Employment fluctuations and tobacco: How changing employment conditions impact smoking behavior and cigarette tax policy

In the last 35 years, the United States has experienced periods of extraordinary job growth, as well as four economic recessions, one of which was the longest downturn since the Great Depression. Although cyclical variation triggers questions about economic and housing stability, changing labor market conditions may also impact population health through financial and psychosocial mechanisms. This dissertation assesses the impact of both aggregate and individual level employment conditions on smoking, the leading preventable cause of death in this country. Understanding relationships between employment and smoking can help policymakers and health professionals design targeted health promotion programs, enhance tobacco control policies, and plan for future healthcare needs. In the first essay, I use nationally representative data to examine the influence of state labor market conditions on smoking behaviors, finding that smoking probabilities decline as state unemployment rates rise, but only in relatively strong economies. In the second essay, I assess how individual employment changes impact smoking status and intensity. Analyses of repeated observations of individuals over time suggest that people smoke more when they are unemployed than when they are working, but smoke less when they are out of the labor market altogether. In the third essay, I use thirty years of data from all 50 states to explore predictors of higher state cigarette tax rates, which are associated with lower smoking prevalence. My results demonstrate little support for claims that high state unemployment rates drive higher cigarette tax rates. As the economy continues to recover from recent downturns, the results presented here illustrate several opportunities to enhance progress toward national smoking-related goals. In these analyses, economic growth and employment are associated with greater smoking risks, underscoring the need for continued workplace programs and policies that discourage or prohibit smoking. Looking for work also appears to be a smoking risk factor; pairing smoking prevention resources with unemployment assistance programs could help ameliorate this risk. Finally, while economic and employment conditions are not key predictors of cigarette excise taxes in my analyses, other political or regional factors may create policy windows that advocates can leverage to foster tobacco control policy.Doctor of Philosoph

Structural Approaches to Health Promotion: What Do We Need to Know About Policy and Environmental Change?

Although the public health literature has increasingly called on practitioners to implement changes to social, environmental, and political structures as a means of improving population health, recent research suggests that articles evaluating organization, community, or policy changes are more limited than those focused on programs with individuals or their social networks. Even when these approaches appear promising, we do not fully understand whether they will benefit all population groups or can be successful in the absence of accompanying individually oriented programs. The role of this broad category of approaches, including both policy and environmental changes, in decreasing health disparities is also unclear, often benefiting some communities more than others. Finally, the political nature of policy and environmental change, including the impact on personal autonomy, raises questions about the appropriate role for public health professionals in advancing specific policies and practices that alter the conditions in which people live. This article addresses these issues and ends with a series of questions about the effectiveness and ethical implementation of what we have termed “structural initiatives.

Structural Approaches to Health Promotion: What Do We Need to Know About Policy and Environmental Change?

Although the public health literature has increasingly called on practitioners to implement changes to social, environmental, and political structures as a means of improving population health, recent research suggests that articles evaluating organization, community, or policy changes are more limited than those focused on programs with individuals or their social networks. Even when these approaches appear promising, we do not fully understand whether they will benefit all population groups or can be successful in the absence of accompanying individually oriented programs. The role of this broad category of approaches, including both policy and environmental changes, in decreasing health disparities is also unclear, often benefiting some communities more than others. Finally, the political nature of policy and environmental change, including the impact on personal autonomy, raises questions about the appropriate role for public health professionals in advancing specific policies and practices that alter the conditions in which people live. This article addresses these issues and ends with a series of questions about the effectiveness and ethical implementation of what we have termed “structural initiatives.

Racial and Ethnic Differences in What Smokers Report Paying for Their Cigarettes

Smoking rates and tobacco-related health problems vary by race and ethnicity. We explore whether cigarette prices, a determinant of tobacco use, differ across racial and ethnic groups, and whether consumer behaviors influence these differences

Losing jobs and lighting up: Employment experiences and smoking in the Great Recession

The Great Recession produced the highest rates of unemployment observed in decades, in part due to particularly high rates of people losing work involuntarily. The impact of these job losses on health is unknown, due to the length of time required for most disease development, concerns about reverse causation, and limited data that covers this time period. We examine associations between job loss, employment status and smoking, the leading preventable cause of death, among 13,571 individuals participating in the 2001-2011 waves of the U.S.-based Panel Study of Income Dynamics. Results indicate that recent involuntary job loss is associated with an average 1.1 percentage point increase in smoking probability. This risk is strongest when people have returned to work, and appears reversed when they leave the labor market altogether. Although some job loss is associated with changes in household income and psychological distress levels, we find no evidence that these changes explain smoking behavior modifications. Smoking prevention programs and policies targeted at displaced workers or the newly employed may alleviate some negative health effects produced by joblessness during the Great Recession

Comparing projected impacts of cigarette floor price and excise tax policies on socioeconomic disparities in smoking

About half of all US states have cigarette minimum price laws (MPLs) that require a per cent mark-up on prices, but research suggests they may not be very effective in raising prices. An alternative type of MPL sets a floor price below which packs cannot be sold, and may be more promising. This new type of MPL policy has only been implemented in 1 city, therefore its benefits relative to excise taxes is difficult to assess

E-Cigarette Availability, Price Promotions and Marketing at the Point-of Sale in the Contiguous United States (2014-2015): National Estimates and Multilevel Correlates

Electronic cigarette (e-cigarette) sales and use have increased rapidly, yet point-of-sale e-cigarette availability and marketing is understudied. We estimated changes in e-cigarette availability and marketing among tobacco retailers in the U.S., and associations with neighborhood characteristics. A national sample of tobacco retailers in the Contiguous U.S. was audited in 2014 and 2015 (n = 1,905 and n = 2,126, respectively) to observe e-cigarette availability and marketing (signs, ads, displays and promotions) and generate national prevalence estimates. Store, neighborhood and state level correlates of 2015 e-cigarette availability, price promotions and exterior advertising were analyzed using multilevel mixed-effects generalized linear models. E-cigarettes were sold at 72.0% of retailers in 2014 and at 79.2% in 2015. Price promotions increased from 11.9% to 20.2% of retailers. Among retailers that did not previously sell e-cigarettes in 2012, availability in 2015 was greater for retailers in neighborhoods with the highest proportion of Black residents (vs. lowest). E-cigarette price promotions were more prevalent in neighborhoods with more Hispanic residents, while exterior e-cigarette marketing was more prevalent in neighborhoods with more Black residents. State smoking prevalence was positively associated with e-cigarette availability, promotions and advertising. E-cigarette point-of-sale availability and marketing increased between 2014 and 2015 and expanded to neighborhoods with a higher proportion of Black residents between 2012 and 2015. Retailers located within states with high smoking prevalence appear to be targeted by e-cigarette marketing. As e-cigarettes become the target of more regulations, understanding changes in the e-cigarette retail environment is critical to inform potential policies regulating their sale and marketing

Upending the Social Ecological Model to Guide Health Promotion Efforts Toward Policy and Environmental Change

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere

Troubled Times, Troubled Relationships: How Economic Resources, Gender Beliefs, and Neighborhood Disadvantage Influence Intimate Partner Violence

We evaluate race/ethnicity and nativity-based disparities in three different types of intimate partner violence (IPV), and examine how economic hardship, maternal economic dependency, maternal gender beliefs, and neighborhood disadvantage influence these disparities. Using nationally representative data from urban mothers of young children who are living with their intimate partners (N=1,886), we estimate a series of unadjusted and adjusted logit models on mother’s reports of physical assault, emotional abuse, and coercion. When their children were age three, more than one in five mothers were living with a partner who abused them. The prevalence of any IPV was highest among Hispanic (26%) and foreign-born (35%) mothers. Economic hardship, economic dependency on a romantic partner, and traditional gender beliefs each increased women’s risk for exposure to one or more types of IPV, whereas neighborhood conditions were not significantly related to IPV in adjusted models. These factors also explained most of the race/ethnic and nativity disparities in IPV. Policies and programs that reduce economic hardship among women with young children, promote women’s economic independence, and foster gender equity in romantic partnerships can potentially reduce multiple forms of IPV

Beyond excise taxes: a systematic review of literature on non-tax policy approaches to raising tobacco product prices

Raising the price of tobacco products is considered one of the most effective ways to reduce tobacco use. In addition to excise taxes, governments are exploring other policies to raise tobacco prices and minimise price dispersion, both within and across price tiers. We conducted a systematic review to determine how these policies are described, recommended and evaluated in the literature