United States: Significant disparities in smoking rates across population groups

The Surgeon General has released a new report[1] on Tobacco-Related Health Disparities in the United States, which found that while the country has made substantial progress in reducing smoking and exposure to secondhand smoke among the U.S. population as a whole, this progress has not been equal for all segments of the population.

Disparities in smoking persist based on race, income, education, sexual orientation and gender identity, occupation, and geography.

Different prevalence rates depending on population categories

Smoking among American adults has declined by more than 70% since 1965, from 42.4% in 1965 to 11.5% in 2021. But this progress has not been uniform across all segments of the American population.

In 2020, the latest year for which complete data are available, 27.1% of American Indians and Alaska Natives reported being current smokers. This is more than double the rate among white adults (13.3% of American Indians) and nearly double the rate among African Americans (14.4% of American Indians). In addition, current smoking is three times higher among Americans earning less than $35,000 per year than among those earning more than $100,000 per year (20.2% of American Indians vs. 6.2% of American Indians).

Smoking is also higher among Americans who identify as gay, lesbian, or bisexual. According to the report, 16.3 percent of LGB adults reported smoking between 2019 and 2021, compared to 12.5 percent of heterosexual adults. Looking at rates among high school students during the same period, 10.4 percent of LGB teens reported smoking cigarettes at the time of the survey, double the 5.3 percent of heterosexual teens.

The report also highlights geographic disparities in tobacco consumption and confirms the findings of a previous report by the Truth Initiative.[2]. The latter had shown that in the 12 states of the "tobacco nation" - Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee and West Virginia, the prevalence of smoking and the level of consumption were higher than the average recorded in the other states of the country, regardless of the age group chosen. Thus, adults aged 18 and over have a prevalence of 19.2 % on average in these states.

The Health Burden of Smoking in the United States

As a result, some segments of the population continue to suffer greatly from the health consequences of tobacco use, and the overall health situation remains a concern. It is estimated that more than 490,000 deaths are attributable to tobacco use and exposure to secondhand smoke in the United States each year. This represents approximately one in five deaths in the country. This figure includes more than 473,000 deaths attributable to cigarette smoking and more than 19,000 deaths attributable to exposure to secondhand smoke.

Each year, more than 50,000 African Americans, 15,000 Hispanics, and 400,000 whites are estimated to die from causes attributable to smoking. Despite large disparities in the number of deaths attributable to smoking by race, smoking accounts for a similar proportion of deaths among African Americans (18 %) and whites (20 %), and for approximately 10 % of deaths among Hispanics.

While deaths from secondhand smoke exposure have declined by more than 50% since 2006, secondhand smoke exposure remains disproportionately high among children, African Americans, low-income individuals, and adults with low education. The magnitude of these disparities has increased since 2000.

The different factors leading to health disparities linked to tobacco

For decades, the tobacco industry has targeted its products and marketing to specific groups, particularly in neighborhoods where African Americans, Hispanics, and low-income people are most prevalent. Tobacco companies employ multiple tactics to undermine tobacco prevention and control efforts and improve their brand image.

The Centers for Disease Control and Prevention (CDC) and court rulings against tobacco companies have helped fund public education campaigns about the dangers of smoking, but the report says the tobacco industry has continued to target new and existing customers with lucrative marketing campaigns. The tobacco industry spends $8.5 billion each year on advertising and promotion of tobacco and nicotine products. For every dollar spent by health organizations on tobacco control, the report says, about $12 is spent by the industry on marketing.

The authors also point out that interventions aimed at reducing tobacco use and the influence of the tobacco industry on society should be accompanied by efforts to remove the various social, structural, commercial and political factors associated with these health inequalities.

The authors cite, for example, poverty, racism and discrimination, which are important and long-standing social and structural determinants in the United States. These marginalize ethnic, gender identity and sexual orientation groups. This context is associated with the development of social inequalities that have developed over the last few decades. Disparities exist in access to and use of smoking cessation treatments, particularly according to ethnic origin, socioeconomic status and health insurance. Disparities persist in having received advice to quit smoking from a health professional, particularly among these categories of the population. Finally, people from these categories of the population are generally less likely to consult a health professional.

Strengthening the fight against tobacco at the federal level

THE report identifies evidence-based policies that can further reduce tobacco use and close tobacco-related disparities. These include higher tobacco taxes, establishing smoke-free spaces in every state, high-impact and targeted media campaigns, universal access to smoking cessation aids, policies that regulate the location of tobacco retailers and reduce their number (particularly in more disadvantaged areas where retailers are more prevalent), and reducing nicotine in cigarettes and other combustible tobacco products to minimally addictive or nonaddictive levels.

The report estimates that reducing nicotine content to reduce the addictiveness of cigarettes and other products could prevent more than 33 million people from starting to smoke, avert more than 8 million deaths and achieve adult smoking prevalence below 2% by 2100.

The report’s authors also urge the federal government to act quickly on banning menthol products. They say menthol products “increase the likelihood of tobacco initiation, dependence, and continued use.” They also say they are “disproportionately used” by African Americans (nearly 9 in 10 African American smokers use menthol cigarettes), Native Hawaiians and Pacific Islanders, women, and people who identify as lesbian, gay, or bisexual. A 2023 study found that a national ban on the sale and marketing of menthol cigarettes could prevent up to 654,000 deaths over the next four decades in the United States.

©Generation Without Tobacco

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[1] US Department of Health and Human Services. Eliminating Tobacco-Related Disease and Death: Addressing Disparities—A Report of the Surgeon General: Executive Summary. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2024.

[2] Tobacco-free generation, United States: Report finds significant geographic disparities in smoking across Midwest and Southern states, published on July 27, 2023, consulted on November 20, 2024