Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach

Tobacco use results in exposure to nicotine, a powerfully addictive substance, often leading to tobacco dependence. Tobacco dependence is considered a pediatric disease because most tobacco use and subsequent addiction begin in adolescence.^1,2  Tobacco dependence is a chronic disease,³  and users are prone to relapse and remission.⁴  People who use tobacco suffer consequences, including disease and premature death. Their children suffer from the direct impact of parental tobacco use, including prenatal, secondhand smoke (SHS), and thirdhand smoke (THS) exposure, as well as the economic and social consequences of family tobacco use. Most tobacco users want to quit, and many make multiple quit attempts. People who smoke are more likely to quit when they receive treatment from clinicians.⁴ 

Although the overall use of combustible tobacco products is declining,⁵  tobacco use and exposure continue to affect marginalized^* populations disproportionately. These groups include people living in poverty, people suffering from mental illness, and people with lower educational attainment. Other groups are highlighted in Table 1. The consequences of tobacco use and exposure are more concentrated in people already more likely to face greater health and economic challenges.⁶ 

The same children who are exposed to SHS are exposed to THS, or the “residues left behind by smoking,” which can include chemicals that “remain, react, re-emit, and/or are resuspended long after active smoking ends.”¹¹  Children are uniquely exposed to THS because of home exposure, dermal uptake from crawling, and increased respiratory rates compared with adults. However, distinguishing health effects of THS from SHS is challenging. For the purpose of this clinical report, the term SHS exposure is used, understanding that this designation may refer to both SHS and THS.

Although combustible tobacco use has declined in the United States, electronic cigarette (e-cigarette), vaping, or Juuling usage has accelerated, reaching epidemic proportions among youth¹² ; more than 20% of high school students now vape.¹³  The American Academy of Pediatrics (AAP) policy statement “E-Cigarettes and Similar Devices” details the clear links between e-cigarette companies’ coordinated, targeted advertising to youth and subsequent rapid increase in e-cigarette initiation among youth. That report also highlights research showing that adolescents and young adults who vape are 3.6 times more likely to progress to traditional cigarettes than those who never vaped, paving the way for new cycles of addiction.¹⁴  Although it is clear that e-cigarette use is rapidly changing the landscape of tobacco use and nicotine addiction, a comprehensive review of disparities related to e-cigarette use is beyond the scope of this clinical report. This report will focus on disparities related to combustible tobacco, recognizing the need for a separate report on disparities related to e-cigarette uptake and use.

This report proposes interventions to reduce disparities in combustible tobacco use and exposure using a structural competency framework. Pediatricians treating children whose parents or other caregivers use tobacco (and adolescents using tobacco) are urged to offer consistent cessation advice and tobacco-dependence treatment. Parents who have a primary care provider should also be advised to seek additional counseling and support from that clinician. If caregivers are unable to stop smoking, pediatricians should advise maintaining smoke-free clothing, homes, and cars.¹  Pediatricians may feel frustrated when counseling patients and caregivers who continue to smoke despite discussions about cessation^15,16 ; however, pediatricians who gain a deeper understanding of structural factors perpetuating tobacco dependence may be better able to help families break the cycle of tobacco use. Viewing family tobacco use as a social determinant of health (SDH), systematically screening for tobacco exposure, and offering tobacco-dependence treatment to caregivers who smoke are ways to overcome structural barriers to smoking cessation. Advocacy steps and policy changes are also recommended to address structural inequalities reinforcing tobacco use.

Although some see tobacco use as a personal choice among adult informed decision-makers, looking at tobacco use through a structural competency framework calls attention to the larger societal forces that lead people to use tobacco. The structural competency approach frames health inequities “in relation to the institutions and social conditions that determine health related resources” and is focused on structural changes to address upstream causes of health disparities.¹⁷  The structural competency framework adds to the SDHs approach by acknowledging that social injustice and power dynamics underlie health inequity.¹⁸  Although the structural competency approach is used in social work and public health, it may be a new paradigm for clinicians focused on the care of individual patients.

Many structural issues perpetuate tobacco initiation and use on both a global and domestic scale. The tobacco industry aggressively targets vulnerable and marginalized groups, including children. People who smoke often have poor access to health insurance and health care, lack access to cessation resources, and live in poverty, all of which, in addition to other factors, perpetuate tobacco use and dependence. The lack of effective enforcement of age-for-sale laws means that too often youth have unregulated access to tobacco products.^19,20  Tobacco dependence and exposure reinforces existing health disparities, and these health disparities perpetuate tobacco dependence, creating a cycle of intergenerational tobacco dependence, poverty, and poor health (Fig 1). Pediatricians can continue to engage and support individuals in cessation attempts while also recognizing and addressing economic, social, and political structures that reinforce tobacco dependence and exposure. Adding a structural competency approach to individual clinical interventions will help pediatricians recognize and address some of the structural factors promoting tobacco dependence and will allow pediatricians to push back against a cycle of addiction and disadvantage that reinforces its use.

Targeting vulnerable populations is a well-established tactic used by the tobacco industry to recruit new smokers and maintain current smokers. Children, the most vulnerable group, have long been targeted and tasked to serve as “replacement smokers” by the tobacco industry.²¹  The rapidly developing adolescent brain is uniquely susceptible to nicotine addiction,²²  and 90% of adults who smoke started smoking before 19 years of age,²³  thus giving tobacco companies great incentive to recruit youth smokers. Documents reveal that the tobacco industry has clearly recognized this opportunity. Philip Morris executives noted, "Today’s teenager is tomorrow’s potential customer...”²⁴  The 2014 US Surgeon General’s report acknowledged that “the root cause of the smoking epidemic is evident: the tobacco industry aggressively markets and promotes lethal and addictive products, and continues to recruit youth and young adults as new consumers of these products.”²  Although tobacco companies deny intentional marketing to children, they continue to advertise tobacco in outlets designed to reach children.²⁵ 

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals are a focus of targeted campaigns, likely contributing to higher smoking rates compared with non-LGBTQ individuals. In 1992, a tobacco industry memo stated, “We see the gay community as an area of opportunity.… Philip Morris would be one of the first (if not the first) tobacco advertiser in this category and would thus ‘own the market.’”²⁶  The tobacco industry subsequently began advertising in publications aimed at the LGBTQ community and financially supporting LGBTQ organizations.²⁷ 

Black and African American youth and adults have been systematically targeted through advertisements, retailers, and promotion of menthol products. More tobacco advertisements are found in communities with a higher density of Black and African American residents. In these communities, Black and African American youth have been recruited to smoke through advertising and the distribution of free cigarette samples.²⁸  The proportion of Black and African American smokers who use menthol cigarettes increased from 5% in 1952 to 89% in 2011, likely because of aggressive racial targeting by the menthol cigarette industry. Between 1998 and 2002, Ebony magazine, a monthly publication with a large Black and African American readership, was nearly 10 times as likely to contain ads for menthol cigarettes as People magazine, which has a larger readership among white Americans.²⁹  This targeted advertising has contributed to nearly 90% of Black and African American smokers using menthol cigarettes, which are more addictive and more harmful than nonmenthol cigarettes.⁷ 

American Indian and Alaskan native people are also subject to predatory targeting by the tobacco industry. Tobacco companies exploit the federal exemptions that accompany the unique sovereign status of tribal lands to increase their own economic profit, using tactics such as promotional coupons, price reductions, giveaways, and sponsorships.³⁰  Tobacco companies employ manipulative strategies to exploit sacred use of tobacco. For example, the Santa Fe Natural Tobacco Company, now owned by R.J. Reynolds, produced “an exclusive line of authentic reproductions of Native American pipes, snuff containers, tobacco pouches, and other natural tobacco implements.”³¹  These and other tactics are believed to contribute to the disproportionate burden of tobacco-related disease in Indigenous populations.³⁰ 

Since the 1920s, women have been targeted through appealing tobacco advertising that gave them perceived psychosocial needs around weight loss, independence, stress relief, and the need to escape.³²  As smoking rates for increasingly educated women started to decrease, targeting of low-income women increased, with significant resources devoted to understanding the psychological profiles of potential customers.³²  R.J. Reynolds Tobacco Company attempted to distribute coupons for packs of cigarettes in envelopes with foods stamps. Coupons were for individual packs, not cartons, because “the lower-income groups tend to buy single packs.”³² 

People living in rural areas are also at higher risk of smoking and tobacco-related disease. Rural adolescents start smoking earlier and are more likely to be daily smokers than adolescents living in nonrural areas. Young rural men have historically been targeted through tobacco advertisements featuring cowboys, hunters, and other “rugged images.” Antitobacco media are less likely to reach youth living in rural areas.¹⁰  This targeting contributes to higher rates of tobacco use and lower life expectancies in the 12 contiguous states collectively known as “Tobacco Nation”⁹ : Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia.

The industry also cultivated relationships with organizations working with people with mental illness and funded research to encourage the erroneous ideas that cessation is too stressful for people with mental illness and that people with mental illness need to self-medicate with nicotine to relieve negative moods.⁸ 

Tobacco companies use targeted marketing strategies because they are incredibly effective in recruiting smokers. As “big tobacco” and “big vaping” become increasingly entwined,³³  a resurgence of these advertising tactics aimed at attracting youth to e-cigarettes has been observed. Pediatricians need to be aware of this targeted advertising and its impact on vulnerable populations.³⁴ 

Structural barriers maintain intergenerational smoking by reinforcing economic disparities and limiting access to tobacco-dependence treatment.

Access to health insurance is one example. In more than 40 states, people who smoke can be charged higher insurance rates than those who do not smoke³⁵ ; in some states, these rates can be up to 25% higher than rates for nonsmokers.³⁶  People from marginalized groups are already much less likely to have health insurance; raising premiums for people who smoke makes health insurance even harder and more expensive to obtain. In a 2016 study, authors examined the impact of tobacco surcharges on insurance coverage and cessation among people who smoked and found that smokers were 7.3% less likely to have health insurance coverage than nonsmokers.³⁷  The authors also noted that “tobacco surcharges increased neither smoking cessation nor financial protection from high health care costs.”³⁷  Without health insurance, tobacco users may have limited access to care for smoking-related illnesses as well as less access to tobacco-dependence treatment. The treatment they can access may be inadequate, for example, providing limited medication only for a limited period of time. Such regressive policies do little to treat nicotine addiction as a chronic illness; instead, they limit access to treatment for people who are addicted to nicotine.³⁶ 

Life insurance is also more expensive for people who smoke,³⁸  which affects the ability of those who smoke, who have a higher mortality rate from numerous health problems, to provide financial security for their survivors, including minor children or grandchildren, in the event of their demise.

Discrimination in employment is another example of a structural barrier. Cross-sectional studies have consistently demonstrated an association between smoking and unemployment.³⁹  A 2006–2007 study of more than 52 000 construction workers found that those who smoked were more likely to be unemployed than those who did not smoke.⁴⁰  In one study of unemployed job seekers, people who smoke were found to be less likely to be reemployed after 1 year than those who did not smoke and were paid less when they were rehired.³⁹  The cost of hiring someone who smokes is estimated at nearly $6000 more than the cost of hiring a nonsmoker,⁴¹  meaning that some employers simply refuse to hire people who smoke.⁴²  Those who are living in poverty, are unemployed, and have less formal education are more likely to use tobacco. Refusing to employ smokers effectively restricts access to jobs and ensures that people who smoke remain at an economic disadvantage.⁴³ 

Adding to the economic burden is hardship caused by missed work because of caregiver or child illness. Children are more likely to be absent from school if their caregiver smokes,⁴⁴  meaning caregivers may have to miss work to care for their sick child. The cost of missing work to care for a sick child can be high; caregivers lose an estimated $227 million per year caring for ill children,⁴⁴  which reinforces economic disparities. Repeated school absences can hinder a child’s school performance⁴⁵  and, in the long-term, may influence career trajectory and earning potential.⁴⁴ 

The cycle of health and economic disparities among people who use tobacco is self-perpetuating; adults who smoke who are unable to escape the cycle of addiction are more likely to have children who smoke,^46,47  giving rise to new generations addicted to nicotine and susceptible to these same economic hardships.

For young children, out-of-home child care may represent a significant portion of their day and a source of exposure, particularly for parents who have low incomes, do not speak English, have lower educational levels, or are single parents. These families are more likely to use non–center-based care⁴⁸  and instead may rely on child care with less oversight, where children may be more likely to be exposed to SHS.

Smoking during pregnancy is a risk factor for perpetuating intergenerational health disparities. Data from the Pregnancy Risk Assessment Monitoring System reveal that although prevalence of maternal smoking during pregnancy declined significantly between 2000 and 2010,⁴⁹  differences in prevalence by race and/or ethnicity persist. In 2010, smoking during pregnancy was highest among American Indian women (26.0%), followed by non-Hispanic white women (14.3%), non-Hispanic Black women (8.9%), Hispanic women (3.4%), and Asian American and/or Pacific Islander women (2.1%).⁴⁹  Birth certificate data for 2014 reveal that, overall, approximately 8.4% of women smoked at any time during pregnancy. Higher smoking rates during pregnancy were observed in women with fewer than 12 years of education (14.1%), women with Medicaid coverage (14.0%), women between 20 and 24 years of age (13.0%), unmarried women (14.7%), and non-Hispanic American Indian women (18.0%).⁵⁰  Smoking during pregnancy is associated with maternal vulnerability: women who experienced intimate partner violence were more likely to smoke during pregnancy and less likely to stop smoking.⁵¹ 

A large body of literature describes links between smoking during pregnancy and short- and long-term health issues in offspring, including increased infant mortality, sudden unexpected infant death,⁵²  low birth weight, and respiratory problems. In addition to these detrimental outcomes of exposure to smoking in utero, epidemiological observational evidence links prenatal smoking to increased risks of obesity, behavioral problems, conduct disorder, attention-deficit/hyperactivity disorder (ADHD), and cognitive issues in children.^53–59  Recent research has revealed a dose-response relationship between maternal cotinine concentrations (indicating nicotine exposure) during pregnancy and presence of ADHD in children.⁶⁰  These associations remain even after controlling for confounding factors, such as maternal income and education and maternal and paternal ADHD diagnoses, and are linked to poor health and lower educational attainment. The research cited here has been conducted internationally (United States, Canada, and Europe), so it does not reflect a particular geographic confounding factor to explain the association between smoking during pregnancy and poor outcomes in children. Such pregnancy exposure can be said to perpetuate disparities because children with behavioral, conduct, and learning issues are likely to have a more difficult time throughout the life span. The potential mechanisms for adverse outcomes from prenatal smoking include direct effects of nicotine, carbon monoxide, and other tobacco toxicants on the developing fetal brain along with the potential for fetal adaptation to an adverse prenatal environment, potentially through epigenetic changes. Although epigenetic research is in the early stages,⁶¹  smoking-related epigenetic modifications of gene transcription in specific cells may be mechanisms by which the effects of maternal smoking during pregnancy are transmitted to the next generation.^61,62  Further research will elucidate the epigenetic effects of prenatal smoking on alterations in neural circuitry during fetal development⁶²  and may help establish mechanisms of the relationships between prenatal smoking and poor behavioral and cognitive outcomes in children.

Women who stop smoking during pregnancy are at risk for relapse after birth, leading to SHS exposure in infants and children.⁶³  Relapse may also perpetuate the cycle of beginning the next pregnancy with fetal exposure to maternal smoking.

Children’s SHS exposure is a socioeconomic and educational disparity⁴  that leads to differences in health outcomes. It can be difficult to separate effects of prenatal smoking and postnatal SHS exposure; several of these outcomes, including sleep problems (sleep-disordered breathing, sleep apnea, nighttime awakenings)^64–67  and sudden infant death syndrome,^68–70  are linked to both prenatal smoking and postnatal smoke exposure. Impaired sleep itself during childhood is linked to cognitive and behavior issues and poor quality of life.^71–75 

Children exposed to SHS are more likely to develop asthma, and their asthma is more severe than that in nonexposed children.^76–80  The prevalence and severity of bronchiolitis, acute otitis media, chronic otitis media, influenza, and preclinical cardiovascular changes^81–88  is linked to childhood SHS exposure. Smoke exposure in utero and during childhood sets children up for poorer physical and mental health throughout their lives, which leads to poor school performance and may affect future job success and earning potential.

Finally, parents who are addicted to tobacco may prioritize tobacco over food and other basic needs,^89–93  exacerbating negative health outcomes for children.

Pediatricians are well-positioned to help break the cycle of tobacco dependence at both the individual and structural levels. In this section, office-level interventions are described.

Tobacco use and exposure are SDHs that contribute to a more difficult future for already marginalized children, adolescents, and adults. Pediatricians have embraced screening and referral systems for other SDHs (eg, food insecurity, insurance access, mental health concerns, housing insecurity, unstable employment) that connect families to necessary resources.^94,95  SDHs are complex and often intertwined, increasing the challenge of addressing them, but tobacco use in parents and other caregivers is an SDH for which there currently are effective and actionable interventions.

Adults who smoke are able to achieve quit rates of more than 30% with a combination of medication and counseling from a primary care provider.⁹⁶  The pediatric visit provides a unique opportunity for pediatricians to offer tobacco-dependence treatment to parents and caregivers because most young parents see their children’s pediatrician more frequently than they see their own health care providers. Pediatricians can identify children who are exposed to tobacco smoke and assist parents, caregivers, and other household members who want to stop smoking.

The AAP policy statement “Clinical Practice Policy to Protect Children from Tobacco, Nicotine, and Tobacco Smoke”¹  clearly delineates mechanisms for screening for tobacco use and exposure at each visit and providing support to people who smoke. This assistance may include connecting them to state quitlines (such as 1-800-QUIT-NOW) or cessation services and recommending or prescribing nicotine replacement therapy (NRT). This policy addresses parameters for prescribing NRT to parents, including potential liability, disease assessment, risks versus benefits, and documentation.¹ 

There are many ways to help caregivers cut down on or stop smoking⁹⁶ ; accessible resources are available from the AAP (Table 2). One option for office practices is Clinical Effort Against Secondhand Smoke Exposure (CEASE), a program for clinicians designed to increase smoking cessation through brief motivational interviewing, a recommendation or prescription for NRTs, and referral to cessation helplines.^97,98  CEASE has been shown to increase tobacco-dependence treatment offered by pediatric clinics; recent research has revealed promising results that parents who received CEASE interventions at their child’s clinic were more likely to quit smoking.^96,99 

Social networks also affect smoking cessation. Smoking cessation by a spouse, sibling, friend, or co-worker increases the chance that an individual will also stop smoking.¹⁰⁰  Therefore, it may be beneficial to ask about other people who use tobacco within a tobacco user’s social network and to suggest cessation resources for those people as well. In addition, tobacco users may be able to help identify ways in which their social networks can support cessation.

Evidence-based smoking cessation counseling techniques can be integrated into curricula for medical students and residents so that trainees become familiar with behavioral and pharmacologic strategies to help people stop smoking.¹  Trainees should learn that tobacco dependence is a chronic disease similar to other chronic diseases that need consistent treatment by clinicians. Important components of treatment include cessation medications approved by the US Food and Drug Administration, including the nicotine patch, gum, and lozenge. E-cigarettes and similar devices should not be prescribed for tobacco-dependence treatment.¹³  Counseling and recommending or prescribing NRT can be incorporated into their practice. Trainees who plan to prescribe NRT for parents should review the guidelines described above.¹  In addition, as part of their curriculum, trainees can be educated on big tobacco’s history of deceptive, targeted marketing techniques and encouraged to discuss potential parallels with the current vaping epidemic. Framing this information as a structural issue will make it clearer to trainees that tobacco use and its consequences are not uniformly distributed in the population.

Including smoking cessation counseling as part of pediatric graduate medical education will help trainees recognize that the most effective way to treat children exposed to SHS (and to prevent the children from using tobacco themselves) is to treat their caregivers. Regular trainings in this area will increase workforce capacity to treat tobacco dependence in families, which will decrease structural barriers to smoking cessation and eventually help improve child outcomes. Trainees can be taught smoking cessation approaches by using a structural competency framework as part of the advocacy curriculum required in pediatric residency training.¹⁰¹ 

Pediatricians are trusted members of their communities and can play important roles in advocating for policies to protect children from tobacco use. Although a comprehensive review of advocacy strategies is beyond the scope of this document, we encourage readers to consult the resources available through the AAP (Table 2) for advocacy and policy actions related to tobacco use.

Larger systems that keep people in poverty need to change to address the disparities that perpetuate tobacco use. Changing these systems may be difficult because they have significant up-front costs and may threaten existing power structures. These structural changes are discussed above; Table 3 includes several key recommendations. Actions taken by pediatricians at local, state, and federal levels can support these and other initiatives aimed at addressing structural barriers that perpetuate intergenerational cycles of tobacco dependence and health disparities.

Tobacco dependence is a chronic, relapsing, addictive disease, and tobacco use causes 480 000 deaths in the United States every year. Structural barriers ensure that some marginalized groups initiate and use tobacco at disproportionately high rates. Members of these groups continue to experience health and economic disparities because of tobacco dependence, which, in turn, perpetuate tobacco dependence through generations. Pediatricians have opportunities to reframe their understanding of tobacco-dependence treatment to include both individual and structural interventions. Viewing tobacco exposure as an SDH can help pediatricians systematically identify and provide support to family members using tobacco. Framing tobacco dependence through a structural competency lens and supporting appropriate advocacy and policy actions can disrupt tobacco use patterns and increase opportunities for children and their caregivers to live healthy, tobacco-free lives.

AAP

American Academy of Pediatrics

ADHD

attention-deficit/hyperactivity disorder

CEASE

Clinical Effort Against Secondhand Smoke Exposure

e-cigarette

electronic cigarette

LGBTQ

lesbian, gay, bisexual, transgender, and queer

NRT

nicotine replacement therapy

SDH

social determinant of health

SHS

secondhand smoke

THS

thirdhand smoke

Jyothi Marbin, MD, FAAP

Sophie J. Balk, MD, FAAP

Valerie Gribben, MD, FAAP

Judith Groner, MD, FAAP

Susan C. Walley, MD, FAAP

Rachel Boykan, MD, FAAP

Judith Groner, MD, FAAP

Brian P. Jenssen, MD, FAAP

Jyothi Marbin, MD, FAAP

Bryan Mih, MD, FAAP

Nina L. Alfieri, MD, FAAP

Alice Little Caldwell, MD, FAAP

Karen S. Smith

Colleen Spatz, MSBA