The burden of tobacco-related illness and death disproportionately impacts priority populations in the US including African Americans, American Indians/Alaska Natives (AI/AN), rural Americans, veterans, sexual and gender minorities1, people living with mental illness, people with substance use disorders,2,3 people with criminal legal system involvement,4,5and people living below the federal poverty line,6,7 including those facing deep poverty such as people experiencing homelessness.8
To understand why smoking prevalence is high in these populations, it is important to understand the root causes of inequities that lead to high rates of tobacco use:
- Disparities in access to economic and social opportunities, including low minimum wage
- Chronic exposure to trauma, increasing the risk of developing post traumatic stress disorder and tobacco and substance use
- Systemic racism and discrimination leading to chronic stress
- Tobacco industry targeting and high tobacco retail density increasing exposure and availability of tobacco products
- Lack of access to health care and tobacco treatment
- Experiences of social stigma and provider bias
To address the high rates of tobacco use in behavioral health populations, it is important to go beyond the individual who smokes to understand the systems and structures that have contributed to their high rates.
The following pages provide an overview of recent literature that describes the individual and structural context of tobacco use and cessation across intersections of race/ethnicity, sexual orientation, socioeconomic status, and criminal legal system involvement. We extend our deep gratitude to the trainees who conducted and synthesized the literature. To stay current, we synthesized literature from the past five years, with a preference for literature from the past three years. We hope this is a useful resource for you.
1. Lee JGL, DeMarco ME, Beymer MR, Shover CL, Bolan RK. Tobacco-Free Policies and Tobacco Cessation Systems at Health Centers Serving Lesbian, Gay, Bisexual, and Transgender Clients. LGBT Health. 2018 May/Jun;5(4):264-269. doi: 10.1089/lgbt.2017.0208. Epub 2018 Apr 16. PMID: 29658846; PMCID: PMC6913102.
2. Guydish J, Wahleithner J, Williams D, Yip D. Tobacco-free grounds implementation in California residential substance use disorder (SUD) treatment programs. J Addict Dis. 2020 Jan-Mar;38(1):55-63. doi: 10.1080/10550887.2020.1713687. Epub 2020 Jan 25. PMID: 32186480.
3. Schroeder SA, Morris CD. Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems. Annu Rev Public Health. 2010;31:297-314 1p following 314. doi: 10.1146/annurev.publhealth.012809.103701. PMID: 20001818.
4. Ahalt C, Buisker T, Myers J, Williams B. Smoking and Smoking Cessation Among Criminal Justice-Involved Older Adults. Tob Use Insights. 2019;12:1179173x19833357. doi:10.1177/1179173x19833357
5. Binswanger IA, Carson EA, Krueger PM, Mueller SR, Steiner JF, Sabol WJ. Prison tobacco control policies and deaths from smoking in United States prisons: population based retrospective analysis. Bmj. Aug 5 2014;349:g4542. doi:10.1136/bmj.g4542
6. Vijayaraghavan M, King BA. Advancing Housing and Health: Promoting Smoking Cessation in Permanent Supportive Housing. Public Health Rep. 2020 Jul/Aug;135(4):415-419. doi: 10.1177/0033354920922374. Epub 2020 Apr 30. PMID: 32353245; PMCID: PMC7383751.
7. Brown T, Platt S, Amos A. Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review. Drug Alcohol Depend. 2014 May 1;138:7-16. doi: 10.1016/j.drugalcdep.2014.03.001. Epub 2014 Mar 13. PMID: 24674707.
8. Vijayaraghavan M, Elser H, Frazer K, Lindson N, Apollonio D. Interventions to reduce tobacco use in people experiencing homelessness. Cochrane Database Syst Rev. Dec 3 2020;12:CD013413. doi:10.1002/14651858.CD013413.pub2