Who smokes?

In this space, we have explored some real conspiracies, using as an example the tobacco companies’ war on truth. Smoking, and smoking-related disease, continues to be a significant burden on the health of Americans. For example, chronic obstructive pulmonary disease (COPD) affects between 10-25 million Americans. This disabling illness, which includes emphysema and chronic bronchitis, is horrifying to watch, and worse to experience. Smoking is also one of the strongest risks for heart disease which kills over half-a-million Americans yearly.

But it seems that smoking is on the decline, at least in my rarefied world of home/office/hospital. Even as I go to the coffee shops, book stores, and restaurants around town, I see very few smokers. So it was a shock when I arrived here in Key West on vacation that I found everyone smoking—not just at the bars and open air restaurants, but a huge number of people just walking down the street. What gives?

Now, I obviously haven’t done any actual counting or data collection—it’s my vacation, after all. But I couldn’t help observing. I started listening for accents, observing manner of dress, looking for any clues to a pattern. The most obvious pattern is that it’s everyone else’s vacation too. I presume (and hope) that they aren’t all drunk every night at home as they are here. But smoking tends not to be just a “vacation thing”. One thing my wife and I both noticed was that there are a lot of young (to us) people around, perhaps having just finished the semester at college. The other thing we both noticed was a high percentage of Southern accents, which shouldn’t perhaps surprise anyone in the Southernmost city in the continental U.S. I pulled up some stats (I love the CDC!). In 2006, smoking rates in Michigan and Florida weren’t that different (21% vs. 22.4%). The highest rates are in Kentucky and Tennessee. Georgia, one of Florida’s immediate neighbors, was only 20%. Another nearby state Mississppi, is way up there at almost 30%. Hmm…no clear pattern here.

OK, let’s check age: 18-24 years (23.9%), 25-44 years (23.5%), 45-64 years (21.8%), and 65 years or older (10.2%). Until you hit the “elderly” category, rates are about equal (which could be partly explained by smokers dying early). Well, looking out on the street, I’m not surrounded by older folks.

OK, let’s check ethnicity. Looking out the window and listening to voices, most folks appear to be Anglo, followed by Latino, witha few African Americans, Haitians, and others. According to the CDC, rates are highest in Native Americans, followed by African Americans. Maybe my observations aren’t worth too much.

But wait, here’s the real news:

Cigarette smoking estimates are highest for adults with a General Education Development (GED) diploma (46.0%) or 9-11 years of education (35.4%), and lowest for adults with an undergraduate college degree (9.6%) or a graduate college degree (6.6%).

Cigarette smoking is more common among adults who live below the poverty level (30.6%) than among those living at or above the poverty level (20.4%).

I have no idea what the education level of the people around me is right now, but I can be pretty sure it isn’t what I’m used to. Almost all of my friends have a college degree, and most have a post-graduate degree of some sort.

So it is, after all, all about me. I do live in a rarefied world of highly educated non-smokers.

But why are those least able to afford it doing the most smoking? I’m a doctor but there’s no way I could budget in a pack-a-day habit.

Yes, yes, it’s terribly addictive, but that’s not the whole story. I’m sure this has been studied, but from my little perch treating the individual distasters wrought by smoking, I see a lot of factors. For one, lot’s of workplaces forbid smoking. If you want to keep your job, you have to severely limit or quit your tobacco use. At my own hospital, there was a long campaign to help people quit before the campus went smoke-free.

In surveys, smokers have reported many factors:

* Smoking may reduce stress, anger and anxiety or “nerves.”
* It can lessen boredom, depression and help one deal with pain.
* It can help someone have more energy and feel more relaxed.
* For some people, smoking helps them control their weight.
* It also can improve learning and memory and help one stay alert.

This certainly helps explain some things. Poor and unemployed people have serious existential worries—getting food, keeping a home, staying safe. Smoking may help allay some of these fears and anxieties. Of course, it’s also horribly expensive and bad for you.

We’re doing a terrible job. We are enabling our most vulnerable to continue smoking. Fighting tobacco and tobacco-related diseases requires fighting poverty and improving education. It’s a societal problem as much as an individual problem.

Let’s get to it.


11 responses to “Who smokes?”

  1. Ha! I just came back from Europe. Compared to them, nobody smokes in the US, and when someone does, the people around give mean looks. Not many people smoke in London and Cambridge, but those who do are not regarded as criminals. More smoke in Italy and Germany, and even more in Serbia. One can smoke in a restaurant at the Belgrade airport AFTER crossing the security.

  2. Callicebus

    As a currently off-the-band-wagon quitter who is psyching herself up to quit again once finals are done, I’ll pop in my two cents.

    As I’m sure everyone is aware, it’s very easy to say “I’ll quit” and much much harder to actually do. When I quit last year I had incredibly bad mood swings when I wasn’t on the patch, and the patches, although about equalling out what cigarettes cost in the long run, cost almost $50 a pop – which was often a larger lump sum than what I had laying around at any given time. Selling them in smaller groups (they come in boxes of 14), for about the cost of a pack of cigarettes might help with this problem.

    Also, having admitted to being off the band wagon at the moment – due in large part to having poor stress management and feeling the crunch of grad school, I’d also suggest that all of the stop-smoking programs focus more on alternative forms of stress relief. Most of the counselling you get just says “keep candies around to suck on” and “avoid stressful situations.” Not helpful when you’re studying for a huge exam or presenting at a conference. I get a lot of rude comments when I bring this up, because, you know, you’re just weak for doing something that you know is bad for you – but people tend to forget that just because it’s really easy for THEM not smoke when they’re stressed doesn’t mean that it’s easy for me because that is how I have handled stress for the past 6 years. It takes a large amount of reconditioning, and there’s not really a good amount of help available with that (at least that I’ve found – if anyone knows differently please let me know because I am really dreading the insomnia and constant state of jitters I went into last time I quit). I’m guessing that this is why it takes people on average 5 trys to sucessfully quit – it’s a constant learning curve.

    Um, yeah. That got long. But I thought it might offer some perspective on things that would better aid people in quitting.

  3. I have tried to quit many, many times.

    One issue is what Callicebus mentioned, the $4.00 for a pack as opposed to the layout of $50. We can’t really afford either, but it’s easier to come up with $4.00 than $50.00. You can sell plasma and come up with enough to get through a week.

    The other, for me, is that I have to go to work and deal with people all day. I have a customer service job and work in an office full of other people. I can’t be irritable and short-tempered. I’ll lose my job.

    Keith smokes. That makes it difficult.

    And yes, we fit quite nicely into those stats. I have some college, Keith has a high school diploma.

  4. chezjake

    It doesn’t help either that the current “best drug available,” Chantix, only has about a 50% success rate after 6 months and has been recently reported to induce depression in a significant number of users.

    Some hints for wannabe quitters that I’ve picked up over he years:
    – Team up with at least one other person who is quitting in a mutual support and friendly competition arrangement — daily phone calls or other progress reporting, plus a serious wager — first one to smoke has to buy the other dinner at a fancy restaurant, or something like that.
    – In the first couple weeks, have some project to do that involves keeping your hands busy much of the time. Hands that are busily occupied don’t pick up cigarettes.
    – Also for the first couple weeks, drink lots of non-alcoholic, non-caffeinated fluids (one person recommends Gatorade or similar sports drinks) to help flush existing nicotine out of your system.

  5. One word: class.

    I’m not convinced about the existential worries thing; I think what matters is what you think when you are about 13 years old.

  6. Here in Ireland, the number of smokers has increased in the past three years (from 27% to 29%)- a national workplace and (most distressingly) bar ban was introduced some four years ago – it has clearly not worked. The population is highly educated, but we still love our smokes… It may have something to do with our national anti-authoritarian streak, even though it was reported recently that we live in the most regulated society in Europe! I have resisted giving up simply because they (that being any they) want me to. Now that the ban is in for long enough, I can stop without feeling that I was forced to so so. Many smokers start because it is forbidden, mysterious and cool.. But I’ve been drinking too much this evening so I have no idea how to end this meandering missi

  7. Richard Simons

    In the 70s I saw some UK data tying in smoking with occupation, with non-medical biologists being particularly low. This fits with my own experience. At a conference of 250 crop scientists comments were made that just two were smokers, neither of them heavy. Civil servants also had a low rate while, as I recall, medical personnel were close to the average.

    I have been teaching mathematics and statistics to adults in remote northern communities and in each place we have tested to see if the proportion of smokers in the class is higher than the Canadian average. The results have been highly significant at each place even with sample sizes of less than 20, typically with 70% or more being smokers.

    There are clearly large differences between groups of people. I have not followed the reasearch in this area but it would be interesting to know more about what influences a teenager’s decision to start smoking and how this interacts with other choices they make. Why do some people find it easy to stop while for many others who, I’m sure, have similar amounts of willpower, it is extremely difficult?

  8. I got here from Respectful Insolence……

    I used to smoke also. I only smoked about 1/4 pack per day, but it was still very addicting and “routine.” I’ve now been smoke free for 13 weeks today……

    what helped me, was just up and deciding that the pressure was very high to quit, and then the last smoke I had was on my way to school, and when I got home, I wrote on a dry-erase board the number of hours I’d been smoke free. After 48 hours I changed it to number of days. I’d try to go as many days as possible without updating, so I could “surprise” myself…….the last time I’d updated before yesterday, was 15 days before that. So that meant I was going a lot longer without even thinking of when I’d last updated the board….It’s still really hard on me when I see someone else smoking……..makes me crave them. Regardless of how much or how little one smokes, its still very addicting.

    I would wager that when people get off the quitting bandwagon, it’s directly related to major life changes. Change is stressful! I know that very well, because I’m autistic, and I don’t deal very well with stress.

    So…..quitters who’ve come off the bandwagon…..don’t beat yourselves up! PLEASE! Doing so only hurts your future chances of successfully quitting…….if you have to smoke, do it, but don’t obsess over it, and when you think you’re ready to try quitting again, go for it with a positive attitude. Try writing your quit date somewhere, and update it every so often….works for me because I like seeing numbers increase.

    awesome blog, PalMD….enjoy vacation…….

    The Integral of athenivanidx

  9. Usually Not Anon

    Poor and unemployed people have serious existential worries—getting food, keeping a home, staying safe. Smoking may help allay some of these fears and anxieties. Of course, it’s also horribly expensive and bad for you. We’re doing a terrible job. We are enabling our most vulnerable to continue smoking. Fighting tobacco and tobacco-related diseases requires fighting poverty and improving education. It’s a societal problem as much as an individual problem.

    As a smoker who lives in poverty, I can attest to this. While there are certainly people who are doing just fine who also smoke, the rates go up the poorer the demographic.

    There have been times in my life when cigarettes were a substitute for food. I could live with the hunger, but without the comfort of my familiar cigarettes, I was in bad shape. And now days it’s even worse, in spite of the fact that it has been a good long while since I have gone hungry.

    Now I have a family to support. I make enough to cover the bills and little more. We have virtually no safety net, when I get sick or just run out of work for even a week, I have to scrape and borrow to get by and then struggle to catch back up. Living in poverty, means pretty much living in crisis mode 24/7. Even good times like the holidays are a time for acid stomach, trying to figure out how were going to get through it with a roof over our heads.

    Quitting smoking is hard enough, trying to quit while dealing with a crisis is even harder. Which is why a lot of smoking cessation materials recommend that people not try unless they can take some time to relax. Unfortunately, most people in poverty can’t afford the luxury of relaxing. We’re too busy worrying about what we will do if we end up on the street with our family. Or worrying about the thugs our kids are hanging out with. Or worrying that our child might actually become one of those thugs. Or worrying about how we’ll manage even more medical bills if we get injured or really get sick. Or worrying that the next innocent bystander hit by the crossfire will be us or someone in our family.

    Poverty is a crushing force that is hell to attempt to get out of. Smoking OTOH, does all the things that are listed at the end of Pal’s post. It’s expensive and it’s really bad for me, I know this all too well. But when put into contrast with other things that might make me feel the things that smoking does, it’s not very expensive at all.

  10. Much of my work has been in the computer field, with odd stints in call centres. Both seem to have a significant portion of smokers. My suspicion has often been that stress is a contributing factor. The stress experienced in both fields of work can be extraordinary.

  11. anomymous

    Allen Carr’s Easy Way to Stop Smoking has helped many people to quit.

    The technique he advocates must be effective, since he was ignored by the anti-smoking interests and Big Pharma.

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