DOI: 10.1158/1055-9965.epi-23-0873 ISSN: 1055-9965

The association between state-level structural racism and alcohol and tobacco use behaviors among a national probability sample of Black Americans

Nathaniel Woodard, James Butler, Debarchana Ghosh, Kerry M. Green, Cheryl L. Knott
  • Oncology
  • Epidemiology


Background: Structural racism is how society maintains and promotes racial hierarchy and discrimination through established and interconnected systems. Structural racism is theorized to promote alcohol and tobacco use, which are risk factors for adverse health and cancer-health outcomes. The current study assesses the association between measures of state-level structural racism and alcohol and tobacco use among a national sample of 1,946 Black Americans. Methods: An existing composite index of state-level structural racism including five dimensions (subscales; i.e., residential segregation and employment, economic, incarceration, and educational inequities) was merged with individual-level data from a national sample dataset. Hierarchical linear and logistic regression models, accounting for participant clustering at the state level, assessed associations between structural racism and frequency of alcohol use, frequency of binge drinking, smoking status, and smoking frequency. Two models were estimated for each behavioral outcome, one using the composite structural racism index and one modeling dimensions of structural racism in lieu of the composite measure, each controlling for individual-level covariates. Results: Results indicated positive associations between the incarceration dimension of the structural racism index and binge drinking frequency, smoking status, and smoking frequency. An inverse association was detected between the education dimension and smoking status. Conclusions: Results suggest that state-level structural racism expressed in incarceration disparities, is positively associated with alcohol and tobacco use among Black Americans. Impact: Addressing structural racism, particularly in incarceration practices, through multilevel policy and intervention may help to reduce population-wide alcohol and tobacco use behaviors and improve the health outcomes of Black populations.

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