On April 12, the book Natural Causes, by Barbara Ehrenreich, will be released. An edited extract was recently published in The Guardian entitled, “Why are the poor blamed and shamed for their deaths?” Some of the themes identified by the author are consistent with those highlighted by the Foundation’s State of Smoking Survey released last month. In our assessment, the global poll data debunks several stereotypes associated with smokers. At the Foundation, we believe action is required to cut the most tangible contributor to social class differences in mortality – smoking. The Foundation is committed to the following measures: engage the smoker in developing solutions that work for the individual in every economic and social class, leverage product innovations and advances for the benefit of the consumer, continue the enforcement of tobacco control measures that are working, and accept the FDA’s approach which places nicotine and the issue of addiction at the center of the agency’s tobacco regulation efforts. 

Focus on the smoker

Our focus is on the smoker – not the concept of the “smoker,” but on the individual. We believe the experience of smoking is multifaceted and deeply personal. Indeed, the State of Smoking Survey findings reinforce our view that smoking is deeply integrated into most smokers’ daily lives, so quitting means more than just giving up cigarettes. That is why our approach is to increase awareness of and empathy for the unique experiences and struggles of smokers and what support they really need, while simultaneously accelerating the development of more effective tools for health professionals to help smokers quit or reduce their risks.

The results of our global poll find that smokers are not ill-informed. Smokers demonstrate high self-awareness – most smokers know smoking is harmful to their health; most smokers consider themselves addicted to cigarettes; and smokers don’t think they are as healthy as non-smokers. With this in mind, we agree with Ms. Ehrenreich’s statement in referring to the wealthier classes of people, “What they need right now is a little humility. We will all die – whether we slake our thirst with kombucha or Coca-Cola, whether we run five miles a day or remain confined to our trailer homes, whether we dine on quinoa or KFC. This is the human condition.”

How did we get here?

The 1964 US Surgeon General’s report is commonly regarded as a turning point in the recognition of health harms from smoking. We agree with the author in that over the past several decades smoking became “a firewall between the classes. To be a smoker in almost any modern, industrialized country is to be a pariah.” Again, in the words of Ms. Ehrenreich, “As more affluent people gave up the habit, the war on smoking – which was always presented as an entirely benevolent effort – began to look like a war against the working class… Escalating cigarette taxes hurt the poor and the working class hardest.” Did the tobacco companies target the young and less educated? Yes. In this manner, the tobacco industry is complicit in the formation of the division between the economic and social classes which exists today.

Why do people smoke?

Our survey findings identify not only physical, but also behavioral and emotional underpinnings – smoking is a big part of many smokers’ daily rituals and routines; smokers tend to have close friends who smoke; smokers are more likely to have partners/spouses who smoke. There is no doubt nicotine is physically addictive – the tobacco companies realized this and what they were selling long ago. Our global poll focus groups acknowledge the intense need/craving for nicotine, difficulty in concentration, insomnia and weight gain. The percentage of smokers in our global poll that consider themselves addicted range from 60% (India) to 91% (Japan). That said, the behavioral and emotional factors of smoking are also strong.

Ms. Ehrenreich, in referring to her experience working in a restaurant years ago, expands on the idea of fellow employees “catching a puff” in the following manner. “Everything else they did was done for the boss or the customers; smoking was the only thing they did for themselves. In one of the few studies of why people smoke, a British sociologist found smoking among working-class women was associated with greater responsibilities for the care of family members – again suggesting a kind of defiant self-nurturance.” Incorporating the concept of stress, the author believes that stress “increases as you move down the socioeconomic scale, with the most stress inflicted on those who have the least control over their work.” Again, in the words of the author, “Add to these workplace stresses the challenges imposed by poverty and you get a combination that is highly resistant to, for example, anti-smoking propaganda.”

Smoking and the poor

Smoking prevalence in many countries has an inverse relationship with income. On a global basis, according to the WHO Report on the Global Tobacco Epidemic, 2017, much of the decline in smoking prevalence since 2007 has occurred in high-income countries. While 85% of the population residing in high-income countries has benefitted from declining smoking prevalence, only half of those in middle-income countries and a third in low-income countries saw reductions in their countries. Furthermore, smoking prevalence in low- and middle-income countries is projected to decline more slowly than in high-income countries.

Cigarette taxes are regressive. This needs to be acknowledged, given the current state of smoking globally and the reality that one of the tobacco control’s primary measures is to raise taxes on tobacco. The tobacco control community’s argument is as follows: tobacco use in poor households exacerbates poverty by increasing healthcare costs, reducing incomes, and decreasing productivity, as well as diverting limited family resources from basic needs (i.e., crowding out); significantly increasing the excise tax and price of tobacco products is the single most consistently effective tool for reducing tobacco use; health benefits that result from tax increase are progressive.

What does the data tell us? A recent article regarding sin taxes, in particular the sugar tax taking effect in the U.K., describes them as designed to punish the poor. In Britain, the poorest decile spend 34% of their disposable income on indirect taxes, including 2.9% on tobacco duty and 2.0% on alcohol duty. For the richest decile, the equivalent figures are 14%, 0.1% and 0.9% respectively. In the 1950s, smoking rates were much the same across the socio-economic spectrum. If people on low incomes were more responsive to sin taxes, we would expect decades of rising tobacco duty to have made smoking the preserve of the wealthy. The reality could not be more different. People who earn less than £10,000 a year are now twice as likely to smoke as people who earn more than £40,000 a year. Smoking has increasingly become the preserve of the poor.

Bottom line, we find a favorable (i.e., inverse) relationship between the cost of a pack of cigarettes and smoking prevalence. The cost of a pack of cigarettes is largely driven by taxation. We are not suggesting that taxation policies in place today are rolled back. We argue that the effectiveness of incremental tax increases in many cases will likely be subject to diminishing marginal returns – with the costs being borne unfairly by the poorest among us.

Confusion remains

Unfortunately, our survey finds there is significant confusion among smokers about relative harms of smoking and less harmful alternatives. Further, misconceptions impact their motivations and choices about the best pathways to quit or switch to reduced-harm products. Our survey findings reveal – smokers generally view nicotine as a harmful substance; many smokers believe nicotine in e-cigarettes causes cancer; in some countries, e-cigarettes ranked as or more harmful than smoking.

In 1976, the late Professor Michael Russell wrote, “People smoke for nicotine, but they die from the tar.” Yet, more than forty years later, the cigarette is still the primary source of nicotine delivery in the world and by far the largest cause of avoidable death and disease. According to Ms. Ehrenreich, “Affluent reformers are perpetually frustrated by the unhealthy habits of the poor, but it is hard to see how problems arising from poverty could be cured by imposing the doctrine of ‘personal responsibility.’ I have no objections to efforts encouraging people to stop smoking or add more vegetables to their diets. But the class gap in mortality will not be closed by tweaking individual tastes. This is an effort that requires concerted action on a vast scale.”

We agree that concerted action is needed. For example, our global poll results find that more than 30% of smokers in each of the thirteen countries believe smoking nicotine in products like e-cigarettes causes a serious health condition such as lung cancer, heart disease, mouth cancer, etc. Smokers in eight of the thirteen survey countries ranked e-cigarettes as more or equally harmful than smoking compared to less harmful than smoking.

The end goal

The poorest in any society have multiple pressures on them – putting food on the table, paying the bills, educating the children, and much more. Barbara Ehrenreich’s work stresses the plight of the poor; in reality, the working poor in modern society. The Foundation’s work as it pertains to smoking and the poor will be centered around the following measures.

First, engage the smoker in developing solutions that work for the individual in every economic and social class, including the poor and working poor.

Second, leverage product innovations and advances for the benefit of the consumer – help the smoker who seeks to quit do so; help the smoker who seeks to reduce his risk and continue to get the pleasures he seeks do so with the least risky products; enable the ex-smoker to remain so; and aid the young person in never starting to smoke. And in all cases, we must ensure that products and interventions are designed with and for smokers across the social class spectrum.

Third, regulatory regimes and customer education must be properly aligned with the risk/benefit trade-off of combustible and other products. We believe this is particularly important for the poor smoker. Therefore, we support policies that tax combustible cigarettes at substantially higher rates than lower risk products; we support the elimination of tax breaks for rolled and other tobacco products; and in some countries (like the U.S.) we support the ban of flavors such as menthol in combustibles, but their allowance in reduced-harm products. Further, we support the communication of such initiatives with Public Health England style messages in the vernacular of poorer communities.

Fair-minded people can agree that the health consequences of tobacco use disproportionately burden lower income populations. The Foundation seeks to work with others committed to identifying and implementing actions toward ending the detrimental contribution from smoking to the socio-economic class gap.