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.     

Alcohol Environments and Disparities in Exposure Associated With Adolescent Drinking in California

Objectives. We investigated sociodemographic disparities in alcohol environments and their relationship with adolescent drinking.Methods. We geocoded and mapped alcohol license data with ArcMap to construct circular buffers centered at 14 595 households with children that participated in the California Health Interview Survey. We calculated commercial sources of alcohol in each buffer. Multivariate logistic regression differentiated the effects of alcohol sales on adolescents'' drinking from their individual, family, and neighborhood characteristics.Results. Alcohol availability, measured by mean and median number of licenses, was significantly higher around residences of minority and lower-income families. Binge drinking and driving after drinking among adolescents aged 12 to 17 years were significantly associated with the presence of alcohol retailers within 0.5 miles of home. Simulation of changes in the alcohol environment showed that if alcohol sales were reduced from the mean number of alcohol outlets around the lowest-income quartile of households to that of the highest quartile, prevalence of binge drinking would fall from 6.4% to 5.6% and driving after drinking from 7.9% to 5.9%.Conclusions. Alcohol outlets are concentrated in disadvantaged neighborhoods and can contribute to adolescent drinking. To reduce underage drinking, environmental interventions need to curb opportunities for youth to obtain alcohol from commercial sources by tightening licensure, enforcing minimum-age drinking laws, or other measures.Despite federal, state, and local interventions, underage drinking continues to be a serious problem. A national survey found that 17.6% of adolescents drank alcohol in the past 30 days, 11.1% were binge drinkers, and 2.7% were heavy drinkers.¹ Health and social problems associated with youths'' drinking include motor vehicle crashes,^2,3 violence,⁴ risky sexual behaviors,^5,6 assault and rapes,⁷ and brain impairment.^8–11 Adolescent alcohol use has substantial societal costs.¹² Drinking at an early age also increases the risk of addiction and other alcohol-related problems in adulthood.^13–15 In 2007, the surgeon general responded to this problem in the Call to Action to Prevent and Reduce Underage Drinking, which emphasized environmental contributions to the problem.¹⁶Underage drinkers obtain their alcoholic beverages from a variety of sources, including parents'' stocks, friends, parties, and commercial outlets.¹⁷ In 1 study, buyers who looked underage were able to purchase alcohol with high success rates from both on-site (for consumption on the premises, such as bars and restaurants) and off-site (for consumption elsewhere, such as liquor stores) establishments.^18,19 Sales to minors have been found to be significantly associated with the percentage of Hispanic residents in a neighborhood and with population density.²⁰As long as adolescents can obtain alcohol from commercial sources, neighborhood outlets are likely to play a role in underage drinking. Rhee et al. argued that environment plays an essential role in drinking initiation and that genetics are important in developing alcohol dependence.²¹ Perceived alcohol availability was significantly associated with higher levels of alcohol consumption among young men²² and with drinking in public locations for adolescent girls.²³ Density of outlets for alcohol in cities was associated with youths'' drinking and driving and with riding in a car driven by a person under the influence of alcohol.²⁴Differences in alcohol environments may exacerbate health disparities across sociodemographic groups. LaVeist and Wallace found that in Baltimore, MD, predominantly Black and low-income census tracts have more liquor stores per capita than do tracts of other race and income groups.²⁵ Gorman and Speer found retail liquor outlets abundantly located in poor and minority neighborhoods in a city in New Jersey.²⁶ Only 1 national study has been published, and it reported higher densities of liquor stores in zip codes with higher percentages of Blacks and lower-income non-Whites.²⁷ That study covered all urban areas in the United States, but the urban zip codes had a mean land area of 40.1 square miles and a mean population of 21 920 persons,²⁷ arguably too large to represent neighborhoods. Even census tracts may be too large and too dissimilar to capture neighborhood effects: in Los Angeles County they can range from 0.04 square miles to 322 square miles.The objectives of this study were (1) to describe the quantity and geographic pattern of alcohol retailers in small areas around individual homes and (2) to examine relationships between alcohol environments and adolescent drinking. We analyzed data from the entire state of California to investigate the effects of spatial accessibility on alcohol sales to adolescents.     

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.     

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     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

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.     

Association Between Residential Exposure to Outdoor Alcohol Advertising and Problem Drinking Among African American Women in New York City

We evaluated the association between residential exposure to outdoor alcohol advertising and current problem drinking among 139 African American women aged 21 to 49 years in Central Harlem, New York City. We found that exposure to advertisements was positively related to problem drinking (13% greater odds), even after we controlled for a family history of alcohol problems and socioeconomic status. The results suggest that the density of alcohol advertisements in predominantly African American neighborhoods may add to problem drinking behavior of their residents.Substantial literature shows that alcohol advertisements are disproportionately located in African American neighborhoods.^1–3 Much of this research was conducted in the 1990s, and it was argued that the alcohol industry''s marketing strategies targeted 2 vulnerabilities in the African American community: “high aspirations for upward mobility at one end, and social despair and a general lack of economic vitality at the other.”^4(p454) In the 1980s, given the economic deprivation associated with urban African American enclaves, the proliferation of advertising at that time has been described as a blatant attempt to profit from human misery.⁵ Today, outdoor advertisements promote alcohol as a means to realize social mobility and reproduce stereotypical narratives about African American individuals.⁶ Taken together, the targeted marketing of health-damaging products has been described as a form of institutional racism,⁷ and community activists have resisted their proliferation.⁸Large-scale econometric data on the effects of advertising on alcohol intake are mixed,⁹ but neighborhood-level research suggests that the local alcohol environment affects behavior. Studies have shown that the density of alcohol retail outlets is associated with heavy drinking among college students¹⁰ and negative outcomes, including violence and injury.¹¹ However, to date, researchers have not studied the effects of outdoor advertising on the alcohol intake of residents in African American neighborhoods. We addressed this gap in knowledge by investigating whether exposure to alcohol advertisements is related to problem drinking among African American women.     

Off-Premise Alcohol Sales Policies, Drinking, and Sexual Risk Among People Living With HIV

Drinking among HIV-positive individuals increases risks of disease progression and possibly sexual transmission. We examined whether state alcohol sales policies are associated with drinking and sexual risk among people living with HIV. In a multivariate analysis combining national survey and state policy data, we found that HIV-positive residents of states allowing liquor sales in drug and grocery stores had 70% to 88% greater odds of drinking, daily drinking, and binge drinking than did HIV-positive residents of other states. High-risk sexual activity was more prevalent in states permitting longer sales hours (7% greater odds for each additional hour). Restrictive alcohol sales policies may reduce drinking and transmission risk in HIV-positive individuals.More than 1 million people in the United States are living with HIV,¹ and about 56 000 people are newly infected each year.² Approximately one half of those who have had positive test results for HIV drink alcohol; about 1 in 6 regularly binge drinks.³ Drinking in this population is associated with poor treatment adherence,^4,5 disease progression,^6–8 and spread of the virus through risky sexual activity.^9–12Thus, reducing drinking and problem drinking among HIV-positive individuals is an important public health goal. Alcohol sales policies may be 1 tool for accomplishing this. Research has linked geographic variations in off-premise alcohol sales practices (e.g., regulations regarding the sale of alcohol in stores) to drinking and drinking problems in the general population.¹³ Other types of alcohol regulation have been linked to sexual health.^14–16 Sales policies may influence drinking and sexual activity by making purchases inconvenient or affecting where and when people drink.^17–20 We investigated (1) whether findings linking off-premise sales policies to drinking extend to those living with HIV (who have unique demographic characteristics, drinking patterns, and life circumstances) and (2) whether off-premise sales policies predict sexual risk behavior in this group.     

First-Trimester Working Conditions and Birthweight: A Prospective Cohort Study

Objectives. We investigated the relationship between women''s first-trimester working conditions and infant birthweight.Methods. Pregnant women (N = 8266) participating in the Amsterdam Born Children and Their Development study completed a questionnaire gathering information on employment and working conditions. After exclusions, 7135 women remained in our analyses. Low birthweight and delivery of a small-for-gestational-age (SGA) infant were the main outcome measures.Results. After adjustment, a workweek of 32 hours or more (mean birthweight decrease of 43 g) and high job strain (mean birthweight decrease of 72 g) were significantly associated with birthweight. Only high job strain increased the risk of delivering an SGA infant (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.1, 2.2). After adjustment, the combination of high job strain and a long workweek resulted in the largest birthweight reduction (150 g) and the highest risk of delivering an SGA infant (OR = 2.0; 95% CI = 1.2, 3.2).Conclusions. High levels of job strain during early pregnancy are associated with reduced birthweight and an increased risk of delivering an SGA infant, particularly if mothers work 32 or more hours per week.Delivery of a low-birthweight or small-for-gestational-age (SGA) infant as a result of fetal growth restriction is one of the principal adverse pregnancy outcomes. In the short term, low birthweight and small size for gestational age are major determinants of infant mortality and morbidity¹ and impaired neonatal development.² In the long term, they increase metabolic and cardiovascular disease risk.^3–5 Prevention of fetal growth restriction is therefore of undisputed clinical and economic importance.Maternal factors, obstetric factors (e.g., placental dynamics), and social factors,⁵ including employment-related factors, can all play a role in fetal growth impairment.^6–24 Although employment in general is associated with enhanced outcomes,^6,20,21 certain working conditions represent potential risk factors for the mother and child. Increased levels of risk resulting from long working hours,^{12,13,17,18,24} high physical workloads,^13–16 prolonged standing,^13,18 and psychosocial job strain^7,9,10,24 have been suggested, but the findings in this area are not unequivocal.^8,11,22,23 So far, 2 reviews have been conducted that focused on physical workload and delivery of an SGA infant. Mozurkewich et al.¹⁶ concluded from their review of 29 studies that physically demanding work is associated with SGA births (pooled odds ratio [OR] = 1.37; 95% confidence interval [CI] = 1.30, 1.44). Bonzini et al.¹⁹ reached the same conclusion in their study. To our knowledge, job strain has not been considered in any published review.Limitations in research designs,^6,8,19–21 variability in definitions and measurement of work-related factors,^6,18–20 and true variability across countries and cultures may account for the inconsistent results observed to date. Another important limitation of occupational hazard research is the focus on third-trimester exposures.^11,13 Experimental data and emerging theory point to the first rather than the second or third trimester as a crucial period for regulating the relevant fetal hormonal set points, in particular the hypothalamic pituitary axis (HPA).^25–27 Stress-dependent dysregulation of the HPA affects birthweight and a child''s subsequent growth and development.^25–31 From this perspective, employment during pregnancy is perhaps the most prevalent potential stress factor, given that few working women quit their jobs early in pregnancy.In an effort to overcome the limitations of previous studies, we explored the association between infant birthweight and employment-related conditions (e.g., hours worked per week, hours standing or walking, physical demands of work, and job strain) in an unselected urban cohort of pregnant women. We hypothesized that after adjustment for all known major cofactors, first-trimester work-related effects on birthweight would exceed the third-trimester effects reported in previous research.     

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.     

Walking and Cycling to Health: A Comparative Analysis of City, State, and International Data

Objectives. We sought to determine the magnitude, direction, and statistical significance of the relationship between active travel and rates of physical activity, obesity, and diabetes.Methods. We examined aggregate cross-sectional health and travel data for 14 countries, all 50 US states, and 47 of the 50 largest US cities through graphical, correlation, and bivariate regression analysis on the country, state, and city levels.Results. At all 3 geographic levels, we found statistically significant negative relationships between active travel and self-reported obesity. At the state and city levels, we found statistically significant positive relationships between active travel and physical activity and statistically significant negative relationships between active travel and diabetes.Conclusions. Together with many other studies, our analysis provides evidence of the population-level health benefits of active travel. Policies on transport, land-use, and urban development should be designed to encourage walking and cycling for daily travel.Many nations throughout the world have experienced large increases in obesity rates over the past 30 years.^1,2 The World Health Organization estimates that more than 300 million adults are obese,³ putting them at increased risk for diseases such as diabetes, hypertension, cardiovascular disease, gout, gallstones, fatty liver, and some cancers.^4,5 Several studies have linked the increase in obesity rates to physical inactivity^6–8 and to widespread availability of inexpensive, calorie-dense foods and beverages.^1,9The importance of physical activity for public health is well established. A US Surgeon General''s report in 1996, Physical Activity and Health,¹⁰ summarized evidence from cross-sectional studies; prospective, longitudinal studies; and clinical investigations. The report concluded that physical inactivity contributes to increased risk of many chronic diseases and health conditions. Furthermore, the research suggested that even 30 minutes per day of moderate-intensity physical activity, if performed regularly, provides significant health benefits. Subsequent reports have supported these conclusions.^11–13The role of physical activity in prevention of weight gain is well documented.¹⁴ Strong evidence from cross-sectional studies has established an inverse relationship between physical activity and body mass index.^15,16 In addition, longitudinal studies have shown that exercisers gain less weight than do their sedentary counterparts.^6,8 Thus, the obesity epidemic may be explained partly by declining levels of physical activity.^1,17,18A growing body of evidence suggests that differences in the built environment for physical activity (e.g., infrastructure for walking and cycling, availability of public transit, street connectivity, housing density, and mixed land use) influence the likelihood that people will use active transport for their daily travel.^19,20 People who live in areas that are more conducive to walking and cycling are more likely to engage in these forms of active transport.^21–25 Walking and cycling can provide valuable daily physical activity.^26–30 Such activities increase rates of caloric expenditure,³¹ and they generally fall into the moderate-intensity range that provides health benefits.^32–35 Thus, travel behavior could have a major influence on health and longevity.^29,30,36,37Over the past decade, researchers have begun to identify linkages between active travel and public health.^38–40 Cross-sectional studies indicate that walking and cycling for transport are linked to better health. The degree of reliance on walking and cycling for daily travel differs greatly among countries.^39,41 European countries with high rates of walking and cycling have less obesity than do Australia and countries in North America that are highly car dependent.²⁶ In addition, walking and cycling for transport are directly related to improved health in older adults.⁴² The Coronary Artery Risk Development in Young Adults Study found that active commuting was positively associated with aerobic fitness among men and women and inversely associated with body mass index, obesity, triglyceride levels, resting blood pressure, and fasting insulin among men.^26,39,41,43Further evidence of the link between active commuting and health comes from prospective, longitudinal studies.⁴⁴ Matthews et al. examined more than 67 000 Chinese women in the Shanghai women''s health study and followed them for an average of 5.7 years.³⁷ Women who walked (P < .07) and cycled (P < .05) for transport had lower rates of all-cause mortality than did those who did not engage in such behaviors. Similarly, Andersen et al. observed that cycling to work decreased mortality rates by 40% among Danish men and women.³⁶ A recent analysis of a multifaceted cycling demonstration project in Odense, Denmark, reported a 20% increase in cycling levels from 1996 to 2002 and a 5-month increase in life expectancy for males.⁴⁵We analyzed recent evidence from a variety of data sources that supports the crucial relationship between active travel, physical activity, obesity, and diabetes. We used city- and state-level data from the United States and national aggregate data for 14 countries to determine the magnitude, direction, and statistical significance of each relationship.     

Alcohol consumption in early adulthood and schooling completed and labor market outcomes at midlife by race and gender

Objectives. We assessed the relation of alcohol consumption in young adulthood to problem alcohol consumption 10 years later and to educational attainment and labor market outcomes at midlife. We considered whether these relations differ between Blacks and Whites.Methods. We classified individuals on the basis of their drinking frequency patterns with data from the 1982 to 1984 National Longitudinal Survey of Youth 1979 (respondents aged 19–27 years). We assessed alcohol consumption from the 1991 reinterview (respondents aged 26–34 years) and midlife outcomes from the 2006 reinterview (respondents aged 41–49 years).Results. Black men who consumed 12 or more drinks per week at baseline had lower earnings at midlife, but no corresponding relation for Black women or Whites was found. Black men and Black women who consumed 12 or more drinks per week at baseline had lower occupational attainment than did White male non-drinkers and White female non-drinkers, respectively, but this result was not statistically significant.Conclusions. The relation between alcohol consumption in young adulthood and important outcomes at midlife differed between Blacks and Whites and between Black men and Black women, although Blacks’ alcohol consumption at baseline was lower on average than was that of Whites.Alcohol consumption is relatively high among individuals in college or of college age.^1–4 The short-term consequences of heavy drinking—emergency room visits,⁵ intimate partner violence,^6–8 and motor vehicle fatalities,^9,10 among others—are well documented. With a few exceptions,^11,12 until recently a lack of longitudinal data has inhibited researchers’ ability to track events occurring much later in the life course that are associated with alcohol consumption levels in early adulthood.The alcohol consumption of Blacks tends to be similar to or less than that of Whites.^13–18 However, this generalization obscures more subtle differences. For one, there is less of a decline in alcohol consumption after the early 20s among Blacks than Whites.¹⁹Some studies, for example, of mortality and high-density lipoprotein cholesterol,^20,21 have supported a conclusion of no difference between Blacks and Whites in the relation between alcohol consumption and various outcomes. However, other studies, which focused on alcohol use in early adulthood and subsequent occupational attainment (an index of the occupation''s prestige), have found that heavy alcohol use in early adulthood is associated with lower occupational attainment in Blacks but not in Whites.^22,23 These results came from 1 longitudinal database—the Coronary Artery Risk Development in Young Adults study—which was drawn from residents of 4 geographically disperse US cities.Race is a social, not a biological, construct. There is substantially more variation genetically within than among racial categories.²⁴ Yet previous research has documented racial differences in psychosocial factors, which are highly correlated with both baseline drinking and long-term drinking trajectories.^19,23,25,26 Important differences in outcomes among Blacks versus Whites have also been reported.^{22,23,27–29}We investigated the relations of alcohol consumption to educational attainment and labor market outcomes at midlife and how these relations differ between Blacks and Whites. We used national longitudinal data from the National Longitudinal Survey of Youth 1979 (NLSY79) to assess (1) whether there are relations between an individual alcohol consumption level at 19 to 27 years of age and various outcomes at later stages in the life course (alcohol consumption, abuse, and dependence; educational attainment; occupational attainment; and earnings), and (2) whether these relations differ between Blacks and Whites in the full sample and when stratified by gender.     

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.     

Ethnic Density Effects on Birth Outcomes and Maternal Smoking During Pregnancy in the US Linked Birth and Infant Death Data Set

Objectives. We investigated whether mothers from ethnic minority groups have better pregnancy outcomes when they live in counties with higher densities of people from the same ethnic group—despite such areas tending to be more socioeconomically deprived.Methods. In a population-based US study, we used multilevel logistic regression analysis to test whether same-ethnic density was associated with maternal smoking in pregnancy, low birthweight, preterm delivery, and infant mortality among 581 151 Black and 763 201 Hispanic mothers and their infants, with adjustment for maternal and area-level characteristics.Results. Higher levels of same-ethnic density were associated with reduced odds of infant mortality among Hispanic mothers, and reduced odds of smoking during pregnancy for US-born Hispanic and Black mothers. For Black mothers, moderate levels of same-ethnic density were associated with increased risk of low birthweight and preterm delivery; high levels of same ethnic density had no additional effect.Conclusions. Our results suggest that for Hispanic mothers, in contrast to Black mothers, the advantages of shared culture, social networks, and social capital protect maternal and infant health.Numerous studies have shown that living in a socioeconomically deprived neighborhood exerts a contextual effect on the health of individual residents beyond their own socioeconomic status.^1,2 This is likely to have a differential impact on some ethnic minority groups, such as African Americans and Hispanics. (Throughout this paper we have defined “ethnicity” as a global indicator of a person''s heritage including both racial and ethnic origins.) Whereas the majority of poor White people live in nondeprived areas, poor African Americans are concentrated in areas of high poverty.³ Thus, it might be paradoxical to suggest that members of ethnic minority groups might be healthier when they live in areas with a high concentration of people of the same ethnicity.^4,5 However, there is some evidence that living in communities that contain proportionally more people from the same ethnic group is protective for some health outcomes, once material deprivation is accounted for. The evidence for the protective effects of same-ethnic density is strongest for mental health,^4,5 with the evidence for maternal and infant health outcomes more mixed.The majority of studies that have investigated the impact of same-ethnic density on maternal and infant health have focused on African Americans or Black families (in this article, we use whichever term was used in the studies we describe). Two older ecological studies^6,7 found that increasing levels of same-ethnic density for New York City African Americans were associated with increased fetal and neonatal mortality but not postneonatal mortality. Another study found no association between ethnic density measured in US cities and postneonatal mortality.⁸ More recent studies have tended to use multilevel analyses that controlled for individual-level measures of socioeconomic status, and focused on measures of morbidity, such as low birthweight (LBW), with less consistent results.^9–14One study of Chicago neighborhoods found that an increasing proportion of African American residents was associated with a reduced risk of LBW.¹³ Two other studies found that an increasing proportion of Black residents was associated with increased risk of LBW.^11,14 However, other studies have found no significant associations between same-ethnic density and LBW.^9,10,12Five studies have investigated the impact of ethnic density on preterm delivery rates among African Americans.^{9,10,12,15,16} Studies of neighborhoods in Minnesota⁹ and North Carolina¹⁵ found same-ethnic density to be associated with increased risk of preterm delivery after adjustment for individual but not area measures of socioeconomic circumstances. Three other studies found no association between same-ethnic density and preterm delivery in models that included individual-level maternal education and area-level measures of socioeconomic circumstances.^10,12,16We are aware of only 1 study that has investigated the impact of same-ethnic density on maternal smoking during pregnancy, which found that it was associated with reduced risk of maternal smoking after adjustment for both individual and area measures of socioeconomic conditions.¹⁷We found only 2 studies that have investigated the impact of ethnic density on Hispanic maternal and infant health. The first, conducted in the states of Arizona, California, New Mexico, and Texas, found lower rates of infant mortality for US-born Mexican-origin mothers living in counties with high concentrations of mothers of the same ethnicity.¹⁸ However, this effect was not found for mothers born outside the United States. The second study found no associations between same-ethnic density, as measured in Chicago census tracts, and LBW, preterm delivery, and maternal smoking after adjustment for economic disadvantage, maternal education, and violent crime.¹²Further support for the protective effects of Hispanic density comes from the “Hispanic paradox.”¹⁹ Compared with the White majority population, Hispanic mothers tend to have better or equal pregnancy outcomes and better health-related behaviors despite generally having more disadvantaged socioeconomic circumstances.^20–24 It has been proposed that this “paradox” can be explained by dietary factors, social support and cohesion, and cultural differences in relation to the importance of motherhood.^23,24 However, long-term US residents who move away from ethnic enclaves²⁵ are more likely to adopt Western health behaviors and values²⁶ and may lose any protective effects of Hispanic culture. Thus, the protective effects of Hispanic culture are more likely to be maintained in communities of higher Hispanic density.We hypothesized that maternal smoking during pregnancy, infant mortality, LBW, and preterm birth would be lower for non-Hispanic Black and Hispanic White (hereafter referred to as “Hispanic mothers”) mothers living in counties with a higher percentage of people of the same ethnicity, relative to their counterparts living in counties with a low percentage of people of the same ethnicity.