Low Socioeconomic Status and Cancer Prevention in the American Cancer Society Great West Division

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1 Low Socioeconomic Status and Cancer Prevention in the American Cancer Society Great West Division Amanda Parrish, MA Caitlin Mason, PhD Jeff Harris, MD, MPH, MBA June 13 Report funded by the American Cancer Society Great West Division This publication is a product of the University of Washington Health Promotion Research Center, a Centers for Disease Control and Prevention (CDC) Prevention Research Center, and was supported by Cooperative Agreement Number U48-DP1911 from the CDC. The findings and conclusions in this report are those of the author(s) and do not necessarily represent CDC's official position.

2 Low Socioeconomic Status and Cancer Prevention in the ACS Great West Division Amanda Parrish, MA Caitlin Mason, PhD Jeff Harris, MD, MPH, MBA EXECUTIVE SUMMARY Defining Low-SES Using income and education data from the CDC s Behavioral Risk Factor Surveillance System, we assessed cancer risk factors and screening associated with low socioeconomic status (SES) in the American Cancer Society s Great West Division (GWD). We chose the following definition of low-ses as the most appropriate: education high school, and/or annual household income $25,. Prevalence of Low-SES within the Great West Division Within the GWD, 43% of individuals are low-ses. At the state level, Colorado has the lowest proportion of low-ses residents (39%), while Montana has the highest (51%). See Appendices 1 to 12 for snapshot data of the 12 states within the GWD: Alaska, Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, North Dakota, Oregon, Utah, Washington, and Wyoming. Highlights of Findings Most GWD residents younger than age 35 or older than age 64 are low-ses. 66% of the low-ses population is white. Hispanics are the next largest racial/ethnic group, and also experience the greatest need (76% of Hispanics in the GWD are low-ses). Low-SES individuals are almost 2.5 times more likely to be current smokers compared to the higher-ses population. Regardless of their insurance status, low-ses individuals are much less likely than the higher-ses population to have received recommended screenings for breast, cervical, and colorectal cancers. Low-SES individuals report poor access to health care; for example, they are more than three times as likely as the higher-ses population to have no health insurance. Even after the Affordable Care Act is fully implemented and health insurance is expanded, SESrelated inequities in healthcare are likely to persist.

3 Recommendations We highlight three domains (policy, media, and partnerships) through which ACS can help reduce the cancer burden in the low-ses population. Policy: Increase taxes on tobacco products. Increase access to and stable funding for telephone quitlines that also provide cessation medications such as nicotine replacement therapy. Expand smoke-free zones. Support state-wide initiatives to encourage physical activity through community-scale and street-scale urban design and land-use policies. Small Media: Use small media to disseminate information on cancer prevention and screening specifically tailored for low-ses individuals. Provide materials in Spanish (and possibly other languages). Ensure that educational materials address any cultural, literacy, and health literacy factors that may otherwise reduce their effectiveness. Business, Clinical, and Community Partnerships: Work with large employers in low-wage industries to support employees healthy behaviors and promote cancer screenings. Provide federally qualified health centers with cancer prevention resources, such as multilingual small media and funding/training for prevention navigators. Work with community partners to engage low-ses populations, disseminate culture/languageappropriate educational materials, and increase awareness of cancer screening services. 2

4 Defining Low-SES Low Socioeconomic Status and Cancer Prevention in the ACS Great West Division At the request of the American Cancer Society s Great West Division (GWD), we assessed the effects of socioeconomic status (SES) on cancer prevention in twelve Western states using income and education data from the CDC s 1 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is a series of state-level annual health surveys that collect data on health-related risk behaviors, chronic health conditions, and use of preventive services in the United States. BRFSS surveys are administered by telephone in either English or Spanish to adults aged 18 years and older. Surveys are overseen by the Centers for Disease Control and Prevention, and conducted by state health departments. We examined the GWD region overall, as well as each state within the region. We chose the following definition of low-ses as the most appropriate: education high school, and/or annual household income $25,. Regardless of income, individuals with a high school education or less may have limited health literacy and experience challenges navigating the healthcare system. Likewise, individuals with a higher level of education but an annual household income of less than $25, are likely to face difficulties accessing and paying for quality healthcare. This definition does not account for household size, because similar studies have found that doing so does not meaningfully affect results (Harris et al., 11). Varying definitions of low-ses have been used in previous studies of the relationship among SES, cancer incidence, and mortality. Regardless of how SES is defined, the results are consistent: while incidence of specific cancers varies by socioeconomic status (Clegg et al., 9), cancer survival is lower among individuals with low-ses. The lower survival rate is largely due to later-stage diagnoses and differences in treatment, but these factors do not entirely explain the SES-related disparities (Woods et al., 6; Kogevinas & Porta, 1997). To provide further context for our discussion of cancer prevention in the GWD, we have included stateby-state data on incidence and mortality for four of the most preventable cancers: breast, cervical, colorectal, and lung (see Appendices 13-16). This data is not subdivided by SES, although our evidence suggests that in the low- SES population these cancer rates Table 1: Annual household income, education level, and prevalence of low socioeconomic status (SES) within the ACS Great West Division. ANNUAL HOUSEHOLD INCOME % of GWD <$15, 6.94 $15, to <$25, $25, to <$35, 8.85 $35, to <$5, $5, Don't Know/Missing EDUCATION COMPLETED % of GWD Did not graduate High School 7.97 Graduated High School Attended College or Technical School Graduated College or Technical School Don't Know/Missing.28 LOW-SES: High school education and/or 42.78% Household income $25,/y 3

5 will be higher than state averages. We include this data to highlight the sometimes dramatic betweenstate differences in both cancer incidence and mortality rates. Some of this variation may be due to differences in behavior, some to differences in available treatments. The focus of this report, however, is on the modifiable risk factors and screenings that can help prevent these four cancers in the GWD s low-ses population. Prevalence of Low-SES within the Great West Division In the GWD, 43% of the population is low-ses (Table 1). The prevalence of low-ses within each GWD state is shown in Figure 1. State-specific data are also available in the Appendices. At the state level, Colorado has the lowest proportion of low-ses residents (39%), while Montana has the highest (51%). Figure 1: Low-SES prevalence (%) within GWD States % Demographic Characteristics of the Low-SES Population Our analysis compares the low-ses population to the remaining GWD population (higher-ses) across a variety of demographic categories including sex, age, race/ethnicity, employment status, and rural residence. Sex: The proportion of men and women categorized as low-ses is approximately equal to the proportion categorized as higher-ses. This was true in all GWD States, with little variation. Age: The low-ses population is spread fairly evenly across age categories, while the higher-ses population is concentrated in the middle age categories, with a combined 44% between the ages of 35 and 54 years (Figure 2). 4

6 Examining the data in this way highlights the age distribution within these two populations (low-ses and higher-ses). Figure 3 highlights where the need is greatest by presenting the data in another way, as the prevalence of low-ses within each age group. For example, 72% of GWD residents aged 18 to 24 years are low-ses, and 55% of GWD residents aged 65 years and older are low-ses. In other words, most GWD residents who are younger than age 35 or older than age 64 are low-ses. Figure 2: Age distribution (%) within the low-ses and higher-ses populations in the GWD 1 Low-SES Higher-SES 8 6 % y 25-34y 35-44y 45-54y 55-64y 65y Figure 3: Prevalence of low-ses (%) within age groups in the GWD % y 25-34y 35-44y 45-54y 55-64y 65y Race/Ethnicity: In the GWD, more than 8% of the higher-ses population is white and about 7% is Hispanic, while the low-ses population is approximately 65% white and % Hispanic (Table 2). Whites 5

7 make up a majority of the low-ses population, which indicates that racial and ethnic inequities are not the only cause of socioeconomic disadvantage in this region. On the other hand, although most low-ses individuals are white, racial and ethnic minorities are overrepresented in this group (Figure 4). For example, 76% of Hispanics in the GWD are low-ses, as are 7% of American Indians and Alaskan Natives. Programs aimed at combatting the disadvantages of low-ses should balance these two perspectives. For example, although 7% of American Indians in the GWD are low-ses, addressing the needs of this group alone will only affect 2% of the total population. Hispanics are the largest racial/ethnic group after whites and also experience the greatest need (76% are low-ses). Table 2. Racial/ethnic distribution (%) within the low-ses and higher-ses populations in the GWD Low-SES (%) Higher-SES (%) Race/Ethnicity White, non-hispanic Hispanic Other race or multiracial American Indian or Alaskan Native Black, non-hispanic Asian Native Hawaiian or Pacific Islander.4.2 Figure 4: Prevalence of low-ses (%) within racial/ethnic groups in the GWD Hispanic American Indian or Alaskan Native Native Hawaiian or Pacific Islander Other race or multiracial Black, non-hispanic White, non-hispanic Asian % Consistent with the finding that Hispanics are over-represented within the low-ses population, we found that individuals with low-ses were more likely than higher-ses respondents to choose to take the 1 BRFSS survey in Spanish (Figure 5). This indicates that low-ses individuals are more likely to have limited English proficiency. 6

8 Wide variability was noted within the GWD, however. For example, 13% of the low-ses population in Arizona and 12% in New Mexico elected to take the survey in Spanish, compared to 1% and 1.5% of the higher-ses population in those states, respectively. In contrast, less than 1% of the low-ses population in Alaska, Montana, and North Dakota elected to take the survey in Spanish. Figure 5: Low-SES vs. higher-ses (%) who chose to take the survey in Spanish 15 It is important to note that the BRFSS was offered only in English and Spanish. Thus, individuals who have a different preferred language may not have taken the survey at all. These individuals are an important group to consider, and they cannot be accounted for in these analyses. % Low-SES Higher-SES Employment: An average of 7.2% of the low-ses population has been out of work for 1 year or longer, compared with 2.2% of the remaining GWD population. An additional 7.2% of the low-ses population has been out of work for less than one year, compared to 2.4% of the remaining population (Figure 6). Thus, low-ses individuals in the GWD are more than three times as likely to be unemployed, compared to higher-ses individuals. % The rate of long-term low-ses unemployment varies across states in the GWD, with the highest level in Nevada (9.9%), and the lowest in North Dakota (2.5%). Forty-five percent of low-ses individuals are employed for wages, compared to 65% of higher-ses individuals (the remaining percentages of these populations include those who are unemployed, homemakers, students, unable to work, and retired). These employment figures indicate that a two-pronged approach may be necessary to promote health among low-ses residents of the GWD. Just under half could be reached using workplace-related health programs and benefits, while other strategies will be needed to reach the rest. Figure 7: Low-SES vs. higher-ses (%) living in non-metro (rural) area % Figure 6: Unemployment among low-ses vs. higher-ses (%) Low-SES Higher-SES Unemployed >1y Unemployed <1y Rural Residence: Overall, most persons in the GWD live in metropolitan areas. Low-SES individuals are more likely than the remaining population to live in non-metropolitan (rural) areas, however (Figure 7). This means they are less likely to live in counties with a metropolitan city center or in suburban counties that surround a city center. Low-SES Higher-SES 7

9 It is important to note that there is significant state-by-state variation in the proportion of the total population living in non-metropolitan areas, however. This makes it difficult to determine what the connection is, if any, between SES and rural residence (see Appendices). For example, in Montana, North Dakota, and Wyoming a majority of both low-ses and higher-ses individuals live in rural areas. In Arizona, only 1% of low-ses individuals and 6% of higher-ses individuals live in rural areas. Demographic Characteristics: Key Findings Most GWD residents who are younger than age 35 or older than age 64 are low-ses. 66% of the low-ses population is white. Hispanics are the next largest racial/ethnic group, and also experience the greatest need (76% of Hispanics in the GWD are low-ses). 45% of the low-ses population is employed for wages, compared to 65% of the higher-ses population. Modifiable Cancer Risk Factors in the Low-SES Population Using the self-reported data available in the BRFSS, we examined several lifestyle-related risk factors associated with common cancers, including smoking, overweight and obesity, and participation in recreational physical activity. Smoking: Smoking is a well-established risk factor for lung cancer but is also associated with increased risk of cancers of the upper digestive tract, pancreas, and lower urinary tract, colon, rectum, and ovary (Secretan et al., 9). One-third of the cancer deaths that occur in the United States each year can be attributed to exposure to tobacco products (WCRF/IACR, 7). In the GWD, the smoking rate in the low-ses population is 23.9%, more than twice as high as in the remaining population (Figure 8). In several states, low-ses individuals are nearly three times more likely to be current smokers than the rest of the population. Alaska has the highest prevalence of smoking among low-ses individuals (31.9%), while Utah has the lowest (16.2%). Both states, however, have large differences in smoking rates between low-ses and higher-ses individuals. 8

10 Figure 8: Cancer risk factors among low-ses vs. higher-ses (%) % Low-SES 36.6 Current smoker Overweight (BMI = ) Higher-SES Obese (BMI 3) 13.2 No recreational physical activity in past 3 days Overweight and Obesity: In population analyses, overweight and obesity are typically classified according to a ratio of weight to height known as the body mass index (BMI). A BMI between 25 and 29.9 denotes overweight, while obesity is defined by a BMI of 3 or above. Higher body mass index, especially above 3, is associated with an increased incidence of several cancers, including cancers of the breast, colon, endometrium, esophagus, gallbladder, kidneys, pancreas, and thyroid, as well as leukemia, multiple myeloma, and non-hodgkins lymphoma (Rehehan et al., 8). Obesity is also associated with greater risk of cancer progression and worse prognosis (Demark-Wahnefried et al., 12). In the GWD, low-ses individuals are more likely to be obese and therefore carry a higher risk of cancer incidence and death (Figure 8). Overall, 26.5% of the low-ses population is considered obese compared to 21.8% of the remaining population. There are state-by-state differences, however, both in the overall prevalence of obesity and in the disparities between the low-ses population and others. For example, the largest difference in obesity prevalence between the low-ses population and the remaining population is in New Mexico (28.2 vs. 21.4%), while there is no meaningful difference in Utah (22.1% vs. 22.%). Physical Activity: Physical activity is associated with a lower risk of several types of common cancers, most notably cancers of the breast, colon, and endometrium (Kushi, 12). Moderate physical activity is also associated with a reduced risk of lung cancer in smokers (Buffart, 13). For cancer survivors, physical activity is associated with a lower risk of death and with favorable effects on depression, fatigue, pain, weight gain and other adverse effects of treatment (Ballard-Barbash et al., 11; Alfano et al., 13). In the GWD, the low-ses population is more than twice as likely as the higher-ses population to be physically inactive outside of the workplace, with 28.1% reporting no recreational activity in the past 3 days, compared to 13.2% of the remaining population (Figure 8). Physical inactivity in the low-ses 9

11 population was highest in Arizona (32.4%) and North Dakota (31.%); it was lowest, though still high, in Utah (24.%) and Oregon (24.4%). Unfortunately, no information on occupational physical activity is available in the 1 BRFSS survey. Therefore, it is not possible to determine the degree to which low-ses individuals may compensate for more physically demanding jobs with reduced physical activity during leisure-time. Modifiable Cancer Risk Factors: Key Findings Low-SES individuals are almost 2.5 times as likely to be current smokers, compared to the rest of the GWD population. Compared to higher-ses individuals, low-ses individuals in the GWD are more likely to be obese and therefore carry a higher risk of cancer incidence and death. Low-SES individuals are more than twice as likely to be physically inactive outside of work, compared to the rest of the GWD population. Cancer Screening in the Low-SES Population We assessed the cancer screenings (breast, cervical, and colorectal) reported by low-ses individuals in the GWD, and compared these to the cancer screenings reported by the rest of the population. Breast Cancer Screening: Among women aged 4 years and older, 34.1% of low-ses individuals have not had a mammogram within the past 2 years, compared to 22.6% of higher-ses women (Figure 9). 1 8 Figure 9: Women without recommended breast and cervical cancer screenings (%), low-ses vs. higher-ses Low-SES Higher-SES Cervical Cancer Screening: Among women aged 18 years and older, 29.2% of low-ses individuals have not had a pap test in the past 3 years, compared to 14.7% of higher- SES women (Figure 9). % Women (4+) with no mammogram in past 2y Women (18+) with no pap test in past 3y 1

12 Colorectal Cancer Screening: Adults 5 years and older are considered up-to-date with colorectal cancer screening if they have received one or more of the following: FOBT within the last year Sigmoidoscopy in the last 5 years Colonoscopy within the last 1 years Figure 1: Adults (5+) without recommended CRC screening (%), low-ses vs. higher-ses Overall, 49.2% of the low-ses population 5 years and older % have not received any recommended colorectal cancer screening, compared to 34.3% of the remaining GWD population (Figure 1). Low-SES Higher-SES Among adults 5 years and older, 53% of the low-ses population have not had a sigmoidoscopy within the past 5 years or a colonoscopy within the past 1 years. This compares to 37.8% of the remaining population who have not received these recommended screenings. The rate of fecal occult blood testing (FOBT) is universally low, with 9.1% of the low-ses population and 88.9% of the remaining population reporting no blood stool test within the past year. Cancer Screening: Key Findings Low-SES women in the GWD are more likely than higher-ses women to have missed recommended breast cancer screenings, and more than twice as likely to have missed recommended cervical cancer screenings. Low-SES individuals are more likely than higher-ses individuals to have missed recommended colorectal cancer screenings. Low-SES Access to Healthcare and Anticipated Effects of the Affordable Care Act The 1 BRFSS included three questions relating to healthcare access. Our analysis reveals significantly lower availability of care for the low-ses population compared to the higher-ses population in the GWD. Compared to the rest of the population, low-ses individuals are more than 3 times as likely to have no health insurance, and almost twice as likely to have no personal doctor or healthcare provider (Figure 11). In addition, low-ses individuals are more than 2.5 times as likely to report that within the last 12 months they were unable to see a doctor because of cost. 11

13 It is clear that education and income can have a meaningful effect on an individual s ability to access and afford healthcare. Reduced access to both preventive care and treatment services in the low- SES population may contribute to and compound their higher risk for cancer and chronic disease. It might be assumed that the full implementation of the Affordable Care Act (ACA) in 14 will ameliorate these SES-related disparities, because healthcare and preventive services should become both more accessible and more affordable for the % No health insurance Figure 11: Access to healthcare low-ses vs. higher-ses (%) Low-SES low-ses population. To examine the potential effect of ACA implementation, we looked at cancer screening behavior and other variables for all GWD residents by both SES and health insurance status (Table 3). We found that, regardless of their insurance status, low-ses individuals are still less likely than the rest of the population to receive recommended cancer screenings. It is not clear why this is so, but we can speculate that language barriers, low education, low health literacy, and other cultural factors may play a role Higher-SES 16. No personal doctor or healthcare provider Did not see doctor because of cost (past 12 mo) Table 3. Cancer screening and healthcare access among low-ses individuals with and without a health plan. Have Health Plan Low-SES (%) Higher-SES (%) No Health Plan Low-SES (%) Higher-SES (%) CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without recommended CRC screening HEALTH CARE ACCESS Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider

14 Furthermore, we know that provider recommendations are an important avenue for patients to learn about and receive cancer screenings. Thirty percent of low-ses individuals currently have no personal healthcare provider. Even if the ACA helps individuals get access to insurance, it is less clear that this will translate to individuals having consistent access to a personal healthcare provider. This data suggests that disparities in care will likely persist even after the ACA is fully implemented. This speculation is further supported by the fact that SES-related health disparities are also observed in countries with universal health insurance. For those left out of the ACA, such as undocumented residents, inequities may increase. This situation will require careful attention as the ACA moves forward. Health Care Access and Effects of the ACA: Key Findings Compared to the rest of the population, low-ses individuals are at greater risk for cancer and chronic disease, yet they are more than three times as likely to have no health insurance. SUMMARY Regardless and of RECOMMENDATIONS their insurance status, low-ses individuals are less likely to receive recommended cancer screenings. Even after the Affordable Care Act is fully implemented, these disparities in care are likely to persist. 13

15 SUMMARY and RECOMMENDATIONS Residents of the ACS Great West Division with low-ses (low income and/or low education) are predominantly white and Hispanic. Forty-five percent are employed for wages, and 14% are unemployed. Low-SES individuals report higher levels of several modifiable cancer risk factors, including obesity and physical inactivity. They are almost 2.5 times more likely to be current smokers compared to higher-ses individuals, and report lower rates of screening for cancer. The fact that low-ses individuals are less likely to have health insurance and/or a personal care provider than higher-ses individuals may contribute to and compound these cancer risks. When the Affordable Care Act is fully implemented, it is expected that more individuals will have access to quality affordable healthcare. Although this will help, it is unlikely to solve the problem. Our data suggest that underlying issues, beyond insurance status, contribute to a greater cancer burden among low-ses individuals. For context, please see Appendices for incidence and mortality rates of the four most preventable cancers: breast, cervical, colorectal, and lung cancer. This is average data for total GWD state populations, and our evidence suggests that in the low-ses population these rates are likely higher than state averages. Recommendations for Action Given their demographics, members of the low-ses population in the GWD may face some or all of the following barriers to healthcare access: Low literacy Low English proficiency Low health literacy Low access to culturally appropriate medical materials and interactions Inability to pay for treatment Lack of a personal healthcare provider The ACS Great West Division is already doing important work to prevent cancer; focusing on the low-ses population provides an opportunity to increase the impact of this work. Based on the findings of this report, and backed by the best available evidence as summarized in CDC s Guide to Community Preventive Services (The Community Guide), we believe targeted action within the following three domains would help reduce the cancer burden within the GWD s low-ses population. Policy: ACS is well positioned to influence policy decisions that affect the health of low-ses individuals. For example, this report finds that low-ses individuals in the GWD are almost 2.5 times more likely to be current smokers than others. Policies that increase taxes on tobacco products, increase access to and stable funding for telephone quitlines, reduce out-of-pocket costs for cessation medications such as nicotine replacement therapy, and expand smoke-free zones are recommended by the Community Guide and would support tobacco cessation in the low-ses population. 14

16 Furthermore, as low-ses individuals are more likely to face increased cancer risks connected to physical inactivity and obesity, ACS could consider leading or supporting state-wide initiatives to encourage physical activity and access to healthy foods. These initiatives include community-scale and street-scale urban design and land-use policies as recommended by the Community Guide. Small Media: A key finding of this report is that low-ses individuals with health insurance continue to face barriers to receiving cancer screenings and other preventive services. The Community Guide recommends small media (such as letters, brochures, newsletters, and video) as a particularly effective means of increasing screening for breast, cervical, and colorectal cancers. The benefit of small media is that it can be tailored to target the needs of specific groups, making it a useful strategy for reaching the low-ses population which may face barriers connected to literacy, health literacy, English-proficiency, and cultural appropriateness. ACS could devote resources to fighting cancer in the low-ses population by using small media to disseminate information on cancer prevention and screening specifically tailored for low-ses individuals. This would include research to ensure that educational materials address any cultural, literacy, and health literacy factors that may reduce effectiveness and screening rates. Given the potential literacy issues in this population, it is important to make information available by video as well as in print. Our findings on race and ethnicity in the low-ses population suggest that all materials should be available in English and Spanish. Other languages may also be important to consider. Business, Clinical, and Community Partnerships: ACS can broaden and enhance cancer prevention efforts in the low-ses population by working with business partners (such as large employers in lowwage industries and government), clinical partners (such as federally qualified health centers), and community partners (such as community centers and places of worship). Businesses in low-wage industries retailers such as Wal-Mart, hotel chains such as Marriott, restaurant chains such as McDonalds, waste-disposal companies such as Waste Management, and local governmental agencies including school districts employ substantial numbers of low-ses individuals. By working with these large employers to increase internal messaging, support healthy behaviors, and promote cancer prevention services, ACS could improve the health of millions. Federally qualified health centers (FQHCs) are likely to be important access points for cancer screening services in the low-ses population, and their importance will likely increase after the ACA is fully implemented. Any resources that ACS can provide to enhance education about and access to cancer screenings at FQHCs will benefit low-ses individuals. These resources could include Spanish-language small media as discussed above, but also funding and training for navigators who help patients learn about and access prevention resources. These recommendations are supported by our research for a related project, in which GWD FQHCs confirm their need for multi-lingual small media resources and support for prevention navigators. ACS could also work with community partners such as community centers, culture clubs, and places of worship to engage low-ses populations, increase awareness of cancer screening services, and disseminate culture/language-appropriate educational materials. ACS has a thriving network of volunteers, and these existing social connections could be leveraged to expand the reach of community education efforts. 15

17 References: Alfano, C. M., A. Molfino, et al. (13). "Interventions to promote energy balance and cancer survivorship: Priorities for research and care." Cancer 119 Suppl 11: Buffart, L. M., A. S. Singh, et al. (13). "Physical activity and the risk of developing lung cancer among smokers: A meta-analysis." J Sci Med Sport. Clegg, L. X., M. E. Reichman, et al. (9). "Impact of socioeconomic status on cancer incidence and stage at diagnosis: selected findings from the surveillance, epidemiology, and end results: National Longitudinal Mortality Study." Cancer Causes Control (4): Dubay, L. C. and L. A. Lebrun (12). "Health, behavior, and health care disparities: disentangling the effects of income and race in the United States." Int J Health Serv 42(4): Faggiano, F., T. Partanen, et al. (1997). "Socioeconomic differences in cancer incidence and mortality." IARC Sci Publ(138): Guide to Community Preventive Services. Centers for Disease Control and Prevention. Last updated: 6/21/13. Harris, J. R., Y. Huang, et al. (11). "Low-socioeconomic status workers: their health risks and how to reach them." J Occup Environ Med 53(2): Kogevinas, M., M. G. Marmot, et al. (1991). "Socioeconomic differences in cancer survival." J Epidemiol Community Health 45(3): Kogevinas, M. and M. Porta (1997). "Socioeconomic differences in cancer survival: a review of the evidence." IARC Sci Publ(138): Kushi, L. H., C. Doyle, et al. (12). "American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity." CA Cancer J Clin 62(1): Secretan, B., K. Straif, et al. (9). "A review of human carcinogens--part E: tobacco, areca nut, alcohol, coal smoke, and salted fish." Lancet Oncol 1(11): Wiseman, M. (8). "The second World Cancer Research Fund/American Institute for Cancer Research expert report. Food, nutrition, physical activity, and the prevention of cancer: a global perspective." Proc Nutr Soc 67(3): Woods, L. M., B. Rachet, et al. (6). "Origins of socio-economic inequalities in cancer survival: a review." Ann Oncol 17(1):

18 APPENDIX 1: Alaska Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish.2. Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 17

19 APPENDIX 2: Arizona Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander.1.1 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo).5 7. No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 18

20 APPENDIX 3: Colorado Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander.2.1 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 19

21 APPENDIX 4: Idaho Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic.2.2 Asian Native Hawaiian or Pacific Islander.3. American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish 5.8. Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y

22 APPENDIX 5: Montana Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic.9.2 Asian.1.8 Native Hawaiian or Pacific Islander.1.3 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused.4.7 Survey taken in Spanish.2.1 Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 21

23 APPENDIX 6: Nevada Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander.2.8 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 22

24 APPENDIX 7: New Mexico Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander..2 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 23

25 APPENDIX 8: North Dakota Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian.6.8 Native Hawaiian or Pacific Islander.2. American Indian or Alaskan Native Other race or multiracial.7.4 Hispanic Don't know/not sure/refused Survey taken in Spanish.. Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 24

26 APPENDIX 9: Oregon Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic.9.5 Asian Native Hawaiian or Pacific Islander.7.1 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 25

27 APPENDIX 1: Utah Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic.9.3 Asian Native Hawaiian or Pacific Islander.9.2 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused.8.9 Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 26

28 APPENDIX 11: Washington Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic Asian Native Hawaiian or Pacific Islander.7.4 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 27

29 APPENDIX 12: Wyoming Low-SES (%) Higher-SES (%) DEMOGRAPHICS Sex Female Male Age (years) Race/Ethnicity White, non-hispanic Black, non-hispanic.8.4 Asian.3.8 Native Hawaiian or Pacific Islander.1.1 American Indian or Alaskan Native Other race or multiracial Hispanic Don't know/not sure/refused Survey taken in Spanish Unemployed (>1 year) Live in Non-Metropolitan Status (Rural) Area HEALTH CARE ACCESS No healthcare coverage Did not see doctor because of cost (past 12 mo) No personal doctor or healthcare provider RISK FACTORS Overweight (BMI ) Obese (BMI 3) Current smoker No recreational physical activity in past 3 days CANCER SCREENING Women (4+) with no mammogram in past 2 y Women (18+) with no pap test in past 3 y Adults (5+) without sigmoidoscopy (<5y) or colonoscopy (<1y) Adults (5+) with no blood stool test in past year Adults (5+) without recommended CRC screening *Low SES= High school education and/or Household income $25,/y 28

30 APPENDIX 13: Breast cancer incidence and mortality rates in GWD states Data obtained from statecancerprofiles.cancer.gov, provided by CDC and the National Cancer Institute. Rates are age-adjusted to the US standard population. Incidence and mortality rate of female breast cancer (invasive) in GWD states (all ages, all SES levels) Annual Incidence Rate (per 1, women) Annual Mortality Rate (per 1, women) Ranked annual mortality rates (per 1, women) of breast cancer in GWD states

31 APPENDIX 14: Cervical cancer incidence and mortality rates in GWD states Data obtained from statecancerprofiles.cancer.gov, provided by CDC and the National Cancer Institute. Rates are age-adjusted to the US standard population. Incidence and mortality rate of cervical cancer in GWD states (all ages, all SES levels) (some data has been suppressed to ensure confidentiality and stability of rate estimates) 3 25 Annual Incidence Rate (per 1, women) Annual Mortality Rate (per 1, women) Annual mortality rates (per 1, women) of cervical cancer in GWD states (data from some states is not shown, due to small numbers)

32 APPENDIX 15: Colorectal cancer incidence and mortality rates in GWD states Data obtained from statecancerprofiles.cancer.gov, provided by CDC and the National Cancer Institute. Rates are age-adjusted to the US standard population. Incidence and mortality rate of colorectal cancer in GWD states (all ages, all SES levels) Annual Incidence Rate (per 1,) Annual Mortality Rate (per 1,) Ranked annual mortality rates (per 1,) of colorectal cancer in GWD states