Structural Drivers of Persistent Disparities in Tobacco Use and Secondhand Smoke Exposure

Abstract

While the prevalence of tobacco use has declined substantially in recent decades, smoking remains the leading cause of preventable death in the United States. Moreover, patterns of tobacco use vary widely across socio-demographic groups. This dissertation explored structural drivers of persistent disparities in tobacco-related health outcomes, focusing on two examples in the U.S.: patterns of secondhand smoke (SHS) exposure among nonsmokers, and the high risk of smoking among sexual minority (SM) adults. In Chapter 2, I examined the relationship between smoke-free law coverage of workplaces and hospitality venues (restaurants and bars) and disparities in SHS exposure between 1999 and 2014. I found that smoke-free law coverage was associated with narrowing the differentials in SHS exposure between males and females, however, workplace smoke-free laws may have exacerbated SHS exposure disparities across quartiles of poverty income ratio, particularly for younger adults. In Chapter 3, I adopted attributable fraction and simulation modeling methods to quantify disparities in deaths attributable to SHS exposure between 2000 and 2016, and to project potential SHS exposure patterns through 2040. I found that Non-Hispanic Black adults have experienced a disproportionate burden of SHS-attributable mortality, compared to adults of other racial/ethnic backgrounds. In simulating the potential impacts of multiple intervention scenarios, I found that an intervention that weakened the association between smoking prevalence and SHS exposure resulted in more substantial declines in SHS exposure compared to an intervention that increased smoking cessation. Finally, in Chapter 4, I shifted focus to examine the high smoking prevalence among SM adults, including gay, lesbian, and bisexual individuals. I explored the relationship between smoking and exposure to state-level structural stigma, which encompasses societal norms and policies that constrain access to resources among stigmatized groups. Among SM adults, I found evidence of a curvilinear relationship between stigma and current smoking, where the probability of smoking was lowest at the lowest and highest levels of stigma. In sum, this dissertation examined patterns of tobacco-related health outcomes through a health equity lens. By combining empirical methods and simulation-based approaches, these studies provide insight into potential levers for reducing tobacco use and tobacco-related health disparities in the United States.PHDEpidemiological ScienceUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/162964/1/titusa_1.pd