Research Shows Impact of Structural Racism on Lung Cancer Risk

In the United States, lung cancer is the leading cause of death attributed to cancer, with long-standing and persistent racial and ethnic disparities in incidence and survival. Despite increased recognition of structural racism and its association with greater risk of developing chronic medical and mental health conditions among racial and ethnic minority groups, a gap remains in understanding how lung cancer risk may be impacted by structural racism.

According to Sidra N. Bonner, MD, MPH, and colleagues, it is important to investigate how structural racism—via polices, practices, unfair treatment, and oppression—creates inequitable population-level risks for lung cancer across racial and ethnic groups. Additionally, without consideration of structural racism and its association with lung cancer risk, the possibility to implement effective interventions to mitigate lung cancer risk is limited. Researchers conducted a scoping review of how structural racism contributes to differential population-level exposure to lung cancer risk factors across racial and ethnic groups. Their findings were reported in JAMA Oncology [published online November 30, 2023; doi:10.1001/jamaoncol.2023.4897].

For the scoping review, the researchers conducted a comprehensive search of the PubMed, Embase, and MedNar databases covering English-language studies published in the United States from January 1, 2010, through June 30, 2022. Exclusion criteria included if a study did not focus on lung cancer, did not include a domain of structural racism, or focused on lung cancer mortality and survival but not risk or lung cancer risk factors. The analysis included 22 studies focused on assessing structural domains associated with systemic racism. The key domains examined included housing and built environment, occupation and employment, health care, economic and educational opportunity, private industry, perceived stress and discrimination, and criminal justice involvement.

Housing and built environment were explored in 12 studies, showing that racial residential segregation, concentrated neighborhood deprivation, and poor housing quality increased exposure to air pollution, radon, asbestos, and secondhand smoke among minority groups. Additionally, Black and Hispanic populations faced higher exposure levels of environmental carcinogens such as fine particulate air pollution, nitrogen oxide, benzenes, and carbon monoxide.

Three studies examined employment and lung cancer risk, demonstrating how racial and ethnic minority groups, in particular Black populations, experienced higher occupational exposure to carcinogens because of disproportionate employment in manual work industries. Furthermore, Black individuals were more likely to have higher silica and asbestos exposures, contributing to greater lung cancer risk.

The impact of racial inequities in health care on lung cancer risk was evaluated in five studies, showing how poor access to primary care services, discrimination, and bias in health care contribute to minority groups’ access to tobacco cessation programming. Black and Hispanic individuals also faced difficulties in obtaining high-quality medical insurance and accessing tobacco cessation services.

Economic and education opportunity were examined in three studies, highlighting structural racism as a fundamental driver of racial inequities in economic mobility and education attainment. These factors were associated with a higher risk of lung cancer among minority populations.

Private industry practices were the focus of two review studies, identifying discriminatory tobacco industry practices that contribute to differential lung cancer risk by race and ethnicity. Targeted marketing and advertisement of tobacco products persisted in minority communities. Specific examples in Black neighborhoods include higher prevalence of tobacco billboards, targeted menthol cigarette marketing, and tobacco retailers.

Perceived stress and discrimination were discussed in one study, describing higher rates of perceived stress and social discrimination, secondary to the social and economic consequences of racism, among Black and Hispanic individuals. The study authors concluded that the known association between perceived levels of stress and social discrimination with cancer burden and tobacco smoking are factors for increased risk of lung cancer in racial and ethnic minority groups.

In the final domain examined, the researchers looked at criminal justice involvement and lung cancer risk in two studies. Criminal justice involvement was defined as long-term incarceration, a short stay in jail, probation, or parole. These studies indicated that individuals with a history of criminal justice involvement, disproportionately Black and Hispanic individuals, had higher tobacco use rates. This finding was attributed to economic precarity, stress, higher unemployment rates, lapses in insurance coverage, and limited access to tobacco cessation services. Despite smoking rates decreasing among all people with substance abuse disorders from 2010 to 2019, smoking rates did not change for those individuals with a history of criminal justice involvement.

The authors cited study limitations, including that the use of search terms related to structural racism has changed over time. Thus, it is possible that the research terms used in this study did not fully capture all the articles within the study period. Additionally, the researchers acknowledged that they did not perform a quality assessment of articles and included all forms of literature, which is standard in scoping reviews; therefore, the information included may vary in quality because of the small nature of specific studies or the inclusion of broad reviews.

“The findings of this scoping review suggest that structural racism contributes to unequal exposure to lung cancer risk factors and thus to disparate lung cancer risk among racial and ethnic minority groups,” the researchers concluded. “Addressing racial and ethnic inequities in lung cancer risk will require prioritization and investments in large-scale observation studies to allow for intervention creation by health care professionals, public health stakeholders, and policymakers.”

The researchers noted that additional research is warranted to identify specific mechanisms that contribute to these inequities and tailor preventive interventions.