may need targeted messages toward non-daily smokers educating them that there is no safe level of smoking and even smoking few cigarettes on a regular basis can cause harms comparable with daily smoking.18
NIS in our study were also more likely to be over the age of 45 years. Motivations to smoke differ among age categories.19 ,20 Among older adults, the stigma of repeated failure in quitting efforts and higher nicotine dependence may increase the perception of social disapproval and lead individuals to avoid the ‘smoker’ label especially if prolonged smoking has led to negative health consequences such as lung cancer.21 ,22 Younger age categories, however, may be driven more by social facilitation,1 ,2 ,5 ,9 ,19 drinking3 ,5 and a greater perceived control of smoking behaviour,2 ,7 ,9 arguing that they are not addicted to smoking and can quit at any time.
NIS are likely in part a result of stigmatisation produced by comprehensive tobacco control programmes, such as California's,23 which focus on creating non-smoking social norms.24–27 Stigmatisation has pushed smokers to become marginalised parts of society with little advantage for those who smoke to identify as ‘smokers’ or provide accurate reports of smoking behaviour.14 ,28 ,29
Ethnic minority groups may also be associated with being NIS. The large racial diversity present in California30 is a unique advantage of our study to detect such an association and to our knowledge this characteristic has not been explored in the literature on NIS. Minority groups may be more affected by stigma than other major ethnicities. Future studies with larger sample size or ethno-cultural qualitative focus might further explore this concept.
Being male smokers,3 from young age groups,2 ,3 perceiving no addiction to smoking,2 ,5 ,6 and positive or negative association with quitting attempts in the last 12 months3 ,4 ,11 have been NIS characteristics reported by others. Of these characteristics, our study found only perception of addiction was associated with being NIS. The differences may be a result of alternative covariate category definitions between studies, defining NIS differently (eg, ‘I like being a smoker’) or different sample populations.1 ,4 ,11 ,26 Future studies should seek to provide a wider range of smoking identity than asking if someone considers themselves a smoker (eg, ‘Would you say you're a?: Social smoker, non-smoker, occasional smoker, etc..’), as described by other investigators.6 ,31
We must note that there are limitations to our study. The selection criteria of our study may have excluded college students and recent smokers who would not categorise themselves as smoking more than 100 cigarettes and therefore underestimate the absolute number of NIS in the population. Studies among college students are usually restricted only to individuals who have smoked at least 1 day within the 30 days prior to their interview1–3 ,8 and even those who have not smoked in the last 30 days.6 ,9 Such criteria are more sensitive and may explain why the prevalence of NIS has been estimated as high as 56.3%2 compared with just 12.3% in our study.
Conclusions
To allow for a wider range of smoking identity we recommend that national and subnational surveys of smokers consider pursuing selection criteria that are more inclusive than asking if an individual has smoked at least 100 cigarettes in his or her lifetime. This will require studies to assess predictive validity and relevance of new questions for understanding how smokers perceive themselves. Future interventions, media campaigns and public health policies need to address this newly emerging phenomenon and healthcare providers need to be educated to query more deeply beyond just asking if their patient is a smoker.
What this paper adds
Recent studies suggest that individuals can report smoking cigarettes in questionnaire surveys, but not consider themselves smokers. This has been characterised as a phenomenon among the young and adults who smoke on a non-daily basis, but little is known about this phenomenon in the general population of smokers.
We found that a large number of adults in California report smoking cigarettes but do not consider themselves smokers, demonstrating that this phenomenon is pronounced in the general population. Older age groups, ethnic minority smokers and overwhelmingly non-daily smokers were more likely to be in this group, but these categories did not entirely explain the phenomenon.
Acknowledgments
The authors would like to acknowledge the California Department of Public Health (contract number 12-10046) for supporting the collection of the data needed for analyses of this manuscript.
References
Footnotes
Contributors WKA-D designed data collection tools, monitored data collection for the entire survey, wrote the statistical analysis plan and revised the draft paper. He is the guarantor. EL wrote the statistical analysis plan, analysed the data, drafted and revised the paper. SDE wrote the statistical analysis plan specifically with regard to population weighting, cleaned the data, interpreted results and revised the paper. RWZ cleaned and analysed the data, monitored data collection for the whole study and revised the draft paper.
Competing interests None.
Ethics approval Westat, University of California, San Diego, California Department of public Health, and University of California, Los Angeles.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data from the California Longitudinal Smokers Survey (CLSS) will be made available after completion of the forthcoming official State report.