Smoking became analogous to a bad neighborhood that kept getting worse because everyone who had the resources to move out did so, leaving a progressively beaten down group behind. Poorer smokers simply have a hard time quitting, for at least three reasons:
2) Because income tends to segregate where people work and live, poor smokers often have to make quit-attempts alongside people who are continuing to smoke, but wealthier smokers usually do not. The last physician in a hospital who still smokes will face social disapproval from colleagues for smoking and receive social approval from those same individuals for quitting; the first worker on a roadside cleanup crew who tries to quit may face precisely the reverse social incentives from his smoking coworkers.
3) Although lower income people’s access to health care is being improved by the Affordable Care Act, they are still likely to lag middle class people in their access to effective smoking cessation treatments. They also may face challenges in accessing care for co-occurring mental health problems (e.g., depression) which make quitting smoking more difficult.
Because smoking remains the leading cause of premature death in the United States, the concentration of smoking among the poor is likely to exacerbate inequalities in health. It may also lead to a reappraisal of the role of tobacco taxes in reducing smoking.
As recently pointed out by public health experts Ken Warner and Harold Pollack, endlessly raising tobacco taxes eventually becomes cruelly regressive for addicted low-income smokers who can’t or won’t stop smoking. Taxes are powerful inducements to quit and are clearly too low in some parts of the U.S.
But in places like New York City, where taxes may drive the price of cigarettes to $10-$15 a pack, deeply-addicted, low-income smokers may face the choice between spending much needed income on tobacco or venturing into the black market for untaxed cigarettes, which carries significant risks of its own.
Keith Humphreys is a Professor and Director of Mental Health Policy at the Stanford University Department of Psychiatry. Follow him on twitter @KeithNHumphreys.