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).     

Racial Differences in the Relationship Between Alcohol Consumption in Early Adulthood and Occupational Attainment at Midlife

Objectives. We assessed the relationship between alcohol consumption in young adulthood (ages 18–30 years) and occupational success 15 years later among Blacks and Whites.Methods. We analyzed data from the Coronary Artery Risk Development in Young Adults Study on employment status and occupational prestige at year 15 from baseline. The primary predictor was weekly alcohol use at baseline, after stratification by race and adjustment for socioeconomic factors.Results. We detected racial differences in the relationship between alcohol use in early adulthood and employment status at midlife. Blacks who were very heavy drinkers at baseline were more than 4 times as likely as Blacks who were occasional drinkers to be unemployed at year 15 (odds ratio [OR] = 4.34; 95% confidence interval [CI] = 2.22, 8.47). We found no statistically significant relationship among Whites. Occupational prestige at midlife was negatively related to very heavy drinking, but after adjustment for marital status, active coping, life stress, and educational attainment, this relationship was statistically significant only among Blacks.Conclusions. Heavy drinking during young adulthood was negatively associated with labor market success at midlife, especially among Blacks.Patterns of heavy drinking during early adulthood are well known.^1–4 Efforts to curb such drinking on college campuses reflect concerns that such drinking may lead to personal harm in the short run⁵ and impaired functioning later in life.⁶ Particular population subgroups may be especially vulnerable to long-term adverse effects from high levels of alcohol use in early adulthood. For example, although Blacks consume less alcohol than do Whites in general,⁷ high levels of alcohol consumption in early adulthood are associated with reduced odds of employment in a profession 10 years later.⁸ Costanzo et al. reported that among individuals with high stress or negative-affect levels, high levels of alcohol consumption during youth persist into later adulthood, especially among Blacks.⁹We addressed 4 questions regarding this issue. First, to what extent is heavy alcohol consumption in early adulthood associated with lower employment rates and lower occupational prestige in midlife? Second, do such relationships differ by race? Third, are observed racial differences in labor market outcomes attenuated by adjustment for psychosocial factors such as exposure to stress? Fourth, for persons enrolled in college, does heavy alcohol consumption reduce rates of college completion?     

Race,Ethnicity, and Self-Reported Hypertension: Analysis of Data From the National Health Interview Survey, 1997–2005

Objective. I estimated the association between race and self-reported hypertension among Hispanics and non-Hispanics and determined whether this association was stronger among non-Hispanics.Methods. With data from the 1997–2005 National Health Interview Survey, I used logistic regression to estimate the strength of the association between race/ethnicity and self-reported hypertension among US adults.Results. The overall prevalence of self-reported hypertension was 24.5%, with lower prevalence among Hispanics (16.7%) than among non-Hispanics (25.2%; P < .01). Blacks, regardless of ethnicity, had the highest prevalence. Compared with non-Hispanic Whites, non-Hispanic Blacks had 48% (odds ratio [OR] = 1.48; 95% confidence interval [CI] = 1.41, 1.55) greater odds of reporting hypertension; Hispanic Whites had 23% (OR = 0.81; 95% CI = 0.76, 0.88) lower odds. There was no difference in the strength of the association between race and self-reported hypertension observed among non-Hispanics (OR for Blacks = 1.47) and among Hispanics (OR for Blacks = 1.20; for interaction, P = 0.43).Conclusions. The previously reported hypertension advantage of Hispanics holds for Hispanic Whites only. As Hispanics continue their rapid growth in the United States, race may have important implications on their disease burden, because most US health disparities are driven by race and its socially patterned experiences.Hypertension affects more than 65 million US adults¹ and is a major risk factor for cardiovascular disease (CVD).^2,3 The prevalence of hypertension in the US population increased by 30% between the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994) and NHANES 1999–2000.¹ Previous studies have consistently reported that, compared with non-Hispanic Whites, Hispanics have a lower prevalence of hypertension and that non-Hispanic Blacks have a higher prevalence of hypertension.^1,2,4–7 However, these studies focused mostly on Mexican Americans, ignoring the heterogeneity of the Hispanic population. For example, because of their colonization patterns, Hispanics can be of any race (i.e., White, Black, or some other race).⁸ Despite the impact of race on health in US society^9–11 and the projected growth of the Hispanic population,^12–14 there is a dearth of knowledge addressing the relationship between race and health among Hispanics. However, the evidence that does exist parallels findings observed among non-Hispanics: Hispanic Blacks experience worse health outcomes than do Hispanic Whites.^15–18 Thus, the investigation of race and health outcomes in Hispanics is imperative.Hypertension has been attributed to obesity, sodium and potassium intake, physical inactivity, alcohol consumption, smoking, and psychosocial stress.³ Of these, only psychosocial stress has been shown to be unequally distributed across racial/ethnic groups. Research suggests that racial discrimination—a trigger of psychosocial stress—is common in the everyday life of non-Hispanic Blacks and may lead to CVD.^19–26 Given this, and consistent with the historical pattern of disadvantage among non-Hispanic Blacks,^9,11,27,28 it is possible that Hispanic Blacks could be exposed to the same deleterious experiences of racial discrimination and racism as non-Hispanic Blacks because of the salience and social visibility associated with their race or dark skin color. These experiences may lead to disadvantaged life chances, which then translate into poorer health.The availability of 9 years of data from the National Health Interview Survey (NHIS, 1997–2005) afforded the opportunity to investigate the association between race and self-reported hypertension in Hispanics and non-Hispanics before and after adjustment for selected characteristics and known risk factors and to compare the strength of this association in Hispanics and non-Hispanics. If race as a social construct channels Hispanic Blacks to exposures detrimental to health as it does for non-Hispanic Blacks, the lower odds of hypertension for Hispanics observed in previous studies would apply only to Hispanic Whites whereas Hispanic Blacks would have odds of hypertension similar to those of non-Hispanic Whites or intermediate between non-Hispanic Whites and non-Hispanic Blacks. However, the magnitude of the association between race and hypertension would be stronger among non-Hispanics than among Hispanics.     

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.     

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.     

Associations of acculturation and socioeconomic status with subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis

Objectives. We assessed whether markers of acculturation (birthplace and number of US generations) and socioeconomic status (SES) are associated with markers of subclinical cardiovascular disease—carotid artery plaque, internal carotid intima-media thickness, and albuminuria—in 4 racial/ethnic groups.Methods. With data from the Multi-Ethnic Study of Atherosclerosis (n = 6716 participants aged 45–84 years) and race-specific binomial regression models, we computed prevalence ratios adjusted for demographics and traditional cardiovascular risk factors.Results. The adjusted US- to foreign-born prevalence ratio for carotid plaque was 1.20 (99% confidence interval [CI] = 0.97, 1.39) among Whites, 1.91 (99% CI = 0.94, 2.94) among Chinese, 1.62 (99% CI = 1.28, 2.06) among Blacks, and 1.23 (99% CI = 1.15, 1.31) among Hispanics. Greater carotid plaque prevalence was found among Whites, Blacks, and Hispanics with a greater number of generations with US residence (P < .001) and among Whites with less education and among Blacks with lower incomes. Similar associations were observed with intima-media thickness. There was also evidence of an inverse association between albuminuria and SES among Whites and Hispanics.Conclusions. Greater US acculturation and lower SES were associated with a higher prevalence of carotid plaque and greater intima-media thickness but not with albuminuria. Maintenance of healthful habits among recent immigrants should be encouraged.Beginning with the Ni-Hon-San study,^1,2 which was initiated in the 1960s, research has associated increased acculturation to Western lifestyles with more-adverse cardiovascular disease (CVD) risk factor profiles and with increased CVD morbidity and mortality. Specifically, greater Western acculturation has frequently been linked to increased body mass index (BMI; weight in kilograms divided by height in meters squared),^3–5 waist circumference and abdominal obesity,^6,7 hypertension,^7–9 type II diabetes,^10,11 and CVD morbidity and mortality.^1,12,13 However, little research has explored associations between acculturation and subclinical CVD.^14,15Abundant research also exists that links low socioeconomic status (SES) to increased levels of CVD risk factors, morbidity, and mortality.^14,16–18 In general, SES has been found to be inversely related to subclinical measures of CVD, including coronary artery calcification (CAC),^14,19–22 carotid artery plaque, and intima-media thickness^20,23–26 and albuminuria.²⁷ Relations with peripheral artery disease have been inconsistent.^28–30 The extent to which these associations vary by race/ethnicity has been examined infrequently. There is, however, some evidence that the relation between SES and disease may differ across racial/ethnic groups.^14,31,32 Specifically, in the Multi-Ethnic Study of Atherosclerosis (MESA) there was a higher prevalence of CAC among Whites with low education than among those with more education, whereas the reverse was true for Hispanics.¹⁴We investigated whether acculturation and SES were associated with other measures of subclinical disease, specifically with carotid plaque and albuminuria. The relation of acculturation and SES to CAC has been described in MESA.¹⁴ Although CAC, carotid plaque, and albuminuria are all subclinical measures of CVD and are related to adverse clinical outcomes, these measures represent different aspects of the disease process and have relatively weak intercorrelations.³³ Thus, they may be differentially related to our exposures of interest.The investigation of these patterns is important from a public health perspective and may yield clues regarding the etiology of atherosclerosis. On the basis of previous work,¹⁴ we hypothesized that increased Western acculturation, as assessed by place of birth, migration history, and duration of US residence, is associated with increased carotid plaque, intima-media thickness, and albuminuria. Additionally, we expected there to be an interaction between race/ethnicity and SES with respect to their associations with subclinical CVD. Specifically, we expected Whites and Blacks at lower SES to have more-adverse subclinical CVD profiles than those at higher SES, whereas for Hispanics and Chinese, we expected the reverse to be true.     

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.     

Mortality Patterns of Native Hawaiians Across Their Lifespan: 1990�C2000

Objectives. We examined mortality patterns across the lifespan of Native Hawaiians and compared mortality disparities across races.Methods. We determined the age-specific and age-adjusted mortality rates of Native Hawaiians from 1990 to 2000 by using national census and vital registration data.Results. Among Native Hawaiians aged younger than 1 year, expected deaths were 15% lower than for Blacks and 50% higher than for Whites. Among older adults, Native Hawaiians had higher rates of mortality compared with the general population, particularly in 1990 and 1995. Crude death rates for Native Hawaiians were similar to those for Blacks in 1990 and 1995 but were 20% lower than those for Blacks by 2000. Crude death rates for Native Hawaiians were 30% higher than for Whites in 1990 and 1995 and more than 40% higher than for Whites in 2000.Conclusions. Compared with Whites, Native Hawaiians and Blacks face similar challenges regarding infant and early-life mortality and increasing risks of mortality in mid-life and early old age. Our analyses document a need for renewed efforts to identify the determinants of ill health and commitment to address them.In 1997, the US Office of Management and Budget (OMB) implemented a new classification for identifying racial groups that, for the first time, designated “Native Hawaiians and Other Pacific Islanders” (NHPIs) as a distinct racial group, separate from Asians.^1,2 Traditionally, Pacific Islanders have been aggregated with Asian populations in statistical reports and public-use data sets under the “Asian/Pacific Islander” category. This Asian/Pacific Islander grouping has created ongoing measurement problems because of high levels of heterogeneity within the category.^3–5 The disaggregation of Asians from the category comprising NHPIs was a major first step in accurately characterizing these culturally, linguistically, demographically, and sociopolitically diverse populations.^6–10 Additionally, the OMB 1997 classification of race and ethnicity facilitated new opportunities for analysis of national-level data on NHPI health.^11–19The Native Hawaiian group represents the largest sector (46%) of the NHPI population²⁰ and is the only indigenous subpopulation within the NHPI designation. Thus, the Native Hawaiian population is similar sociopolitically to other indigenous populations such as American Indians and Alaska Natives, in that their indigenous status reflects a distinct relationship with the US federal government, which can have important implications for their health. Historically, Native Hawaiians were the first inhabitants of the Hawaiian archipelago. Their population was about 800 000 at the time of the first Western contact ²¹ in 1778, although by the early 1900s, the introduction of new diseases and cultures had reduced the native population by 85%.^22–29Little is known about the health of Native Hawaiians outside of the state of Hawaii, owing in large part to the sample limitation in most national-level surveys. An accurate assessment of morbidity and mortality among Native Hawaiians has also been hampered by their aggregation with Asians, which increased sample sizes but made it impossible to look at heterogeneity within this diverse population.^30,31 Still, reports of health outcomes among NHPIs have increased somewhat in recent years. These reports suggest that NHPIs face elevated risks for cardiovascular disease,¹⁹ poor health,^13,14,17,18 cancer,^15,16 obesity and diabetes,^32,33 and mortality across the life course.^11,12,34,35 However, baseline health statistics from larger national databases on specific health issues, which represent a vital element for informing policies on NHPI health and well-being, remain sparse.Because mortality represents a key outcome measure to inform policymakers and public health officials on the overall health of a population, we examined mortality patterns across the lifespan of Native Hawaiians. Using well-established demographic estimation techniques, we calculated age-specific and age-adjusted mortality for the period 1990 through 2000, allowing us to compare Native Hawaiian health disparities with those of Blacks and Whites.     

Income Inequality,Alcohol Use,and Alcohol-Related Problems

Objectives. We examined the relationship between state-level income inequality and alcohol outcomes and sought to determine whether associations of inequality with alcohol consumption and problems would be more evident with between-race inequality measures than with the Gini coefficient. We also sought to determine whether inequality would be most detrimental for disadvantaged individuals.Methods. Data from 2 nationally representative samples of adults (n = 13 997) from the 2000 and 2005 National Alcohol Surveys were merged with state-level inequality and neighborhood disadvantage indicators from the 2000 US Census. We measured income inequality using the Gini coefficient and between-race poverty ratios (Black–White and Hispanic–White). Multilevel models accounted for clustering of respondents within states.Results. Inequality measured by poverty ratios was positively associated with light and heavy drinking. Associations between poverty ratios and alcohol problems were strongest for Blacks and Hispanics compared with Whites. Household poverty did not moderate associations with income inequality.Conclusions. Poverty ratios were associated with alcohol use and problems, whereas overall income inequality was not. Higher levels of alcohol problems in high-inequality states may be partly due to social context.A growing literature examines the impact of area-level income inequality on health. Inequality, or the size of the difference in income between rich and poor, is distinct from absolute income or socioeconomic status (SES).1 Recent systematic reviews have found associations between income inequality and health.2–6 Theoretical3,7 and empirical work suggests that income inequality may affect health through psychosocial pathways, whereby people compare themselves with those who are better (or worse) off,4,8–10 and neomaterial pathways, whereby inequality leads to limited public investment in social goods such as education, health services, and welfare that directly affect health.3,11,12 (The term “neomaterial” is used to acknowledge the fact that material conditions relevant to present-day health outcomes differ from those material conditions that influenced infectious diseases in the 19th century.3)Most research on income inequality and health has focused broadly on health status and mortality,2 but a few studies focus on specific health outcomes and health behaviors.2,13,14 Among these is a small literature on alcohol that suggests that income inequality is associated with increased frequency of alcohol consumption,13 volume of alcohol consumed,14,15 drinking to drunkenness,14 and death from chronic alcohol-attributable illnesses.16 Results are not unequivocal, however. Findings for alcoholic cirrhosis are mixed, with one study finding a positive association for men but not women15 and others finding no association.17,18 Another study documented a curvilinear relationship with alcohol-related hospitalization, suggesting an initial decline in hospitalizations followed by a rapid rise as inequality increases.16 Finally, one study found that state-level income inequality was negatively associated with women’s alcohol dependence, but not after adjustment for state beer taxes.19To date, this literature on income inequality and alcohol has not examined whether income inequality affects alcohol consumption and related problems equally across SES and race/ethnicity. Furthermore, it has primarily measured income inequality using the Gini coefficient, a measure that captures the difference between an observed income distribution and a condition of complete equality.1 We have expanded on the existing literature by examining SES and race/ethnicity as moderators of associations between income inequality and alcohol outcomes, and by examining race-based measures of income inequality in addition to the Gini coefficient.Income inequality may not affect everyone in the same way.2,20 Affluent individuals may benefit from2 or be immune to the negative effects of²¹ living in unequal areas, whereas poorer people and Black and Hispanic people may suffer a “double jeopardy” in unequal areas.20,21 This double jeopardy hypothesis, however, may be specific to certain health and social outcomes.18 For example, compared with more egalitarian areas, areas with more unequal income distribution have stronger inverse associations between individual SES and adolescent literacy21 as well as mortality from alcoholic liver disease.18 These studies indicate that there is an interaction of individual SES and income inequality for certain outcomes. By contrast, some evidence suggests largely uniform (rather than differential) effects of income inequality on poor self-rated health22; however, most alcohol studies have not examined possible moderators of effects of income inequality.Income inequality can be measured overall or by comparing the status of 2 groups. Overall measures incorporate the range and distribution of incomes with the extent of inequality. The most commonly used overall measure is the Gini coefficient.1 By contrast, relative measures emphasize income or poverty differences between groups based on demographic characteristics. For example, between-race income inequality measures summarize differentials in income between various racial/ethnic groups living in the same area and have been used in the criminology literature.23,24 In the United States, there are stark differences in income and poverty status between Whites, Blacks, and Hispanics. In 2000, the ratio of per capita income of Whites to Blacks was 1.66 and of Whites to Hispanics was 1.97, with 15% of Whites, almost 30% of Blacks, and more than 20% of Hispanics having family incomes below the federal poverty threshold.25 Use of these relative measures seems especially relevant given our interest in examining whether race/ethnicity moderates the associations between income inequality and alcohol outcomes.We examined whether income inequality, measured by the Gini coefficient and 2 between-race measures, is associated with light to moderate alcohol consumption, heavy alcohol consumption, alcohol-related consequences, and alcohol dependence. Although not tested explicitly here, heavy (but not light) alcohol consumption may be linked to income inequality primarily through the psychosocial pathway (such as drinking to cope with stress), whereas alcohol problems additionally may be influenced by neomaterial effects of inequality (such as increased policing24 or decreased funding for alcohol treatment services). We also investigated whether associations with inequality were most detrimental for disadvantaged individuals (people in poor neighborhoods, with low household income, or racial/ethnic minority status), which also may suggest neomaterial effects of inequality.3     

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.     

A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors

Objectives. We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults.Methods. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data.Results. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy.Conclusions. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.Racial/ethnic minorities in the United States experience a disproportionate burden of smoking-related diseases, including cancer and heart disease, despite having larger proportions of light and intermittent smokers and generally lower adult smoking prevalence rates than non-Hispanic Whites.^1–3 Racial/ethnic minorities are also less likely to quit smoking successfully than are non-Hispanic Whites.^4–8 For example, rates of successful smoking cessation among African American smokers are lower than they are among non-Hispanic Whites, despite reports citing lower cigarette consumption.^2,5,7,9 Similarly, Hispanics/Latinos do not experience higher rates of successful quitting than non-Hispanic Whites, despite being more likely to be light and intermittent smokers.^2,9 There is currently no evidence indicating that Asian Americans quit at higher rates than non-Hispanic Whites in the United States.¹⁰ The examination of racial/ethnic disparities in smoking behaviors, successful quitting, and factors associated with quitting can provide valuable information for focusing strategies for groups currently experiencing lower rates of successful smoking cessation, and can lead to decreases in smoking-related disease rates across all racial/ethnic populations.Previous research on population-level data has found several factors to be associated with successful smoking cessation. For example, banning smoking in one''s home can greatly increase the chances of successfully quitting smoking. The presence of a complete ban on smoking in one''s home is associated with being quit for at least 90 days¹¹ and with being a former smoker.¹² However, an analysis of national data found that smaller percentages of non-Hispanic Whites (64.0%) and African Americans (64.4%) have a complete home smoking ban than do Hispanics/Latinos (78.0%) and Asian Americans/Pacific Islanders (79.2%).¹³ Being advised to quit smoking by health care professionals, especially physicians, has also been associated with increased rates of smoking cessation.^14–17 Despite progress in smokers being advised to quit by health care practitioners in the past 5 years, African American and Hispanic/Latino smokers remain less likely than non-Hispanic Whites to be advised to quit.^16,18 Finally, although evidence of the effectiveness of nicotine replacement therapy (NRT) at the population level has been challenged recently,^19,20 there is evidence that NRT can aid successful cessation.^17,21–23 There is substantial evidence that racial/ethnic minorities are less likely to be prescribed NRT^14,15,18 and to use NRT to quit smoking.^23–25The Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) have provided invaluable data for the examination of various smoking-related issues at the national level.^11,13 In 2003, the TUS-CPS included a special supplement that focused heavily on smoking cessation. This supplement was the first TUS-CPS with this focus (and is the only one to date), and it provides arguably the richest representative national-level data on smoking cessation in the United States. This special supplement thus presented a unique opportunity to examine in detail the disparities between racial/ethnic groups in smoking cessation and important related factors.For our study, we hypothesized the following: (1) African Americans would experience less success in quitting smoking than would non-Hispanic Whites, (2) Asian Americans/Pacific Islanders and Hispanics/Latinos would be more likely to have a complete home smoking ban than would non-Hispanic Whites, (3) African Americans and Hispanics/Latinos would be less likely than would non-Hispanic Whites to report being advised by a health professional to quit smoking, and (4) racial/ethnic minorities would be less likely to use NRT than would non-Hispanic Whites.To examine these hypotheses, we conducted a secondary data analysis of the 2003 TUS-CPS to assess smoking cessation rates and examine how factors associated with successful smoking cessation differed across racial/ethnic groups among adults in the United States. Findings from this report may provide insight into optimal design of targeted smoking cessation interventions for members of specific racial/ethnic groups.     

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.     

Trust in the health care system and the use of preventive health services by older black and white adults

Objectives. We sought to find racial differences in the effects of trust in the health care system on preventive health service use among older adults.Methods. We conducted a telephone survey with 1681 Black and White older adults. Survey questions explored respondents'' trust in physicians, medical research, and health information sources. We used logistic regression and controlled for covariates to assess effects of race and trust on the use of preventive health services.Results. We identified 4 types of trust through factor analysis: trust in one''s own personal physician, trust in the competence of physicians'' care, and trust in formal and informal health information sources. Blacks had significantly less trust in their own physicians and greater trust in informal health information sources than did Whites. Greater trust in one''s own physician was associated with utilization of routine checkups, prostate-specific antigen tests, and mammograms, but not with flu shots. Greater trust in informal information sources was associated with utilization of mammograms.Conclusions. Trust in one''s own personal physician is associated with utilization of preventive health services. Blacks'' relatively high distrust of their physicians likely contributes to health disparities by causing reduced utilization of preventive services. Health information disseminated to Blacks through informal means is likely to increase Blacks'' utilization of preventive health services.There is strong empirical evidence of health care disparities between Black and White Americans. Blacks are less likely than are Whites to receive many needed services, including routine preventive care.^1–5 The causes of disparities in health care are complex and have been the subject of considerable research; socioeconomic differences and structural characteristics (such as lack of access to care) are important sources of care disparities, and there is significant evidence that racial bias in the health care system is also a major factor in disparities in care between Blacks and Whites.¹Blacks'' distrust of physicians and the health care system may also contribute to health care disparities. Studies have demonstrated that Blacks exhibit less trust in the health care system.^6–9 There are a variety of mechanisms through which this distrust may occur, including Blacks'' personal experiences with racism, their knowledge of a history of racism in the health care system—including circumstances in which Blacks were victimized, such as the Tuskegee Syphilis Study^10–12—and social and cultural distance between Black patients and White physicians.¹³ Taken together, these individual experiences constitute a broader cultural memory of abuse that may contribute to belief in conspiracy theories among Blacks.^14,15 Goertzel reported that belief in conspiracies was correlated with lack of interpersonal trust and that Blacks were more likely to believe in conspiracy theories than were Whites.¹⁶Trust plays a central role in all medical relationships and is an important contributor to positive therapeutic outcomes.^17–20 Lack of patient trust is associated with less doctor–patient interaction, poor clinical relationships that exhibit less continuity, reduced adherence to recommendations, worse self-reported health, and reduced utilization of health care services^17–22; thus, Blacks'' relatively lower trust in the health care system puts them at greater risk of all these negative outcomes. When O''Malley et al.²² evaluated respondents'' answers to a global question assessing overall trust in personal physicians, they found that greater trust was associated with higher overall use of a number of preventive services among low-income Black women 41 years and older.However, little is known about whether distrust affects use of specific preventive services differently. Because trust in the health care system is conceived as consisting of a number of types and dimensions,^17,19,20 it is also possible that different aspects of trust may affect service use differently, thus warranting more detailed study of how the dimensions of trust may affect use of preventive services among various populations. Because of its likely origins in racial bias, Blacks'' health care–related distrust may have somewhat different effects from that of Whites, perhaps manifesting as institutional distrust as opposed to interpersonal distrust.We explored these issues by examining the association of different aspects of health care–related trust with receipt of preventive health services among older Blacks and Whites. We focused on older adults because preventive services such as immunizations, routine physical examinations, and screening for cancer and other diseases can greatly reduce premature mortality and morbidity among this population and are critical to sustaining older adults'' health.²³ Thus, disparities in receipt of preventive services are an especially strong contributor to disparities in health outcomes for older adults.     

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.     

Differential Trends in Weight-Related Health Behaviors Among American Young Adults by Gender, Race/Ethnicity, and Socioeconomic Status: 1984�C2006

Objectives. We investigated temporal patterns from 1984 to 2006 in 6 weight-related health behaviors by using longitudinal data for multiple cohorts of young adults (aged 19–26 years) from the nationally representative Monitoring the Future Study.Methods. We used growth curve models to examine historical trends in 6 health behaviors: frequency of eating breakfast, eating green vegetables, eating fruit, exercising, watching television, and sleeping 7 hours each night. Variations across gender, race/ethnicity, and socioeconomic status were investigated.Results. Frequency of exercising was consistently lower among young adult women than young adult men over this 23-year period. Compared with White women, Hispanic women, and women from other race/ethnic groups, Black women showed declines in the frequency of exercise since 1984. In general, young adult women showed a marked increase in the frequency of eating breakfast over this period, although Black women did not show any net gains.Conclusions. Social disparities in body weight may increase because Black women, Hispanic women, and men with lower socioeconomic status show declining trends in positive weight-related health behaviors compared with White young adults with higher socioeconomic status.As the prevalence of obesity and overweight rises in the United States,^1–5 researchers continue to investigate a range of mechanisms by which people attain excessive body weight.^6–10 Agreement is growing that the source of the obesity epidemic lies in an environment that produces an energy gap,^11–15 where energy intake exceeds energy expenditure even by as little as 100 excess calories per day.^12,13 Yet, it is unclear whether this 100-calorie excess is a function of increased intake or decreased output (or some combination of both) in American activity and consumption behaviors over time.Limited data exist on trends in energy intake and energy expenditure among Americans over the past 3 decades, but the data that are available are nonetheless consistent with the rise in obesity observed over the same period. Between 1977 and 1996, Americans increased their total energy consumption by about 200 kcal/day.¹⁶ This was largely a result of increased consumption of snacks and soft drinks, particularly among young adults,^16,17 while vegetable and fruit consumption remained low.^18–21 These consumption behaviors have all been linked to excess weight gain.^22–25 The increased availability of inexpensive, energy-dense food and beverages^26–30 coupled with a lack of access to fresh fruits and vegetables^31,32 are some of the environmental factors that may contribute to these trends. The US population has also adopted an increasingly sedentary lifestyle^33–36 in an environment that is associated with a reduction in energy expenditure, including car-dependent neighborhoods that discourage walking and biking^37–41 and limited physical activity in schools.^28,42 On average, American youth spend over 30 hours per week watching television,⁴³ which is positively associated with being overweight, either through sedentary activity or through exposure to the marketing of poor-quality foods.^43–46 Modern lifestyles are increasingly characterized by skipping breakfast and sleeping less,^36,47–49 which have also been linked to energy imbalance.^50–56These reported trends in health behaviors, however, are based on data from repeated cross-sectional surveys^18,21,57 that were often conducted up to 5 years or more apart,^16,21,57 the results of which are typically reported in aggregate across a time span of 4 to 7 years.^20,57 Moreover, published articles frequently focus on trends in only 1 health behavior (e.g., fruit and vegetable consumption^18,20) and not the relative practice of energy consumption and expenditure behaviors among individuals over time. As a result, more detailed trends in health behaviors, particularly as they illustrate subtle changes in the balance of energy intake and output occurring annually among American young adults over the last quarter century, are poorly understood.Also, differences in these behaviors and their trends by gender, socioeconomic status (SES), and racial/ethnic background are not well described at a population level, even though well-documented health disparities in obesity by social position exist.^4,58–61 Using data from the National Health and Nutrition Examination Survey (1988–2002), one study found that non-Hispanic Blacks, persons in poverty, and those with less than a high school education were less likely to meet US Department of Agriculture fruit and vegetable guidelines than were non-Hispanic Whites and socioeconomically advantaged individuals.⁵⁷ However, these results were based on 2 cross-sectional data sets collected 5 years apart. Delva et al.¹⁰ used repeat cross-sectional data collected annually from secondary school students between 1986 and 2003 to report declining trends in the proportion of adolescents who ate breakfast or exercised regularly, with a lower prevalence among women, racial/ethnic minorities, and those with low SES. Trends in the frequency of these behaviors beyond the secondary school setting, however, remain largely undocumented.The purpose of our study was, first, to investigate long-term patterns in weight-related health behaviors among young adults (aged 19–26 years) over the past 23 years (1984–2006) and, second, to assess how these patterns varied by social position (race/ethnicity, gender, and SES). Analyses were based on longitudinal data for multiple cohorts of individuals with frequent repeat measures to better track historical changes in weight-related health behaviors over time. By focusing on young adults, we aimed to better understand how weight-related health behaviors have changed in this early period of the adult life course, when many adult health behavior patterns show their formative roots. The transition to adulthood (sometimes referred to as emerging or early adulthood) is a period when individuals are on their own typically for the first time, when life plans are put into action, and when distinctive life paths become more manifest.⁶² We hypothesized that the frequency of healthy behaviors would generally decline among young adults over this period, and that the rate of decline would be greater among those in disadvantaged social positions (women, Blacks, Hispanics, and those of lower SES).     

Socioeconomic and ethnic differences in disease burden and disparities in physical function in older adults

Objectives. We investigated whether a greater burden of disease among poorer individuals and ethnic minorities accounted for socioeconomic and racial disparities in self-reported physical functioning among older adults.Methods. We used data from adults aged 60 years or older (n = 5556) in the Third National Health and Nutrition Examination Survey, 1988–1994 to test associations between education level, poverty index, and race/ethnicity and limitations in 11 functions. We adjusted for demographic features and measures of disease burden (comorbid conditions, smoking, hemoglobin level, serum albumin level, knee pain, body mass index, and skeletal muscle index).Results. Associations between education and functional limitations were attenuated after adjustment, but those with 0–8 years of education were more likely than those with 13 or more years of education to have limitations in 3 functions. Poverty was associated with a higher likelihood of limitations despite adjustment. The likelihood of limitations among non-Hispanic Blacks and Mexican Americans was similar to that of non-Hispanic Whites after adjustment.Conclusions. Socioeconomic disparities in functional limitations among older Americans exist independent of disease burden, whereas socioeconomic differences and disease burden account for racial disparities.Although the prevalence of disability among older adults in the United States has generally declined over the past decade, this trend has not extended to all segments of the population.^1–4 Disability among ethnic minorities and economically disadvantaged groups has not declined, resulting in widening ethnic and socioeconomic disparities.^5–11 Racial minorities and those who are economically disadvantaged are up to 3 times more likely to experience disability than are Whites and those who are not economically disadvantaged, respectively.^8,10,12,13 Achieving health equity has been a public policy priority, and collective interventions have been proposed.^12,14,15 Functional limitations in older adults are particularly important because of their prognostic and economic implications.¹⁶ Functional limitations predict further future decline in physical function,¹⁷ an increased risk of dementia,¹⁸ loss of independence, institutionalization, and mortality.^19–21According to the Institute of Medicine model of the enabling–disabling process, disability is a product of the complex interactions between a person and his or her psychological, social, and physical environments.²² In this context, functional limitations are partly a consequence of an individual''s burden of disease. Musculoskeletal conditions, chronic neurological and cardiopulmonary disorders, sensory and cognitive deficits, anemia, sarcopenia, and chronic pain may lead to functional limitations and disability. Many of the chronic health conditions that can affect physical functioning are more common among ethnic minorities and economically disadvantaged groups,^5,6,9–12 raising the question of whether a greater burden of disease can primarily explain the higher prevalence of functional limitations and disability in these groups.Previous studies of socioeconomic and ethnic disparities in functional limitations reported unadjusted data or data adjusted only for differences in demographic characteristics.^{10,11,23–27} Few studies have examined the role of differences in comorbid conditions, obesity, or smoking or simultaneously examined a range of indicators of disease burden.^6,9,28 We sought to determine whether socioeconomic and ethnic differences in functional limitations among noninstitutionalized older adults in the United States remain after adjusting for measures of disease burden.     

Combining Explicit and Implicit Measures of Racial Discrimination in Health Research

Objectives. To improve measurement of discrimination for health research, we sought to address the concern that explicit self-reports of racial discrimination may not capture unconscious cognition.Methods. We used 2 assessment tools in our Web-based study: a new application of the Implicit Association Test, a computer-based reaction-time test that measures the strength of association between an individual''s self or group and being a victim or perpetrator of racial discrimination, and a validated explicit self-report measure of racial discrimination.Results. Among the 442 US-born non-Hispanic Black participants, the explicit and implicit measures, as hypothesized, were weakly correlated and tended to be independently associated with risk of hypertension among persons with less than a college degree. Adjustments for both measures eliminated the significantly greater risk for Blacks than for Whites (odds ratio = 1.4), reducing it to 1.1 (95% confidence interval = 0.7, 1.7).Conclusions. Our results suggest that the scientific rigor of research on racism and health will be improved by investigating how both unconscious and conscious mental awareness of having experienced discrimination matter for somatic and mental health.A small but fast-growing body of public health research is investigating the association between self-reported experiences of racial discrimination and population health.^1–5 To date, the strongest positive and generally linear associations have been observed for what are also the most commonly studied outcomes: self-reported psychological distress and self-reported health behaviors (e.g., smoking, alcohol use, and other drug use).^1–5 By contrast, evidence for somatic health outcomes, chiefly cardiovascular health, has been more mixed, with studies variously reporting linear, nonlinear, and no associations between self-reported experiences of discrimination and health status.^1–5The largest published study on racial discrimination and risk of elevated blood pressure reported a positive linear (dose–response) relationship among professional Blacks but a curvilinear association among working-class Blacks, whose data revealed a J-shaped curve (i.e., blood pressure was higher among respondents reporting no discrimination than among those reporting moderate discrimination and highest among those reporting the most discrimination).⁶ This phenomenon of a linear relationship among persons with more socioeconomic resources but a J-shaped curve among those with fewer has been replicated in other studies on self-reported discrimination and health.^7,8One hypothesis that accounts for these results concerns what people are willing or able to say.^1,6 For persons with more socioeconomic resources, a response of no discrimination may more accurately capture the lack of personally experienced discrimination, whereas among persons with fewer socioeconomic resources, the same response may reflect an accurate report of no discrimination; a positive illusion, denial, or internalized oppression that is not consciously perceived; or a conscious decision not to report the discrimination because it is uncomfortable or dangerous to do so.^1,6 The latter 2 scenarios imply that a health risk may exist, via pathways involving physiological and behavioral responses to racial discrimination as a psychosocial stressor,^1–5 with bodies revealing health effects of exposures that can be subject to distortions in perceptions, memory, and rationalizations.^1,9 If so, reliance solely on self-report measures of racial discrimination, which has been standard to date,^1–5 may be problematic.¹The need to critically assess measurement of exposure to discrimination is demonstrated by what psychologists term person–group discrimination discrepancy (PGDD).^10–15 It is well-documented that people typically report more discrimination for their group than for themselves personally, even though, statistically, the group level cannot be high if every individual''s is low. PGDD is postulated to arise from an automatic protective mechanism,¹⁶ reflecting a larger psychological tendency to view and present oneself positively, even when such denial may not be in one''s ultimate self-interest.^17–19During the past decade, social psychologists, borrowing basic methods of cognitive psychology, have developed a new approach—the Implicit Association Test (IAT), a computer-based reaction-time measure—to study phenomena for which self-report data might not fully capture what people think and feel.^20–23 An outgrowth of several decades of experimental research in the social, cognitive, clinical, and neuropsychological sciences concerned with the general architecture of the human mind, human learning, and unconscious mental processes,^20,24–28 the IAT is now one of the most robust and widely employed measures in social, cognitive, and even clinical psychology; it is used to assess the ease with which the mind makes associations. Building on the central finding that learning involves changes in neural function of different neurons that are active at the same time, the underlying cognitive principle is that concepts in the mind that are more closely associated with each other are more closely linked. These associations can occur both for conscious cognitive processes and for unconscious mental processes that lie beyond the reach of introspective access, with evidence indicating that implicit (unconscious) associations can form about many different phenomena—the self, other people, places, animals, memories, fantasies, inanimate objects, and nontangible ideas.^20,27For example, an IAT could measure how much a person prefers flowers to bugs by contrasting the time it takes to make associations between the word pairs flowers and good and bugs and bad and then comparing what happens when participants are asked to pair flower with bad and bugs with good. A difference in average matching speed for opposite pairings determines the IAT score, a measure of strength of association. Participants are typically aware that they are making these connections but are unable to control them because of the rapid response times and the structure of the test. IAT methods are well-described in the social psychology literature,^21,22 and programming resources to develop IATs are available online.²⁹To address extant questions about measuring experiences of discrimination,^1–5,30,31 we employed a novel application of the IAT to assess unconscious cognition about discrimination and consider the implications of using both explicit (self-report) and implicit measures for research on racism and health. Our work builds on and extends research that used the IAT to study racial prejudice and stereotypes.^32–35 Recent health-related studies found that the IAT for racial prejudice can predict physicians'' clinical decisions.^36,37 Focusing on the somatic health of Black Americans, we hypothesized that the explicit and implicit measures would be weakly associated with each other (because of their varying abilities to measure unconscious processes) and independently associated with risk of hypertension (as modified by socioeconomic position) and with the greater hypertension risk among Blacks than Whites in the United States.     

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.