Although apartheid, the period of legalized institutional racial discrimination in South African history, ended less than 20 years ago (1950–1994), few articles exist on discrimination and health in South Africa. This lack of literature stands in contrast to the large number of publications produced by some other countries with a history of legalized discrimination, such as the United States.[1–6] Race relations remain strained in South Africa today.[7] Historically, the racial status structure of South Africa consisted of Whites at the top, Black Africans at the bottom, and Coloured (a term that generalized South Africans of mixed race into a single category) and Indians or Asians in the middle.[8] According to mid-year 2011 population estimates, 79.5% of South Africans were Black Africans, 9.0% were White, 9.0% were Coloured, and 2.5% were Indian or Asian.[9]

In 2003, approximately 35% of South African men and 10% of South African women smoked daily or occasionally.[10] Among men, prevalence of daily or occasional smoking was 32.8% for Black South Africans, 52.1% for Coloured, 35.7% for Whites, and 55.5% for Indians.[10] Among women, prevalence was 5.2% for Black Africans, 41.8% for Coloured, 27.3% for Whites, and 13.1% for Indians.[10] Racial differences in smoking prevalence are also evidenced by racial disparities in smoking-attributable mortality rates in South Africa.[11] Smoking is associated with increased odds of tuberculosis, chronic obstructive pulmonary disease (COPD), lung cancer, upper digestive tract cancer, ischemic heart disease, cirrhosis of the liver, and other alcohol related conditions among South Africans.[11–12]

We were able to locate only one article on racial discrimination and smoking in South Africa. Brook et al [13] found a positive association between racial discrimination and smoking status among South African adolescents (OR=1.46, 95%CI: 1.21–1.75).

Existing research suggests a relationship between discrimination and smoking.[3–5, 14–23] Several studies have found a significant relationship between experiences of racial and ethnic discrimination and current smoking for African American [1, 3, 5, 16–17] and Hispanic/Latino and Asian American samples in the U.S.[4] Using a multi-state sample of adults ages 45 to 84, Borrell et al [3] found that African American who reported one or more lifetime experiences of racial or ethnic discrimination had 34% greater odds of current smoking than those who reported none. Among Asian Americans, Chae et al [4] found a positive association between both racial and ethnic discrimination and unfair treatment with smoking. Similar findings exist for research conducted in New Zealand.[14, 24–25] Among adults in New Zealand, racial discrimination was significantly associated with smoking status, and the authors found a positive dose-response relationship between number of types of discrimination reported and odds of current smoking.[25]

In order to fully understand the relationship between discrimination and smoking in South Africa, both racial and nonracial discrimination should be assessed. South Africans tend to report lower levels of racial discrimination and higher levels of nonracial discrimination than US samples.[26] However, no English language publication has examined nonracial discrimination and smoking among South Africans.[26] However, several studies conducted outside of South Africa found positive associations between specific types of nonracial discrimination, such as sexual orientation,[27] sexism,[28–29] immigration-based discrimination,[30] and smoking.

This analysis examined the role of chronic and acute racial and nonracial discrimination in smoking among respondents to the South Africa Stress and Health Study (SASH), a representative sample of South African adults. Prior research on discrimination indicates that like other stressful experiences, discrimination is multidimensional, consisting of acute experiences that are discrete and time-limited and chronic experiences that are ongoing.[31]

The first aim was to examine six types of discrimination, total chronic, chronic racial, chronic nonracial, total acute, acute racial, and acute nonracial, in association with smoking status. The second aim was to explore the association between the number of experiences of each type of discrimination and smoking intensity. We hypothesized that all types of discrimination would be associated with a higher risk of smoking. We also hypothesized a significant positive relationship between number of experiences of discrimination and smoking intensity among smokers.

The majority of the sample was Black African (76.4%), female (54.0%), between the ages of 18 and 34 (51.1%), and reported 12 years of education or less (84.7%; Table 1).

Chronic racial discrimination varied significantly by race (p<.0001; Table 2). Indians/Asians and Black Africans reported the highest levels of chronic racial discrimination (17.6% and 15.6% respectively) and nonracial discrimination (29.6% and 31.1% respectively).

Acute racial (p=.0033) discrimination varied significantly by race (Table 2), with Indian/Asians and Black Africans reporting the highest levels of acute racial discrimination (11.2% and 7.8% respectively). Indians/Asians and Whites had highest levels of acute nonracial discrimination (20.0% and 17.3% respectively).

Analyses of subtypes of nonracial chronic discrimination revealed that, compared to smokers, nonsmokers reported a higher prevalence of discrimination related to gender (7.8% versus 6.1%, p=.2628) and “other” (13.7% versus 2.7%, p=.0047), and smokers reported a higher prevalence of discrimination related to age (8.7% versus 6.2%, p=.2269) and physical appearance (7.8% versus 5.9%, p=.3966; see Table S1). Blacks reported higher levels of discrimination based on age (10.5%, p=.0062) and physical appearance (10.5%, p<.0001) than other racial groups (see Table S2). Women reported higher levels of sexism than men (17.7% versus 9.7%, p=.0034; see Table S3).

For subtypes of nonracial acute discrimination, smokers had a higher prevalence of discrimination attributed to “other” (13.1% versus 7.9%, p=.0125) than nonsmokers (Table S1). Whites had a higher prevalence of discrimination attributed to physical appearance (14.5%, p=.0001) and “other” (86.9%, p<.0001) than other racial groups (Table S2). The prevalence of sexism was higher for women than men (8.3% versus 3.5%, p=.0393; Table S3).

This analysis used a nationally representative probability sample of South African adults to examine the association between multiple types of discrimination and smoking status. For racial and nonracial discrimination, the significance of these associations varied by whether discrimination was acute or chronic. However, both total chronic and acute discrimination were significant predictors of smoking status. Analyses of the number of experiences of discrimination and both smoking status and smoking intensity suggest that a dose-response relationship may exist for some types of discrimination and smoking.

Interaction terms suggested variation in the relationship between discrimination and smoking by gender and race. Chronic racial discrimination may impact smoking more for men than women, and acute nonracial discrimination may impact smoking more for women than men. A number of potential explanations exist for this finding. Gender-based differences in the prevalence and reaction to experiences of sexism, as well as differences in psychological and physiological responses to chronic and acute stress, may explain these relationships. Unmeasured mediators or confounders, differences in stress responses to discrimination,[37–38] gender differences in socialization patterns and social support networks,[39] and gender norms about smoking in South Africa may have also influenced these findings.[28, 37] Analyses of subtypes of nonracial discrimination did not explain the interactions we found as women were more likely than men to report sexism for both chronic (p=.0034) and acute (p=.0393) discrimination.

The association between chronic nonracial discrimination and smoking was significant for Black Africans and Whites but not Coloured or Indians, Asians, or other race. This finding is consistent with studies that found racial/ethnic variation in the relationship between discrimination and smoking in U.S. samples.[17, 19, 23] Interestingly, the Coloured and White groups had low levels of discrimination but a high prevalence of smoking. These findings are likely due to the fact that these groups have a higher prevalence of demographic characteristics associated with higher smoking prevalence in the sample (e.g., male gender, ages 35 to 49, low or high income, and separated, widowed, or divorced marital status; see Table S4). Unmeasured confounders, variation in successful smoking cessation by race in South Africa,[38, 40] and racial differences in influences on smoking behavior may have also contributed to these findings.[38]

Surprisingly low levels of racial discrimination were reported given South Africa’s history of racial conflict, particularly when compared to levels of racial discrimination in the U.S.[26] In addition to a positive view of race relations post-apartheid and marked racial differences in SES, current segregation and isolation may limit interracial interaction, especially as equals, contributing to artificially low levels of perceived interpersonal racial discrimination. [35, 41]

Our results were similar to those of the only other study on racial discrimination and smoking in South Africa. Among South African adolescents, Brook et al [13] found a significant positive association between racial discrimination and being an experimental (OR=1.41, 95%CI: 1.14–1.75) or current smoker (OR=1.46, 95%CI: 1.21–1.75) versus a nonsmoker.

Our results were also consistent with findings from non-South African samples. We were able to locate one such study that examined both chronic and acute discrimination. However, the analysis did not differentiate between racial and nonracial discrimination. High (PR=1.41, 95%CI: 1.15–1.74) and moderate (PR=1.19, 95%CI: 1.05–1.36) scores on the Everyday Discrimination Scale were associated with a higher prevalence of current smoking among pregnant women in the U.S.[1] There was also a significant relationship between scores from a two-item acute discrimination scale and current smoking, but the relationship was not significant in adjusted models. Borrell et al [3] found a positive association between racial discrimination and current (versus never) smoking for both Black (OR=1.34, 95%CI: 1.00–1.81) and White Americans (OR=1.88, 95%CI: 1.02–3.49) enrolled in the Multi-Ethnic Study of Atherosclerosis (MESA). In a study of African American college students, respondents who experienced racial harassment were twice as likely to smoke on a daily basis as those who reported none (OR=2.10, 95%CI: 1.23–3.58) [15]. Chae et al [4] found a significant relationship between high levels of racial discrimination and current smoking among Asian Americans (OR=3.06, 95%CI: 1.07–9.72). Using a New Zealand sample, Harris et al [25] found a significant relationship between overall discrimination (OR=1.36, 95% CI: 1.17–1.58), as well as discrimination-related personal attacks in general (OR=1.46, 95%CI: 1.25–1.71) and physical (OR=2.29, 95%CI: 1.64–3.21) and verbal attacks specifically (OR=1.34, 95%CI: 1.15–1.57), and current smoking status.

Although we were unable to locate any publications that studied nonracial discrimination as one overarching category, studies on specific types of nonracial discrimination, such as sexism, support a relationship between nonracial discrimination and smoking. Among Chinese female rural-to-urban migrant restaurant and hotel workers and sex workers in China, perceived discrimination (due to migrant status) was positively associated with the risk of being a current smoker.[30] Restaurant and hotel workers, and sex workers, who reported one or more experiences of discrimination had 2.52 (95% CI: 1.32–4.79) and 1.63 (95% CI: 1.28–2.06) times the prevalence of smoking, respectively, compared to members of those groups who reported none. Borrell and colleagues [29] found that female Spanish natives in Spain who reported any experience of sexism in the past year had higher odds of being a current or ex-smoker (versus never smoker, OR=1.45, 95%CI: 1.07–1.96). An analysis of female American college students also found a positive significant relationship between sexism and smoking status (p<.05).[28]

Several potential explanations [3, 42] have been offered for the relationship between discrimination and smoking. First, smokers may actually experience higher levels of discrimination due to smoking-related stigma, especially Black women in South Africa, for whom smoking is considered especially taboo.[38] Some smokers may falsely attribute this discrimination to personal characteristics other than smoking status. It is possible that our “other” discrimination category may have captured discrimination related to smoking status. However, reports of “other” discrimination did not differ significantly by smoking status. Second, smoking may seem less risky to an individual whose experiences of discrimination have been life-threatening. If these experiences are perceived as a greater health risk than smoking, these individuals may not be motivated to quit.[43] Third, discrimination is a stressor that impacts physiological reactivity to stress, such as cortisol production, and smoking also impacts perceived stress.

Because of different physiological responses, mild chronic stressors may have a greater impact on health outcomes than infrequent (acute) stressors, even when severe.[1, 34] We hypothesize that the differences in our results between acute and chronic discrimination are due to differences in the physiological effects of acute and chronic stress.[44] Acute stressors lead to an initial increase in cortisol exposure, which returns to normal or slightly below normal shortly after the stressor is removed. In contrast, chronic stressors are associated with chronically high cortisol levels,[45] which may impact nicotine sensitivity [31] and psychological coping with stress,[3] as well as decrease self control in resisting unhealthy behaviors.[42] Smoking is often used as a coping mechanism because nicotine decreases anxiety and generate a sense of well-being.[46] In an analysis of American girls ages 11 to 19, Guthrie et al [5] found that stress explained a significant proportion (p<.05) of the relationship between discrimination and smoking. However, additional research is needed.

The primary limitation of this analysis is the cross-sectional nature of the data, which precludes us from making causal statements based on our results. One of the limitations of this analysis is its use of self-report. However, existing research suggests that self-reported smoking is a reasonably valid measure of cigarette consumption in population-level studies.[47] As always, unmeasured confounding must be considered as a potential limitation. However, careful assessment of potential confounders decreases the likelihood of unmeasured confounding. Another potential limitation is our use of two-category smoking outcome, which may have occluded differences between former smokers and current and non-smokers. However, we conducted additional analyses that coded smoking status into three categories (current, former, never) but did not find any significant differences between current and former or former and never smokers.

Because many of the respondents did not specify the type of acute or chronic nonracial discrimination (e.g., sexism, ageism), another limitation is that there was insufficient statistical power to analyze each type of nonracial discrimination separately (e.g., sexism, ageism) for the entire sample. However, cell sizes were large enough to run these analyses for Black Africans. The relationship between chronic discrimination and smoking was driven by racial discrimination (RR=1.20, 95%CI: 1.08–1.33), age (RR=1.98, 95%CI: 1.14–3.44), and “other” (RR=1.56, 95%CI: 1.04–2.32). Acute racial and nonracial discrimination were not significant for this group. Unfortunately, despite these analyses, we were still unable to make comparisons across multiple races.

In addition, because of the small number of Whites who reported chronic (n=5, 1.6%) and acute (n=5, 3.1%) racial discrimination, these percentages should be interpreted with care given high relative standard errors (50.0% and 29.4% respectively). However, these values did not appear to impact our analyses; dropping Whites from analyses yielded similar results for chronic (racial: RR=1.39, 95%CI: 1.08–1.79; nonracial: RR=1.53, 95%CI: 1.20–1.93) and acute discrimination (racial: RR=1.05, 95%CI: 0.66–1.65; nonracial: RR=1.04, 95%CI: 0.77–1.41). A final limitation is that, although we used the labels “acute” and “chronic” discrimination to conform to previous publications on these questionnaires,[32, 34] we acknowledge that these terms are complex and that definitions may overlap.

This analysis also has several strengths. This is the first analysis of discrimination and smoking among South African adults. Because of the inclusion of both racial and nonracial discrimination, this analysis captured experiences of discrimination that may not have been examined had analyses only focused on either racial or nonracial discrimination. South Africans may tend to attribute racial discrimination to other factors, possibly due to a reluctance to discuss race in the post-apartheid era.[34–35] This analysis is also unique because it provides insight into the role of both chronic and acute racial and nonracial discrimination in smoking behavior. Also, the use of SUDAAN and weighting allowed researchers to adjust for any bias created by sampling techniques and made the results generalizable to South African adults. Yet another strength of this analysis is the use of relative risks, which provided more conservative effect estimates than odds ratios, thereby reducing the risk of Type I error. The finding of a dose-response relationship between chronic discrimination and smoking intensity suggests that our findings are unlikely to be spurious.

Despite our extensive analysis of multiple types of discrimination, additional research is needed. Future research should use longitudinal data to examine the temporal ordering of racial and nonracial discrimination and smoking initiation, maintenance, and cessation in South Africa, as well as to examine stress as a potential mediator. Additional research should also attempt to generalize our results to populations outside of South Africa. We also recommend that, despite our non-significant results, the potential role of ethnic identity be considered in future analyses of discrimination and smoking.[4, 17] We also propose that future research tests social policies that may combat discrimination. In October of 2013, South African President Jacob Zuma called for a conference to combat discrimination suffered by apartheid victims, proposing measures such as increasing opportunities for Black businesses.[48] In addition to these types of policies, social policies that promote racial integration also have the potential to increase positive interracial relations by reducing prejudice and increasing tolerance.[49] Because of the link between socioeconomic status and race, housing and educational policies that provide opportunities for low-income individuals to live in middle income settings may decrease racial and socioeconomic segregation. These policies have been somewhat effective in the United States, where SES and race are closely related.

We also propose additional research on smoking cessation interventions in South Africa, which could be tailored by race and consider the potential role of stress and discrimination and smoking behavior. A study of South African adolescents found that social and cognitive predictors of being a former smoker, such as attitudes towards smoking, mood, and smoking by friends and family, varied by race.[38] However, because of a lack of research, effective targets for smoking cessation remain unclear. The link between stress and smoking [50–52] suggests that interventions that combine smoking cessation with stress management techniques may be effective, especially for disadvantaged populations.[53] However, we are unaware of any study that has used randomized controlled trials to examine the efficacy of a stress management component. Because of a potential link between alcohol dependence and smoking cessation in South Africa,[54] another opportunity for intervention is to incorporate smoking cessation into alcohol dependence programs.

The solution to these issues, if one exists, is extremely complex. However, given the potential link between discrimination and smoking, we cannot afford to ignore it.