1750 words

Almost two years ago, I wrote an article on smoking and race, discussing racial differences in smoking, the brains smoked, and biochemical differences brought on by different physiological differences when smoke is inhaled. In this article, I will look at how smoking can be prevented for all race/ethnies, the contribution of smoking to the black/white difference in mortality, and certain personality traits that may have one more likely to pick up the habit.

Tobacco and poverty are “inextricably linked“, with smoking contributing to more than 10 percent of household income among those in poverty. Tobacco has even been said to be a ‘social justice issue‘ since tobacco use is more prevalent in lower-income communities.

It is true that advertisements are concentrated around certain areas to target certain sociodemographic communities (Seidenberg et al, 2010). They looked at two communities in Boston, Massachusets, one high -income non-minority population, and the other a minority low-income population. They found that the low-income community was more likely to have stores which had larger advertisements, have more stores selling tobacco, promote menthol cigarettes (which low-income people are more likely to smoke, mainly blacks), and finally that advertisements for cigarettes would be more likely to be found 1000 feet away from a school zone in low-income communities compared to high-income communities.

They say that their study shows “evidence that features of tobacco advertising are manipulated to attract youth or racial minority sub-groups, and these features are disproportionately evident in low income, minority communities.” So, according to analysis, at least in the urban area of Dorchester, near Boston, if advertisements were to be lessened near schools, along with fewer overall advertisements, the percentage of minority smokers would decrease. (This same effect of low SES affecting the odds of smoking was also seen in a sample of Argentine children; Linetzky et al, 2012).

Higher SES communities have fewer tobacco advertisements than lower SES communities (Barbeau et al, 2005; Hillier et al, 2015). Big Tobacco (along with Big Food and Big Soda) advertise the most in lower-income communities, which then have deleterious health consequences in those populations, further increasing national health spending per year.

Among Americans, as income increases, smoking decreases:

Nationwide, the Gallup-Healthways Well-Being Index reveals that 21% of Americans say they smoke. As the accompanying graph illustrates, the likelihood of smoking generally increases as annual incomes decrease. One exception to this pattern occurs among those making less than $6,000 per year, an income bracket often skewed because many in that bracket are students. Among those making $6,000 to $11,999 per year, 34% say they smoke, while only 13% in the top two income brackets (those with incomes of at least $90,000 per year) say the same — a 21 percentage-point gap.

The Well-Being Index also confirms distinctions in U.S. smoking rates relating to gender and race. Among respondents, 23% of men and 19% of women say they smoke. Blacks are the most likely to smoke (23%) and Asians are least likely to smoke (12%). Hispanics and whites fall in between, at 17% and 20%, respectively.

Further, according to the CDC, the prevalence of smoking of people with a GED is at 40 percent, the highest amongst any SES group. The fact that tobacco companies attempt to advertise in low-income areas and to women is also well-studied. These factors combined to then cause higher rates of smoking in lower-income populations, and blacks are some of the most affected. There are also a slew of interesting physiological differences between blacks and whites regarding smoking.

Ho and Elo (2013) show that smoking differences between blacks and whites at age 50 accounted for 20 and 40 percent of the gap between 1980 and 2005, but not for women. Without adjusting for SES, smoking explains 20 percent of the excessive risk blacks have regarding all-cause mortality.

A study of 720 black smokers from Los Angeles, California showed that 57 percent only smoked menthols, 15 smoked regulars while 28 percent smoked both menthols and regulars (Unger et al, 2010). One of their main findings was that blacks who smoked menthol cigarettes thought that it was a ‘healthier alternative’ to regular cigarettes. Unger et al (2010: 405) also write:

This cross-sectional study identified correlates of menthol smoking, but it does not prove causality. It is possible that smoking menthol cigarettes causes changes in some of the psychological, attitudinal, social, and cultural variables. For example, people who smoke menthols may form beliefs about the positive medicinal benefits of menthols as a way of reducing their cognitive dissonance about smoking.

Figuring out the causation will be interesting, and I’m sure that advertisements outside of storefronts are causally related. Okuyemi et al (2004) also show that blacks who smoke menthol cigarettes are less likely to quit smoking than blacks who smoke regulars. Younger children were more likely to smoke cigarettes with a “longer rod length” (for instance, Newport 100s over Newport regulars). People smoke menthol cigarettes because they taste better, while menthol also “is a prominent design feature used by cigarette manufacturers to attract and retain new, younger smokers.” (Klausner, 2011). Klausner, though, advocates to ban menthol cigarettes, writing:

This evidence suggests that a ban on menthol in cigarettes would result in fewer people smoking cigarettes. Menthol is a prominent design feature used by cigarette manufacturers to attract and retain new, younger smokers. In addition, not only would some current smokers decide to quit rather than smoke non-mentholated cigarettes, but some young people would not make the transition from experimenting with cigarettes to becoming a confirmed smoker. The FDA should ban menthol in cigarettes which will help lower smoking rates particularly among African Americans and women.

Sterling et al (2016) also agree, but argue to ban little cigars and cigarillos (LCCs) writing “Our data add to the body of scientific evidence that supports the FDA’s ban of all characterising flavours in LCCs.” Numerous studies attest to the availability of menthol cigarettes and LCCs which then contributes to influence different demographics to begin smoking. Hersey et al (2006) also shows menthol cigarettes to be a ‘starter product for youth’, stating one reason that children begin smoking mentholated cigarettes is that they are more addictive than non-menthols. Menthol cigarettes are a ‘starter product’ because they taste better than regular cigarettes and, as shown above, seem like they are more ‘theraputic’ due to their taste and coolness compared to regular cigarettes.

Smokers are more likely to be extroverted, tense, anxious and impulsive, while showing more traits of neuroticism and psychoticism than ex- or non-smokers (Rondina, Gorayeb, and Botelho III, 2007). In a ten-year longitudinal study, Zvolensky et al (2015) showed that people who were more likely to be open to experience and be more neurotic would be more likely to smoke, whereas conscientiousness ‘protected’ against picking up the habit. Neuroticism is one of the most important factors of personality to study regarding the habit of smoking. Munafo, Zetteler, and Clark (2006) show in their meta-analysis on personality factors and smoking that neuroticism and increased extraversion were risk factors for being a smoker. I am aware of one study on the effects of different personality and smoking. Choi et al (2017) write:

The results emerging from this study indicate that neuroticism and conscientiousness are associated with the likelihood of being a current smoker, as well as level of ND. Furthermore, personality traits have a greater influence on smoking status and severity of ND in AAs relative to EAs. These relationships were particularly pronounced among smokers with reporting TTFC of ≤5 min.

…

… we found that higher neuroticism and lower conscientiousness were associated with higher likelihood of being a current smoker in the AA sample.

So black smokers were more likely to be conscientious, neurotic and open to experience whereas white smokers were more likely to be neurotic and conscientious.

Finally, racial differences in serum cotnine levels are seen, too. Black smokers have higher levels of cotnine than white smokers (Caraballo et al, 1998; Signorello et al, 2010). Perez-Stable et al (2006) show that higher levels of cotnine can be explained by slower clearance of cotnine along with a higher intake of nicotine per cigarette, because blacks take deeper pulls than whites (though they smoke fewer cigarettes than whites, taking deeper pulls off-sets this; Ho and Elo, 2013).

Smoking can be lessened in all populations—no matter the race/ethincity—with the right universal and intervention efforts (Kandel et al, 2004; Kahende et al, 2011). This can be achieved—especially in low-income areas—by lessening and eventually ridding storefronts of these advertisements for menthol cigarettes, which would then decrease the population of smokers in that area because most only smoke menthols. This would then close some of the black-white mortality gap since smoking causes a good amount of it.

Dauphinee et al (2013) even noted how 52 percent of students recognized Camel cigarettes, whereas 36 percent recognized Marlboro and 32 percent recognized Newports. Black students were three times more likely to recognize Newports than Marlboros (because, in my experience, blacks are way more likely to smoke Newports than Marlboros, which whites are more likely to smoke), while this effect held even after controlling for exposure to smoking by parents and peers. This is yet more proof of the ‘menthol effect’ in lower-income communities that partly drives the higher rates of smoking.

In conclusion, it seems that most of the disparity can be pinned down on Big Tobacco advertising mostly in low-income areas where they spend more than 10 percent of their income on cigarettes. Young children are more likely to know what menthol cigarettes are, what they look like and are more likely to know those type of brains of cigarettes, due mainly to how often and how much they are advertised in low-income areas in comparison to high-income areas. Blacks are also more likely than whites to have the personality traits found in smokers, so this, too, contributes to the how and why of black smoking in comparison to whites; they are more susceptible to it due to their personality  along with being exposed to more advertisements since they are more likely to live in lower-income areas than whites.

I don’t believe in banning things, but the literature on this suggests that many people only smoke menthols and that if they were ever banned, most would just quit smoking. I don’t think that we need to go as far as banning menthol cigarettes—or cigarettes in general—we just need to educate people better and, of course, reel in Big Tobaccos reach in lower-income communities. Smoking also began to decline the same year that Joe Camel was ‘voluntarily’ discontinued by its parent company (Pampel and Aguilar, 2008), and so, that is good evidence that at least banning or reforming laws in low-income areas would change the number of smokers in a low-income area, and, along with it, close at least a small part of the black-white mortality gap.