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. Author manuscript; available in PMC: 2020 Jul 30.
Published in final edited form as: Subst Use Misuse. 2018 Jan 17;53(10):1638–1644. doi: 10.1080/10826084.2017.1421226

Perceived Discrimination as a Risk Factor for Use of Emerging Tobacco Products: More Similarities Than Differences Across Demographic Groups and Attributions for Discrimination

Jennifer B Unger 1
PMCID: PMC7392176  NIHMSID: NIHMS1609876  PMID: 29338581

Abstract

Background:

Perceived discrimination has been associated with cigarette smoking and other substance use among members of disadvantaged minority groups. However, most studies have focused on a single minority group, have not considered the individual’s attribution for the discrimination, and have not considered emerging tobacco products.

Objective:

This study examined the associations between perceived discrimination and use of six tobacco products (cigarettes, e-cigarettes, cigars, pipe tobacco, hookah, and smokeless tobacco) in a diverse sample of 1,068 adults in the United States.

Methods:

Participants were recruited on Amazon’s Mechanical Turk and participated in an online survey. Logistic regression models were used to examine the association between perceived discrimination and use of each tobacco product. Interactions between discrimination and demographic characteristics, and between discrimination and perceived reasons for discrimination, were evaluated.

Results:

Controlling for age, sex, race/ethnicity, education, and socioeconomic status, perceived discrimination was a risk factor for current use of five of the six tobacco products. These associations were consistent across racial/ethnic groups and regardless of the individual’s attribution for the reason for the discrimination.

Conclusions:

Results indicate that perceived discrimination is a risk factor for the use of multiple tobacco products, and that this association is not limited to particular demographic groups or types of discrimination. Public health programs could potentially reduce tobacco-related disease by teaching healthier ways to cope with discrimination.

Keywords: Cigarette, discrimination, e-cigarette, tobacco

Discrimination—the prejudicial treatment of an individual based on their actual or perceived membership in a minority, low-status, or stigmatized group—has been associated with numerous adverse physical, psychological, and behavioral health outcomes across diverse populations living in various cultural contexts (Meyer, 2003; Pascoe & Richman, 2009; Schmitt, Branscombe, Postmes, & Garcia, 2014). Associations between perceived discrimination and physical health outcomes are typically explained in terms of stress processes; discrimination is a potent stressor that activates the body’s stress responses, leading to a chronic increase in allostatic load and eventual morbidity and mortality (Richman, Blodorn, & Major, 2016). In addition to its biological effects, discrimination also can influence health-related behaviors such as substance use, which subsequently influence morbidity and mortality. Discrimination can lead to substance use when individuals use substances in an attempt to self-medicate the emotional distress caused by the discrimination, or when social identity processes cause the individual to identify more strongly with a minority group that has a stereotype of involvement in substance use (Richman et al., 2016; Stock, Gibbons, Walsh, & Gerrard, 2011).

Numerous studies have documented associations between perceived discrimination and tobacco use (Bennett et al., 2010; Chen & Yang, 2014; Clark, 2014; Crengle, Robinson, Ameratunga, Clark, & Raphael, 2012; Cuevas et al., 2014; Fagan, Brook, Rubenstone, Zhang, & Brook, 2009; Hurd, Varner, Caldwell, & Zimmerman, 2014; Kam, Cleveland, & Hecht, 2010; Lorenzo-Blanco, Unger, Oshri, Baezconde-Garbanati, & Soto, 2016; Lorenzo-Blanco, Unger, Ritt-Olson, Soto, & Baezconde-Garbanati, 2011; Okamoto, Ritt-Olson, Soto, Baezconde-Garbanati, & Unger, 2009; Pokhrel & Herzog, 2014; Schwartz et al., 2015; Shin et al., 2013; Sims et al., 2016; Tamí-Maury et al., 2013; Todorova, Falcón, Lincoln, & Price, 2010; Tran, Lee, & Burgess, 2010; Unger, 2014; Unger, Soto, & Baezconde-Garbanati, 2016). Most of those studies focused on cigarette smoking, but other tobacco products such as electronic cigarettes (e-cigarettes) and hookah have become increasingly popular in the past decade (Hu, Neff, & Agaku, 2016). It is unclear whether discrimination increases the risk of use of these products as well.

Most studies of perceived discrimination as a risk factor for substance use have focused on a single racial or ethnic minority group, making the implicit assumption that the discrimination perceived by the respondents was a consequence of their membership in that particular group. However, many people belong to multiple minority, low-status, or stigmatized groups (Cole, 2009). Members of multiple minority groups might experience and respond to discrimination differently depending on which of their minority groups they attribute the discrimination to.

Several studies have found that the individual’s perception of the reason for the discrimination influences the strength of the effects of discrimination on physical and mental health outcomes. For example, Mouzon, Taylor, Woodward, and Chatters (2017) found that racial discrimination was associated with 11 of 13 adverse health outcomes (e.g., self-rated health, cardiovascular and respiratory problems, pain, and number of chronic health problems) among African Americans, whereas nonracial discrimination was not associated with any of these outcomes. Other studies have found that discrimination adversely affects health regardless of the individual’s perception of the reason for the discrimination (Assari, Watkins, & Caldwell, 2015 for depression among Blacks; Kessler, Mickelson, & Williams, 1999 for depression and anxiety among diverse adults; Lewis et al., 2006 for cardiovascular disease among African American women; Williams et al., 2012 for a review of findings across health outcomes).

Although most discrimination research focuses on disadvantaged minority groups, members of majority or privileged groups can perceive discrimination as well. It is unclear whether the effects of discrimination vary across demographic groups. Some studies have found similar adverse effects of discrimination across racial and ethnic groups (Crengle et al., 2012 for self-rated health, depression, and substance use among diverse adolescents; Fagan et al., 2009 for smoking among African American and Hispanic young adults; Purnell et al., 2012 for smoking and psychological distress among diverse adults; Tran et al., 2010 for smoking and alcohol use among diverse adults). Other studies have shown that discrimination affects health outcomes more strongly among racial/ethnic minorities than among Whites (Landrine, Klonoff, Corral, Fernandez, & Roesch, 2006 for psychiatric symptoms; Krieger, Smith, Naishadham, Hartman, & Barbeau, 2005 for psychological distress and smoking). Other studies have found gender differences in the effects of discrimination. For example, the association between discrimination and psychological distress was stronger among Arab men than among Arab women (Assari & Lankarani, 2017); the association between increases in discrimination and increases in anxiety and depression was significant among African American men but not among African American women (Assari, Moazen-Zadeh, Caldwell, & Zimmerman, 2017); and the association between discrimination and smoking was stronger among adolescent boys than girls (Wiehe, Aalsma, Liu, & Fortenberry, 2010). Some studies have found more complex two- or three-way interactions (e.g., discrimination was associated with body mass index only among older White women [Assari, 2016]; discrimination was associated with depression only among African American men with high socioeconomic status [Hudson et al., 2012]).

This study examined associations between perceived discrimination and current use of six tobacco products: cigarettes, e-cigarettes, cigars, pipe tobacco, hookah, and smokeless/chewing tobacco. Additionally, this study assessed whether the associations between perceived discrimination and tobacco product use varied across demographic groups or across participants’ attributions for the discrimination. We hypothesized that (1) perceived discrimination would be significantly associated with use of all six tobacco products; and (2) the association between perceived discrimination and tobacco product use would be stronger when the discrimination was attributed to race/ethnicity. We did not have a priori hypotheses about which demographic groups would have the strongest association between perceived discrimination and tobacco product use because previous findings have been inconsistent.

Method

Participants

Survey participants (n = 1,068) were recruited from Mechanical Turk (mTurk), a website run by Amazon that serves as a marketplace to match “workers” with available work from various “requesters.” MTurk gives researchers access to a large population of willing participants for research studies. The demographics of mTurk users in the United States are similar to those of the U.S. adult population (http://demographics.mturk-tracker.com). Previous studies of tobacco product use and attitudes have used mTurk samples (Bauhoff, Montero, & Scharf, 2017; Hershberger, Karyadi, VanderVeen, & Cyders, 2017; Nicksic et al., 2017; Snider, Cummings, & Bickel, 2017).

MTurk workers were eligible to participate if they were at least 18 years of age, lived in the United States, and had at least 90% of their previous mTurk assignments accepted (to eliminate mTurk members who complete tasks carelessly or incompletely). Participants were directed to a Survey Monkey survey where they viewed a consent script, clicked a button to indicate consent, and proceeded to the survey. The survey took approximately 20 min to complete. Participants received $5 for their time, paid through the mTurk system. Participants were identified in the dataset by code numbers, not by their names or other identifying characteristics. The procedure was approved by the university’s Institutional Review Board.

Measures

Measures were obtained from the PhenX Toolkit (Hamilton, 2011), a catalog of recommended, standard measures of phenotypes and environmental exposures. PhenX measures are selected by working groups of domain experts using a consensus process. Measures obtained from PhenX included perceived discrimination, attributions for discrimination, tobacco product use, and sociodemographics.

Perceived discrimination was assessed with the Everyday Discrimination Scale (Williams, Yu, Jackson, & Anderson, 1997). This scale asks, “In your day-to-day life, how often do any of the following things happen to you?,” followed by a list of nine discriminatory experiences (e.g., “You are treated with less courtesy than other people are,” “People act as if they’re better than you”). Responses are rated on a six-point scale ranging from “never” to “almost every day” The perceived discrimination score was the mean of the nine items (Cronbach’s alpha = .94).

Attributions for discrimination were assessed with the following item from the Everyday Discrimination Scale (Williams et al., 1997): “What do you think is the main reason for this experience?” Response options included, “Your ancestry or national origin,” “Your gender,” “Your race,” “Your age,” “Your religion,” “Your height,” “Your weight,” “Some other aspect of your physical appearance,” “Your sexual orientation,” “Your education or income level,” “A physical disability,” and “Your shade of skin color.” For ease of interpretation, these attributions were recoded into seven categories: race/ethnicity (race, ancestry, national origin, and shade of skin color), sex (gender), age (age), socioeconomic status (education and income), sexual orientation (sexual orientation), appearance (height, weight, and other aspect of appearance), and other (religion, physical disability, and other).

Tobacco product use was assessed with items adapted from PhenX and the Population Survey of Tobacco and Health (Hyland et al., 2017). Respondents were asked whether they currently use the following products “every day,” “some days,” or “not at all”: cigarettes, electronic cigarettes/e-cigarettes/vaping, tobacco in a pipe, hookah, smokeless/chewing tobacco, and heat-not-burn product such as IQOS. Heat-not-burn products, which are not currently available in the United States, were excluded because only 2% of respondents reported using them. Responses of “every day” or “some days” were coded as current tobacco product use.

Sociodemographic characteristics included race, ethnicity, age, sex, highest level of education completed, and household income (measures obtained from PhenX Toolkit).

Statistical analysis

Logistic regression models were used to examine the association between perceived discrimination and use of each tobacco product. Covariates were race, ethnicity, age, sex, education, household income, and attributions for discrimination. Effects were considered significant if p < .008 (.05 divided by 6 to adjust for multiple tests). To determine whether attributions for discrimination and/or sociodemographic characteristics moderated the associations between perceived discrimination and tobacco product use, two-way interaction terms were created for each potential moderator variable (e.g., attribution X discrimination, sex X discrimination). These interaction terms were entered into the logistic regression model one at a time after the main effects and were retained in the model if they were significant. Analyses were conducted with SAS 9.4.

Results

Table 1 shows the demographic characteristics of the sample. Most respondents (76%) were 21–39 years of age and 59% were male. The majority (79%) were White, 13% were African American, 12% were Hispanic, 10% were Asian or Pacific Islander, and 2% were American Indian or Alaska Native. Most (59%) had annual household incomes between $25,000 and $75,000 per year. All had at least a high school education or GED, and 59% had an Associate’s degree or higher. The most prevalent tobacco products were cigarettes (35% used every day or some days), e-cigarettes (25%), cigars (13%), and hookah (10%). Most of the respondents (73%) reported experiencing at least one of the discriminatory experiences in the past year.

Table 1.

Demographic characteristics and substance use.

Age group
 18–20 2%
 21–29 39%
 30–39 37%
 40–49 13%
 50–59 7%
 60+ 3%
Sex
 Male 59%
 Female 41%
Education
 Less than high school 0%
 High school or GED 14%
 Some college 27%
 Associate degree 14%
 Bachelor degree 38%
 Graduate degree 7%
Race/Ethnicity*
 White 79%
 Black or African American 13%
 Hispanic 12%
 Asian or Pacific Islander 10%
 American Indian or Alaska Native 2%
Household income
 $0–$24,999 19%
 $25,000–$49,999 35%
 $50,000–$74,999 24%
 $75,000 or more 22%
Tobacco product use (% every day or some days)
 Cigarettes 35%
 E-cigarettes 25%
 Cigars 13%
 Pipes 6%
 Hookah 10%
 Smokeless/Chewing tobacco 4%
 Heat-not-burn products 2%
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*

Total is greater than 100% because participants could choose multiple racial/ethnic groups.

Discrimination scores were highest among younger participants (β = −.15, p < .0001), among African Americans (β = .17, p < .0005), and among participants with lower levels of education (β = −.07, p < .05). Discrimination scores were not significantly associated with sex or household income. The most frequent attributions for discrimination were appearance (33%), socioeconomic status (20%), age (12%), race/ethnicity (11%), and sex (10%). Non-White participants were significantly more likely than White participants to attribute their discrimination to race/ethnicity (chi-square = 108.6, p < .0001). Women were more likely than men to attribute their discrimination to sex (chi-square = 81.2, p < .0001). Participants who were age 18–20 or 60+ were more likely than other age groups to attribute their discrimination to age (chi-square = 71.9, p < .0001). Attributions for discrimination did not vary significantly by education or income.

Table 2 shows the association between perceived discrimination and substance use, controlling for the demographic covariates. Perceived discrimination was associated with a higher risk of use of five of the six tobacco products, even after controlling for covariates and adjusting the p value for multiple tests. None of the attributions for discrimination were significantly associated with tobacco product use. None of the discrimination X demographics or discrimination X attributions interactions were significantly associated with tobacco product use.

Table 2.

Associations between discrimination and tobacco product use, controlling for covariates.

Effect Cigarettes
 E-cigarettes
 Cigar
 Pipe
 Hookah
 Smokeless
OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Age   .97 (.85, 1.10)   .92 (.79, 1.06)   .81 (.65, 1.01)   .80 (.57, 1.11)   .55 (.42, .74)   .71 (.48, 1.03)
Female   .74 (.57, .97)   .80 (.59, 1.07)   .33 (.21, .52)   .27 (.13, .57)   .70 (.44, 1.10)   .20 (.08, .51)
White   .69 (.37, 1.28) 1.31 (.69, 2.47)   .54 (.24, 1.25)   .66 (.20, 2.19)   .67 (.28, 1.59)   .77 (.18, 3.29)
African American   .74 (.38, 1.44) 1.18 (.60, 2.34)   .85 (.35, 2.06)   .91 (.25, 3.27) 1.29 (.52, 3.19)   .68 (.14, 3.23)
Asian   .40 (.19, .83) 1.14 (.55, 2.35)   .44 (.16, 1.21)   .46 (.09, 2.29) 1.07 (.40, 2.86)   .16 (.01, 1.71)
Hispanic   .91 (.60, 1.38) 1.48 (.97, 2.26) 1.23 (.72, 2.13) 1.39 (.66, 2.94) 1.02 (.54, 1.90) 1.01 (.42, 2.43)
Education   .89 (.80, 1.00)   .88 (.78, 1.00) 1.11 (.94, 1.31)   .94 (.73, 1.20) 1.09 (.91, 1.32) 1.04 (.79, 1.36)
Subjective SES   .92 (.83, 1.03)   .93 (.83, 1.04)   .86 (.74, .99)   .89 (.72, 1.10)   .84 (.71, .99)   .94 (.74, 1.20)
Household income   .92 (.83, 1.03) 1.01 (.90, 1.13) 1.00 (.86, 1.15)   .95 (.75, 1.19) 1.00 (.85, 1.17) 1.02 (.80, 1.29)
Discrimination 1.51* (1.33, 1.72) 1.42* (1.24, 1.62) 1.49* (1.25, 1.77) 1.77* (1.40, 2.25) 1.58* (1.31, 1.91) 1.40+ (1.06, 1.83)
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Odds ratio is significant at p < .008 (.05 divided by 6 to adjust for multiple tests).

+

Odds ratio is significant at p < .05 but not at p < .008.

Discussion

Previous studies have demonstrated associations between perceived discrimination and cigarette smoking. This study extends those findings by demonstrating that perceived discrimination is also associated with the use of four additional tobacco products (e-cigarettes, cigars, pipes, and hookah, in addition to cigarettes).

This study also adds to the discrimination literature by examining the association between discrimination and tobacco product use among adults who are members of various minority and majority groups, rather than focusing on a single minority group. The strength of the association between perceived discrimination and tobacco product use was consistent across age, sex, race/ethnicity, and SES, and it was consistent regardless of the participants’ attributions for their discriminatory experiences. Whereas other researchers have suggested that racial/ethnic discrimination is more harmful than other types of discrimination, this study suggests that discrimination for any reason is associated with an increased risk of tobacco product use. Other studies (e.g., Assari, Moghani Lankarani, & Caldwell, 2017) also suggest that the adverse effects of discrimination are similar across demographic groups.

Future research should elucidate the mediating mechanisms underlying the association between discrimination and tobacco product use. It is possible that people who experience discrimination use tobacco in an effort to self-medicate the distress caused by the discrimination. Alternatively, it is possible that people use tobacco products to project a social image or to strengthen social relationships with other tobacco users. Because people who experience high levels of discrimination may be at especially high risk for tobacco use, health education interventions are needed to teach more effective methods of coping with discrimination without resorting to the use of addictive substances such as nicotine.

Limitations

These findings are based on a sample of U.S. adults who use mTurk to complete surveys online, who might not be representative of the U.S. population. Nevertheless, previous studies have shown that the mTurk population is demographically similar to the U.S. population. Relative to the U.S. population, the current sample was overrepresented by men, Whites, and tobacco users; it was similar to the U.S. population in age distribution, education, and income (U.S. Census Bureau, 2017). This cross-sectional survey cannot establish a causal association between discrimination and tobacco product use. It is also plausible that people who use tobacco tend to experience more discriminatory treatment, which they subsequently attribute to other characteristics such as their appearance or SES. Longitudinal studies will be necessary to confirm whether increases in discrimination lead to increases in tobacco product use. The survey did not ask about frequency or quantity of tobacco use. It is possible that people make different attributions for different discriminatory experiences, but we could not disentangle these complex effects in this study. The study might have lacked statistical power to detect interactions.

Despite these limitations, this study documents a strong association between perceived discrimination and the use of several tobacco products. This association is consistent across demographic groups and regardless of the individual’s attribution for the discrimination. Discrimination is an important risk factor for tobacco product use and should be addressed in health communications to prevent tobacco-related disease.

Acknowledgments

Funding

US FDA Center for Tobacco Products, USC Tobacco Center of Regulatory Science, P50-CA-180905-01.

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