Top 10 Populations Disproportionately Affected by Cigarette Smoking and Tobacco Use

It's no secret that quitting smoking significantly reduces the risk for a wide range of diseases and early death. Yet, tobacco use remains the leading cause of preventable death and disease in the U.S. The good news is smoking rates have decreased over the past decade and are near historically low levels. In 2019, 14.0% of adults smoked cigarettes.1 However, not all Americans are benefiting equally from this decline. Certain parts of the country and populations continue to smoke at high rates, highlighting the uneven progress where we need to do a better job of preventing and reducing tobacco use. Here are the top 10 populations disproportionately affected by cigarette smoking and tobacco use:

1. Adults that Live in Rural Areas

Adults that live in rural areas smoke at a rate of 16.6% compared to 11.6% among adults that live in urban areas. They are also more likely to be heavier smokers, smoking 15 or more cigarettes per day, compared to smokers in urban areas.2 Kids in rural areas are also more likely to start smoking at a much younger age and smoke daily, making addiction more severe and smoking harder to quit.3

2. Adults Living in Traditional Tobacco-Growing States

The average smoking rate in traditional tobacco-growing states (Georgia, Kentucky, North Carolina, South Carolina, Tennessee and Virginia) is 17.8%, but this hides significantly higher smoking rates in several of the states.4 For decades, tobacco industry influence has blocked tobacco control policies in these states. However, there has been some progress on tobacco-control policies and smokefree laws at the state or local level in many of them in recent years.

3. Military Veterans 

Military veterans smoke at a rate of 21.6%. That number jumps significantly in certain age groups—the highest being a shocking 50.2% among male veterans aged 18-25.5 Sadly, the military has a long history with tobacco use, including cigarettes previously being included with rations. Many veterans report beginning tobacco use in the military or reinforcing their tobacco use during their service.

4. Lesbian/Gay/Bisexual Adults (LGB)

LGB* individuals have a smoking rate of 19.2%, meaning about one in five LGB adults smoke cigarettes compared with about one in seven straight adults.6 While we don't have good national data on smoking among transgender individuals, LGBT individuals often face risk factors such as daily stress related to prejudice and stigma. The tobacco industry has aggressively targeted and marketed to the LGBT community, advertising in publications aimed at LGBT audiences and depicting tobacco use as an “accepted” part of LGBT life.7, 8
*The statistic around this smoking rate does not include transgender individuals.

5. Adults that Did Not Graduate High School

Adults with lower levels of educational attainment smoke at higher rates than the general population, and smoking rates decrease significantly with increased education. Adults who did not graduate high school smoke at a rate of 25.5%, adults who did graduate high school smoke at a rate of 20.1%, and adults who graduated from a technical school or college smoke at a rate of 6.1%.8

6. Americans Making Less Than $20,000 a Year

Americans making less than $25,000 a year have a smoking rate of 24.7%, close to double the rate of 12.7% among those making $25,000 a year or more.9 People living in poverty smoke cigarettes more heavily and smoke for nearly twice as many years as people with a family income three times the poverty rate.10 Lower income cigarette smokers suffer more from smoking-caused diseases than smokers with higher incomes.11 Tobacco companies often target advertising campaigns toward low-income communities12 and a higher density of tobacco retailers can often be found in low-income neighborhoods.13

Americans making less than $20,000 a year have a smoking rate of 26.6 percent.

7. Uninsured Americans

Uninsured Americans smoke at a rate of 22.5%, more than double the rate of adults with private insurance, whose smoking rate is 10.7%.14 Research shows that gaining insurance coverage increases the odds of quitting smoking, due to more primary care visits, follow-up smoking assessments and smoking cessation medication ordered.15

Uninsured Americans smoke at a rate more than double that of Americans with private insurance.

8. American Indians/Alaskan Natives

American Indians/Alaska Natives smoke at a rate of 20.9% and have the highest prevalence of cigarette smoking among all racial/ethnic groups in the U.S.16 For the Native community, it is important to distinguish between commercial tobacco use and tobacco use in traditional ceremonies as some Natives use tobacco for ceremonial, religious or medicinal purposes.

9. Americans with Mental or Behavioral Health Conditions

Individuals with Generalized Anxiety Disorder smoke at rates of 21.5% for those with mild symptoms, 27.0% for those with moderate symptoms, and 34.5% for those with severe symptoms, compared to 12.0% among those with no or minimal symptoms. Rates can be even higher among those with other mental or behavioral health conditions.17 Even more alarming is that people with mental health conditions make up 22% of the population, but account for 36% of all cigarettes smoked.18 Nicotine's mood-altering effects can also mask the negative symptoms of mental illness, putting people with mental health conditions at higher risk for nicotine addiction and cigarette use.19

People with mental health conditions and substance abuse make up 22 percent of the population, but account for 38 percent of all cigarettes smoked.

10. Adults in Public Housing

Adults living in public housing smoke at a rate of 33.6%,20 more than twice the national rate. Secondhand smoke is also a pressing issue in public housing since the movement of secondhand smoke between units cannot be controlled in multifamily buildings. In July 2018, the Department of Housing and Urban Development (HUD) implemented a rule requiring all public housing authorities (PHA) to have smokefree policies in place to protect residents, staff and guests from secondhand smoke, which may also prompt some smokers to quit.

How Do We Keep Those at Greatest Risk from Being Left Behind?
All Americans deserve the chance to live a full and healthy life. Yet smoking rates are now higher in certain parts of the country and among certain populations in America. Complicating this crisis are that the factors listed above tend to combine and compound the risk. For example, low-income adults are more likely to be uninsured and live in public housing. To achieve health equity in tobacco control, tobacco prevention and cessation efforts must focus on the policies called for in our “State of Tobacco Control” report, and on reaching the communities disproportionately impacted by tobacco use and exposure to secondhand smoke.

Sources
  1. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults — United States, 2019. MMWR Morb Mortal Wkly Rep 2020;69:1736–1742. DOI: http://dx.doi.org/10.15585/mmwr.mm6946a4external icon
  2. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2019. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  3. American Lung Association. Cutting Tobacco’s Rural Roots: Tobacco Use in Rural Communities. Chicago: American Lung Association, 2015.
  4. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2019. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  5. Odani S, Agaku I, Graffunder CM, Tynan M, Armour B. Tobacco Product Use Among Military Veterans – United States, 2010-2015. MMWR Morb Mortal Wkly Rep 2018;67:7-12.
  6. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults — United States, 20198. MMWR Morb Mortal Wkly Rep 2020;69:1736–1742.
  7. American Lung Association. The LGBT Community: A Priority Population for Tobacco Control. Available at: lgbt-issue-brief-update.pdf.pdf (lung.org)
  8. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2019. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  9. Ibid.
  10. Siahpush M, Singh GH, Jones PR, Timsina LR. Racial/Ethnic and Socioeconomic Variations in Duration of Smoking: Results from 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey. Journal of Public Health 2009;32(2):210-8.
  11. Campaign for Tobacco-Free Kids. Tobacco and Socioeconomic Status. Washington, D.C., last updated Nov. 9. 2018.
  12. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA, 2014.
  13. Yu D, Peterson NA, Sheffer MA, Reid RJ, Schneider JE. Tobacco Outlet Density and Demographics: Analyzing the Relationships with a Spatial Regression Approach. Public Health, 2010;124(7):412–6.
  14. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults — United States, 20198. MMWR Morb Mortal Wkly Rep 2020;69:1736–1742.
  15. Bailey SR, Hoopes MJ, Marino M, et al. Effect of Gaining Insurance Coverage on Smoking Cessation in Community Health Centers: A Cohort Study. Journal of General Internal Medicine. 2016;31(10):1198-1205.
  16. Cornelius ME, Wang TW, Jamal A, Loretan CG, Neff LJ. Tobacco Product Use Among Adults — United States, 20198. MMWR Morb Mortal Wkly Rep 2020;69:1736–1742.
  17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance Survey, 2018. Analysis by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  18. Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 2018. Analysis performed by the American Lung Association Epidemiology and Statistics Unit using SPSS software.
  19. Centers for Disease Control and Prevention. Vital Signs: Adult Smoking Focusing on People With Mental Illness, February 2013.
  20. Helms V, King B, Ashley P. Cigarette smoking and adverse health outcomes among adults receiving federal housing assistance. Preventative Medicine 2017; 99:171-7.

Page last updated: January 27, 2021

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