title: The association of area-level social class and tobacco use with adverse breast cancer characteristics among white and black women: evidence from Maryland, 1992-2003.
abstract: BACKGROUND
  In breast cancer, worse disease characteristics are associated with fewer social resources and black race. However, it is unknown whether social gradients have similar impact across race, and whether behaviors, including tobacco use, may explain a portion of the social gradient.
  
  
  METHODS
  We modeled relationships between area-level social class, tobacco spending and tumor characteristics, using 50,062 white and black cases diagnosed from 1992-2003 in Maryland, a racially and economically diverse state on the east coast of the United States. Multi-level models estimated the effect of area-level social class and tobacco consumption on tumor grade, size, and stage at diagnosis.
  
  
  RESULTS
  Adjusting for race, age and year of diagnosis, higher social class was associated with lower risk for tumors with histological grade 3 or 4 (O.R. 0.96, 95% C.I. 0.94,0.99), those diagnosed at SEER stage 2 or later (O.R. 0.89, 95% C.I. 0.86, 0.91), and tumor size >2 cm (O.R. 0.87, 95% C.I. 0.84, 0.90). Higher tobacco spending was associated with higher risk for higher grade (O.R. 1.01, 1.00, 1.03) and larger tumors (O.R. 1.03, 95% C.I. 1.01, 1.06), but was not statistically significantly related to later stage (O.R. 1.00, 95% C.I. 0.98, 1.02). Social class was less protective for black women, but tobacco effects were not race-specific.
  
  
  CONCLUSIONS
  Results suggest that in one U.S. geographic area, there is a differential protection from social class for black and white women, supporting use of intersectionality theory in breast cancer disparities investigations. Area-level tobacco consumption may capture cases' direct use and second hand smoke exposure, but also may identify neighborhoods with excess cancer-related behavioral or environmental exposures, beyond those measured by social class. Given the growing global burden of both tobacco addiction and aggressive breast cancer, similar investigations across diverse geographic areas are warranted.
authors.affiliation: Department of Community Health and Prevention, Drexel University School of Public Health, 3215 Market Street, 4th Floor, Philadelphia, PA, 19104, USA. ack57@drexel.edu.|Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. ack57@drexel.edu.
authors.forename: Ann C
authors.initials: AC
authors.lastname: Klassen
authors.affiliation: Department of Community Health and Prevention, Drexel University School of Public Health, 3215 Market Street, 4th Floor, Philadelphia, PA, 19104, USA. aaron.pankiewicz@gmail.com.
authors.forename: Aaron
authors.initials: A
authors.lastname: Pankiewicz
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. steph.hsieh.510@gmail.com.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Hsieh
authors.affiliation: Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. dancesonsnow@yahoo.com.
authors.forename: Abigail
authors.initials: A
authors.lastname: Ward
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. fcurrier@jhsph.edu.|Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. fcurrier@jhsph.edu.
authors.forename: Frank C
authors.initials: FC
authors.lastname: Curriero
mesh_terms: D000328:Adult; D001741:Black or African American / Q000208:ethnology*; D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000175:diagnosis / Q000191:economics* / Q000208:ethnology*; D005260:Female; D006801:Humans; D008396:Maryland / Q000208:ethnology; D008875:Middle Aged; D012923:Social Class; D064424:Tobacco Use / Q000191:economics* / Q000208:ethnology*; D044465:White People / Q000208:ethnology*; D055815:Young Adult