Why People Smoke: Addressing the ‘Causes of Causes’ of Health Inequities

As we approach the tenth anniversary of the release of the World Health Organization’s (WHO’s) report on the social determinants of health, the American College of Physicians finally released a position paper recognizing the need to address the social determinants of health to reduce health disparities and promote health equity.

Social determinants of health

Healthy People 2020 defines the social determinants of health as “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”. However, limited progress has been made in meeting the national objectives for improving the health of Americans, with only 15 out of 33 (45.5%) of the social determinants of health objectives improving since 2010.

Now that health and public health professionals are on the same page regarding the social determinants of health, we all need to work together to address what epidemiologist Geoffrey Rose termed the ‘causes of causes’ or the underlying causes of disease, to ensure that every American has access to the conditions of daily living that lead to good health.

We have known for decades that social factors are associated with poorer health. In 1978, Michael Marmot and colleagues found that lower social class was associated with a higher risk of death from coronary heart disease (CHD), and that social class was a stronger predictor of CHD death than other known medical and behavioral risk factors. In 2000, it was estimated that approximately 245,000 deaths in the United States were attributable to low education, which was higher than the number of deaths attributable to acute myocardial infarction, the leading medical cause of death.

Despite this knowledge, the focus of health and public health professionals has been on the identification and modification of the more immediate behavioral factors related to ill health–smoking, dietary excesses, and inadequate physical activity. Unfortunately, interventions directed at these immediate factors may not lead to substantial or sustainable improvements in behavior change or health outcomes.

Applying the World Health Organization’s recommendations

By turning our focus toward implementing the recommendations of the WHO’s report, such as: (1) improving daily living conditions, (2) equitably distributing the structural drivers of conditions of daily life (i.e., power and resources), and (3) evaluating the impact of action, we may better address the ‘causes of causes’. As Geoffrey Rose points out in his book, “The Strategy of Preventive Medicine”, it is not enough to know that lung cancer is caused by smoking; we need to know why people smoke. As it turns out, there is a strong relationship between social factors and smoking: both poor people and people living in poor neighborhoods are more likely to smoke.

Applying the WHO’s recommendations to reduce health disparities related to smoking, we could improve daily living conditions by alleviating poverty and stress, and promoting healthy behaviors in neighborhoods through urban policy. Smoking may be a coping mechanism, particularly among those who are stressed and living in poverty. Therefore, reducing poverty and stress may decrease smoking initiation and intensity, and increase smoking cessation. Local retailer-oriented urban policy that limits the number of stores selling cigarettes, particularly in poor neighborhoods, may reduce economic disparities in cigarette use

To equitably distribute the structural drivers related to smoking, we could better regulate tobacco use and sales, and provide more funding for tobacco prevention and control programs. Local governments could implement smoke-free laws in multiunit housing structures, worksites and restaurants. State and federal governments could impose higher tobacco taxes. State taxes on cigarettes range from 17 cents per pack in Missouri to $4.35 per pack in Connecticut and New York. Interestingly, the proportion of adults who smoke is lower in states that have higher taxes. A study found that after implementing a state tax increase on cigarettes, low-income adults were more likely to make behavioral changes toward smoking cessation compared to higher income adults.

Currently, a mere 2.6% of the $27.5 billion that states receive from taxes and the 1998 tobacco company settlement is used toward tobacco programs. The Surgeon General’s report on the health consequences of smoking notes that states that have made greater investments in tobacco control programs have seen greater decreases in cigarettes sales and the proportion of people who smoke. Overall, increases in tobacco taxes and a more serious commitment toward funding tobacco prevention and control programs may further reduce economic disparities in cigarette use.

In terms of evaluating the impact of action, we need to fund and perform additional research to gain a better understanding of the relationships between social factors and smoking, and to assess which of the above interventions are more likely to reduce health disparities related to smoking.

Pathway forward

To date, most research has been conducted as nonexperimental studies, where the effect of an intervention is assessed among groups that are not completely comparable. These types of studies may lead to biased or incorrect results. Randomized controlled trials that randomly assign people or neighborhoods to receive an intervention are able to assess the causal effect of a policy on health disparities, yet these trials are costly and potentially infeasible. Therefore, novel research methods will be needed. One such method is complex systems modeling, computer modeling that can simulate the effect of implementing one or more interventions among artificial people living in artificial cities.

The Congressional Budget Office (CBO) conducted a hypothetical analysis of a 50-cent per pack increase in federal tax on cigarettes and small cigars. During the first ten years of the tax increase, CBO estimated that health care spending and the proportion of adults who smoke would decrease, while federal revenue and longevity would increase. In particular, federal revenue was estimated to increase by $38 billion from taxes and by $3 billion in earnings from better health that allowed people to work and be more productive. Surely implementing policies that decrease spending by Medicare and Medicaid, and that lead to healthier self-sufficient people is something that we can all support.

To reduce health disparities, we must address the social determinants of health using a multifaceted and multilevel approach. While there has been a gradual recognition that the social determinants of health are fundamental causes of health inequities, let us not wait another 10 years before we–health and public health professionals, governments, and community organizations and members–all act to address these inequities.