Author ORCID Identifier

https://orcid.org/0000-0001-5530-5088

Date of Award

8-10-2021

Degree Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor

Dr. Claire Spears

Second Advisor

Dr. Terry Pecháček

Third Advisor

Dr. Dawn Aycock

Abstract

Tobacco use is the leading cause of preventable morbidity and mortality, both in the U.S. and worldwide. There has been tremendous progress in reducing overall tobacco use in the general U.S. population. Nevertheless, tobacco control measures have not sufficiently aided certain subpopulations, and significant tobacco-related health disparities persist. African Americans and low-socioeconomic status (SES) populations are at disproportionately high risk for tobacco-related diseases and mortality. During the current (2020-2021) sociopolitical climate (e.g., increased unemployment rates, police killings of unarmed African Americans) and the COVID-19 pandemic, racial and ethnic minorities and low-SES populations are disproportionately experiencing health risks and financial challenges. There is reason for concern that these highly stressful circumstances may contribute to increased tobacco use and a lower likelihood of quitting, thus contributing to exacerbated health disparities among African Americans. The purpose of the current dissertation is to examine risk and protective factors for use of cigarettes and non-cigarette combustible tobacco products among African Americans. Whereas there are many established risk and protective factors regarding combustible cigarettes, more research is needed to understand the use of non-cigarette combustible products among African Americans. Furthermore, an updated examination of factors affecting tobacco use during the COVID-19 pandemic and the current sociopolitical climate is needed.

For study 1, a critical literature review of literature on combustible tobacco use among African Americans informed a conceptual model including factors from the individual to policy levels of the socioecological model. Non-cigarette combustible tobacco products of interest were little cigars and cigarillos (LCCs), traditional cigars, and hookah. The findings of the articles were categorized by the socioecological model (i.e., individual level, interpersonal level, etc.). Once the findings were categorized, the factors were arranged according to the socioecological model. At the individual level, factors included socioeconomic status, racial/ethnic identity, religiosity/spirituality, stress and discrimination, and perceptions of non-combustible tobacco products. Factors at the interpersonal and organizational levels included use of other substances and social norms regarding non-cigarette combustible tobacco use. Community and policy level factors included availability of flavored tobacco products, exposure to tobacco advertising, and price and taxation. Based on the model, recommendations were provided to inform interventions targeting specific factors at each level of the socioecological model, from individual interventions to regulatory actions.

Study 2 examined the association between perceived racial discrimination and tobacco use among African American adults. It was hypothesized that 1) Greater baseline experiences with everyday, lifetime, and burden of discrimination attributed to race would be associated with a higher likelihood of using combustible tobacco products; and 2) Religion, religious coping, and spirituality would moderate associations between experiences with discrimination and combustible tobacco use. Cross-sectional data for this study were drawn from the Jackson Heart Study. A series of binary logistic regression models were fit to test baseline experiences with discrimination attributed to race and the association with current cigarette smoker status. Everyday discrimination was associated with a higher likelihood of being a current cigarette smoker. To assess the association between discrimination and current smoker status with religiosity/spirituality as a moderator, a series of binary logistic regression models were fit, including interaction terms between religiosity/spirituality and discrimination in predicting smoking status. The interaction term of lifetime discrimination and prayer as a reaction to lifetime discrimination was statistically significant (B=-1.14, p=.032) while controlling for demographics, general stress, and coping strategies. The association between major lifetime discrimination and current cigarette smoker status was weakened for those who prayed as a reaction to discrimination compared to those who reported not praying as a reaction.

Study 3 utilized qualitative interviews to examine protective and risk factors associated with using multiple tobacco products among low-income African American adults and changes that may have occurred due to COVID-19 and the current sociopolitical climate. Twenty-two African American adult smokers from the metro Atlanta area completed short surveys and an in-depth interview. The survey included questions about demographic information, stress, tobacco use, racial/ethnic identity, and religiosity/spirituality. The interview covered topics including combustible tobacco use, changes in combustible tobacco use during COVID-19, risk perceptions of other combustible tobacco products compared to cigarettes, awareness of racism or discrimination due to recent social justice issues, methods of coping with stress, intention to reduce or stop the use of combustible products, and the impact of COVID-19 (e.g., changes in living situation). The median age was 38.5 years old. Most of the participants were single (81.8%), male (59.1%), and had an annual household income of less than $30,000 (72.7%). About half (54.5%) were classified as poly users (use of two or more tobacco products), while 32% were classified as dual users of cigarettes and LCCs. Overall, participants expressed low risk perceptions of LCCs compared to cigarettes, especially when used with marijuana. Increases in tobacco use were attributed to higher stress levels experienced during the current sociopolitical climate. Some of the specific stressors included financial insecurity, changes in living situation, and uncertainty of post-pandemic life.

In summary, the current dissertation contributes to our understanding of tobacco-related health disparities among African Americans. Our findings suggest that inaccurate risk perceptions, social norms, and use of other substances contribute to the persistent use of non-cigarette combustible tobacco products among African Americans. Additionally, daily discrimination was found to increase the likelihood of being a current cigarette smoker. Moreover, our findings suggest the need for protective factors related to stressors experienced during the current sociopolitical climate. Ultimately, future research should focus on the context in which African Americans use multiple tobacco products, further informing interventions to eliminate health disparities for this population.

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