Years ago, while working on a street outreach program feeding the homeless, I observed that virtually every one of our clients was a smoker. (In fact, researchers now estimate that about 94% of the North American homeless population smoke). These are men and women whose health is already severely compromised because of their living conditions, mental health issues, addictions or disease – not to mention lack of money for smokes.
Why are they adding a known health threat like tobacco to the mix as well?
A fascinating study in the UK shed some light on that question by observing that the poorer you are, the more likely you’ll be to take up smoking, and the less likely you’ll also be to quit smoking.(1) It helps to explain the spectacular lack of success that otherwise effective anti-smoking campaigns have among lower socioeconomic populations.
This is a curious reality, say the UK researchers, because clear overall health benefits – like the remarkable decrease in lung cancer diagnoses among UK men – has been attributed specifically to the public health success of these anti-smoking campaigns. So why aren’t the poorest of the poor getting the same message?
The research team from the Department of Social Medicine at the University of Bristol revisited British health data as far back as 1931 for five distinct occupational social class categories that have been used in Britain since 1911. Their research was published in the American Journal of Public Health.
These socioeconomic categories include:
- Group 1 Professional Career
- Group 2 Managerial and Technical
- Group 3 Non-Manual Skilled Labour
- Group 4 Partly Skilled Labour
- Group 5 Unskilled
To help understand risky health-related behaviours, the UK researchers explain that humans are not that different from other complex organisms who develop creative strategies to maximize survival, growth and reproduction. We’re always apparently balancing the need to invest our time and resources in immediate survival issues vs focusing on longer term development down the road.
In hazardous environments, for example, where life expectancy is known to be tragically short, it makes evolutionary sense for the women in that society to have babies at a much earlier age than if they were not quite so worried about dying young.
On the other hand, the better living conditions and clear health advantages of those in higher socioeconomic positions allow the luxury of focusing on future long-range plans instead of on immediate survival issues. These are the people who spend time thinking about higher education for their children, investments, mortgages, or their pension plans.
So those who expect to live long and happy lives are apparently easier to convince to quit smoking in light of smoking’s health-damaging effects in the long run. But people whose daily reality convinces them that long life is not a likely option have far fewer reasons to become a non-smoker in order to become healthier in their old age.
In other words, the UK researchers conclude that disadvantaged populations will continue to resist health promotion measures like ‘quit smoking’ campaigns until their more urgent short-term problems are successfully addressed.
The study found that from 1931 to 1961, smoking rates among the most advantaged Group 1 men were similar to or even higher than among the most disadvantaged Group 5. By 1972, smoking rates began to drop significantly among Group 1 smokers, but not in Group 5. And by 1999, smoking rates according to social class ranged from just 13% among men in the advantaged Group 1 to 44% among men in the disadvantaged Group 5.
Although overall smoking rates continue to decline both in the UK and world-wide, the study found that among the most disadvantaged members of society, Group 5 forms the “increasing proportion of those who remain smokers.”
One important factor that researchers found was that the category of all causes of death for disadvantaged groups included a significant number of non-smoking-related causes. For example, statistics showed an increased mortality from accidental death that was four times greater in the disadvantaged men than in the higher socioeconomic groups. Accidents account for far fewer deaths than lung cancer in the total population, but disadvantaged groups’ daily circumstances – like poor working and housing environments – suddenly makes avoidance of such dangerous exposures more important and meaningful for members of their groups.
Consider also parents’ attitudes toward child road safety. The Bristol study cited research conducted in the 1980s showing that only 28% of the advantaged Group 1 parents of junior school age children described themselves as “very worried” about road safety. But 70%of parents from the disadvantaged Groups 4 and 5 were “very worried” about this issue. The researchers explained:
“These parents’ perceptions accurately reflected the true differences in magnitude in the road safety of their children, as assessed via road traffic accident statistics. Others have suggested that an important influence on people’s decision to invest in human capital (e.g., education and skill acquisition) is perceived life span.”
And that makes sense when we consider that the balance for these disadvantaged groups is shifted toward improving the immediate environmentand removing hazards. Poor housing conditions, occupational hazards, and environmental dangers are more immediate threats to the health of those in lower socioeconomic positions than is smoking.
So the Bristol researchers conclude that among these disadvantaged groups inwhich the relative risks to life expectancy from smoking are much less pronounced, incentives to quit are far from clear.
Read more about this study published in the American Journal of Public Health.
D. Lawlor et al., “Smoking and Ill Health: Does Lay Epidemiology Explain the Failure of Smoking Cessation Programs Among Deprived Populations?” American Journal of Public Health, February 1, 2003: 266-270.
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This is bang on correct, in my experience as a factory foreman for the past 17 years. Even though they say it’s not smart to generalize, in some cases theres a reason to generalize if it appears to be True. There is a real ‘class divide’ between the “haves” and “have nots” on my crew at work, and you can almost pick them out across a crowded room just by whether they smoke or not. There is zero interest in even attempting to quit smoking in certain groups. Zero. Interesting stuff here.
“…There is a real ‘class divide’ between the “haves” and “have nots” on my crew at work, and you can almost pick them out across a crowded room just by whether they smoke or not…”
There’s a sweeping and elitist generalization if I ever heard one, Anon. You are seeing what you want to see. I’m betting you are a non-smoker.
I’m a lifelong smoker who’s trying to quit. I’m not a homeless person. I work hard and make a good living and live in a nice well-kept home in a pleasant neighborhood with my wife and two very bright kids who are are doing great in school and in sports. l would resent being considered a “have not” by my boss just because I smoke.
If this is true, and an academic review going back to 1931 sounds like it’s pretty comprehensive, it should mean big changes for those who come up with public education campaigns against smoking – a waste of money if they are not working to reach the very smokers whose ranks are continuing to grow. This makes sense – the people with the luxury of affluence who ponder their pensions and investments have good reason to quit smoking, the people who are worried about the basics of survival and the safety of their kids on the roads have much bigger problems.
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