(64) Local Policy Matters: Structural Violence, Vaping, and Immigrant-Inclusive Protections

Background & Introduction: A lack of inclusionary immigration policies represents a form of structural violence that shapes health behaviors among Latine communities by embedding chronic stress, marginalization, and restricted access to protective resources into daily life (1). While discrimination has been linked to substance use among Latine populations, (2), few studies have examined how policy-level structural violence influences substance use during emerging adulthood, a critical developmental period marked by heightened vulnerability to substance initiation and escalation (3). Grounded in dislocation theory, which posits that addiction risk increases when social structures erode belonging and stability (4), this study investigated associations between state-level lack of inclusionary immigrant policies and seven substance use outcomes, including e-cigarette use, heavy drinking, binge drinking, marijuana use, cigarette smoking, and lifetime smoking, among Latine adults aged 18–29 in the United States.

Methods: We analyzed cross-sectional data from 2023 Behavioral Risk Factor Surveillance System (BRFSS) respondents who self-identified as Hispanic/Latino(a)/Latine and were aged 18-29 years. Policy exposure was operationalized using the GR.SV3 measure from the Ogun Dataset, which captures the proportion of counties within each state lacking Welcoming City certification, a formal designation indicating comprehensive immigrant-inclusive protections across seven domains (civic engagement, connected communities, economic development, education, equitable access, government leadership, and safe communities). We conducted generalized linear models (GLM) and multilevel mixed-effects models (GLMM) with state random intercepts, adjusting for age, gender, education, income, employment status, and survey language.

Results: The analysis showed lack of inclusionary immigrant policies were significantly associated with increased tobacco and e-cigarette use, whereas no significant associations were observed for alcohol or marijuana outcomes. In models treating policy exposure as a continuous predictor, higher proportions of counties lacking immigrant protections were strongly associated with e-cigarette use. Specifically, the adjusted multilevel model (GLMM) accounting for state clustering yielded an adjusted odds ratio (aOR) of 36.46 (95% CI: 3.06–434.97, p = 0.004). This association remained robust across both standard GLM and multilevel specifications. For smoking behaviors, continuous policy exposure was significantly associated with higher smoking status categories in adjusted ordinal logistic regression (aOR = 10.26; 95% CI: 1.11–95.11, p = 0.041), and lifetime smoking of 100+ cigarettes (aOR = 9.98; 95% CI: 1.09–97.48, p = 0.045). In multilevel specifications, these smoking associations showed a similar magnitude but approached rather than reached conventional significance (p = 0.091 and p = 0.086, respectively). No significant associations were found for heavy drinking, binge drinking frequency, or marijuana use frequency; for binge drinking status, odds ratios ranged from 0.31 to 1.10 with all confidence intervals including 1.0. Notably, when policy exposure was operationalized as a binary variable (fully exposed vs. any protection), no significant associations emerged for any outcome (all p > 0.05). This indicates a potential dose-response relationship where the density of exclusionary policies within a state, rather than a simple binary presence of protection, is the primary correlate of tobacco-related risk. These findings highlight that the policy gradient of exclusion captures meaningful variations in substance use risk that binary measures obscure, suggesting that cumulative exposure to exclusionary environments significantly compounds tobacco-related health risks for young Latine adults.

Conclusion & Discussion: Lack of inclusionary immigrant policies is significantly associated with increased tobacco and e-cigarette use among young Latine adults, independent of sociodemographics. These findings suggest that policy environments characterized by structural exclusion and a lack of local protections function as critical determinants of addiction risk.

Limitations include a cross-sectional design that precludes causal inference and the aggregation of county-level data to the state level, which may obscure within-state heterogeneity. Additionally, the use of binary sex categories and potential self-report bias in substance use data are noted.

Implications: From an addiction medicine perspective, the robust association with tobacco suggests that specific nicotine-use behaviors may serve as distinct coping mechanisms for the psychosocial stressors generated by exclusionary policy climates. Expanding immigrant-inclusive local and state policies may represent critical upstream interventions to reduce health disparities. For clinicians and policymakers, addressing addiction requires moving beyond individual-level cessation models to consider the broader structural and political determinants that shape health behaviors in immigrant-impacted communities during key developmental periods.

References: 1. Farmer P. Social inequalities and emerging infectious diseases. Emerg Infect Dis. 1996;2(4):259-269. doi:10.3201/eid0204.960402
2. Pinedo M, Zemore SE, Beltrán-Girón J, et al. Immigration enforcement and substance use among U.S.-born Latinos. Soc Sci Med. 2020;255:113023. doi:10.1016/j.socscimed.2020.113023
3. Arnett JJ. Emerging adulthood: A theory of development from the late teens through the twenties. Am Psychol. 2000;55(5):469-480. doi:10.1037/0003-066x.55.5.469
4. Alexander BK. The Globalization of Addiction: A Study in Poverty of the Spirit. Oxford University Press; 2008.