Are state patterns of smoking different for different racial/ethnic groups? An application of multilevel analysis

Objectives. Tobacco use research has often assumed "average" effects across place, race, and socioeconomic position. We explored and mapped the variation in smoking prevalence for racial/ethnic groups by gender and state after adjusting for demographic factors. Methods. We executed a cross-sectional, weighted, two-level multilevel multiple regression analysis (individuals in states), with current smoking as the outcome, using the 1995-1996 Current Population Survey Tobacco Use Supplement, for non-Hispanic (NH) whites, NH blacks, and Hispanics. We also calculated adjusted smoking prevalence, 95% confidence intervals, Spearman correlations, and state residual-based maps to examine state patterns. Results. We found different smoking patterns for each racial group. Black women's smoking rates were markedly lower than the national subgroup rate in six clustered states in the deep South. Smoking rates for whites were higher than the subgroup national rate in several Great Lakes states, Texas, Nevada, and North Carolina. For white women, several rural Midwest states displayed lower-than-expected smoking rates (Idaho, Utah, South Dakota, and Nebraska). We documented positive correlations for smoking prevalence between men and women within each racial group, but not between racial groups, indicating a race-specific pattern of smoking. We found that state tobacco variables (taxation and agriculture) did not account for remaining state smoking variance after inclusion of demographic variables. Conclusion. Multilevel modeling may enhance surveillance of tobacco use patterns. Focusing on race-specific state smoking patterns may illuminate why racial/ethnic minority groups exhibit lower smoking prevalence compared to their white counterparts, by examining context of smoking that may be race-specific.