Association of Educational Attainment and Race/Ethnicity With Exposure to Tobacco Advertisement Among US Young Adults | Adolescent Medicine | JAMA Network Open | JAMA Network
[Skip to Navigation]
Sign In
Table 1.  Descriptive Statistics Summary of the Overall Sample
Descriptive Statistics Summary of the Overall Sample
Table 2.  Advertisement Exposure Based on the Intersection of Race/Ethnicity and Educational Attainment
Advertisement Exposure Based on the Intersection of Race/Ethnicity and Educational Attainment
Table 3.  Logistic Regression on Tobacco Advertisement Exposure in the Pooled Sample
Logistic Regression on Tobacco Advertisement Exposure in the Pooled Sample
Table 4.  Poisson Regression on Tobacco Advertisement Exposure in the Pooled Sample
Poisson Regression on Tobacco Advertisement Exposure in the Pooled Sample
1.
Ellickson  PL, Orlando  M, Tucker  JS, Klein  DJ.  From adolescence to young adulthood: racial/ethnic disparities in smoking.  Am J Public Health. 2004;94(2):293-299. doi:10.2105/AJPH.94.2.293PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention.  Racial disparities in smoking-attributable mortality and years of potential life lost—Missouri, 2003-2007.  MMWR Morb Mortal Wkly Rep. 2010;59(46):1518-1522.PubMedGoogle Scholar
3.
Trinidad  DR, Pérez-Stable  EJ, White  MM, Emery  SL, Messer  K.  A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors.  Am J Public Health. 2011;101(4):699-706. doi:10.2105/AJPH.2010.191668PubMedGoogle ScholarCrossref
4.
Soulakova  JN, Huang  H, Crockett  LJ.  Racial/ethnic disparities in consistent reporting of smoking-related behaviors.  J Addict Behav Ther Rehabil. 2015;4(4). doi:10.4172/2324-9005.1000147PubMedGoogle Scholar
5.
Blumenthal  DS.  Racial and ethnic disparities in smoking prevalence in Israel and the United States: progress to date and prospects for the future.  Isr J Health Policy Res. 2017;6(1):51. doi:10.1186/s13584-017-0177-9PubMedGoogle ScholarCrossref
6.
Cokkinides  VE, Halpern  MT, Barbeau  EM, Ward  E, Thun  MJ.  Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey.  Am J Prev Med. 2008;34(5):404-412. doi:10.1016/j.amepre.2008.02.003PubMedGoogle ScholarCrossref
7.
Tran  ST, Rosenberg  KD, Carlson  NE.  Racial/ethnic disparities in the receipt of smoking cessation interventions during prenatal care.  Matern Child Health J. 2010;14(6):901-909. doi:10.1007/s10995-009-0522-xPubMedGoogle ScholarCrossref
8.
Greaves  L, Hemsing  N.  Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure.  Drug Alcohol Depend. 2009;104(suppl 1):S121-S130. doi:10.1016/j.drugalcdep.2009.05.001PubMedGoogle ScholarCrossref
9.
Wallace  JM  Jr, Vaughn  MG, Bachman  JG, O’Malley  PM, Johnston  LD, Schulenberg  JE.  Race/ethnicity, socioeconomic factors, and smoking among early adolescent girls in the United States.  Drug Alcohol Depend. 2009;104(suppl 1):S42-S49. doi:10.1016/j.drugalcdep.2009.06.007PubMedGoogle ScholarCrossref
10.
Laveist  TA, Thorpe  RJ  Jr, Mance  GA, Jackson  J.  Overcoming confounding of race with socio-economic status and segregation to explore race disparities in smoking.  Addiction. 2007;102(suppl 2):65-70. doi:10.1111/j.1360-0443.2007.01956.xPubMedGoogle ScholarCrossref
11.
Reid  JL, Hammond  D, Driezen  P.  Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use?  Can J Public Health. 2010;101(1):73-78. doi:10.1007/BF03405567PubMedGoogle ScholarCrossref
12.
Zhang  X, Martinez-Donate  AP, Jones  NR.  Educational disparities in home smoking bans among households with underage children in the United States: can tobacco control policies help to narrow the gap?  Nicotine Tob Res. 2013;15(12):1978-1987. doi:10.1093/ntr/ntt090PubMedGoogle ScholarCrossref
13.
Reimer  RA, Gerrard  M, Gibbons  FX.  Racial disparities in smoking knowledge among current smokers: data from the health information national trends surveys.  Psychol Health. 2010;25(8):943-959. doi:10.1080/08870440902935913PubMedGoogle ScholarCrossref
14.
Rock  VJ, Davis  SP, Thorne  SL, Asman  KJ, Caraballo  RS.  Menthol cigarette use among racial and ethnic groups in the United States, 2004-2008.  Nicotine Tob Res. 2010;12(suppl 2):S117-S124. doi:10.1093/ntr/ntq204PubMedGoogle ScholarCrossref
15.
Drope  J, Liber  AC, Cahn  Z,  et al.  Who’s still smoking: disparities in adult cigarette smoking prevalence in the United States.  CA Cancer J Clin. 2018;68(2):106-115. doi:10.3322/caac.21444PubMedGoogle ScholarCrossref
16.
Assari  S, Mistry  R.  Educational attainment and smoking status in a national sample of American adults: evidence for the blacks’ diminished return.  Int J Environ Res Public Health. 2018;15(4):E763. doi:10.3390/ijerph15040763PubMedGoogle Scholar
17.
Assari  S, Mistry  R.  Diminished return of employment on ever smoking among Hispanic whites in Los Angeles.  Health Equity. 2019;3(1):138-144. doi:10.1089/heq.2018.0070PubMedGoogle ScholarCrossref
18.
Assari  S.  Health disparities due to diminished return among black Americans: public policy solutions.  Soc Issues Policy Rev. 2018;12(1):112-145. doi:10.1111/sipr.12042Google ScholarCrossref
19.
Assari  S.  Blacks’ diminished return of education attainment on subjective health: mediating effect of income.  Brain Sci. 2018;8(9):E176. doi:10.3390/brainsci8090176PubMedGoogle Scholar
20.
Assari  S.  Unequal gain of equal resources across racial groups.  Int J Health Policy Manag. 2018;7(1):1-9. doi:10.15171/ijhpm.2017.90PubMedGoogle ScholarCrossref
21.
Assari  S, Farokhnia  M, Mistry  R.  Education attainment and alcohol binge drinking: diminished returns of Hispanics in Los Angeles.  Behav Sci (Basel). 2019;9(1):E9. doi:10.3390/bs9010009PubMedGoogle Scholar
22.
Assari  S.  Socioeconomic determinants of systolic blood pressure: minorities’ diminished returns.  J Health Econ Dev. 2019;1(1):1-11.PubMedGoogle Scholar
23.
Assari  S.  Parental educational attainment and mental well-being of college students: diminished returns of blacks.  Brain Sci. 2018;8(11):E193. doi:10.3390/brainsci8110193PubMedGoogle Scholar
24.
Assari  S, Lapeyrouse  LM, Neighbors  HW.  Income and self-rated mental health: diminished returns for high income black Americans.  Behav Sci (Basel). 2018;8(5):E50. doi:10.3390/bs8050050PubMedGoogle Scholar
25.
Ruglass  LM, Root  JC, Dambreville  N,  et al.  Smoking policies in the home have less influence on cigarettes per day and nicotine dependence level among African American than white smokers: a cross-sectional analysis.  J Natl Med Assoc. 2019;S0027-9684(19)30091-4. doi:10.1016/j.jnma.2019.07.002PubMedGoogle Scholar
26.
Assari  S, Bazargan  M.  Unequal effects of educational attainment on workplace exposure to second-hand smoke by race and ethnicity: minorities’ diminished returns in the National Health Interview Survey (NHIS).  J Med Res Innov. 2019;3(2):e000179. doi:10.32892/jmri.179PubMedGoogle Scholar
27.
Simon  P, Camenga  DR, Morean  ME,  et al.  Socioeconomic status and adolescent e-cigarette use: the mediating role of e-cigarette advertisement exposure.  Prev Med. 2018;112:193-198. doi:10.1016/j.ypmed.2018.04.019PubMedGoogle ScholarCrossref
28.
Terry-McElrath  YM, Wakefield  MA, Emery  S,  et al.  State anti-tobacco advertising and smoking outcomes by gender and race/ethnicity.  Ethn Health. 2007;12(4):339-362. doi:10.1080/13557850701300723PubMedGoogle ScholarCrossref
29.
Keeler  C, Max  W, Yerger  V, Yao  T, Ong  MK, Sung  HY.  The association of menthol cigarette use with quit attempts, successful cessation, and intention to quit across racial/ethnic groups in the United States.  Nicotine Tob Res. 2017;19(12):1450-1464.PubMedGoogle Scholar
30.
Giovenco  DP, Spillane  TE, Merizier  JM.  Neighborhood differences in alternative tobacco product availability and advertising in New York City: implications for health disparities.  Nicotine Tob Res. 2019;21(7):896-902. doi:10.1093/ntr/nty244PubMedGoogle ScholarCrossref
31.
Lewis  MJ, Delnevo  CD, Slade  J.  Tobacco industry direct mail marketing and participation by New Jersey adults.  Am J Public Health. 2004;94(2):257-259. doi:10.2105/AJPH.94.2.257PubMedGoogle ScholarCrossref
32.
Audrain-McGovern  J, Tercyak  KP, Shields  AE, Bush  A, Espinel  CF, Lerman  C.  Which adolescents are most receptive to tobacco industry marketing: implications for counter-advertising campaigns.  Health Commun. 2003;15(4):499-513. doi:10.1207/S15327027HC1504_07PubMedGoogle ScholarCrossref
33.
Anderson  SJ.  Marketing of menthol cigarettes and consumer perceptions: a review of tobacco industry documents.  Tob Control. 2011;20(suppl 2):ii20-ii28. doi:10.1136/tc.2010.041939PubMedGoogle ScholarCrossref
34.
Brock  B, Schillo  BA, Moilanen  M.  Tobacco industry marketing: an analysis of direct mail coupons and giveaways.  Tob Control. 2015;24(5):505-508. doi:10.1136/tobaccocontrol-2014-051602PubMedGoogle ScholarCrossref
35.
Choi  K, Soneji  S, Tan  ASL.  Receipt of tobacco direct mail coupons and changes in smoking status in a nationally representative sample of US adults.  Nicotine Tob Res. 2018;20(9):1095-1100. doi:10.1093/ntr/ntx141PubMedGoogle ScholarCrossref
36.
Brock  B, Carlson  SC, Moilanen  M, Schillo  BA.  Reaching consumers: how the tobacco industry uses email marketing.  Prev Med Rep. 2016;4:103-106. doi:10.1016/j.pmedr.2016.05.020PubMedGoogle ScholarCrossref
37.
Huang  J, Tauras  J, Chaloupka  FJ.  The impact of price and tobacco control policies on the demand for electronic nicotine delivery systems.  Tob Control. 2014;23(suppl 3):iii41-iii47. doi:10.1136/tobaccocontrol-2013-051515PubMedGoogle ScholarCrossref
38.
Choi  K, Forster  JL.  Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest.  Am J Public Health. 2014;104(11):2179-2183. doi:10.2105/AJPH.2014.302123PubMedGoogle ScholarCrossref
39.
Brown-Johnson  CG, England  LJ, Glantz  SA, Ling  PM.  Tobacco industry marketing to low socioeconomic status women in the USA.  Tob Control. 2014;23(e2):e139-e146. doi:10.1136/tobaccocontrol-2013-051224PubMedGoogle ScholarCrossref
40.
Soneji  S, Knutzen  KE, Tan  ASL,  et al.  Online tobacco marketing among US adolescent sexual, gender, racial, and ethnic minorities.  Addict Behav. 2019;95:189-196. doi:10.1016/j.addbeh.2019.03.015PubMedGoogle ScholarCrossref
41.
Moore  DJ, Williams  JD, Qualls  WJ.  Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States.  Ethn Dis. 1996;6(1-2):83-98.PubMedGoogle Scholar
42.
Assari  S, Thomas  A, Caldwell  CH, Mincy  RB.  Blacks’ diminished health return of family structure and socioeconomic status: 15 years of follow-up of a national urban sample of youth.  J Urban Health. 2018;95(1):21-35. doi:10.1007/s11524-017-0217-3PubMedGoogle ScholarCrossref
43.
Assari  S.  Parental education better helps white than black families escape poverty: National Survey of Children’s Health.  Economies. 2018;6(2):30. doi:10.3390/economies6020030Google ScholarCrossref
44.
Assari  S, Preiser  B, Kelly  M.  Education and income predict future emotional well-being of whites but not blacks: a ten-year cohort.  Brain Sci. 2018;8(7):E122. doi:10.3390/brainsci8070122PubMedGoogle Scholar
45.
Assari  S.  Parental education attainment and educational upward mobility: role of race and gender.  Behav Sci (Basel). 2018;8(11):107. doi:10.3390/bs8110107PubMedGoogle ScholarCrossref
46.
Assari  S.  Parental educational attainment and academic performance of American college students: blacks’ diminished returns.  J Health Econ Dev. 2019;1(1):21-31.PubMedGoogle Scholar
47.
Assari  S.  Race, education attainment, and happiness in the United States.  Int J Epidemiol Res. 2019;6(2):76-82. doi:10.15171/ijer.2019.14PubMedGoogle ScholarCrossref
48.
Assari  S, Caldwell  CH, Mincy  R.  Family socioeconomic status at birth and youth impulsivity at age 15: blacks’ diminished return.  Children (Basel). 2018;5(5):E58. doi:10.3390/children5050058PubMedGoogle Scholar
49.
Tourangeau  R, Yan  T, Sun  H, Hyland  A, Stanton  CA.  Population Assessment of Tobacco and Health (PATH) reliability and validity study: selected reliability and validity estimates.  Tob Control. 2019;28(6):663-668. doi:10.1136/tobaccocontrol-2018-054561PubMedGoogle ScholarCrossref
50.
Hyland  A, Ambrose  BK, Conway  KP,  et al.  Design and methods of the Population Assessment of Tobacco and Health (PATH) Study.  Tob Control. 2017;26(4):371-378. doi:10.1136/tobaccocontrol-2016-052934PubMedGoogle ScholarCrossref
51.
Duke  JC, Lee  YO, Kim  AE,  et al.  Exposure to electronic cigarette television advertisements among youth and young adults.  Pediatrics. 2014;134(1):e29-e36. doi:10.1542/peds.2014-0269PubMedGoogle ScholarCrossref
52.
Pierce  JP, Sargent  JD, Portnoy  DB,  et al.  Association between receptivity to tobacco advertising and progression to tobacco use in youth and young adults in the PATH Study.  JAMA Pediatr. 2018;172(5):444-451. doi:10.1001/jamapediatrics.2017.5756PubMedGoogle ScholarCrossref
53.
Moran  MB, Heley  K, Pierce  JP, Niaura  R, Strong  D, Abrams  D.  Ethnic and socioeconomic disparities in recalled exposure to and self-reported impact of tobacco marketing and promotions.  Health Commun. 2019;34(3):280-289. doi:10.1080/10410236.2017.1407227PubMedGoogle ScholarCrossref
54.
Nicksic  NE, Snell  LM, Barnes  AJ.  Does exposure and receptivity to e-cigarette advertisements relate to e-cigarette and conventional cigarette use behaviors among youth: results from wave 1 of the Population Assessment of Tobacco and Health Study.  J Appl Res Child. 2017;8(2):3. https://eric.ed.gov/?id=EJ1188554. Accessed November 27, 2019.Google Scholar
55.
Agaku  IT, Ayo-Yusuf  OA.  The effect of exposure to pro-tobacco advertising on experimentation with emerging tobacco products among US adolescents.  Health Educ Behav. 2014;41(3):275-280. doi:10.1177/1090198113511817PubMedGoogle ScholarCrossref
56.
Stevens  P, Carlson  LM, Hinman  JM.  An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention.  Health Promot Pract. 2004;5(3)(suppl):129S-134S. doi:10.1177/1524839904264617PubMedGoogle ScholarCrossref
57.
Dilley  JA, Spigner  C, Boysun  MJ, Dent  CW, Pizacani  BA.  Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities?  Tob Control. 2008;17(6):385-390. doi:10.1136/tc.2007.024216PubMedGoogle ScholarCrossref
58.
Pierce  JP, Sargent  JD, White  MM,  et al.  Receptivity to tobacco advertising and susceptibility to tobacco products.  Pediatrics. 2017;139(6):e20163353. doi:10.1542/peds.2016-3353PubMedGoogle Scholar
59.
Pucci  LG, Joseph  HM  Jr, Siegel  M.  Outdoor tobacco advertising in six Boston neighborhoods: evaluating youth exposure.  Am J Prev Med. 1998;15(2):155-159. doi:10.1016/S0749-3797(98)00034-8PubMedGoogle ScholarCrossref
60.
Soneji  SS, Knutzen  KE, Villanti  AC.  Use of flavored e-cigarettes among adolescents, young adults, and older adults: findings from the Population Assessment for Tobacco and Health Study.  Public Health Rep. 2019;134(3):282-292. doi:10.1177/0033354919830967PubMedGoogle ScholarCrossref
61.
Schneller  LM, Bansal-Travers  M, Goniewicz  ML, McIntosh  S, Ossip  D, O’Connor  RJ.  Use of flavored electronic cigarette refill liquids among adults and youth in the US: results from wave 2 of the Population Assessment of Tobacco and Health Study (2014-2015).  PLoS One. 2018;13(8):e0202744. doi:10.1371/journal.pone.0202744PubMedGoogle Scholar
62.
Soulakova  JN, Danczak  RR.  Impact of menthol smoking on nicotine dependence for diverse racial/ethnic groups of daily smokers.  Healthcare (Basel). 2017;5(1):E2. doi:10.3390/healthcare5010002PubMedGoogle Scholar
63.
Levy  DT, Mays  D, Boyle  RG, Tam  J, Chaloupka  FJ.  The effect of tobacco control policies on US smokeless tobacco use: a structured review.  Nicotine Tob Res. 2017;20(1):3-11. doi:10.1093/ntr/ntw291PubMedGoogle ScholarCrossref
64.
Jones  MR, Apelberg  BJ, Tellez-Plaza  M, Samet  JM, Navas-Acien  A.  Menthol cigarettes, race/ethnicity, and biomarkers of tobacco use in US adults: the 1999-2010 National Health and Nutrition Examination Survey (NHANES).  Cancer Epidemiol Biomarkers Prev. 2013;22(2):224-232. doi:10.1158/1055-9965.EPI-12-0912PubMedGoogle ScholarCrossref
65.
Mustonen  TK, Spencer  SM, Hoskinson  RA, Sachs  DP, Garvey  AJ.  The influence of gender, race, and menthol content on tobacco exposure measures.  Nicotine Tob Res. 2005;7(4):581-590. doi:10.1080/14622200500185199PubMedGoogle ScholarCrossref
66.
Seidenberg  AB, Caughey  RW, Rees  VW, Connolly  GN.  Storefront cigarette advertising differs by community demographic profile.  Am J Health Promot. 2010;24(6):e26-e31. doi:10.4278/ajhp.090618-QUAN-196PubMedGoogle ScholarCrossref
67.
Assari  S, Mistry  R, Bazargan  M.  Race, educational attainment, and e-cigarette use.  Journal of Medical Research and Innovation. 2020;4(1):e000185. In press. doi:10.32892/jmri.185Google Scholar
68.
Assari  S, Bazargan  M.  Second-hand smoke exposure at home in the United States: minorities’ diminished returns.  Int J Travel Med Glob Health. In press. http://www.ijtmgh.com/article_95971.html. Posted November 5, 2019. Accessed November 27, 2019.Google Scholar
69.
Assari  S, Chalian  H, Bazargan  M.  High education level protects European Americans but not African Americans against chronic obstructive pulmonary disease: National Health Interview Survey.  Int J Biomed Eng Clin Sci. 2019;5(2):16-23. doi:10.11648/j.ijbecs.20190502.12PubMedGoogle ScholarCrossref
70.
Assari  S, Moghani Lankarani  M.  Poverty status and childhood asthma in white and black families: National Survey of Children’s Health.  Healthcare (Basel). 2018;6(2):E62. doi:10.3390/healthcare6020062PubMedGoogle Scholar
71.
Assari  S, Bazargan  M.  Minorities’ diminished returns of educational attainment on hospitalization risk: national Health Interview Survey (NHIS).  Hosp Pract Res. 2019;4(3):86-91. doi:10.15171/hpr.2019.17PubMedGoogle ScholarCrossref
72.
Assari  S, Lankarani  MM.  Race and urbanity alter the protective effect of education but not income on mortality.  Front Public Health. 2016;4:100. doi:10.3389/fpubh.2016.00100PubMedGoogle Scholar
73.
Assari  S, Lankarani  M.  Educational attainment promotes fruit and vegetable intake for whites but not blacks.  J. 2018;1(1):29-41. doi:10.3390/j1010005Google ScholarCrossref
74.
Assari  S.  Educational attainment and exercise frequency in american women: blacks’ diminished returns.  Womens Health Bull. 2019;6(3):e87413. doi:10.5812/whb.87413PubMedGoogle Scholar
75.
Assari  S.  Family income reduces risk of obesity for white but not black children.  Children (Basel). 2018;5(6):E73. doi:10.3390/children5060073PubMedGoogle Scholar
76.
Assari  S.  High income protects whites but not African Americans against risk of depression.  Healthcare (Basel). 2018;6(2):E37. doi:10.3390/healthcare6020037PubMedGoogle Scholar
77.
Assari  S, Caldwell  CH, Zimmerman  MA.  Family structure and subsequent anxiety symptoms; minorities’ diminished return.  Brain Sci. 2018;8(6):E97. doi:10.3390/brainsci8060097PubMedGoogle Scholar
78.
Assari  S, Bazargan  M.  Educational attainment better increases the chance of clinical breast exam for non-Hispanic than Hispanic American women.  Hosp Pract Res. In press. http://www.jhpr.ir/article_96044.html. Posted November 9, 2019. Accessed December 4, 2019.Google Scholar
79.
Assari  S, Boyce  S, Bazargan  M, Mincy  R, Caldwell  CH.  Unequal protective effects of parental educational attainment on the body mass index of black and white youth.  Int J Environ Res Public Health. 2019;16(19):3641. doi:10.3390/ijerph16193641PubMedGoogle ScholarCrossref
80.
Assari  S, Caldwell  CH.  Family income at birth and risk of attention deficit hyperactivity disorder at age 15: racial differences.  Children (Basel). 2019;6(1):E10. doi:10.3390/children6010010PubMedGoogle Scholar
81.
Assari  S, Bazargan  M.  Educational attainment and self-rated oral health among American older adults: Hispanics’ diminished returns.  Dent J (Basel). 2019;7(4):97. doi:10.3390/dj7040097PubMedGoogle ScholarCrossref
82.
Assari  S.  Socioeconomic status and self-rated oral health: diminished return among Hispanic whites.  Dent J (Basel). 2018;6(2):E11. doi:10.3390/dj6020011PubMedGoogle Scholar
83.
Assari  S.  The benefits of higher income in protecting against chronic medical conditions are smaller for African Americans than whites.  Healthcare (Basel). 2018;6(1):E2. doi:10.3390/healthcare6010002PubMedGoogle Scholar
84.
Assari  S, Schatten  HT, Arias  SA, Miller  IW, Camargo  CA, Boudreaux  ED.  Higher educational attainment is associated with lower risk of a future suicide attempt among non-Hispanic whites but not non-Hispanic blacks.  J Racial Ethn Health Disparities. 2019;6(5):1001-1010. doi:10.1007/s40615-019-00601-zPubMedGoogle ScholarCrossref
85.
Assari  S, Bazargan  M.  Educational attainment and subjective health and well-being: diminished returns of lesbian, gay, and bisexual individuals.  Behav Sci (Basel). 2019;9(9):90. doi:10.3390/bs9090090PubMedGoogle ScholarCrossref
86.
Assari  S.  Education attainment and obesity: differential returns based on sexual orientation.  Behav Sci (Basel). 2019;9(2):E16. doi:10.3390/bs9020016PubMedGoogle Scholar
87.
Berke  EM, Tanski  SE, Demidenko  E, Alford-Teaster  J, Shi  X, Sargent  JD.  Alcohol retail density and demographic predictors of health disparities: a geographic analysis.  Am J Public Health. 2010;100(10):1967-1971. doi:10.2105/AJPH.2009.170464PubMedGoogle ScholarCrossref
88.
Food and Drug Administration.  Research priorities. https://www.fda.gov/tobacco-products/research/research-priorities. Accessed February 5, 2019.
89.
Feliu  A, Filippidis  FT, Joossens  L,  et al.  Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014.  Tob Control. 2019;28(1):101-109. doi:10.1136/tobaccocontrol-2017-054119PubMedGoogle Scholar
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    Original Investigation
    Public Health
    January 17, 2020

    Association of Educational Attainment and Race/Ethnicity With Exposure to Tobacco Advertisement Among US Young Adults

    Author Affiliations
    • 1Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, California
    JAMA Netw Open. 2020;3(1):e1919393. doi:10.1001/jamanetworkopen.2019.19393
    Key Points español 中文 (chinese)

    Question  What are the associations of educational attainment with exposure to tobacco advertisements among racial/ethnic groups of young adults?

    Findings  This cross-sectional study among 6700 US young adults found a weaker inverse association of educational attainment with exposure to tobacco advertisement among Hispanic young adults compared with non-Hispanic young adults.

    Meaning  This finding suggests that elimination of racial/ethnic disparities in tobacco use may require more than equalizing educational attainment across racial/ethnic groups.

    Abstract

    Importance  Associations of educational attainment with improved health outcomes have been found to be weaker among racial/ethnic minority groups compared with those among the racial/ethnic majority group. Recent research has also documented higher than expected prevalence of smoking in highly educated African American and Hispanic adults.

    Objective  To compare the association of educational attainment with exposure to tobacco advertisements among racial/ethnic groups of US young adults.

    Design, Setting, and Participants  This cross-sectional study included data from 6700 young adults who participated in wave 1 of the Population Assessment of Tobacco and Health Study, a nationally representative survey of US adults in 2013. Educational attainment was classified as less than high school diploma, high school graduate, or college graduate. Analysis was conducted between September 20 and October 4, 2019.

    Main Outcomes and Measures  The independent variable was educational attainment (less than high school diploma, high school graduate, and college graduate). The dependent variable was any exposure to tobacco advertisements in the past 12 months. Race/ethnicity, age, sex, poverty status, unemployment, and region were the covariates. Binary logistic and Poisson regression were used to analyze the data.

    Results  The study included 6700 participants (3366 [50.2%] men) between ages 18 and 24 years. Most participants were non-Hispanic (5257 participants [78.9%]) and white (5394 participants [80.5%]), while 1443 participants (21.5%) were Hispanic. Educational levels included 1167 participants (17.4%) with less than a high school diploma, 4812 participants (71.8%) who were high school graduates, and 4812 participants (10.8%) who were college graduates. A total of 4728 participants (70.6%) reported exposure to tobacco advertisements in the past 12 months. Exposure to tobacco advertising was reported by 383 participants (53.1%) who were college graduates, 3453 participants (71.8%) who were high school graduates, and 892 participants (76.4%) with less than high school educational attainment. In regression analysis, high school graduation (odds ratio, 0.79; 95% CI, 0.68-0.92) and college graduation (odds ratio, 0.46; 95% CI, 0.39-0.54) were associated with lower odds of exposure to tobacco advertisements compared with young adults with lower educational attainment. Compared with non-Hispanic participants, high school education had a weaker protective association for tobacco advertisement exposure among Hispanic participants (odds ratio, 1.44; 95% CI, 1.03-2.01; P = .03), suggesting that the association of high school graduation with lower exposure to tobacco advertisement is weaker among Hispanic young adults than non-Hispanic young adults.

    Conclusions and Relevance  This study found that high school graduation had a weaker inverse association with tobacco advertisement exposure among Hispanic than non-Hispanic young adults. Future research should explore the role of targeted marketing strategies of the tobacco industry that largely advertise tobacco in areas with high concentrations of racial/ethnic minority groups. Future research should also evaluate the efficacy of more restrictive marketing policies on racial/ethnic disparities in tobacco use.

    Introduction

    In the United States, considerable racial/ethnic disparities exist in the burden of tobacco use.1-5 Despite some racial/ethnic minority groups, such as Hispanic and African American people, having a lower prevalence of tobacco use compared with non-Hispanic white people, racial/ethnic minority groups continue to have higher rates of adverse tobacco outcomes—a paradox well known to tobacco researchers.3,6,7 Owing to low access to tobacco cessation programs3,6,7 combined with low acceptability and trust in the health care system overall and tobacco cessation services in particular, African American and Hispanic young adults remain at an increased risk of adverse tobacco-related outcomes, such a cancer, respiratory conditions, and heart disease.8

    Traditionally, some of the racial/ethnic differences in tobacco use have been associated with lower socioeconomic status of racial/ethnic minority groups.9-12 The role of socioeconomic status as a social determinant of tobacco disparities has recently increased in the United States, which can be seen as a challenge to the success of US policies in reducing tobacco use prevalence.12-14 From 1966 to 2015, cigarette smoking declined by 83% among people in the United States with college degrees. The same decline was less than half as strong (40%) among individuals who did not have a high school diploma.15 If the socioeconomic gap was solely responsible for racial/ethnic disparities in tobacco use, then policies aimed at the elimination of economic inequalities would have had some success in narrowing the tobacco gap across racial/ethnic and socioeconomic groups, which is clearly not the case.12-14 Thus, socioeconomic status does not seem to be the sole mediator of the racial/ethnic gap in tobacco burden. Therefore, to eliminate racial/ethnic and socioeconomic gaps, noneconomic interventions, such as restricting tobacco marketing, may be required.

    Studies from 201816 and 201917 have shown that not all of the racial/ethnic differences in tobacco use are associated with socioeconomic status inequalities across such groups. The inverse association of educational attainment with substance use, particularly tobacco use, has been found to be smaller among racial/ethnic minority groups than among non-Hispanic white individuals.16,17 This is a phenomenon that I have labeled “minorities’ diminished returns.”18-20 This phenomenon refers to a weaker than expected association of educational attainment with health outcomes among racial/ethnic minority individuals, particularly Hispanic and African American individuals, compared with non-Hispanic white individuals.18,20 Similarly, prevalence of tobacco use would be higher than expected in highly educated Hispanic and African American individuals.19,21,22 Such greater-than-expected tobacco use imposes a considerable potential threat to middle-class Hispanic and African American individuals.16,17 Although similar patterns have been repeatedly shown for other outcomes in Hispanic17,22 and African American21,23,24 individuals, the exact mechanisms of a weaker association of educational attainment with tobacco use remain unknown, to my knowledge.

    Despite replicability of studies showing diminished health outcomes associated with educational attainment among racial/ethnic minority groups,16,17 few studies have explored specific mechanisms for this phenomenon in the field of tobacco use.25 In a 2019 study,26 secondhand workplace exposure to cigarette smoke was higher in highly educated Hispanic and African American individuals, which was attributed to labor market discrimination, which often results in Hispanic and African American individuals working in occupations with higher stress and lower pay than non-Hispanic white individuals. Another 2019 study25 suggested that home smoke-free tobacco policies were associated with African American households at a lower rate than expected compared with white households. One mechanism to be examined in this study is the differential role of higher educational attainment associated with risk of exposure to tobacco advertisement in Hispanic, African American, and white individuals.27

    At least some of the disparities across racial/ethnic groups in the burden of tobacco-related health outcomes are not associated with individuals’ choices but with higher exposure to tobacco marketing among racial/ethnic minority groups and individuals with lower socioeconomic status compared with non–racial/ethnic minority groups and individuals with higher socioeconomic status.28-30 Previous studies have shown that individuals with lower socioeconomic status and in racial/ethnic minority groups are at increased risk for exposure to point-of-sale advertising, retail displays, and coupons or discounts.31,32 Tobacco coupons, discounts, and advertisement are widely recognized as marketing practices that the tobacco industry uses in communities at increased risk of harm secondary to tobacco use.33,34 Coupons or discounts are risk factors for tobacco use31,34-38 and may be associated with tobacco disparities, given that racial/ethnic minority groups and lower socioeconomic status communities may be more likely to be targeted by tobacco marketing.31,38,39

    In theory, at least some of the weaker than expected association of educational attainment with tobacco use among Hispanic and African American individuals may be associated with the tobacco industry’s marketing practices that disproportionately target communities of color.31,40,41 One study by Soneji et al40 suggested that the tobacco industry may specifically target Hispanic and African American individuals. The exact marketing practices that are associated with influencing people of different races, ethnicities, and educational levels are unknown, to my knowledge. I argue that differential exposure to tobacco advertisements may be associated with tobacco use by Hispanic and African American individuals, even among those with high educational attainment.16,17 A study by Brock et al34 found that as educational attainment increases, exposure to cigarette advertisement and coupons decreases. However, in the presence of weaker associations of educational attainment with exposure to tobacco advertising,17-19,21,42 highly educated Hispanic and African American individuals would likely still be exposed to tobacco advertisements at higher rates than their white peers. This may be because educational attainment has been shown to be more weakly associated with improvements in life conditions among Hispanic and African American individuals compared with non-Hispanic white individuals. In addition, African American and Hispanic individuals have been shown to remain at risk of poverty despite high educational attainment.43 Educational attainment has also been shown to be more strongly associated with increased income and upward social mobility among non-Hispanic white individuals than among Hispanic and African American individuals.44-46 Similarly, educational attainment has been shown to be associated with improved mental health,23 happiness,47 and impulse control48 among non-Hispanic white individuals compared with Hispanic and African American individuals.45 This study was conducted to assess if Hispanic and African American race/ethnicity are associated with higher risk of exposure to tobacco marketing regardless of level of educational attainment in a national sample of US young adults.

    I expected to find an inverse association of educational attainment with exposure to tobacco advertisements and a weaker negative association of higher educational attainment with exposure to tobacco advertisements among Hispanic and African American individuals compared with non-Hispanic white individuals.

    Methods
    Design and Settings

    For this cross-sectional study, I analyzed wave 1 data from the Population Assessment of Tobacco and Health (PATH) Study,49,50 which was conducted from 2013 to 2014. This analysis was conducted between September 20 and October 4, 2019. Jointly funded by the National Institutes of Health and the US Food and Drug Administration, the PATH Study is the primary source of epidemiological information regarding tobacco use among US residents. The PATH Study enrolled adults 18 years or older.49,50 This report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    Ethics

    All adult participants in the PATH Study provided written informed consent. The institutional review board of Westat approved the study protocol. Data were collected, stored, and analyzed anonymously. This was a secondary analysis of fully deidentified public data, and the Charles R. Drew University of Medicine and Science exempted this study from an institutional review as it was considered non–human subject research. Westat did not have any role in this study.

    Sampling, Sample, and Analytical Sample

    The PATH sample included civilian, noninstitutionalized, US adults 18 years or older. A multistage sampling design was used (ie, 4-stage probability sampling). First, a stratified sample of geographical primary sampling units were drawn. Second, smaller geographical segments in each primary sampling unit were selected. Third, residential addresses (ie, households) were selected using US Postal Service data files. Fourth, 1 individual was selected from each sampled household.49,50 The analysis included individuals who were aged 18 to 24 years (ie, young adults), had valid data on tobacco advertisement exposure, and were either white or African American and Hispanic or non-Hispanic. People with mixed (multiple) race/ethnicity, missing data on race/ethnicity, unknown race/ethnicity, or who identified as another race/ethnicity were excluded.

    Variables

    The study variables included demographic factors (ie, race/ethnicity, sex, and region), socioeconomic status (ie, educational attainment and poverty status), and tobacco advertisement exposures. Variables were all measured at an individual level.

    Race/Ethnicity

    Race/ethnicity was self-identified. For the purpose of this study, race and ethnicity were operationalized as 2 dichotomous variables: African American vs white and Hispanic vs non-Hispanic.

    Confounders

    Sex was treated as a dichotomous variable (male, 1; female, 0). Region was defined as a categorical variable: West, South, Midwest, and Northeast. West was used as the reference group. Poverty status was defined based on the federal poverty threshold based on the household income and household size. This variable was a dichotomous variable, with 1 indicting living out of poverty and 0, living in poverty.

    Tobacco Advertisement Exposure

    The outcome was the number of different tobacco advertisements51-58 that were seen by the participant in the year before the survey was conducted. A total of 20 advertisements were shown to the individuals. The advertisements were selected randomly and included Marlboro, Camel, Newport, Wave, American Spirit, Winston, American Gold, Pall Mall, L & M, Grizzly, Copenhagen, Blue Cig, Green Smoke, Swisher Sweets, Ploom, Triple Crown, General Swedish Snus, Apollo, and NJOY. After each advertisement was shown, the participant was asked “In the past 12 months, have you seen this advertisement before this study?” The 2 possible responses for each item were yes or no. The total score was calculated (range, 0-20), with a higher score indicating higher exposure to tobacco advertisement. Although the measure is highly reliant on recalling, it is unlikely that the person would recall an advertisement without being exposed to it. Tobacco advertisement exposure was treated as a binary outcome and as a count variable, with a higher score indicating more exposure to tobacco advertisements.

    Educational Attainment

    For the main analysis, educational attainment was operationalized as a 3-level variable: (1) less than high school or general educational development diploma; (2) high school graduate, some college (no degree), or associate’s degree; and (3) bachelor’s degree or advanced degree. A 6-level educational level variable was used for the sensitivity analysis: (1) less than high school, (2) general educational development diploma, (3) high school graduate, (4) some college (no degree) or associate’s degree, (5) bachelor’s degree, and (6) advanced degree. Education ranged from 1 to 6 as a continuous measure, with a higher score indicating higher educational attainment.

    Statistical Analysis

    Data were analyzed using SPSS statistical software version 23.0 (IBM Corp). The PATH Study data were adjusted for complex survey design, including examination of the distribution of variables and ruling out collinearity between variables, such as race/ethnicity, educational attainment, and poverty status, using Spearman correlation tests. For multivariable analysis, logistic regression models were fitted with any tobacco advertisement exposure as the outcome. For sensitivity analysis, a Poisson regression model was used, which also confirmed the observed interaction. Models in the pooled sample were performed without and with interaction terms between race/ethnicity and educational attainment (ie, African American × high school graduation, Hispanic × high school graduation, African American × college graduation, and Hispanic × college graduation). From the logistic regression model, odds ratios (ORs), SEs, 95% CIs, and P values were calculated. P values were 2-sided, and statistical significance was set at less than .05. None of the study variables had missing data.

    Results

    This study included 6700 young adults (3366 [50.2%] men) between ages 18 and 24 years who provided a valid answer about their tobacco advertisement exposure during the past 12 months. Most participants were non-Hispanic (5257 participants [78.9%]) and white (5394 participants [80.5%]); 1443 participants (21.5%) were Hispanic. Educational levels included 1167 participants (17.4%) with less than a high school diploma, 4812 participants (71.8%) who were high school graduates, and 721 participants (10.8%) who were college graduates. A total of 4728 participants (70.6%) reported exposure to tobacco advertisements (Table 1).

    Advertisement Exposure

    Table 2 provides frequency and percentage of exposure to tobacco advertisements during the past 12 months by the intersection of race/ethnicity and educational attainment. In the total sample, compared with individuals without high school education, those who had high school graduation, and those who were college graduates were associated with a stepwise reduction in exposure to tobacco advertisements (76.4% vs 71.8% vs 53.1%; P < .001). The same associated stepwise increase in exposure to tobacco advertisements was observed in white (75.7% vs 70.5% vs 51.8%; P < .001) and non-Hispanic (78.3% vs 71.8% vs 52.8%; P < .001) individuals. Although still statistically significant, this associated stepwise reduction was weaker and showed a different pattern in African American (78.9% vs 76.7% vs 63.8%; P = .005) and Hispanic (71.9% vs 71.6% vs 55.8%; P = .02) individuals. The rates of tobacco advertisement exposure were comparable between individuals with vs without high school graduation among African American (76.7% vs 78.9%) and Hispanic (71.6% vs 71.9%) individuals (Table 2).

    Logistic Regression Models

    Table 3 presents the summary of the results of 2 logistic regression models with categorical educational attainment as the independent variable and any exposure to tobacco advertisement during the past 12 months as the dependent variable. Both models were performed in the overall sample. Model 1 did not have any interaction term. Model 2 included 4 interaction terms: African American race with high school graduation, Hispanic ethnicity with high school graduation, African American race with college graduation, and Hispanic ethnicity with college graduation.

    Model 1 showed an inverse association of educational attainment with tobacco advertisement exposure for high school graduates (OR, 0.79; 95% CI, 0.68-0.92; P = .002) and for college graduates (OR, 0.46; 95% CI, 0.39-0.54; P < .001) after adjustment for all covariates. Based on model 2, Hispanic ethnicity showed a significant interaction association with high school graduation for increased exposure to tobacco advertisements (OR, 1.44; 95% CI, 1.03-2.01; P < .001), suggesting that the inverse association of high school graduation with tobacco advertisement exposure is significantly weaker for Hispanic than for non-Hispanic individuals (Table 3).

    Sensitivity Analysis

    Table 4 presents the summary of the results of 2 Poisson regression models with continuous educational attainment as the independent variable and exposure to tobacco advertisement as the dependent variable. Both models were performed in the overall sample. Model 1 did not have any interaction terms. Model 2 also included 2 interaction terms: Hispanic ethnicity with educational attainment and African American race with educational attainment.

    Model 1 showed an inverse association of educational attainment with tobacco advertisement exposure (B = −0.17; 95% CI, −0.21 to −0.14; P < .001), after adjustment for all covariates. Based on model 2, there were significant interactions with educational attainment on tobacco advertisement exposure associated with African American (B = 0.10; 95% CI, 0.07-0.13; P < .001) or Hispanic (B = 0.06; 95% CI, 0.03-0.09; P < .001) race/ethnicity. This finding suggests that the inverse associations of educational attainment with tobacco advertisement exposure are weaker among Hispanic and African American individuals than among white and non-Hispanic individuals (Table 4).

    Discussion

    This cross-sectional study found that high school and college graduation were associated with a stepwise reduction in exposure to tobacco advertisement in the overall sample of young adults. However, the inverse association of high school graduation with tobacco advertisement exposure was weaker among Hispanic individuals than non-Hispanic individuals. Thus, in line with my hypothesis, the weaker inverse association of educational attainment with tobacco advertisement exposure meant that Hispanic high school graduates reported higher-than-expected exposure to tobacco advertisements.

    At least some of the racial/ethnic tobacco burden disparities are not associated with individuals’ choices but with higher exposure to tobacco marketing among communities of racial/ethnic minority groups and communities with lower socioeconomic status compared with communities of non–racial/ethnic minority groups and communities with higher socioeconomic status.28-30 People of color and individuals who live in lower socioeconomic status areas are at an increased risk for exposure to point-of-sale advertising, retail displays, and coupons or discounts.31,32 Tobacco coupons, discounts, and advertisements specifically target these communities.33,34 Advertisements and coupons or discounts are among the main risk factors of tobacco use31,34-38 and are potential contributors to tobacco use disparities.31,38,39

    Marketing practices may be associated with the higher tobacco risk associated with lower socioeconomic status and with African American and Hispanic race/ethnicity. One study in 6 neighborhoods in Boston, Massachusetts,59 found that people were heavily exposed to outdoor cigarette advertising, particularly people in areas with significant African American and Hispanic or Latino populations and with lower socioeconomic status. The results of this study provide some suggestive evidence for high exposure to tobacco advertisements in Hispanic and African American populations, regardless of socioeconomic status. Other studies have also suggested that the tobacco industry disproportionately targets these communities,14,53,60-66 which may increase the risk of tobacco use in their residents. Such place-based activity may also impose risk to high socioeconomic status African American and Hispanic individuals who live in communities that include predominantly African American and Hispanic populations.

    Previous research has shown disproportionately high risk of tobacco use in highly educated and high–socioeconomic status Hispanic and African American individuals, across tobacco products.16,17,21,67 Highly educated Hispanic and African American individuals are also exposed to higher levels of secondhand tobacco smoke inside their homes68 and at work26 compared with white individuals. Thus, highly educated racial/ethnic minority groups remain at high risk of chronic medical conditions, such as chronic obstructive pulmonary disease,69 asthma,70 and hypertension.22 Similarly, rates of hospitalization71 and mortality72 are higher in highly educated racial/ethnic minority groups than in racial/ethnic majority groups. This pattern of weaker-than-expected associations of educational attainment in the lives of people of color compared with their white peers has been described previously as “minorities’ diminished returns.”18,20 The findings of this study suggest in a similar pattern in that highly educated racial/ethnic minority groups had higher-than-expected rates of exposure to tobacco advertisements, disproportionate to their education level.

    Weaker-than-expected associations of health outcomes with socioeconomic status indicators are not limited to tobacco outcomes and have been documented for diet,73 exercise,74 obesity,42,75 depression,76 anxiety,77 self-rated health,19,24 and health care use,78 and have been described in children,70 youths,79,80 adults,20 and older adults.81 Similar patterns are also shown for marginalizing social identities other than race/ethnicity,17,19,42,71,82,83 such as sexual orientation.84-86 The robust and systemic nature of the weaker than expected associations of health outcomes with education suggests that socioeconomic status may lose some of its protective associations among people marginalized by society, regardless of socioeconomic status, marginalizing identity, and outcome.

    Given the existing weaker-than-expected associations of health outcomes with education for racial/ethnic minority groups, racial/ethnic gaps in tobacco exposure may increase, rather than decrease, as socioeconomic status increases.26 Rather than socioeconomic status per se, the major risk factors for tobacco disparities in middle-class racial/ethnic minority groups16,17 may be residual environmental exposures that continue regardless of socioeconomic status. The findings in this study suggest that at least some of the additional risk of tobacco use in highly educated racial/ethnic minority groups may be associated with environmental risk factors for tobacco use. Increased exposure to tobacco advertisement is a form of structural and place-based discrimination that is associated with worse health and well-being of people of color in the United States.39,41,59 Given existing residential segregation, people of color are more likely to live in proximity to tobacco retail stores, liquor shops, and tobacco outlets.87 Future research is needed on societal mechanisms that expose highly educated individuals from racial/ethnic minority groups to tobacco advertisement.

    If marketing is responsible for greater than expected tobacco use among highly educated racial/ethnic minority groups, then restricting marketing may be a solution to the tobacco burden disparities14,60-65 in racial/ethnic minority groups across socioeconomic levels, and more restrictive regulatory policies may be needed. However, even tobacco regulatory policies may be differently associated with outcomes across social groups.

    Implications

    These results have some policy and public health implications. The results may encourage the Food and Drug Administration and local authorities to consider more restrictive regulation of tobacco marketing that has traditionally targeted people of color.30,41,65,66 Tighter restrictions on tobacco marketing in communities of color may reduce some of the tobacco-related disparities that affect high socioeconomic status racial/ethnic minority groups. Reducing disparities is a strategic priority for the Food and Drug Administration and the National Institutes of Health.88 Further research is needed to identify interventions, including restrictive national and local regulations, such as banning advertisements that target racial/ethnic minority groups, and to implement evidence-backed policies. A 2019 study by Feliu et al89 suggested that US residents favor restrictive tobacco regulations and do not consider such restrictions to be an imposition on their autonomy.

    Future Research

    Future studies should specifically explore how different types of advertisements affect populations based on the intersection of race/ethnicity and socioeconomic status. Researchers may also study differential associations of tobacco policies, such as banning certain marketing practices, point-of-sale advertisements, flavoring, and direct mailing, with tobacco outcomes across diverse racial/ethnic groups. As this study only focused on the role of educational attainment as a marker of socioeconomic status, future research should also explore associations of health outcomes with wealth, income, employment, occupational prestige, marital status, and area-level socioeconomic status. Additionally, this study only included African American, Hispanic, non-Hispanic, and white individuals. Future investigations may explore other minority groups, such as other racial/ethnic groups and immigrants. Future research may go beyond dichotomous outcomes and capture the frequency of exposure to advertisement.

    This study was performed in the general population that included both tobacco users and nonusers. Although smoking status could alter the association of education with exposure to tobacco advertisement, this study did not perform models based on smoking status for statistical power concerns, given that very few individuals were highly educated, smokers, and black or Hispanic. Future research should use larger samples to test variation of exposure to tobacco advertisements among smoking and nonsmoking adults. Additionally, this study could not explore the association based on smoking status, as the estimates were unstable and CIs were wide. Still, future research may use larger samples to explore how these processes differ for smokers and nonsmokers.

    Limitations

    This study has some limitations. Given the cross-sectional design of this study, causation cannot be shown. The unbalanced sample size by ethnicity could generate differential statistical power across racial/ethnic groups. Thus, models were not performed within racial/ethnic groups. Instead, models with interaction terms in the pooled sample were performed, which is not affected by the unbalanced sample size distribution across racial/ethnic minority groups. This study did not measure all confounders, such as physical and mental health, tobacco use, and access to tobacco cessation programs. The PATH Study also did not have data on details of exposure to tobacco advertisement. These factors may explain why and how highly educated racial/ethnic minority groups may remain at high risk of exposure to tobacco marketing. Additionally, similar to any other study relying on self-reported measures, this study is prone to measurement bias. This problem is not limited to advertisement exposure, and any retrospective measurement would be accompanied by some degree of recall bias. Despite this limitation, many scholars have measured exposure by relying on self-report and recall as exposure to tobacco advertisement.51-58

    This reliance on self-report may become a problem if social groups differ in how they recall advertisements that they are exposed to. However, I am not aware of any previous study showing cross–racial/ethnic variation in the validity of this measure. Recognizing advertisements may not function as an exposure to marketing; however, prior research has used advertisement recall as a measure of exposure to advertisement.51-58 Interpretation of the results on recalls requires caution because the nature of the data are cross-sectional rather than longitudinal. This study could not rule out the likelihood of cultural or behavioral differences that may have contributed to differential recall despite equal exposure to advertisements. Additionally, this study did not measure frequency of exposure to tobacco advertisement but rather number of types of advertisements. If someone saw a particular advertisement every day for 12 months, this would be counted as yes with a score of 1, and if a person saw 3 different types of advertisements over the course of 12 months, the score would be 3. As a nationally representative sample was used, these results are likely generalizable to US young adults, but there is still a need to study geographic variation of exposure to tobacco advertisements by race/ethnicity and socioeconomic status.

    Conclusions

    In the United States, racial/ethnic minority status is associated with weakened inverse association of educational attainment with exposure to tobacco advertisement. While highly educated people are less likely to be exposed to tobacco advertisements, this pattern is less true for highly educated Hispanic and African American individuals than non-Hispanic white individuals. Additional exposure to tobacco advertisements may, in part, explain the results of previous studies on higher-than-expected tobacco risk among highly educated racial/ethnic minority groups.

    Back to top
    Article Information

    Accepted for Publication: November 21, 2019.

    Published: January 17, 2020. doi:10.1001/jamanetworkopen.2019.19393

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Assari S. JAMA Network Open.

    Corresponding Author: Shervin Assari, MD, MPH, Department of Family Medicine, Charles R. Drew University of Medicine and Science, 1731 E 120th St, Los Angeles, CA 90059 (assari@umich.edu).

    Author Contributions: Dr Assari had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Assari.

    Acquisition, analysis, or interpretation of data: Assari.

    Drafting of the manuscript: Assari.

    Critical revision of the manuscript for important intellectual content: Assari.

    Statistical analysis: Assari.

    Obtained funding: Assari.

    Administrative, technical, or material support: Assari.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: Research reported in this article was supported by the National Institutes of Health (U54CA229974, U54MD008149, U54MD008149, R25MD007610, U54MD007598, U54TR001627, and CA201415-02).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Ellickson  PL, Orlando  M, Tucker  JS, Klein  DJ.  From adolescence to young adulthood: racial/ethnic disparities in smoking.  Am J Public Health. 2004;94(2):293-299. doi:10.2105/AJPH.94.2.293PubMedGoogle ScholarCrossref
    2.
    Centers for Disease Control and Prevention.  Racial disparities in smoking-attributable mortality and years of potential life lost—Missouri, 2003-2007.  MMWR Morb Mortal Wkly Rep. 2010;59(46):1518-1522.PubMedGoogle Scholar
    3.
    Trinidad  DR, Pérez-Stable  EJ, White  MM, Emery  SL, Messer  K.  A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors.  Am J Public Health. 2011;101(4):699-706. doi:10.2105/AJPH.2010.191668PubMedGoogle ScholarCrossref
    4.
    Soulakova  JN, Huang  H, Crockett  LJ.  Racial/ethnic disparities in consistent reporting of smoking-related behaviors.  J Addict Behav Ther Rehabil. 2015;4(4). doi:10.4172/2324-9005.1000147PubMedGoogle Scholar
    5.
    Blumenthal  DS.  Racial and ethnic disparities in smoking prevalence in Israel and the United States: progress to date and prospects for the future.  Isr J Health Policy Res. 2017;6(1):51. doi:10.1186/s13584-017-0177-9PubMedGoogle ScholarCrossref
    6.
    Cokkinides  VE, Halpern  MT, Barbeau  EM, Ward  E, Thun  MJ.  Racial and ethnic disparities in smoking-cessation interventions: analysis of the 2005 National Health Interview Survey.  Am J Prev Med. 2008;34(5):404-412. doi:10.1016/j.amepre.2008.02.003PubMedGoogle ScholarCrossref
    7.
    Tran  ST, Rosenberg  KD, Carlson  NE.  Racial/ethnic disparities in the receipt of smoking cessation interventions during prenatal care.  Matern Child Health J. 2010;14(6):901-909. doi:10.1007/s10995-009-0522-xPubMedGoogle ScholarCrossref
    8.
    Greaves  L, Hemsing  N.  Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure.  Drug Alcohol Depend. 2009;104(suppl 1):S121-S130. doi:10.1016/j.drugalcdep.2009.05.001PubMedGoogle ScholarCrossref
    9.
    Wallace  JM  Jr, Vaughn  MG, Bachman  JG, O’Malley  PM, Johnston  LD, Schulenberg  JE.  Race/ethnicity, socioeconomic factors, and smoking among early adolescent girls in the United States.  Drug Alcohol Depend. 2009;104(suppl 1):S42-S49. doi:10.1016/j.drugalcdep.2009.06.007PubMedGoogle ScholarCrossref
    10.
    Laveist  TA, Thorpe  RJ  Jr, Mance  GA, Jackson  J.  Overcoming confounding of race with socio-economic status and segregation to explore race disparities in smoking.  Addiction. 2007;102(suppl 2):65-70. doi:10.1111/j.1360-0443.2007.01956.xPubMedGoogle ScholarCrossref
    11.
    Reid  JL, Hammond  D, Driezen  P.  Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use?  Can J Public Health. 2010;101(1):73-78. doi:10.1007/BF03405567PubMedGoogle ScholarCrossref
    12.
    Zhang  X, Martinez-Donate  AP, Jones  NR.  Educational disparities in home smoking bans among households with underage children in the United States: can tobacco control policies help to narrow the gap?  Nicotine Tob Res. 2013;15(12):1978-1987. doi:10.1093/ntr/ntt090PubMedGoogle ScholarCrossref
    13.
    Reimer  RA, Gerrard  M, Gibbons  FX.  Racial disparities in smoking knowledge among current smokers: data from the health information national trends surveys.  Psychol Health. 2010;25(8):943-959. doi:10.1080/08870440902935913PubMedGoogle ScholarCrossref
    14.
    Rock  VJ, Davis  SP, Thorne  SL, Asman  KJ, Caraballo  RS.  Menthol cigarette use among racial and ethnic groups in the United States, 2004-2008.  Nicotine Tob Res. 2010;12(suppl 2):S117-S124. doi:10.1093/ntr/ntq204PubMedGoogle ScholarCrossref
    15.
    Drope  J, Liber  AC, Cahn  Z,  et al.  Who’s still smoking: disparities in adult cigarette smoking prevalence in the United States.  CA Cancer J Clin. 2018;68(2):106-115. doi:10.3322/caac.21444PubMedGoogle ScholarCrossref
    16.
    Assari  S, Mistry  R.  Educational attainment and smoking status in a national sample of American adults: evidence for the blacks’ diminished return.  Int J Environ Res Public Health. 2018;15(4):E763. doi:10.3390/ijerph15040763PubMedGoogle Scholar
    17.
    Assari  S, Mistry  R.  Diminished return of employment on ever smoking among Hispanic whites in Los Angeles.  Health Equity. 2019;3(1):138-144. doi:10.1089/heq.2018.0070PubMedGoogle ScholarCrossref
    18.
    Assari  S.  Health disparities due to diminished return among black Americans: public policy solutions.  Soc Issues Policy Rev. 2018;12(1):112-145. doi:10.1111/sipr.12042Google ScholarCrossref
    19.
    Assari  S.  Blacks’ diminished return of education attainment on subjective health: mediating effect of income.  Brain Sci. 2018;8(9):E176. doi:10.3390/brainsci8090176PubMedGoogle Scholar
    20.
    Assari  S.  Unequal gain of equal resources across racial groups.  Int J Health Policy Manag. 2018;7(1):1-9. doi:10.15171/ijhpm.2017.90PubMedGoogle ScholarCrossref
    21.
    Assari  S, Farokhnia  M, Mistry  R.  Education attainment and alcohol binge drinking: diminished returns of Hispanics in Los Angeles.  Behav Sci (Basel). 2019;9(1):E9. doi:10.3390/bs9010009PubMedGoogle Scholar
    22.
    Assari  S.  Socioeconomic determinants of systolic blood pressure: minorities’ diminished returns.  J Health Econ Dev. 2019;1(1):1-11.PubMedGoogle Scholar
    23.
    Assari  S.  Parental educational attainment and mental well-being of college students: diminished returns of blacks.  Brain Sci. 2018;8(11):E193. doi:10.3390/brainsci8110193PubMedGoogle Scholar
    24.
    Assari  S, Lapeyrouse  LM, Neighbors  HW.  Income and self-rated mental health: diminished returns for high income black Americans.  Behav Sci (Basel). 2018;8(5):E50. doi:10.3390/bs8050050PubMedGoogle Scholar
    25.
    Ruglass  LM, Root  JC, Dambreville  N,  et al.  Smoking policies in the home have less influence on cigarettes per day and nicotine dependence level among African American than white smokers: a cross-sectional analysis.  J Natl Med Assoc. 2019;S0027-9684(19)30091-4. doi:10.1016/j.jnma.2019.07.002PubMedGoogle Scholar
    26.
    Assari  S, Bazargan  M.  Unequal effects of educational attainment on workplace exposure to second-hand smoke by race and ethnicity: minorities’ diminished returns in the National Health Interview Survey (NHIS).  J Med Res Innov. 2019;3(2):e000179. doi:10.32892/jmri.179PubMedGoogle Scholar
    27.
    Simon  P, Camenga  DR, Morean  ME,  et al.  Socioeconomic status and adolescent e-cigarette use: the mediating role of e-cigarette advertisement exposure.  Prev Med. 2018;112:193-198. doi:10.1016/j.ypmed.2018.04.019PubMedGoogle ScholarCrossref
    28.
    Terry-McElrath  YM, Wakefield  MA, Emery  S,  et al.  State anti-tobacco advertising and smoking outcomes by gender and race/ethnicity.  Ethn Health. 2007;12(4):339-362. doi:10.1080/13557850701300723PubMedGoogle ScholarCrossref
    29.
    Keeler  C, Max  W, Yerger  V, Yao  T, Ong  MK, Sung  HY.  The association of menthol cigarette use with quit attempts, successful cessation, and intention to quit across racial/ethnic groups in the United States.  Nicotine Tob Res. 2017;19(12):1450-1464.PubMedGoogle Scholar
    30.
    Giovenco  DP, Spillane  TE, Merizier  JM.  Neighborhood differences in alternative tobacco product availability and advertising in New York City: implications for health disparities.  Nicotine Tob Res. 2019;21(7):896-902. doi:10.1093/ntr/nty244PubMedGoogle ScholarCrossref
    31.
    Lewis  MJ, Delnevo  CD, Slade  J.  Tobacco industry direct mail marketing and participation by New Jersey adults.  Am J Public Health. 2004;94(2):257-259. doi:10.2105/AJPH.94.2.257PubMedGoogle ScholarCrossref
    32.
    Audrain-McGovern  J, Tercyak  KP, Shields  AE, Bush  A, Espinel  CF, Lerman  C.  Which adolescents are most receptive to tobacco industry marketing: implications for counter-advertising campaigns.  Health Commun. 2003;15(4):499-513. doi:10.1207/S15327027HC1504_07PubMedGoogle ScholarCrossref
    33.
    Anderson  SJ.  Marketing of menthol cigarettes and consumer perceptions: a review of tobacco industry documents.  Tob Control. 2011;20(suppl 2):ii20-ii28. doi:10.1136/tc.2010.041939PubMedGoogle ScholarCrossref
    34.
    Brock  B, Schillo  BA, Moilanen  M.  Tobacco industry marketing: an analysis of direct mail coupons and giveaways.  Tob Control. 2015;24(5):505-508. doi:10.1136/tobaccocontrol-2014-051602PubMedGoogle ScholarCrossref
    35.
    Choi  K, Soneji  S, Tan  ASL.  Receipt of tobacco direct mail coupons and changes in smoking status in a nationally representative sample of US adults.  Nicotine Tob Res. 2018;20(9):1095-1100. doi:10.1093/ntr/ntx141PubMedGoogle ScholarCrossref
    36.
    Brock  B, Carlson  SC, Moilanen  M, Schillo  BA.  Reaching consumers: how the tobacco industry uses email marketing.  Prev Med Rep. 2016;4:103-106. doi:10.1016/j.pmedr.2016.05.020PubMedGoogle ScholarCrossref
    37.
    Huang  J, Tauras  J, Chaloupka  FJ.  The impact of price and tobacco control policies on the demand for electronic nicotine delivery systems.  Tob Control. 2014;23(suppl 3):iii41-iii47. doi:10.1136/tobaccocontrol-2013-051515PubMedGoogle ScholarCrossref
    38.
    Choi  K, Forster  JL.  Frequency and characteristics associated with exposure to tobacco direct mail marketing and its prospective effect on smoking behaviors among young adults from the US Midwest.  Am J Public Health. 2014;104(11):2179-2183. doi:10.2105/AJPH.2014.302123PubMedGoogle ScholarCrossref
    39.
    Brown-Johnson  CG, England  LJ, Glantz  SA, Ling  PM.  Tobacco industry marketing to low socioeconomic status women in the USA.  Tob Control. 2014;23(e2):e139-e146. doi:10.1136/tobaccocontrol-2013-051224PubMedGoogle ScholarCrossref
    40.
    Soneji  S, Knutzen  KE, Tan  ASL,  et al.  Online tobacco marketing among US adolescent sexual, gender, racial, and ethnic minorities.  Addict Behav. 2019;95:189-196. doi:10.1016/j.addbeh.2019.03.015PubMedGoogle ScholarCrossref
    41.
    Moore  DJ, Williams  JD, Qualls  WJ.  Target marketing of tobacco and alcohol-related products to ethnic minority groups in the United States.  Ethn Dis. 1996;6(1-2):83-98.PubMedGoogle Scholar
    42.
    Assari  S, Thomas  A, Caldwell  CH, Mincy  RB.  Blacks’ diminished health return of family structure and socioeconomic status: 15 years of follow-up of a national urban sample of youth.  J Urban Health. 2018;95(1):21-35. doi:10.1007/s11524-017-0217-3PubMedGoogle ScholarCrossref
    43.
    Assari  S.  Parental education better helps white than black families escape poverty: National Survey of Children’s Health.  Economies. 2018;6(2):30. doi:10.3390/economies6020030Google ScholarCrossref
    44.
    Assari  S, Preiser  B, Kelly  M.  Education and income predict future emotional well-being of whites but not blacks: a ten-year cohort.  Brain Sci. 2018;8(7):E122. doi:10.3390/brainsci8070122PubMedGoogle Scholar
    45.
    Assari  S.  Parental education attainment and educational upward mobility: role of race and gender.  Behav Sci (Basel). 2018;8(11):107. doi:10.3390/bs8110107PubMedGoogle ScholarCrossref
    46.
    Assari  S.  Parental educational attainment and academic performance of American college students: blacks’ diminished returns.  J Health Econ Dev. 2019;1(1):21-31.PubMedGoogle Scholar
    47.
    Assari  S.  Race, education attainment, and happiness in the United States.  Int J Epidemiol Res. 2019;6(2):76-82. doi:10.15171/ijer.2019.14PubMedGoogle ScholarCrossref
    48.
    Assari  S, Caldwell  CH, Mincy  R.  Family socioeconomic status at birth and youth impulsivity at age 15: blacks’ diminished return.  Children (Basel). 2018;5(5):E58. doi:10.3390/children5050058PubMedGoogle Scholar
    49.
    Tourangeau  R, Yan  T, Sun  H, Hyland  A, Stanton  CA.  Population Assessment of Tobacco and Health (PATH) reliability and validity study: selected reliability and validity estimates.  Tob Control. 2019;28(6):663-668. doi:10.1136/tobaccocontrol-2018-054561PubMedGoogle ScholarCrossref
    50.
    Hyland  A, Ambrose  BK, Conway  KP,  et al.  Design and methods of the Population Assessment of Tobacco and Health (PATH) Study.  Tob Control. 2017;26(4):371-378. doi:10.1136/tobaccocontrol-2016-052934PubMedGoogle ScholarCrossref
    51.
    Duke  JC, Lee  YO, Kim  AE,  et al.  Exposure to electronic cigarette television advertisements among youth and young adults.  Pediatrics. 2014;134(1):e29-e36. doi:10.1542/peds.2014-0269PubMedGoogle ScholarCrossref
    52.
    Pierce  JP, Sargent  JD, Portnoy  DB,  et al.  Association between receptivity to tobacco advertising and progression to tobacco use in youth and young adults in the PATH Study.  JAMA Pediatr. 2018;172(5):444-451. doi:10.1001/jamapediatrics.2017.5756PubMedGoogle ScholarCrossref
    53.
    Moran  MB, Heley  K, Pierce  JP, Niaura  R, Strong  D, Abrams  D.  Ethnic and socioeconomic disparities in recalled exposure to and self-reported impact of tobacco marketing and promotions.  Health Commun. 2019;34(3):280-289. doi:10.1080/10410236.2017.1407227PubMedGoogle ScholarCrossref
    54.
    Nicksic  NE, Snell  LM, Barnes  AJ.  Does exposure and receptivity to e-cigarette advertisements relate to e-cigarette and conventional cigarette use behaviors among youth: results from wave 1 of the Population Assessment of Tobacco and Health Study.  J Appl Res Child. 2017;8(2):3. https://eric.ed.gov/?id=EJ1188554. Accessed November 27, 2019.Google Scholar
    55.
    Agaku  IT, Ayo-Yusuf  OA.  The effect of exposure to pro-tobacco advertising on experimentation with emerging tobacco products among US adolescents.  Health Educ Behav. 2014;41(3):275-280. doi:10.1177/1090198113511817PubMedGoogle ScholarCrossref
    56.
    Stevens  P, Carlson  LM, Hinman  JM.  An analysis of tobacco industry marketing to lesbian, gay, bisexual, and transgender (LGBT) populations: strategies for mainstream tobacco control and prevention.  Health Promot Pract. 2004;5(3)(suppl):129S-134S. doi:10.1177/1524839904264617PubMedGoogle ScholarCrossref
    57.
    Dilley  JA, Spigner  C, Boysun  MJ, Dent  CW, Pizacani  BA.  Does tobacco industry marketing excessively impact lesbian, gay and bisexual communities?  Tob Control. 2008;17(6):385-390. doi:10.1136/tc.2007.024216PubMedGoogle ScholarCrossref
    58.
    Pierce  JP, Sargent  JD, White  MM,  et al.  Receptivity to tobacco advertising and susceptibility to tobacco products.  Pediatrics. 2017;139(6):e20163353. doi:10.1542/peds.2016-3353PubMedGoogle Scholar
    59.
    Pucci  LG, Joseph  HM  Jr, Siegel  M.  Outdoor tobacco advertising in six Boston neighborhoods: evaluating youth exposure.  Am J Prev Med. 1998;15(2):155-159. doi:10.1016/S0749-3797(98)00034-8PubMedGoogle ScholarCrossref
    60.
    Soneji  SS, Knutzen  KE, Villanti  AC.  Use of flavored e-cigarettes among adolescents, young adults, and older adults: findings from the Population Assessment for Tobacco and Health Study.  Public Health Rep. 2019;134(3):282-292. doi:10.1177/0033354919830967PubMedGoogle ScholarCrossref
    61.
    Schneller  LM, Bansal-Travers  M, Goniewicz  ML, McIntosh  S, Ossip  D, O’Connor  RJ.  Use of flavored electronic cigarette refill liquids among adults and youth in the US: results from wave 2 of the Population Assessment of Tobacco and Health Study (2014-2015).  PLoS One. 2018;13(8):e0202744. doi:10.1371/journal.pone.0202744PubMedGoogle Scholar
    62.
    Soulakova  JN, Danczak  RR.  Impact of menthol smoking on nicotine dependence for diverse racial/ethnic groups of daily smokers.  Healthcare (Basel). 2017;5(1):E2. doi:10.3390/healthcare5010002PubMedGoogle Scholar
    63.
    Levy  DT, Mays  D, Boyle  RG, Tam  J, Chaloupka  FJ.  The effect of tobacco control policies on US smokeless tobacco use: a structured review.  Nicotine Tob Res. 2017;20(1):3-11. doi:10.1093/ntr/ntw291PubMedGoogle ScholarCrossref
    64.
    Jones  MR, Apelberg  BJ, Tellez-Plaza  M, Samet  JM, Navas-Acien  A.  Menthol cigarettes, race/ethnicity, and biomarkers of tobacco use in US adults: the 1999-2010 National Health and Nutrition Examination Survey (NHANES).  Cancer Epidemiol Biomarkers Prev. 2013;22(2):224-232. doi:10.1158/1055-9965.EPI-12-0912PubMedGoogle ScholarCrossref
    65.
    Mustonen  TK, Spencer  SM, Hoskinson  RA, Sachs  DP, Garvey  AJ.  The influence of gender, race, and menthol content on tobacco exposure measures.  Nicotine Tob Res. 2005;7(4):581-590. doi:10.1080/14622200500185199PubMedGoogle ScholarCrossref
    66.
    Seidenberg  AB, Caughey  RW, Rees  VW, Connolly  GN.  Storefront cigarette advertising differs by community demographic profile.  Am J Health Promot. 2010;24(6):e26-e31. doi:10.4278/ajhp.090618-QUAN-196PubMedGoogle ScholarCrossref
    67.
    Assari  S, Mistry  R, Bazargan  M.  Race, educational attainment, and e-cigarette use.  Journal of Medical Research and Innovation. 2020;4(1):e000185. In press. doi:10.32892/jmri.185Google Scholar
    68.
    Assari  S, Bazargan  M.  Second-hand smoke exposure at home in the United States: minorities’ diminished returns.  Int J Travel Med Glob Health. In press. http://www.ijtmgh.com/article_95971.html. Posted November 5, 2019. Accessed November 27, 2019.Google Scholar
    69.
    Assari  S, Chalian  H, Bazargan  M.  High education level protects European Americans but not African Americans against chronic obstructive pulmonary disease: National Health Interview Survey.  Int J Biomed Eng Clin Sci. 2019;5(2):16-23. doi:10.11648/j.ijbecs.20190502.12PubMedGoogle ScholarCrossref
    70.
    Assari  S, Moghani Lankarani  M.  Poverty status and childhood asthma in white and black families: National Survey of Children’s Health.  Healthcare (Basel). 2018;6(2):E62. doi:10.3390/healthcare6020062PubMedGoogle Scholar
    71.
    Assari  S, Bazargan  M.  Minorities’ diminished returns of educational attainment on hospitalization risk: national Health Interview Survey (NHIS).  Hosp Pract Res. 2019;4(3):86-91. doi:10.15171/hpr.2019.17PubMedGoogle ScholarCrossref
    72.
    Assari  S, Lankarani  MM.  Race and urbanity alter the protective effect of education but not income on mortality.  Front Public Health. 2016;4:100. doi:10.3389/fpubh.2016.00100PubMedGoogle Scholar
    73.
    Assari  S, Lankarani  M.  Educational attainment promotes fruit and vegetable intake for whites but not blacks.  J. 2018;1(1):29-41. doi:10.3390/j1010005Google ScholarCrossref
    74.
    Assari  S.  Educational attainment and exercise frequency in american women: blacks’ diminished returns.  Womens Health Bull. 2019;6(3):e87413. doi:10.5812/whb.87413PubMedGoogle Scholar
    75.
    Assari  S.  Family income reduces risk of obesity for white but not black children.  Children (Basel). 2018;5(6):E73. doi:10.3390/children5060073PubMedGoogle Scholar
    76.
    Assari  S.  High income protects whites but not African Americans against risk of depression.  Healthcare (Basel). 2018;6(2):E37. doi:10.3390/healthcare6020037PubMedGoogle Scholar
    77.
    Assari  S, Caldwell  CH, Zimmerman  MA.  Family structure and subsequent anxiety symptoms; minorities’ diminished return.  Brain Sci. 2018;8(6):E97. doi:10.3390/brainsci8060097PubMedGoogle Scholar
    78.
    Assari  S, Bazargan  M.  Educational attainment better increases the chance of clinical breast exam for non-Hispanic than Hispanic American women.  Hosp Pract Res. In press. http://www.jhpr.ir/article_96044.html. Posted November 9, 2019. Accessed December 4, 2019.Google Scholar
    79.
    Assari  S, Boyce  S, Bazargan  M, Mincy  R, Caldwell  CH.  Unequal protective effects of parental educational attainment on the body mass index of black and white youth.  Int J Environ Res Public Health. 2019;16(19):3641. doi:10.3390/ijerph16193641PubMedGoogle ScholarCrossref
    80.
    Assari  S, Caldwell  CH.  Family income at birth and risk of attention deficit hyperactivity disorder at age 15: racial differences.  Children (Basel). 2019;6(1):E10. doi:10.3390/children6010010PubMedGoogle Scholar
    81.
    Assari  S, Bazargan  M.  Educational attainment and self-rated oral health among American older adults: Hispanics’ diminished returns.  Dent J (Basel). 2019;7(4):97. doi:10.3390/dj7040097PubMedGoogle ScholarCrossref
    82.
    Assari  S.  Socioeconomic status and self-rated oral health: diminished return among Hispanic whites.  Dent J (Basel). 2018;6(2):E11. doi:10.3390/dj6020011PubMedGoogle Scholar
    83.
    Assari  S.  The benefits of higher income in protecting against chronic medical conditions are smaller for African Americans than whites.  Healthcare (Basel). 2018;6(1):E2. doi:10.3390/healthcare6010002PubMedGoogle Scholar
    84.
    Assari  S, Schatten  HT, Arias  SA, Miller  IW, Camargo  CA, Boudreaux  ED.  Higher educational attainment is associated with lower risk of a future suicide attempt among non-Hispanic whites but not non-Hispanic blacks.  J Racial Ethn Health Disparities. 2019;6(5):1001-1010. doi:10.1007/s40615-019-00601-zPubMedGoogle ScholarCrossref
    85.
    Assari  S, Bazargan  M.  Educational attainment and subjective health and well-being: diminished returns of lesbian, gay, and bisexual individuals.  Behav Sci (Basel). 2019;9(9):90. doi:10.3390/bs9090090PubMedGoogle ScholarCrossref
    86.
    Assari  S.  Education attainment and obesity: differential returns based on sexual orientation.  Behav Sci (Basel). 2019;9(2):E16. doi:10.3390/bs9020016PubMedGoogle Scholar
    87.
    Berke  EM, Tanski  SE, Demidenko  E, Alford-Teaster  J, Shi  X, Sargent  JD.  Alcohol retail density and demographic predictors of health disparities: a geographic analysis.  Am J Public Health. 2010;100(10):1967-1971. doi:10.2105/AJPH.2009.170464PubMedGoogle ScholarCrossref
    88.
    Food and Drug Administration.  Research priorities. https://www.fda.gov/tobacco-products/research/research-priorities. Accessed February 5, 2019.
    89.
    Feliu  A, Filippidis  FT, Joossens  L,  et al.  Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014.  Tob Control. 2019;28(1):101-109. doi:10.1136/tobaccocontrol-2017-054119PubMedGoogle Scholar
    ×