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Inequalities in tobacco outlet density by race, ethnicity and socioeconomic status, 2012, USA: results from the ASPiRE Study
  1. Joseph G L Lee1,2,
  2. Dennis L Sun3,
  3. Nina M Schleicher4,
  4. Kurt M Ribisl2,5,
  5. Douglas A Luke6,
  6. Lisa Henriksen4
  1. 1Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, North Carolina, USA
  2. 2Department of Health Behavior, UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  3. 3Department of Statistics, College of Science and Mathematics, Cal Poly, San Luis Obispo, California, USA
  4. 4Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California, USA
  5. 5Lineberger Comprehensive Cancer Center, UNC School of Medicine, Chapel Hill, North Carolina, USA
  6. 6George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA
  1. Correspondence to Dr Joseph GL Lee, Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, 1000 E. 5th Street, Mail Stop 529, Greenville, NC 27858, USA; leejose14{at}


Background Evidence of racial/ethnic inequalities in tobacco outlet density is limited by: (1) reliance on studies from single counties or states, (2) limited attention to spatial dependence, and (3) an unclear theory-based relationship between neighbourhood composition and tobacco outlet density.

Methods In 97 counties from the contiguous USA, we calculated the 2012 density of likely tobacco outlets (N=90 407), defined as tobacco outlets per 1000 population in census tracts (n=17 667). We used 2 spatial regression techniques, (1) a spatial errors approach in GeoDa software and (2) fitting a covariance function to the errors using a distance matrix of all tract centroids. We examined density as a function of race, ethnicity, income and 2 indicators identified from city planning literature to indicate neighbourhood stability (vacant housing, renter-occupied housing).

Results The average density was 1.3 tobacco outlets per 1000 persons. Both spatial regression approaches yielded similar results. In unadjusted models, tobacco outlet density was positively associated with the proportion of black residents and negatively associated with the proportion of Asian residents, white residents and median household income. There was no association with the proportion of Hispanic residents. Indicators of neighbourhood stability explained the disproportionate density associated with black residential composition, but inequalities by income persisted in multivariable models.

Conclusions Data from a large sample of US counties and results from 2 techniques to address spatial dependence strengthen evidence of inequalities in tobacco outlet density by race and income. Further research is needed to understand the underlying mechanisms in order to strengthen interventions.

  • Tobacco
  • Health inequalities

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  • Contributors JGLL and LH originated the study. JGLL and DLS conducted the data analysis. NMS advised on data analysis. All authors interpreted the data. JGLL wrote the first draft of the manuscript. All authors provided critical revisions and edits to the manuscript. All authors approved the final version of the manuscript.

  • Funding Research reported in this publication was supported by the National Cancer Institute of the US National Institutes of Health under award number U01CA154281 as part of the State & Community Tobacco Control Research Initiative.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests JGLL and KMR receive licensing royalties from a store audit/compliance and mapping system, Counter Tools (, owned by the University of North Carolina at Chapel Hill. KMR has served as an expert consultant in litigation against cigarette manufacturers and internet tobacco vendors.

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