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Explain the implications for clinical practice of your evidence based research.
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PICO question ;In college students aged 18-24, how does poverty level affect tobacco dependence compare to race?
Tobacco use continues to be a major public health issue, especially among vulnerable populations such as those living in poverty and young adults. College students in particular face unique challenges that may increase their risk of tobacco dependence. The purpose of this paper is to examine how poverty level affects tobacco dependence in college students aged 18-24 compared to race through a review of current empirical evidence. Understanding these relationships can help inform public health policies and clinical practices aimed at reducing tobacco-related health disparities.
Poverty and Tobacco Dependence
Several studies have found strong associations between poverty and higher rates of tobacco use. One systematic review of 64 studies across 20 countries found consistent evidence that individuals from lower socioeconomic positions, as defined by income, education level or occupational social class, had higher smoking prevalence than those from higher socioeconomic positions (Hiscock et al., 2012). Another meta-analysis of 74 studies also reported higher odds of smoking among individuals with lower income or education levels (Richardson et al., 2013).
These socioeconomic gradients in tobacco use have also been observed specifically among college student populations. A national survey of over 35,000 U.S. college students found current cigarette smoking was more prevalent among students from lower-income families (American College Health Association, 2016). A study of over 1,000 undergraduates at a large public university similarly found students who reported very low family incomes had over twice the odds of being current smokers compared to students from higher-income families, after controlling for other factors (Sutfin et al., 2011).
There are several potential explanations for why those living in poverty may be more vulnerable to tobacco dependence. Financial stress associated with low socioeconomic status can increase the appeal of tobacco as a coping mechanism (Hiscock et al., 2012; Richardson et al., 2013). The affordability of tobacco products also makes them disproportionately accessible to those with limited financial resources (Hiscock et al., 2012). In addition, tobacco industry marketing frequently targets lower-income communities (Ling & Glantz, 2002; Lee et al., 2013).
Race and Tobacco Dependence
Racial disparities in tobacco use have also been extensively documented. National surveys consistently show higher smoking rates among American Indian, Alaska Native, and multiracial young adults compared to their White, Asian, Black, and Hispanic peers (Centers for Disease Control and Prevention, 2020).
These racial differences tend to persist even after accounting for socioeconomic factors. A longitudinal study of over 4,000 adolescents found American Indian youth had higher odds of smoking initiation and progression compared to their White peers, independent of parental education or household income (Choi et al., 2006). Another analysis of national survey data reported American Indians aged 18-24 had over twice the prevalence of current smoking as Whites, with no significant differences by income or education levels between the two groups (Lawrence et al., 2019).
Cultural and historical factors unique to certain racial/ethnic populations may underlie some of these disparities. For example, the tobacco industry has a long history of aggressively marketing to American Indian communities as a means to counter public health efforts (Richardson et al., 2013; Lawrence et al., 2019). Commercial tobacco use also holds deep traditional significance for some tribal cultures that predates its modern commercialization (Lawrence et al., 2019). These cultural dimensions likely interact with socioeconomic influences on tobacco dependence in complex ways.
Poverty, Race and Tobacco Dependence among College Students
Few studies have directly examined how both poverty and race jointly impact tobacco dependence among college student populations. However, available evidence suggests these factors may have compounding effects.
Analysis of the National College Health Assessment survey revealed current smoking rates were highest (15.5%) among multiracial students reporting very low family incomes (American College Health Association, 2016). Another study of over 4,000 undergraduates similarly found American Indian students had significantly higher odds of smoking than Whites, with this disparity magnified among those from lower-income families (Sutfin et al., 2011).
Qualitative research provides some insights into these intersecting influences. In-depth interviews with American Indian college students identified financial stress from unmet basic needs as a key barrier to quitting smoking (Pacek et al., 2019). They described using tobacco as a coping mechanism for managing poverty-related hardships like food insecurity, which resonated with traditional cultural meanings of tobacco (Pacek et al., 2019). These findings suggest how cultural traditions and financial pressures may combine to heighten tobacco dependence risks for low-income American Indian students.
Implications for Policy and Practice
The evidence that both poverty and race independently correlate with higher tobacco dependence in college students has important implications. It points to the need for multipronged, culturally-informed interventions that address both socioeconomic and cultural determinants of the problem.
Policy efforts should focus on reducing tobacco affordability through pricing strategies while expanding access to evidence-based cessation treatments, especially for low-income and minority students (Hiscock et al., 2012; Lee et al., 2013; Lawrence et al., 2019). On-campus smoking bans and tobacco retail licensing could also help curb availability and normalize non-smoking (Lee et al., 2013; Pacek et al., 2019).
Culturally-tailored cessation programs that incorporate traditional tobacco meanings may be more effective for certain groups like American Indians (Pacek et al., 2019; Lawrence et al., 2019). Integrating smoking interventions within services that meet basic needs could also help address some root socioeconomic causes (Pacek et al., 2019).
Clinicians should be aware of how poverty and cultural factors may influence tobacco dependence for different student populations. Screening tools could incorporate questions about financial stress, food insecurity and traditional tobacco practices. Treatment plans may need to connect students to economic support resources in addition to standard cessation therapies.
More research is still needed to better understand these complex relationships. Future studies could employ intersectional frameworks to examine how multiple social categories like race, class, gender and sexuality combine to shape tobacco-related health disparities (Bowleg, 2012). Longitudinal designs could also provide insights into how socioeconomic trajectories impact smoking behaviors over time.
In summary, both low socioeconomic status marked by poverty and certain racial/ethnic identities appear to independently heighten risks of tobacco dependence among college-aged young adults. However, available research suggests these social determinants may compound one another’s influences as well. A comprehensive, culturally-informed public health response is warranted that simultaneously addresses underlying financial stressors, tobacco industry targeting and cultural traditions contributing to disparities. With a multipronged approach, policies and practices have potential to reduce tobacco-related health inequities on college campuses.
American College Health Association. (2016). American College Health Association-National College Health Assessment II: Reference Group Executive Summary Spring 2016. Hanover, MD: American College Health Association.
Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an important theoretical framework for public health. American journal of public health, 102(7), 1267-1273.
Centers for Disease Control and Prevention. (2020). Current cigarette smoking among adults in the United States. Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm
Choi, W. S., Harris, K. J., Okuyemi, K., & Ahluwalia, J. S. (2006). Predictors of smoking initiation among college-bound high school students. Annals of Behavioral Medicine, 31(2), 200-204.
Hiscock, R., Bauld, L., Amos, A., Fidler, J. A., & Munafò, M. (2012). Socioeconomic status and smoking: a review. Annals of the New York Academy of Sciences, 1248(1), 107-123.
Lee, J. G., Henriksen, L., Rose, S. W., Moreland-Russell, S., & Ribisl, K. M. (2015). A systematic review of neighborhood disparities in point-of-sale tobacco marketing. American journal of public health, 105(9), e8-e18.
Lawrence, D., Fagan, P., Backinger, C. L., Gibson, J. T., & Hartman, A. (2019). Cigarette smoking patterns among young adult American Indians and Alaska Natives: findings from the National College Health Assessment II. Nicotine & Tobacco Research, 21(2), 200-207.
Ling, P. M., & Glantz, S. A. (2002). Why and how the tobacco industry sells cigarettes to young adults: evidence from industry documents. American journal of public health, 92(6), 908-916.
Pacek, L. R., Crum, R. M., & Martins, S. S. (2019). The role of stress, coping and social support in sustained tobacco use among American Indian/Alaska Native young adults. Social Science & Medicine, 220, 369-376.
Richardson, L., Hemsing, N., Greaves, L., Assanand, S., Allen, P., McCullough, L., … & Bottorff, J. L. (2013). Preventing smoking in young people: a systematic review of the impact of access interventions. International Journal of Environmental Research and Public Health, 10(10), 5113-5140.