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

Abstract

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user’s adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Effects of E-Cigarette Exposure on Prenatal Life and Childhood Respiratory Health: A Review of Current Evidence

“…Indeed, the pediatric visit may be an opportunity for pediatricians to offer smoking-cessation treatment to parents and caregivers because parents generally see their children's pediatrician more often than their own healthcare provider. Pediatricians can identify children exposed to passive smoke and help parents and caregivers to quit, connecting them to state quit-lines or to local cessation services, or prescribing them with nicotine replacement therapy (NRT) (66). Even brief advice can increase smoking cessation rates (67).…”

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda

“…Factors such as housing, discrimination, employment, and education have been shown to impact individual and population-level health, resulting in systematic and avoidable health disparities among certain populations [ 1 – 3 ]. Tobacco use, for example, disproportionately affects those living in poverty, suffering from mental illness, and with lower educational attainment [ 4 ]. In fact, smoking contributes substantially to health disparities; low socioeconomic status (SES) populations have higher smoking rates [ 5 , 6 ] and greater smoking-related mortality [ 7 ].…”

Disparities in Marijuana and Tobacco Smoke Incursions Among New York City Families During Early Months of the COVID-19 Pandemic

“… 1 Low-income communities of color face greater exposure to indoor environmental hazards such as secondhand tobacco smoke (SHTS) and pest infestations. 1 , 2 The long-standing structural inequities that contribute to environmental and housing injustices fuel similar disparities in the health and financial impacts of the COVID-19 pandemic. 3 The public health measures implemented in the United States to slow the spread of the SARS-CoV-2 virus in early 2020 (including stay-at-home orders, in-person school closures) led to more time spent at home, potentially exacerbating disproportionate exposures to environmental hazards such as SHTS.…”

“…Causal relationships between SHTS and respiratory tract infections, asthma, persistent adverse effects on lung function, acute and recurrent otitis media, chronic middle ear effusions, and sudden infant death syndrome (SIDS) have been established. 2 , 5 , 6 Children can be regularly exposed to SHTS even if they live in a smoke-free household. Cigarette smoking within 25 ft of a building can lead to SHTS drift through doors and windows.…”

“…Black children are more likely to be exposed to SHTS than children in other racial/ethnic groups and face predatory marketing efforts by the tobacco industry. 2 , 13 Children in low-income neighborhoods are at an increased risk for SHTS exposure, given higher rates of tobacco use and greater concentration of tobacco retailers than high-income neighborhoods. 2 Adults living in public housing smoke tobacco at rates higher than the national average.…”