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标题：Tobacco Retailer Proximity and Density and Nicotine Dependence Among Smokers With Serious Mental Illness
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作者：Kelly C. Young-Wolff ; Lisa Henriksen ; Kevin Delucchi 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2014
卷号：104
期号：8
页码：1454-1463
DOI：10.2105/AJPH.2014.301917
语种：English
出版社：American Public Health Association
摘要：Objectives. We examined the density and proximity of tobacco retailers and associations with smoking behavior and mental health in a diverse sample of 1061 smokers with serious mental illness (SMI) residing in the San Francisco Bay Area of California. Methods. Participants’ addresses were geocoded and linked with retailer licensing data to determine the distance between participants’ residence and the nearest retailer (proximity) and the number of retailers within 500-meter and 1-kilometer service areas (density). Results. More than half of the sample lived within 250 meters of a tobacco retailer. A median of 3 retailers were within 500 meters of participants’ residences, and a median of 12 were within 1 kilometer. Among smokers with SMI, tobacco retailer densities were 2-fold greater than for the general population and were associated with poorer mental health, greater nicotine dependence, and lower self-efficacy for quitting. Conclusions. Our findings provide further evidence of the tobacco retail environment as a potential vector contributing to tobacco-related disparities among individuals with SMI and suggest that this group may benefit from progressive environmental protections that restrict tobacco retail licenses and reduce aggressive point-of-sale marketing. Tobacco use among people with serious mental illness (SMI) is common and has serious health and financial costs. 1 Nationally, individuals with psychiatric or addictive disorders consume 44% to 46% of cigarettes purchased and are more likely than those in the general population to be daily and heavy smokers. 2,3 In one study, it was estimated that smokers with SMI spend, on average, 27% of their income on tobacco. 4 Individuals with SMI suffer disproportionately from tobacco-related diseases and, as a group, have a 25-year premature mortality rate. 5 Increasingly, researchers and practitioners highlight the need for more targeted prevention and intervention strategies to reduce the burden of smoking-related diseases in this vulnerable group. 6,7 Cigarette smoking among people with SMI reflects a complex interplay of genetic, neurobiological, cultural, and psychosocial factors. 6 Studies have examined shared genetic effects between smoking and SMI, 8–11 as well as associations with attention and cognition, stress and mood, and reductions in the side effects of psychotropic medications. 6 In addition to individual-level risk factors, a complete understanding of smoking disparities among individuals with SMI requires examination of “upstream” social determinants of health, including social, political, and economic contexts. Accordingly, research on the etiology and maintenance of cigarette use in this disproportionately affected group has increasingly focused on systemic factors outside of an individual’s control, such as tobacco industry targeting, reduced access to smoking cessation services, and tobacco control policies. 7,12 Notably, smokers with SMI are responsive to tobacco control policies that have been effective in the general population, such as smoking bans and cigarette tax increases. 13–16 The built environment is another important social determinant of health that has the potential to affect smoking among people with SMI. In the general population, retail availability of tobacco, which includes the number of retailers per area or population (i.e., density) and the distance to the nearest retailer (i.e., proximity) from one’s home or school, is associated with earlier smoking initiation, 17,18 increased current smoking 19–22 and cigarette purchases, 23 and reduced smoking cessation over time. 24,25 Smokers who live in neighborhoods with higher densities of tobacco retailers have greater exposure to retail advertisements and promotions, which can obstruct quit attempts by increasing cues to smoke, provoking cravings, and triggering impulse purchases. 26–29 Smokers are price sensitive, 30,31 and the financial costs of smoking are lower in communities with more convenient tobacco access and reduced travel time to purchase. 22 Moreover, retailers and point-of-sale tobacco advertisements are more prevalent in socially and economically disadvantaged neighborhoods. 19,22,32–36 The effects of increased tobacco availability may be particularly strong among smokers with SMI given that factors such as unreliable transportation and limited resources 37 in this population may lead to a greater reliance on readily obtainable consumer goods. Furthermore, people with SMI have been targeted by the tobacco industry, 12,38 and they may be especially sensitive to aggressive tobacco advertisements and promotions. Surprisingly, in spite of the public health relevance, to our knowledge no studies of the retail availability of tobacco have involved clinical samples of individuals with SMI. Our goals in this study, which included a diverse sample of adults with SMI, were to characterize the proximity (roadway distance to the nearest retailer) and density (number of retailers per acre) of tobacco retailers within 500 meters and 1 kilometer of participants’ residences and to assess whether retail availability of tobacco is associated with severity of mental illness, nicotine dependence, and readiness to quit smoking. We also evaluated whether these associations vary according to gender. We hypothesized that smokers with SMI would reside in neighborhoods with greater than average tobacco retailer density for their county area and that this neighborhood characteristic would be associated with greater severity of mental illness. Furthermore, we predicted that increased retail availability of tobacco would be associated with greater nicotine dependence and lower readiness to quit, regardless of severity of mental illness. We also examined gender differences given calls to assess such differences in tobacco control research, policy, and practice 39 and recent evidence that proximity to a tobacco retailer is associated with a lower likelihood of smoking cessation among men but not women who are moderate to heavy smokers. 24