Although national smoking rates have steadily decreased, one area of the population has seen a dramatic increase; Light and Intermittent Smokers (LITS) now comprise roughly 25-33% of all smokers. The rates have risen dramatically in the last decade and the trend is expected to continue.1,2,3 Understanding this trend is essential in providing effective smoking cessation and prevention programs targeting this population.1,2 Smoking tobacco negatively affects virtually every organ in the human body, and regardless of quantity, smoking any tobacco is associated with an overall decrease in health as well as quality of life.4,5
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 age21,22
- Have higher levels of education22,23,24
- Have higher socioeconomic status22,24
- Have higher levels of self-control25,26
- Have lower sensation-seeking impulses25,26,27
- Smoke fewer cigarettes per smoking day28
- Report fewer physiological dependence symptoms28
- Perceive quitting as not difficult14,28
- 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.”
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
- Husten, C. G. (2009). How should we define light or intermittent smoking? Does it matter? Nicotine & Tobacco Research, 11(2), 111-121.
- White, H. R., Nagin, D., Replogle, E., & Stouthamer-Loeber, M. (2004). Racial differences in trajectories of cigarette use. Drug and Alcohol Dependence, 76, 219 – 227.
- Shiffman, S., & Paty, J. (2006). Smoking patterns and dependence: Contrasting chippers and heavy smokers. Journal of Abnormal Psychology, 115(3), 509-523.
- Salive M. C., Cornoni-Huntley J., LaCroix A. Z., Ostfield A. M., Wallace R. B., Hennekens C. H. Predictors of smoking cessation and relapse in older adults. American Journal of Public Health 1992; 82: 1268–71.
- Tait, R. J., Hulse, G. K., Waterreus, A., Flicker, L., Lautenschlager, N. T., Jamrozik, K., & Almeida, O. P. (2007). Effectiveness of a smoking cessation intervention in older adults. Addiction, 102 (1), 148-155.
- Sayette, M. A., Martin, C. S., Werz, J. M., Shiffman, S., & Perrott, M. A. (2001). A multi-dimensional analysis of cue-elicited craving in heavy smokers and tobacco chippers. Addiction, 96, 1419–1432.
- Wellman, R. J., DiFranza, J. R., & Wood, C. (2006). Tobacco chippers report diminished autonomy over smoking. Addictive Behaviors, 31, 717–721.
- Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
- Kenford, S. L., Wetter, D. W., Welsch, S. K., Stevens, S. S., Fiore, M. C., & Baker, T. B. (2005). Progression of college-age cigarette samplers: What influences outcome. Addictive Behaviors, 30, 285–294.
- Prescott, E., Scharling, H., Osler, M., & Schnohr, P. (2002). Importance of light smoking and inhalation habits on risk of myocardial infarction and all cause mortality. A 22-year follow-up of 12149 men and women in the Copenhagen City Heart Study. Journal of Epidemiology and Community Health, 56, 702 – 706.
- White, H. R., Pandina, R. J., & Chen, P. H. (2002). Developmental trajectories of cigarette use from early adolescence into young adulthood. Drug and Alcohol Dependence, 65, 167 – 178.
- Arcavi, L., Jacob, P., 3rd, Hellerstein, M., & Benowitz, N. L. (1994). Divergent tolerance to metabolic and cardiovascular effects of nicotine in smokers with low and high levels of cigarette consumption. Clinical Pharmacology and Therapeutics, 56, 55–64.
- Etter, J. F. (2004). The psychological determinants of low-rate daily smoking. Addiction, 99, 1342–1350.
- Owen N., Kent P., Wakefield M., Roberts L. (1995) Low-rate smokers. Prevention Medicine 24:80–84.
- Zvolensky, M. J., Bernstein, A., Cardenas, S. J., Colotla, V. A., Marshall, E. C., & Feldner, M. T. (2007). Anxiety sensitivity and early relapse to smoking: A test among Mexican daily, low-level smokers. Nicotine & Tobacco Research, 9, 483–491.
- Gilpin, E. A., Cavin, S. W., & Pierce, J. P. (1997). Adult smokers who do not smoke daily. Addiction, 92, 473–480.
- Biener, L., & Albers, A. B. (2004). Young adults: Vulnerable new targets of tobacco marketing. American Journal of Public Health, 94, 326–330.
- Stanton, C. A., Papandonatos, G., Lloyd-Richardson, E. E., & Niaura, R. (2007). Consistency of self-reported smoking over a 6-year interval from adolescence to young adulthood. Addiction, 102, 1831–1839.
- Gilpin, E. A., White, V. M., & Pierce, J. P. (2005). How effective are tobacco industry bar and club marketing efforts in reaching young adults? Tobacco Control, 14, 186–192.
- Morley, K. I., Hall, W. D., Hausdorf, K., & Owen, N. (2006). “Occasional” and “social” smokers: Potential target groups for smoking cessation campaigns? Australian and New Zealand Public Health, 30, 550–554.
- Shiffman S. (2009) Light and intermittent smokers: Background and perspective. Nicotine & Tobacco Research 11, 122–125.
- Wortley P.M., Husten C.G., Trosclair A., Chrismon J., Pederson L.L. (2003) Nondaily smokers: A descriptive analysis. Nicotine & Tobacco Research, 5, 755–759.
- Korhonen T., Broms U., Levälahti E., Koskenvuo M., Kaprio J. (2009) Characteristics and health consequences of intermittent smoking: Long-term follow-up among Finnish adult twins. Nicotine & Tobacco Research, 11 :148–155.
- Lindström M., Isacsson S.O. (2002) Long-term and transitional intermittent smokers: A longitudinal study. Tobacco Control, 11 :61–67.
- Presson, C. C., Chassin, L., & Sherman, S. J. (2002). Psychosocial antecedents of tobacco chipping. Health Psychology, 2 1, 384–392.
- Heyman G.M., Gibb S.P. (2006) Delay discounting in college cigarette chippers. Behavioral Pharmacology 17, 669–679.
- Odum A.L., Baumann A.A. (2007) Cigarette smokers show steeper discounting of both food and cigarettes than money. Drug and Alcohol Dependence 91, 293–296.
- Shiffman S., Sayette M.A. (2005) Validation of the nicotine dependence syndrome scale (NDSS): a criterion-group design contrasting chippers and regular smokers. Drug and Alcohol Dependence 79, 45–52.
- Coggins, C. R. E., E. L. Murrelle, et al. (2009). Light and intermittent cigarette smokers: A review (1989–2009). Psychopharmacology, 207 (3): 343-363.
- Levy, D. E., Biener, L., & Rigotti, N. A. (2009). The natural history of light smokers: A population-based cohort study. Nicotine & Tobacco Research, 11(2), 156-163.
- Barrett, S.P., Tichauer, M., Leyton, M., & Pihl, R.O. (2006). Nicotine increases alcohol self-administration in non-dependent male smokers. Drug and Alcohol Dependence, 81, 197-204.
- Harrison, E.L.R. & McKee, S.A., (2007). Young Adult Nondaily Smokers: Patterns of Alcohol and Cigarette Use, Addictive Behaviors, 33, 668-674.
- Kirchner, T. R. & Sayette, M. A. (2007). Effects of smoking abstinence and alcohol consumption on smoking-related outcome expectancies in heavy smokers and tobacco chippers. Nicotine & Tobacco Research, 9, 365-376.
- Ridner, S. L. (2005). Predicting smoking type in a college-age population. Public Health Nursing, 22, 494-505.
- Reed, M. B., McCabe, C., Lange, J. E., Clapp, J. D., & Shillington, A. M. (2010). The relationship between alcohol consumption and past-year smoking initiation in a sample of undergraduates. The American Journal Of Drug And Alcohol Abuse, 36(4), 202-207.
- U.S. Department of Health and Human Services (2014). 2014 Surgeon General's Report: The Health Consequences of Smoking—50 Years of Progress. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health.
- Okuyemi, K. S., Ahluwalia, J. S., Richter, K. P., Mayo, M. S., & Resnicow, K. (2001). Differences among African American light, moderate, and heavy smokers. Nicotine & Tobacco Research, 3, 45-50.
- Schane, R. E., Ling, P. M., & Glantz, S. A. (2010). Health effects of light and intermittent smoking a review. Circulation, 121, 1518-1522.
- Zhu, S. H., Sun, J., Hawkins, S., Pierce, J., & Cummins, S. (2003). A population study of low-rate smokers: quitting history and instability over time. Health Psychology, 22, 245-252.
- White, H. R., Bray, B. C., Fleming, C. B., & Catalano, R. F. (2009). Transitions into and out of light and intermittent smoking during emerging adulthood. Nicotine & Tobacco Research, 11, 211-219.
- Tong, E. K., Nguyen, T., Vittinghoff, E., & Pérez-Stable, E. J. (2009). Light and intermittent smoking among California's Asian Americans. Nicotine & Tobacco Research, 11, 197-202.