Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift.

INTRODUCTION: To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities. AIMS AND METHODS: In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020. RESULTS: Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process. CONCLUSIONS: Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity. IMPLICATIONS: Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Ethical publishing in 'Indigenous' contexts.

Ethical publishing practices are vital to tobacco control research practice, particularly research involving Indigenous (Indigenous peoples: For the purposes of this Special Communication, we use the term Indigenous people(s) to include self-identified individuals and communities who frequently have historical continuity with precolonial/presettler societies; are strongly linked to the land on which they or their societies reside; and often maintain their own distinct language(s), belief and social-political systems, economies and sciences. The authors humbly acknowledge, respect and value that Indigenous peoples are diverse and constitute many nations, cultures and language groups. Many Indigenous peoples also exist as governments in treaty relations with settler-colonial societies, and all Indigenous peoples have inherent rights under international law. The language and terminology used should reflect the local context(s) and could include, but are not limited to, terms such as Aboriginal, Bagumani, Cherokee, First Peoples, First Nations, Inuit, Iwaidja, Kungarakan, Lakota, Maori, Mѐtis, American Indian, Navajo, Wagadagam, Wiradjuri, Yurok, etc) people. These practices can minimise, correct and address biases that tend to privilege Euro-Western perspectives. Ethical publishing practices can minimise and address harms, such as appropriation and misuse of knowledges; strengthen mechanisms of accountability to Indigenous peoples and communities; ensure that tobacco control research is beneficial and meaningful to Indigenous peoples and communities; and support Indigenous agency, sovereignty and self-determination. To ensure ethical practice in tobacco control, the research methodology and methods must incorporate tangible mechanisms to include and engage those Indigenous peoples that the research concerns, affects and impacts.Tobacco Control is currently missing an ethical research and evaluation publishing protocol to help uphold ethical practice. The supporters of this Special Communication call on Tobacco Control to adopt publication practice that explicitly upholds ethical research and evaluation practices, particularly in Indigenous contexts. We encourage researchers, editors, peer reviewers, funding bodies and those publishing in Tobacco Control to reflect on their conduct and decision-making when working, developing and undertaking research and evaluation of relevance to Indigenous peoples.Tobacco Control and other publishers, funding bodies, institutions and research teams have a fundamental role in ensuring that the right peoples are doing the right work in the right way. We call for Tobacco Control to recognise, value and support ethical principles, processes and practices that underpin high-quality, culturally safe and priority-driven research, evaluation and science that will move us to a future that is commercial tobacco and nicotine free.

Microecological Relationships Between Area Income, Off-Premise Alcohol Outlet Density, Drinking Patterns, and Alcohol Use Disorders: The East Bay Neighborhoods Study.

BACKGROUND: Distinguishing the impacts of neighborhood income and off-premise alcohol outlet density on alcohol use has proven difficult, particularly given the conflation of these measures across neighborhood areas. We explicitly test for differential effects related to individual and area income and outlet densities on alcohol use and alcohol use disorders (AUDs) by implementing a stratified microecological sample. METHODS: The East Bay Neighborhoods Study included a survey of 984 residents of 72 microenvironments within a geographically contiguous 6-city area in California and Systematic social observations of each site. The sites included 18 areas in each of 4 strata (high/low median household income and off-premise outlet density). We assessed 4 outcomes: 28-day drinking frequency, average quantity of alcohol consumed per drinking occasion, 28-day drinking volume, and Alcohol Use Disorders Identification Test (AUDIT) score. We used zero-inflated negative binomial regression with standard errors adjusted for site clusters to relate drinking measures to individual-level age, race/ethnicity, gender, marital status, education, and income, and neighborhood indicators of site strata, physical disorder, and physical decay. An interaction term was tested representing site-level by individual-level income. RESULTS: Living in a high-income site, regardless of off-premise alcohol outlet density, was associated with more frequent drinking and higher alcohol dependence/problems. Both individual-level income and site-level income were related to greater frequencies of use, but lower income drinkers in high-income areas drank more than comparable drinkers in low-income areas. Study participants living in high-density off-premise alcohol outlet sites drank less frequently but did not differ in terms of either AUDIT scores or heavy drinking from participants living in low-density sites. CONCLUSIONS: Using a stratified microecological sampling design, we were able to directly assess statistical associations of off-premise outlet density and neighborhood median household income with patterns of drinking and AUDs. Caution should be used interpreting prior study findings linking off-premise outlet densities to drinking.

Prevention of Underage Drinking on California Indian Reservations Using Individual- and Community-Level Approaches.

OBJECTIVES: To evaluate combined individual- and community-level interventions to reduce underage drinking by American Indian/Alaska Native (AI/AN) youths on rural California Indian reservations. METHODS: Individual-level interventions included brief motivational interviewing and psychoeducation for Tribal youths. Community-level interventions included community mobilization and awareness activities, as well as restricting alcohol sales to minors. To test effects, we compared 7 waves of California Healthy Kids Survey data (2002-2015) for 9th- and 11th-grade AI/AN and non-AI/AN students in intervention area schools with California AI/AN students outside the intervention area (n = 617, n = 33 469, and n = 976, respectively). RESULTS: Pre- to postintervention mean past 30-day drinking frequency declined among current drinkers in the intervention group (8.4-6.3 days) relative to comparison groups. Similarly, heavy episodic drinking frequency among current drinkers declined in the intervention group (7.0-4.8 days) versus the comparison groups. CONCLUSIONS: This study documented significant, sustained past 30-day drinking or heavy episodic drinking frequency reductions among AI/AN 9th- and 11th-grade current drinkers in rural California Indian reservation communities exposed to multilevel interventions. Public Health Implications. Multilevel community-partnered interventions can effectively reduce underage alcohol use in this population.

Spatial Epidemiology of Alcohol- and Drug-Related Health Problems Among Northern Plains American Indians: Nebraska and South Dakota, 2007 to 2012.

BACKGROUND: Despite high abstinence rates, American Indians experience elevated rates of many alcohol and other drug problems. American Indians also predominantly reside in poor and rural areas, which may explain some observed health disparities. We investigated whether geographic areas including reservations or large American Indian populations exhibited greater incidence of alcohol- and drug-related hospitalizations. METHODS: We obtained inpatient hospitalization records for 2 Northern Plain states (Nebraska and South Dakota) for the years 2007 to 2012. We constructed zip code counts for 10 categories of hospitalization with diagnoses or injury causation commonly associated with alcohol or drug use. We related these to community sociodemographic characteristics using Bayesian Poisson space-time regression models and examined associations with and without controls for whether each zip code was located within an American Indian reservation. RESULTS: Controlling for other demographic and economic characteristics, zip codes with greater percentage of American Indians exhibited greater incidence for all 10 substance abuse-related health outcomes (9 of 10 well supported); zip code areas within American Indian reservations had greater incidence of self-inflicted injury and drug dependence and abuse, and reduced incidence of alcohol cirrhosis and prescription opioid poisoning. However, the analyses generally demonstrated no well-supported differences in incidence associated with local residence percentages of American Indian versus African American. CONCLUSIONS: In our analyses, ethnicity or heredity alone did not account for alcohol- and drug-related hospitalizations among Native populations. Aspects of social, economic, and political dimensions of Native lives must be considered in the etiology of alcohol- and drug-related problems for rural-dwelling indigenous peoples.

Ethnographic research in immigrant-specific drug abuse recovery houses.

Access to study populations is a major concern for drug use and treatment researchers. Spaces related to drug use and treatment have varying levels of researcher accessibility based on several issues, including legality, public versus private settings, and insider/outsider status. Ethnographic research methods are indispensable for gaining and maintaining access to hidden or "hard-to-reach" populations. Here, we discuss our long-term ethnographic research on drug abuse recovery houses created by and for Latino migrants and immigrants in Northern California. We take our field work experiences as a case study to examine the problem of researcher access and how ethnographic strategies can be successfully applied to address it, focusing especially on issues of entrée, building rapport, and navigating field-specific challenges related to legality, public/private settings, and insider/outsider status. We conclude that continued funding support for ethnography is essential for promoting health disparities research focused on diverse populations in recovery from substance use disorders.

Late night environments: Bar "morphing" increases risky alcohol sales in on-premise outlets.

Niche theory proposes that in areas of high alcohol availability, alcohol sales outlets will compete for patrons by diversifying their operating characteristics to provide a diversity of drinking contexts. We aimed to characterize features of outlet operations which contribute to increased risk for alcohol problems across communities. We conducted ethnographic observations in 97 on-premise outlets across 6 California cities and interviewed staff and patrons in a subsample of these. We observed outlet managers deliberately altering the environments in 17.5% of establishments. These modifications aimed to increase bar/nightclub effects, enabling venues to "morph" (i.e., alter operating conditions from restaurant to bar, or from bar to club) and display environmental characteristics associated with over-service and alcohol-related problems (e.g., more young male patrons, crowding, and dancing). Late night morphing was observed in some outlets in most cities and included outlets operating with restaurant licenses. Staff and patrons identified morphing as a strategy to increase alcohol sales in late night hours. Competition for late night customers may encourage business practices that increase the number of alcohol sales establishments operating under risky circumstances. Community alcohol policies and practices should attend to the potential expansion of risky alcohol sales niches in night time economies.

The Reliability of Naturalistic Observations of Social, Physical and Economic Environments of Bars.

Drinking in bars contributes to numerous public health problems, including violence and motor vehicle crashes. In order to formulate effective preventive interventions it is essential to identify which specific features of bar environments are related to increased risks. Unobtrusive ethnographic observations are one approach that has been used to characterize these features; however no studies have assessed reliability in a representative sample of bars. We performed brief scouting assessments in all 165 bars in six purposively selected California cities, followed by unobtrusive observations from a subsequent representative sample of 97 bars which were located in low and high bar density areas of the cities. Inter-rater reliability between two independent observers assessed individual item reliability, and principal components analyses assessed the reliability of a series of scales describing the physical, social, and economic characteristics of the bars. For the scouting assessment, items exhibited at least moderate reliability (κ or r ≥ 0.40). For the unobtrusive observations, items assessing physical and economic environments (e.g., pool table present, κ = 0.90; index beer cost, r = 0.82) had moderate to outstanding reliability (κ or r > 0.80). Items describing the social environment generally had poorer reliability, though group aspects (e.g., patron count, r = 0.78; patron circulation, r = 0.64) had better reliability than individual behaviors (e.g., derogatory speech, κ = 0.12). Scales constructed from specific sets of items exhibited modest reliability. The individual metrics and principal components we present will enable future studies seeking to disaggregate relationships between bar characteristics and public health problems.

Are Barroom and Neighborhood Characteristics Independently Related to Local-Area Assaults?

BACKGROUND: Two separate but complementary literatures examine bar-related violence: one has focused on barroom features, and the other has focused on features of neighborhoods near bars. This study unifies these 2 perspectives using a microenvironmental approach. METHODS: In a purposive sample of 65 bars in 4 California cities, we used premise assessments to characterize the physical, social, and economic environments of barrooms (e.g., patron count, average pace of drinking, and restaurant service); and a combination of systematic social observation, census, and alcohol license data to characterize the neighborhoods in which they were located (e.g., physical disorder, alcohol outlet density, and median household income). Hierarchical Poisson models then assessed relationships between these features and counts of police-reported assaults within buffer areas around bars. RESULTS: Aspects of both barroom environments (more patrons, more dancing, and louder music) and neighborhood environments (greater bar density, greater physical disorder, lower population density, and lower income) were independently related to increased incidence of assaults. CONCLUSIONS: Preventive intervention to reduce bar-area violence may be directed at both bar environments (e.g., limiting the number of patrons) and neighborhood environments (e.g., limiting outlet density).

A Critical Assessment of Bias in Survey Studies Using Location-Based Sampling to Recruit Patrons in Bars.

Location-based sampling is a method to obtain samples of people within ecological contexts relevant to specific public health outcomes. Random selection increases generalizability; however, in some circumstances (such as surveying bar patrons), recruitment conditions increase risks of sample bias. We attempted to recruit representative samples of bars and patrons in six California cities, but low response rates precluded meaningful analysis. A systematic review of 24 similar studies revealed that none addressed the key shortcomings of our study. We recommend steps to improve studies that use location-based sampling: (i) purposively sample places of interest, (ii) use recruitment strategies appropriate to the environment, and (iii) provide full information on response rates at all levels of sampling.

Stigma among California's Medical Marijuana Patients.

The enactment of California's Proposition 215 stipulates that patients may use marijuana for medical reasons, provided that it is recommended by a physician. Yet, medical marijuana patients risk being stigmatized for this practice. This article examines the way in which medical marijuana patients perceive and process stigma, and how it affects their interactions and experiences with others. Eighteen semi-structured interviews of medical marijuana patients were carried out using a semi-structured interview guide. Most patients circumvented their own physicians in obtaining a recommendation to use medicinal marijuana, and also used a host of strategies in order to justify their medical marijuana use to family, friends, and colleagues in order to stave off potential stigma. The stigmatization of medical marijuana thus has a profound effect on how patients seek treatment, and whether they seek medical marijuana treatment at all.

Off-premise alcohol outlets on and around tribal land: risks for rural California Indian youth.

Investigating the alcohol environment for rural American Indian youth, we conducted 70 interviews with leading members and youth representatives of nine Southern California tribes. We also conducted brief observations in all 13 stores licensed to sell alcohol on and close to the reservation lands of the nine tribes. Underage youth may obtain alcoholic beverages at stores either directly through illegal sales to minors or indirectly through social sources. Stores are also environments within which alcoholic beverages and heavy drinking may become normalized for youth. Limitations and implications for convenience store-based prevention research on alcohol retail environment for youth in rural populations areas are discussed.

Understanding alcohol use among U.S. Cambodians: how useful is the concept of cultural norms?

Observed differences in substance use are frequently attributed to cultural norms, which in turn are often interpreted as fixed properties of ethnically defined groups. During a community-based participatory research study (2009-2011), U.S. Cambodian women identified community-specific drinking behaviors and beliefs. To test how widely other U.S. Cambodians shared their views, we formulated them into a series of normative statements and surveyed local community members (N = 172). We identified few consensualized norms, which suggests that (A) norms may not be reducible to normative statements; and/or (B) norms may not be shared by all group members; and (C) if neither A nor B holds, then the attribution of observed drinking patterns to cultural norms lacks internal validity. Study's limitations were noted.

Tobacco environment for Southeast Asian American youth: results from a participatory research project.

Despite reports of high rates of smoking among Southeast Asian refugees in the United States, few studies have described the environmental aspects of tobacco use among this population, particularly for the second-generation youths. This absence is notable because the social environment within which second-generation youths are exposed to tobacco products differs radically from the natal environment of their parents. We describe results of a youth-led community participatory research project for Southeast Asians in Northern California. Using multiple data sources, second-generation youths documented the salience of tobacco products in their social environment, notably products such as blunts and mentholated cigarettes.

Micro-temporal analyses of crime related to alcohol outlets: A comparison of outcomes over weekday, weekend, daytime and nighttime hours.

INTRODUCTION: Causal relationships between alcohol outlets and crime are inferred from their statistical associations across neighbourhoods. However, many unobserved covariates may confound these effects. Recognising that outlet sales vary by time of day and day of week, we assess whether areas with more bars/pubs, restaurants or off-premise outlets have more crime during days and times when alcohol sales are greatest. METHODS: Annual administrative crime counts, sociodemographic data and other area characteristics of 336 Census block groups in Oakland, California, USA, were related to outlet densities from 2000 to 2015. Bayesian space-time Poisson models were used to measure associations between outlet densities and crime during: (i) weekday daytime; (ii) weekday nighttime; (iii) weekend daytime; and (iv) weekend nighttime periods (four seemingly unrelated equations). Comparisons of parameter estimates across equations provided an assessment of outlet effects on crime across days and times within the same analysis units using the same constellation of confounding covariates. RESULTS: Assault and driving under the influence crime incidents during weekend evening hours were more frequent in Census block group areas with greater numbers of bar/pubs. Burglaries were consistently greater in areas with greater densities of restaurants. DISCUSSION AND CONCLUSIONS: The spatiotemporal signature relating densities of bars/pubs over weekend evening hours to assault and driving under the influence incidents suggests that these outlets are a critical source of these crimes across neighbourhoods. Prevention programs and policies that focus upon specific drinking establishments, days and times may be most effective in reducing assault and impaired driving incidents in neighbourhoods.

Tobacco Use, Quitting, and Service Access for Northern California Arab Americans: A Participatory Study.

BACKGROUND: Cigarette smoking rates have decreased in the United States, particularly in California. Despite representing a large population in the United States and particularly in California, Arab Americans are not typically assessed in tobacco-related health studies. Disparately high smoking rates have been found in community samples of Arab Americans. In a formative participatory research study, we aimed to assess experiences with tobacco products and access to cessation and prevention services for Arab Americans who use commercial tobacco products. METHODS: In partnership with a community advisory board, we conducted a brief survey of adult Northern California Arab Americans who use tobacco products, both men and women (n = 101), followed by assets mapping to identify services, and focus groups with a subset of survey participants (n = 30), to assess tobacco product use, readiness to quit, and access to culturally appropriate cessation services. RESULTS: The majority of people who smoked did so daily. Waterpipe use was as common as cigarette smoking, and more so for women. Intent to quit was offset by highly normative tobacco use in the social environment, and limited access to culturally appropriate cessation services. CONCLUSIONS: Improvement in outreach and services specific to Arab Americans may support prevention and cessation of commercial tobacco products.

Assessing the impacts of alcohol outlets on crime as a natural experiment: agglomeration, churning and spatial effects.

BACKGROUND AND AIMS: Retail alcohol outlets appear to open in neighborhoods with low land and structure rents near sources of demand; they may 'agglomerate', open near to one another or 'churn', replace one another, over time. We used the turnover in numbers of outlets over time to measure agglomeration and churning and the impacts of openings and closings of outlets on neighborhood crime. DESIGN: Interrupted quasi-experiments using spatial panel population data from 3768 synthetic block areas over 6 years. SETTING: City of Oakland, CA, USA. PARTICIPANTS: City population. MEASUREMENTS: Census-based socio-demographic estimates and counts of openings and closings of bars/pubs, restaurants and off-premises outlets related to assault, burglary and robbery crime incidents across synthetic Census blocks. Bayesian space-time models were used to assess agglomeration and churning and measure impacts of openings/closings on crime. FINDINGS: Churning was substantial; openings followed closings for all outlets [bars/pubs, relative risk (RR) = 50.9, 95% credible interval (CI) = 3.0-449.9; restaurants, RR = 3.1, CI = 1.5-6.1; off-premises, RR = 23.5, CI = 2.0-129.8]. Bars/pub and restaurant openings agglomerated with other outlets (e.g., RR = 1.02, CI = 1.00-1.03 and RR = 1.01, CI = 1.00-1.01), but off-premises outlets did not. Covarying out effects related to outlet densities, bar/pub openings were related to a 3.5% increase in assaults (RR = 1.04, CI = 1.01-1.06) and 6.9% increase in robberies (RR = 1.07, CI = 1.03-1.11). Restaurant openings were related to a 5.3% increase in burglaries (RR = 1.05, CI = 1.04-1.06). Openings and closings of off-premises outlets were unrelated to all three crime types. CONCLUSIONS: Retail alcohol outlets appear to follow a pattern of opening near to one another and replacing each other over time. Bar, pub and restaurant openings appear to be related to increases in neighborhood crime.