The inequitable distribution of tobacco outlet density: the role of income in two Black Mid-Atlantic geopolitical areas

Neighbourhood inequities in the availability of retailers selling tobacco products: a systematic review

OBJECTIVE

To examine inequities in tobacco retailer availability by neighbourhood-level socioeconomic, racial/ethnic and same-sex couple composition.

DATA SOURCES

We conducted a 10 November 2022 search of PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus.

STUDY SELECTION

We included records from Organisation for Economic Co-operation and Development member countries that tested associations of area-level measures of tobacco retailer availability and neighbourhood-level sociodemographic characteristics. Two coders reviewed the full text of eligible records (n=58), including 41 records and 205 effect sizes for synthesis.

DATA EXTRACTION

We used dual independent screening of titles, abstracts and full texts. One author abstracted and a second author confirmed the study design, location, unit of analysis, sample size, retailer data source, availability measure, statistical approach, sociodemographic characteristic and unadjusted effect sizes.

DATA SYNTHESIS

Of the 124 effect sizes related to socioeconomic inequities (60.5% of all effect sizes), 101 (81.5%) indicated evidence of inequities. Of 205 effect sizes, 69 (33.7%) tested associations between retailer availability and neighbourhood composition of racially and ethnically minoritised people, and 57/69 (82.6%) documented inequities. Tobacco availability was greater in neighbourhoods with more Black, Hispanic/Latine and Asian residents (82.8%, 90.3% and 40.0% of effect sizes, respectively). Two effect sizes found greater availability with more same-sex households.

CONCLUSIONS

There are stark inequities in tobacco retailer availability. Moving beyond documenting inequities to partnering with communities to design, implement, and evaluate interventions that reduce and eliminate inequities in retail availability is needed to promote an equitable retail environment.

PROSPERO REGISTRATION NUMBER

CRD42019124984.

The Association between State-Level Structural Racism and Alcohol and Tobacco Use Behaviors among a National Probability Sample of Black Americans

BACKGROUND

Structural racism is how society maintains and promotes racial hierarchy and discrimination through established and interconnected systems. Structural racism is theorized to promote alcohol and tobacco use, which are risk factors for adverse health and cancer-health outcomes. The current study assesses the association between measures of state-level structural racism and alcohol and tobacco use among a national sample of 1,946 Black Americans.

METHODS

An existing composite index of state-level structural racism including five dimensions (subscales; i.e., residential segregation and employment, economic, incarceration, and educational inequities) was merged with individual-level data from a national sample dataset. Hierarchical linear and logistic regression models, accounting for participant clustering at the state level, assessed associations between structural racism and frequency of alcohol use, frequency of binge drinking, smoking status, and smoking frequency. Two models were estimated for each behavioral outcome, one using the composite structural racism index and one modeling dimensions of structural racism in lieu of the composite measure, each controlling for individual-level covariates.

RESULTS

Results indicated positive associations between the incarceration dimension of the structural racism index and binge drinking frequency, smoking status, and smoking frequency. An inverse association was detected between the education dimension and smoking status.

CONCLUSIONS

Results suggest that state-level structural racism expressed in incarceration disparities, is positively associated with alcohol and tobacco use among Black Americans.

IMPACT

Addressing structural racism, particularly in incarceration practices, through multilevel policy and intervention may help to reduce population-wide alcohol and tobacco use behaviors and improve the health outcomes of Black populations.

Tobacco and Alcohol Retailer Availability and Neighborhood Racialized, Economic, and Racialized Economic Segregation in North Carolina

BACKGROUND

Despite evidence of racialized and socioeconomic inequities in tobacco and alcohol outlet availability, few studies have investigated spatial inequities in areas experiencing both concentrated residential racialized segregation and socioeconomic disadvantage. This study examined whether segregation-racialized, economic or both-was associated with alcohol and tobacco retailer counts in North Carolina (NC).

METHODS

The NC Alcoholic Beverage Control Commission provided lists of 2021 off-premise alcohol retailers. We created a list of 2018 probable tobacco retailers using ReferenceUSA. We calculated three census tract-level measures of the Index of Concentrations at the Extremes (ICE), indicating racialized segregation between non-Hispanic White and Black residents and economic segregation based on household income. We used negative binomial regression to test associations between quintiles of each ICE measure and tobacco and, separately, alcohol retailer counts.

RESULTS

Tracts with the greatest racialized disadvantage had 38% (IRR, 1.38; 95% CI, 1.15-1.66) and 65% (IRR, 1.65; 95% CI, 1.34-2.04) more tobacco and alcohol outlets, respectively, as tracts with the lowest. Tracts with the highest racialized economic disadvantage had a predicted count of 1.51 tobacco outlets per 1000 people while those in the lowest had nearly one fewer predicted outlet. Similar inequities existed in the predicted count of alcohol outlets.

DISCUSSION

Tobacco and alcohol outlet availability are higher in NC places experiencing concentrated racialized and economic segregation. A centralized agency overseeing tobacco and alcohol outlet permits and strategies to reduce the retail availability of these harmful products (e.g., capping the number of permits) are needed to intervene upon these inequities.

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Retailer experiences with tobacco sales bans: lessons from two early adopter jurisdictions

BACKGROUND

Beverly Hills and Manhattan Beach, California, are the first two US cities to prohibit the sale of tobacco products, passing ordinances that went into effect on 1 January 2021. We sought to learn about retailers' experiences with these laws 22 months after implementation.

METHODS

Brief in-person interviews with owners or managers of businesses that formerly sold tobacco (n=22).

RESULTS

Participant experiences varied by type of retailer. Managers at large chain stores reported no problems adapting to the law and little effect on overall sales. Many were largely indifferent to the sales bans. By contrast, most managers or owners of small, independent retailers reported losses of both revenue and customers, and expressed dissatisfaction with the laws. Small retailers in Beverly Hills objected particularly to exemptions that city made allowing hotels and cigar lounges to continue their sales, which they saw as undermining the health rationale for the law. The small geographical area covered by the policies was also a source of frustration, and retailers reported that they had lost business to retailers in nearby cities. The most common advice small retailers had for other retailers was to organise to oppose any similar attempts in their cities. A few retailers were pleased with the law or its perceived effects, including a reduction in litter.

CONCLUSION

Planning for tobacco sales ban or retailer reduction policies should include considering impacts on small retailers. Adopting such policies in as wide a geographical area as possible, as well as allowing no exemptions, may help reduce opposition.

Patient Engagement by the Tobacco Quitline After Electronic Referrals

INTRODUCTION

Referrals through the electronic health record (EHR) system provide an efficient evidence-based method to connect patients to the Tobacco Quitline. However, patients frequently do not respond to Quitline phone calls or accept services. The goal of this study was to characterize factors associated with successful engagement with Quitline following e-referrals by physicians in Maryland.

AIMS AND METHODS

This is a cross-sectional study with hierarchical data modeling. Data for 1790 patients e-referred in 2018-2019 by the University of Maryland Medical System (UMMS) were analyzed. Patients' engagement was assessed using a generalized estimating equation multivariable regression model for ordinal outcomes at two levels: Picking up a phone call from Quitline (1-800-QUIT-NOW) and enrollment in tobacco cessation programs.

RESULTS

Older age, female gender, black race, low socioeconomic status, and provider's skills were significantly associated with successful outcomes of Quitline referral. The engagement with Quitline was higher in black non-Hispanic patients compared to other racial/ethnic groups (phone call response odds ratio [OR] = 1.99, 95% confidence interval [CI] = 1.35% to 2.93% and service acceptance OR = 1.89, 95% CI = 1.28% to 2.79%). Patients residing in socioeconomically deprived areas were more likely to respond to Quitline phone calls compared to those from affluent neighborhoods (OR = 1.52, 95% CI = 1.03% to 2.25%). Patients referred by faculty or attending physicians were more likely to respond compared to those referred by residents (OR = 1.23, 95% CI 1.04, 1.44, p = .0141).

CONCLUSIONS

Multiple factors impact successful engagement with Quitline. Additional means to improve Quitline engagement success may include focused messaging on tobacco cessation benefits to patients, and skillful counseling by the provider.

IMPLICATIONS

Implementation of the clinical decision support (CDS) tool for electronic referrals to the Tobacco Quitline at the UMMS was successful in providing evidence-based free service to elderly patients and socioeconomically disadvantaged racial and ethnic minorities. The CDS also served to engage physicians in conversation about tobacco use and cessation with every tobacco-using patient. Curricular content for physicians in training should be enriched to expand tobacco use and treatment.

The Association Between Tobacco Retailer Outlet Density and Prevalence of Cigarette Smoking in Virginia

OBJECTIVE

We examine the association between tobacco retail outlet density and adult smoking prevalence at the county level in Virginia, controlling for spatial autocorrelations.

AIMS AND METHODS

Pooling data from 2020 County Health Rankings (compiled data from various sources including, but not limited to, the National Center for Health Statistics-Mortality Files, the Behavioral Risk Factor Surveillance System (BRFSS), and the American Community Survey) and Counter Tools, we conducted regression analyses that accounted for spatial autocorrelation (spatial lag models, LMlag) and adjusted for county-level access to healthcare, demographics, SES, environmental factors, risk conditions or behaviors, and population health measures.

RESULTS

Our estimates provide evidence that every increase of one tobacco retail outlet per 1000 persons was associated with 1.16 percentage points (95% CI: 0.80-1.52) higher smoking prevalence at the county level in Virginia after controlling for spatial autocorrelation. The effect of outlet density was largely explained by social determinants of health such as SES, risky conditions or behaviors, and environmental factors. We further noticed that the impact of social determinants of health were closely related and can be explained by indicators of population health (rates of mental distress (β = 1.49, 95% CI: 1.31-1.67) and physical inactivity (β = 0.07, 95% CI: 0.04-0.10).

CONCLUSIONS

Although higher tobacco outlet density was associated with an increase in county-level smoking prevalence, the impact of outlet density was largely explained by social determinants of health and mental illness. Improving well-being at the community level could be a promising strategy in future tobacco control policies.

IMPLICATION

The influence of tobacco outlet density seems to be explained by other social determinants of health and population level of mental or physical health. Thus, efforts to reduce tobacco use and consequent negative health effects should explore the impact of improving regional living standards. However, a sole focus on economic growth may not be sufficient, whereas a focus on such things as promoting work-life balance and improving overall well-being at the community level may be more.

Variations in Tobacco Retailer Type Across Community Characteristics: Place Matters

Introduction

The density of tobacco retailers varies by community characteristics such as poverty levels or racial and ethnic composition. However, few studies have investigated how specific types of tobacco retailers vary by community characteristics. Our objective was to assess how the types of tobacco retailers in Ohio varied by the characteristics of the communities in which they were located.

Results

For all US Census tracts, convenience stores were the most common type of retailer selling tobacco. Yet, the prevalence of convenience stores was higher in high-poverty urban tracts than in low-poverty urban tracts. Discount stores were the second-most common type of tobacco retailer and were most prevalent in rural tracts and high-racial and ethnic minority urban tracts. Grocery stores, pharmacies, and vape or hookah shops typically had the highest prevalence in more advantaged tracts.

Conclusion

Our findings demonstrate that the distribution of specific retailer types varies by community characteristics. The distribution of these retailer types has implications for product availability and price, which may subsequently affect tobacco use and cessation. To create equitable outcomes, policies should focus on retailers such as convenience and discount stores, which are heavily located in communities experiencing tobacco-related health disparities.

'We're not gonna have a big quit if loose ones are around': urban, African American smokers' beliefs concerning single cigarette use reduction

Single cigarette use (i.e. loosies, loose ones, singles) poses risks for smoking continuation among urban, African American smokers. There is, however, limited research to inform health education interventions addressing this behavior. We conducted 25 in-depth interviews with urban, African American users (ages 20-58 years) from Baltimore, MD and the District of Columbia in June and July 2018 to assess their beliefs about reducing single cigarette use. Interviews were guided by the Health Belief Model and its constructs of perceived benefits, perceived barriers, perceived susceptibility, perceived severity and self-efficacy. We analyzed qualitative data using framework analysis. Perceived benefits of reducing single cigarette use involved the avoidance of health risks, including concerns about buying fake cigarettes and exposure to unknown personal hygiene practices from sellers. Perceived barriers were the convenience of buying singles due to their availability, accessibility and low cost. Participants shared they were willing to use cognitive behavioral strategies to reduce their purchasing and use of singles. This study provides insights on potential intervention targets related to beliefs towards reducing single cigarette use. These findings can inform enforcement policies and health education interventions targeting single cigarette use among urban, African American smokers who use singles.

Spatial analysis of tobacco outlet density on secondhand smoke exposure and asthma health among children in Baltimore City

RATIONALE

Tobacco outlets are concentrated in low-income neighbourhoods; higher tobacco outlet density is associated with increased smoking prevalence. Secondhand smoke (SHS) exposure has significant detrimental effects on childhood asthma. We hypothesised there was an association between higher tobacco outlet density, indoor air pollution and worse childhood asthma.

METHODS

Baseline data from a home intervention study of 139 children (8-17 years) with asthma in Baltimore City included residential air nicotine monitoring, paired with serum cotinine and asthma control assessment. Participant addresses and tobacco outlets were geocoded and mapped. Multivariable regression modelling was used to describe the relationships between tobacco outlet density, SHS exposure and asthma control.

RESULTS

Within a 500 m radius of each participant home, there were on average six tobacco outlets. Each additional tobacco outlet in a 500 m radius was associated with a 12% increase in air nicotine (p<0.01) and an 8% increase in serum cotinine (p=0.01). For every 10-fold increase in air nicotine levels, there was a 0.25-point increase in Asthma Therapy Assessment Questionnaire (ATAQ) score (p=0.01), and for every 10-fold increase in serum cotinine levels, there was a 0.54-point increase in ATAQ score (p<0.05).

CONCLUSIONS

Increased tobacco outlet density is associated with higher levels of bedroom air nicotine and serum cotinine. Increasing levels of SHS exposure (air nicotine and serum cotinine) are associated with less controlled childhood asthma. In Baltimore City, the health of children with asthma is adversely impacted in neighbourhoods where tobacco outlets are concentrated. The implications of our findings can inform community-level interventions to address these health disparities.

Piloting a spatial mixed method for understanding neighborhood tobacco use disparities

The tobacco retail environment is where most advertising dollars are spent. However, most research on the retail environment has not methodologically situated tobacco retailers as part of a larger community, and few studies have incorporated community member perspectives of their own tobacco use in relation to their local environments. The purpose of this study is to describe and evaluate a multilevel, multimodal, mixed methods approach for understanding tobacco use in context. We combine quantitative data collected from tobacco retailer audits and geographically-explicit interviews with neighborhood residents to tell a more complete story of tobacco use behavior among adults in San Francisco's Marina district, and the Oakland Coliseum neighborhood in Alameda County, California. We find that while area-level and retail data provide a broad snapshot of two distinct communities with respect to sociodemographic characteristics and tobacco availability, interviews with community residents who use tobacco add important perspectives regarding how tobacco retailers are viewed and how residents interact with their neighborhood landscapes on a daily basis. The method we describe and critique has the potential to be scaled to incorporate a broader set of geographies, or tailored to address a multitude of health-related questions. Our approach further demonstrates the utility of including geolocated participant narratives as a means of understanding where researcher interpretations of urban environments diverge from those of community residents.

Black, white, or green? The effects of racial composition and socioeconomic status on neighborhood-level tobacco outlet density

Objective: To compare predominantly-Black and predominantly-White Maryland areas with similar socioeconomic status to examine the role of both race and socioeconomic status on tobacco outlet availability and tobacco outlet access.Design: Maryland tobacco outlet addresses were geocoded with 2011-2015 American Community Survey sociodemographic data. Two-sample t-tests were conducted comparing the mean values of sociodemographic variables and tobacco outlet density per Census Tract, and spatial lag based regression models were conducted to analyze the direct association between covariables and tobacco outlet density while accounting for spatial dependence between and within jurisdictions.Results: Predominantly-White jurisdictions had lower tobacco outlet availability and access than predominantly-Black jurisdictions, despite similar socioeconomic status. Spatial lag model results showed that median household income and vacant houses had consistent associations with tobacco outlet density across most of the jurisdictions analyzed, and place-based spatial lag models showed direct associations between predominantly-Black jurisdictions and tobacco outlet availability and access.Conclusion: Predominantly-White areas have lower levels of tobacco outlet density than predominantly-Black areas, despite both areas having similar socioeconomic statuses.

The legacy of redlining: Associations between historical neighborhood mapping and contemporary tobacco retailer density in Ohio

In the 1930s United States, urban neighborhoods were graded on their desirability for investment (often based on race), a process known as "redlining." This study examined how historical redlining relates to current disparities in an important health determinant: tobacco retailer density. Analyses were conducted for thirteen Ohio cities using negative binomial models that accounted for retailer spatial dependence and controlled for present-day sociodemographic characteristics. Findings indicated that as grades increased from "Best" to "Still Desirable" to "Definitely Declining" and "Hazardous," retailer density increased monotonically. These results highlight the persisting impacts of redlining and how disparities, once intentionally created, can be perpetuated over time.

Are Waterpipe Café, Vape Shop, and Traditional Tobacco Retailer Locations Associated with Community Composition and Young Adult Tobacco Use in North Carolina and Virginia?

PURPOSE

We examined whether waterpipe café, vape shop, and traditional tobacco retailer (e.g. stores selling cigarettes, cigars, smokeless tobacco) locations were associated with census tract composition and tobacco use among young adults in North Carolina and Virginia. Methods: We identified waterpipe cafés, vape shops, and traditional tobacco retailers in North Carolina and Virginia and conducted multivariable analyses between community characteristics (gender, race, ethnicity, education, college enrollment, and poverty) and density per 1000 population. Using fall 2017 data from 1099 young adults residing in North Carolina and Virginia, we conducted logistic regression analyses to determine whether tobacco retailer density and proximity were associated with tobacco use. Results: Waterpipe café, vape shop, and traditional retailer density were higher in communities with more people who were Hispanic, college-educated, and college-enrolled (each p < .05). Waterpipe café and traditional retailer density were higher in communities with more people living below the poverty level (each p < .05). Waterpipe café density was higher in communities with more people who were male (p < .05), while traditional retailer density was lower (p < .05). Waterpipe café and vape shop proximity were associated with increased likelihood of waterpipe tobacco use in the past 6 months (each p < .05; unadjusted). Traditional retailer proximity and waterpipe café, vape shop, and traditional retailer density were not associated with tobacco use. Conclusions: Waterpipe cafés and vape shops are located in both impoverished and college-educated communities in North Carolina and Virginia, similar to where traditional tobacco retailers are located. Further research is needed to examine associations with tobacco use.

Sociodemographic Disparities in the Tobacco Retail Environment in Washington, DC: A Spatial Perspective

Objective

Studies assessing sociodemographic disparities in the tobacco retail environment have relied heavily on non-spatial analytical techniques, resulting in potentially misleading conclusions. We utilized a spatial analytical framework to evaluate neighborhood sociodemographic disparities in the tobacco retail environment in Washington, DC (DC) and the DC metropolitan statistical area (DC MSA).

Methods

Retail tobacco availability for DC (n=177) and DC MSA (n=1,428) census tract was assessed using adaptive-bandwidth kernel density estimation. Density surfaces were constructed from DC (n=743) and DC MSA (n=4,539) geocoded tobacco retailers. Sociodemographics were obtained from the 2011-2015 American Community Survey. Spearman's correlations between sociodemographics and retail density were computed to account for spatial autocorrelation. Bivariate and multivariate spatial lag models were fit to predict retail density.

Results

DC and DC MSA neighborhoods with a higher percentage of Hispanics were positively correlated with retail density (rho = .3392, P = .0001 and rho = .1191, P = .0000, respectively). DC neighborhoods with a higher percentage of African Americans were negatively correlated with retail density (rho = -.3774, P = .0000). This pattern was not significant in DC MSA neighborhoods. Bivariate and multivariate spatial lag models found a significant inverse relationship between the percentage of African Americans and retail density (Beta = -.0133, P = .0181 and Beta = -.0165, P = .0307, respectively).

Conclusions

Associations between neighborhood sociodemographics and retail density were significant, although findings regarding African Americans are inconsistent with previous findings. Future studies should analyze other geographic areas, and account for spatial autocorrelation within their analytic framework.

Locations of licensed and unlicensed cannabis retailers in California: A threat to health equity?

This study examined whether unlicensed and licensed cannabis retailers in California are disproportionately located in neighborhoods with minority populations or populations living below the Federal Poverty Level. We mapped the locations of licensed and unlicensed cannabis retailers in California in October 2018, combining advertisements from cannabis websites with licensing data. Demographic characteristics of neighborhoods with and without licensed and/or unlicensed cannabis retailers were compared. We identified 1110 cannabis retailers in California (448 licensed and 662 unlicensed). Relative to neighborhoods without retailers, neighborhoods with retailers had higher proportions of Hispanics, African Americans, and residents living below the poverty level. Compared with neighborhoods with only licensed retailers, neighborhoods with only unlicensed retailers had higher proportions of Hispanics and African Americans, and lower proportions of non-Hispanic whites. Neighborhoods with both licensed and unlicensed retailers had higher proportions of African Americans, Asian Americans, and people living in poverty, relative to neighborhoods with only licensed retailers. Unlicensed retailers were disproportionately located in unincorporated areas and jurisdictions that allow cannabis retailers. Minority populations in California are disproportionately exposed to unlicensed cannabis retailers, potentially exacerbating health disparities by selling unregulated products or selling to minors.

The Potential of Smartphone Apps in Informing Protobacco and Antitobacco Messaging Efforts Among Underserved Communities: Longitudinal Observational Study

Background

People from underserved communities such as those from lower socioeconomic positions or racial and ethnic minority groups are often disproportionately targeted by the tobacco industry, through the relatively high levels of tobacco retail outlets (TROs) located in their neighborhood or protobacco marketing and promotional strategies. It is difficult to capture the smoking behaviors of individuals in actual locations as well as the extent of exposure to tobacco promotional efforts. With the high ownership of smartphones in the United States—when used alongside data sources on TRO locations—apps could potentially improve tobacco control efforts. Health apps could be used to assess individual-level exposure to tobacco marketing, particularly in relation to the locations of TROs as well as locations where they were most likely to smoke. To date, it remains unclear how health apps could be used practically by health promotion organizations to better reach underserved communities in their tobacco control efforts.

Objective

This study aimed to demonstrate how smartphone apps could augment existing data on locations of TROs within underserved communities in Massachusetts and Texas to help inform tobacco control efforts.

Methods

Data for this study were collected from 2 sources: (1) geolocations of TROs from the North American Industry Classification System 2016 and (2) 95 participants (aged 18 to 34 years) from underserved communities who resided in Massachusetts and Texas and took part in an 8-week study using location tracking on their smartphones. We analyzed the data using spatial autocorrelation, optimized hot spot analysis, and fitted power-law distribution to identify the TROs that attracted the most human traffic using mobility data.

Results

Participants reported encountering protobacco messages mostly from store signs and displays and antitobacco messages predominantly through television. In Massachusetts, clusters of TROs (Dorchester Center and Jamaica Plain) and reported smoking behaviors (Dorchester Center, Roxbury Crossing, Lawrence) were found in economically disadvantaged neighborhoods. Despite the widespread distribution of TROs throughout the communities, participants overwhelmingly visited a relatively small number of TROs in Roxbury and Methuen. In Texas, clusters of TROs (Spring, Jersey Village, Bunker Hill Village, Sugar Land, and Missouri City) were found primarily in Houston, whereas clusters of reported smoking behaviors were concentrated in West University Place, Aldine, Jersey Village, Spring, and Baytown.

Conclusions

Smartphone apps could be used to pair geolocation data with self-reported smoking behavior in order to gain a better understanding of how tobacco product marketing and promotion influence smoking behavior within vulnerable communities. Public health officials could take advantage of smartphone data collection capabilities to implement targeted tobacco control efforts in these strategic locations to reach underserved communities in their built environment.

Association between neighborhood socioeconomic status, tobacco store density and smoking status in pregnant women in an urban area

Smoking during pregnancy can lead to serious health consequences. Given such health risks, an understanding of factors that influence maternal smoking behaviors during pregnancy is critical. The objective of this study is to assess the relationship between tobacco store density, neighborhood socioeconomic status, and neighborhood rates of maternal smoking during pregnancy. Fifty-five community areas in Baltimore City were summarized using data from the Neighborhood Health Profiles. Associations between tobacco store density and smoking while pregnant in a community were determined using Moran's I and spatial regression analyses to account for autocorrelation. The fully adjusted model took into account the following community-level socioeconomic variables as covariates: neighborhood median income, percentage of those living in poverty, percentage of uninsured, and percentage of persons with at least a college degree. In regards to the findings, the percentage of women by community area who identified as actively smoking while pregnant was 10.4% ± 5.8%. The tobacco store density was 21.0 ± 12.7 per 10,000 persons (range 0.0-49.1 tobacco store density per 10,000 persons). In the adjusted model, an increase in density of 1 tobacco store per 10,000 persons was associated with a 10% increase in women who reported smoking during pregnancy (β = 0.10, p = 0.04). In conclusion, tobacco store density and neighborhood socioeconomic factors were associated with prevalence of maternal smoking while pregnant. These findings support the need to further assess and develop interventions to reduce the impact of tobacco store density on smoking behaviors and health risks in communities.

Tobacco industry and public health responses to state and local efforts to end tobacco sales from 1969-2020

BACKGROUND

In June 2019, Beverly Hills, California, became the first American city in the 21st century to pass an ordinance ending the sale of most tobacco products, including cigarettes, and it is unlikely to be the last. Knowledge of previous efforts to ban tobacco sales in the US, both successful and unsuccessful, may help inform tobacco control advocates' approach to future efforts.

METHODS

We retrieved and analyzed archival tobacco industry documents. We confirmed and supplemented information from the documents with news media coverage and publicly available state and local government materials, such as meeting minutes and staff reports, related to proposed bans.

RESULTS

We found 22 proposals to end the sale of cigarettes or tobacco products from 1969-2020 in the US. Proposals came from five states, twelve cities or towns, and one county. Most came from elected officials or boards of health, and were justified on public health grounds. In opposing tobacco sales bans, the tobacco industry employed no tactics or arguments that it did not also employ in campaigns against other tobacco control measures. Public health groups typically opposed sales ban proposals on the grounds that they were not evidence-based. This changed with Beverly Hills' 2019 proposal, with public health organizations supporting this and other California city proposals because of their likely positive health impacts. This support did not always translate into passage of local ordinances, as some city council members expressed reservations about the impact on small businesses.

CONCLUSION

Tobacco control advocates are likely to encounter familiar tobacco industry tactics and arguments against tobacco sales ban proposals, and can rely on past experience and the results of a growing body of retail-related research to counter them. Considering how to overcome concerns about harming retailers will likely be vital if other jurisdictions are to succeed in ending tobacco sales.

The Association Between Neighborhood Socioeconomic Disadvantage and Chronic Obstructive Pulmonary Disease

Rationale

Individual socioeconomic status has been shown to influence the outcomes of patients with chronic obstructive pulmonary disease (COPD). However, contextual factors may also play a role. The objective of this study is to evaluate the association between neighborhood socioeconomic disadvantage measured by the area deprivation index (ADI) and COPD-related outcomes.

Methods

Residential addresses of SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) subjects with COPD (FEV₁/FVC <0.70) at baseline were geocoded and linked to their respective ADI national ranking score at the census block group level. The associations between the ADI and COPD-related outcomes were evaluated by examining the contrast between participants living in the most-disadvantaged (top quintile) to the least-disadvantaged (bottom quintile) neighborhood. Regression models included adjustment for individual-level demographics, socioeconomic variables (personal income, education), exposures (smoking status, packs per year, occupational exposures), clinical characteristics (FEV₁% predicted, body mass index) and neighborhood rural status.

Results

A total of 1800 participants were included in the analysis. Participants residing in the most-disadvantaged neighborhoods had 56% higher rate of COPD exacerbation (P<0.001), 98% higher rate of severe COPD exacerbation (P=0.001), a 1.6 point higher CAT score (P<0.001), 3.1 points higher SGRQ (P<0.001), and 24.6 meters less six-minute walk distance (P=0.008) compared with participants who resided in the least disadvantaged neighborhoods.

Conclusion

Participants with COPD who reside in more-disadvantaged neighborhoods had worse COPD outcomes compared to those residing in less-disadvantaged neighborhoods. Neighborhood effects were independent of individual-level socioeconomic factors, suggesting that contextual factors could be used to inform intervention strategies targeting high-risk persons with COPD.

School proximity and census tract correlates of e-cigarette specialty retail outlets (vape shops) in central Texas

E-cigarettes are the most widely used tobacco product among middle and high school students in the United States. This study investigates the proximity of e-cigarette retail outlets (vape shops) to middle and high schools in Austin, Texas, as well as the sociodemographic determinants of outlet presence, at the census tract level. A proximity analysis was conducted using school geo-data derived from the Texas Education Agency and vape shop geo-data derived from a validated online search. Logistic regressions using 5-year estimates of the 2014 American Community Survey were performed to determine the correlates of vape shop presence in census tracts. Overall, 20% of the census tracts in Austin, Texas, had at least one vape shop. The proportion of vape shop-containing census tracts that met the criteria for classification as a “poverty area” (36.5%) was greater than that of vape shop-free census tracts (26.3%). Vape shops were more likely to be present in census tracts classified as poverty areas; however, the odds of vape shop presence declined as the percentage of the non-Hispanic Black population and the percentage of persons aged 10–14 years in census tracts increased. About 40% of the vape shops were located within 0.5 miles of a middle or high school. Sociodemographic disparities exist in the e-cigarette retail environment. In addition to the need to address the disparities identified in this study, our results showing the presence of vape shops within walkable distances of schools calls for tighter regulations and continued surveillance around the marketing practices of e-cigarette retailers.

Social Capital and Tobacco Retail Outlet Density: An Empirical Test of the Relationship

PURPOSE

To examine the relationship between tobacco outlet density and social capital.

PARTICIPANTS

Parents of at least one teen (N = 2734) in a representative sample of US households with teens (ages 13-16).

DESIGN

Population-based, cross-sectional survey of a web panel of adolescent-parent pairs matched with spatial data for address to characterize household neighborhoods.

SETTING

US households identified by latitude and longitude with a 50-ft random shift.

MEASURES

Perceived social capital (trust and informal social control as reported by parents), tobacco outlet density (retailers per land area in 1/2-mile buffer around each household), neighborhood demographics (derived from American Community Survey), and parent demographics.

ANALYSIS

Multivariable regression examined the relationship between tobacco outlet density and social capital controlling for household buffer and individual-level covariates, including correlates of social capital.

RESULTS

Tobacco outlet density was inversely correlated with perceived trust in neighbors (B = -1.12, P = .0004), but not social control (B = 0.11, P = .731).

CONCLUSION

This study is the first we are aware of to find that social capital is related to tobacco outlet density. The results imply that individuals with low social capital may benefit from policies regulating tobacco outlet density and may benefit from policies that address neighborhood inequality by increasing social capital and reducing poverty.

Does Tobacco Outlet Inequality Extend to High-White Mid-Atlantic Jurisdictions? A Study of Socioeconomic Status and Density

Tobacco outlet density research has evolved to require a more refined examination of socioeconomic status' influence beyond median household income. This study investigates the effects of SES on census-tract-level tobacco outlet density in five predominantly White Maryland jurisdictions. Tobacco license addresses and demographic data were analyzed via t tests and spatial lag modeling. Results showed that higher SES jurisdictions had lower tobacco outlet density than lower SES jurisdictions despite similar White populations and that median household income had consistent associations with tobacco outlet density. This study corroborates findings that differences in SES correlate with differences in tobacco outlet density between racially similar areas.

E-Cigarettes in Baltimore Alcohol Outlets: Geographic and Demographic Correlates of Availability

There is limited research on e-cigarette availability despite increased use. E-cigarette availability within Baltimore alcohol outlets was analyzed for disparities among residential neighborhoods. Data were obtained via field surveys of alcohol outlets, and then spatially merged with sociodemographic data; 18.8% of alcohol outlets had any e-cigarette availability. Regression models showed greater odds ratios for e-cigarette availability when cigarettes, cigars, or hookah paraphernalia were sold, and lower odds ratios when alcohol outlets had an on-site consumption license. Outlets with e-cigarette availability were in predominantly lower-income, nonwhite neighborhoods. It is important to assess exposure of another potentially damaging substance among perpetually disadvantaged populations.

Neighbourhood characteristics and health outcomes: evaluating the association between socioeconomic status, tobacco store density and health outcomes in Baltimore City

INTRODUCTION

Several studies suggest that the health of an individual is influenced by the socioeconomic status (SES) of the community in which he or she lives. This analysis seeks to understand the relationship between SES, tobacco store density and health outcomes at the neighbourhood level in a large urban community.

METHODS

Data from the 55 neighbourhoods of Baltimore City were reviewed and parametric tests compared demographics and health outcomes for low-income and high-income neighbourhoods, defined by the 50th percentile in median household income. Summary statistics are expressed as median. Tobacco store density was evaluated as both an outcome and a predictor. Association between tobacco store densities and health outcomes was determined using Moran's I and spatial regression analyses to account for autocorrelation.

RESULTS

Compared with higher-income neighbourhoods, lower-income neighbourhoods had higher tobacco store densities (30.5 vs 16.5 stores per 10 000 persons, P=0.01), lower life expectancy (68.5 vs 74.9 years, P<0.001) and higher age-adjusted mortality (130.8 vs 102.1 deaths per 10 000 persons, P<0.001), even when controlling for other store densities, median household income, race, education status and age of residents.

CONCLUSION

In Baltimore City, median household income is inversely associated with tobacco store density, indicating poorer neighbourhoods in Baltimore City have greater accessibility to tobacco. Additionally, tobacco store density was linked to lower life expectancy, which underscores the necessity for interventions to reduce tobacco store densities.

Educational Attainment and Smoking Status in a National Sample of American Adults; Evidence for the Blacks' Diminished Return

BACKGROUND

Although higher socioeconomic status (SES) indicators such as educational attainment are linked with health behaviors, the Blacks’ Diminished Return theory posits that the protective effects of SES are systemically smaller for Blacks than Whites.

AIMS

To explore the Black/White differences in the association between education and smoking.

METHODS

This cross-sectional study used the Health Information National Trends Survey (HINTS) 2017 (n = 3217). HINTS is a national survey of American adults. The current analysis included 2277 adults who were either Whites (n = 1868; 82%) or Blacks (n = 409; 18%). The independent variable was educational attainment, and the dependent variables were ever and current (past 30-day) smoking. Demographic factors (age and gender) were covariates. Race was the focal moderator.

RESULTS

In the pooled sample, higher educational attainment was associated with lower odds of ever and current smoking. Race interacted with the effects of higher educational attainment on current smoking, suggesting a stronger protective effect of higher education against current smoking for Whites than Blacks. Race did not interact with the effect of educational attainment on odds of ever smoking.

CONCLUSIONS

In line with previous research in the United States, education is more strongly associated with health and health behaviors in Whites than Blacks. Smaller protective effects of education on health behaviors may be due to the existing racism across institutions such as the education system and labor market.

Sociodemographic disparities in e-cigarette retail environment: Vape stores and census tract characteristics in Orange County, CA

Research shows disproportionate availability of tobacco retailers in disadvantaged neighborhoods, but little is known about the neighborhood correlates of e-cigarette specialty retailers (i.e., "vape stores"). We compiled addresses for all vape stores in Orange County (OC) (n = 174), CA, using a systematic internet search. Using American Community Survey data, we investigated the spatial structure and census tract correlates of vape store count. 23.4% of census tracts had at least one vape store, and those areas had higher percentage Hispanic population. Multivariate zero-inflated Poisson regressions revealed a higher incidence rate of vape stores in tracts with larger proportions of Hispanics, lower population density, and greater tobacco retailer density, net of other sociodemographic factors and zoning. These results suggest nicotine control initiatives in the age of e-cigarettes must consider the locational strategies of e-cigarette retailers, which are more common in Hispanic communities and areas already marked by tobacco retail activity.

Inequalities in tobacco outlet density by race, ethnicity and socioeconomic status, 2012, USA: results from the ASPiRE Study

BACKGROUND

Evidence of racial/ethnic inequalities in tobacco outlet density is limited by: (1) reliance on studies from single counties or states, (2) limited attention to spatial dependence, and (3) an unclear theory-based relationship between neighbourhood composition and tobacco outlet density.

METHODS

In 97 counties from the contiguous USA, we calculated the 2012 density of likely tobacco outlets (N=90 407), defined as tobacco outlets per 1000 population in census tracts (n=17 667). We used 2 spatial regression techniques, (1) a spatial errors approach in GeoDa software and (2) fitting a covariance function to the errors using a distance matrix of all tract centroids. We examined density as a function of race, ethnicity, income and 2 indicators identified from city planning literature to indicate neighbourhood stability (vacant housing, renter-occupied housing).

RESULTS

The average density was 1.3 tobacco outlets per 1000 persons. Both spatial regression approaches yielded similar results. In unadjusted models, tobacco outlet density was positively associated with the proportion of black residents and negatively associated with the proportion of Asian residents, white residents and median household income. There was no association with the proportion of Hispanic residents. Indicators of neighbourhood stability explained the disproportionate density associated with black residential composition, but inequalities by income persisted in multivariable models.

CONCLUSIONS

Data from a large sample of US counties and results from 2 techniques to address spatial dependence strengthen evidence of inequalities in tobacco outlet density by race and income. Further research is needed to understand the underlying mechanisms in order to strengthen interventions.

Risky Substance Use Environments and Addiction: A New Frontier for Environmental Justice Research

Substance use disorders are widely recognized as one of the most pressing global public health problems, and recent research indicates that environmental factors, including access and exposure to substances of abuse, neighborhood disadvantage and disorder, and environmental barriers to treatment, influence substance use behaviors. Racial and socioeconomic inequities in the factors that create risky substance use environments may engender disparities in rates of substance use disorders and treatment outcomes. Environmental justice researchers, with substantial experience in addressing racial and ethnic inequities in environmental risk from technological and other hazards, should consider similar inequities in risky substance use environments as an environmental justice issue. Research should aim at illustrating where, why, and how such inequities in risky substance use environments occur, the implications of such inequities for disparities in substance use disorders and treatment outcomes, and the implications for tobacco, alcohol, and drug policies and prevention and treatment programs.