You can get garden variety health advice from the daily newspaper, the "health" section of most book stores, and of course thousands of web sites. I'm hoping to present thought provoking and maybe change provoking thoughts about individual and community health. This blog is not just what to do about health, but how to think about it. I'm looking forward to an exchange of ideas with readers. July, 2010


Friday, September 10, 2010

Tobacco and Health Have Nots

Last year I started watching the show Mad Men, and for a number of weeks was really into it.  This is out of character for me because I don't really watch much television, but was fascinated because the show takes place when I was growing up.  Characters on the show are portrayed as adults at the time I was a teenager.  I guess it was a flashback for me.  After a while I had to look away.  It was not good people against bad people that bothered me.  I found it such a bleak and dreary moral landscape, and I couldn't deal with a micro world where people treated each other with complete disregard for respect and decency.  Perhaps that was reality in the business world at the time, but I just couldn't see it as entertaining.  Nevertheless, one of the things so much on display on the show is that every man smoked cigarettes, and most of the women.  There was no hint of social disapproval.  People smoked whenever and wherever, with no thought that someone might object.  Smoking was entirely normative, and viewed as a symbol of success, prosperity, and sophistication.  That was mostly true in those years.

In the 40 plus years that have passed since the time portrayed on Mad Men, profound social change has occurred regarding smoking attitudes and behavior.  While female smoking is up a little since the early 1960s, male smoking has gone down by half.  More than that, smokers are constantly aware that "Yes, I do mind if you smoke!"  You will never see a public figure, unless in a dramatic movie or TV show, smoking a cigarette in public.  It has become something which causes smokers just a little bit of shame. 

For this and other reasons, smoking now is becoming clustered among the outcasts of society.  The educated and affluent are initiating smoking at a smaller and smaller rate, and smokers in this social strata are quitting at a higher and higher rate.  They do this because they are more aware than ever about smoking risks, they are sensitive to the social image of smoking, and they have easy access to cessation resources, including a regular source of primary medical care who is likely to encourage them to quit smoking until they do.

In contrast, smoking is becoming clustered among the poor and those with limited education.  About 21% of all adults smoke cigarettes, while smoking is done by 31% of those living below the poverty level.  For those over the age of 24 (by when most people are finished with higher education), 29% of those who failed to graduate from high school smoke cigarettes but only 6% of those with a college degree. Check here for more information.

These socioeconomic comparisons are becoming fairly well known.  Less understood is the clustering of smoking among those with mental illness.  There is more and more evidence that those with a diagnosed mental illness smoke at a substantially higher rate compared to persons without a history of mental illness.  About 23% of those with no mental illness history smoke; those with some lifetime history, or more recent history smoke at 35% and 41%, respectively.  It is estimated that those with a recent mental illness diagnosis smoke about half of all cigarettes consumed in the U.S.  Incidentally, there is evidence both ways, showing that prior smoking leads to more mental illness, while other evidence suggests that mental illness leads to smoking. Check here for more information.

The frame which comes into focus is that smoking is becoming associated with society's outer limits: the poor, the undereducated, the outcast, and those not quite accepted in mainstream society.  What a stunning change from the days of Mad Men!  It remains a challenge to social justice to find the purpose and creativity to provide prevention and cessation resources tailored to meet the needs of these segments of society.  If we succeed, all will benefit, even the Haves.

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