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Why do poor people smoke, and rich people quit?

We know that people would be healthier if they "just quit smoking". But in reality it's not so simple.

Let's step out of the trinity trap and look to the real, deeper solutions for smoking cessation.

Julia is a 28-year-old single mom of three. She had her first child when she was 16, and dropped out of high school. Since then, she has been struggling to make ends meet.

Julia works at Wal-Mart and is on social assistance. Even though money is tight, she has not been able to quit smoking. She smokes two packs per day and spends approximately $400 monthly on cigarettes. She started purchasing at reserves to offset costs. Julia often finds herself struggling to decide between buying her children’s school supplies or purchasing cigarettes. She hates herself for this, but getting up to face another stressful day feels impossible without her morning smoke.

She has tried multiple times to quit smoking, and failed each time. She was diagnosed with depression four years ago. The main reasons were identified to be constant stress and guilt.

You might be thinking, “Julia should just stop smoking!”

We know that it would benefit her health, her children’s health, her finances, and her mental health, amongst many other advantages.

"If we really want people to stop smoking, we must take intersectional, social justice approaches that focus on the underlying social determinants of health."

“Quitting smoking is one of the best things you can do for your health” is a refrain Julia has probably heard a lot. Whether it’s through loved ones, physicians or public health campaigns, most smokers know that smoking is bad for their health. Despite the declining smoking rates in North America, people living in poverty face many barriers and have much higher smoking rates. Canadian smokers are often those who are marginalized most in our society: our Indigenous and LGBTQ+ community members, those struggling with trauma, addictions and mental illness, and the poor.

Let’s consider why quitting smoking for Julia may not be as easy.

Education: While the smoking rate for adult Americans sits at 15%, the rate jumps astonishingly higher among the nation’s less educated. If your educational attainment is that of a high school-equivalency diploma, the smoking rate climbs above 40%. National rates are similar in Canada, with 17.7% of Canadians age 12 or older smoking daily or occasionally.

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Gender: Smoking rates are declining across the nation, but they are declining much more slowly in women. Women are also starting to smoke at a younger age than men. The data show that stress is a leading cause of female smoking.

Mental Health: Addressing stress may be the key to helping people quit smoking— the data show smoking rates are highest in women who reported the highest levels of stress. This speaks to failings in our healthcare system and societal supports for women, as they navigate complex roles as breadwinners and caregivers.

Indigenous peoples face unique and powerful stressors, faced every day with the past and current processes of colonialism. This includes intergenerational trauma, increased substance use and increased prevalence of chronic disease — all of which contribute to increased tobacco use rates in Indigenous communities, which is more than double the Canadian average.

Income: The smoking gap by income keeps getting wider. In 2013, Canadian smokers in the lowest income level were twice the number of those in the highest. This can be partly explained by the fact that “smoking culture” is much more common in poorer populations. This means people trying to quit smoking constantly see others smoking, which adds to the challenge. Low income individuals also face more barriers to finding help to stop.

Smoking cessation is also expensive. The Ontario Drug Benefit currently reimburses for drugs to stop smoking, like Champix and Wellbutrin, for only 12 weeks of treatment every per year. This means people trying to quit must come up with 75% of the costs for addiction support, if they are unsuccessful within this period. Clinics and nicotine replacement therapy are also not readily accessible to all people. Marginalized populations have difficulty accessing primary health care service in the first place, and are less likely to even be aware of these programs.

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"If smoking cessation programs fail to address the underlying stressors and social inequalities that cause people to start and continue smoking, we are unlikely to be successful in changing behaviours."

Julia’s journey to smoking cessation is far from straightforward, and we can't just simplify it as an issue of behavior or personal responsibility. If we really want people to stop smoking, we must take intersectional, social justice approaches that focus on the underlying social determinants of health. How else will we be able to address that fact that low income neighbourhoods are now “market priorities” for tobacco companies, and that black neighbourhoods have 10 times more advertisements for tobacco than other neighbourhoods? Some strategies may include:

  1. Basic income guarantee to ensure no one is living in poverty.  This will remove some of the barriers that low income individuals face when trying to quit smoking.
  2. Social assistance for smoking cessation programs that account for failures in attempts to quit.
  3. Health promotion around smoking cessation that is sensitive of the unique barriers faced by marginalized populations for both adolescents and adults.
  4. Increasing and improving education on the social determinants of health among health professionals, to diagnose the underlying socioeconomic causes of smoking, instead of just personal behaviour.

If smoking cessation programs fail to address the underlying stressors and social inequalities that cause people to start and continue smoking, we are unlikely to be successful in changing behaviours. We need to shift our focus from empty talk about personal responsibility when the data consistently shows us this isn’t the case.

"We can't just simplify it as an issue of behavior or personal responsibility."

We must disrupt the status quo and move our focus upstream. We must address financial stress, inadequate education, social isolation, past trauma, and the many other factors that lay beneath smoking to provide a robust and comprehensive cessation strategy for all Canadians.

 

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Elizabeth_Lee.jpgElizabeth Lee is a third-year medical student at McMaster University. Elizabeth has developed and executed provincial health campaigns for youth smoking cessation in the past. She has a special interest in public health, education and advocacy for equitable access to healthcare.

Giuliana_Guarna.jpgGiuliana Guarna holds a B.Sc. in Biology with a minor in Music and Music Cognition from McMaster University. She is currently attending McMaster University as a medical student and has lived in Hamilton for the last six years. Her interests include writing for her personal blog, reading, practicing her calligraphy skills, and engaging in political advocacy.

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