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Although tobacco control measures have reduced overall smoking rates in the U.S. (from 42% in 1965 to 15% in 2015), a new report reveals several vulnerable subpopulations continue to smoke at high rates. The report by American Cancer Society investigators calls high rates of smoking among specific subpopulations one of the most pressing challenges facing the tobacco control community.

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Investigators led by Jeffrey Drope, PhD, report these populations include individuals in lower education and/or socioeconomic groups; from certain racial/ethnic groups; in the lesbian, gay, bisexual, and transgender community; with mental illness; and in the military, particularly among those in the lowest pay grades (CA Cancer J Clin 2018; doi:10.3322/caac.21444).



Although smoking prevalence in the U.S. has decreased in all education groups over the last 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 percent of college-educated individuals smoking along with approximately 45 percent of individuals in all other education groups. Five decades later, 6.5 percent of college-educated individuals continue to smoke, while the prevalence is more than triple that among those with a high school education or less (23.1%).



Although all income groups experienced overall declines in smoking over the last few decades, the largest relative decreases have been with higher socioeconomic groups. In 2015 and 2016, current tobacco use prevalence was about 10 percent for adults in higher income households (greater than 400% of the federal poverty level) compared with almost 25 percent 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 2-decade downward trend. Individuals of Asian and Hispanic/Latino descent have the lowest prevalence of smoking (12.6% male and 3.5% female).


Mental Illness

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% vs. 12.9%). There is also significant variation among different mental illnesses. Smoking prevalence was highest among those with schizophrenia, at nearly 60 percent. 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.


Sexual Orientation

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 four pay grades of enlisted members (E1-E4), smoking prevalence remained around 30 percent in 2011. In contrast, smoking prevalence in the highest six pay grades of commissioned officers (O4-O10) had dropped below 5 percent.



Smoking prevalence varies considerably across states, from 8.7 percent in Utah to 26.2 percent 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 Truth Initiative calls this "Tobacco Nation" and points to several driving factors, including policy, culture, and the strong and persistent influence of the tobacco industry in this region.


"The high prevalence of cigarette smoking among vulnerable populations is one of the most pressing challenges facing the tobacco control community," the authors noted. "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."