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

Abstract

ObjectivesDevelop 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.MethodsWe 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.ResultsThe 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.ConclusionsThe CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

The current state of complex systems research on socioeconomic inequalities in health and health behavior—a systematic scoping review

“…morbidity, mortality); Chronic disease Majowicz [ 61 ] 2016 Conceptual systems map Modified thematic synthesis (systematic search, inductive thematic analysis, mapping) SEP (in general) Diet or eating behavior General health or well-being (incl. morbidity, mortality); Obesity Mills [ 68 ] 2023 Causal loop diagram Literature and stakeholder consultation Occupation or employment Smoking behavior Mental health outcomes Neff [ 62 ] 2009 Conceptual model Literature, author expertise, and snowballing SEP (in general) Diet or eating behavior General health or well-being (incl. morbidity, mortality) Picard [ 63 ] 2011 Conceptual framework Literature SEP (in general) Health behavior in general (incl.…”

Recommendations to advance equity in tobacco control

“…Discussing causes of inequities in smoking, such as structural racism and income inequality, may dispel incorrect presumptions that biological factors drive observed differences in smoking prevalence across racial groups 36. For example, persistent residential segregation enables the tobacco industry to target marketing of menthol cigarettes to Black communities, driving health inequities 36. Surveillance systems should monitor distributions of social privileges to assess relationships between these factors and smoking.…”

“…Some individuals smoke to deal with experiences of discrimination and marginalisation and to alleviate the associated stress 36. To have a lasting impact, interventions are needed that target root causes of inequities in smoking such as environmental racism, income inequality and stress.…”

Applying Theory to Explain the Influence of Factors External to an Organization on the Implementation of an Evidence-Based Intervention

“…Mills and colleagues' causal loop diagram of individual, environmental, and root causes influencing disparities in smoking rates (13) visualizes the complexity surrounding tobacco control efforts. Their diagram illuminates pathways to explain how implementing smoke-free policies in multiunit housing could decrease smoking, and possible unintended effects that could sustain or exacerbate smoking disparities.…”