Social inequalities are an important predictor of disease incidence, including cancer. Persons with low socioeconomic status (SES) have increased rates of lung and other tobacco-related cancers. Although smoking prevalence is higher in persons with lower levels of education and occupational status, smoking prevalence does not explain this excess risk. In prospective cohort studies, the associations between low SES and elevated lung cancer risk persist after adjustment for smoking amount and duration. The investigators'overall hypothesis is that the unaccounted increased risk in populations with lower SES is due to higher smoke exposure that cannot be accounted for by self-reported smoking habits. Their previous laboratory studies demonstrate that there is a wide degree of variation in biological exposure to tobacco smoke toxins and carcinogens per cigarette smoked. The investigators propose to conduct a community-based participatory study in the medically underserved area of Appalachian Pennsylvania to determine the relationship between SES and the dose of inhaled mainstream smoke and the dose of biological markers of tobacco smoke exposure.
Specific aims are:
Specific Aim 1. Determine whether SES is associated with smoking puffing behaviors including puff volume, duration, interval, and length of cigarette smoked.
Specific Aim 2. Determine whether SES is associated with biomarkers of smoking exposure including salivary cotinine and expired carbon monoxide. This addresses the SES hypothesis using biological measures of dose in addition to environmental measures such as puffing dose.
Specific Aim 3. Correlate environmental and biological measures of smoke exposure.
This aim will determine whether levels of mainstream smoke exposure, as estimated by puffing profiles are determinants of the biological levels of cigarette smoke exposure, and whether this relationship differs by SES. This brings together aims 1 and 2 to comprehensively address the SES hypothesis.
Specific Aim 4. Determine the effects of psychological stress, as assessed by psychological scales and salivary stress biomarkers, on smoking puffing parameters and salivary cotinine levels. The proposed research study will be conducted in Appalachia, Pennsylvania (PA), a NIH-designated medically underserved but socioeconomically diverse population. The investigators predict that lower SES is associated with higher smoke intake as determined by topography and smoke biomarkers, and that this finding will help to explain the long-observed patterns of lung cancer incidence disparities.

Public Health Relevance

A major objective of cancer control efforts is to understand the causes of social inequalities in cancer rates. Cigarette smokers of lower socioeconomic status (SES) have increased rates of lung cancer and other tobacco-related diseases than smokers of higher SES. Because smoking is a modifiable behavior, findings that demonstrate more intensive smoking and greater exposure to tobacco smoke among low SES smokers may be helpful in developing more effective and targeted smoking control efforts.

National Institute of Health (NIH)
National Institute on Drug Abuse (NIDA)
Research Project (R01)
Project #
Application #
Study Section
Risk, Prevention and Intervention for Addictions Study Section (RPIA)
Program Officer
Kimmel, Heather L
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Pennsylvania State University
Public Health & Prev Medicine
Schools of Medicine
United States
Zip Code
Stennett, Andrea; Krebs, Nicolle M; Liao, Jason et al. (2018) Ecological momentary assessment of smoking behaviors in native and converted intermittent smokers. Am J Addict 27:131-138
Hobkirk, Andréa L; Krebs, Nicolle M; Muscat, Joshua E (2018) Income as a moderator of psychological stress and nicotine dependence among adult smokers. Addict Behav 84:215-223
Joseph, Sarah; Krebs, Nicolle M; Zhu, Junjia et al. (2018) Differences in nicotine dependence, smoke exposure and consumer characteristics between smokers of machine-injected roll-your-own cigarettes and factory-made cigarettes. Drug Alcohol Depend 187:109-115
Chen, Allshine; Krebs, Nicolle M; Zhu, Junjia et al. (2018) Nicotine metabolite ratio predicts smoking topography: The Pennsylvania Adult Smoking Study. Drug Alcohol Depend 190:89-93
Wasserman, Emily J; Reilly, Samantha M; Goel, Reema et al. (2018) Comparison of Biomarkers of Tobacco Exposure between Premium and Discount Brand Cigarette Smokers in the NHANES 2011-2012 Special Sample. Cancer Epidemiol Biomarkers Prev 27:601-609
Chen, Allshine; Krebs, Nicolle M; Zhu, Junjia et al. (2017) Sex/Gender Differences in Cotinine Levels Among Daily Smokers in the Pennsylvania Adult Smoking Study. J Womens Health (Larchmt) 26:1222-1230
Krebs, Nicolle M; Chen, Allshine; Zhu, Junjia et al. (2016) Comparison of Puff Volume With Cigarettes per Day in Predicting Nicotine Uptake Among Daily Smokers. Am J Epidemiol 184:48-57
Branstetter, Steven A; Mercincavage, Melissa; Muscat, Joshua E (2015) Predictors of the Nicotine Dependence Behavior Time to the First Cigarette in a Multiracial Cohort. Nicotine Tob Res 17:819-24
Conway, David I; Brenner, Darren R; McMahon, Alex D et al. (2015) Estimating and explaining the effect of education and income on head and neck cancer risk: INHANCE consortium pooled analysis of 31 case-control studies from 27 countries. Int J Cancer 136:1125-39
Branstetter, Steven A; Lengerich, Eugene; Dignan, Mark et al. (2015) Knowledge and perceptions of tobacco-related media in rural Appalachia. Rural Remote Health 15:3136

Showing the most recent 10 out of 12 publications