SMOKING RATES HAVE plummeted in recent decades thanks to mass media campaigns, cigarette taxes and public bans, yet nearly 38 million Americans still light up regularly.
The divide between who puffs and who passes on traditional tobacco cigarettes today is largely drawn by often overlapping factors such as income, education and geography. Disparities in these areas are stark, and are key to whether and how smokers try to quit the country’s leading cause of preventable disease and death.
For example, the smoking rate for adults who had earned a GED certificate was about 41 percent in 2016, while less than 5 percent of adults with a graduate degree smoked cigarettes, according to the Centers for Disease Control and Prevention. About a quarter of adults living below the federal poverty line smoked cigarettes, while 14 percent of those at or above that level did, CDC data show.
Nationwide, 15.5 percent of all adults were smokers in 2016, according to the CDC, a figure on par with a recent Gallup poll that found 16 percent of adults had smoked a cigarette within the last week. Additional CDC estimates indicate the adult smoking rate is continuing to decline.
Led by Kentucky and West Virginia – where nearly a quarter of adults in each state smoked in 2016 – states with higher poverty rates and fewer tobacco regulations also tend to have higher smoking rates.
Truth Initiative, an anti-tobacco advocacy group, has dubbed a 12-state bloc stretching from the upper Midwest to the Southeast “Tobacco Nation” because the region’s smoking rates are so high and “smoking is much more a part of the culture there,” says Robin Koval, the organization’s CEO and president.
On average, counties within most of those states fall in the bottom half in U.S. News’ assessment of the nation’s Healthiest Communities, a rankings project that examines myriad social, environmental and health measures to determine the overall well-being of nearly 3,000 counties and county equivalents across the country.
“Cigarettes are cheap there – they don’t have the higher taxes that we know work incredibly well to bring down smoking rates among young people,” Koval says. “You can smoke because (some states) don’t have clean-air law protections … and because regulations are different in these areas, point-of-sale advertising and retail advertising are very prominent.”
Of course, the fact that some people are still smoking may not be for a lack of trying to quit. Those of lower socioeconomic status are equally likely to attempt quitting as those of higher status, but are far less likely to succeed, according to the CDC.
Koval says that’s because while some smokers can quit without help, many need counseling and medication, and it can be harder for people in poorer communities to access those aids and other health care services.
But even within safety-net clinics – health facilities that tend to provide care for the most low-income and otherwise vulnerable patients – disparities exist when it comes to who receives smoking-cessation assistance, particularly by health insurance coverage and race and ethnicity, according to a recent study published in the American Journal of Public Health.
Patients who are uninsured, non-white or diabetic are less likely to receive both counseling and medication to help them quit smoking, according to the study, which analyzed visits to safety-net clinics in 12 states between 2014 and 2016. It’s unclear whether doctors did not offer these services or if patients refused them, says Steffani Bailey, who designed the study and is a research assistant professor at the Oregon Health and Science University’s School of Medicine.
“Health care disparities are often complex and include many factors,” Bailey says.
Separate research has shown Hispanic adults – who are less likely to smoke than white adults – are also less likely to be screened for tobacco use and to try medication or counseling when attempting to quit. Black adults are less likely to use those aids as well, despite attempting to quit more often than either white or Hispanic smokers, according to the CDC.
Hispanic and black adults are also less likely than white adults to have health insurance. Because uninsured patients may seek care only when a condition reaches emergency status, Bailey says doctors may have less time to address smoking or other unhealthy habits, choosing instead to focus on diabetes or other chronic conditions that appear more pressing.
“Patients who smoke and have diabetes are at higher risk for serious complications, but providers may not be thinking about the smoking aspect because they’re talking about medications or other acute needs of people who have diabetes,” Bailey says.
Bailey’s study suggests the odds of receiving help quitting smoking are higher for patients with asthma, chronic obstructive pulmonary disease and hyperlipidemia, as well as for women and those assessed as ready to quit.
Most of the 12 states included in the study have expanded their Medicaid eligibility to allow more low-income residents to gain coverage – a move associated with decreased smoking rates among program enrollees, according to another analysis published in March.
Medicaid patients also were more likely to receive help quitting smoking than those with commercial insurance, Bailey says of her study’s findings. But uninsured adults were significantly less likely to receive help than either Medicaid recipients or those with commercial insurance – a disparity she says could be reduced by “ensuring the availability of affordable, accessible, continuous insurance coverage.”
In addition to increasing insurance coverage and giving doctors more information about other services that could help their patients quit smoking – such as state “quitlines” – Bailey says advocates should focus on curbing smoking before the most at-risk groups even pick up the habit.
“We should be not only providing more resources for providers to do this care, but also looking at the community level as well,” Bailey says. “We know smoking doesn’t just occur within individuals – there are populations where they’re more likely to smoke, so (advocates should be) really looking at those community-level factors and the culture around smoking, and trying to develop targeted interventions that really look at these underserved populations.”
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