Op-Ed/Editorials: Lay Epidemiology and Smoking Rates in Social Classes


Researchers and the public have observed the relationship
between social class and likelihood of smoking; for example, professionals are
less likely to smoke than unskilled laborers (Petersen, Mockford, & Rayner,
1999; Wald, Kiryluk, Darby, Doll, Pike, & Peto, 1988). In a recent
commentary, Lawlor, Frankel, Shaw, Ebrahim, and Smith (2003) claim that lay
perceptions of quality of life disparities between social classes best explain
differential rates in smoking. They argue that poor housing conditions,
occupational hazards, and other environmental dangers all pose a more immediate
threat to health than smoking. As a result, for the poor, smoking becomes a
rational choice. Indeed, when coping with such day-to-day challenges, quitting
smoking seems less of a priority and comparatively might have lesser benefits:
if a person is not likely to live long enough to experience the negative
consequences of smoking, giving up the pleasures smoking provides might not seem

Poverty is undoubtedly a major contributor to disparities in
general health. Poverty also contributes more specifically to the continuation
of smoking in lower socio-economic groups. To effectively address smoking
addiction among the economically disadvantaged, one must also account for the
powerful psychological influence of poverty. The persistent resistance of
disadvantaged populations to past and current anti-smoking initiatives is a
“rational response within a particular cultural context” (Lawlor et al., 2003,
p. 266). The “cultural context” is an expression of the psychological impact of
living in poverty with all of its sequelae. One illustration of this
circumstance relates to problem gambling: people of lower socio-economic groups
tend to spend a greater proportion of their income gambling than their more
affluent counterparts because they seemingly have more to gain by winning. The
hope and desire to relieve financial problems by a large gambling win minimizes
the perceived risk of gambling and perhaps rationalizes the amount of money
lost—after all, the poor will not become poor by losing, but they might become
wealthy, even if it is only a remote possibility. This is the psycho-economics
of gambling. There is a similar psycho-economics of smoking. Smoking might seem
less dangerous to those living in poverty because this population has less to
gain by quitting; the wealthy have more to lose by not quitting.

It is also important to consider the global cultures
represented in impoverished populations when defining the “cultural context.” In
Britain, for example, ethnic minorities are much more likely than whites to fall
in the low-income bracket. In 2001, 68% of Pakistani and Bangladeshi households,
49% of Black Non-Caribbean households, and almost 40% of “other” households in
Great Britain were considered “low income;” comparatively, only 21% of White
households were low income (National Statistics: United Kingdom, 2001). Hence,
economic social groups are in many ways heterogeneous and are unlikely to hold a
single common rationale for smoking.

Though Lawlor et al. acknowledge that medical and public
health approaches to smoking intervention have reduced smoking rates
successfully across socioeconomic groups, they note that these approaches have
not been particularly successful with impoverished segments of the population
and question their validity. They argue that such interventions distract from
the real issue—social inequality. Dismissing current medical and public health
prevention models seems too drastic a response to the powerful influence of
poverty. Current treatment models have proved to be effective tools for some
people attempting to quit smoking. This is because these approaches address the
chemical components of nicotine addiction common to all who try to quit smoking.
Now, it is time to adjust these models to be more effective across social
groups, account for differences that might lie within, and draw more attention
to the socio-economic differences among population groups that increase
resistance to stopping smoking.

The effects of smoking pose a great threat to the health of
those who engage in this activity and those around them. Therefore, it is
important to find interventions that are effective regardless of socio-economic
attributes. Socio-economic status seems to have a marked impact on both the
likelihood of smoking and the motivation to quit. It is time to increase our
collective efforts to deal with both the physical and psychological consequences
of poverty. Both of these conditions deserve more scientific attention. Current
medical and public health approaches to smoking intervention should not be
scrapped, but new efforts can make these strategies more effective. To
accomplish this goal, health workers must consider and address the physical and
psychological manifestations of poverty, as well as the rich diversity of social

What do you think? Comments on this article can be addressed to Siri Odegaard.


Lawlor, D. A., Frankel, S., Shaw, M., Ebrahim, S., &
Smith, G. D. (2003). Smoking and ill health: Does lay epidemiology explain the
failure of smoking cessation programs among deprived populations? American
Journal of Public Health, 93(2), 266-270.

Petersen, S., Mockford, C., & Rayner, M. (1999).
Coronary Heart Disease Statistics: British Heart Foundation Statistics Database
1999. London, England: British Hearth Foundation.

Wald, N., Kiryluk, S., Darby, S., Doll, R., Pike, M., &
Peto, R. (1988). UK Smoking Statistics. Oxford, England: Oxford University Press

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