04/06/2019
Saimon Islam
POV 101- Introduction to Poverty Studies and Human Capabilities
Charred Lungs of the Working-Class Marlboro Man:
Impact of Smoking on Lower Income Communities
In POV-101, we discussed the impact of several variables like education, health, environment, income etc. on low income individuals and communities. But due to time constraints, we could only discuss so many aspects of poverty. In my understanding, the most important poverty related issue we did not discuss in depth in our class is smoking and poverty. I believe that smoking is one of the most important poverty related aspects because it is one of the main factors behind a sustained state of poverty, the systematic structure of smoking oppresses low-income communities, and there are several ethical objections to how we have tried solving the problem of smoking. I will expand on how smoking exacerbates poverty by showing how an overwhelming majority of the smokers in the US are from the low-income population and how they spend a higher percentage of their income on smoking, lowering their net disposable income for other needs. I will show how smoking and exposure to smoking impacts their health and capabilities, thus exacerbating their poverty. Then I will show how the structure of smoking is oppressive by showing that the tobacco companies have exploited the poor through marketing, and the socio-political treatments of smokers fit Marion Young’s five faces of oppression theory. Furthermore, I will show that the structural difficulties of quitting smoking for the poor violate the preconditions argument Mead outlines in Welfare Reform and Political Theory. And finally, I will raise ethical and functional objections on two anti-smoking platforms US industries and local governments have undertaken, namely sin taxes and corporate non-inclusion. I will evaluate the success of sin taxes on low income households and show that they fail the consolidation objection from Stuart White and the non-inclusion policy of private entities violate Rawls’ equal basic liberties.
While the national smoking rate has fallen to historic lows in recent years, with just 15% of the adult population still smoking, cigarettes are becoming the habit of the poor. According to CDC, around 32% of the population around poverty level use tobacco. While smoking overall has decreased drastically in the last 50 years, the uneducated (some high school) have only reduced smoking at half the rate when compared to college graduates (Wan, 2017). And this disparity between smoking patterns based on socio-economic status has been widening. People living in poverty smoke for a duration of nearly twice as many years as people with a family income of three times the poverty rate. Similar patterns hold for people with high school education and college degree. People of low socio-economic status also start smoking at a younger age and smoke more heavily (CDC). And it gets worse as we go down the socio-economic ladder, the homeless and the unemployed are hit the hardest. Around three quarters of homeless adults use tobacco. When we account for multiple markers of low socio-economic status, we see that, “Americans with lower socioeconomic status today are suffering from epidemic smoking rates, and they make up nearly three-fourths of all our remaining smokers (Levinson, 2017)."
Considering smoking is expensive, and with ever-increasing sin taxes, will continue to become even more expensive, and around 72% of smokers in America are poor, it’s no wonder that the poor have been disproportionately affected financially by smoking. If we just consider the amount of money spent, the average spending on tobacco for a heavy user ranges from $2000-$4700 a year. Additionally, there’s an average 15-20% monthly premium on health insurance. Many studies have shown that in the poorest households in many low-income countries, spending on tobacco products often represent more than 10% of total household expenditure. As a result, these families have less expendable income for necessities such as food, education and health care. Similar results were found among homeless adults. From Duflo and Banerjee’s data on spending habits of the poor, we have seen this pattern holding in developing and under-developed nations as well.
By far the biggest impact of smoking on the poor comes in the form of health problems and reduced capabilities. The connection between long term smoking and lung cancer has been well established in the medical community. According to CDC, people with less education, income near the poverty line, and generally low socioeconomic status have higher rates of lung cancer than the average. Over 480,000 deaths every year are attributable to smoking and a disproportionate amount of that are people from low socioeconomic status. The low-income population are also at risk from second hand smoking (henceforth addressed as SHS) at double the rate (43% to 21%) from their white-collar counterparts, causing 10% of all tobacco-related death. The children are at high risk, with over 40% exposed to SHS (MMWR, 2015). Additionally, WHO stated that tobacco use accounts for a significant share of the health disparities between the rich and poor” worldwide. From Currie’s Inequality at Birth, we have seen the large and persistent inequalities in health at birth between the poor and others, and how it’s a predictor of important future outcomes such as income, earnings, education etc. Smoking is one of the key factors determining health at birth (low birth weight) and early childhood health (developmental risks, neurological and mental disorders) contributing to the future outcomes by impacting capabilities (lifelong risk of obesity, diseases) (Nicogossian, 2016).
Considering the link between smoking, income, and health impacts, we can safely determine how Tobacco and poverty have become linked in a vicious circle, through which tobacco exacerbates poverty and poverty is also associated with higher prevalence of tobacco use.
Two of the five faces or types of oppression Marion Young outlines in Justice and Politics of Difference matches the nature of targeted marketing of tobacco products by the tobacco companies, and the social treatment of smokers. Young explained that oppression takes five major forms: exploitation, violence, marginalization, powerlessness, and cultural imperialism. I will expand on how aggressive marketing tactics amount to exploitation and the marginalization of the smokers that arises from social treatment.
Since low-income communities are the most valuable and consistent consumer bases for the tobacco industry, Big Tobacco has historically exploited the lack of education, services, resources and social supports via point-of-sale promotions, denser concentration of retailers, bright advertising, and targeted products towards youths and African-American communities. There are an estimated 375,000 tobacco retailers in the US, and they are disproportionately located in low-income communities. For example, in Philadelphia, the low-income neighborhoods have 69% more tobacco retailers per person than high-income areas (TruthInitiative, 2017). They are also more likely to be near schools and communities with minority populations (Smith, 2010). Tobacco companies have also targeted their marketing on low socio-economic status women since the late 70s, by distributing discount coupons with food stamps to reach the very poor, discount offers at point-of-sale and via direct mail to keep cigarette prices low. Additionally, they have developed new brands for low-income women and targeted commercials towards poor African-American women (Brown-Johnson, 2014). Furthermore, since retail marketing make up over 95% of the industry’s marketing expenditure, more retailers in poor communities mean the community members are more exposed to the marketing. Like Young explains the Marxist theory of exploitation as oppression, the tobacco companies use capitalist marketing tactics to oppress the poor.
In our effort to denormalize smoking, we have engaged in large-scale anti-smoking campaigns, created smoke free air laws, limited selling cigarettes to the young in local areas and made a public effort via social media and media to make smoking scary rather than cool like the days of the old. However, in doing so, we have largely stigmatized smoking in social situations, excluded them in designated areas, resulting in marginalization of the poor. Marginalization is the act of relegating or confining a group of people to a lower social standing or outer limit or edge of society. Overall, it is a process of exclusion. Young argues that marginalization is perhaps the most dangerous form of oppression. In the case of smoking, this is indirect marginalization of the poor. Research has shown that smokers are an increasingly marginalized population, involved in fewer organizations and activities and with less interpersonal trust than nonsmokers. Furthermore, this marginalization may also extend beyond the interpersonal level to attitudes toward political systems and institutions (Albright, 2015). This marginalization is creating an environment where the smokers feel socially disconnected, and it is resulting in further isolation as research is showing that they are significantly less likely to vote as well. Case studies have shown that boredom, isolation are significant factors for the poor to smoke. Under Young’s frame, even if the poor here are not being materially harmed via stigmatization, the injustice remains in the form of boredom and lack of self-respect. Smokers feel less welcome in social activities, and social structures and processes that close persons out of participation in such social cooperation are unjust (Young, 55). And we see this exact impact in different studies. One study shows that legislation such as plain packaging and designated smoke-free zones served to "denormalize" smoking, which can lead to smokers being treated as community outsiders (ANU, 2016). Another study on current and former smokers show that overwhelming majority of the participants agreed that “Most people would not hire a smoker to take care of their children” (81%) and that “Most non-smokers would be reluctant to date someone who smokes” (72%). Moreover, around a third of them agreed with the perception that “Most people believe smoking is a sign of personal failure” and, “Most people think less of a person who smokes” (Stuber, 2008).
While there is a growing concern about the stigma and how it marginalizes people, we cannot deny the positive impact of anti-tobacco public health campaigns. They focus on raising awareness about the health consequences of smoking and denormalizing smoking behavior, thereby motivating prevention among the general public and motivating smokers specifically toward cessation. In the last decade, there has been a 12% drop in the smoking rate of 18-29-year-old (Riley, 2017). Furthermore, Smoke free air laws in bars have been greatly effective. They significantly reduce the chances of smoking initiation and reduce heavy initiation by 2-4% and the positive effect is larger on young people. The laws also reduce relapse into heavy smoking (Shang, 2014). However, we can all agree that we can try to come to a sweet spot of maximizing impact and reducing the stigma on smokers and their marginalization.
While we see similar quitting attempts between the people of low socioeconomic status and high status, the failure rate among the poor is significantly higher due to some structural disadvantages, violating Mead’s precondition criterion. CDC data shows that around 66.6% of smokers below the poverty line attempt to quit smoking compared to the 70% of those living at or above poverty level. And people with no high school diploma have a 39% attempt rate versus 44% of those with some college education. However, there’s a 23% gap between the people below and above the poverty line and a 30.5% gap between college educated and high school dropouts. A new survey shows that affluent counties across the nation have experienced the biggest, and fastest, declines in smoking rates, while progress in the poorest ones has stagnated. The findings are particularly stark for women: About half of all high-income counties showed significant declines in the smoking rate for women, but only 4 percent of poor counties did (Tavernese, 2014). Clearly, education is one of the largest markers to understand and acknowledge the negative consequences of smoking. In poorer rural counties, it is often not even considered as a problem. Also, smoking cessation is expensive. Most smokers who are poverty stricken can’t afford sustaining buying drugs for cessation. Clinics and nicotine replacement therapy also aren’t valid options for them. Studies have shown that high prevalence and acceptance is another structural barrier for cessation programs in low socioeconomic communities. The high prevalence of cigarettes is directly linked to the exploitative nature of tobacco marketing campaigns. Moreover, since the blue-collar workers statistically smoke more and are more exposed to SHS, it is harder for them to avoid smoking and maintain a successful quitting pattern. Mead argues regarding welfare that to impose welfare conditions, certain preconditions should be met first, giving the recipients the capabilities to meet the conditions and fulfill the intended goals. Without meeting them, imposing conditions would be unethical. A similar argument can be drawn here. In poorer communities, there is a lack of social and medical support, and there is a lack of education in general. These elements are crucial in smoking cessation programs. Unless we can improve the level of education and provide access to trained health professionals and support, we do not meet the preconditions to successfully quitting a strong addiction like smoking. Therefore, to meet Mead’s precondition standard, we must try to remove these structural barriers to help the low-income communities get the same opportunity to quit smoking as the high-income communities.
In the plethora of anti-smoking measures introduced by local, federal governments and private entities, two measures stand out the most as both effective and problematic, namely sin taxes and barring smokers from employment. Federal government, state governments and sometimes city councils impose excise taxes on products and services which are considered to have negative social impacts, such as gambling, liquor, tobacco, pornography etc. One of the biggest reasons for the differences in cigarette prices across states is state cigarette taxes. The taxes, in addition to generating revenue for the state government, act as deterrents to smoking in an attempt to improve public health. States such as New York, and Massachusetts have the highest cigarette taxes in the US ($4.35/packet for New York, $3.51/packet in Massachusetts, $1.50 NYC tax) while Virginia and Missouri have the lowest state taxes on cigarettes. Majority of available studies on sin taxes reported significant impact on consumption effects for low income, low education populations. Low income people tend to reduce their consumption of things like alcohol or tobacco in response to tax increases. For tobacco in particular, “These health benefits translate into economic benefits down the line because these people become more productive on their jobs and they have better-paid jobs that end up offsetting any taxes that they may be paying, more than high-income people.” If these economic tools are used to reduce consumption among the poor, it turns out the poor may be benefited more than others because they are going to save money on medical costs (Young, 2018). For behavior modification incentives, taxes work the most efficiently.
However, a central ethical concern regarding the impact of sin taxes on cigarettes on low socio-economic status groups is whether the taxes are equitable and in violation of consolidation principle. White explained that if a policy meant to benefit a particular target group end up consolidating their struggles, then that policy is subjected to the consolidation objection. Sin taxes on tobacco are often argued as regressive tax on the poor. A tax is regressive if lower incomes are taxed proportionally more than higher incomes. Therefore, tobacco taxes are regressive in percentage terms, as lower income individuals devote a higher percentage of their income to paying the tobacco tax than do higher income individuals. In addition, because people of lower socioeconomic status have higher smoking rates, they pay more tobacco tax per capita than those with higher incomes (Bader, 2011).
A possible counter to the regressive argument is that if sin taxes result in a differential behavior change, meaning if the poor are quitting smoking or reducing consumption of cigarettes at higher rates than the general population, then it’s not a regressive tax. But this argument doesn’t consider the impact of price hike on long term smokers. A study on French smokers’ motivations and effect of price increases on smoking behavior shows that through cigarette price increases between 2000 and 2008, smoking prevalence remained stable among manual workers, and it increased among the unemployed. Poor smokers were heavier smokers, they were more frequently tobacco-dependent, and they were more prone to smoke automatically or to reduce “negative feelings”. they were aware of their addiction, but they also talked about the pleasure they get from smoking, and they highlighted the essential needs satisfied by smoking: stress relief, cheap leisure, compensation for loneliness, break-up or redundancy (Peretti-Watel, 2008). Combining that with previously discussed difficulties of quitting, the negative feelings generated by marginalization, we see a somewhat inelastic demand for cigarettes among the poor long-term smokers, thus remaining impervious to price increases. They are especially victims of a policy that is ideally supposed to help them the most.
Private corporations and other entities, to denormalize smoking, have adopted the policy of not hiring smokers, or establishing a no-tolerance policy on smoking for their employees. While this policy addresses some of the employers’ cost of smoking via less productivity, healthcare expenses etc. it is in complete violation of Rawls’ theory of justice. Rawls theory consisted of two principles. First one being each person is to have an equal right to equal basic liberties. The second principle allows for some inequalities as long as they don’t violate the first principle and the inequalities benefit those who are the least advantaged. Preventing individuals from having opportunities for employment because they may smoke off duty would contradict that of an equal basic liberty for all. Furthermore, under Rawls’ “veil of ignorance”, we are less likely to agree to it because it is a form of discrimination since arbitrarily giving some individuals giving less opportunities to compete for jobs than others in unjust (Lecker, 2008).
However, Nozick might support the employer’s right to ban smokers. He would be opposed to a law intervening with employers who want to ban smokers because the employer owns the property and is free to select who to associate with. There is also a strong case for employers’ choice to ban smokers from the perspective of them saving costs, as studies show that workers who smoke each cost their employers ranging from $2900 to $10,000 annually (Wile, 2014). Thus, any intervention might be considered as a violation of employers’ rights. Moreover, from a productivity perspective, the employer is justified in not hiring the less productive employee.
Considering the impact of smoking on the poor, the ethical concerns over the institution of smoking and our treatment of smokers, and the possible grounds of exploration- I believe poverty and smoking would be an ideal topic of discussion for POV-101. It works well with the philosophers we have studied and discussed in class and is a natural extension of Unit 3: Causes, effects, and remedies. Smoking impacts tens of millions of people in the US, and it a unique case where we are making progress, but the most impacted and least advantaged group are improving the least, thus deserving a significant portion of the public conversation regarding poverty.
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