As the prevalence of cigarette smoking has declined in the USA, residual smoking has become concentrated in historically disadvantaged groups, including those on lower incomes, those with lower levels of educational attainment, some racial/ethnic minorities, and the LGBTQ+ community. Smoking rates are also higher among rural, southern, and disabled communities; those experiencing housing insecurity, and those with diagnoses for mental health conditions, or a history of incarceration (Cornelius et al. 2023).
There are several possible explanations for these disparities. Perhaps the economics of lower SES areas stimulates and perpetuates smoking among America’s less affluent communities; a greater density of retail outlets, more exposure to tobacco marketing and lower cigarette prices have all been reported in deprived areas (Arrazola et al. 2023). Perhaps the inverse association between educational qualifications and smoking harm suggests that some smokers underestimate the risk of smoking. The reality, however, is more complicated (Krosnick et al, 2017). Smokers variously overestimate and underestimate different smoking-related risks; many engaging in rationalizing narratives to resolve cognitive dissonance. More likely the experience of living a life defined by disadvantage, however defined, dives smoking as a stress management tactic, compounding group-specific psycho-social and environmental drivers of smoking behavior (Businelle et al. 2010). Intersectionality effects are also evident (Leventhal et al, 2019), meaning that individuals who are members of multiple disadvantaged groups experience even worse outcomes.
Stress management is often reported as a driver of smoking behaviors. For nicotine dependent smokers, the acute effects of nicotine consumption do feel like relief. That’s one of the reasons why the provision of safer sources of nicotine, delivered in an affordable, accessible and acceptable format, are proving to be powerful change agents (Hampsher-Monk et al, 2024). But are oral nicotine pouches, e-cigarettes and heated tobacco products helping resolve smoking-related disparities?
The answer is complicated. Regarding consumers of these products in the aggregate, it does appear that the social gradients to use are flatter than they are with smoking (Friedman & Horn, 2019), but if you look at consumers who use these products and have a history of smoking (and that is the group who should use these products!) a different picture emerges: What seems to be happening is that transitions to exclusive use of safer nicotine products are concentrated among the same social groups where smoking is least common: white, educated and reasonably high-income groups (Friedman & Horn, 2019, Harlow et al, 2023). Accordingly, disadvantaged groups seem less likely to fully transition away from smoking, and more likely to (falsely) perceive e-cigarettes as being as – or more – harmful than cigarettes (Harlow et al, 2023). In other words, many of the people who really need these products are at risk of being left behind.
In 2018, British ethnographer, Francis Thurlway observed that substitution behaviors may be influenced by class dynamics (Thurlway, 2018): for higher SES groups where smoking is heavily stigmatized, the uptake of, for example, e-cigarettes might align with the group’s values (namely abstinence from smoking). However, lower SES groups use tobacco products at different rates and are more likely to view tobacco positively. Further, in reaction to the stigma placed on smoking by higher SES groups, and motivated by a desire to identify away from the higher SES Group, lower SES groups may view smoking as a performative aspect of group membership. That could engender strong social pressure against health positive substitutions for the groups with the greatest rates of smoking. These effects flow from phenomena known as "Social Control," specifically the influence of a "majority" vs. "minority" or "ingroup" vs. "outgroup" mindset (Moscovici & Lage 1976; Mugny & Papastamou, 1982). Social Identity informs Intergroup Behavior (Cadinu and Rothbart, 1996) and the resulting dynamics are precisely why social and behavioral scientific contributions are so vital to the discourse on tobacco control and tobacco harm reduction.
In public health terms, all substitutions away from smoking to less risky alternatives are desireable, regardless of the sub-populations in which these are located. However, from the health equity perspective, it is problematic that the groups that appear to be benefiting the most from THR are not the groups experiencing the most significant harms. Resolving this disparity is going to require more marketing authorizations, including for the kinds of products consumers actually use. While FDA has begun to authorize a handful of safer nicotine products, the proportion of adult frequent users who do use authorized products is vanishingly small (Crespi et al 2024). Regulations that inform product selection by creating differentials that advantage (regulated) safer products could change that, and my result in a compounding effect: if marketing authorization does promote market share, more of the manufacturers producing the bands that Americans use will be incentivized to engage with the PMTA process.
We’re not there yet. Consider the many federal, state and municipal restrictions on safer nicotine products enacted over the past ten years. These demand-reduction strategies are almost universally implemented to discourage youth access. But limiting the appeal accessibility, and affordability of safer products promotes the more dangerous alternatives. Cigarettes remain ubiquitous, and far too few Americans understand the distinction between combustible cigarettes that shorten the life of every second long term user (Doll et al, 2004), and the safer non-combustible alternative nicotine products that don’t. We need a public discourse that informs consumers of all backgrounds of that salient distinction. If disparities remain, we may also need further interventions that specifically target vulnerable populations: Educational campaigns could correct misinformation among at-risk groups and, perhaps, the front-line healthcare workers who would be well positioned to advise them. With the evidence in favor of THR growing each year, the social justice imperative to ensure that the most vulnerable in society are not, once again, left behind is ever more compelling.