Structural racism and tobacco and alcohol use among Black Americans

Despite advances in cancer treatment and prevention, stark racial disparities persist in the United States. Black Americans face higher cancer rates and lower survival rates compared to their White counterparts — a gap that reflects deep-rooted systemic inequities. According to the American Cancer Society, Black people have the highest death rate and shortest survival of any racial/ethnic group in the United States for many types of cancer. For example, Black women are 41% more likely to die from breast cancer than White women, despite far fewer Black women being diagnosed with breast cancer. These troubling statistics underscore the urgent need for targeted interventions to reduce cancer risk and improve survival outcomes for Black communities.

 

Addressing the use of substances like alcohol and tobacco is crucial to reducing cancer incidence and mortality. Smoking and drinking promote various types of cancer, including breast, lung, colorectal, liver, oral, and stomach cancers. Black Americans are disproportionately affected by the consumption of alcohol and tobacco. Structural racism promotes alcohol and tobacco use and negatively impacts cancer incidence, treatment, and mortality among Black Americans. Thus, addressing structural racism is a vital component of any strategy to reduce cancer rates among Black Americans.

 

A new study aimed to assess the relationship between structural racism and alcohol and tobacco use among Black Americans, with the goal of understanding which facets of structural racism most influence alcohol and tobacco use.

What is structural racism?

In this study, the researchers define structural racism as the way through which society maintains and promotes racial hierarchy and discrimination via established and interconnected systems.

 

There are several pathways through which structural racism impacts health, including:

• Adverse exposures to negative physical, social, and economic situations.
• Stereotype threats, where members of a minority fear providing negative racial stereotypes correct.
• Promotion of maladaptive coping mechanisms such as smoking and drinking.

Structural racism may contribute to increased tobacco and alcohol use in Black communities. Previous research has found that racially-segregated communities have higher densities of tobacco and alcohol retailers. The increased availability of alcohol and tobacco in these communities promotes increased usage of those products. In addition, the social, physical, and socioeconomic contexts of living in a segregated neighborhood negatively impact many facets of health for Black people, including cancer treatment and survival.

 

What did this study do?

In a new study, researchers used state- and individual-level data to assess associations between structural racism and alcohol and tobacco use behaviors among Black Americans. They were specifically interested in how structural racism impacted Black Americans’ frequency of alcohol use, binge drinking episodes, smoking status, and tobacco use frequency.

 

The researchers used state-level data on structural racism collected nationally in the 2010 US Census. Information on drinking and smoking was collected by participant self-report via telephone interviews with 1,949 Black Americans from around the United States.

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The study used state-level data to calculate a structural racism index score based on five dimensions of structural racism:

• Residential segregation, which is the degree to which two or more racial groups live apart from one another.
• Gaps in incarceration rates between Black and White residents of each state.
• Gaps in educational attainment, which compares the proportion of Black to White residents with college degrees within each state.
• Gaps in economic indicators, which compare the poverty status gap ratio, the median annual household income gap, and the rental housing percent gap between Black and White Americans.

Gaps in employment status, which compares unemployment and labor force participation between Black and White Americans.
Possible values for each indicator range from 0 to 100, with higher values indicating greater levels of disparity for Black Americans.

A multilevel analysis

The researchers tested two different models in their analysis of structural racism and substance use. Model A used the state-level structural racism composite index as the primary independent variable. Model B used the dimensions of the state-level index as the primary independent variables. Both models controlled for participant age, gender, income, education, employment, and religious behaviors. This multilevel analysis permitted the researchers to identify which forms of structural racism most significantly impacted drinking and smoking behaviors among Black Americans.

 

The researchers removed the Employment dimension from their analysis due to concerns about multicollinearity with other dimensions used in the index. Thus, the final analysis included four dimensions of structural racism: residential segregation, economic, incarceration, and education.

 

What were the results?

This study looked at how different forms of structural racism at the state level relate to alcohol and tobacco use. In the initial bivariate analysis, the researchers found that most of the measures they used to assess structural racism were linked to higher levels of alcohol or tobacco use among Black Americans. In other words, in places where structural racism was more present, people were more likely to use alcohol or tobacco. However, the links between the composite measure of structural racism and substance use weakened in the multivariate analysis when they controlled for personal and state-level factors.

 

Additionally, the single-factor analysis of each dimension of structural racism revealed some interesting insights that demonstrate the complex interplay between structural racism and substance use. These insights underscore the importance of unpacking the facets of structural racism rather than treating it as a broad measure.

Frequency of alcohol use

This study found no significant relationship between state-level structural racism, either composite or single-factor, and the number of drinking days per month among Black Americans. The average number of drinking days per month was 3.01.

 

Binge-drinking episodes

This study found a positive relationship between incarceration and binge drinking episodes among Black Americans. Increases in the incarceration gap between Black and White Americans were associated with an increase in the number of binge drinking events per month. In total, the analysis suggested that participants in states with the highest scores in incarceration had 9.38 more binge-drinking episodes per year compared to those in states with a smaller incarceration gap.

The composite measure of state-level structural racism was not associated with binge-drinking episodes.

Smoking status

This study identified relationships between racial disparities in incarceration and education and the smoking status of Black Americans. Participants in states with the highest levels of structural racism in incarceration were 2.17 times more likely to be current smokers than those in states with lower levels of racism in incarceration. To the researchers’ surprise, however, those in states with the highest levels of structural racism in education were 0.37 times less likely to smoke than those with less racism in education.

 The composite measure of state-level structural racism was not associated with smoking status.

 

Frequency of tobacco use

Finally, this study found a positive relationship between incarceration and smoking frequency among Black Americans. Those in states with high levels of structural racism in incarceration had 2.17 times the odds of being a former or everyday smoker as compared with states with the lowest levels of structural racism.

The composite measure of state-level structural racism was not associated with the frequency of tobacco use.

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Multilevel Modelling

The study highlights the importance of looking at specific facets of structural racism rather than relying only on a broad, combined measure. Different dimensions of structural racism had varying effects on alcohol and tobacco use. Incarceration had the most consistent and strongest link to alcohol and tobacco use. Contrary to the researchers’ hypothesis, however, segregation did not show a clear link to smoking or drinking. This finding suggests that the effects of segregation may be better studied at a neighborhood or county level rather than at the state level.

 

Another unexpected finding was in education, wherein states with more structural racism in education had lower smoking rates. This finding contradicted the researchers’ expectations; they posited that other factors, such as access to healthcare, might explain this surprising result.

 

How does structural racism in incarceration rates impact substance use?

This study identified that incarceration was the dimension of structural racism most frequently associated with alcohol and tobacco use behaviors. The authors unpack how higher incarceration rates among Black Americans compared to White Americans may influence tobacco and alcohol use, explaining the negative toll that incarceration takes on individual and community health.

 

Mass incarceration of Black Americans, a product of racially targeted policies and practices such as Jim Crow laws, over-policing in Black communities, and harsher sentencing for Black offenders, has contributed to Black men having the highest incarceration rates in the US. Mass incarceration degrades social support, a vital determinant of health, in Black communities, increases stress and instability, and promotes the use of alcohol and tobacco as maladaptive coping mechanisms.

 

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It is important to note that this study only used state-level measures of structural racism rather than city or county-level indicators. Incarceration is the only dimension of structural racism directly tied to state-level policies, which could partly explain why it had the most influence in this study’s analyses. Future research should account for nuances and intra-state racial disparities to more accurately identify the impacts of structural racism on tobacco and alcohol use.

What are the implications of these findings?

The findings suggest that higher levels of structural racism are linked to increased alcohol and tobacco use among Black Americans. Different aspects of structural racism have varying effects on substance use, with mass incarceration standing out as a significant factor associated with binge drinking, smoking status, and smoking frequency. Addressing mass incarceration is essential to reduce high levels of substance use and related cancers in Black communities. More broadly, the study reinforces that structural racism is a critical public health issue, shaping behaviors that contribute to long-term health risks. Tackling structural racism through policy changes and public health interventions could help reduce health disparities, as systemic inequities in areas like incarceration and education have direct and indirect consequences on individual and population health.

Key Takeaways

• Structural racism is a predictor of tobacco and alcohol use in minorities such as Black Americans.
• Different dimensions of structural racism, such as incarceration and education, impact substance use differently.
• Mass incarceration of Black Americans is closely associated with binge drinking and tobacco use.
• Policies that address the structural racism in policing and incarceration systems are needed to reduce substance use and related cancers among Black Americans.

References

Woodard, N., Butler, J., Ghosh, D., & Green, K. M. (2024). The association between state-level structural racism and alcohol and tobacco use behaviors among a national probability sample of Black Americans. Cancer Epidemiology, Biomarkers & Prevention, 33(2), 261–269. https://doi.org/10.1158/1055-9965.EPI-23-0873

American Cancer Society. (2022). Cancer facts & figures for African American/Black people 2022-2024.

https://www.cancer.org/research/cancer-facts-statistics/cancer-facts-figures-for-african-americans.html