The more disadvantages you face, the more likely you are to smoke — and have difficulty quitting — according to a new Keck School of Medicine of USC study in JAMA Internal Medicine that sheds light on populations that are resistant to anti-smoking efforts.

In a U.S. nationally representative survey of 278,048 adults, people were asked about smoking and their experience with six socioeconomic or health-related disadvantages — unemployment, poverty, low education, disability, serious psychological distress and heavy drinking. Differences in smoking prevalence were substantial: Of people reporting no disadvantages, 13.8% currently smoked. Smoking rates climbed with each additional disadvantage, reaching 58.2% in people reporting five or six disadvantages.

It all adds up

“It’s striking that these six unique disadvantages, each of which are very different from one another, all add up to the same smoking outcome,” said the study’s corresponding author, Adam Leventhal, PhD, professor of preventive medicine and psychology and director of the USC Health, Emotion and Addiction Laboratory at the Keck School. “They just keep piling on your risk of smoking.”

The study also found that the gap in smoking rates widened from 2008-2017. “The steep decline in smoking among Americans we’ve seen this decade is near historic,” Leventhal said. “Our results show that nearly all of this reduction was concentrated in people with little or no disadvantage, despite recent tax hikes on smoking, stricter cigarette regulation, and available quit aids.”

Cigarette smoking is responsible for 480,000 deaths per year in the United States, according to the Centers for Disease Control and Prevention. Leventhal said the study suggests anti-smoking efforts need to move beyond current strategies and reach people struggling with multiple forms of adversity.

People smoke for pleasure, too

“If you are experiencing a lot of stress — whether it’s because you’re unemployed, struggling with an alcohol problem, or coping with mental illness — there’s evidence you’re more liable to smoke to manage stress,” Leventhal said. “People also smoke for pleasure. If you are limited in your life about the types of things you can do for fun because of your income or disability, it is understandable why you would turn to a product that instantly and reliably delivers pleasure, like a cigarette.”

Leventhal added that “until we can do something about the life circumstances that drive disadvantaged populations to smoke, encouraging them to quit may be an uphill battle.”

by Leigh Hopper

The study was supported by the Tobacco Centers of Regulatory Science (U54CA180908, U54DA036114), the National Cancer Institute, the U.S. Food and Drug Administration, the National Institute on Drug Abuse, the Centers of Biomedical Research Excellence (P20GM103644) award from the National Institute of General Medical Sciences, and a National Science Foundation Graduate Research Fellowship.