The Effect of Area-Level Disadvantage and Race on Smoking Abstinence in a Clinical Trial

Public Health Significance Area-level socioeconomic disadvantage but not race predicted month 6 abstinence among treatment seeking Black and White individuals who smoke enrolled in a smoking cessation clinical trial. Findings point to the importance of examining factors associated with race that lead to health inequities, rather than concluding that race is the cause of these differences. The disadvantage index score examined in this article reflects one consequence of systemic racism and underscores the need to consider how neighborhood context can constrain or facilitate smoking cessation when developing interventions. Real and important consequences of systemic racism not captured by the disadvantage index score are critical areas for future study. Reasons for Black-White disparities in smoking abstinence are not well understood. This study examined area-level socioeconomic disadvantage as a contributor to lower quit rates for Blacks who smoke among 223 Black and 221 White low-income individuals who smoke enrolled in a smoking cessation trial. Outcome was cotinine-verified abstinence at week 26. Census tract-level disadvantage was measured using 5-year estimates linked to participants' home address and included percentage of: female headed households; public assistance; unemployed; 25% having less than a high school education. A neighborhood disadvantage index score (DIS) was calculated as the sum of z scores for each variable. Black participants lived in more disadvantaged areas than White participants [DIS mean (SD): 3.2 (4.3), -1.0 (3.2), p < .001]. Similar rates of abstinence were observed at the same level of disadvantage [DIS >= 50th percentile (less disadvantage): 21.9% Blacks, 26.2% Whites, p = .50; DIS <50th percentile (more disadvantage): 10.7% Blacks, 15.8% Whites, p = .31]. Only DIS but neither race nor the interaction was retained in the final model predicting abstinence; each unit increase in DIS was associated with 9% reduced odds of abstinence, OR: 0.91, 95% CI [0.87,0.96]. Findings point to the importance of examining factors associated with race that contribute to health inequities and underscore the need to consider how consequences of systemic racism, such as neighborhood context and other consequences not captured by the DIS, can constrain or facilitate smoking cessation when developing interventions.