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TABLE 1

Effects of Tobacco Use and Exposure on Marginalized Populations

High-risk GroupaSmoking RateCoexisting Challenges (Examples)Comments
Black or African American people Black or African American people usually smoke fewer cigarettes and start smoking at older ages compared with white people. Black or African American people are more likely to die of smoking-related diseases than are white people. Black or African American children and adults are more likely to be exposed to SHS than other racial or ethnic groups. 
Hispanic peopleb Cigarette smoking prevalence generally is lower than for most other US racial or ethnic groups, but rates are significantly higher for men compared with women. Acculturation plays a role: smoking prevalence is higher among Hispanic people born in the United States. Current prevalence is higher among Puerto Rican adults compared with Cuban, Mexican, and Central or South American adults. 
Immigrants and refugeesc Smoking rates among immigrants to the United States (especially female immigrants) generally are lower than rates in US populations. Smokers from these groups have vulnerability compounded by economic disadvantage, preimmigration experiences, attitudes toward smoking, and sociocultural and/or language barriers influencing access to care, including smoking cessation. Research is limited because studies have been focused mainly on Mexican, other Hispanic, and Asian populations. More research is needed to investigate tobacco exposure in these and other immigrant populations. 
Incarcerated peopled Smoking prevalence is approximately 4 times higher in criminal justice populations than in the general population. Characteristics often found in individuals who are incarcerated, (eg, history of substance abuse, mental illness, poverty, low educational attainment) also increase likelihood of tobacco use. The United States has the highest rate in the world of incarcerating adults. People of racial and ethnic minority groups are disproportionately affected; Black men are incarcerated at higher rates than non-Hispanic white men and Hispanic men. 
LGBTQ peoplee Of lesbian, gay, and bisexual adults, 20.5% smoke cigarettes, versus 15.3% of straight adults; 30.7% of transgender individuals smoke. Gay men have high rates of HPV infection; coupled with tobacco use, this increases risk for anal and/or other cancers; LGBTQ individuals are less likely to have health insurance, which may affect cessation treatment options. The tobacco industry targets LGBTQ individuals. 
American Indian peoplef The American Indian population has the highest cigarette smoking rates compared with other US racial or ethnic groups. More American Indian women smoke during the last 3 mo of pregnancy compared with all other groups. Some American Indian populations use tobacco for religious, ceremonial, or medicinal reasons. It is important to distinguish traditional versus commercial use. In addition, casino smoke exposure is difficult to regulate because of jurisdictional issues on reservations. 
People of low socioeconomic statusg Adults below the poverty level are approximately 2 times more likely to use cigarettes, cigars, and smokeless tobacco as adults who live at greater than twice the poverty level. There are higher lung cancer rates in those living in poverty compared with affluent groups; there is also less access to health care; therefore, tobacco-related conditions are diagnosed at later stages. Low-income neighborhoods have a higher concentration of tobacco retailers. 
People with mental illness and substance use disorders Approximately 25% of US adults have some form of mental illness or substance use disorder; these adults consume approximately 40% of all cigarettes smoked by adults. People with mental illness more likely to have stressful living conditions, have low annual household income, and have inferior access to health insurance, health care, and help with quitting. The tobacco industry perpetuates idea that it is impossible for these individuals to stop smoking. 
People living in Tobacco Nation Twenty-two percent of Tobacco Nation’s adults smoke, compared with 15% of adults in the rest of the United States. Those in Tobacco Nation smoke many more cigarettes per capita annually (66.6 packs) than those in the rest of the United States (40.6 packs). Residents of Tobacco Nation earn 20% less than those in the rest of the United States. There are 12% fewer doctors in Tobacco Nation, meaning that accessing primary care can be more challenging. Compared with the rest of the country, Tobacco Nation has fewer smoke-free laws and tobacco-control policies, measures which have been proven to protect the public, deter youth smoking, and encourage cessation. 
People living in rural communities10  The prevalence of cigarette smoking among US adults is highest among those living in rural areas (28.5%). The health of people living in rural areas is affected by tobacco more than the health of those living in urban and metropolitan areas, in part because of socioeconomic factors and lack of health care options. Adolescents in rural regions begin smoking cigarettes earlier in life. Thirty-five percent of children in rural areas live in a household where someone smokes. 
High-risk GroupaSmoking RateCoexisting Challenges (Examples)Comments
Black or African American people Black or African American people usually smoke fewer cigarettes and start smoking at older ages compared with white people. Black or African American people are more likely to die of smoking-related diseases than are white people. Black or African American children and adults are more likely to be exposed to SHS than other racial or ethnic groups. 
Hispanic peopleb Cigarette smoking prevalence generally is lower than for most other US racial or ethnic groups, but rates are significantly higher for men compared with women. Acculturation plays a role: smoking prevalence is higher among Hispanic people born in the United States. Current prevalence is higher among Puerto Rican adults compared with Cuban, Mexican, and Central or South American adults. 
Immigrants and refugeesc Smoking rates among immigrants to the United States (especially female immigrants) generally are lower than rates in US populations. Smokers from these groups have vulnerability compounded by economic disadvantage, preimmigration experiences, attitudes toward smoking, and sociocultural and/or language barriers influencing access to care, including smoking cessation. Research is limited because studies have been focused mainly on Mexican, other Hispanic, and Asian populations. More research is needed to investigate tobacco exposure in these and other immigrant populations. 
Incarcerated peopled Smoking prevalence is approximately 4 times higher in criminal justice populations than in the general population. Characteristics often found in individuals who are incarcerated, (eg, history of substance abuse, mental illness, poverty, low educational attainment) also increase likelihood of tobacco use. The United States has the highest rate in the world of incarcerating adults. People of racial and ethnic minority groups are disproportionately affected; Black men are incarcerated at higher rates than non-Hispanic white men and Hispanic men. 
LGBTQ peoplee Of lesbian, gay, and bisexual adults, 20.5% smoke cigarettes, versus 15.3% of straight adults; 30.7% of transgender individuals smoke. Gay men have high rates of HPV infection; coupled with tobacco use, this increases risk for anal and/or other cancers; LGBTQ individuals are less likely to have health insurance, which may affect cessation treatment options. The tobacco industry targets LGBTQ individuals. 
American Indian peoplef The American Indian population has the highest cigarette smoking rates compared with other US racial or ethnic groups. More American Indian women smoke during the last 3 mo of pregnancy compared with all other groups. Some American Indian populations use tobacco for religious, ceremonial, or medicinal reasons. It is important to distinguish traditional versus commercial use. In addition, casino smoke exposure is difficult to regulate because of jurisdictional issues on reservations. 
People of low socioeconomic statusg Adults below the poverty level are approximately 2 times more likely to use cigarettes, cigars, and smokeless tobacco as adults who live at greater than twice the poverty level. There are higher lung cancer rates in those living in poverty compared with affluent groups; there is also less access to health care; therefore, tobacco-related conditions are diagnosed at later stages. Low-income neighborhoods have a higher concentration of tobacco retailers. 
People with mental illness and substance use disorders Approximately 25% of US adults have some form of mental illness or substance use disorder; these adults consume approximately 40% of all cigarettes smoked by adults. People with mental illness more likely to have stressful living conditions, have low annual household income, and have inferior access to health insurance, health care, and help with quitting. The tobacco industry perpetuates idea that it is impossible for these individuals to stop smoking. 
People living in Tobacco Nation Twenty-two percent of Tobacco Nation’s adults smoke, compared with 15% of adults in the rest of the United States. Those in Tobacco Nation smoke many more cigarettes per capita annually (66.6 packs) than those in the rest of the United States (40.6 packs). Residents of Tobacco Nation earn 20% less than those in the rest of the United States. There are 12% fewer doctors in Tobacco Nation, meaning that accessing primary care can be more challenging. Compared with the rest of the country, Tobacco Nation has fewer smoke-free laws and tobacco-control policies, measures which have been proven to protect the public, deter youth smoking, and encourage cessation. 
People living in rural communities10  The prevalence of cigarette smoking among US adults is highest among those living in rural areas (28.5%). The health of people living in rural areas is affected by tobacco more than the health of those living in urban and metropolitan areas, in part because of socioeconomic factors and lack of health care options. Adolescents in rural regions begin smoking cigarettes earlier in life. Thirty-five percent of children in rural areas live in a household where someone smokes. 

HPV, human papillomavirus.

a

These groups may not represent all of the high-risk groups. See text for other examples.

b

Centers for Disease Control and Prevention. Burden of cigarette use in the U.S. Available at: https://www.cdc.gov/tobacco/campaign/tips/resources/data/cigarette-smoking-in-united-states.html#by_race. Accessed November 17, 2020.

c

Bosdriesz JR, Lichthart N, Witvliet MI, Busschers WB, Stronks K, Kunst AE. Smoking prevalence among migrants in the US compared to the US-born and the population in countries of origin. PLoS One. 2013;8(3):e58654. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3592805/. Accessed November 17, 2020.

d

Valera P, Reid A, Acuna N, Mackey D. The smoking behaviors of incarcerated smokers. Health Psychol Open. 2019;6(1):2055102918819930. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328956/. Accessed November 17, 2020.

e

Centers for Disease Control and Prevention. Lesbian, gay, bisexual, and transgender persons and tobacco use. Available at: https://www.cdc.gov/tobacco/disparities/lgbt/index.htm. Accessed November 17, 2020.

f

Centers for Disease Control and Prevention. American Indians/Alaska Natives and tobacco use. Available at: https://www.cdc.gov/tobacco/disparities/american-indians/index.htm. Accessed November 17, 2020.

g

Centers for Disease Control and Prevention. Cigarette smoking and tobacco use among people of low socioeconomic status. Available at: https://www.cdc.gov/tobacco/disparities/low-ses/index.htm. Accessed November 17, 2020.

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