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Review
. 2023 May;32(3):287-295.
doi: 10.1136/tobaccocontrol-2021-056695. Epub 2021 Sep 17.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

Sarah D Mills  1   2 , Shelley D Golden  3   2 , Meghan C O'Leary  2   4 , Paige Logan  3 , Kristen Hassmiller Lich  4
Affiliations
Review

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

Sarah D Mills et al. Tob Control. 2023 May.

Abstract

Objectives: Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.

Methods: We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.

Results: The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.

Conclusions: The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Keywords: disparities; priority/special populations; public policy.

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Conflict of interest statement

Competing interests: Not required.

Figures

Figure 1.
Figure 1.
Initial causal loop diagram of smoking with individual and environmental factors
Figure 2.
Figure 2.
Final causal loop diagram of smoking with individual, environmental, and fundamental factors
Figure 3.
Figure 3.
The expected impacts of the smoke-free air policy
See this image and copyright information in PMC

References

    1. Creamer MR, Wang TW, Babb S, et al. Tobacco product use and cessation indicators among adults - United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68(45):1013–19. - PMC - PubMed
    1. Mills SD, Golden SD, Queen TL, et al. Are state-level income-based disparities in adult smoking declining? Prev Med 2020;133:106019. - PMC - PubMed
    1. 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):106–15. - PubMed
    1. King BA, Graffunder C. The Tobacco Control Vaccine: a population-based framework for preventing tobacco-related disease and death. Tob Control 2018;27(2):123–24. - PMC - PubMed
    1. National Cancer Institute. Greater than the sum: Systems thinking in tobacco control. Tobacco Control Monograph No. 18. 2007. https://cancercontrol.cancer.gov/brp/tcrb/monographs/monograph-18 (accessed August 4 2021).

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