Effect of Macro-Level Factors (Policies, Prices, and Neighborhood Social Environment) on Smoking Behavior in Two Multi-Ethnic Cohorts of U.S. Adults
Authors:   , Mayne Stephanie Lynn , Auchincloss Amy H. 
Published: July 2021

OBJECTIVE: This dissertation explores the effect of three macro-level factors on smoking behavior among U.S. adults: 1) bar and restaurant smoking ban policies, 2) cigarette prices, and 3) social aspects of the neighborhood environment. METHODS: Longitudinal epidemiologic cohort data from two sources: 1) the Coronary Artery Risk Development in Young Adults (CARDIA, 1985-2011, N=5071 young/middle-aged adults); 2) Multi-Ethnic Study of Atherosclerosis (MESA, 2000-2012, middle-aged to older adults, samples used were N=4884 and N=5856). Cohort data were geocoded and linked to three datasets: 1) state, county, city 100% smoke-free policies in bars and restaurants (American Non-Smokers Rights Foundation's Local Ordinance Database 1985-2011); 2) cigarette prices at chain supermarkets and drug stores within 3 miles of the participant's residence (IRI 2001-2011); and 3) neighborhood social environment scores for three domains: aesthetic quality, safety, and social cohesion (MESA Neighborhood Survey, 2002-2005 and 2010-2012). Various statistical modeling approaches were used: econometric models with subject fixed effects for within-person change in smoking outcomes, modified Poisson regression, and generalized linear mixed models for longitudinal and cross-sectional analyses. RESULTS: Smokefree policies: Restaurant/ bar smoking bans were associated with a significant decline in current smoking risk and smoking intensity (risk ratio (RR): 0.92, 95% confidence interval (CI): 0.87, 0.97, and RR: 0.91 (0.83, 0.99), respectively), and an increased likelihood of a quit attempt (RR: 1.10 (1.02, 1.19)). Policy impacts on declines in current smoking were strongest among those with higher education (>bachelor's degree) but the impact on quit attempts was strongest among women and lower income individuals. Cigarette prices: A $1 higher cigarette pack price was associated with lower smoking prevalence (prevalence ratio (PR): 0.88 (0.77, 1.01)) and smoking intensity in MESA year 10 (PR: 0.77 (0.62, 0.95)). A $1 increase in pack price was associated with reductions in current smoking risk (RR: 0.97 (0.93, 1.01)), intensity (RR: 0.93 (0.87, 0.99), and risk of relapse (RR: 0.72 (0.56, 0.95). Social environment: Participants living in areas with higher baseline neighborhood social environment composite score (reflecting a better environment) had 13% lower prevalence of baseline smoking (PR: 0.87 (0.78, 0.98). Similar results were observed for neighborhood safety and aesthetic quality but not for social cohesion. No associations were observed between neighborhood social environment and changes in smoking status or smoking intensity over time. CONCLUSIONS: Macro-level factors play an important role in smoking behavior. The differential effect of smoking bans by socioeconomic status underscores the importance of evaluating equity throughout policy implementation. Future work is needed to evaluate whether the neighborhood social environment influences earlier life smoking patterns.