Quantitative Research

American Journal of Health Promotion

1-7
An Epidemiological Study of Population ª The Author(s) 2017
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Health Reveals Social Smoking as a Major DOI: 10.1177/0890117117706420
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Cardiovascular Risk Factor

Kate Sustersic Gawlik, DNP1, Bernadette Mazurek Melnyk, PhD1,

and Alai Tan, PhD1

Abstract
Purpose: To present nationally representative data on the prevalence of “social” smoking and its relationship to cardiovascular
health.
Design: A population-based, cross-sectional survey on cardiovascular health and its risk factors across the United States.
Setting: Million Hearts1 cardiovascular screenings that took place in community settings.
Participants: De-identified data were collected on a convenient sample of 39, 555 participants.
Measures: Reported smoking status, blood pressure, and total cholesterol.
Analysis: The prevalence of current smoking, social smoking, and non-smoking were cross-tabulated and stratified by sample
characteristics. The adjusted estimates were derived from multiple logistic regression models, adjusting for demographics and
other biometric measures.
Results: Ten percent identified as social smokers. Social smokers were more likely to be aged between 21 and 40, male, and
Hispanic. Social smokers had significantly higher risks of having hypertension (odds ratio [OR]: 2.08, 95% confidence interval [CI]:
1.80-2.41) and elevated cholesterol (OR: 1.53, 95% CI: 1.33-1.75) than non-smokers. There was no significant difference between
social smokers and current smokers (OR ¼ 0.94, 95% CI ¼ 0.80-1.14 for hypertension and OR ¼ 0.95, 95% CI ¼ 0.81-1.11 for
elevated cholesterol).
Conclusion: This is the first population health study to compare the blood pressure and cholesterol levels of people who
self-identify as current verses social smokers. Although previous smoking behavior was not controlled for in the analysis,
this study demonstrates there is no significant difference in the prevalence of elevated blood pressure or cholesterol among
the 2 smoking groups.

Keywords
smoking, health promotion, heart disease, population health, million hearts1

Purpose grade A recommendation from the United States Preventive

Services Force that health-care providers screen all adults for
Cardiovascular disease continues to lead the way year after
tobacco use and advise quitting if applicable.8 Despite these
year as the number 1 cause of morbidity and mortality in both
recommendations, only half of all smokers receive advice to
men and women throughout the United States and world-
quit from any health-care provider.9,10 What may further com-
wide.1,2 Cardiovascular disease is not only the most common
plicate this for health-care providers is the practice of “social
and costly of the chronic diseases but is also the most preven- smoking/occasional smoking/intermittent smoking” by
table.3-5 Implementing simple preventive behavioral modifica-
patients. There is currently no universal term used to define
tions, including aspirin therapy, blood pressure control,
cholesterol management, and smoking cessation, could prevent
more than 100 000 cardiovascular-related deaths per year and
reduce the risk of heart attack and stroke by more than 80%.5-7
1
Department of Nursing, The Ohio State University, Columbus, OH, USA
Despite continued attempts to improve cardiovascular popula-
Corresponding Author:
tion health, prevalence and incidence remain high. Kate Sustersic Gawlik, The Ohio State University, 1585 Neil Avenue,
Smoking is a well-known risk factor for cardiovascular dis- Columbus, OH 43210, USA.
ease as well as many other chronic illnesses. There is a current Email: gawlik.2@osu.edu
2 American Journal of Health Promotion XX(X)
this type of smoking pattern, causing methodological and the-
oretical concerns.11,12 For the purpose of this paper, the authors
will define this pattern of social smoking as individuals who do
not smoke cigarettes on a daily basis but who smoke in certain
social situations on a regular basis.
Many health-care providers do not have knowledge of this
smoking subpopulation; therefore, they are not screening or
providing appropriate cessation advice for these individuals.
These individuals often go unidentified because social smokers
typically will not identify themselves as “smokers” when asked
and will self-identify as “nonsmokers.”11,13,14 Additional chal-
lenges for health-care providers are the other beliefs held by
this subpopulation including: denial of nicotine addiction, per-
ceived immunity to the harmful effects of nicotine, and the
belief that they could quit smoking at any time.12,13 Contrary
to these beliefs, it is projected that about half of these individ-
uals will continue smoking and that this pattern of social or
occasional smoking is increasing within the general population,
making this a significant public health concern.14-17
In an attempt to shift the focus of cardiovascular health to
one of prevention, the Department of Health and Human Ser-
vices launched the Million Hearts1 initiative in September
2011. Million Hearts1 is a national initiative to prevent 1
million heart attacks and strokes by 2017.6 It is a population
health promotion strategy focused on evidence-based cardio-
vascular risk reduction through healthy behavioral lifestyle
modifications. The initiative focuses on the “ABCS” of care.
“A” is for appropriate aspirin therapy, “B” is for blood pressure
control, “C” is for cholesterol management, and “S” is for
smoking cessation.6 As part of this initiative, health-care pro-
fessionals and health-care professionals’ students have joined
together, as part of the National Interprofessional Education
and Practice Consortium to Advance Million Hearts1, and
participate in a free, online educational program that includes
providing cardiovascular screenings and individualized cardi-
ovascular risk reduction education.18
As part of these cardiovascular screenings, de-identified
data about participants’ are collected during each screening.
Screenings verbally assess each participant for the presence
of smoking. Participants must identify themselves as either a
nonsmoker, a current smoker, or a social smoker. This infor-
mation, along with 10 other parameters obtained from the
screening, is then entered by the screeners into a secure online
survey system.18 The online survey results provide valuable
insight into social smoking in the population. The purpose of
this epidemiological study is to present nationally representa-
tive data on the prevalence of social smoking, its relationship to
cardiovascular risk factors and population health, and impor-
tant implications for health promotion practitioners.
Methods
Study Design
Cross-sectional survey data from 39 555 participants who were
screened via the Million Hearts1 educational program were
collected from February 2013 through February 2016.
Approval from a full institutional board review process was
obtained. All data were collected online and were obtained
by screeners while completing Million Hearts1 cardiovascular
screenings.
Population
The target population for Million Hearts1 screenings was the
general adult population across the United States. Convenience
sampling was used. Participants volunteered and provided ver-
bal consent to participate in the screening process. Data from
participants were uploaded into a secure online survey system
that is located in a secure firewalled location on the institu-
tion’s server. All data were fully de-identified such that it was
not possible to know the identities of individual participants or
the screeners due to the utilization of 2 different software sys-
tems within the educational program, which do not interface.
Measures
The study included measures of age, gender, ethnicity/race,
smoking status, body mass index (BMI), perceived stress,
blood pressure, and total cholesterol level. The data were gath-
ered on an anonymous basis and did not have any of the 18
Health Insurance Portability and Accountability Act privacy
rule identifiers.19
The demographics (age, gender, and race/ethnicity) were
self-explanatory. Participants self-identified as either a non-
smoker, a current smoker, or a social smoker. As stated above,
the definition of a social smoker is an individual who does not
smoke cigarettes on a daily basis but who smokes in certain
social situations on a regular basis. Body mass index was cate-
gorized into underweight (BMI <18.5), normal (BMI of 18.5-
24.9), overweight (BMI of 25-29.9), and obese (BMI 30)
according to classification from the National Heart, Lung, and
Blood Institute.20
Blood pressure and total cholesterol were used as measures
for cardiovascular health. Blood pressure was categorized as
normal (systolic blood pressure [SBP] <120 and diastolic blood
pressure [DBP] <80 mm hg), prehypertension (SBP, 120-139
and/or DBP, 80-89 mm hg), stage 1 hypertension (SBP, 140-
159 and/or DBP, 90-99 mm hg), and stage 2 hypertension (SBP
160 and/or DBP 100 mm hg) according to the classification
from the Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure.21 We tested the total cholesterol in a partici-
pant’s blood and categorized it into <200 mg/dL, 200-240 mg/
dL, and >240 mg/dL.
Analysis
The survey collected data at categorical levels on demo-
graphics (age, gender, and race/ethnicity) and biometric mea-
sures (BMI, smoking status, perceived stress, blood pressure,
and total cholesterol). Descriptive statistics were used to
Gawlik et al. 3

describe the sample characteristics. The prevalence of current Table 1. Sample Characteristics (N ¼ 39 555) on Demographics and
smoking, social smoking, and nonsmoking was cross-tabulated Biometric Measures.
and stratified by sample characteristics. Bar charts were used to Characteristics n (%)
visually illustrate the proportion of participants with prehyper-
tension/hypertension and proportion of participants with total Age, years
cholesterol 200 mg/dL, by smoking status. The bar charts Younger than 20 3883 (9.82)
include both unadjusted and adjusted estimates. The adjusted 21-30 10 663 (26.96)
31-40 5774 (14.60)
estimates were derived from multiple logistic regression mod-
41-50 6297 (15.92)
els, adjusting for demographics and other biometric measures. 51-60 6528 (16.50)
Finally, the odds ratio (OR) and 95% confidence interval (CI) Older than 60 6410 (16.21)
estimates from the logistic regression models were presented. Gender
The study is overpowered because of the large sample size. Male 18 052 (45.64)
Therefore, greater emphasis was placed on clinical significance Female 21 503 (54.36)
rather than statistical significance. SAS 9.4 (SAS Institute, Race/ethnicity
Non-Hispanic white 27 554 (69.66)
Cary, North Carolina) was used for all analyses.
Non-Hispanic black 6561 (16.59)
Hispanics 2715 (6.86)
Results Asian American 1778 (4.50)
Native American 163 (0.41)
Demographics of the Study Participants Multiracial 648 (1.64)
Other 136 (0.34)
The total sample consisted of 39 555 participants. Demo- Smoking status
graphics of the participants included a slightly higher percent- Current smoker 6820 (17.24)
age of women (54.4% vs 45.6%). Caucasians comprised the Social smoker 4084 (10.32)
largest percentage of participants (69.7%), followed by black Nonsmoker 28 523 (72.11)
Americans (17.0%), Hispanic Americans (6.9%), Asian Amer- BMI
Underweight 1839 (4.65)
icans (4.5%), the multiracial group (1.6%), and finally, native
Normal 17 497 (44.23)
Americans (<1%). Participants aged 21 to 30 years were the Overweight 11 738 (29.68)
largest percentage of the participant sample (27.0%). Partici- Obese 7719 (19.51)
pants aged 60 years or older (16.2%), aged 51 to 60 (16.5%) Blood pressure
years, and aged 41 to 50 (15.9%) years were all roughly 16% of Normal 19 188 (48.51)
the sample followed by participants aged 31 to 40 (14.6%) Prehypertension 12 251 (30.97)
years, and finally, participants aged 20 years (9.8%). Demo- Stage 1 hypertension 6364 (16.09)
Stage 2 hypertension 1584 (4.00)
graphics on the participant population is found in Table 1.
Total cholesterol
<200 mg/dL 7495 (18.95)
Biometric Profile of the Study Participants 200-240 mg/dL 4020 (10.16)
>240 mg/dL 1107 (2.80)
Table 1 also describes the biometric profile of the study’s par-
ticipants. Almost half of the participants were either over- Abbreviation: BMI, body mass index.
weight (29.68%) or obese (19.51%). Only 48.51% of the
participants had a normal blood pressure, with the rest having
prehypertension (30.97%), stage 1 hypertension (16.09%), or reported higher rates of social smoking than women (12.3% vs
stage 2 hypertension (4.0%). One-third of the sample had data 8.6%). Participants aged between 21 to 30 years had the highest
on total cholesterol, with 18.95% lower than 200 mg/dL, rates of reported social smoking (13.8%), followed by the 31 to
10.16% in the range of 200 to 240 mg/dL, and 2.8% higher 40 years age group (13.6%), the 41 to 50 years age group
than 240 mg/dL. (10.7%), the younger than 20 years group (8.9%), the 51 to
60 years age group (7.3%), and finally, the older than 60 years
group (5.2%). When merging rates of current smokers with
Prevalence of Smoking With Select Variables social smokers, the prevalence of smoking was much higher
Seventy-two (72.1%) percent of the sample identified them- with the highest rates found in the 31 to 40 years age group
selves as a nonsmoker, 17.2% identified themselves as a cur- (34.7%), the 41 to 50 years age group (34.2%), and the 51 to 60
rent smoker, and 10.3% identified themselves as a social years age group (29.1%). The largest increase in participants
smoker. The prevalence of smoking was further evaluated by moving from the category of a nonsmoker to either current or
demographics and other biometric measures (Table 2). Social social smoking occurred in the younger population with the
smoking rates were the highest among native Americans younger than 20 years group having 83.3% of participants
(21.5%), followed by Hispanic Americans (16.8%), multiracial identify themselves as a nonsmoker to the 21 to 30 years group
Americans (14.5%), black Americans (13.4%), Asian Ameri- having 73.4% of participants identify themselves as a nonsmo-
cans (9.6%), and non-Hispanic white Americans (8.9%). Men ker to 64.9% of participants in the 31 to 40 years group.
4 American Journal of Health Promotion XX(X)

Table 2. Prevalence of Smoking by Demographics and Biometric

Measures.

Row, %

Current Social
Smoker Smoker Nonsmoker

Age, years
Younger than 20 7.55 8.91 83.29
21-30 12.44 13.78 73.37
31-40 21.11 13.58 64.93
41-50 23.46 10.66 65.67
51-60 21.83 7.34 70.68
Older than 60 16.85 5.23 77.50
Gender
Male 21.45 12.34 65.82
Female 13.71 8.64 77.39
Race/ethnicity
Non-Hispanic white 15.02 8.85 75.85
Non-Hispanic black 25.59 13.41 60.59
Hispanics 21.88 16.80 60.88
Asian American 12.26 9.56 77.90
Native American 30.06 21.47 47.85
Multiracial 20.52 14.51 64.20
Other 6.62 7.35 86.03
BMI
Underweight 19.85 11.42 68.19
Normal 13.55 10.33 75.79
Overweight 18.90 11.18 69.74
Obese 22.74 9.08 67.88
Blood pressure
Normal 10.36 8.83 80.49
Prehypertension 19.08 12.23 68.31 Figure 1. Proportion of participants with prehypertension/hyper-
Stage 1 hypertension 29.89 11.05 58.83 tension (A) and proportion of participants with total cholesterol >200
Stage 2 hypertension 35.54 11.17 52.97 mg/dL (B), by smoking status. Both unadjusted and adjusted rates are
Total cholesterol presented. The adjusted rates were estimated from logistic regression
<200 mg/dL 13.17 10.81 75.72 models, adjusting for demographics and other biometric measures.
200-240 mg/dL 24.98 13.68 61.02
>240 mg/dL 33.79 15.27 50.77
had lower rate of prehypertension/hypertension than current
Abbreviation: BMI, body mass index. smokers (58.4% vs 70.7%). However, the rates were compara-
ble (74.6% for social smokers vs 75.5% for current smokers),
after adjusting for demographics and other biometric measures.
Table 2 also shows smoking rates were higher among parti- The unadjusted and adjusted rates of total cholesterol >200 mg/
cipants with higher risk biometric profiles (overweight/obese, dL showed a similar pattern (Figure 1B). After adjusting for
higher blood pressure, and higher total cholesterol). For exam- other covariates, 53.3% social smokers had high cholesterol
ple, smoking rates (current smokers and social smokers) were levels versus 54.6% for current smokers.
19.2% in participants with a normal blood pressure. The rates Using logistic regression modeling, the effects of smok-
increased to 21.3%, 40.9%, and 46.7%, respectively, for those ing on cardiovascular health were estimated, adjusting for
with prehypertension, stage 1 hypertension, and stage 2 hyper- demographics (age, gender, and race/ethnicity) and other
tension. The corresponding percentages looking only at social biometric measures (eg, BMI; Table 3). Compared to non-
smokers were 8.8%, 12.2%, 11.1%, and 11.2% for these 4 smokers, social smokers had a significantly higher risk of
blood pressure categories. having hypertension (OR: 2.08, 95% CI: 1.80-2.41) and
elevated cholesterol (OR: 1.53, 95% CI: 1.33-1.75). The
estimates for current smokers were OR ¼ 2.18 (95%
Association of Smoking With Cardiovascular Health CI: 1.92-2.48) for hypertension and OR ¼ 1.61 (95%
Figure 1 shows that smoking was associated with worse CI: 1.44-1.80) for elevated cholesterol using nonsmokers
cardiovascular health. The proportions of participants with as reference. There was no significant difference between
prehypertension/hypertension were higher among smokers social smokers and current smokers in cardiovascular risks
(both current and social smokers) than that of nonsmokers (OR ¼ 0.94, 95% CI ¼ 0.80-1.14 for hypertension and
(Figure 1A). When comparing unadjusted rates, social smokers OR ¼ 0.95, 95% CI ¼ 0.81-1.11 for elevated cholesterol).
Gawlik et al. 5

Table 3. The Effect of Smoking Status on Cardiovascular Health, The findings from this study indicate that social smoking
Adjusting for Demographics and Other Biometric Measures. has an overall prevalence in adults of 10.3%. Certain ethnici-
Odds Ratio (95% CI)a
ties, age groups, and males reported significantly higher rates
of social smoking. Health-care providers need to be educated
Pre-Hypertension Total Cholesterol on social smoking and need to screen for social smoking across
Variables or Hypertension 200 mg/dL all ethnicities, ages, and genders. Males, younger, and minority
Smoking status
populations appear to be especially vulnerable to this smoking
Current smoker 2.18 (1.92-2.48) 1.61 (1.44-1.80) pattern and should be more aggressively screened. Existing
Social smoker 2.08 (1.80-2.41) 1.53 (1.33-1.75) smoking cessation modalities have only been tested and vali-
Nonsmoker Reference Reference dated in current, chronic smokers. Therapeutic and treatment
Covariates programs need to be researched and explored in this population
Age, years in order to determine the most efficacious means to achieving
Younger than 20 Reference Reference both deceleration of smoking and long-term smoking cessation.
21-30 1.82 (1.46-2.28) 1.32 (1.05-1.66)
31-40 3.08 (2.45-3.88) 1.61 (1.27-2.04)
Obtaining greater insight into the characteristics and vulner-
41-50 4.73 (3.76-5.95) 2.12 (1.68-2.66) abilities of this group could improve public health and clinician
51-60 5.07 (4.03-6.38) 2.55 (2.03-3.21) awareness and lead to improved prevention and cessation
Older than 60 8.29 (6.58-10.44) 2.47 (1.96-3.11) approaches specific to this group of individuals in addition to
Gender improved cardiovascular preventive care.
Male 1.67 (1.52-1.83) 1.22 (1.11-1.33) When providing cardiovascular assessments, health-care
Female Reference Reference providers need to be reframing the way they ask about tobacco
Race/ethnicity
Non-Hispanic white Reference Reference
use. Questions such as “Are you a smoker?” or “Do you
Non-Hispanic black 1.65 (1.45-1.88) 1.18 (1.05-1.33) smoke?” should be avoided. Questions that also capture the
Hispanics 1.25 (1.06-1.48) 1.35 (1.15-1.58) social smoking population should be encouraged such as “Do
Other 1.07 (0.90-1.27) 1.42 (1.21-1.68) you ever smoke cigarettes or use tobacco in social situations
BMI such as at bars, parties, work events, or family gatherings? “ or
Underweight Reference Reference “When was the last time you had a cigarette or used tobacco
Normal 1.82 (1.45-2.29) 1.22 (0.96-1.54) with friends?” The Joint Commission’s recent Tobacco Use
Overweight 5.53 (4.38-6.98) 2.56 (2.02-3.25)
Obese 10.83 (8.43-13.93) 3.32 (2.60-4.25)
Performance Measure Set for hospitals incorporates a similar
Blood pressure form of screening by advising that on admission all patients are
Normal NA Reference asked the question, “Have you used tobacco in the last 30 days
Prehypertension NA 2.68 (2.41-2.98) prior to hospitalization?”23 By reframing the question, more
Stage 1 hypertension NA 5.13 (4.48-5.87) social smokers can be identified, monitored, and targeted
Stage 2 hypertension NA 6.62 (5.22-8.41) accordingly for tobacco cessation modalities.
Total cholesterol
<200 mg/dL Reference NA
200-240 mg/dL 3.25 (2.93-3.61) NA Limitations
>240 mg/dL 3.64 (2.94-4.50) NA
This study has several important limitations. This study relies
Abbreviations: BMI, body mass index; CI, confidence interval; NA: not on screeners to accurately input information on the participants
applicable.
a
Derived from logistic regression modeling.
they screened. Screeners are not routinely monitored for con-
sistency and accuracy of screening and/or counseling tech-
niques. Screeners may also ask participants about their
smoking behaviors in a variety of ways that could affect the
Discussion validity of the question. Clear definitions and thresholds for the
Social smoking is documented in the literature but has not differences between current smokers, social smokers, and non-
become mainstream in health screenings. There are no large smokers are not well delineated; therefore, some overlap may
scale studies documenting the prevalence or demographics exist in those who identify themselves as current smokers
of social smokers in the adult US population. This is the verses social smokers. These issues pose the potential risk for
first population health study to demonstrate the prevalence inaccuracies and inconsistencies in quality of data and data
of social smoking in the US adult population and to com- collection.
pare the blood pressure and cholesterol levels of people who The survey instrument also has some limitations. The survey
self-identify as current verses social smokers. The Centers uses categorical data in lieu of continuous variables. In design-
for Disease Control and Prevention reports that 17.8% of ing the survey, the authors wanted to be able to make inferences
adults in the United States identify themselves as smokers.22 about categories commonly used in clinical practice. Although
The data from this population health study report current the survey instrument assesses BMI, it does not take muscle
smoking rates of 17.2%, hence demonstrating alignment verses fat into consideration. Total cholesterol was assessed as
with national statistics. the primary marker for cholesterol and is a less ideal measure
6 American Journal of Health Promotion XX(X)
for predicting cardiovascular risk than either low-density lipo-
protein (LDL) or LDL/high-density lipoprotein ratio.
This study does not assess or control for previous smoking
behavior, environmental or second-hand smoke exposure, or
other forms of tobacco use such as the use of chewing tobacco,
e-cigarettes, or smoking from a hookah. At the time of data
analysis, geographical information was not collected on parti-
cipants. These data are an important determinant and could
have influenced outcome data. The cross-sectional study
design is also a limiting factor in that conclusions cannot be
drawn about cause and effect.
Summary
This study demonstrates there is no significant difference in the
prevalence of high blood pressure or cholesterol among current
smoking and social smoking groups, hence contributing to the
growing body of knowledge that social smokers have similar
cardiovascular health risks and consequences to those of
current, every day smokers.11,24-28 Although some studies have
suggested that social smokers may not experience nicotine
dependence, social smoking is still a stable consumption pat-
tern with significant health risks.14,29,30 Clinicians need to edu-
cate patients that social smoking is still a major cardiovascular
SO WHAT? Implications For Health
Promotion Practitioners And
Researchers
What is already known on this topic?
Research has identified social smoking as a public health
concern. However, little has been documented about
prevalence, demographics, and cardiovascular risks asso-
ciated with this subsmoking population. No systematic
reviews exist on this topic.
What does this article add?
This is the first population health study to compare the
blood pressure and cholesterol levels of people who are
self-identified as current verses social smokers. The
study demonstrates there is no significant difference in
the prevalence of high blood pressure or cholesterol
among the 2 groups of smokers.
What are the implications for health promotion
practice or research?
There is an urgent need for health-care providers to
recognize social smoking as a modifiable cardiovascular
risk factor. Many individuals at risk for cardiovascular
disease are being missed. Social smoking needs to be
addressed and treated to promote optimal cardiovascu-
lar health.
health risk and should not be presented to patients as a long-
term healthy choice when contemplating smoking cessation.
Complete cessation is the only known modality that can reduce
the risk of cardiovascular and cancer morbidity and mortality
as well as slow the progression of chronic obstructive pulmon-
ary diseases.31–34
With stricter enforcement of tobacco control policies, this
smoking subpopulation will continue to grow.29 This study
provides a comprehensive look at the cardiovascular health
of a large segment of the US population and delivers insight
into the characteristics and cardiovascular risks of the social
smoking subpopulation. Cardiovascular preventive care needs
to encompass screening and counseling for social smoking, and
clinicians need increased awareness and knowledge of its exis-
tence. By including these elements in cardiovascular preven-
tive care, costs could be reduced, cardiovascular disease could
be prevented, and ultimately, more lives could be saved.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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