Other Vulnerable Populations

Tobacco use is not an equal opportunity killer. Smoking disproportionately affects those most in need such as the poor, the homeless, racial minorities, LGBT persons and those suffering from mental illness and substance use disorders. While there have been declines in both youth and adult tobacco use in America, gaps in health equity persist. These trends are well documented, having been the subject of many policy statements, academic analyses, and the subject of the 1998 Surgeon General’s report, Tobacco Use among U.S. Racial/Ethnic Minority Groups. 

The facts are compelling. Americans with lower levels of education and income are significantly more likely to smoke than more affluent or educated Americans. Smoking prevalence is 50% higher among LGBT Americans compared with straight Americans. Those grappling with mental illness comprise nearly a third of all adult smokers. Even among populations who smoke less than the general population (such as African American adults), death and disease is greater than among the general population, partially due to lack of cessation resources and treatment options. Moreover, those groups most impacted by the tobacco epidemic have consistently been targets of marketing by the tobacco industry designed to hook them on their deadly product.

To end the tobacco epidemic in America, all populations must be included in developing policies and practices designed to reduce tobacco use, increase cessation, and improve access to treatment for tobacco-related disease. Below is a summary of key facts on prevalence, cessation, health effects, and marketing among demographic groups most severely impacted by the tobacco epidemic.



Low Socioeconomic Status (SES)

Smoking Prevalence: In 2013, smoking prevalence was significantly higher among persons living below poverty (29.9%) than those living at or above poverty (20.6%).1

  • Among adults under age 65, 30 % of Medicaid enrollees and 30% of uninsured individuals smoke, compared to 15 % with private insurance coverage. 2

Cessation: People living at or below the poverty line are less likely to successfully quit smoking (5.1%) than those living at or above poverty (6.5%).3,4

Health Effects:

  • Among the primary causes of death in the U.S., the diseases with the strongest gradients in SES are those related to smoking, such as chronic obstructive pulmonary disease and lung cancer.5
  • Occupational exposures place low SES employees in blue collar or working class sectors (i.e., industrial, service professions) at increased risk of tobacco-related health outcomes, including lung cancer and restrictive and chronic obstructive lung disease, due to secondhand smoke or chemical and other agents that are synergistic with tobacco smoke in contributing to health outcomes.6

Marketing: An analysis of previously secret tobacco industry documents found that tobacco companies strategically marketed their products to low SES women by distributing coupons with food stamps, discounting cigarettes, developing new brands, and promoting luxury images to low SES, African-American women.7

Education Level

Smoking Prevalence: 2013 smoking prevalence was higher for those with a GED (41.4%) or high school diploma (22.0%) compared with those with an undergraduate degree (9.1%) or graduate degree (5.6%).1

  • Smoking among non-college bound high school seniors is more than twice that of college-bound high school seniors (25.3% vs. 10.8%, respectively).8
  • A study of cigarette smoking prevalence in U.S. counties found that, while the U.S. as a whole has made significant progress in reducing smoking from 1996-2012, rates vary dramatically between counties with different income levels, even within the same state. Counties with higher average incomes experienced more rapid declines than counties with lower average incomes.9


  • According to data from 2012, quit attempts increase as education level rises,4 with only 39% of adult smokers with less than 12 years of education making a quit attempt versus 49.0% of those with a college degree.
  • According to data from 2010, successful quitting also increases as education level rises.4 11.4% of adult smokers with an undergraduate degree have quit successfully compared with only 3.2% of those with less than 12 years of education.3

Health Effects: A 14-year follow-up study found that lower education was associated with greater ischemic stroke incidence, a condition exacerbated by smoking.10


African American

Smoking Prevalence: 18.3 % of African American adults are current smokers. Smoking among African American men is higher than among African-American women (21.8% vs. 15.4%).1

  • African American high school students smoke at lower rates than their White and Hispanic/Latino peers. Currently, 8.2 % of African American high school students smoke, compared to 18.6 % of White high school students and 14 % of Hispanic/Latino high school students.11


  • Although African Americans tend to be lighter smokers, they have more difficulty quitting compared with other racial/ethnic groups. While more African American adult smokers want to quit and more make quit attempts than White or Hispanic/Latino smokers, African Americans successfully quit at a lower rate. Every year, 59.1% of African Americans make a quit attempt, but only 3.3% succeed in quitting compared with 6.6% of Whites.3 African Americans are 11 times more likely to smoke menthol cigarettes than Whites, with the highest rates of menthol smoking among African American youth aged 12-17.12,13 Despite starting smoking later and smoking fewer packs per day, African American menthol smokers successfully quit at a lower rate than non-menthol smoking African Americans.14

Health Effects:

  • Heart disease and cancer, both tobacco-related diseases, are the top two leading causes of death among African Americans.15 African Americans, and particularly males, have experienced lung cancer at higher rates than Whites for many years. Experts believe that racial differences in smoking habits, socioeconomic factors, and the metabolism of tobacco carcinogens may all play a role.16,17
  • Lung cancer kills more African Americans than any other type of cancer.18 In 2013, more than 24,000 new cases of lung cancer were estimated to occur among African Americans and more than 16,000 African Americans were estimated to die from the disease.18
  • The estimated number of smoking-attributable deaths and years of potential life lost among Whites and Blacks indicate that the average annual smoking-attributable mortality rate is 18% higher for Blacks (338 deaths per 100,000) than for Whites (286 deaths per 100,000).19
  • Menthol cigarettes have higher carbon monoxide concentrations than regular cigarettes and may increase the risk of both lung and bronchial cancer more than regular cigarettes.12,20,21

Hispanic and Latino

Smoking Prevalence: In 2013, smoking prevalence among Hispanic/Latino American adults was 12.1% compared with 19.4% among Whites.1 However, wide variations exist in smoking prevalence across Hispanic/Latino subgroups. While data is limited, national surveillance from CDC collected between 2002 and 2005 found that Puerto Ricans had the highest rates of smoking at 31.5%, followed by Cubans (25.2%), Mexicans (23.8%), and Central and South Americans (20.2%).22

  • In 2013, 14.0 % of Hispanic/Latino high school students smoked (15.0% of males and 13.1% of females). Current smoking rates for Hispanic/Latino high school students are higher than smoking rates for African American students but lower than the rates of White students.11


  • Though Hispanic/Latino smokers have high motivation to quit, with concern for health effects on children and the family as a primary motivator, they mostly rely on themselves for cessation, with little use of cessation medication and support services.23 Hispanic/Latino smokers also experience lower levels of practitioner intervention and physician advice to quit.3,24

Health Effects: Hispanics/Latinos are the least likely of any racial/ethnic group to have health insurance.25,26 Cancer and heart disease are the first and second leading causes of death among Hispanics/Latinos, and tobacco use is a major risk factor.27,28

  • In 2012, over 8,000 new cases of lung cancer are expected to occur among Hispanics/Latinos; and more than 5,000 Hispanics/Latinos are expected to die from this disease.29

American Indian/Alaska Native

Smoking Prevalence: 2013 smoking prevalence among American Indians and Alaskan Natives is 26.1% compared to 19.4% among U.S. adults, and is the highest among all racial/ethnic groups.1

  • According to National Survey on Drug Use and Health (NSDUH) 2008-2010, among both adolescents and young adults, American Indians/Alaska Natives had the highest prevalence of current smoking.30
  • American Indian women are the only group in whom smoking prevalence has increased over the past two decades.31


  • According to the National Health Interview Survey (NHIS) in 2012, American Indians/Alaska Native had the lowest quit ratio at 48.2% compared to Whites at 57.1%.4

Health Effects: Cigarette smoking has become one of the leading causes of death and disability for the American Indian/Alaska Native population.32 Cardiovascular disease is the leading cause of death and lung cancer the leading cause of cancer death among American Indian/Alaska Native. Tobacco use is one of the major risk factors for both diseases.

  • Overall, from 2001 to 2009, age-adjusted death rates, smoking-attributable fractions, and smoking-attributable mortality for all-cause mortality were higher among American Indian/Alaska Native than among Whites for adult men and women aged ≥ 35 years.33
  • Smoking caused 21% of ischemic heart disease, 15% of other heart disease, and 17% of stroke deaths in American Indian/Alaska Native men, compared with 15%, 10%, and 9%, respectively, for White men.33
  • Among American Indian/Alaska Native women, smoking caused 18% of ischemic heart disease deaths, 13% of other heart diseases deaths, and 20% of stroke deaths, compared with 9%, 7%, and 10%, respectively, among White women.33


Asian American

Smoking Prevalence: Smoking prevalence in 2013 was 9.6% among Asian American adults compared with 19.4% among Whites.1 Asian American men smoke at a substantially higher rate – 15.1%, compared with 4.8% of Asian American women.1 Smoking prevalence varies greatly by gender, ethnicity, and language fluency across different Asian American communities. While data is limited, national surveillance from 1999-2001 found prevalence ranging from 12.3% among Chinese-Americans to 27.2% among Korean Americans.34

  • Local community studies have shown that males among certain Asian American ethnic groups actually have some of the highest smoking prevalence in the U.S.35

Health Effects:

  • Cancer is the second-leading cause of death for Asian Americans.36
  • Lung cancer rates among Southeast Asians are 18% higher than among White Americans.37
  • Chinese have the highest mortality rates for lung and bronchial cancer among all Asian subgroups.38
  • When data is disaggregated by ethnicity, it reveals that specific Asian American subgroups are at a higher risk and face higher mortality rates for cancer as compared to the general population. For example, lung cancer is the most common cause of cancer-related death among all Asian men with the exception of South Asian men, and the most common cause of cancer-related death for Chinese, Korean, Lao and Vietnamese women.36

Native Hawaiians and Pacific Islanders

Smoking Prevalence: Data have also shown very high smoking prevalence among Native Hawaiian and Pacific Islanders, particularly among Pacific Islander men (e.g., 37% among Palauan men and 36% among Marshallese men).39

  • Native Hawaiians consistently have one of the highest smoking prevalence among all ethnic groups in Hawaii and are the only group where women smoke more than men with a smoking prevalence of 23% and 20% among Native Hawaiian women and men, respectively.40
  • Statistics among Native Hawaiian and Pacific Islander youth are also disconcerting. Nationwide, Pacific Islander youth smokers start earlier than any other ethnic or racial group, with 31.1% starting to smoke in grade school.41
  • The Global Youth Tobacco Survey [GYTS] conducted in the Pacific Islands revealed a high prevalence of smoking among Pacific Islander boys aged 13-15 years (58.6% in Palau, 51.9% in FSM, 43.1% in Guam, and 29.4% in Marshall Islands).42
  • Other forms of tobacco use have high impact in the Pacific. For some Pacific Islander communities, chewing betel nut with tobacco continues to be a common practice among both men and women in some jurisdictions like Palau.43

Marketing to Racial and Ethnic Groups

  • Several studies have found a greater number of tobacco advertisements and a larger presence of menthol cigarette advertising in African American neighborhoods.44-48
  • A 2011 study of cigarette prices in retail stores across the U.S. found that Newport cigarettes are significantly less expensive in neighborhoods with higher proportions of African Americans.49
  • A study of neighborhoods with high schools in California found that as the proportion of African-American high school students rose, the proportion of menthol advertising increased, the odds of a Newport promotion were higher, and the cost of Newport cigarettes was lower.50
  • Tobacco-selling retailer density near schools is higher in minority or lower-income communities.45 A higher density of such retailers near schools has been found to increase experimental smoking among high school students.47,51-54
  • The tobacco industry has targeted African American communities by using urban culture and language to promote menthol cigarettes, sponsoring hip-hop bar nights, and targeting direct-mail promotions.55
  • Marketing to Hispanics/Latinos and American Indians/Alaska Natives has included the promotion of cigarette brands with names such as Rio, Dorado, and American Spirit.55
  • Hispanic and Latino neighborhoods tend to have a high concentration of retail tobacco outlets, and these neighborhoods have significantly more businesses selling tobacco products to underage consumers.56-59
  • Tobacco companies have sponsored cultural events tied to racial and ethnic culture, including Mexican rodeos; American Indian powwows; racial/ethnic minority dance companies, parades, and festivals; Tet festivals; Chinese New Year and Cinco de Mayo festivities; and activities related to Black History Month, Asian/Pacific American Heritage month, and Hispanic Heritage Month.60


Smoking Prevalence: In 2013, the smoking rate was 51% higher among LGBT adults (26.6%) than straight adults (17.6%).1

  • Overall, sexual minorities are 1.5 to 2.5 times more likely to smoke cigarettes than their heterosexual counterparts.61 Bisexual women are up to three and a half times more likely to be smokers than heterosexual women.61
  • Smoking rates among LGBT youth are estimated to be considerably higher (38%- 59%) than those among adolescents in general (28% -35%).62
  • Several factors such as higher levels of social stress, frequent patronage of bars and clubs, higher rates of alcohol and drug use, and direct targeting of LGBT consumers by the tobacco industry may be related to higher prevalence rates of tobacco use among LGBT groups compared to the general population.62


  • Data on interest in quitting, quit attempts and successful smoking cessation among LGBT populations is very limited. A 2012 study using a convenience sample of LGBT smokers in Colorado found that 47.2% had made a past year quit attempt, a rate that is lower than the NHIS 2010 rate among all adults ages 18-54 at 53.1%.63
  • Compared to all adult smokers, more LGBT smokers believe smoking increases their risk of diseases such as lung cancer and heart disease. However, some research indicates that fewer LGBT smokers have made quit attempts (75% compared with 80% of all adults).64
  • Although lesbians and women who have sex with women (WSW) smoke at the highest rates, one study found that lesbian periodicals had the fewest cessation ads: only eight appeared over a ten-year period, compared to over 1,000 in periodicals targeted to gay men.65

Health Effects:

  • Smoking compounds many of the health risks presented by HIV/AIDS, which continues to disproportionately affect members of the LGBT community, especially gay men. It appears that HIV increases the risk of lung cancer by twofold independent of smoking behavior, a smaller but still significant risk factor compared with smoking, which raises risk tenfold.66


  • Industry documents show that tobacco companies were aware of high smoking rates among sexual minorities, and marketing plans illustrate the companies’ efforts to exploit the LGBT market.67-69 Analysis of tobacco marketing has demonstrated lesbian and gay youth as an emerging target community.70
  • One tobacco industry document explained, “A large percentage of gays and lesbians are smokers. In order to grow the Benson & Hedges brand, it is imperative to identify new markets with growth potential . . . Gays and Lesbians are good prospects for the Benson & Hedges brand.”67
  • The tobacco industry has targeted gays and lesbians through direct advertising in LGBT publications and indirect advertising in mainstream publications, community outreach and community promotions (such as “LGBT bar nights featuring specific cigarette brands”), event sponsorships, and the provision of advertising dollars.71
  • In 1995, a tobacco company conducted a marketing plan called “Project SCUM” (Sub Culture Urban Marketing) targeting urban San Francisco populations, including gays.69


Smoking Prevalence: National surveys indicate that smoking prevalence among homeless adults is approximately 73%87 compared with 17.8% among the general population.


  • A 2009 nationally representative survey found that, despite having a quit ratio less than half of that seen in the U.S. general population, homeless smokers did not differ from non-homeless smokers in their rates of desire to quit.88 More homeless episodes were found to be associated with lower odds of successful cessation.87

Health Effects:


  • In 1994, the Phillip Morris (under the brand name Merit) donated 7,000 blankets to homeless shelters in Brooklyn, in order to “generate media coverage.”60
  • RJR directly targeted the homeless as part of an urban marketing plan in the 1990s, focused on the advertising of ‘‘value’’ brands to ‘‘street people.’’90
  • In 1995, one tobacco company developed a marketing plan aimed at homeless people and gays. They called it project SCUM: Sub Culture Urban Marketing.91




Source: "Achieving Health Equity in Tobacco Control"