In our study, financial difficulties but not educational attainment predicted smoking cigarettes and drinking alcohol among economically disadvantaged African American older adults. This suggests that in economically disadvantaged urban areas, educational attainment fails to protect its residents, at least against substance use. That is, more educated African American older adults remain at the same risk of substance use as their less educated counterparts. At the same time, financial need is associated with smoking cigarettes and drinking alcohol among African American older adults.
This study showed that financial difficulties are a risk factor for smoking and drinking among African American older adults. Chronic financial difficulties are consequential for African Americans [75
], particularly for older adults [78
]. Financial difficulties predict future heart disease in the African American community [81
]. The detrimental effects of financial difficulty are highest when the population lacks access to buffering resources, such as social support [82
]. This is one reason economically disadvantaged African American older adults may be more vulnerable to financial difficulty.
The association between SES and health behaviors such as smoking and drinking are multidimensional and bidirectional [83
]. Some people may use substances to cope with stressors such as financial difficulties. Low SES, both objective and subjective, are proxies of life circumstances. Individuals with low educational attainment may have lower knowledge regarding tobacco harm [84
]. Individuals with low SES have worse emotion regulation and may use less healthy coping strategies to deal with their stressors [50
]. Individuals with lower SES live in closer proximity to outlets and shops that sell tobacco products and alcoholic beverages [85
] and have a higher risk of exposure to point-of-sale advertisements, coupons, and discounts [86
]. In addition, low-SES individuals may be specially targeted by the tobacco industry through predatory marketing, including but not limited to flavoring [87
]. Finally, low-SES individuals are more likely to live in areas with less restrictive tobacco policies, defined as lower age for tobacco and alcohol purchase, lower cigarette taxes, and no smoke-free laws [89
Among low-income African American older adults, variation in financial difficulties impacts cigarette smoking and alcohol drinking. Financial difficulties can be a consequence of structural racism, segregation, combined with low SES. A high level of financial difficulty is a risk factor for poor health in the general population [82
], for individuals with CMCs [90
] and for older adults [91
]. A high level of financial difficulty increases the risk of heart disease [81
] and complicates the management of diseases like diabetes [90
] and cancer [92
]. Financial difficulties operate as a stressor and increase oxidative stress [94
], limiting available choices needed to maintain health [91
]. Financial difficulties limit access to and use of health care services [91
] and are a risk factor for health-risk behaviors such as poor diet [95
]. Financial difficulties also increase the risk of CMC [81
], poor SRH [96
], depression [77
], smoking cigarettes [97
], alcohol use [33
], and suicide [98
], which are barriers to maintaining health.
Our results showed that high education fails to reduce health-risk behaviors of African American older adults who live in low-income urban settings, which are limited in resources and full of stress. At the same time, the unmet financial needs and financial distress of the African American population strongly impact their health behaviors. The health hazard of poverty and unmet financial needs are well described across populations [75
], including but not limited to African American older adults [78
]. African Americans with high levels of financial difficulties are at increased risk for heart disease [81
], depression [56
], and other health problems. African Americans have not fully benefited from education as a resource for achieving financial security. This is in line with the MDR hypothesis.
Supporting our findings on the undesired effects of financial difficulties on health behaviors, multiple studies have documented the effects of financial strain on cigarette smoking [97
] and alcohol use [33
]. The effects of financial stress go beyond these two behaviors and expand to self-rated health [96
], chronic disease [81
], depression [77
], suicide [98
], and mortality [99
]. These effects are repeatedly documented for the general population [102
] and for people with chronic disease [90
]. Older adults [91
] and individuals who have diabetes [90
], cancer [99
], and heart disease [100
] are hit hard by chronic financial difficulties. All these studies collectively provide undeniable evidence that financial difficulties are one of the strongest social determinants of health [96
]. Our findings extend this literature to older African Americans in urban areas that are economically disadvantaged.
Extending our results, financial difficulties increase health problems in various ways. It is a stressor and increases oxidative stress [94
]. It reflects availability of money, cash, expendable income, and other financial resources. It limits the choices that are needed to maintain health [91
] and worsens health-risk behaviors such as cigarette smoking [97
] and alcohol use [33
]. It reduces access to healthy food [95
] and health care when needed [91
]. Thus, long-term financial difficulties become a major constraint in addition to what already limits the lives of low-SES African Americans.
Small or no protective effects of educational attainment and other SES resources on health outcomes is predicted by the MDR theory. These patterns might be due to structural racism across institutions [40
]. These diminished returns for African Americans [16
], Hispanics [32
], and sexual minorities [46
] stand in contrast to Whites (the socially dominant group), for whom educational attainment does translate to healthier behaviors and, thus, better health [28
Although we called our measure “subjective” SES, we do not imply that it is unreal or less real. Subjective SES is a result of real financial pressures in the lived experience of low-income African American geriatric populations. Perceived financial difficulty is a real consequence of low SES, and it is important to assess its impact on health behaviors and overall health.
This study extends the existing literature to economically challenged African American older adults who live in low-income resource scarce areas. Most of the previous studies on the effects of SEP on cigarette smoking [97
] and alcohol use [33
] are among youth and adult rather than older African Americans. Context matters, and SEP resources may not similarly impact all behaviors across all groups, and understanding the nuances regarding group differences in the risk factors may help program planners to more effectively improve public health of subpopulations.
This study demonstrates that socioeconomic policy is a critical component of health promotion in underserved African American populations. However, not all social determinants of health have equally causative effects on health disparities. Unless structural factors are addressed, we should not rely on educational attainment alone to protect populations in poor urban areas that have limited resources and are full of all types of stressors, including but not limited to hunger, crime, and unsafety. The results of this study highlight the need for policies providing financial support for individuals who encounter financial emergencies. Even when there is educational attainment, a policy that reduces or buffers financial difficulties is needed for many older adults. Older adults often do not have access to other buffers, such as social support, and may be hit harder by financial difficulties [82
We argue that economic and social policies that provide financial support may reduce risky behaviors like cigarette smoking and alcohol drinking among the general population, but particularly among African American older adults in urban settings. Policies that provide economic resources or social services are important components of efforts tackling health disparities. Deep chronic poverty compounded with the complexity of multiple chronic diseases adds to the challenge. Policies that increase access to financial support are extremely important [101
]. Unfortunately, such policies are not viewed favorably in the US and are often charged with being communistic based on the assumption that people in poverty should simply pull themselves up by their own bootstraps. Real fundamental changed cannot happen before African Americans and other underrepresented groups have political power to shape discourse about social justice, equity, and relevant economic and public policies [101
]. To make matters worse, studies show that early mortality of African Americans results in a lost opportunity to correct the policies that have the potential to address the problem of poverty among African Americans [101
]. The people who need the policy changes the most have far less capacity to influence policy simply because per capita, African Americans have fewer voting years than Whites due to their lower life expectancy.
Moreover, promotion of educational attainment as a means of addressing health inequities will fail to generate lasting results if other social and structural causes of health disparities are left unaddressed [105
]. Policy makers should be aware that merely enhancing education may have less of an impact than expected because racial and minority groups gain fewer health benefits from education than Whites. Interventions should make sure that cross-racial variations exist in the effects of SES indicators such as education [28
]. If we only address SES and fail to help racial and ethnic minorities to mobilize their SES, we may be surprised to discover that our interventions have not had the desired impact. In addition, while enhancement of educational attainment is still needed as it changes life style and increases health through multiple mechanisms [106
], increasing access of people to income is also important. Our findings also suggest that policy makers should focus on reducing absolute poverty, probably more urgently than enhancing access to education. We should also be aware that merely altering educational attainment will not be enough to solve the problem of health disparities, given the evidence that objective SES indicators such as education fail to promote health among African Americans [16
The proximal experience of financial difficulties was associated with risk behaviors, while a more distal measure like education was not. Our data showed a very weak association between educational attainment and financial difficulties. This suggests to us that there may be a historical lack of access to good-paying jobs and other opportunities for African Americans, regardless of their education, which is where interventions may focus. Although we called our SES measures subjective and objective, this does not suggest that financial difficulties are only in individuals’ minds and not real (objective). In fact, our finding shows that this “subjective SES” may matter more than education. Thus, these “subjective” measures of SES reflect very real and consequential financial difficulties, leading to lower access to money in retirement age. At the same time, educational attainment had a very weak effect on the financial security in this sample of African American older adults.
There is a need to further study why educational attainment had less than expected protective effects on health behaviors in this sample of African American older adults. It is still unknown which social and economic policies can maximize the health benefits that are expected to follow from educational attainment for African American individuals and families. Policies should be implemented that help to eliminate this aspect of MDR of SES across populations and health outcomes [101
]. However, one policy avenue suggested by this study is addressing poverty as a means of addressing health disparities. We are not aware of many previous attempts to reduce the health disparities of economically disadvantaged African Americans through reducing their financial difficulties. Socioeconomic interventions should be designed, implemented, and evaluated in order to tackle behavioral health disparities in African American communities. This also includes attempts to reduce tobacco and alcohol use and misuse. Future research may also focus on dual use, i.e., individuals who both smoke and drink.
The study had several limitations. First, the study used a cross-sectional design, limiting causal inferences. In addition, the study used a nonrandom sample, which reduces generalizability of the results. In addition, the study only used self-reports to measure smoking and drinking. For example, the drinking variable does not allow us to examine whether participants are drinking at risky levels for older adults, whether they have experienced consequences associated with drinking, or if they meet criteria for alcohol use disorder. In addition, we used data on having any insurance, regardless of its type. Future studies may include more detailed information about the types of insurance. It would also be useful to collect more detailed data on the employment and salary experiences of the sample. There is a need to measure retirement savings or income that are necessary to pay for basic needs. Finally, the study only included African Americans. The processes studies here may differ for biracial or multiracial African Americans. More research is needed with more detailed information about race and ethnicity.
Financial difficulties may be more relevant to the health behaviors (smoking and drinking) of economically disadvantaged African American older adults than educational attainment. This might be because urban areas may limit how much health gain can follow educational attainment. Although most of our participants were no longer in the labor market, which carries some of the health gains of educational attainment through giving participants good-paying jobs, urban areas limit healthy lifestyles that are expected to follow educational attainment.