• Won K Cook, William C Kerr, Katherine J Karriker-Jaffe, Libo Li, Camillia K Lui, and Thomas K Greenfield.
• Public Health Institute, Alcohol Research Group, Emeryville, California. Electronic address: wcook@arg.org.
• Am J Prev Med. 2020 Jan 1; 58 (1): e21-e29.

IntroductionAlcohol misuse, cigarette smoking, poor diet, and physical inactivity, known as the "big four" contributors to chronic conditions and mortality, typically co-occur or cluster together, with their synergistic effect more detrimental to health than their cumulative individual effects. Little research has been reported on race/ethnicity-specific analyses of the clustering of these behaviors in the U.S. This study identified clustered risk behaviors among whites, blacks, and Hispanics and examined whether unhealthy clusters were associated with lower SES (assessed by education level and family income) and poor health status.MethodsA nationally representative sample of U.S. adults aged 30-69 years (n=9,761) from the 2010 and 2015 National Alcohol Surveys was used to perform latent class analysis and multinomial and logistic regression modeling in 2018-2019. Obesity was used as a proxy for unhealthy diet.ResultsThree lifestyle classes were identified in each group. The relatively healthy lifestyle class was identified among whites and Hispanics. The nonsmoking and low risky drinking class among blacks, though showing a healthier lifestyle than the other 2 classes, still had relatively high prevalence of inactivity and obesity. The inactive and obese class was found in all 3 groups. Also identified were the smoking and risky drinking class among whites; the smoking and inactive class among blacks; and the smoking, inactive, and risky drinking class among Hispanics. For all 3 groups, unhealthy lifestyle classes mostly were associated with lower SES. Unhealthy lifestyle classes were also associated with poorer health status.ConclusionsMulti-behavior interventions are warranted to address inactivity and obesity in all 3 groups and unhealthy clusters involving smoking in each group.Copyright © 2019 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.

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