Smoking is a well-established leading cause of cancer, with decades of research confirming the link between tobacco use and at least 15 different types of cancer. Globally, a vast majority of adults acknowledge smoking as a significant cancer risk factor. Despite this widespread awareness of the dangers, smoking persists, and disproportionately affects certain population groups. Understanding why this disparity exists is crucial for tackling health inequalities and reducing cancer incidence. This article delves into the complex factors behind smoking habits, exploring why some individuals are more susceptible to smoking than others, and what can be done to address this critical public health issue.
The Unequal Burden of Smoking: Health Inequalities
Smoking is not just a personal health choice; it is a significant driver of health inequalities. It is the largest preventable cause of cancer, and because smoking rates and cessation success vary across different communities, it becomes a major contributor to disparities in cancer outcomes. Certain populations face a higher risk of smoking and encounter greater challenges in quitting, exacerbating existing health inequities.
Professor Jamie Hartmann-Boyce, an expert in evidence-based medicine from the University of Oxford, highlights these vulnerable groups. “We know that there are certain groups in the population who are more likely to smoke. Those include people in deprived areas, people with mental health conditions, and the LGBTQ+ community,” she states.
Individuals from disadvantaged backgrounds often experience more severe nicotine addiction, tend to initiate smoking at a younger age, and consequently face greater obstacles when attempting to quit. Furthermore, disparities exist in access to cessation resources such as medications and behavioral support, which should ideally be readily available to everyone seeking to quit smoking. Stop smoking services, which provide crucial medications and counseling, are not uniformly accessible across all regions, even though they are proven to significantly enhance the chances of successful quitting.
However, unequal access to cessation support is only one facet of the problem. To comprehensively understand smoking disparities, it’s essential to investigate the underlying factors that predispose individuals to smoking in the first place.
The Roots of Smoking: Understanding the Underlying Factors
Health behaviors, including smoking, are shaped by a complex interplay of factors, often referred to as the ‘wider determinants of health.’ These encompass the cumulative pressures and opportunities encountered throughout life, alongside current living conditions.
“There are a number of forces at play, and I think it’s important to note that most people who start smoking do so as children,” explains Professor Hartmann-Boyce. The tobacco industry has meticulously engineered cigarettes to maximize their addictive potential. Starting smoking in youth often leads to entrenched addiction by adulthood, making cessation incredibly challenging, particularly without adequate support.
Children’s vulnerability to smoking is heavily influenced by their environment and social context, with family environment, especially parental smoking habits, playing a significant role.
“If your parents smoke you are much more likely to smoke and continue to smoke, and so that creates a cycle,” Hartmann-Boyce points out. A child growing up in a less deprived area benefits from greater protection against factors that might encourage experimentation with cigarettes, compared to a child in a deprived area facing multiple risk factors.
In practical terms, a child in a more deprived environment might be more likely to live with smokers, reside near numerous outlets selling cigarettes, encounter frequent tobacco imagery in media, and have peers who smoke. This constant exposure normalizes smoking and diminishes the perceived risks, even if children are aware of the health hazards. The pervasive presence of smoking in their immediate environment, including family and friends who are themselves subject to similar pressures, undermines the effectiveness of health warnings.
The Sinister Role of the Tobacco Industry
While individual circumstances are undeniably influential, the role of industry cannot be ignored. In the case of tobacco, the pursuit of profit has consistently overshadowed public health concerns. The tobacco industry has a long history of actively promoting smoking through various channels, including aggressive advertising, ensuring easy access to products, and maintaining high product visibility in retail environments.
Recognizing this, national policy measures restricting tobacco marketing have proven highly effective in reducing smoking rates. Hartmann-Boyce notes, “If you think back 20 years, cigarettes were a lot more visible than they are right now and that is thanks to things like smoking and advertising bans, point of sale, display bans etc.” These regulations have coincided with sustained declines in smoking prevalence in the UK.
However, the tobacco industry remains adept at finding new avenues to recruit smokers, understanding that early initiation is crucial for long-term customer loyalty. By meticulously studying their target demographics and the factors that increase smoking susceptibility, the industry employs sophisticated, targeted marketing strategies to cultivate dependable customer bases within specific segments of society.
“There’s evidence of the tobacco industry really putting a lot of effort into targeting specific groups,” explains Hartmann-Boyce. The LGBTQ+ community, for instance, has been a specific target for tobacco industry marketing efforts. Historically, this targeting was overt, including promoting smoking in LGBTQ+ media outlets, sponsoring pride events, and running targeted advertising campaigns in LGBTQ+ publications. A particularly egregious example is ‘Project SCUM,’ an alleged campaign from the 1990s aimed at boosting sales among gay and homeless populations in San Francisco.
Even today, the tobacco industry continues to profit significantly from the LGBTQ+ community. Data from 2018 indicates that smoking rates were considerably higher among individuals identifying as gay or lesbian (22.2%) compared to heterosexual individuals (15.5%).
Smoking and Mental Health: A Vicious Cycle
Beyond industry targeting, numerous interconnected factors contribute to elevated smoking rates in marginalized groups. Notably, there is a considerable overlap between groups at higher risk of smoking and those more likely to experience mental health difficulties, such as LGBTQ+ individuals and those living in deprived areas. People with mental health conditions themselves also face a heightened risk of smoking.
These overlaps are not coincidental. Health inequalities, economic disparities, and social marginalization are deeply intertwined. Addressing health inequalities requires collaborative action across various sectors of government and society, extending beyond just healthcare. It is crucial to examine the direct drivers of smoking within specific populations.
One contributing factor to the link between smoking and mental health is the perceived stress-relieving effect of smoking. Some individuals view smoking as a calming activity or a coping mechanism in stressful situations. Even some mental health professionals have expressed hesitation in encouraging their patients to quit, fearing it might add to their existing burdens.
However, this perception is misleading. The temporary relief from stress experienced when smoking is actually the alleviation of nicotine withdrawal symptoms between cigarettes. In reality, nicotine withdrawal itself is a source of stress. Research consistently demonstrates that smoking cessation leads to genuine and lasting improvements in mental health.
Breaking Free: How to Quit Smoking
Considering the powerful influence of wider determinants of health, industry targeting, and unequal access to support, it is understandable why certain groups face greater challenges in adopting healthy behaviors and are disproportionately affected by tobacco-related harms. While these systemic factors can feel overwhelming, individuals seeking to reduce their cancer risk by quitting smoking should not feel discouraged.
“There are definitely things that an individual who smokes can do to increase their chances of successfully quitting,” assures Hartmann-Boyce. A range of effective options are available, including medications, nicotine replacement therapy (NRT), behavioral support, and nicotine-containing e-cigarettes.
The most effective approach is combining prescription medication with behavioral support from free, local stop smoking services. This combination triples the likelihood of successful quitting compared to relying on willpower alone.
Hartmann-Boyce offers further encouragement: “The important thing is to remember is that you can keep trying, so just because you haven’t succeeded once, doesn’t mean you won’t succeed next time. Most people who successfully quit smoking have tried multiple times.”
Collective Responsibility: Government and Public Health
While individual actions are important for reducing personal cancer risk, population-level health outcomes are largely shaped by wider determinants of health. Factors like smoking, despite often being framed as individual choices, are heavily influenced by societal and environmental factors, creating an illusion of free choice and individual responsibility.
This illusion benefits industries that profit from unhealthy products and addiction, while simultaneously obscuring the government’s significant role and responsibility in safeguarding public health. Governments have substantial power and a clear obligation to protect populations at higher risk of tobacco-related harm.
Across the UK, governments must implement ambitious and comprehensive tobacco control strategies aimed at ultimately eliminating smoking. These strategies should encompass bold new policy measures to prevent smoking initiation, such as introducing dissuasive cigarette packaging or raising the minimum age of sale to 21. Furthermore, improving the accessibility and reach of existing stop smoking services is crucial to support those who already smoke in their quit attempts. Adequate funding is essential for these initiatives, and it is only fair that the tobacco industry, as the manufacturer of such harmful products, should bear the financial burden.
Therefore, advocating for a ‘polluter pays’ principle is vital. This would involve requiring Big Tobacco to contribute financially to address the harms caused by their products, without granting them any influence over how these funds are utilized.
Rachel Orritt is a health information manager at Cancer Research UK
*UK-wide survey of 2,446 adults, Cancer Research UK’s Cancer Awareness Measure (September 2021)
