Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Health status, neighborhood socioeconomic context, and premature mortality in the United States: The National Institutes of Health-AARP Diet and Health Study

Objectives. We examined whether the risk of premature mortality associated with living in socioeconomically deprived neighborhoods varies according to the health status of individuals.Methods. Community-dwelling adults (n = 566 402; age = 50–71 years) in 6 US states and 2 metropolitan areas participated in the ongoing prospective National Institutes of Health–AARP Diet and Health Study, which began in 1995. We used baseline data for 565 679 participants on health behaviors, self-rated health status, and medical history, collected by mailed questionnaires. Participants were linked to 2000 census data for an index of census tract socioeconomic deprivation. The main outcome was all-cause mortality ascertained through 2006.Results. In adjusted survival analyses of persons in good-to-excellent health at baseline, risk of mortality increased with increasing levels of census tract socioeconomic deprivation. Neighborhood socioeconomic mortality disparities among persons in fair-to-poor health were not statistically significant after adjustment for demographic characteristics, educational achievement, lifestyle, and medical conditions.Conclusions. Neighborhood socioeconomic inequalities lead to large disparities in risk of premature mortality among healthy US adults but not among those in poor health.Research dating back to at least the 1920s has shown that the United States has experienced persistent and widening socioeconomic disparities in premature mortality over time.^1–5 However, it has been unclear whether socioeconomic inequalities affect the longevity of persons in good and poor health equally. Socioeconomic status (SES) and health status are interrelated,^6–8 and both are strong independent predictors of mortality.⁹ Low SES is associated with greater risk of ill health and premature death,^{1–5,8,10–13} partly attributable to disproportionately high prevalence of unhealthful lifestyle practices^10,14,15 and physical and mental health conditions.^13,16 Correspondingly, risk of premature mortality is higher in poor than in more affluent areas.^16,17 Although the association between neighborhood poverty and mortality is independent of individual-level SES,^17,18 aggregation of low-SES populations in poor areas may contribute to variations in health outcomes across neighborhoods. Conversely, economic hardships resulting from ill health may lead persons in poor physical or mental health to move to poor neighborhoods.¹⁹ This interrelatedness may create spurious associations between neighborhood poverty and mortality.Although previous studies have found that the risk of premature death associated with poor health status varies according to individuals'' SES,^20,21 no published studies have examined whether the relative risks for premature mortality associated with living in neighborhoods with higher levels of socioeconomic deprivation vary by health status of individuals. Clarifying these relationships will inform social and public health policies and programs that aim to mitigate the health consequences of neighborhood poverty.^22,23We used data from a large prospective study to examine whether the risk of premature mortality associated with neighborhood socioeconomic context differs according to health status at baseline and remains after adjustment for person-level risk factors for mortality, such as SES, lifestyle practices, and chronic medical illnesses.     

Branding the Rodeo: A Case Study of Tobacco Sports Sponsorship

Rodeo is one of the few sports still sponsored by the tobacco industry, particularly the US Smokeless Tobacco Company. Rodeo is popular in rural communities, where smokeless tobacco use is more prevalent.We used previously secret tobacco industry documents to examine the history and internal motivations for tobacco company rodeo sponsorship. Rodeos allow tobacco companies to reach rural audiences and young people, enhance brand image, conduct market research, and generate positive press. Relationships with athletes and fans were used to fight proposed restrictions on tobacco sports sponsorship. Rodeo sponsorship was intended to enhance tobacco sales, not the sport.Rural communities should question the tradition of tobacco sponsorship of rodeo sports and reject these predatory marketing practices.SPORTS SPONSORSHIP HAS been part of tobacco promotion since the industry invented baseball cards to associate cigarettes with sport,¹ and it continues to represent a challenge for tobacco control worldwide.^2–5 Sports sponsorship is associated with smoking behavior⁴ and appeals to youths,² maintains presence on television in restricted markets,^3,6,7 and recruits third-party allies to fight marketing restrictions.⁸Rodeo originated in the 1800s. The Cowboy''s Turtle Association was formed in 1936 and became the Professional Rodeo Cowboys Association (PRCA) in 1975.⁹ Cigarette companies explored rodeo sponsorship during the early 1970s, when tobacco advertising was banned from broadcast media in the United States.^3,5,6,10 The US Smokeless Tobacco Company (USST)^11,12 has sponsored the PRCA since 1986 and the National Intercollegiate Rodeo Association (NIRA) since 1974. The 1998 Smokeless Tobacco Master Settlement Agreement limits USST to 1 sponsorship per year bearing a product''s brand name. In 2008 USST made Professional Bull Riding (PBR) its single branded sponsorship (Copenhagen).¹³ USST uses its PRCA corporate sponsorship to continue other marketing activities at rodeos.Spending on advertising and promotion by the 5 major smokeless tobacco companies reached a record high of $251 million in 2005, including $15.8 million specifically on sports and sporting events.¹⁴ The PRCA stated in 2007 that it had 650 rodeos annually in 41 states, with more than 33 million attending, ranking it seventh in overall attendance among all sports.¹¹ Both PRCA and PBR events are televised.¹⁵ Although tobacco advertising on television is banned, television cameras may pick up branded banners, chute signs, scoreboards, and cowboys'' vest patches during televised rodeo events.Smokeless tobacco use is associated with oral cancer, gum disease, and nicotine addiction.^16,17 Although the overall prevalence of smokeless tobacco use among adults and adolescents declined between 1986 and 2003,¹⁸ sales of moist snuff products (USST''s main products) increased by 109% from 36.1 million pounds in 1986 to 75.7 million pounds in 2005, as did overall sales revenues.¹⁴ Rodeos provide tobacco companies access to rural audiences, which have higher rates of tobacco use¹⁹ and are reached less effectively by anti-tobacco media campaigns.²⁰ Rodeos are also attended by and popular with children.Previously secret tobacco industry documents can help guide tobacco control efforts by providing insights into how and why tobacco companies pursue marketing activities.²¹ We analyzed tobacco industry documents to address 3 questions: (1) What audiences did tobacco companies hope to reach at rodeos? (2) What marketing strategies were used to promote tobacco products at rodeos? (3) In addition to increasing sales, what other benefits did tobacco companies obtain through rodeo sponsorship?     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.     

Tobacco Retailer Proximity and Density and Nicotine Dependence Among Smokers With Serious Mental Illness

Objectives. We examined the density and proximity of tobacco retailers and associations with smoking behavior and mental health in a diverse sample of 1061 smokers with serious mental illness (SMI) residing in the San Francisco Bay Area of California.Methods. Participants’ addresses were geocoded and linked with retailer licensing data to determine the distance between participants’ residence and the nearest retailer (proximity) and the number of retailers within 500-meter and 1-kilometer service areas (density).Results. More than half of the sample lived within 250 meters of a tobacco retailer. A median of 3 retailers were within 500 meters of participants’ residences, and a median of 12 were within 1 kilometer. Among smokers with SMI, tobacco retailer densities were 2-fold greater than for the general population and were associated with poorer mental health, greater nicotine dependence, and lower self-efficacy for quitting.Conclusions. Our findings provide further evidence of the tobacco retail environment as a potential vector contributing to tobacco-related disparities among individuals with SMI and suggest that this group may benefit from progressive environmental protections that restrict tobacco retail licenses and reduce aggressive point-of-sale marketing.Tobacco use among people with serious mental illness (SMI) is common and has serious health and financial costs.1 Nationally, individuals with psychiatric or addictive disorders consume 44% to 46% of cigarettes purchased and are more likely than those in the general population to be daily and heavy smokers.2,3 In one study, it was estimated that smokers with SMI spend, on average, 27% of their income on tobacco.4 Individuals with SMI suffer disproportionately from tobacco-related diseases and, as a group, have a 25-year premature mortality rate.5 Increasingly, researchers and practitioners highlight the need for more targeted prevention and intervention strategies to reduce the burden of smoking-related diseases in this vulnerable group.6,7Cigarette smoking among people with SMI reflects a complex interplay of genetic, neurobiological, cultural, and psychosocial factors.6 Studies have examined shared genetic effects between smoking and SMI,8–11 as well as associations with attention and cognition, stress and mood, and reductions in the side effects of psychotropic medications.6 In addition to individual-level risk factors, a complete understanding of smoking disparities among individuals with SMI requires examination of “upstream” social determinants of health, including social, political, and economic contexts. Accordingly, research on the etiology and maintenance of cigarette use in this disproportionately affected group has increasingly focused on systemic factors outside of an individual’s control, such as tobacco industry targeting, reduced access to smoking cessation services, and tobacco control policies.7,12 Notably, smokers with SMI are responsive to tobacco control policies that have been effective in the general population, such as smoking bans and cigarette tax increases.13–16The built environment is another important social determinant of health that has the potential to affect smoking among people with SMI. In the general population, retail availability of tobacco, which includes the number of retailers per area or population (i.e., density) and the distance to the nearest retailer (i.e., proximity) from one’s home or school, is associated with earlier smoking initiation,17,18 increased current smoking19–22 and cigarette purchases,23 and reduced smoking cessation over time.24,25 Smokers who live in neighborhoods with higher densities of tobacco retailers have greater exposure to retail advertisements and promotions, which can obstruct quit attempts by increasing cues to smoke, provoking cravings, and triggering impulse purchases.26–29 Smokers are price sensitive,30,31 and the financial costs of smoking are lower in communities with more convenient tobacco access and reduced travel time to purchase.22 Moreover, retailers and point-of-sale tobacco advertisements are more prevalent in socially and economically disadvantaged neighborhoods.19,22,32–36The effects of increased tobacco availability may be particularly strong among smokers with SMI given that factors such as unreliable transportation and limited resources37 in this population may lead to a greater reliance on readily obtainable consumer goods. Furthermore, people with SMI have been targeted by the tobacco industry,12,38 and they may be especially sensitive to aggressive tobacco advertisements and promotions. Surprisingly, in spite of the public health relevance, to our knowledge no studies of the retail availability of tobacco have involved clinical samples of individuals with SMI.Our goals in this study, which included a diverse sample of adults with SMI, were to characterize the proximity (roadway distance to the nearest retailer) and density (number of retailers per acre) of tobacco retailers within 500 meters and 1 kilometer of participants’ residences and to assess whether retail availability of tobacco is associated with severity of mental illness, nicotine dependence, and readiness to quit smoking. We also evaluated whether these associations vary according to gender.We hypothesized that smokers with SMI would reside in neighborhoods with greater than average tobacco retailer density for their county area and that this neighborhood characteristic would be associated with greater severity of mental illness. Furthermore, we predicted that increased retail availability of tobacco would be associated with greater nicotine dependence and lower readiness to quit, regardless of severity of mental illness. We also examined gender differences given calls to assess such differences in tobacco control research, policy, and practice39 and recent evidence that proximity to a tobacco retailer is associated with a lower likelihood of smoking cessation among men but not women who are moderate to heavy smokers.24     

Public Support for Family Smoking Prevention and Tobacco Control Act Point-of-Sale Provisions: Results of a National Study

Objectives. We assessed public and smoker support for enacted and potential point-of-sale (POS) tobacco-control policies under the Family Smoking Prevention and Tobacco Control Act.Methods. We surveyed a US nationally representative sample of 17 507 respondents (6595 smokers) in January through February 2013, and used linear regression to calculate weighted point estimates and identify factors associated with support for POS policies among adults and smokers.Results. Overall, nonsmokers were more supportive than were smokers. Regardless of smoking status, African Americans, Hispanics, women, and those of older ages were more supportive than White, male, and younger respondents, respectively. Policy support varied by provision. More than 80% of respondents supported minors’ access restrictions and more than 45% supported graphic warnings. Support was lowest for plain packaging (23%), black-and-white advertising (26%), and a ban on menthol cigarettes (36%).Conclusions. Public support for marketing and POS provisions is low relative to other areas of tobacco control. Tobacco-control advocates and the Food and Drug Administration should build on existing levels of public support to promote and maintain evidence-based, but controversial, policy changes in the retail environment.In 2009, the Family Smoking Prevention and Tobacco Control Act (FSPTCA),1 enabled the Food and Drug Administration to regulate tobacco products in the United States.2 Many provisions affect how tobacco products are sold and marketed in retail stores at the point of sale (POS). Major POS components of the FSPTCA focus on (1) youth access to tobacco, (2) regulating promotion (restricting gifts with purchase, prohibiting free samples), (3) product bans (banning cigarette flavors and a possible menthol ban), (4) advertising and labeling restrictions, and (5) graphic warnings on packs and ads. Some aspects of these regulations are controversial, such as a possible ban on menthol cigarettes.3 Tobacco industry litigation has blocked or delayed implementation of other aspects such as black-and-white text advertising and graphic warnings.4Public policy scholars provide insight into the role of public opinion in shaping tobacco-control policies. First, previous tobacco-control efforts such as efforts to raise federal cigarette excise taxes have met with failure, in part because of lack of public support.5 In addition, a recent proposal to ban sales of all tobacco products in Westminster, Massachusetts, generated public backlash and was withdrawn.6 Conversely, documenting public support for tobacco-control regulations has helped enact measures such as a tobacco tax increase in Massachusetts,7 or initial attempts to assert Food and Drug Administration jurisdiction over tobacco products.8 Public support can influence the policy agenda, decision-maker support, policy implementation, and compliance with new policies.9–11Previous studies have examined public opinions about some POS provisions, notably related to a ban on menthol cigarettes,12–14 and graphic warnings.15 Additional studies have focused on support for potential FSPTCA policies including nicotine reductions15,16 and bans on tobacco advertising.15 Another study examined support among New York City adults for emerging retail strategies such as a tobacco product display ban or limiting retailer licenses.17 But none, to date, have examined national public support for a wide range of POS provisions proposed or enacted under the FSPTCA. As a consequence, little is known about what characteristics contribute to developing supportive policy attitudes at POS where tobacco is ubiquitous and highly normative.18Previous studies have found that nonsmokers are more likely to support traditional tobacco-control regulations (e.g., tobacco taxes, indoor smoke-free laws) than are smokers,19–21 African Americans are more supportive than Whites,15,20,22 and high socioeconomic status (SES) individuals are more supportive than those of low SES.22,23 Studies also have found that policy support may increase following implementation.24–26 Policies that have already been implemented may have greater public support than proposed, but not implemented, policies. In conjunction with this, policies that have been implemented may also be the ones with the most preexisting support (i.e., “low-hanging fruit”). For example, in California, which enacted a statewide first in nation workplace smoking ban in 1995, support for smoking restrictions in public venues increased by 17 percentage points, compared with only 11 points in the rest of the nation, over 7 pre- to postban years.27 This type of finding suggests that policy implementation itself may increase support perhaps by spurring norms changes.We also identified factors associated with support for POS measures among smokers. Preserving “smokers’ rights” has often been used as an argument against new tobacco-control regulations.28 However, smokers are not a monolithic group; some smokers support regulations including advertising and promotion,19 smoke-free air restrictions,24,29 and youth access restrictions.19,30 In previous studies, intention to quit has been associated with support for smoke-free environments31–33 and advertising restrictions.31,32Beyond individual factors, support for tobacco-control regulations may vary by jurisdiction. Studies suggest that those who live in jurisdictions with stronger tobacco-control policies (e.g., higher tobacco taxes and extensive indoor smoke-free restrictions) may have stronger antismoking norms and more support for tobacco-control measures.34 Geographic region may also play a countervailing force; those living in tobacco-producing states may demonstrate less support for tobacco-control policies.34,35 As a result, statistical models should include state-level associations when one is examining public opinion nationally.The purpose of this study was to (1) identify which individual policies have the greatest support, (2) examine the overall level of support for POS policies in the FSPTCA among the general public and among smokers, and (3) identify individual respondent and state-level characteristics associated with support in the general population and among smokers.     

Alcohol advertising at Boston subway stations: an assessment of exposure by race and socioeconomic status

Objectives. We investigated the frequency of alcohol ads at all 113 subway and streetcar stations in Boston and the patterns of community exposure stratified by race, socioeconomic status, and age.Methods. We assessed the extent of alcohol advertising at each station in May 2009. We measured gross impressions and gross rating points (GRPs) for the entire Greater Boston population and for Boston public school student commuters. We compared the frequency of alcohol advertising between neighborhoods with differing demographics.Results. For the Greater Boston population, alcohol advertising at subway stations generated 109 GRPs on a typical day. For Boston public school students in grades 5 to 12, alcohol advertising at stations generated 134 GRPs. Advertising at stations in low-poverty neighborhoods generated 14.1 GRPs and at stations in high-poverty areas, 63.6 GRPs.Conclusions. Alcohol ads reach the equivalent of every adult in the Greater Boston region and the equivalent of every 5th- to 12th-grade public school student each day. More alcohol ads were displayed in stations in neighborhoods with high poverty rates than in stations in neighborhoods with low poverty rates.Excessive alcohol use is the third-leading lifestyle-related cause of death in the United States.¹ Immediate health risks include unintentional injuries,² violence,^2,3 risky sexual behaviors,^4,5 miscarriage and stillbirth among pregnant women,^6,7 fetal alcohol syndrome,⁷ and alcohol poisoning.⁸ Long-term health risks include neurological,^9,10 cardiovascular,^11,12 and psychiatric problems,¹³ as well as an increased risk of cancer,^12,14 liver disease,^12,15,16 and pancreatitis.^12,17,18 Excessive alcohol use is also linked to a variety of social problems, including increased unemployment¹⁹ and frequency of violent crime and incarceration.^20,21 Drinking among underage youths is increasing.^22–25 Excessive alcohol use also has economic consequences. Alcohol-related health care utilization (e.g., motor vehicle crashes, fires), productivity losses, social welfare (e.g., food stamps), and criminal justice cost the United States an estimated $184.6 billion in 1998 alone.^12,26Alcohol advertising has historically been linked to increased consumption of alcohol in youths,^25,27–31 and a more recent study also shows an increase in consumption by adults.³² These data come from studies of advertising in a variety of media, including television, music video, public transit, and outdoor advertising.^25–31 Alcohol is disproportionately advertised in low-income neighborhoods^33,34 and in neighborhoods with a high proportion of racial and ethnic minorities.^32,34–36Studies have shown that people of color experience poorer health outcomes and shorter life expectancies than do Whites.³⁷ Individuals of lower socioeconomic status also have been found to have higher morbidity and mortality and more risk factors for heart disease and stroke than do people of higher socioeconomic status.³⁸ Minorities are more likely to live in poverty, which exacerbates the negative consequences of alcohol use.³⁹ Because racial and ethnic minorities and individuals of lower socioeconomic status are at a higher risk for poor health and have been identified as targets of alcohol advertising, it is critical that advertising policies change to protect these disadvantaged groups. Hackbarth et al. suggest that reducing alcohol consumption among disadvantaged groups through community intervention, such as banning alcohol advertising, would be one way to eliminate such health disparities.³⁶In 2007 Kwate et al. determined that Black neighborhoods in New York City had more advertising space than White neighborhoods and that these spaces were disproportionately used to market alcohol and tobacco products.³⁵ However, they did not find a significant relationship between median income and ad density, which suggests that relative affluence did not protect Black neighborhoods from targeted outdoor advertising.Advertising on public transportation has received little attention in the literature. In 2007, a report issued by the Marin Institute documented the advertising practices of 20 public transit agencies nationwide. The report found that 2 major cities, Boston, Massachusetts and New York City, lagged far behind other cities that had policies in place to protect children from alcohol advertising.²⁵ Chicago, Illinois; Los Angeles, California; San Francisco, California; Washington, DC; and other places explicitly prohibit alcohol advertising on public transit systems. For example, San Francisco imposes a $5000 per day fine for violating advertising policies.²⁵ By contrast, the Massachusetts Bay Transit Authority (MBTA), which serves the Boston area, has no such restrictions against alcohol advertising, although it claims to prohibit all “adult-oriented goods and services.” The MBTA bans advertising that features tobacco, violence, or nudity because they are considered inappropriate for viewing by minors.²⁵ It is disturbing that one of the largest cities in the United States has not yet adopted stricter policies to protect its riders from potentially harmful alcohol ads.In 2009, Nyborn et al. studied the frequency of alcohol advertising on MBTA train cars and found that alcohol advertisers were able to reach the equivalent of nearly half of all transit passengers each day.⁴⁰ These data showed that roughly 315 000 people, or 11% of the entire adult population in the greater Boston area (Suffolk, Middlesex, and Norfolk counties; total 2008 population = 2 841 374⁴¹) may be exposed to alcohol ads on the MBTA train lines alone. However, that study focused on ads on moving trains and did not consider the frequency of alcohol ads at train stations and how this frequency might differ between neighborhoods. We expanded the focus to include train stations to investigate whether alcohol advertising targeted particular socioeconomic or racial/ethnic groups.We aimed to (1) quantify exposure to alcohol advertising at MBTA train stations among adults in the greater Boston area and among Boston public school students in grades 5 to 12 and (2) compare the frequency of alcohol ads in different MBTA train stations to determine whether minority or poor populations were disproportionately exposed.     

Racial/Ethnic and Socioeconomic Differences in Short-Term Breast Cancer Survival Among Women in an Integrated Health System

Objectives. We examined the combined influence of race/ethnicity and neighborhood socioeconomic status (SES) on short-term survival among women with uniform access to health care and treatment.Methods. Using electronic medical records data from Kaiser Permanente Northern California linked to data from the California Cancer Registry, we included 6262 women newly diagnosed with invasive breast cancer. We analyzed survival using multivariable Cox proportional hazards regression with follow-up through 2010.Results. After consideration of tumor stage, subtype, comorbidity, and type of treatment received, non-Hispanic White women living in low-SES neighborhoods (hazard ratio [HR] = 1.28; 95% confidence interval [CI] = 1.07, 1.52) and African Americans regardless of neighborhood SES (high SES: HR = 1.44; 95% CI = 1.01, 2.07; low SES: HR = 1.88; 95% CI = 1.42, 2.50) had worse overall survival than did non-Hispanic White women living in high-SES neighborhoods. Results were similar for breast cancer–specific survival, except that African Americans and non-Hispanic Whites living in high-SES neighborhoods had similar survival.Conclusions. Strategies to address the underlying factors that may influence treatment intensity and adherence, such as comorbidities and logistical barriers, should be targeted at low-SES non-Hispanic White and all African American patients.Breast cancer is the most common cancer among women in the United States, and it is the second leading cause of cancer death.1 Despite significant improvements in breast cancer survival from 1992 to 2009,1,2 racial/ethnic and socioeconomic survival disparities have persisted.3,4 African American women have consistently been found to have worse survival after breast cancer,3,5–11 Hispanic women have worse or similar survival,3,9,11,12 and Asian women as an aggregated group have better or similar survival3,9,11,12 than do non-Hispanic White women. Underlying factors thought to contribute to these racial/ethnic disparities include differences in stage at diagnosis,8,12,13 distributions of breast cancer subtypes,14–16 comorbidities,12,13,17 access to and utilization of quality care,13,18 and treatment.12,13Numerous studies also have found poorer survival after breast cancer diagnosis among women residing in neighborhoods of lower socioeconomic status (SES).6,9,19,20 Research has shown that inadequate use of cancer screening services, and consequent late stage diagnosis and decreased survival, contribute to the SES disparities.21,22 Similar to racial/ethnic disparities, SES disparities have been attributed to inadequate treatment and follow-up care and comorbidities.18 Previous population-based studies have continued to observe racial/ethnic survival disparities after adjusting for neighborhood SES, but these studies have not considered the combined influence of neighborhood SES and race/ethnicity.3,9,11,12,23 These disparities may remain because information on individual-level SES, health insurance coverage, comorbidities, quality of care, and detailed treatment regimens have typically not been available.3,8,9,11,13 Even among studies using national Surveillance Epidemiology and End Results–Medicare linked data, in which more detailed information on treatment and comorbidities are available among some patients aged 65 years and older, survival disparities have remained.12,23,24 However, not all data on medical conditions and health care services are captured in Medicare claims, including data on Medicare beneficiaries enrolled in HMOs (health maintenance organizations).25,26Using electronic medical records data from Kaiser Permanente Northern California (KPNC) linked to data from the population-based California Cancer Registry (CCR), we recently reported that chemotherapy use followed practice guidelines but varied by race/ethnicity and neighborhood SES in this integrated health system.27 Therefore, to overcome the limitations of previous studies and address simultaneously the multiple social28 and clinical factors affecting survival after breast cancer diagnosis, we used the linked KPNC–CCR database to determine whether racial/ethnic and socioeconomic differences in short-term overall and breast cancer–specific survival persist in women in a membership-based health system. Our study is the first, to our knowledge, to consider the combined influence of neighborhood SES and race/ethnicity and numerous prognostic factors, including breast cancer subtypes and comorbidities, thought to underlie these long-standing survival disparities among women with uniform access to health care and treatment.     

Community-Based Participatory Research: A Capacity-Building Approach for Policy Advocacy Aimed at Eliminating Health Disparities

There have been increasing calls for community–academic partnerships to enhance the capacity of partners to engage in policy advocacy aimed at eliminating health disparities. Community-based participatory research (CBPR) is a partnership approach that can facilitate capacity building and policy change through equitable engagement of diverse partners. Toward this end, the Detroit Community–Academic Urban Research Center, a long-standing CBPR partnership, has conducted a policy training project. We describe CBPR and its relevance to health disparities; the interface between CBPR, policy advocacy, and health disparities; the rationale for capacity building to foster policy advocacy; and the process and outcomes of our policy advocacy training. We discuss lessons learned and implications for CBPR and policy advocacy to eliminate health disparities.Stressors in the social and physical environment are associated with poor health outcomes and contribute to the gaps in health status between rich and poor and between Whites and non-Whites.^1–7 There is growing recognition that community-based participatory research (CBPR) is a viable approach for addressing these health disparities,^8–11 and that such community–academic–practice partnerships can engage the participation of community members in public health advocacy to effect structural change in communities aimed at eliminating health disparities.^12–16 To have a broader and more sustained effect on health, models for influencing policy need to enhance the capacity of community residents and organizations to engage in the policy change process.^11,17,18 By equitably engaging diverse partners in all aspects of the policy process, CBPR can be particularly effective at facilitating capacity building for policy change among community residents.^9,13,14 However, there are limited examples in the literature of CBPR efforts involving capacity-building strategies aimed at enhancing the knowledge and skills of community members to successfully engage in the policy process.The Detroit Community–Academic Urban Research Center (URC), a long-standing CBPR partnership,^19–21 has conducted the Neighborhoods Working in Partnership (NWP) project aimed at strengthening policy advocacy skills within local neighborhoods, extending community voices in policymaking, and affecting policies aimed at creating healthy neighborhoods. We describe CBPR and its relevance to addressing health disparities, discuss the interface between CBPR and policy advocacy, provide a rationale for why capacity building for policy advocacy is needed at the community level, describe the process and outcomes of the NWP, and discuss lessons learned and implications for CBPR and policy advocacy aimed at eliminating health disparities.     

Racial residential segregation and low birth weight in Michigan's metropolitan areas

Objectives. We examined the influence of racial residential segregation, independent of neighborhood economic factors, on the overall and specific etiological risks of low birth weight.Methods. We geocoded all singleton births in Michigan metropolitan areas during 2000 to census tracts. We used hierarchical generalized linear models to investigate the association between low birth weight (< 2500 g) and neighborhood-level economic and racial segregation, controlling for individual and neighborhood characteristics. We analyzed competing risks of the 2 etiologies of low birth weight: intrauterine growth restriction and preterm birth.Results. Living in a Black segregated area was associated with increased odds (odds ratio [OR] = 1.15; 95% confidence interval [CI] = 1.03, 1.29; P < .05) of low birth weight after adjusting for individual- and tract-level measures. The analysis suggested that the association between low birth weight and racial segregation was attributable primarily to increased risk of intrauterine growth restriction (OR = 1.19; 95% CI = 1.03, 1.37; P < .05).Conclusions. Odds of low birth weight are higher in racially segregated Black neighborhoods in Michigan''s metropolitan areas, independent of economic factors. The association appears to operate through intrauterine growth restriction rather than preterm birth.As the leading cause of death among non-Hispanic Black infants and second-leading cause of death among non-Hispanic White infants, complications related to short gestation and low birth weight represent a significant clinical and public health issue.^1–3 Low birth weight also leads to long-term health consequences through increased rates of childhood and adult chronic diseases.^3–6 Racial disparities in rates of low birth weight have persisted even as total infant mortality has declined and prenatal care utilization among women of color has increased.^1–3 Because differences in individual-level risk factors cannot completely explain the differences in outcomes for White and Black mothers,^3,7 researchers have begun investigating contextual influences on racial disparities in birth outcomes.^3,8Racial segregation is a contextual factor that might contribute to racial disparities in low birth weight by isolating Blacks from the resources and opportunities found more frequently in White communities.^9–13 Residents in Black segregated neighborhoods accumulate less home equity,^14,15 have decreased access to quality primary education,¹⁶ and are exposed to greater residential and economic instability than are residents of nonsegregated communities.⁹ The accumulation of disadvantages in racially isolated neighborhoods could lead to negative birth outcomes for women by limiting opportunities associated with improved health (e.g., educational opportunities or access to quality medical care) and by exposing them to increased stress from neighborhood-level factors.Evidence from a small number of studies suggests that low birth weight is associated with racial residential segregation.^17–24 With few exceptions,^17,25,26 studies link metropolitan-level segregation or the percentage of Black residents in a community to low birth weight. However, because isolation is inherently spatial, to understand how the racial isolation of an individual mother''s neighborhood affects her pregnancy outcomes, isolation is most appropriately measured by considering her neighborhood along with its immediate surroundings (e.g., bordering neighborhoods) rather than by the metropolitan area or a single neighborhood.¹⁷Some authors have argued that racial segregation simply serves as a proxy for economic segregation.^27,28 By contrast, we posit that racial segregation is a distinct form of neighborhood-level disadvantage that presents an increased risk for low birth weight beyond that caused by economic segregation. Sociologists have shown that, even in the presence of economic segregation, the circumstances of racially segregated Black neighborhoods differ from those of White neighborhoods at similar socioeconomic levels.^29–32 This means that although residents of Black middle-class neighborhoods may live in residential areas that are separate from poor Black neighborhoods, they have greater exposure than do middle-class Whites to negative contextual factors and have fewer resources in their vicinity. This also suggests that any attempt to distinguish between the effects of racial and economic segregation on low birth weight requires that economic segregation also be measured spatially, taking a mother''s neighborhood and its immediate surroundings into account.It is also important to consider that the drivers of low birth weight—preterm birth and intrauterine growth restriction—have distinct physiological mechanisms.^33–35 Assessing the degree to which racial isolation is associated with each can provide important insight into the etiological mechanisms relating racial segregation to low birth weight. Spontaneous preterm birth is commonly precipitated by an infection,^36–40 which could be associated with racial segregation if, for instance, racial segregation reduces access to quality care.²⁵ Intrauterine growth restriction, on the other hand, typically stems from a chronic deficiency in oxygen and nutrient delivery to the fetus.^41–46 Chronic stress associated with the circumstances of racially isolated neighborhoods might affect placental vasculature function, creating an oxygen–nutrient insufficiency that leads to intrauterine growth restriction.⁴⁷ We know of no research that has considered the competing risks of growth restriction and preterm birth in the relationship of neighborhood environments with low birth weight.We examined births to mothers living in Michigan metropolitan areas to ascertain whether neighborhood racial segregation was associated with low birth weight independent of economic factors. We explicitly captured the spatial nature of both racial and economic segregation through a localized segregation index. We also analyzed the degree to which racial segregation was associated with different etiologies of low birth weight.     

Marketing Little Cigars and Cigarillos: Advertising,Price, and Associations With Neighborhood Demographics

Objectives. We have documented little cigar and cigarillo (LCC) availability, advertising, and price in the point-of-sale environment and examined associations with neighborhood demographics.Methods. We used a multimodal real-time surveillance system to survey LCCs in 750 licensed tobacco retail outlets that sold tobacco products in Washington, DC. Using multivariate models, we examined the odds of LCC availability, the number of storefront exterior advertisements, and the price per cigarillo for Black & Mild packs in relation to neighborhood demographics.Results. The odds of LCC availability and price per cigarillo decreased significantly in nearly a dose-response manner with each quartile increase in proportion of African Americans. Prices were also lower in some young adult neighborhoods. Having a higher proportion of African American and young adult residents was associated with more exterior LCC advertising.Conclusions. Higher availability of LCCs in African American communities and lower prices and greater outdoor advertising in minority and young adult neighborhoods may establish environmental triggers to smoke among groups susceptible to initiation, addiction, and long-term negative health consequences.During the past decade, the popularity of little cigars and cigarillos (LCCs) has risen dramatically. From 2000 to 2011, cigar sales increased by 221%,1 whereas cigarette sales continued a decades-long decline.2,3 As other venues for tobacco advertising have become increasingly limited, the point-of-sale environment is a critical battleground for companies to market their products.4 Although there is no recent data on tobacco industry advertising budgets for LCCs specifically, the latest reports indicate that companies spent more than 90% of their $8.4 billion marketing budget in 2011 for retail advertising and promotions.2 Evidence suggests this strategy is highly effective: exposure to point-of-sale displays is a risk factor for youth initiation5,6 and higher levels of smoking among adults.7LCCs are popular among populations of interest to tobacco control, including young adults and African Americans. National surveys show that the average age at first cigar use was 20.5 years in 2010.8 Young adults aged 18 to 25 years have the highest rates of past month cigar use (11.2%) compared with youths and older adults.8 However, these estimates may underestimate prevalence. Because most state and national surveillance surveys do not ask questions specific to LCCs, it is difficult to validly estimate patterns of use of these products among different populations.9–12 One exception is a recent nationally representative study of young adults aged 18 to 34 years, which reported that 26.0% of respondents had ever smoked little cigars, cigarillos, or bidis and that 16.0% of everyday or occasional smokers currently smoked these products.13Recent regional surveys that include brand-specific items for LCCs document higher estimates of use, particularly for minority populations. Tercheck et al.12 found a near doubling of reported cigar use among adolescents when use of the brand Black & Mild, a popular cigarillo product, was measured by a question added to a regional Youth Risk Behavior Survey. This increase was most distinctive among African Americans, among whom reported prevalence rose from 11.7% to 22.0%. LCC product use and dual use of cigars and cigarettes14 have been found to be more common among males, African Americans, and low-income adults.9,15,16Ample evidence demonstrates greater point-of-sale cigarette advertising in neighborhoods with minority and younger populations, including more storefront cigarette advertising,17 a greater number of cigarette advertisements and promotions,18,19 and a trend toward higher levels of cigar self-service in low-income communities.20 Furthermore, studies suggest selective marketing to young people and minorities with specific product types, such as smokeless tobacco in neighborhoods with younger populations21 and menthol cigarettes in minority communities.17,22–29 Although self-reported data from inner-city youths and young adults point to community-level factors as determinants of LCC use,30,31 to our knowledge no previous research has systematically documented how LCCs are advertised and priced in the retail environment and how marketing may differ by community demographics.Unlike cigarettes, LCCs are not currently regulated by the Food and Drug Administration under the 2009 Family Smoking Prevention and Tobacco Control Act (FSPTCA).32 Thus, LCCs are not subject to the same regulations as cigarettes regarding characterizing flavors, sales, and marketing. For example, the FSPTCA bans on flavored cigarettes and sales of packages containing fewer than 20 cigarettes do not apply to LCCs. LCCs are often sold individually or in packs of fewer than 20. Furthermore, these products often come in flavors appealing to youth and young adult populations, including candy and alcohol flavors. Moreover, differences in federal and state taxing of cigarettes, cigars, and LCCs often make these products less expensive than cigarettes.33Surveillance of LCC advertising in the point-of-sale environment is critical for monitoring tobacco industry marketing strategies and informing Food and Drug Administration policy. Because of the current lack of data on LCC marketing and a history of differential marketing of tobacco products in vulnerable communities, we have documented LCC availability, advertising, and price in the retail environment and examined differences by neighborhood demographics. We examined availability and store exterior advertising of LCCs overall and across communities as a function of neighborhood proportion of African Americans and young adults. We also examined prices for Black & Mild LCC packs, a top-selling cigarillo brand.1,9,12,15 Specifically, we examined Black & Mild price per cigarillo as a function of neighborhood and other characteristics.     

Neighborhoods and obesity in later life

Objectives. We examined the influence of neighborhood environment on the weight status of adults 55 years and older.Methods. We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability.Results. When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese.Conclusions. The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.Over the past few decades the prevalence of obesity has been rising for men and women across all age groups, including the elderly.¹ For example, in 2001 to 2002 in the United States, about 1 in 3 adults 60 years or older was obese.² This trend raises concerns because excess weight is associated with a number of chronic health conditions, including diabetes, high blood pressure, asthma, and arthritis.³ Moreover, obesity can have very important implications for publicly financed health care.⁴ Recent research suggests that a number of demographic, socioeconomic, and family factors⁵ influence obesity, but the role of the neighborhood context has not been fully explored.Excess weight results from an energy imbalance in which caloric intake exceeds energy expenditures, the latter closely related to physical activity. The neighborhood environment may influence energy intake (through its influence on food availability⁶) and energy expenditure (by facilitating or impeding physical activity). For example, the presence of supermarkets in the neighborhood is associated with higher fruit and vegetable intake,⁷ whereas eating at fast-food restaurants is associated with a high-fat diet and higher body mass index (BMI; weight in kilograms divided by height in meters squared).⁸ In terms of physical activity, individuals living in neighborhoods with less crime,^9–13 higher land-use mix,¹⁴ higher street connectivity,^11,14,15 higher residential density,^11,14 a greater number of destinations,^9,16 better aesthetics,^9,10,17 and sidewalks^10,12,17,18 tend to walk more often.^19,20Only a handful of studies linking neighborhood features to late-life obesity have focused on older adults.^{11,13,16,21–23} National studies are particularly lacking for the elderly. Yet evidence from national studies of adults of all ages suggests plausible connections between obesity and neighborhood factors. Using the 1990 to 1994 waves of the National Health Interview Survey, for example, Boardman et al.²⁴ found that adults residing in neighborhoods with a high concentration of poverty and in neighborhoods with a high percentage of Blacks were more likely to be obese. In another study, Robert and Reither²⁵ found that higher community socioeconomic disadvantage was related to higher BMI among women but not among men. Because these studies had very limited characterizations of the neighborhoods, the mechanism through which poor neighborhoods result in obesity remains unclear. It could be, for instance, that poor neighborhoods tend to have fewer supermarkets^26–28 and more-limited access to places for physical activity.^29,30Using a large, nationally representative survey, we examined the relationship between the economic, built, and social environments and weight status among men and women 55 years and older. We included 8 previously validated neighborhood scales reflecting neighborhood safety and segregation, concentration of immigrants, air pollution, residential stability, connectivity, density or access, and high and low neighborhood socioeconomic status.³¹ We modeled both obesity and overweight status by using multilevel modeling techniques in which we controlled for detailed individual- and family-level confounders.     

Quid pro quo: tobacco companies and the black press

Objectives. We explored the relationship between tobacco companies and the Black press, which plays an important role in conveying information and opinions to Black communities.Methods. In this archival case study, we analyzed data from internal tobacco industry documents and archives of the National Newspaper Publishers Association (NNPA), the trade association of the Black press.Results. In exchange for advertising dollars and other support, the tobacco industry expected and received support from Black newspapers for tobacco industry policy positions. Beginning in the 1990s, resistance from within the Black community and reduced advertising budgets created counterpressures. The tobacco industry, however, continued to sustain NNPA support.Conclusions. The quid pro quo between tobacco companies and the Black press violated journalistic standards and represented an unequal trade. Although numerous factors explain today''s tobacco-related health disparities, the Black press''s service to tobacco companies is problematic because of the trust that the community placed in such media. Understanding the relationship between the tobacco industry and the NNPA provides insight into strategies that the tobacco industry may use in other communities and countries.Tobacco use is a leading cause of health disparities affecting African Americans.^1–4 Older African Americans (≥ 44 years) have the highest smoking rates of any group (about 30%).⁵ Among lower-income African Americans, smoking rates are as high as 59%.^6,7 Over 45 000 African Americans die from tobacco-related diseases each year,^3,8,9 which constitutes the highest smoking-related disease burden of any US group.^7,10–12 African American communities also disproportionately bear lost productivity from tobacco-caused diseases. Although constituting only 6% of California''s population, African Americans account for 8% of smoking-attributable expenditures and 13% of smoking-attributable mortality costs.¹³Although smoking prevalence results from complex interactions of multiple factors, including socioeconomic status, cultural characteristics, acculturation, stress, advertising, cigarette prices, parental and community disapproval, and abilities of local communities to mount effective tobacco-control initiatives,¹⁴ the disproportionate tobacco-related disease burden among African Americans suggests the need for closer examination of the factors related to smoking prevalence that may be unique to the community. One factor in creating a climate in which smoking seems acceptable is the influence of the tobacco industry on cultural and social institutions,¹⁵ including the media.African American communities have long been targeted with tobacco advertisements, products, and philanthropy.^7,16–18 Tobacco companies have also sought to influence journalism¹⁹ and sustain extensive ties with African American leadership groups¹⁵ to undermine tobacco control. Although some research has previously recognized tobacco company support of minority-targeted media,^20,21 no previous studies have examined the longstanding relationship between tobacco companies and the National Newspaper Publishers Association (NNPA), the most important Black media organization. We explored the role of tobacco industry patronage of African American newspaper publishers and the expectations that such patronage involved. (Note that we use the terms Black and African American here interchangeably, as is common in US minority health research.²² Additional terms may be used, depending on the context and historical period; for instance, Negro was a common term used to refer to people of African descent through the 1970s.)     

The California Endowment's Healthy Eating, Active Communities Program: A Midpoint Review

Objectives. We conducted a midpoint review of The California Endowment''s Healthy Eating, Active Communities (HEAC) program, which works in 6 low-income California communities to prevent childhood obesity by changing children''s environments. The HEAC program conducts interventions in 5 key childhood environments: schools, after-school programs, neighborhoods, health care, and marketing and advertising.Methods. We measured changes in foods and beverages sold at schools and in neighborhoods in HEAC sites; changes in school and after-school physical activity programming and equipment; individual-level changes in children''s attitudes and behaviors related to food and physical activity; and HEAC-related awareness and engagement on the part of community members, stakeholders, and policymakers.Results. Children''s environments changed to promote healthier lifestyles across a wide range of domains in all 5 key childhood environments for all 6 HEAC communities. Children in HEAC communities are also engaging in more healthy behaviors than they were before the program''s implementation.Conclusions. HEAC sites successfully changed children''s food and physical activity environments, making a healthy lifestyle a more viable option for low-income children and their families.Childhood obesity is at epidemic levels in the United States. More than 1 in 7 children and adolescents aged 6 to 17 years are considered obese.¹ Additionally, disparities in obesity rates exist among ethnic groups. Black, Hispanic, and Native American children and adolescents have higher rates of diabetes and obesity than do White children and adolescents.¹ Poor diet and inadequate physical activity have been linked to obesity and preventable chronic illnesses.^2,3 Overweight and obese children may develop a number of risk factors for chronic disease and are increasingly diagnosed with diseases that have historically had their onset in adulthood, such as type 2 diabetes, hypertension, and high cholesterol.⁴Most strategies to prevent or reduce childhood obesity have focused on individual behavior modification and pharmacological treatment, with limited success.⁵ Current research suggests that childhood dietary habits and physical activity levels are influenced by a variety of environmental factors,⁶ such as increasing portion sizes,^7–10 increasing availability of fast food and soft drinks,^11–20 availability of soda and unhealthy food on school campuses,^21–29 curtailment or elimination of physical education and recess in schools,³⁰ insufficient or inadequate parks and recreational facilities,³¹ public policy favoring personal transportation over mass transit,^32–39 limited access to healthy foods and ready availability of unhealthy foods,^37,40–44 and disproportionate advertising of low-nutrient-dense foods and sedentary activities to children and their families.^25,45–49Many of these factors are exacerbated in low-income communities, where healthy and affordable food options and safe opportunities for physical activity are noticeably absent.^40,42 These factors are contributing to high levels of diseases related to nutrition and physical activity among Black and Latino populations.^34,40,42,50A better understanding of the underlying factors that lead to obesity has led to the emergence of a new type of initiative that seeks to reduce childhood obesity by making environmental improvements that promote healthy eating and physical activity, rather than focusing on changing individual eating and activity patterns. Although this type of environmental intervention is relatively new, early results are encouraging.^51–53 It has been demonstrated that better access to healthy foods and opportunities for physical activity results in healthier diets and increased physical activity: people in the presence of supermarkets eat more fruits and vegetables,^40,42,54 and when a venue for physical activity is available, people are more likely to be physically active.^34,55To help prevent obesity and type 2 diabetes among children and adolescents, the Healthy Eating, Active Communities (HEAC) program was established to promote public health environmental change in 6 California communities. We conducted a midpoint review of HEAC''s progress to assess how well these communities were translating models for change into on-the-ground practices resulting in real improvements in the food and physical activity opportunities available to low-income children and families.     

Policy Support, Norms, and Secondhand Smoke Exposure Before and After Implementation of a Comprehensive Smoke-Free Law in Mexico City

Objectives. We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City.Methods. Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n = 800), 4 months after implementation (n = 961), and 8 months after implementation (n = 761).Results. Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers'' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars.Conclusions. Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.Smoke-free policies can reduce involuntary exposure to toxic secondhand tobacco smoke (SHS), reduce tobacco consumption and promote quitting,^1,2 and shift social norms against smoking.^3–5 These policies are fundamental to the World Health Organization''s Framework Convention on Tobacco Control, an international treaty that promotes best-practices tobacco control policies across the world.⁶Evidence of successful implementation of smoke-free policies generally comes from high-income countries. Low- and middle-income countries increasingly bear the burden of tobacco use,⁷ however, and these countries may face particular challenges in implementing smoke-free policies, including greater social acceptability of tobacco use, shorter histories of programs and policies to combat tobacco-related dangers, and greater tolerance of law breaking.^8–10 There is a need for research that will help identify effective strategies for promoting and implementing smoke-free policies in low- and middle-income countries.Studies in high-income countries generally indicate that popular support for laws that ban smoking in public places and workplaces is strong and increases after such laws are passed.^11–15 Weaker laws that allow smoking in some workplaces can leave policy support unchanged.¹⁶ Policy-associated increases in support have been shown across populations that include smokers^{11,13,14,17,18} and bar owners and staff.^19,20 Beliefs about rights to work in smoke-free environments¹¹ and the health benefits of these environments²¹ have also been shown to increase with policy implementation. Support for banning smoking in all workplaces appears high in Latin American countries,²² but responses to smoke-free policies are less well known. In Uruguay, the first country in the Americas to prohibit smoking in all workplaces, including restaurants and bars,²³ support before the law was unknown. However, the level of support was high among both the general population²² and smokers²⁴ after the law''s implementation.Compliance with smoke-free laws in high-income countries has been good, particularly when laws apply across all workplaces, including restaurants and bars, and involve media campaigns. Self-reported declines in exposure in regulated venues^11,17,25 are consistent with findings from observational studies,^11,26 biomarkers of exposure,^11,25,27 and air quality assessments.^11,12Approximately 26% of Mexican adults residing in urban areas smoke.⁸ Most Mexicans recognize the harms of SHS and support smoke-free policies.^9,24,28,29 According to an opinion poll conducted before the August 2007 passage of a smoke-free law in Mexico City, about 80% of both Mexico City inhabitants and Mexicans in general supported prohibiting smoking in enclosed public places and workplaces.²⁸ In 2006, 60% of smokers reported that their workplace had a smoking ban, with Mexico City smokers reporting the lowest percentage of workplace bans at 37%.²⁴Mexico City''s smoke-free workplace law^30–32 initially allowed for designated smoking areas that were ventilated and physically separate.^22,33 Concerns about the inequity of this law for small business owners who could not afford to build designated smoking areas led the hospitality industry to support a comprehensive smoke-free law^31,32 that prohibited smoking inside all enclosed public places and workplaces, including public transport, restaurants, and bars. This law entered into force on April 3, 2008.Media coverage of the law was similar to that in high-income countries, pitting arguments about the government''s obligation to protect citizens from SHS dangers against arguments about discrimination toward smokers and the “slippery slope” of regulating behavior^4,32,34 (J. F. Thrasher et al., unpublished data, 2010). Most print media coverage was either positive or neutral, with much less coverage pitched against tobacco control policies.³⁴In the month before and after the law came into effect, the Mexico City Ministry of Health and nongovernmental organizations disseminated print materials and aired radio spots describing the dangers of SHS and the benefits of the law.³⁰ Community health promoters informed businesses about the law. From September through December 2008, a television, radio, print, and billboard campaign emphasized the law''s benefits.³⁵ We assessed, among Mexico City inhabitants, the prevalence of and increases in support, beliefs, norms, and compliance around the smoke-free law, as well as decreases in SHS exposure.     

Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans��A Qualitative Approach

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.