
America’s new tobacco crisis: The rich stopped smoking, the poor didn’t - pmcpinto
https://www.washingtonpost.com/national/americas-new-tobacco-crisis-the-rich-stopped-smoking-the-poor-didnt/2017/06/13/a63b42ba-4c8c-11e7-9669-250d0b15f83b_story.html
======
protonfish
There are some lovely comments about here about how the poor are stupid, they
deserve it, etc. While discussing this, we should also consider that in
situations where there is very little to lose (e.g. going to die soon anyhow,
little chance of a successful life) risky behaviors make more strategic sense
than if the subject had the promise of better opportunities.

Also, the pleasures available to the impoverished are by definition fewer and
smaller than the wealthy. Cigarettes should appear undesirable by those than
can easily afford superior enjoyable experiences. A pack of cigarettes is one
of the most luxurious pleasures available if all you have is $5.

The poor aren't stupid. They are just making the best of poor hand they were
dealt.

~~~
chc
> _A pack of cigarettes is one of the most luxurious pleasures available if
> all you have is $5._

There's nothing luxurious about smelling bad and getting a wicked cough.
Unless you're already addicted, nearly anything under $5 is more luxurious
than a cigarette. I just ate an orange that cost 50¢ and it was more luxurious
than any cigarette I've ever smoked.

~~~
cloverich
There's some subjective aspect to this as well. I smoked off and on for over
10 years. I quit several years ago and don't want for money. But still, to be
100% honest, I've yet to find anything as enjoyable as a cigarette. Its like a
tiny espresso that gives an instant rush that I can revisit as often as I'd
like. It fits into my 5 minute break mindset. It gives me a reason to
(briefly) talk to people I don't know. I could go on, but overall I wasn't
just addicted to them. I honestly enjoyed many things about them. If they
weren't so unhealthy, I would be happily smoking today. And I would gladly
trade a great majority of the other pleasures in my life for them. I say this
because there's two themes so far in these comments, but I didn't notice this
one. For many people, smoking is a legitimately enjoyable, cheap experience,
on top of being insanely addictive. Its not surprising that they are so hard
to be rid of.

~~~
undersuit
>There's some subjective aspect to this as well.

I don't smoke cigarettes. I've probably smoked less than 100. I've smoked less
than 40 cigars. I've spent maybe $100 on pipe tobacco total in my life, and
most of it has gone stale. I've used a Hookah 5 times, just to round out my
experience.

I'm not a smoker, but something about tobacco smoke just smells good to me,
cigars and pipes mostly, but there are some good smelling brands of
cigarettes.

>I've yet to find anything as enjoyable as a cigarette.

I've yet to find anything as a better trigger for happy, emotional memories of
my departed grand mother as cigarettes that smell like her brand.

I don't know where I'm going with this, I guess I'm just saying there can be
some appreciation of tobacco even if I don't think people should be smoking
regularly at all, and that I possibly have very mixed up signals from 2nd hand
exposure to nicotine as a child.

------
ryan606
I was able to quit my 1/2 pack a day addiction four years ago after 15+ years,
but it was challenging. Smoking was expensive (four years ago: 4 packs a week
= $40), but quitting smoking was even more expensive. In addition to the
expense of Chantix, I also started surfing Amazon for things to reward myself
instead of going outside for a smoke break. So it was probably $100 - $200 a
week. Now nicotine-free for 4+ years, it's less costly all around (not to
mention the health costs), but I understand all too well the difficulty and
economics of quitting.

~~~
tomatsu
I quit cold turkey and ate 2 large bags of sunflower seeds in the first 3
weeks. Quitting was cheap.

Quitting isn't that hard. It's just super annoying.

Things like exercising regularly and eating properly take more discipline and
willpower, for example.

~~~
mercer
> Things like exercising regularly and eating properly take more discipline
> and willpower, for example.

From what I've read quitting smoking is one of the most difficult things to
pull off in general (even compared to 'hard drugs'). Do you have any
references in support of your view?

------
ackfoo
In the documentary, "A Billion Lives", the former spokesman for Winston says
he was told by tobacco executives (who did not smoke) that smoking is for "the
poor, the black, the young, and the stupid".

~~~
metaphorm
would add to that, perhaps, "and for foreigners". Tobacco sales in developing
countries are huge. China alone keeps them in so much profit that almost don't
care what happens in America.

~~~
_acme
I think people in developing countries would count as "poor" under this
executive's analysis.

------
Overtonwindow
I think cigarettes share something in common with the meth epidemic in rural
America, and I'm not talking addiction: When you don't have a job or you're
seriously underemployed, no money, no hope, no opportunities for upward
mobility, you look at things almost as a "why not?" issue. Anything to take
the edge off of life, make things a little different. It gets compounded by
the addictive nature of cigarettes and meth and other drugs.

------
Mz
_Among the nation’s less-educated people — those with a high-school-
equivalency diploma — the smoking rate remains more than 40 percent.._

This fits what I have always heard: That education is more predictive of
smoking than income. I am homeless, as are my two adult sons. We do not smoke.
I have about six years of college.

Some random thoughts, in no particular order and not backed up by citations:

Smoking helps control depression. One anti-depression medication has a
shockingly high side effect of causing people to stop smoking.

Smoking suppresses appetite. I strongly suspect this is one of the reasons
that so many homeless people smoke: Because they sometimes don't eat for up to
three days at a time.

Smoking also seems to be common in certain situations where it is the only
stress relief. Many years ago, I volunteered at a homeless shelter in
Vacaville, CA. All the employees seemed to smoke. They had enormous difficulty
giving it up because there was nothing else to do on their breaks but either
smoke or sit with co workers and talk, who were themselves smoking.

If you want to combat this, trying to education the least educated peoples is
probably a better path than framing it as a poor vs rich thing. Poverty grows
out of lack of education, but some very educated people don't have much money
for various reasons.

I run the San Diego Homeless Survival Guide in part because I am convinced
that good information is sorely lacking and is a genuine means to start
solving the difficult problems of the poorest of the poor in the U.S.

------
GeekyBear
So America has massively increased the tax burden on the poorest Americans
(ever increasing tobacco taxes) while simultaneously cutting taxes on Capital
Gains and Inheritance and now we are considering a large cut to the Corporate
rate?

Not to mention all the states with a lottery, which can also be thought of as
a tax on poor people who are bad at math.

This seems like class warfare.

~~~
gscott
In California we have a crisis, not enough people are smoking and paying the
taxes. So the cigarette taxes have to be raised again and again then other tax
sources have to be found.

~~~
wmeredith
That's why you don't use "sin taxes" to do anything but combat "sin". Using
taxes like this to pay for things you actually want to keep messes with
incentives in an evil way.

~~~
lukas099
And unsustainable way, as higher taxes->fewer consumers->higher taxes->...

------
jacquesm
That's not just limited to America. I travel a lot, a few years ago, say 15 or
so it would be pretty rare to see young people smoke and now somehow it is
'cool' again. I've had the unfortunate experience of delivering a couple of
friends to an early grave courtesy of lung cancer, the one thing that seemed
to unite them was that they wished they had never started smoking and that
once they did they had the strength to quit. The youngest of those was mid
40's. It's an intelligence test of sorts with a very high price if you fail.

~~~
mordechai9000
I just got back to the States from Germany. I was struck by how common smoking
seems to be there, but I was glad that it was strictly an outside activity.

I smoked when I was younger, but I started as a teenager. (Intelligence test
failed.)

Once you are addicted, it operates directly on the brain's reward mechanism,
much the same way I imagine opiates would. It seems as vital and necessary as
breathing. (I am generalizing from my experience, not everyone is affected as
strongly as I was.) I am so glad I quit, and now it is more or less completely
out of my system.

On the nine hour flight into Frankfurt, the airline had the flight attendants
try to sell duty free cigarettes to the passengers. They walked up and down
the aisles offering cheap cartons. Of course you can't smoke on the plane. As
a former smoker, that must be torture to people who respond to nicotine the
way I did.

I really hope smoking doesn't become cool again here in the U.S. I have kids,
and I suspect they have inherited at least some of the tendency toward risk
taking I had in my younger years.

~~~
tnorthcutt
Same thing in Italy and France, in my experience. Quite baffling, really.

~~~
exergy
The French have it down to an art form. The difference here is smokers still
seem to be outside hiking, walking, snowboarding, biking and doing all manner
of outdoor things. I'd be interested in how lung cancer rates compare between
the US and France.

~~~
JauntTrooper
US: 38.4 per 100,000

France: 35.0 per 100,000

Note there's a very long lag time, and current cancer rates can reflect
smoking habits from decades ago.

------
coldtea
The decline of the middle class and the huge explosion of the riches of the
rich class will ensure that rich and poor in 50 and 100 years look and live
like different species...

Slum dwellers and "city trash" on one hand, and 150 year old clean shaven
organic vegan genetically modified uberlords on the other.

Warlocks vs Elois all over again...

~~~
Pxtl
Except that wealth is consolidating into the cities where you can't hide from
poverty within gated communities.

~~~
coldtea
You'd be surprised.

Not sure what you mean by "hide", but you can sure avoid it. You can even have
the worst slums next to incredibly luxurious millionaire houses -- like in
India for example, without ever bothering to cross paths.

(An urbanist called Mike Davis has written some very important books on the
subject I can recommend, e.g. concerning closed communities in LA, modern
slums, privatisation of parts of public urban space to keep the poor out,
etc.).

------
gruturo
This, if correctly publicized, would be the best motivation in getting huge
amounts of people to stop.

Think of a slogan like "Only the poor still smoke" or "it's what losers do"
and how it would impact people. Suddenly you'd be embarrassed of being seen
smoking.

~~~
kemiller2002
I don't think so. You are correct that there are a large number of people who
don't want the social stigma of being poor etc., but for many they see it as
one of the few pleasures they can still have. To these people, they smoke,
most of their friends and family smoke, and life is a struggle on a day to day
basis. To them calling them a loser doesn't shame them, it just makes them
more angry towards you.

~~~
anovikov
But it will help a lot for the remaining ~10% or so of middle class people who
smoke, to quit.

~~~
thinkfurther
I once spent a night in the home of an elderly very poor couple on Tenerife,
because they offered some sort of service where the husband would fetch people
from the ferry, and bring them to the airport the next day. They were so kind.
He was near mentally challenged, a super sweet guy working as a garbage man
there, so they could just barely afford it. They lived there because she had
horrible arthritis and the climate there was the only thing that had ever
helped. They had basically no friends there, lived in a poor village in some
outskirts, the broken down look over your shoulder kind.

And I still remember how she offered, just to be hospitable, some watered down
fruit juice with like just a whiff of alcohol, and how she pointed to her
super cheap cigarettes and said with a voice that was so full of cynicism and
despair at the same time, that this was her only pleasure. I still remember
that voice, the look her face had at that second, some kind of snarl -- not
against me, they were so kind to me.. but against her fate I guess, and/or
herself. It's impossible for me to describe, but indelible. Like all that
misery, that is mostly pent up and that will follow her into the grave,
escaping a bit in a short hiss. There is a German saying, to make a good face
in a bad situation, and for just a split second, her face stopped doing that
altogether, and I will never forget. God forbid that I do.

None of what I'm writing makes sense to anyone I'm sure, but I so wish I could
describe the pang I felt then -- and the pang I felt just now, reading the
suggestion that, basically, "they" are beyond help anyway, so let's make
advertisements shaming people for smoking, so that those who still have
something to lose might fear to be associated with those who don't. Would you
also say this in the presence of "the" poor? If I could make one invention, it
would be something that swaps the brains of humans around every 5 years,
completely randomly. People would sober up rather quickly I'm sure.

~~~
jacquesm
> If I could make one invention, it would be something that swaps the brains
> of humans around every 5 years, completely randomly. People would sober up
> rather quickly I'm sure.

A variation on that is that the world where you have no control over who you
will be in it is the world that you should strive to create.

~~~
ss248
This is called "Veil of ignorance". [1]

[1]
[https://en.wikipedia.org/wiki/Veil_of_ignorance](https://en.wikipedia.org/wiki/Veil_of_ignorance)

~~~
jacquesm
Thank you! I never realized it had a formal description.

------
skybrian
Doesn't mention e-cigarettes. Hmm.

------
darkerside
The smoking cessation class teacher they referenced in the article really made
me cringe. She seems like a very positive person, but her ideas about how to
quit smoking just seem so very misdirected. I wonder if she has smoked in the
past and quit herself?

~~~
Overtonwindow
She's not relating to the people she's trying to help. It's like a wealthy
person trying to reason with a poor person.

------
omginternets
>“People down here smoke because of the stress in their life,” Seals said.
“They smoke because of money problems, family problems. It’s the one thing
they have control over. The one thing that makes them feel better. And you
want them to give that up? It’s the toughest thing in the world.”

I'm sorry but this is facile. "Stress" and "problems" cause people to smoke
only in the broadest sense of the word "cause". Something else is at work,
here, and my hunch is that it's cultural. I've found that in much of blue-
collar America, smoking is something of a status symbol.

------
kardos
> Cigarette companies are focusing their marketing on lower socioeconomic
> communities to retain their customer base, researchers say.

> Advocacy groups say funding for smoking cessation is dropping

It seems like an uphill battle to let the tobacco industry tell everyone to
smoke, and then try and undo that with anti-smoking campaigns. Is there a
reason we can't rein in or eliminate tobacco advertising?

~~~
bdavisx
Seems to me like that's a Freedom of Speech issue.

~~~
chc
Case law has established that commercial speech is not the same as other
speech and is much more prone to restrictions.

------
tmaly
I lost my father to lung cancer.

What always puzzles me is if the lower socioeconomic class is
disproportionately affected by smoking and money issues, why are sin taxes the
only political solution?

Some interesting fact on the quitting front, there are some vape shops that
actually help people quit by gradually lowering the amount of nicotine over
time.

------
smileysteve
It seems smoking could be strongly correlated with the growing life expectancy
disparity.

------
mmagin
Well, duh. Anyone with their head out of their ass for the past 15 years would
have noticed that.

------
torrent-of-ions
One of the things that surprised me in Germany was the extremely high smoking
rate. Apparently the adult smoking rate is between 40-45%. My experience was
that it is by no means limited to poor people either. It was really surprising
to me to see a country which presents itself as a modern, progressive force in
the world having cigarette vending machines on almost every street in the
country.

To contrast, I was recently in South Africa at a wedding full of people of all
ages (all white, though). We noted that out of 100+ guests only 2 were
smokers. A recent study shows that the overall rate in both whites and blacks
is about 15%, while in coloureds it is 40%. It's interesting because it shows
more of a race divide rather than class divide.

~~~
dpark
> _It was really surprising to me to see a country which presents itself as a
> modern, progressive force in the world having cigarette vending machines on
> almost every street in the country._

This surprised me, too, the first time I went. Seeing 12 year olds smoking in
public spaces was really, really bizarre. The only logical conclusion is that
the German government and/or populace simply doesn't care about reducing
cigarette usage.

> _A recent study shows that the overall rate in both whites and blacks is
> about 15%, while in coloureds it is 40%._

What are "coloureds" in this context? Typically blacks would be categorized as
"colored".

~~~
torrent-of-ions
Coloured, not colored:
[https://en.wikipedia.org/wiki/Coloureds](https://en.wikipedia.org/wiki/Coloureds)

~~~
dpark
I wasn't aware of this ethnic grouping. Thanks.

------
falcolas
Meta: I appreciate how WP interprets a network failure to load assets as an ad
blocker. Makes for a great user experience.

~~~
TACIXAT
Even better, I have an adblocker and have no problem with the article.

------
davidf18
As of roughly 5 or more years ago, half of tobacco consumed in the US is by
people who are mentally ill and/or substance abusers. For example, people with
Schizophrenia are heavy smokers and 90% smoke. Those with clinical depression
60%. They are self-medicating for their underlying illness. We need to ensure
that they are getting proper treatment.

Income Disparities in Absolute Cardiovascular Risk and Cardiovascular Risk
Factors in the United States, 1999-2014
[https://www.ncbi.nlm.nih.gov/pubmed/28593301](https://www.ncbi.nlm.nih.gov/pubmed/28593301)

This study shows that in the 15 years studied, only the smoking rate of high
income individuals has decreased from 14% to about 9%. Those at the poverty
level or below has remained about 36.5% who are smokers (some of those will be
the mentally ill and/or substance abusers) and middle income is about 24% who
are smokers.

Former NYC Mayor Mike Bloomberg with his latest donation of $360 million in
December, now donated a total of $960 billion to combat tobacco in low- and
middle-income countries (e.g. China, Russia, Bangladesh, but also Turkey).
Bill Gates added another $125 million.

The plan is to implement the World Health Organization's (WHO) MPOWER program
which has been implemented in NYC since 2001. Raising the cost of tobacco has
over half the effect of getting people to quit or never start. Also very
important is banning smoking in public places and hard-hitting, scary,
advertisements spending about $1 to $2 per capita. Clinical interventions such
as doctors speaking with patients about quitting, providing nicotine
replacement therapy, and telephone counseling support are also important. But
most of the gains are from the public policy initiatives.

A frustration I have with the healthcare system in the US is that too little
is sent on public health interventions such as MPOWER compared with the
spending on clinical interventions. If you want to lower healthcare costs,
ultimately more effort has to be put in public health interventions which is
much more scalable and more effective than clinical interventions.

Under ObamaCare, smokers can be charged premiums 50% higher than non-smokers
because the healthcare costs of smoking are so high, yet most insurance plans
don't charge the premium nor does the ObamaCare let insurers really verify if
someone is a non-smoker.

If you want to lower the high costs of healthcare, nationally implement MPOWER
in the US as well as other public health interventions. ObamaCare made a huge
mistake when they did not implement the tobacco tax policies of Canada, UK,
France and other nations which have universal care which is pay for the
healthcare partially with high tobacco taxes in the range $5 to $7 per pack or
more. Our federal tax is about $1. Raising that of these other nations would
result in tens of billions of dollars for paying for healthcare while helping
people, especially the poor, to quit smoking.

~~~
ythn
They are self medicating because there is no proper treatment. We can roll the
dice with treating mental illness, but it's not very consistent or reliable
and often produces undesirable side effects. At least, that's what I've seen
when family members have gone to psychiatrists to treat various things.

~~~
davidf18
Well, there are many levels and types of mental illness and in some cases,
people aren't even aware that they have it. What I know is that there is more
that we can be doing today to help those who have mental illness, both in
terms of diagnosing those who don't know they have it and treatment (both
therapy and pharmacologic) for those that are diagnosed.

------
aszantu
since poor people have shitty or no jobs at all, why does it matter if they
die off of smoking?

~~~
sctb
I understand that this comment may be an expression of exasperation, but
please post civilly and substantively on HN or not at all.

[https://news.ycombinator.com/newsguidelines.html](https://news.ycombinator.com/newsguidelines.html)

------
iscsisounddirty
Nice pay wall

~~~
jessaustin
I wish! If there's any publication we could stand to read less of, it's WaPo.

------
mythrwy
Short term gratification vs. long term thinking may be a common factor in both
smoking and poverty.

Perhaps in the past more rich smoked because it wasn't so manifest how bad
smoking was for a person.

Also culture. In more well off circles being a smoker may raise an eyebrow or
two now as opposed to the past.

