A GTNF panel puts “forgotten smokers” in the spotlight.
Cheryl K. Olson
Skip Murray used to be one of the forgotten smokers. “I think people that have a life like my background are invisible to the people who have more influence in the world,” she says. “I hate to use class terms, but lower class.” Heavy drinking and mental illness ran in her family. Her memories include events psychologists would call “adverse childhood experiences.”
When Murray started smoking at age 10, no one paid any mind. Today, in her sixties, she gets her nicotine from a vaping device. She and her son (who suffered a heart attack at age 29) both used vapor products to quit cigarettes.
People who smoke find that their needs and views are routinely neglected by policymakers, physicians and other potential sources of support. Research shows that cigarette use is increasingly concentrated in what public health people describe as “vulnerable populations.” Some lack resources or homes, are challenged by physical or mental illnesses or are incarcerated. None want to be lectured to or labeled.
On Sept. 28, the Global Tobacco and Nicotine Forum (GTNF) will literally put a spotlight on these issues in a plenary event on “forgotten smokers.” Panelists will share personal experiences and research on ways to raise empathy and visibility for people who smoke and ideas to spread the benefits of harm reduction more equitably. They include Alex Clark, CEO of the Consumer Advocates for Smoke-Free Alternatives Association (CASAA); Will Godfrey, founding editor-in-chief of the Filter news site and executive director of the Influence Foundation; Skip Murray, a Minnesota-based vaping advocate and former vape shop owner; and Brent Taylor, senior director of consumer and marketplace insights at Altria. I will moderate the panel.
Who’s Still Smoking?
In 1965, 42 percent of adult Americans smoked. According to the U.S. Centers for Disease Control and Prevention (CDC), as of 2020, just 12.5 percent, or 25 of every 200 adults, were smoking. Sounds great! But with population growth, the absolute number is still huge: Almost 31 million adults use combustible cigarettes. The plummet in smoking rates has slowed to a crawl because the easy wins are over.
No job, or a poverty-level income. No high school diploma. Serious psychological distress. Disabilities that limit daily activities. Heavy alcohol use. Data from hundreds of thousands of people interviewed for the CDC’s National Health Interview Survey from 2008 to 2017 found that the more of those socioeconomic and health-related disadvantages you face, the more likely you are to start smoking and the less likely you are to quit. The majority of people who quit smoking during that period had zero or one disadvantage.
Sixteen million Americans live with a smoking-related disease, says the CDC. And the fallout is concentrated among those who can least afford it. Those who lack health insurance or use Medicaid are more than twice as likely as those with private insurance to smoke.
Before Covid-19 shutdowns and media-driven fears about vaping safety shuttered her business, Murray and her adult son sold e-liquids and vaping equipment to low-income and disabled nicotine users. “If you make $60,000 a year, you can afford not to smoke if you don’t want to,” she says. “But when you’re surviving on 20 grand a year or less, on a Social Security or disability check—if we don’t keep vaping affordable, and cheaper than smoking, people will smoke.”
The Case of People in Custody
A good example of the link between compounded disadvantages and smoking is found in jails and prisons. People in custody smoke at roughly four times the rate of those “outside,” and most have a history of other substance use. Historically, cigarettes fill multiple important roles in these settings. According to a World Health Organization report, “Tobacco use is completely entangled in prison life where it helps to cope with boredom, deprivation or stress, relieve anxiety and tension and function as a source of pleasure or monetary value in an environment without currency.”
Researching the plight of those held in officially “smoke-free” prisons was eye-opening to me. One recently incarcerated person we interviewed described watching guards spit out chewing tobacco that was quickly scraped up by prisoners to re-chew or to save for later smoking. “That’s how desperate some of these guys are,” he said. “Tobacco in jail is basically air.”
Another said, “People in jail crave tobacco. They want to relieve stress, and that’s a stress-reliever. I actually thought, when they took tobacco away, I thought there were going to be riots.” When cigarettes were banned in his facility, e-cigarettes were introduced. “Now, if they take this [vaping] away, there might be riots,” he said.
Vaping has been introduced with great success as an alternative to smoking in Scotland’s prisons and in some U.S. facilities (with vapes specially designed for safety and trackability). My public health colleagues often think of e-cigarettes exclusively as a health risk to teenagers. I’ve found that talking about vaping in the context of the traumas and needs of people in custody reframes the issue. At the GTNF, Godfrey will say more about this vulnerable population as well as the links between harm reduction for tobacco and for other substances.
Nicotine and Mental Health
Murray has been open about her lifelong mental health struggles and how she perceived the effects of nicotine on her brain. “When I stole my grandpa’s cigarette and snuck it behind his barn, from day one, I liked smoking,” she says. “It wasn’t icky to me. I felt better.”
When she finally sought professional help decades later, after attempts to quit nicotine led to suicidal thoughts, Murray received multiple diagnoses. After initially struggling with shame—“You hear stigmatizing things your whole life that you just accept as true”—she went public on social media with her story. “It was amazing how many people went, ‘Oh my God, me too,’” she says. “And amazing how many say they are self-medicating with nicotine.”
She finds relief from symptoms of attention-deficit/hyperactivity disorder through mindfulness practices and vaping nicotine. “And it helps me sleep. For most people, nicotine is a stimulant, but for people with ADHD, it has the opposite effect.” Many laboratory and real-world studies support the self-medication hypothesis for a range of mental health disorders, from depression to ADHD to schizophrenia.
Understanding the Harm Reduction Journey
New approaches are needed to help forgotten smokers who can’t or don’t want to quit nicotine find lower-risk options that work for them. An obvious next step is to stop blaming and start listening.
“We need to make sure that we bring the voice of the adult tobacco consumer into the center of the discussion about tobacco harm reduction,” says Taylor. “We need to spend time getting to know the individuals, what this means to them and what it can mean if they are successful in their harm reduction journey.”
At the GTNF, he’ll share insights from a recent deep dive into the daily lives of smokers trying to reduce their health risks, called the 21 Project. Named for the popular notion that it takes 21 days to change a habit, the Altria project recruited 21 smokers interested in making a change. Armed with information about the array of reduced-harm recreational nicotine products available, these individuals spent three weeks testing alternatives to cigarettes on their own. Researchers documented their stories of the day-by-day transition.
“You can review numbers and bar charts, but what you never get from them is the heart and feelings of the adult tobacco consumer,” says Taylor. “How do you take the experience of moving from cigarettes to smoke-free alternatives and bring it to life so that everyone can feel and understand what that’s like?”
Taylor is himself a former smoker who now uses alternative products. “Hearing the stories of people who smoked and switched to smoke-free alternatives was powerful and really emotional,” he says.
He says the 21 Project taught invaluable lessons to his organization about how to support and empower people in making changes. “We learned a ton; to hear firsthand people’s challenges and successes and what would sustain them on their transition journey was critically important.”
Adding to that perspective will be Clark of CASAA, which has long worked to highlight the issues facing nicotine consumers. Clark would like to do away with the victim narrative that casts people who smoke as dupes swayed by peer pressure and advertising.
“Even with a growing awareness of the need to address issues of health, racial and economic equity, the legacy of stigma embedded in anti-smoking policies is leaving millions of people behind,” he says. “The overweighted focus on predatory marketing as the driver of youth tobacco use is ultimately dismissive of more powerful underlying factors contributing to any substance use.”