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Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking
  1. Sarah D Mills1,2,
  2. Shelley D Golden1,2,
  3. Meghan C O’Leary2,3,
  4. Paige Logan1,
  5. Kristen Hassmiller Lich3
  1. 1Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Sarah D Mills, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA; sarahmills{at}unc.edu

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.

  • disparities
  • priority/special populations
  • public policy

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

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Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

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Footnotes

  • Contributors SDM, KHL and SDG designed the study. All authors were involved in data collection, interpretation and reporting. All authors drafted and revised the paper. SDM is the guarantor of the study.

  • Funding SDM, SDG, MCO and KHL receive funding from the National Institutes of Health (NIH). SDM also receives funding from the Food and Drug Administration (FDA) Center for Tobacco Products. KHL also receives funding from the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA).

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, CDC, HRSA or the FDA.

  • Competing interests Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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