Low Income Individuals

Why it Matters

  • Individuals with low incomes and/or limited formal education, including the homeless, bear a disproportionate burden from tobacco. Smoking prevalence for this population has not declined at the same pace as for people with high incomes and education.1
  • Individuals with low incomes have more issues with health literacy and may be misinformed about smoking cessation medications.2
  • People with low incomes are just as likely to make quit attempts, bur are less likely to quit smoking cigarettes than those who are not people with low incomes.3
  • Populations of people with low incomes are also more likely to suffer the harmful health consequences of exposure to secondhand smoke.4
  • Every day” or “some days” cigarette use rate by adults by annual household income:5
    •  <$35,000 – 21.3%
    • $35,000 – $74,999 – 14.9%
    • $75,000 – $99,999 – 13.3%
    • > $100,000 – 7.3%
  • People living in poverty smoke cigarettes for a duration of nearly twice as many years as people with a family income three times the poverty rate.6
  • Low income neighborhoods and communities are more exposed to both tobacco retailers and advertising about tobacco.7
    • Tobacco companies often target their advertising campaigns toward low-income neighborhoods and communities.8
    • Researchers have found higher density of tobacco retailers in low-income neighborhoods.9
  • Evidence-based and peer reviewed research on smoking cessation increased slightly between 2000-2004 and 2008-2012. However, research that focused on interventions did not increase. Nor was there a significant increase in research focused on population groups of people with low incomes (as well as people who are homeless, youth who are at-risk,
    incarcerated persons, or people who are indigenous).10
  • This speaks to a limited body of research specific to populations of people with low incomes and tobacco cessation.
  • Providers are often ill-informed regarding tobacco cessation coverage available through Medicaid and/or for individuals who are uninsured. This translates to low rates of tobacco screening and even lower rates of recommending treatment strategies. See Pennsylvania section below for CAHPS data.

What We Know About What Works

  • A study using a pediatric emergency department visit to intervene with caregivers who have low incomes and who smoke found promising results in quit attempts, a reduction in total consumption, and less exposure to children to secondhand smoke. The study also experienced high recruitment results showing that a nontraditional setting can be effective for recruitment.11
  • Integrating therapeutic approaches that promote use of and adherence to medications for quitting smoking and that target stress management and reducing negative affect may enhance smoking cessation among people who smoke and who have low incomes.12
  • In a randomized clinical trial, population-based proactive tobacco cessation treatment appears to be effective in increasing engagement in evidence-based tobacco cessation treatments and for increasing long-term population quit rates among people who are hard to reach, who are socioeconomically disadvantaged, and who smoke.13
    • Intervention included tailored mailings and telephone calls, free nicotine replacement therapy, intensive telephone counseling.
  • A randomized clinical trial using proactive interactive voice response (IVR)-facilitated outreach to eligible individuals using EHR-coded smoking status increased engagement with people who have low incomes and who smoke.  When coupled with access to counseling, NRT, and community-based resources the quit rates were higher than the usual care group. Usual care was also identified via IVR and EHR-coded smoking status but received usual care from their health care team.14
  • A unique federal-state-local-public-private partnership used a systems-change approach to develop an initiative that used Head Start programs to incorporate protocols to engage families in discussions about tobacco use, identify tobacco users in households, build partnerships with groups providing cessation services, and educate families about risks associated with exposure to secondhand smoke. The initiative expanded from pilot to multistate locations to inclusion as part of federal Head Start Standards.15
  • Communications strategies for people with low incomes should expand beyond healthcare organizations because the population is often not engaged in systems of care. Supplemental Nutrition Assistance Program (SNAP), Women, Infants & Children (WIC), 2-1-1, Low-Income Energy Assistance Program are among those entities known to people with low incomes. Messages framed from a “progress” perspective rather than a disparity perspective are
    more motivating, and family and social networks remain a critical avenue for reaching people with low incomes.16
  • Providers are often ill-informed regarding tobacco cessation coverage available through Medicaid and/or for individuals who are uninsured. This often translates to low rates of tobacco screening and even lower rates of recommending treatment strategies. See Pennsylvania section below for Consumer Assessment of Health Plan
    Survey (CAHPS) data.
  • A number of policy initiatives are also effective tools to reduce tobacco use among people with low incomes, including:
    • Raising cigarette prices is “one of the most effective tobacco control interventions” because increasing prices is proven to reduce smoking, especially among youths and people who have low-incomes17,18
    • Barrier-free access to tobacco cessation counseling and medications for the Medicaid population
    • Reducing targeted industry advertising
    • Comprehensive smokefree laws, including e-cigarettes and all localities

What’s Relevant in Pennsylvania

  • Pennsylvania’s tax on cigarettes and little cigars is $2.60/pack. It is $0.55 – $0.66/oz for smokeless tobacco (chew, snuff, loose). There is no tax on cigars. It ranks 13th among state cigarette excise taxes, with Washington, D.C. the highest at $4.50/pack.19
  • In Philadelphia, low-income areas have 69% more tobacco retailers per person than high income areas.20
  • Comprehensive Medicaid coverage for tobacco cessation is a cost-effective proven strategy to reduce tobacco use among people with low incomes.
    • Pennsylvania covers individual counseling, coverage for group counseling varies
    • Medications include: NRT patch, gum, lozenge, bupropion and varenicline. Coverage for NRT nasal spray and inhaler varies.
    • Coverage is not consistent across Medicaid plans, including variation on duration limits, number of counseling visits per year, number of quit attempts, prior authorization, copayments and step therapy.21
  • 2019 Adult Medicaid CAHPS results for the Northeast region are as follows (“Always” and “Usually” responses provided):22
    • Consumer was advised to quit smoking or using tobacco: 56%
    • Provider discussed methods or strategies for quitting smoking or tobacco: 30%
    • How often medication was recommended or discussed to help consumer quit smoking or tobacco (of those with whom provider discussed methods or strategies: 35%
  • Effective July 31, 2018 the U.S. Department of Housing and Urban Development (HUD) mandated that all public housing be smoke-free. This prompted considerable activity and resource development to support the transition to smoke-free housing for residents in public housing with low incomes. Live Healthy PA’s Tobacco and Smoke-Free Multi-Unit Housing Initiative provides information on local resources. https://www.livehealthypa.com/data-resources/resources/healthy-living-practices/healthy-livingpractices-listing/health-living-practices-details/tobacco-and-smoke-free-multi-unit-housing-initiative
  • Southeast Pennsylvania Tobacco Control Project also has housing resources available. https://www.nurseledcare.phmc.org/images/pdf/technical-assistance/2020/Smoking_Cessation_2-13-20_Slides.pdf

What Other States Are Doing

  • The American Legacy Foundation Head Start Initiative was launched in Oregon, Washington, Hawaii, Guam, and the U.S. Associated Pacific Islands (USAPI), and Vermont. It has since evolved into a requirement that the U.S. Department of Health and Human Services has embedded in its Head Start Standards. Head Start must offer parents opportunities to learn about the health risks associated with secondhand smoke, including health and developmental consequences and things they can do to keep their homes safe.23

References and Resources

  1. Kanjilal S, Gregg EW, Cheng YJ, et al. Socioeconomic status and trends in disparities in 4 major risk factors for cardiovascular disease among US adults, 1971-2002. Arch Intern Med. 2006;166(21):2348-2355. doi:10.1001/archinte.166.21.2348
  2. Murphy JM, Mahoney MC, Hyland AJ, Higbee C, Cummings KM. Disparity in the use of smoking cessation pharmacotherapy among Medicaid and general population smokers. J Public Health Manag Pract. 2005;11(4):341-345.doi:10.1097/00124784-200507000-00013
  3. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
  4. Centers for Disease Control and Prevention. Vital Signs: Disparities in Nonsmokers’ Exposure to Secondhand Smoke—United States, 1999–2012.  Morbidity and Mortality Weekly Report 2015;64(04):103–8.
  5. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019; volume 68(issue 45): pages. [accessed 2020 Aug 3].
  6. Siahpush, M, et al., “Racial/ethnic and socioeconomic variations in duration of smoking: results from 2003, 2006 and 2007 Tobacco Use Supplement of the Current Population Survey,” Journal of Public Health, Published online November 5, 2009.
  7. Sweetland J. Framing Tobacco as a Social Justice Issue. Presented to the California Tobacco Control Program, January 10, 2020.
  8. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
  9. Yu D, Peterson NA, Sheffer MA, Reid RJ, Schneider JE. Tobacco Outlet Density and Demographics: Analysing the Relationships with a Spatial Regression Approach. Public Health, 2010;124(7):412–6.
  10. Courtney R., Naicker S., Shakeshaft A., Clare P., Martire K., Mattick R. Smoking Cessation among Low-Socioeconomic Status and Disadvantaged Population Groups: A Systematic Review of Research Output. Int. J. Environ. Res. Public Health 2015, 12, 6403-6422; doi: 10.3390/ijerph120606403.
  11. Mahabee-Gittens E., Khoury J., Ho M., Stone L., Gordon J. A Smoking Cessation Intervention for Low Income Smokers in the Emergency
    Department. Am J Emerg Med. 2015 August. doi: 10.1016/j.ajem.2015.04.058.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4480194/
  12. Bock BC, Papandonatos GD, de Dios MA, et al. Tobacco cessation among low-income smokers: motivational enhancement and nicotine patch treatment. Nicotine Tob Res. 2014;16(4):413-422. doi:10.1093/ntr/ntt166
  13. Fu SS, van Ryn M, Nelson D, et al. Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for
    socioeconomically disadvantaged smokers: a randomised clinical trial.  Thorax. 2016;71(5):446-453. doi:10.1136/thoraxjnl-2015-207904
  14. Haas JS, Linder JA, Park ER, et al. Proactive tobacco cessation outreach to smokers of low socioeconomic status: a randomized clinical trial [published correction appears in JAMA Intern Med. 2015 May;175(5):869]. JAMA Intern Med. 2015;175(2):218-226.doi:10.1001/jamainternmed.2014.6674. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590783/.
  15. Moody-Thomas, S., Sparks, M., Hamasaka, L. et al. The Head Start Tobacco Cessation Initiative: Using Systems Change to Support Staff Identification and Intervention for Tobacco Use in Low-Income Families. J Community Health 39, 646–652 (2014). https://doi.org/10.1007/s10900-014-9827-9
  16. Kreuter M., McBride T., Caburnay C., Poor T. et. al. What Can Health Communication Science Offer for ACA Implementation? Five Evidence-
    Informed Strategies for Expanding Medicaid Enrollment. Milbank Quarterly, Vol. 92, No. 1, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24597555
  17. U.S. Department of Health and Human Services (HHS), The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. https://pubmed.ncbi.nlm.nih.gov/24455788/
  18. CDC, Best Practices User Guide: Health Equity in Tobacco Prevention and Control, Atlanta: HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2015. http://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-healthequity.pdf.
  19. Tobacco & Cigarette Taxes by State, 2020. IGEN excise tax software. https://igentax.com/cigarette-tax-state/#low
  20. The Truth Initiative. Tobacco and Social Justice: Smoking in low-income communities. Jan 31, 2017.
  21. American Lung Association State Medicaid Data Base: https://www.lung.org/policy-advocacy/tobacco/cessation/state-tobacco-cessation-coveragedatabase/states
  22. Agency for Healthcare Research and Quality: CAHPS Aggregated2019 Data for Medicaid Health Plans by Region. https://cahpsdatabase.ahrq.gov/CAHPSIDB/HP/RptBuilder.aspx
  23. The Truth Initiative: Head Start Updates. https://www.truthinitiative.org/research-resources/tobacco-prevention-efforts/head-start-updates-willhelp-protect-children-tobacco

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