Tobacco Endgame: Improving Outcomes for People from Marginalized Communities

Rachel Zajdel, Ph.D., M.A., M.S., Postdoctoral Fellow
Sana Rahman, B.A., Special Volunteer
Chelsea Truong, B.S. Postbaccalaureate Fellow
Erik Rodriquez, Ph.D., M.P.H., Staff Scientist
Division of Intramural Research
National Heart, Lung, and Blood Institute

Since the 1964 Smoking and Health Report of the Advisory Committee to the Surgeon General, public discussion in the U.S. surrounding the use of tobacco has emphasized its detrimental health effects. Through public health efforts, cigarette smoking rates have decreased among adults and youth since that time. However, as the prevalence of cigarette smoking has dropped, these successful efforts have led to a diminished sense of urgency among the public, with people questioning whether tobacco use remains a prominent public health issue. The World Health Organization’s “World No Tobacco Day,” occurring each year on May 31, aims to refocus attention to the dangers of smoking and their relevance today.

Tobacco continues to kill more than 8 million people worldwide and is the leading preventable cause of death in the U.S. Additionally, while the increased risk of lung and throat cancer among smokers is widely known, smoking is also the second leading cause of cardiovascular disease (CVD), with one in every four deaths from CVD caused by smoking. Considering that CVD is the leading cause of death in the U.S., continued advocacy through events such as “World No Tobacco Day” can help improve U.S. health outcomes.

While 7 million worldwide deaths due to tobacco are a result of direct tobacco usage, 1.2 million people each year die because of secondhand exposure to smoking. Research has shown that there is no safe level of secondhand smoke exposure, with even short term exposure heightening the risk of heart attacks. Secondhand smoke has also been identified as a cause of stroke. Increasing awareness about the risks of secondhand smoke exposure remains a key focus in anti-tobacco public health efforts.

The harmful effects of tobacco use are not evenly distributed across the population. In the U.S., commercial tobacco product use is higher among members of groups that have been marginalized, including American Indian or Alaska Native (AI/AN) individuals; lesbian, gay, or bisexual persons; and those with lower levels of education and income. Individuals with multiple social identities that have been marginalized may be particularly affected by tobacco use. Inequitable exposure to tobacco industry marketing and access to cessation therapies contribute to these disparities in tobacco use by race and ethnicity, sexual orientation and gender identity, and socioeconomic status.

Not only have tobacco companies targeted specific populations within the U.S., but they have also turned their attention to international targets as the tobacco market in the U.S. has shrunk. Tobacco use remains high in low- and middle-income countries (LMICs), where 80% of the world’s tobacco users live. Tobacco companies have leveraged their economic influence to prevent implementation of tobacco control policies, sponsor tobacco-farming communities, and target children and women in LMICs. As a result, compared to high-income countries (HICs), a lower proportion of LMICs have implemented tobacco control measures including anti-tobacco campaigns, tobacco taxes, age requirements, graphic packaging, flavor bans, or comprehensive cessation services.

“World No Tobacco Day” reminds us that these glaring national and international inequalities in tobacco use persist, and in some cases are even widening. Researchers at the National Institutes of Health have heeded this call to action by illuminating disparities in tobacco use by social characteristics and demonstrating the significant harms to population health wrought by the tobacco industry. Research in the lab of Dr. Eliseo J. Pérez-Stable in the National Heart, Lung, and Blood Institute has shown that smoking susceptibility and exposure to tobacco marketing are predictive of cigarette smoking even after accounting for the use of electronic nicotine delivery systems. In addition, Dr. Kelvin Choi’s lab in the National Institute on Minority Health and Health Disparities has established that concern about COVID-19 discrimination, an experience disproportionately borne by Asian and Asian American individuals, is associated with increased cigarette consumption. This research can be used to inform policies and interventions addressing the mechanisms underlying tobacco use and the many health disparities they generate.

Various interventions, such as raising the price of tobacco products, passing smoke-free policies in public places, and increasing equitable cessation access, can help further reduce tobacco exposure and its associated health consequences. Specific tactics to ban the sale of flavored tobacco products, restrict price promotions, and implement culturally-informed anti-smoking campaigns can begin to address the disparities caused by the tobacco industry’s legacy of targeting AI/AN, Black, Latino, sexual and gender minority, and low income communities.

Nevertheless, we must also turn our collective attention to think beyond tobacco control and reach for a tobacco endgame, with an emphasis on the upstream causes of tobacco use. With respect to an endgame strategy, policies could be implemented to regulate the content of nicotine in tobacco products, which could reduce it to a non-addictive level, as well tobacco industry marketing at the point of sale, including characteristics of tobacco package labeling and warnings. Among the upstream causes, dismantling the drivers of structural racism could also advance progress towards tobacco health equity. In summary, systematic social changes will be needed before we truly see a “World No Tobacco Day.”