Light and Intermittent Smokers

Who are Light and Intermittent Smokers? Controversy in Labeling

The literature for light and intermittent smokers varies greatly in methodological approaches and measures. Most notably, these studies are inconsistent in their operational definitions for smoking groups; some focus on number of cigarettes consumed per smoking day, others focus simply on number of smoking days, while yet others focus on physiological dependence as basis for definitions. The various definitions used to label light and intermittent smokers include, but are not limited to:

• “Chippers” smoke < 5 cigarettes per day (CPD) on 2-6 days per week and never more than 10 CPD on any given day, with some studies requiring that they have smoked at this level for at least two years.^5,6,7
• “Light smokers” smoke < 10 CPD regardless of number of days per week.⁸
• “Light and Intermittent Smokers” smoke 1-39 cigarettes per week, or an average of 10 CPD, or 1-4 grams of tobacco per day, and have never smoked daily. ^4,9,10,11
• “Low-level Smokers” smoke < 20 CPD and < 1 pack per week. ^12,13
•  “Low-rate smokers” smoke < 5 CPD and never more than 10 CPD.^14,15
• “Non-daily smokers” smoke < 7 days per week and may smoke < 3 packs per week.^16,22
• “Occasional smokers” smoke < 5 CPD and smoke < 3 times per week, usually dependent on circumstances such as partying or drinking or after meals.^17,18
• “Social smokers” smoke < 5 CPD and < 7 days per week in last two years and have never exceeded that limit.^17,19,20

Discrepancies in definitions raise doubts about the reliability of conclusions drawn from these studies. Furthermore, comparative analysis between studies becomes increasingly difficult. Overall, we suggest smoking definitions and terms that are: 1) relevant to your setting and patient/consumer population and 2) based on behavior patterns rather than assumptions about motivations for smoking, which vary from person to person. For conceptualizing special populations of low-use smokers, focusing on distinguishing between those smokers with a daily pattern versus those with nondaily patterns of smoking may be most helpful, and we recommend the terms “nondaily smoker” and “Light and Intermittent Smoker”.^1,2

How do they differ from daily smokers?

In comparison to daily smokers, light and intermittent smokers tend to:

• Be younger in age^21,22
• Have higher levels of education^22,23,24
• Have higher socioeconomic status^22,24
• Have higher levels of self-control^25,26
• Have lower sensation-seeking impulses^25,26,27
• Smoke fewer cigarettes per smoking day²⁸
• Report fewer physiological dependence symptoms²⁸
• Perceive quitting as not difficult^14,28
• Drink alcohol excessively³⁸
• Be female³⁸

^​Moreover, LITS primarily emphasize the “pleasurable” aspects of smoking such as handling a cigarette in contrast to pharmacological and addiction-related motives such as craving and habit. One study reported 75% of LITS smoke only when they could really enjoy the experience while only 17% of daily smokers said the same.²⁹ These findings suggest that LITS behaviors seem to be driven by positive reinforcement, in contrast to daily smokers whose smoking behaviors are primarily driven by negative reinforcement (e.g., alleviation of withdrawal symptoms).One myth about nondaily smoking is that it’s just a stage of smoking initiation, or that all nondaily smokers will become daily smokers. Studies suggest that while not all light and intermittent smokers become daily smokers, they may be more vulnerable to daily use of tobacco as exposure to smoking is increased over time. ³⁰ Furthermore, light and intermittent smoking youth are equally as likely to either quit smoking or become heavier smokers.⁴⁰

Nondaily Smoking and Alcohol Use

Evidence suggests that alcohol use and smoking are uniquely related. Although smokers, in general, have an elevated risk of alcohol use and alcohol-related problems, there may be a strong correlation between alcohol consumption and nondaily smoking in particular. Studies show that while drinking, daily smokers report smoking more cigarettes than nondaily smokers. However, nondaily smokers report a significantly greater proportion of their smoking days as occurring on days in which they also drank alcohol. One study proposed reduced cognitive capacity as a result of alcohol consumption as the most likely reason smoking is increased following intoxication.³⁵ Additional research is needed to appreciate the mechanisms of this relation, which may be social, biological, and psychological.^31,32,33,34

Race Specific Factors

A study from 2001 revealed that 86% of African-American light smokers wanted to quit smoking, yet they were less likely to receive physician intervention compared to their white counterparts.³⁷ Asian-Americans have been found to have disproportionately higher rates of light smoking compared to their white counterparts. This may be explained by findings from genetic research showing that individuals of Asian descent have slower nicotine metabolism compared to individuals from Europe and the Middle East.⁴¹

 

Promoting Cessation for Light and Intermittent Smokers

Light and Intermittent Smokers may be characteristically different from daily smokers in terms of demographics, motives for smoking and biological effects caused by smoking. Consequently, LITS should be approached differently with regard to smoking cessation strategies. Some key points to remember when working with LITS include:

• Always use the 5A’s and Motivational Enhancement to help LITS quit smoking.
• Talk with him/her about the connection between their smoking and alcohol use, and help them to make a plan for addressing alcohol as a trigger for smoking.
• LITS may underestimate the health consequences of light or occasional smoking so providing useful information about the health risks of any level of smoking would be beneficial.
• LITS may have higher confidence in their ability to quit and higher self-control which, combined with a good plan for quitting, may help them be successful when they are ready to quit.
• LITS tend to smoke as a form of positive reinforcement, so it would be valuable to understand specifically what part of smoking they find desirable and suggest alternate methods to achieve that pleasure.
• If they are not interested in quitting, emphasize that a pattern of nondaily smoking increases the likelihood that they will become a daily smoker; send the message that, “it’s better to quit when it’s easy than wait until it’s hard.”

Closing Thoughts

Although daily smokers may consume more cigarettes than nondaily smokers, which in turn leads to increased health complications, no level of cigarette smoking is safe.^{4, 5, 36} From a cessation perspective, nondaily smokers have been neglected because it is widely believed that they are not at risk for major health complications. Studies have revealed that physicians implement fewer cessation interventions and follow-ups for light and intermittent smokers.³⁹ Additionally, many nondaily smokers mistakenly believe their level of smoking will not result in negative health consequences.^{14, 28} Regardless of how these smokers are identified in the literature, it is important to stress that any level of smoking has adverse health effects. Despite the fact LITS report fewer physiological dependence symptoms and perceive quitting as “not difficult,” this population should not be neglected as targets of cessation programs in the literature or in clinical practice.^{14, 28}