Tobacco is the leading preventable cause of death in the United States, contributing to the premature deaths of nearly half-a-million Americans each year. 1 Before it kills, tobacco also exacts a massive toll of sickness. The direct cost of providing medical care to people with tobacco-related diseases is estimated to be between $50 and $75-billion dollars per year. 2 That’s at least five times what it would cost to cover the prescription drugs of everyone on Medicare. 3
The consequences are not only domestic; cigarette smoking is creating a global health crisis of staggering proportions. The current estimate of 3-million deaths worldwide is expected to rise to 10-million tobacco-related deaths a year by the time today’s adolescents reach middle age. 4 The smokers with the most difficulty quitting and the most health problems in adulthood appear to be those who started smoking at the youngest ages. 5
Tobacco control efforts can and are having an effect. 6 While education of nonsmokers and proper treatment and counseling of smokers who are trying to quit can help make a difference for individuals, some of the most effective strategies to reduce cigarette smoking take place on a broader scale. The Institute of Medicine points out that "making worksites, schools, and homes smoke-free zones is a powerful strategy for reducing tobacco use overall because it boosts quit rates and reduces consumption." Raising tobacco taxes also has a clear effect, with each 10 percent increase in excise taxes being associated with a 4 percent drop in tobacco consumption. What’s more, the effect among teens appears to be even greater. 7 However, despite the strides made by comprehensive tobacco control programs, the Healthy People 2000 goal of reducing smoking prevalence to less than 15 percent will not be achieved. 8 The elmination of tobacco use remains a distant and elusive goal.
Unit of Attention
Certainly we should continue to make individualized efforts to prevent young people from beginning to smoke, and to encourage smokers to quit. However, there are compelling reasons to see smoking as a group phenomenon, not just an individual health behavior. First and foremost is the clear and persistant inverse relationship between smoking prevalence and socioeconomic status. 9 This and other characteristics of the group patterns of tobacco use are outlined in the following sections.
Behavior and Context
Ninety percent of smokers first tried cigarettes when they were minors. 10 Every day in the United States 3,000 underage youth become regular smokers, that adds up to more than 1.2-million underage youth every year. Currently it is estimated that at least 4.5-million underage youth smoke cigarettes. The vast majority of youth who smoke wish they had never started. Part of the problem is that youth dangerously underestimate the addictive power of nicotine and overestimate their ability to quit. 11 Once they begin smoking, youth are likely to remain smokers for decades. 12
Initiation of smoking is no accident nor the result of some individual quirk. Indeed, a few simple questions about smoking by friends and family, 13 or possession of a tobacco promotional item 14 can identify nonsmoker adolescents who are likely to begin smoking. This predictability has been used to aim prevention efforts at high-risk youth, with some success. 15 One looming question is whether adolescence is a discrete "hazard period;" that is, does delaying smoking initiation protect susceptible teens from becoming smokers or will they simply begin smoking in adulthood?
Environment – Behavior Relationship
In the United States, the most dramatic variation in smoking prevalence between groups is the socioeconomic gradient. Americans with the highest educational achievement are only half as likely to be smokers as those with the least education. 16 However, the issue is not lack of awareness of the harmful effects of smoking. Only a tiny percentage of adult smokers appear to deny the health risk. These "hard core" smokers are more likely to be retired white males who live alone, and are thus not exposed to social pressure or workplace rules against smoking. 17 Educational achievement appears to a marker of an environment and a constellation of social values that discourage smoking. Education is not a magic shield against tobacco. Between 1993 and 1997, rates of smoking on campus shot up from 22 percent to more than 28 percent. 18
Tobacco use in the United States also varies across racial and ethnic groups, but the relationships are complex. For example, overall smoking prevalence for African-Americans adults and white adults is similar, with about one in four smoking (as of 1995.) However, African-American men smoked at a higher rate than white men, while the rate for African-American women was just slightly lower than that for white women. There is also a clear difference in smoking cessation; about half of those whites who smoked at least 100 cigarettes have quit, while only slightly more than a third of African-American smokers have quit. The US Surgeon General attributes these variations to a complex interaction of multiple factors, including socioeconomic status, cultural characteristics, stress, community capacities and targeted advertising. 19
The Surgeon General’s report also points out that American Indians and Alaska Natives have the highest prevalence of tobacco use, but even within this ethnic grouping there are marked variations. As other researchers note, smoking rates on American Indian reservations ranges from 57 percent among some Plains Indians down to just 15 percent in the southwest. 20 The 15 percent figure is particularly notable given the high rate of poverty and low rates of educational achievement on these southwest Indian reservations. The variations point to the importance of cultural factors.
As striking as the socioeconomic and racial/ethnic variations in smoking prevalence may be, it is important to recognize that these subgroup patterns are not set in stone. Indeed, there are have been substantial changes during this century with respect to who smokes and who does not. Up until the late 1800’s, when cigarettes were first mass-produced by machine, cigarettes were associated with recent immigrants. Socially prominent Americans disdained cigarettes and instead smoked cigars or pipes. 21 Then as manufacturers perfected cigarette rolling machines and needed to sell larger and larger quantities of cigarettes, they elevated the cigarettes’ status. Through the first half of the twentieth century, cigarette smoking was considered a luxury. Perhaps not coincidentally, coronary heart disease rates were higher among higher socioeconomic status individuals. 22 A similar transformation is also occurring on a global scale. As smoking rates stabilize or decline in the United States and other developed nations, smoking rates are mushrooming in developing nations. 23
These shifts in smoking prevalence patterns underscore the importance of considering factors in the social environment. After all, our genetic makeup has not changed in a hundred years. And it seems implausible the characteristics of individuals of high and low social status have become inverted over the decades, suddenly increasing the resistance of high status individuals to smoking while lowering the resistance of lower status individuals. While there has been a dramatic increase in the amount and detail of scientific evidence regarding the harmful effects of tobacco, smoking was considered unhealthy long before that proof was set forth. 24 What has changed during this century are social attitudes, marketing, and other environmental factors that influence patterns of smoking prevalence.
Environment – Behavior Connection
According to reports filed with the Federal Trade Commission, the tobacco industry spends close to $6 billion dollars each year to market its products, with the total rising almost every year. 25 That massive spending is not distributed evenly across the population. Neighborhoods with predominantly minority residents were subjected to the lion’s share of billboard advertising of cigarettes. 26 Indeed, in Chicago, minority wards had three times as many cigarette billboards as white wards. 27 Although recent legal settlements have largely ended cigarette billboard advertising, a study of magazine advertising also shows how marketing of certain brands is tilted toward African-American readers, 28 so it is unlikely that the tobacco companies have altered their practice of aiming ads at minority populations. Kaplan and Weiler urge social workers and others working in vulnerable communitities to advocate against targeted marketing. 29 As an examples of such advocacy, they note the worldwide campaign that ultimately persuaded the Nestle company to change its strategy of marketing infant formula to low-income women in developing nations.
Another avenue for addressing the disparities in smoking prevalence is youth access. In 1993 and 1994, Landrine et al. sent underage youth on a "sting" operation to see which retailers would sell them cigarettes. Four variables stood out; the chance of a "successful" purchase attempt increased if the buyer was a girl, if the buyer was a minority, if the clerk was male, or if the store was in a minority neighborhood. Five years later the researchers returned to test the same stores. Overall it appeared that during the intervening years efforts to reduce youth access had had an effect: the successful purchase attempt rate dropped from over 40 percent to less than 13 percent. Interestingly, just one variable remained significant, clerks were more likely to sell cigarettes to minors who were African-American or Latino. The authors say interventions intended to reduce youth access must address youth ethnicity and the ethnic biases of clerks. 30
While the disparities in smoking prevalence are broadly recognized, there are varying reactions to their existence. Some experts call for smoking cessation programs that are more culturally-appropriate to minority groups who have demonstrated lower quit rates. 31 Other researchers interpret the clustering of smoking within certain ethnic, socioeconomic or age groups simply as a fact to be used in refining the delivery of behavior-change programs to high-risk individuals. 32 The differential access to smoking cessation programs and possible biases of health care providers are also noted as barriers to cessation by members of lower-income or minority groups. 33 However, the ultimate effectiveness of these approaches seems limited by the fact that they do not address the reasons for the disparities in smoking prevalence. They seek to treat symptoms, rather than the causes of the disparities.
In the search for those root causes it is useful to keep in mind that the groups with higher rates of smoking tend to also have poorer diets (and more obesity) and get less physical activity. Some researchers are attempting to adapt the concept of "time preference" from economic theory to explain not only the common patterns of these health behaviors, but also their connection to lower income and educational achievement. 34 Variations in personal value judgements about future consequences or benefits are being investigated in terms of smoking behavior specifically, 35 and also more generally with respect to the use of addictive substances. 36 These investigators will still have to wrestle with the question of whether people who smoke (or engage in other unhealthy behaviors) tend to discount future consequence regardless of their circumstances, or whether their social or economic environment alters their "time preferences."
In considering the available courses of action to address the causes of smoking in our society, it is useful to review the list presented by CDC Director Dr. Jeffrey P. Koplan in a speech to the 1999 National Tobacco Control Conference:
"Today we are fortunate to have a rich and varied toolbox for tobacco control. Our tools include:
Finally, the social gradient in smoking prevalence should not be confused with the inverse relationship between health and socioeconomic status. 38 Smoking explains only a portion of the social gradient in health. As Lantz, et al. put it, "Our results suggest that despite the presence of significant socioeconomic differentials in health behaviors, these differences account for only a modest proportion of social inequalities in overall mortality. Thus, public health policies and interventions that exclusively focus on individual risk behaviors have limited potential for reducing socioeconomic disparities in mortality." 39 The point, then, is not to assume that reducing smoking will close the social gradient in health; it won’t. Instead, the most important fact to keep in mind is that smoking kills, and that in order to reduce tobacco’s toll, the environmental factors that influence tobacco use must be recognized and counteracted.
3. Congressional Budget Office estimated Clinton proposal for a Medicare drug benefit would cost $111 billion over 10 years. The Clinton administration estimated the cost at $45.5 billion over 10 years (reported in the Washington Post, 7/23/1999).
4. Peto, R., Lopez, A., Boreham, J., Thun, M., Heath, C. Jr. (1994). Mortality from smoking in developed countries, 1950–2000: indirect estimates from national vital statistics. Oxford, England: Oxford University Press.
5. Lando HA, Thai DT, Murray DM, Robinson LA, Jeffery RW, Sherwood NE, Hennrikus DJ. Age of initiation, smoking patterns, and risk in a population of working adults. Preventive Medicine. 1999;29(6):590-598.11. http://www.cdc.gov/tobacco/initfact.htm (This document is no longer available online. The following documents contain similar data and findings: http://www.cdc.gov/nchs/data/ad/ad224.pdf
15. Flynn, B. S., Worden, J. K., Secker-Walker, R. H., Pirie, P. L., Badger, G. J., Carpenter, J. H., (1997). Long-term responses of higher and lower risk youths to smoking prevention interventions. Preventive Medicine, 26, 389-394.
17. Emery S, Gilpin EA, Ake C, Farkas AJ, Pierce JP. Characterizing and identifying “hard core” smokers: implications for further reduced smoking prevalence. American Journal of Public Health. 2000;90:387-394.
19. U.S. Department of Health and Human Services. Tobacco Use Among U.S. Racial/Ethnic Groups -- African Americans, American Indian and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 1998.
20. Cheadle A, Pearson D, Wagner E, Psaty BM, Diehr P, Koepsell T. Relationship between socioeconomic status, health status, and lifestyle practices of American Indians: evidence from a Plains reservation population. Public Health Reports. 1994;109(3):405-413.
27. Hackbarth DP, Silvestri B, Cosper W. Tobacco and alcohol billboards in 50 Chicago neighborhoods: market segmentation to sell dangerous products to the poor. Journal of Public Health Policy 1995;16(2):213-3039. Lantz PM, House JS, Lepkowski JM, Williams DR, Mero, RP, Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prosepctive study of US adults. Journal of the American Medical Association. 1998;279(21):1703-1708
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