People with Low Socioeconomic Status Experience a Health Burden from Commercial Tobacco

Commercial tobacco* gets in the way of achieving health equity for people with low socioeconomic status (SES), including those with low income.1 Currently, people with low SES suffer from health problems related to commercial tobacco product use and the burden is not shared evenly across all populations. For example:

  • People with lower income have higher incidence of commercial tobacco-related diseases than people with higher levels of income.2
  • Current tobacco product use prevalence is higher among adults who were uninsured (27.3%), enrolled in Medicaid (28.6%), or had some other public insurance (21.3%) compared to adults with private insurance (16.4%) or Medicare only (12.5%).3
  • Cigarette smoking causes about 80% to 90% of lung cancer deaths in the United States and people experiencing extreme poverty have higher lung cancer risk than those in higher SES groups.4 People with annual family incomes of less than $12,500 have higher lung cancer incidence than those with family incomes of $50,000 or more.5
  • People with low SES are more likely to be diagnosed with diabetes.6 The risk of developing type 2 diabetes is 30 to 40% higher for people who smoke cigarettes than for people who don’t.7
*“Commercial tobacco” means harmful products that are made and sold by tobacco companies. It does not include “traditional tobacco” used by Indigenous groups for religious or ceremonial purposes.
  1. Government Benefits. Updated June 2021 [accessed 2022 Mar 21].
  2. Campaign for Tobacco-Free Kids. Tobacco and Socioeconomic Status [PDF - 225 KB]. November 3, 2021 [accessed 2022 Mar 21].
  3. Cornelius ME, Loretan CG, Wang TW, Jamal A, Homa DM. Tobacco Product Use Among Adults — United States, 2020. MMWR Morb Mortal Wkly Rep. 2022; 71:397–405 [accessed 2022 Mar 21].
  4. Singh GK, Williams SD, Siahpush M, Mulhollen A. Socioeconomic, Rural-Urban, and Racial Inequalities In US Cancer Mortality: Part I—All Cancers and Lung Cancer and Part II—Colorectal, Prostate, Breast, and Cervical Cancers. Journal of Cancer Epidemiology. 2011; 2011:107497 [accessed 2022 Mar 21].
  5. 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 [accessed 2022 Mar 21].
  6. Sheets L, Petroski GF, Jaddoo J, Barnett Y, et al. The Effect of Neighborhood Disadvantage on Diabetes Prevalence.AMIA Annu Symp Proc. 2018; Apr 16;2017:1547-1553 [accessed 2022 Mar 21].
  7. S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2014 [accessed 2022 Mar 21].
  8. Tobacco Control Legal Consortium. 2016. Evans v. Lorillard: A Bittersweet Victory Against the Tobacco Industry. [accessed 2022 Mar 21].
  9. ApollonioDE, Malone RE. Marketing to the marginalised: tobacco industry targeting of the homeless and mentally ill. Tobacco Control. 2005;14:409-415 [accessed 2022 Mar 21].
  10. Brown-Johnson CG, England LJ, Glantz SA, Ling PM Tobacco industry marketing to low socioeconomic status women in the U.S.A. Tobacco Control. 2014; 23(e2):e139–e146 [accessed 2022 Mar 21].
  11. National Academies of Sciences, Engineering, and Medicine; Baciu A, Negussie Y, Geller A, et al., editors. Communities in Action: Pathways to Health Equity. Washington (DC): National Academies Press (US); 2017 Jan 11. 3, The Root Causes of Health Inequity [accessed 2022 Mar 21].
  12. US Department of Housing and Urban Development. Breaking Down Barriers: Housing, Neighborhoods, and Schools of Opportunity [PDF - 2.4 MB] [accessed 2022 Mar 21].
  13. Martin KD, Sykes BL, Shannon S,  Edwards F,  Harris A. Monetary Sanctions: Legal Financial Obligations in US Systems of Justice. Annual Review of Criminology.2018; 1:1:471-495 [accessed 2022 Mar 21].
  14. Harris A, Smith T. 2022. Monetary Sanctions as Chronic and Acute Health Stressors: The Emotional and Physical Strain of People Who Owe Court Fines and Fees. RSF: The Russell Sage Foundation Journal of the Social Sciences 8(2): 36–56. [accessed 2022 Mar 21].
  15. Stewart T, Formica MK, Adachi-Mejia AM, Wang D, Gerrard M. A Tobacco Cessation Intervention with Rural, Medically Underserved, Blue-collar Employees: A Quasiexperimental Study. Safety Health Work. 2016;7(4):293-298 [accessed 2022 Mar 21].
  16. Institute of Medicine 2007. Ending the Tobacco Problem: A Blueprint for the Nation. Washington, DC: The National Academies Press [accessed 2022 Mar 21].
  17. Cole MB, Nguyen KH. Unmet social needs among low-income adults in the United States: Associations with health care access and quality. Health Serv Res. 2020;55 Suppl 2(Suppl 2):873-882 [accessed 2022 Mar 21].
  18. Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006;21(1):71-77 [accessed 2022 Mar 21].
  19. National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Health Care Utilization and Adults with Disabilities. Health-Care Utilization as a Proxy in Disability Determination. Washington (DC): National Academies Press (US); 2018 [accessed 2022 Mar 21].
  20. Weissman JS, Stern R, Fielding SL, Epstein AM. Delayed access to health care: risk factors, reasons, and consequences. Ann Intern Med. 1991;114(4):325-331 [accessed 2022 Mar 21].
  21. Prentice JC, Pizer SD. Delayed access to health care and mortality. Health Serv Res. 2007;42(2):644-662 [accessed 2022 Mar 21].
  22. Unger JM, Gralow JR, Albain KS, Ramsey SD, Hershman DL. Patient Income Level and Cancer Clinical Trial Participation: A Prospective Survey Study. JAMA Oncol. 2016;2(1):137-9 [accessed 2022 Mar21].
  23. Carson NJ, Rodriguez D, Audrain-McGovern J. Investigation of mechanisms linking media exposure to smoking in high school students. Preventive Medicine 2005;41(2):511-20 [accessed 2022 Mar 21].
  24. Charlesworth A and Glantz S. Smoking in the movies increases adolescent smoking: A review. Pediatrics 2005;116(6): 516-28 [accessed 2022 Mar 21].
  25. Yu D, Peterson NA, Sheffer MA, Reid RJ, Schneider JE. Tobacco Outlet Density and Demographics: Analysing the Relationships with a Spatial Regression Approach. Public Health. 2010;124(7):412–6 [accessed 2022 Mar 21].
  26. Wallace LA, Paul R, Gholizadeh S, et al. Neighborhood disadvantage and the sales of unhealthy products: alcohol, tobacco and unhealthy snack food. BMC Public Health. 2021;21(1):1361 [accessed 2022 Mar 21].
  27. D'Angelo H, Ammerman A, Gordon-Larsen P, Linnan L, Lytle L, Ribisl KM. Sociodemographic Disparities in Proximity of Schools to Tobacco Outlets and Fast-Food Restaurants. Am J Public Health. 2016;106(9):1556‐1562 [accessed 2022 Mar 21].
  28. Groom AL, Cruz-Cano R, Mead EL, et al. Tobacco Point-of-Sale Influence on U.S. Adult Smokers. J Health Care Poor Underserved. 2020;31(1):249-264 [accessed 2022 Mar 21].
  29. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribisl KM. A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing. Am J Public Health. 2015;105(9):e8-e18 [accessed 2022 Mar 21].
  30. Mills SD, Golden SD, Henriksen L, Kong AY, Queen TL, Ribisl KM. Neighbourhood disparities in the price of the cheapest cigarettes in the USA. J Epidemiol Community Health. 2019;73(9):894‐896 [accessed 2022 Mar 21].
  31. Ton HT, Smart AE, Aguilar BL, et al. Menthol enhances the desensitization of human alpha3beta4 nicotinic acetylcholine receptors. Mol Pharmacol. 2015;88(2):256-64 [accessed 2022 Mar 21].
  32. Oliver AJ, Jensen JA, Vogel RI, Anderson AJ, Hatsukami DK. Flavored and nonflavored smokeless tobacco products: rate, pattern of use, and effects. Nicotine Tob Res. 2013;15(1):88-92 [accessed 2022 Mar 21].
  33. Lee JG, Henriksen L, Rose SW, Moreland-Russell S, Ribis KM. A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing. American Journal of Public Health. 2015;105(9), e8–e18 [accessed 2022 Mar 21].
  34. Food and Drug Administration. Preliminary Scientific Evaluation of the Possible Public Health Effects of Menthol Versus Nonmenthol Cigarettes  [PDF - 1.6 MB]. 2013 [accessed 2022 Mar 21].
  35. Robertson L, McGee R, Marsh L, Hoek J. A systematic review on the impact of point-of-sale tobacco promotion on smoking.Nicotine & Tobacco Research. 2015; 17(1): 2-17 [accessed 2022 Mar 21].  
  36. Harrell MB, Loukas A, Jackson CD, Marti CN, & Perry CL. Flavored tobacco product use among youth and young adults: what if flavors didn't exist?  [PDF - 7.69 KB]Tobac Regulatory Sci 2017;3(2): 168-173 [accessed 2022 Mar 21].
  37. Tsai J, Homa DM, Gentzke AS, et al. Exposure to Secondhand Smoke Among Nonsmokers — United States, 1988–2014. MMWR Morbidity and Mortality Weekly Report. 2018;67:1342–1346 [accessed 2022 Mar 21].
  38. Ham DC, Przybeck T, Strickland JR, Luke DA, Bierut LJ, Evanoff BA. Occupation and Workplace Policies Predict Smoking Behaviors: Analysis of National Data from the Current Population Survey. Journal of Occupational and Environmental Medicine. 2011;53(11):1337-45 [accessed 2022 Mar 21].
  39. Su CP, Syamlal G, Tamers S, Li J, Luckhaupt SE. Workplace Secondhand Tobacco Smoke Exposure Among U.S. Nonsmoking Workers, 2015. MMWR Morb Mortal Wkly Rep. 2019;68(27):604-607 [accessed 2022 Mar 21].
  40. Wilson KM, Klein JD, Blumkin AK, Gottlieb M, Winickoff JP. Tobacco-smoke exposure in children who live in multiunit housing. Pediatrics. 2011;127(1):85-92 [accessed 2022 Apr 28].
  41. Merianos AL, Jandarov RA, Choi K, Mahabee-Gittens EM. Tobacco smoke exposure disparities persist in U.S. children: NHANES 1999-2014. Prev Med. 2019;123:138-142 [accessed 2022 Mar 21].
  42. Pizacani BA, Maher JE, Rohde K, Drach L, Stark MJ. Implementation of a smoke-free policy in subsidized multiunit housing: effects on smoking cessation and secondhand smoke exposure. Nicotine & Tobacco Research. 2013; 14(9):1027-1034 [accessed 2022 Mar 21].
  43. Hafez AY, Gonzalez M, Kulik MC, Vijayaraghavan M, Glantz SA. Uneven access to smoke-free laws and policies and its effect on health equity in the United States: 2000–2019. American Journal of Public Health. 2019; 109(11):1568-1575 [accessed 2022 Mar 21].
  44. Bridging the Gap: Status of Smokefree Air in the United States, a 2019 report by the Americans Nonsmokers’ Rights Foundation [accessed 2022 Mar 21].
  45. Slopen N, Dutra LM, Williams DR, et al. Psychosocial stressors and cigarette smoking among African American adults in midlife.Nicotine Tobacco Res. 2012;14(10):1161-1169 [accessed 2022 Mar 21].
  46. Purnell JQ, Peppone LJ, Alcaraz K, et al. Perceived discrimination, psychological distress, and current smoking status: results from the Behavioral Risk Factor Surveillance System Reactions to Race module, 2004-2008 . Am J Public Health. 2012;102(5):844-851 [accessed 2022 Apr 28].
  47. Juster RP, McEwen BS, Lupien SJ. Allostatic load biomarkers of chronic stress and impact on health and cognition. Neuroscience & Biobehavioral Reviews.2010; 35(1), 2-16 [accessed 2022 Mar 21].
  48. Guyll M, Matthews KA, Bromberger JT. Discrimination and unfair treatment: relationship to cardiovascular reactivity among African American and European American women.Health Psychology. 2001;20(5): 315 [accessed 2022 Mar 21].
  49. Babb S, Malarcher A, Schauer G, Asman K, Jamal A. Quitting Smoking Among Adults — United States, 2000–2015. MMWR Morb Mortal Wkly Rep 2017;65:1457–1464 [accessed 2022 Mar 21].
  50. Drope J, Liber AC, Cahn Z, et al. Who's still smoking? Disparities in adult cigarette smoking prevalence in the United States. CA Cancer J Clin. 2018;68(2):106–115 [accessed 2022 Mar 21].
  51. DiGiulio A, Jump Z, Babb S, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments — United States, 2008–2018. MMWR Morb Mortal Wkly Rep 2020;69:155–160 [accessed 2022 Mar 21].
  52. Lebrun-Harris LA, Fiore MC, Tomoyasu N, and Ngo-Metzger Q. Cigarette Smoking, Desire to Quit, and Tobacco-Related Counseling Among Patients at Adult Health Centers. American Journal of Public Health. 2015; 105 (1): 180-188 [accessed 2022 Mar 21].
  53. Flocke SA, Hoffman R, Eberth JM, Park H, Birkby G, Trapl E, et al. The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013. Preventing Chronic Disease. 2017; 14:160510 188 [accessed 2022 Mar 21].
  54. S. Department of Health and Human Services. Smoking Cessation. A Report of the Surgeon General [PDF - 9.8 MB]. Atlanta, GA: U.S. 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, 2020 [accessed 2022 Mar 21].
  55. Davis KC, Duke J, Shafer P, Patel D, Rodes R, Beistle D. Perceived effectiveness of antismoking ads and association with quit attempts among smokers: evidence from the Tips from Former Smokers campaign. Health Communication. 2017; 32(8): 931-938. [accessed 2022 Mar 21].