Eight percent of participants were persistent current smokers across both visits, 17% remained former smokers, 70% remained never smokers, 4% had improved smoking status (current to former) and 1% had a worsened smoking status (former or never to current) (table 2). Persistent current smokers were more likely to be younger, men, less college educated and had lower income compared with those who maintained their status as never smokers. Persistent current smokers also reported higher levels of everyday and lifetime discrimination compared with persistent never smokers (table 2).

Eight percent of participants were persistent heavy alcohol drinkers across both visits, 77% were persistent moderate or non-users of alcohol at both visits, 10% improved their alcohol use (heavy to moderate or none) and 5% developed worse alcohol use behaviour (moderate or none to heavy) (table 2). Participants who were persistent heavy alcohol users were younger and more educated than those who engaged in moderate alcohol use/abstained from alcohol over the follow-up period. They were also more likely than persistent moderate users/non-users of alcohol to experience high levels of discrimination (everyday, lifetime) (table 2).

In models adjusted for age, sex and SES, everyday discrimination was associated with higher odds of being a persistent current smoker in a graded fashion (OR for tertiles of score: medium vs low OR 1.51, 95% CI 1.04,2.20; high vs low OR 1.96, 95% CI 1.36,2.84). Each SD higher score was associated with 26% higher odds of being a persistent current smoker (OR 1.26, 95% CI 1.11,1.43). Being in the highest tertile of everyday discrimination was also associated with a higher odds of being a persistent former smoker (high vs low OR 1.32, 95% CI 1.02,1.70) relative to persistent never smokers (table 3, model 3).

ORs and 95% CIs for the effects of everyday discrimination, lifetime discrimination and stress from lifetime discrimination on the alcohol use behaviour status of African Americans in the Jackson Heart Study

Discrimination attribution did not modify the associations between discrimination and health behaviours (smoking status and alcohol use) over time for everyday discrimination (p value for interaction: smoking, p=0.38; alcohol, p=0.67), lifetime discrimination (p value for interaction: smoking, p=0.97; alcohol, p=0.91) or stress derived from lifetime discrimination (p value for interaction: smoking, p=0.21; alcohol, p=0.43).

Most studies investigating discrimination and health behaviours have been cross-sectional and few have included multiple dimensions of discrimination. Our study is the only study, to our knowledge, to examine the associations of discrimination with change in cigarette smoking status and alcohol use over time in a large sample of African American adults. In our study, everyday discrimination, lifetime discrimination and stress from lifetime discrimination were not associated with changes in smoking status or alcohol use. High levels of everyday and lifetime discrimination were, however, associated with being a persistent current smoker and with being a persistent former smoker. High stress derived from lifetime discrimination was also associated with being a persistent former smoker.

Our findings for persistent current smoking status are consistent with previous cross-sectional studies that observed a positive association between lifetime discrimination and current smoking among African Americans in the JHS (only among women, regardless of discrimination attribution),19 Coronary Artery Risk Development in Young Adults20 37 and the Multi-Ethnic Study of Atherosclerosis.21 The only study19 to include everyday discrimination also reported a positive association of everyday discrimination with current smoking among African American men and women in the JHS (regardless of discrimination attribution). Unlike previous work showing that reports of racial discrimination as extremely stressful were associated with higher rates of smoking,22 we found no evidence that stress from lifetime discrimination was associated with persistent current smoking, but the sample size (n=209) in this group was relatively small.

Findings for alcohol use have been mixed, with some studies reporting an association between lifetime discrimination and increased alcohol use,20 21 37 but one study reporting no evidence of an association between workplace discrimination and heavy drinking.38 Everyday discrimination, lifetime discrimination and stress from lifetime discrimination were not associated with changes in alcohol use, which may be due to the lower prevalence of alcohol use observed in the JHS or to measurement error in alcohol use, which is known to be difficult to measure.

There is evidence to suggest that stress associated with discrimination causes individuals to become more vulnerable to depression, anxiety disorder and psychological distress, which can lead to cigarette smoking12 and alcohol use.39 It has also been hypothesised that African Americans may engage in unhealthy behaviours to cope with the elevated stress arising from discrimination.40 Indeed, this hypothesis has been put forward to explain the paradox by which some mental health outcomes are better in African Americans than White Americans, but physical health outcomes show the opposite pattern.40 Our results are consistent with an impact of stress from discrimination on smoking as demonstrated by the association of discrimination with persistent smoking. While we hypothesised that cigarette smoking and alcohol use were strategies used to cope with stress from discrimination, we were unable to explicitly test whether the participants engaged in maladaptive behaviours to reduce stress from discrimination.

Several limitations of the data should be considered when interpreting our findings. The sample only included African American adults residing in Jackson, Mississippi, which limited the generalisability of our findings to African Americans in other regions. Discrimination was analysed at one point in time, which prevented us from examining the impact of time-varying discrimination on health behaviours over time. Due to lack of information on the timing of exposure to discrimination, it was not possible to examine the lag time between exposure to discrimination and occurrence of health behaviours. While the overall sample size was adequate in our study, there was limited power to detect significant associations between discrimination and changes in smoking status due to small numbers in the group of former or never smokers at visit 1 who changed to current smokers at visit 3. Similarly, sample size may have limited our ability to detect effect modification by attribution of discrimination. Additional follow-up of the JHS will allow extension of these analyses, yielding more power.

Residual confounding was also a possibility because of the lack of data on episodic or binge drinking, as well as data on availability of tobacco and alcohol products. In addition, the results may be biased due to the inclusion of participants who were more educated and had a higher income than those who were excluded from our study. Our study benefited from the use of multiple measures of discrimination, a large sample of African American adults, a heterogeneous population, the long follow-up period and the longitudinal study design which allowed for the examination of changes in smoking and alcohol use status.

Our study expands on previous studies to highlight the impact of discrimination on persistent current smoking status. We show that experiences of discrimination may result in persistent smoking. Importantly, stress resulting from these interpersonal experiences may affect smoking by also interacting with other manifestations of structural racism at different levels including living in stressful neighbourhood environments, experiencing stressful jobs and the targeting of tobacco marketing to African American communities, among other factors. The impact of structural racism on health thus needs to be examined using measures of racism (and its consequences) at multiple levels. Our study adds to growing evidence on the many ways in which structural racism affects the health of African Americans.

What is already known on this subject

Previous studies have reported associations between perceived discrimination and adverse health behaviours. However, most studies have been cross-sectional.

What this study adds

This study examined the associations of multiple measures of discrimination (everyday, lifetime) with changes in health behaviours over time in a large population-based cohort of African Americans. We found that everyday discrimination and lifetime discrimination are related to persistent smoking among African Americans. These results further highlight the mechanisms through which discrimination affects the health of African Americans.

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