Other Vulnerable Populations

But smoking is not an equal opportunity killer.

Smoking disproportionately affects certain groups of people, such as the poor, racial minorities, LGBTQ persons, and those with mental health or substance use disorders. Millions of these smokers live with a tobacco-related disease, such as cancer, heart disease, COPD, and diabetes.

There is evidence to suggest that higher rates of tobacco use in certain populations can be attributed, at least in part, to targeted marketing by the tobacco industry. The tobacco industry has a long history of identifying and targeting persons with special vulnerabilities that may make them more susceptible to cigarette use.

For instance, young adults are an important target because they often face major changes in their lives. The tobacco industry studies their attitudes, lifestyles and values with a view toward making smoking a socially acceptable part of their new activities.

Other populations disproportionately affected by cigarette smoking and tobacco use include those living in rural areas, adults that did not graduate from high school, and military veterans.

Another group of people with special vulnerabilities are those living in public housing, who smoke at a rate more than twice the national rate. But they also face another pressing issue: the movement of secondhand smoke between units, which cannot be controlled in multifamily dwellings.

In the following section, we discuss some of the groups disproportionately affected by tobacco use and identify measures being used to address the problem.

HIV/AIDS and Cigarettes: A Deadly Duo

Additional Resources

Guidance from the NYS Department of Health
HIV and Smoking (ny.gov)

Tobacco Use Reduction in People Living with HIV project – from Michigan DOH
Reducing Tobacco Use in People Living with HIV (michigan.gov)

Research on smoking patterns after HIV diagnosis or antiretroviral initiation
Changes in smoking patterns after HIV diagnosis or antiretroviral treatment initiation: a global systematic review and meta-analysis | Infectious Diseases of Poverty | Full Text (biomedcentral.com)

Informative article written for HIV positive smokers
Attention HIV-Positive Smokers: This Article Could Save Your Life – POZ

Information on grants to improve tobacco cessation interventions for people living with HIV
Tobacco and HIV | Division of Cancer Control and Population Sciences (DCCPS)

Sexual Orientation or Gender Identity

Why would someone’s sexual orientation or gender identity affect their likelihood to smoke?

Evidence suggests it is likely due to several social factors, such as stigma and discrimination. Cigarette smoking may start as a stress reliever, but for some individuals it quickly advances to nicotine addiction.

• According to 2009 – 2010 National Adult Tobacco Survey data, LGBTQIA+ individuals are five times more likely than others to never intend to call a smoking cessation quit-line.
• A greater percentage of LGBTQIA+ smokers use menthol cigarettes, which are more addictive and harder to quit. According to the 2018 National Survey of Drug Use and Health, 51% of LG and 46% of bisexual smokers use menthol cigarettes, compared to 39% of heterosexual smokers.
• LGBTQIA+ individuals are less likely to have health insurance than straight individuals, which may negatively impact health as well as access to cessation treatments, including counseling and medication.

There is also evidence to suggest that higher rates of tobacco use in LGBTQIA+ individuals can be attributed, at least in part, to targeted marketing by the tobacco industry. For more than 20 years, the tobacco industry has targeted the LGBTQIA+ community through direct advertisements, sponsorships, and promotional events.

Furthermore, LGBTQIA+ youth may be at particularly high risk for tobacco use given certain risk factors, such as: lack of support from family and peers; depression; low self-esteem; and stressful life events related to coming out.

Increased awareness of disparity is, as usual, the first step in addressing it.

Funders should recognize LGBTQIA+ communities as a priority population. In addition, quit-smoking interventions – campaigns, educational programs, etc. – designed for LGBTQIA+ individuals can make a big difference.

Additional resources

Lesbian, Gay, Bisexual, and Transgender Persons and Tobacco Use | CDC

Smoking Rates in the Lesbian, Gay, Bisexual and Transgender Communities (LGBT) (tobaccofreekids.org)

Why the Risk of Substance Use Disorders Is Higher for LGBTQ People (healthline.com)

Tobacco use cessation interventions for lesbian, gay, bisexual, transgender and queer youth and young adults: A scoping review – PMC (nih.gov)

The last drag: an evaluation of an LGBT-specific smoking intervention – PubMed (nih.gov)

Military: Service Members and Veterans

US military service members or veterans are more likely to use tobacco products than civilians. The CDC notes that during 2010 – 2015, more than one in five military veterans reported being current cigarette smokers. And in 2018, about three in ten used some form of tobacco product.

Military personnel – both active-duty and veterans – face unique factors with regards to tobacco use, including combat stress during deployment; peer influence; boredom; camaraderie; and easy access to discounted tobacco products. Another factor may be the demographic most likely to volunteer for service – those who enter the service are more likely to already be smokers.

Even so, many servicemen and women start using tobacco after they enter military service. And while overall cigarette use in the military has decreased since 2011, there is considerable variability by service and military occupational specialty, as well as differences in use between men and women, and in various age groups.

Consider cigarette prevalence by service, as noted in 2018 by the Truth Initiative:

Tobacco use in military personnel is not, however, limited to cigarettes. Smokeless tobacco use is common in certain services, highest in the Marine Corps (31.9%), Army (20.8%) and Coast Guard (19.6%).

Tobacco companies have a long history of targeting military service members, and that history continues as the industry markets electronic cigarettes. The military is especially desirable to the tobacco industry given that many recruits are 18 to 21 years of age, a high-risk period for tobacco initiation.

The high prevalence of tobacco use is of particular concern to the military because it has been shown to impair readiness, decrease performance, and reduce productivity of active-duty and civilian personnel.

The Marine Corps offers the Semper Fit Health Promotion Program to help Marines become tobacco free. For more information, visit: Semper Fit Health Promotion – Marine Corps Community (usmc-mccs.org)

Additional resources 

SCOPE OF THE PROBLEM – Combating Tobacco Use in Military and Veteran Populations – NCBI Bookshelf (nih.gov)
This resource is excepted from a book on tobacco use in the military. 

Cigarette smoking patterns among U.S. military service members before and after separation from the military | PLOS ONE
This journal article published in 2021 describes smoking use in US military service members before and after separation from the military.

Tobacco use in the military (truthinitiative.org)
A large collection of print articles and videos from a tobacco control non-profit organization.

>About three in ten US veterans use tobacco products | CDC Online Newsroom | CDC
CDC press release from 2018.

Tobacco-Free Living & Vaping – Army Public Health Center
A discussion on various tobacco-related issues on the Army’s Public Health Center website.

Big Tobacco Targets Military Because “Military is Less Educated, Part of ‘Wrong Crowd’ and Have Limited Job Prospects” – Marine Corps Community (usmc-mccs.org)
Related historical military targeting from the Marine Corp Community Services website.

Adults Living with Disabilities

The CDC reports that cigarette smoking is significantly higher among adults with a disability (27.8%) compared to adults without a disability (13.4%). The percentage of adults with disabilities using e-cigarettes is also higher (8%) compared to nondisabled adults (3.9%)

Why might this be? One important factor might be the burden of stress, anxiety, and other mental health conditions linked to living with a disabling medical condition. Adults with a disability may have smaller social circles and fewer opportunities than people without a disability. The situation can be compounded by discrimination and issues related to how people treat those with disabilities.

Other confounding factors may contribute as well. Persons with disabilities in the US, for instance, live in poverty at twice the rate of non-disabled persons.

What exactly is a disability? The CDC defines it as follows:

“Any condition of the body or mind (impairment) that makes it more difficult for the person with the condition to do certain activities and interact with the world around them. This includes key areas of an individual’s life, such as movement, thinking, social relationships, communication, learning, or the ability to hear or see. (As such), two adults living with a disability can have vastly different needs.”

They also report that one in four adults in the US (an estimated 61.4 million) have a functional disability, meaning they reported having serious difficulty with hearing, vision, cognition, mobility, self-care, or independent living.

In NYS, the prevalence of cigarette use of in adults with disabilities has decreased in recent years. According to the NYS DOH, the overall rate decreased from 2017 (21.6%) to 2020 (17.4%). Still, tobacco use continues to disproportionately affect those with disabilities.

Consider, for example, tobacco use in persons with intellectual or developmental disabilities (IDD), who are especially vulnerable as they tend to have higher rates of chronic health conditions such as diabetes, respiratory and cardiovascular issues. In fact, it has been estimated that people with IDD live 20 years less than the general population.

Additional resources 

Evidence for the Fidelity and Effectiveness of Living Independent From Tobacco for People with Disabilities and Their Caregivers – PMC (nih.gov)
A 2019 study about the LIFT program (Living Independent from Tobacco).
Peer Reviewed: Disparities in E-Cigarette and Tobacco Use Among Adolescents With Disabilities – PMC (nih.gov)
A peer-reviewed study published in 2020 of 11th grade students.

Adults with Cognitive Disabilities More than Twice as Likely to Use E-Cigarettes | Global and Community Health (gmu.edu)
A George Mason University study assessing e-cigarette use among working-age adults by

Smoking Cessation and People with Disabilities (Publication #0959) (ny.gov)
A brochure produced and distributed by NYS Dept. of Health about cessation efforts for people with disabilities.

Intellectual and Developmental Disabilities | Maryland TCRC
The Maryland Tobacco Control and Resource Center provides education and guidance associated with tobacco use and intellectual disabilities.

Native Americans: “Traditional” Tobacco versus “Commercial” Tobacco

Native American nations have had for centuries a special relationship with the tobacco plant, which is considered a sacred gift of the earth. As such, we must distinguish between traditional tobacco – used for spiritual and medicinal purposes — and commercial tobacco.

• Traditional tobacco is rarely inhaled into the lungs. Plants are grown/harvested with no added chemicals. Ceremonial use varies across tribes and regions, but it is always central to culture, spirituality and healing.
• Commercial tobacco products include harmful chemicals and are made by companies and sold In stores and online.

Tobacco companies have a well-documented history of targeting/exploiting Native American communities, with their unique sovereign status, exempting them from state cigarette taxes and smoke-free laws.

The tobacco industry has also misappropriated American Indian culture and traditional tobacco by using American Indian imagery – such as headdresses and other cultural symbols – in product branding and advertising. Moreover, traditional tobacco was used to validate commercially available tobacco.

American Indians/Alaska Natives have the highest commercial tobacco use in the United States.

For more information about Quitline services from the American Indian Commercial Tobacco Program (AICTO), call 1-855-524-7848

Oxford Journal – Nicotine and Tobacco Research
Tobacco Industry Promotional Strategies Targeting American Indians/Alaska Natives and Exploiting Tribal Sovereignty – PMC (nih.gov)

CDC
American Indian and Alaska Native People | CDC

Health Cancer Disparities
A Southwestern Tribal Perspective on Traditional and Commercial Tobacco – PMC (nih.gov)

AlterNative: An International Journal of Indigenous People
Engaging Indigenous peoples in research on commercial tobacco control: a scoping review – Kelley Lee, Julia Smith, Sheryl Thompson, 2020 (sagepub.com)

Vapers: an entry into or an exit out of addiction?

Many smokers want to kick the habit. Some may be tempted to turn to electronic cigarettes, such as vape pens and other vaping devices, to ease the transition from cigarettes. But are they less harmful?

The Johns Hopkins University notes that vapers inhale an aerosol made up of nicotine, flavorings, and other chemicals. Cigarettes contain 7,000 chemicals, many of which are toxic. While we do not know exactly what chemicals are in e-cigarettes, some experts believe that vaping exposes a user to fewer toxic chemicals than traditional cigarettes.

That said, there is still plenty of reason for concern.

In February 2020, for instance, there was an outbreak of lung injuries and death associated with vaping. The CDC confirmed 2,807 cases of e-cigarette or vaping use-associated lung injury (EVALI) and 68 deaths attributed to that condition. The cases appeared to predominantly affect people who modified their vaping devices or used black-market modified e-liquids. This was especially true for vaping products containing THC.

Researchers continue to investigate respiratory risks associated with oil dilutants used in the aerosolization of THC-containing vaping products.

The Centers for Disease Control and Prevention (CDC) recommends that people:

• do not use THC-containing e-cigarettes or vaping products
• avoid using informal sources, such as friends, family or online dealers to obtain a vaping device
• do not modify or add any substances to a vaping device that are not intended by the manufacturer

While many unknowns remain, e-cigarettes are potentially dangerous to health. Vaping is just as addictive as traditional cigarettes. It is not the best smoking cessation tool.

And consider this: most cigarettes are smoked within two to five minutes. E-cigarettes on the other hand can last up to 20 minutes, delivering more damaging chemicals and nicotine to the lungs. In addition, some vaping mixtures can contain 20 times more nicotine than a single cigarette contains!

Despite many concerns, millions of US middle and high school students are using e-cigarette products. There are several possible reasons: Students may believe that vaping is less harmful than cigarettes. Vaping has a lower per-use cost than traditional cigarettes. In addition, the lack of combustible smoke – and the absence of tobacco-related smell – makes it possible for young people to hide their behavior from the watchful eyes (and noses) of parents and other adults.

Johns Hopkins Medicine:
5 Vaping Facts You Need to Know | Johns Hopkins Medicine
What Does Vaping Do to Your Lungs? | Johns Hopkins Medicine

US Surgeon General:
Know the Risks: E-cigarettes & Young People | U.S. Surgeon General’s Report

E-Cigs/Vapes & Pod-Based | Tobacco Prevention Toolkit | Stanford Medicine

Harvard:
Can vaping damage your lungs? What we do (and don’t) know – Harvard Health

Mayo Clinic:
Doctor’s warning about dangers of vaping – Mayo Clinic Health System

Tobacco and Pregnancy

Smoking cigarettes during pregnancy can cause serious complications and harm both mother and baby. What’s more, women who smoke have more trouble getting pregnant than non-smokers. In men, smoking can damage sperm and contribute to impotence.

Even so, there are many erroneous “myths” about smoking and pregnancy – “It’s too late for me to quit,” or “Smoking will be too stressful for my baby,” but here are some evidence-based facts, provided by the CDC and the March of Dimes:

• Babies may be born small, even after a full-term pregnancy. Smoking slows a baby’s growth before birth.
• Babies may be born too early (prematurely) and have associated health problems.
• Smoking can damage a baby’s developing lungs and brain. The damage can last through childhood and into the teen years.
• Smoking raises a baby’s risk for birth defects, such as cleft lip, cleft palate, or both.
• Smoking doubles the risk of abnormal bleeding during pregnancy and delivery.
• Smoking increases the risk of an ectopic pregnancy (fertilized egg implants outside of the womb), a miscarriage, or a stillbirth.
• Babies of moms who smoke during pregnancy – and babies exposed to cigarette smoke after birth – have a higher risk of SIDS.

It’s best to quit smoking before getting pregnant, but it is never too late to quit. Quitting during pregnancy can still help reduce the risk of developing serious health problems.

The bottom line: even if someone smoked and had a healthy pregnancy in the past, that is no guaranteed that the next pregnancy will be healthy. If you are pregnant, the best and safest option is to quit.

March of Dimes
Smoking during pregnancy (marchofdimes.org)

CDC
Smoking, Pregnancy, and Babies | Overviews of Diseases/Conditions | Tips From Former Smokers | CDC

National Institute on Drug Abuse (National Institute of Health)
What are the risks of smoking during pregnancy? | National Institute on Drug Abuse (NIDA) (nih.gov)

Smokefree.gov
Myths: Smoking and Pregnancy | Smokefree

American College of Obstetricians and Gynecologists
Tobacco, Alcohol, Drugs, and Pregnancy | ACOG

Youth and Nicotine

According to the CDC, nearly all tobacco use begins during youth and progresses during young adulthood. And yet, youth are uniquely vulnerable to the harmful effects of tobacco products.

• Nearly 9 out of 10 smokers start before the age of 18 and virtually all start smoking by age 26.
• Nicotine can harm the developing adolescent brain. The brain keeps developing until about the age of 25.
• Using nicotine in adolescence can harm the parts of the brain that control attention, learning, mood and impulse control.
• While researchers are still learning about health effects of e-cigarettes, we do know that flavorings in e-cigarette aerosol may be safe to EAT but not necessarily to INHALE, as the gut can process more substances than the lungs.

Most teens believe that occasional smoking won’t cause them to be addicted and that if they do become addicted, they can stop anytime they want to. However, evidence shows that teens can become addicted after smoking as few as five packs of cigarettes.

The tobacco industry has a long, ignoble history of enticing teens to start smoking, callously referring to them as “replacement smokers” (since their current customers are dying). Marketing strategies include candy- and fruit-flavored products, celebrity endorsements, sweepstakes and contests; price discounts; and cartoon characters.

The Mayo Clinic offers a tip sheet on ways to keep teens smoke-free. To read more, visit: Teen smoking: 10 ways to keep teens smoke-free – Mayo Clinic

Still, it may be hard for parents/adults to tell if a teen is vaping, given that it does not cause the telltale smoke smell on clothes or hair, like cigarettes. However, there are clues – especially ones associated with a teen’s behavior. To read more, visit Teen Smoking | MD Anderson Cancer Center

Helping teens – and young adults – avoid tobacco products is one of the most important things adults can do to protect their loved one’s health.

Additional resources 

Centers for Disease Control and Prevention
Smoking and Youth (cdc.gov)
Youth and Tobacco Use | Smoking and Tobacco Use | CDC

Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General
The Health Consequences of Tobacco Use Among Young People – Preventing Tobacco Use Among Youth and Young Adults – NCBI Bookshelf (nih.gov)

Mayo Clinic
Teen smoking: 10 ways to keep teens smoke-free – Mayo Clinic

MD Anderson Cancer Center
Teen Smoking | MD Anderson Cancer Center

National Cancer Institute
Smoking Initiation Shifting from Teens to Young Adults – NCI (cancer.gov)