Unfair and Unjust Practices and Conditions Harm People with Low Socioeconomic Status and Drive Health Disparities

Some policies and practices have led to mental and physical health risks and challenges, and related long-term health outcomes, for people with low socioeconomic status (SES). For example:

People with low SES have been harmed by unjust practices related to the sale of commercial tobacco*. Tobacco companies have a long history of using samples and giveaways to entice people with low SES to try and use their harmful products. For example, tobacco companies have handed out free cigarettes to children in public housing complexes, homeless shelters, and soup kitchens.8,9 They have also included coupons for cigarettes in mailings for government food stamps.10

Other policies and practices related to the social environment also affect health and health outcomes of people with low SES. For example:

Overhead view of a rural area

Rural communities with low SES can lack resources needed for commercial tobacco control and prevention.

  • Lower quality education is associated with lower health literacy, fewer opportunities for employment, less ability to access enough healthy food, and less access to health care, all of which negatively impact health outcomes.11 People with low SES are more likely to live in neighborhoods where most people rent (versus own their own home) and K–12 schools, funded primarily through local property taxes, are subsequently under-funded.12
  • City, county, state, and federal courts can impose fines, fees, and other forms of legal financial obligations on people for traffic violations and other minor offenses. For people without the means to pay, these legal debts can trigger serious and escalating consequences – from the loss of a driver’s license to jail time. These court-imposed fines and fees can add stress and negatively affect health outcomes for people of low SES.13,14
  • Rural communities with low SES can lack resources (e.g. financial resources, access to services), which can serve as a barrier to support for tobacco education, prevention, and cessation.15

People with low SES have also been excluded from systems meant to protect and improve health and well-being, including health care and medical science.

  • People with lower incomes have less access to health care, including affordable health care needed to address smoking-related morbidities.16 People who have unmet needs (including economic or job instability, lack of housing) are more likely to go to the emergency room (ER), to miss medical appointments, and to have unmanaged medical conditions17,18 compared to those with met needs.
  • Being uninsured is related to health care disparities. People who are uninsured may decide not to get needed clinical screening (which could include for tobacco use or cancer) and routine or recommended care due to out-of-pocket cost.19
  • People with lower incomes are more likely to experience delayed access to health care20, which can result in adverse health outcomes.21
  • People with low incomes are less likely to be included in clinical trials for new cancer treatments.22 The lack of lower income populations included in clinical trials could potentially limit knowledge of the effectiveness of treatments across all populations.

The tobacco industry targets low-income communities with marketing and advertising

Marketing plays a big role in whether people try or use commercial tobacco products. Being around commercial tobacco ads makes smoking appear more appealing and increases the chance that someone will try smoking for the first time or start using commercial tobacco products regularly.7,23,24,25

Billboard advertising tobacco products

Tobacco products are made cheap and easy to find in areas with low income.

  • Neighborhoods where people have lower incomes tend to have more stores selling and advertising commercial tobacco.26 In neighborhoods with a lower socioeconomic status, there is a significantly higher weekly unit sales of tobacco products per tobacco retail store.27 Schools that have a larger proportion of low-income students are also more likely to have stores selling commercial tobacco near those schools.28
  • More stores selling commercial tobacco means more advertisements for products like cigarettes, e-cigarettes, chewing tobacco, or other commercial tobacco products. People who see commercial tobacco promotions in places where these products are sold are more likely to smoke.29,30 Tobacco companies target in-store marketing campaigns toward neighborhoods where most residents have low income.10
  • Tobacco companies target communities with low incomes by using use price promotions to increase sales, such as discounts, coupons and special sales.31

Tobacco companies promote flavored products—like menthol—in neighborhoods where people of low SES live.

Menthol has a minty flavor that masks the harsh taste of tobacco. Menthol makes cigarette smoke feel easier to inhale and can make it harder to quit smoking.32,33 To attract customers, tobacco companies target low-income communities with advertising and sales of flavored cigarettes and cigars—especially those with menthol. This can help explain why people with lower income and less education tend to smoke menthol cigarettes at a higher rate than groups with higher incomes and more education.34,35

States and communities can take action to make flavored tobacco products less available.

For example, states and communities can consider increasing prices, prohibiting price discounts, and either allowing fewer stores in a neighborhood to sell commercial tobacco products or prohibiting tobacco product sales altogether.36 Prohibiting the sale of all flavors in tobacco products, including cigarettes, e-cigarettes, cigars, and cigarillos, could also help to reduce the number of youth who use these products.37

Stress can increase commercial tobacco use, and can make health problems worse

When people face many forms of stress—like financial problems, discrimination, or unsafe neighborhoods—they can be more likely to smoke.46,47,48

The pressures of poverty help explain why the health problems caused by commercial tobacco tend to be worse for people with low SES. When people have severe or long-lasting stress, their bodies respond by raising stress hormones and keeping them raised. When this goes on for a long time, they may develop health problems like high blood pressure and type 2 diabetes.49,50 Smoking cigarettes also leads to disease and disability and harms nearly every organ of the body.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. USA.gov. 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 [PDF - 472 KB]. [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].