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Smoking Proves Hard to Shake
Among the Poor
MARCH 24, 2014
The New York Times
By SABRINA TAVERNISE
and ROBERT GEBELOFF
MANCHESTER, Ky. — When smoking first swept the United States
in the early decades of the 20th century, it took hold among the well-to-do.
Cigarettes were high-society symbols of elegance and class, puffed by doctors
and movie stars. By the 1960s, smoking had exploded, helped by the distribution
of cigarettes to soldiers in World War II. Half of all men and a third of women
But as evidence of smoking’s deadly consequences has accumulated, the broad
patterns of use by class have shifted: Smoking, the leading cause of preventable
death in the country, is now increasingly a habit of the poor and the working
While previous data established that pattern, a new analysis of federal smoking
data released on Monday shows that the disparity is increasing. The national
smoking rate has declined steadily, but there is a deep geographic divide. In
the affluent suburbs of Washington, only about one in 10 people smoke, according
to the analysis, by the Institute for Health Metrics and Evaluation. But in
impoverished places like this — Clay County, in eastern Kentucky — nearly four
in 10 do.
“It’s just what we do here,” said Ed Smith Jr., 51, holding up his cigarette in
a hand callused from his job clearing trees away from power lines. Several of
his friends have died of lung cancer, and he has tried to quit, but so far has
“I want to see my grandson grow up,” he said.
The new study, which evaluated federal survey data from 1996 to 2012 to produce
smoking rates by county, offered a rare glimpse beneath the surface of
state-level data. It found that affluent counties across the nation have
experienced the biggest, and fastest, declines in smoking rates, while progress
in the poorest ones has stagnated. The findings are particularly stark for
women: About half of all high-income counties showed significant declines in the
smoking rate for women, but only 4 percent of poor counties did, the analysis
This growing gap in smoking rates between rich and poor is helping drive
inequality in health outcomes, experts say, with, for example, white women on
the lowest rungs of the economic ladder now living shorter lives.
“Smoking is leaving these fancy places, these big urban areas,” said Ali H.
Mokdad, a researcher at the Institute for Health Metrics and Evaluation and an
author of the study. “But it has remained in these poor and rural areas. They
are getting left behind.”
Americans with a high school education or less make up 40 percent of the
population, but they account for 55 percent of the nation’s 42 million smokers,
according to a New York Times analysis of health survey data obtained from the
Minnesota Population Center, at the University of Minnesota. Since 1997, the
smoking rate for adults has fallen 27 percent, but among the poor it has
declined just 15 percent, according to the analysis. And among adults living in
deep poverty in the South and Midwest, the smoking rate has not changed at all.
Health experts say this finer understanding of who still smokes shows that
public health officials need to refocus antismoking efforts on the poor and
working class. Michael P. Eriksen, dean of the school of public health at
Georgia State University, who ran the federal Office on Smoking and Health under
President Bill Clinton, said public programs aimed at struggling Americans were
patchy, even as tobacco companies successfully targeted them. Researchers have
shown that tobacco companies make corporate contributions to local causes, aim
advertising campaigns at low-income areas and even sell cigarettes more cheaply
in those areas.
With the national smoking rate stabilizing in more recent years, experts say
that reaching poor and working-class smokers, whose problems often include
alcohol and drug abuse and mental illness, is crucial to achieving further
declines and reducing the heavy financial burden that smoking puts on the health
“The real conclusion here is we need to figure out clever ways to reach these
groups,” Mr. Eriksen said. “The effort has been pitiful so far compared to the
potential benefit to society from getting these people to stop smoking.”
Clay County, where just 7 percent of residents have a college degree and the
poverty rate is double the nation’s, is trying. Manchester, the county seat, a
small cluster of gas stations, municipal buildings and fast-food restaurants,
banned smoking in restaurants, stores and bars in 2012. The hospital runs a
smoking cessation program that offers free nicotine patches and gum in an effort
to reach low-income smokers.
Still, progress has been slow. By the Institute for Health Metrics and
Evaluation’s analysis, Clay’s smoking rate in 2012, at 36.7 percent, was the
highest of any United States county with a population of at least 15,000, and
had not changed much since 1996.
“Smoking cessation is our biggest uphill battle,” said Jeremy Hacker, the
hospital’s community outreach coordinator. While smoking is no longer normal in
big cities, he said, in Clay, “it’s not viewed as a problem.”
“Smokers aren’t seen as the minority,” he continued.
When Mitzi Jackson, who works at a loan company, went on a trip to New York
recently, the only person she saw smoking was the friend she was traveling with.
He was hustled off sidewalks and away from doors. “I thought he would be
arrested,” she said.
In contrast, visiting Clay County is like traveling back in time. Its smoking
rate was last seen in the country as a whole in 1970. A pack of cigarettes costs
about $5 here, roughly half the cost in New York, where state and city taxes
raise the price. Few people interviewed said they were glad to be smoking, but
many said it was one of the few pleasures they could afford.
“I’d love to quit but I just can’t, I’m too addicted,” said Becky Johnson, 60,
as she screwed the gas cap on her aging station wagon outside Bowling’s Quick
Stop, a convenience store whose electronic slot machines draw a crowd of smokers
most afternoons. Asked why she smoked, she said, “Bored, I guess.”
Until the mid-1960s, when the dangers of smoking became clear, high school and
college graduates smoked at about the same rates. But since then, the rate has
declined much more rapidly among college graduates. In the last 15 years, the
decline has been twice as large among adults with a college degree, according to
the Times analysis. Gaps have also widened between the employed and the
unemployed, and between those with health insurance and those without.
Clay County has some of the worst health outcomes in the nation, and many said
smoking seemed almost safe compared with the raging drug epidemic in the area.
“Smoking is one of the last things to worry about in this county,” said Barbara
Bowling, an owner of Mike’s Discount Tobacco, which has drive-through windows
under a billboard that says, “Let’s Talk God.” She said she was angry when she
found out her daughter was smoking, but at least she was not using drugs.
“Just sit and watch the parking lot for a day,” Mrs. Bowling said. “If smoking
is the worst thing that’s happening, praise the Lord.”
Others expressed a fatalism common among poor Americans, who often control
little of the circumstances of their lives.
“My dad’s attitude was, ‘Well, I’m going to die of something,’ “ said Lynn
Bargo, 35, a part-time cosmetology student who works at a Best Western hotel.
Her father, a smoker, died of lung cancer at 71. She said smoking was dwarfed by
drug use: At the salon where she works, some clients come in high and
occasionally lose consciousness while she does their hair.
Still, government interventions can make a difference, researchers say. While
the smoking rate has largely been stuck for Americans living in deep poverty in
the South, it has fallen significantly among that income group in the Northeast,
where strong antismoking measures such as those enacted under former Mayor
Michael R. Bloomberg in New York have been taken.
Even in Clay County, change could be coming. When Manchester’s ban on smoking in
public places went into effect, it was hard to tell who at the Huddle House
restaurant hated it more: the clientele or the staff. Two years later, Mike
Feltner, a cook, was puffing stealthily on an electronic cigarette (Marlboro
flavor) while cooking eggs. He said all four of the smokers on the staff now
used the devices, which he said were considerably cheaper than his old
two-pack-a-day habit. He put the savings toward a down payment on a house.
“This is a new phase in this town,” he said. “Everybody’s doing it. Young
people, old people, everyone.”
Sabrina Tavernise reported from Manchester,
and Robert Gebeloff from New York.
A version of this article appears in print on March 25, 2014,
on page A17 of the New York edition with the headline:
In a New Divide, Smoking Is Becoming a Habit of the Poor.
Smoking Proves Hard to Shake Among the
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