Although tobacco control measures have reduced overall smoking rates in the United States (from 42% in 1965 to 15% in 2015), a new ACS report says the high prevalence of cigarette smoking among vulnerable populations is one of the most pressing challenges facing the tobacco control community.
Those populations includes individuals in lower education and/or socioeconomic groups; American Indians and Alaskan Natives; people with mental illness, particularly schizophrenia; military personnel, particularly among those in the lowest pay grades; and lesbian, gay, bisexual, and transgender (LGBT) men and women.
Geography also plays a role in smoking rates, due to culture, policy, and the strong and persistent influence of the tobacco industry. Those states, called "Tobacco Nation" by the Truth Initiative, are Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia. (The Truth Initiative® is America’s largest non-profit public health organization dedicated solely to making tobacco use a thing of the past. It was previously known as American Legacy Foundation.)
"Who's Still Smoking? Disparities in Adult Cigarette Smoking Prevalence in the United States" appeared online January 31, in CA: A Cancer Journal for Clinicians. The lead author is Jeffrey Drope, PhD, vice president, Economic and Health Policy Research.
Although smoking prevalence in the U.S. has decreased in all education groups over the last one-half century, the largest decrease has been among those who are college-educated. Fifty years ago, smoking prevalence for all education groups was fairly clustered, with nearly 40% of college-educated individuals smoking, along with approximately 45% of individuals in all other education groups. Today, five decades later, 6.5% of college-educated individuals continue to smoke, while 23.1% of those with a high school education or less smoke.
Although all income groups experienced overall declines in smoking over the last few decades, the largest relative decreases have been in higher socioeconomic groups. In 2015 and 2016, current tobacco use prevalence was about 10% for adults in higher income households (greater than 400% of the Federal Poverty Level) compared with almost 25% for adults in households below the poverty line.
Among all racial and ethnic groups, there has mostly been a downward trend for both men and women, but there also remains considerable variation. Individuals who are of American Indian or Alaskan Native descent exhibit the highest smoking prevalence (24.3% male and 23.4 female), and women in this group also experienced a recent upward trend after a nearly two-decade downward trend. Individuals of Asian and Hispanic/Latino descent have the lowest prevalence of smoking (12.6% male and 3.5% female).
The burden from smoking has been particularly high on individuals struggling with mental illness. Past 30-day cigarette smoking prevalence among people with a past year serious mental illness was more than double those without a past-year mental illness (27.9% versus 12.9%). There is also significant variation among different mental illnesses. Smoking prevalence was highest among those with schizophrenia, at nearly 60%. Individuals with such disorders may also experience additional risk factors, such as the easy availability of tobacco in some treatment centers.
A recent analysis found smoking among individuals with a serious psychological distress accounted for two-thirds of the difference in life expectancy relative to nonsmokers without a serious psychiatric disorder. Evidence suggests that some individuals with mental illness may have a genetic predisposition toward addiction and/or may self-medicate using nicotine.
Smoking prevalence rates among lesbian, gay, bisexual, and transgender (LGBT) men and women in the U.S. are significantly higher than those among heterosexuals. Studies show the social stresses of living in a society that can be hostile to individuals in the LGBT community contribute to the higher prevalence. Furthermore, the authors say, the tobacco industry has for many years marketed specifically to the LGBT community, placing advertisements in community media outlets, attending pride festivals to hand out coupons for discounted cigarettes, and promoting their products in LGBT bars.
Smoking in the military has trended significantly downward in recent decades, mirroring trends in the general population. In 1980, more than one-half of military personnel reported smoking. By 2011, smoking prevalence had dropped to less than one-quarter. Smoking rates are still significantly higher in the military than in the general population (24% in 2011, the most recent reliable survey). And disparities by pay grade within the military persist. For service members in the lowest 4 pay grades of enlisted members (E1-E4), smoking prevalence remained around 30% in 2011. In contrast, smoking prevalence in the highest 6 pay grades of commissioned officers (O4-O10) had dropped below 5%.
Smoking prevalence varies considerably across states, from 8.7% in Utah to 26.2% in Kentucky. There is a smoking belt leading from Michigan to Mississippi, including several adjacent states in the Midwest and Appalachia, where smoking prevalence is substantially above the national average.
The authors say: "More attention to and support for promising novel interventions, in addition to new attempts at reaching these populations through conventional interventions that have proven to be effective, are crucial going forward to find new ways to address these disparities."
The cite these examples of novel and innovative interventions and tools that have recently been developed and implemented at the national, state, and community levels in the U.S. to address smoking disparities:
- The U.S. Food and Drug Administration’s “This Free Life” campaign aimed at the LGBT community
- The establishment of strategic partnerships with the 2-1-1 information and referral system to promote smoke-free, low-income homes and to support cessation among 2-1-1 callers who are disproportionally low-income, unemployed, and/or uninsured (Americans in many parts of the country can call 2-1-1- for referrals to social services.)
- Reducing sales of untaxed or low-tax cigarettes on tribal lands
- Setting minimum floor pricing policies across states
- The development of simplified and standardized tobacco-assessment tools for retail settings to allow state and local partners to record their own retail data about product packaging, price, and placement to inform regulation of the retail environment.
- The development of anti-tobacco media campaigns using nonsmokers and/or former smokers to help smokers to quit, such as the Tips From Former Smokers campaign
- Expand health care access among low-income adults with attendant smoking-cessation counseling and medication benefits via Medicaid expansion and insurance exchange subsidies
- The U.S.Department of Housing and Urban Development’s ban on smoking in public housing