Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach – American Academy of Pediatrics

Why Use a Structural Competency Framework?

Although some see tobacco use as a personal choice among adult informed decision-makers, looking at tobacco use through a structural competency framework calls attention to the larger societal forces that lead people to use tobacco. The structural competency approach frames health inequities in relation to the institutions and social conditions that determine health related resources and is focused on structural changes to address upstream causes of health disparities.17 The structural competency framework adds to the SDHs approach by acknowledging that social injustice and power dynamics underlie health inequity.18 Although the structural competency approach is used in social work and public health, it may be a new paradigm for clinicians focused on the care of individual patients.

Many structural issues perpetuate tobacco initiation and use on both a global and domestic scale. The tobacco industry aggressively targets vulnerable and marginalized groups, including children. People who smoke often have poor access to health insurance and health care, lack access to cessation resources, and live in poverty, all of which, in addition to other factors, perpetuate tobacco use and dependence. The lack of effective enforcement of age-for-sale laws means that too often youth have unregulated access to tobacco products.19,20 Tobacco dependence and exposure reinforces existing health disparities, and these health disparities perpetuate tobacco dependence, creating a cycle of intergenerational tobacco dependence, poverty, and poor health (Fig 1). Pediatricians can continue to engage and support individuals in cessation attempts while also recognizing and addressing economic, social, and political structures that reinforce tobacco dependence and exposure. Adding a structural competency approach to individual clinical interventions will help pediatricians recognize and address some of the structural factors promoting tobacco dependence and will allow pediatricians to push back against a cycle of addiction and disadvantage that reinforces its use.

Tobacco use and exposure reinforce existing health disparities, and these health disparities perpetuate tobacco use.

Targeting vulnerable populations is a well-established tactic used by the tobacco industry to recruit new smokers and maintain current smokers. Children, the most vulnerable group, have long been targeted and tasked to serve as replacement smokers by the tobacco industry.21 The rapidly developing adolescent brain is uniquely susceptible to nicotine addiction,22 and 90% of adults who smoke started smoking before 19 years of age,23 thus giving tobacco companies great incentive to recruit youth smokers. Documents reveal that the tobacco industry has clearly recognized this opportunity. Philip Morris executives noted, "Todays teenager is tomorrows potential customer...24 The 2014 US Surgeon Generals report acknowledged that the root cause of the smoking epidemic is evident: the tobacco industry aggressively markets and promotes lethal and addictive products, and continues to recruit youth and young adults as new consumers of these products.2 Although tobacco companies deny intentional marketing to children, they continue to advertise tobacco in outlets designed to reach children.25

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals are a focus of targeted campaigns, likely contributing to higher smoking rates compared with non-LGBTQ individuals. In 1992, a tobacco industry memo stated, We see the gay community as an area of opportunity. Philip Morris would be one of the first (if not the first) tobacco advertiser in this category and would thus own the market.26 The tobacco industry subsequently began advertising in publications aimed at the LGBTQ community and financially supporting LGBTQ organizations.27

Black and African American youth and adults have been systematically targeted through advertisements, retailers, and promotion of menthol products. More tobacco advertisements are found in communities with a higher density of Black and African American residents. In these communities, Black and African American youth have been recruited to smoke through advertising and the distribution of free cigarette samples.28 The proportion of Black and African American smokers who use menthol cigarettes increased from 5% in 1952 to 89% in 2011, likely because of aggressive racial targeting by the menthol cigarette industry. Between 1998 and 2002, Ebony magazine, a monthly publication with a large Black and African American readership, was nearly 10 times as likely to contain ads for menthol cigarettes as People magazine, which has a larger readership among white Americans.29 This targeted advertising has contributed to nearly 90% of Black and African American smokers using menthol cigarettes, which are more addictive and more harmful than nonmenthol cigarettes.7

American Indian and Alaskan native people are also subject to predatory targeting by the tobacco industry. Tobacco companies exploit the federal exemptions that accompany the unique sovereign status of tribal lands to increase their own economic profit, using tactics such as promotional coupons, price reductions, giveaways, and sponsorships.30 Tobacco companies employ manipulative strategies to exploit sacred use of tobacco. For example, the Santa Fe Natural Tobacco Company, now owned by R.J. Reynolds, produced an exclusive line of authentic reproductions of Native American pipes, snuff containers, tobacco pouches, and other natural tobacco implements.31 These and other tactics are believed to contribute to the disproportionate burden of tobacco-related disease in Indigenous populations.30

Since the 1920s, women have been targeted through appealing tobacco advertising that gave them perceived psychosocial needs around weight loss, independence, stress relief, and the need to escape.32 As smoking rates for increasingly educated women started to decrease, targeting of low-income women increased, with significant resources devoted to understanding the psychological profiles of potential customers.32 R.J. Reynolds Tobacco Company attempted to distribute coupons for packs of cigarettes in envelopes with foods stamps. Coupons were for individual packs, not cartons, because the lower-income groups tend to buy single packs.32

People living in rural areas are also at higher risk of smoking and tobacco-related disease. Rural adolescents start smoking earlier and are more likely to be daily smokers than adolescents living in nonrural areas. Young rural men have historically been targeted through tobacco advertisements featuring cowboys, hunters, and other rugged images. Antitobacco media are less likely to reach youth living in rural areas.10 This targeting contributes to higher rates of tobacco use and lower life expectancies in the 12 contiguous states collectively known as Tobacco Nation9: Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia.

The industry also cultivated relationships with organizations working with people with mental illness and funded research to encourage the erroneous ideas that cessation is too stressful for people with mental illness and that people with mental illness need to self-medicate with nicotine to relieve negative moods.8

Tobacco companies use targeted marketing strategies because they are incredibly effective in recruiting smokers. As big tobacco and big vaping become increasingly entwined,33 a resurgence of these advertising tactics aimed at attracting youth to e-cigarettes has been observed. Pediatricians need to be aware of this targeted advertising and its impact on vulnerable populations.34

Structural barriers maintain intergenerational smoking by reinforcing economic disparities and limiting access to tobacco-dependence treatment.

Access to health insurance is one example. In more than 40 states, people who smoke can be charged higher insurance rates than those who do not smoke35; in some states, these rates can be up to 25% higher than rates for nonsmokers.36 People from marginalized groups are already much less likely to have health insurance; raising premiums for people who smoke makes health insurance even harder and more expensive to obtain. In a 2016 study, authors examined the impact of tobacco surcharges on insurance coverage and cessation among people who smoked and found that smokers were 7.3% less likely to have health insurance coverage than nonsmokers.37 The authors also noted that tobacco surcharges increased neither smoking cessation nor financial protection from high health care costs.37 Without health insurance, tobacco users may have limited access to care for smoking-related illnesses as well as less access to tobacco-dependence treatment. The treatment they can access may be inadequate, for example, providing limited medication only for a limited period of time. Such regressive policies do little to treat nicotine addiction as a chronic illness; instead, they limit access to treatment for people who are addicted to nicotine.36

Life insurance is also more expensive for people who smoke,38 which affects the ability of those who smoke, who have a higher mortality rate from numerous health problems, to provide financial security for their survivors, including minor children or grandchildren, in the event of their demise.

Adding to the economic burden is hardship caused by missed work because of caregiver or child illness. Children are more likely to be absent from school if their caregiver smokes,44 meaning caregivers may have to miss work to care for their sick child. The cost of missing work to care for a sick child can be high; caregivers lose an estimated $227 million per year caring for ill children,44 which reinforces economic disparities. Repeated school absences can hinder a childs school performance45 and, in the long-term, may influence career trajectory and earning potential.44

The cycle of health and economic disparities among people who use tobacco is self-perpetuating; adults who smoke who are unable to escape the cycle of addiction are more likely to have children who smoke,46,47 giving rise to new generations addicted to nicotine and susceptible to these same economic hardships.

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Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach - American Academy of Pediatrics