Document Type : Original Article


Department of Family Medicine, Charles R Drew University of Medicine and Science, Los Angeles, CA


Background and aims: Minorities’ Diminished Returns (MDRs) refer to the smaller effects of
educational attainment for ethnic minorities compared to the majority group. As a result of MDRs,
research has documented more than expected tobacco use among Hispanics and African Americans
(AAs) with high educational attainment. In theory, some of this increased risk may be due to lower
tobacco harm knowledge. Accordingly, the present study compared ethnic groups for the association
between educational attainment and tobacco harm knowledge among American adults in order to
better understand a potential mechanism behind MDRs of educational attainment on tobacco use of
Hispanics and AAs.
Methods: The current cross-sectional study used baseline data of 27,405 adults, which were obtained
from the Population Assessment of Tobacco and Health (2013) study a nationally representative survey
in the United States. The independent and dependent variables were educational attainment and
tobacco harm knowledge, respectively. In addition, age, gender, employment, and poverty status were
the covariates and ethnicity was the moderator. Finally, linear regression was used to analyze the data.
Results: Educational attainment was inversely associated with tobacco harm knowledge in the pooled
sample (b = 0.11, 95% CI = 0.09 - 0.13). Ethnicity showed a statistically significant interaction with
educational attainment (b = -0.05, 95% CI = -0.10 - 0.00 for AAs and b = -0.14, 95% CI = -0.19 - -0.09
for Hispanics versus non-Hispanics), suggesting that the effect of educational attainment on tobacco
harm knowledge was smaller for Hispanics and AAs compared to non-Hispanics and Whites.
Conclusion: In general, although high educational attainment increases tobacco harm knowledge,
highly educated Hispanics and AAs still report a disproportionately low level of tobacco harm
knowledge. Eventually, the MDRs of educational attainment on tobacco harm knowledge may explain
why highly educated Hispanics remain at high risk of tobacco use.


1.Trinidad DR, Pérez-Stable EJ, White MM, Emery SL, Messer K. A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors. Am J Public Health. 2011;101(4):699-706. doi: 10.2105/ajph.2010.191668. 
2.Greaves L, Hemsing N. Women and tobacco control policies: social-structural and psychosocial contributions to vulnerability to tobacco use and exposure. Drug Alcohol Depend. 2009;104 Suppl 1:S121-30. doi: 10.1016/j.drugalcdep.2009.05.001. 
3.Zhang X, Martinez-Donate AP, Jones NR. Educational disparities in home smoking bans among households with underage children in the United States: can tobacco control policies help to narrow the gap? Nicotine Tob Res. 2013;15(12):1978-87. doi: 10.1093/ntr/ntt090. 
4.Wallace JM Jr, Vaughn MG, Bachman JG, O’Malley PM, Johnston LD, Schulenberg JE. Race/ethnicity, socioeconomic factors, and smoking among early adolescent girls in the United States. Drug Alcohol Depend. 2009;104 Suppl 1:S42- 9. doi: 10.1016/j.drugalcdep.2009.06.007. 
5.Rock VJ, Davis SP, Thorne SL, Asman KJ, Caraballo RS. Menthol cigarette use among racial and ethnic groups in the United States, 2004-2008. Nicotine Tob Res. 2010;12 Suppl 2:S117- 24. doi: 10.1093/ntr/ntq204. 
6.Drope J, Liber AC, Cahn Z, Stoklosa M, Kennedy R, Douglas CE, et al. Who’s still smoking? disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin. 2018;68(2):106-15. doi: 10.3322/caac.21444. 
7.Assari S, Mistry R. Diminished return of employment on ever smoking among hispanic whites in Los Angeles. Health Equity. 2019;3(1):138-44. doi: 10.1089/heq.2018.0070. 
8.Assari S. Blacks’ diminished return of education attainment on subjective health; mediating effect of income. Brain Sci. 2018;8(9). doi: 10.3390/brainsci8090176. 
9.Assari S, Farokhnia M, Mistry R. Education attainment and alcohol binge drinking: diminished returns of Hispanics in Los Angeles. Behav Sci (Basel). 2019;9(1). doi: 10.3390/ bs9010009. 
10.Assari S, Mistry R, Bazargan M. Race, Educational Attainment, and E-Cigarette Use. J Med Res Innov. 2020;4(1). doi: 10.32892/jmri.185. 
11.Assari S, Mistry R. Educational attainment and smoking status in a national sample of American adults; evidence for the blacks’ diminished return. Int J Environ Res Public Health. 2018;15(4). doi: 10.3390/ijerph15040763. 
12.Assari S, Bazargan M. Unequal effects of educational attainment on workplace exposure to second-hand smoke by race and ethnicity; minorities’ diminished returns in the National Health Interview Survey (NHIS). J Med Res Innov. 2019;3(2). doi: 10.32892/jmri.179. 
13.Simon P, Camenga DR, Morean ME, Kong G, Bold KW, Cavallo DA, et al. Socioeconomic status and adolescent e-cigarette use: the mediating role of e-cigarette advertisement exposure. Prev Med. 2018;112:193-8. doi: 10.1016/j.ypmed.2018.04.019. 
14.Tourangeau R, Yan T, Sun H, Hyland A, Stanton CA. Population Assessment of Tobacco and Health (PATH) reliability and validity study: selected reliability and validity estimates. Tob Control. 2019;28(6):663-8. doi: 10.1136/ tobaccocontrol-2018-054561. 
15.Minh An DT, Van Minh H, Huong le T, Giang KB, Xuan le TT, Hai PT, et al. Knowledge of the health consequences of tobacco smoking: a cross-sectional survey of Vietnamese adults. Glob Health Action. 2013;6:1-9. doi: 10.3402/gha.v6i0.18707. 
16.Assari S, Moghani Lankarani M. Race and urbanity alter the protective effect of education but not income on mortality. Front Public Health. 2016;4:100. doi: 10.3389/fpubh.2016.00100. 
17.Assari S, Khoshpouri P, Chalian H. Combined effects of race and socioeconomic status on cancer beliefs, cognitions, and emotions. Healthcare (Basel). 2019;7(1). doi: 10.3390/ healthcare7010017. 
18.Lewis MJ, Delnevo CD, Slade J. Tobacco industry direct mail marketing and participation by New Jersey adults. Am J Public Health. 2004;94(2):257-9. doi: 10.2105/ajph.94.2.257. 
19.Soneji S, Knutzen KE, Tan ASL, Moran MB, Yang J, Sargent J, et al. Online tobacco marketing among US adolescent sexual, gender, racial, and ethnic minorities. Addict Behav. 2019;95:189-96. doi: 10.1016/j.addbeh.2019.03.015. 
20.Assari S. Unequal gain of equal resources across racial groups. Int J Health Policy Manag. 2018;7(1):1-9. doi: 10.15171/ ijhpm.2017.90. 
21.Terry-McElrath YM, Wakefield MA, Emery S, Saffer H, Szczypka G, O’Malley PM, et al. State anti-tobacco advertising and smoking outcomes by gender and race/ethnicity. Ethn Health. 2007;12(4):339-62. doi: 10.1080/13557850701300723. 
22.Brock B, Schillo BA, Moilanen M. Tobacco industry marketing: an analysis of direct mail coupons and giveaways. Tob Control. 2015;24(5):505-8. doi: 10.1136/ tobaccocontrol-2014-051602. 
23.FDA. Research Priorities. Available from: https://www.fda. gov/tobacco-products/research/research-priorities. Accessed February 5, 2019.