Current state of unhealthy living characteristics in Black/African American and Latino populations: Tobacco use

Abstract

Over the past six decades, the United States has significantly improved tobacco-related health outcomes through mass efforts in policies, research, and behavioral and clinical interventions. Disparities persist, however, among communities of color who continue to suffer disproportionate rates of cardiovascular disease and other tobacco-related morbidity and mortality. In this review, we synthesize and discuss the tobacco use lifecycle across the lifespan, with special attention paid to socioecological determinants of tobacco-use behavior among Blacks and Latinos. This review summarizes the permeability of tobacco use and tobacco-related determinants across multiple levels of influence, from the individual to the societal, and highlights gaps in the tobacco control and prevention landscape. Given its continued evolution and impact on socially disadvantaged communities, we conclude with recommendations for improving current tobacco research and treatment and prevention efforts.

Introduction

Tobacco use leads to countless preventable diseases and premature mortality, with over 480,000 United States (US) annual deaths attributed to cigarette smoking. (1) Specifically, tobacco use is a primary cause of cardiovascular disease (CVD) and cancer morbidities, the two leading causes of death in the US, especially among Blacks and Latinos. (1) With 800,000 annual CVD deaths, 25% are attributed to smoking. (1) Similarly, 80% of lung cancer deaths are attributed to tobacco exposure. (1) The risk of tobacco use is dependent upon a culminating effect of product type used, the volume or quantity of product consumed per single use, the frequency of use per day, and the duration of use over time, among other social determining factors (Figure 1).

Figure 1.

Three main stages of the tobacco use lifecycle moderated by social determinants of health across historical time and developmental age

Orange Lines – Between-stages pathways of tobacco use behavior

Blue Lines - Within-stages pathways of tobacco use behavior

Despite the steady decline in smoking prevalence in the US since the mid-1990s, alarming trends persisted, while others have emerged. These trends can undermine the progress that has been made since the 1964 US Surgeon General Report on cigarette smoking. Cigarette use in the US increased dramatically from 1910 to the 1960s and has been on a steady decline since then, particularly among men and adolescents. (1,2) For example, smoking prevalence among men has decreased from 51.9% in 1965 to 19.0% in 2011, and from 36% in 1999 to 20% in 2010 among adolescents aged 17 and younger. (1) In addition, past 30-day and daily smoking prevalence rates among both high school Black and White students were at their lowest right before the COVID-19 pandemic. (3,4)

However, this decline has not been observed across all populations and subgroups, especially by age and race/ethnicity. Tobacco use remains prevalent among, for example, 1) older Blacks and those with low socioeconomic status (SES) who are most likely to smoke cigarettes; 2) young adults (ages 18–25) who are more likely to engage in e-cigarette use; and 3) women who, although historically have lower smoking rates than men, continue to smoke cigarettes [especially those who identify as Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+)]. (1,2) Furthermore, adolescent cigarette susceptibility has persisted especially among minority adolescents. Secondly, the tobacco landscape has changed with the introduction of other tobacco products (OTPs), particularly electronic nicotine delivery systems (ENDS) (i.e., e-cigarettes). With the introduction of OTPs, alarming trends are emerging such as rising exposure to, interest in, and use of OTPs among adolescents and young adults, especially non-combustible tobacco (i.e. smokeless, e-cigarettes), and dual and poly use. (2,5,6) For instance, in 1999, adolescent non-combustible tobacco use was at 4%, dual use of cigarette and non-combustible at 3%, dual use of non-cigarette combustible (i.e. cigars, hookah) and non-combustible at 2%, and poly use of all three tobacco types (e.g. cigarette, non-cigarette combustible, and non-combustible) at 7%. These rates increased to 28%, 7%, 13%, and 15%, respectively, by 2014. (5) Together, these trends threaten to erode the progress made over the past five decades that is reflected in declining cigarette smoking trends, contributing to further tobacco-related preventable morbidity and mortality. The long-lasting health implications of these trends are still preliminary, yet tobacco-related CVD mortality and morbidity are exceedingly linked. (7) Data from animal models, in utero studies, and short-term human subjects research suggest that exposure to e-cigarette aerosols can adversely alter cardiopulmonary function, with changes to heart rate and blood pressure. (7) However, prospective, long-term studies are needed to assess the health effects of e-cigarette use despite a lack of standardization across products (i.e., nicotine content, flavor type, variation in component parts). (7)

Tobacco use has been an issue of disparate prevalence and health outcomes. Consistent US surveillance reports show that tobacco use is disproportionally higher among certain groups (e.g., those with low SES, individuals with psychological distress, sexual and gender minorities) compared to that of the general US population or compared to non-Hispanic Whites (Whites). (1,2,7) Specifically, Black/African Americans (Blacks) exhibit unique tobacco use patterns such as their susceptibility to cigarettes as early as ages 9 to 10, late initiation of cigarette use compared to other racial groups, continued use, and addiction into young and late adulthood, low quit rates, and a preference for menthol flavored and non-cigarette combustible products (e.g., cigars). (5) Conversely, Latinos consistently exhibit higher susceptibility to cigarettes throughout adolescence, but are more likely to be intermittent (i.e., non-daily) or light (i.e., those who smoke less than 5 cigarettes per day) as opposed to being regular smokers (i.e., those who smoke 10 or more cigarettes per day). (2) Intermittent and light smokers do not conform to the addiction paradigm as they do not show nicotine-dependent patterns nor experience traditional symptoms of nicotine withdrawal during cessation attempts. (1,2) Historically, these smoking patterns persist although the effects of OTPs on these patterns are yet to be seen. Further disparities exist in access to tobacco treatment and short- and long-term adverse effects. Health inequities became ever more evident during the coronavirus disease 2019 (COVID-19) pandemic, increasing awareness of existing disparate health outcomes among communities of color and marginalized individuals. Although surveillance reports paint an inconsistent picture of tobacco use during the COVID-19 pandemic, there is evidence of increased tobacco use across several products. (8)

The traditional tobacco control landscape underscores the complexity of the tobacco use lifecycle and tobacco health disparities. We offer this bird’s-eye review to summarize the dynamic tobacco landscape today – a space where multiple sectors (e.g., healthcare, business, policy, research), historical context (e.g., discrimination, socio-political, intergenerational norms), and contemporary approaches to treat and prevent tobacco-related morbidity and mortality collide. The depth of tobacco-use research and interventions for both prevention and treatment that reduce the impact of tobacco on disease is expansive. Tobacco control and prevention efforts require multi-prong approaches where all stages of tobacco use, from onset to established use to cessation, are driven by various levels of social determinants of health (SDOH) interacting in parallel or combination, and cumulatively compounding over time. (1,2) Complex, multi-level SDOH, from distal, systemic inequities (e.g., racism and discrimination, policies influencing living environments or resource allocation) to proximal factors (e.g., social norms, family dynamics, self-efficacy, exposure to marketing), are inextricably linked to affect individual tobacco behaviors and health outcomes across communities, suggesting the ideal approach to reduce tobacco-related inequities is holistic, systems-related, and in need of interdisciplinary action. (2)

Most research studies, understandably, focus on isolated stages of the tobacco use lifecycle (e.g., initiation), single tobacco products (e.g., cigarettes), or group product effects (e.g., non-combustibles). (1,2) Research on tobacco use by race/ethnicity in nationally representative datasets is often lacking or limited due to low sample size, aggregated reporting, and insignificant comparisons between- and within-racial/ethnic groups, which creates knowledge deficits and homogenized presumptions for certain racial/ethnic subgroups (i.e., Cubans, Puerto Ricans, Koreans, Vietnamese). This knowledge deficit is further exacerbated considering sex-based differences in tobacco use patterns and other important demographic characteristics (e.g., foreign-born vs. US-born, sexual and gender minorities) within each racial/ethnic group that are often not consistently investigated or left out altogether. Similarly, although evidence of differing trends by minority status is limited, research consistently show that racial/ethnic minorities and underserved populations (e.g., low income, low education) bear the highest burden of tobacco use mortality and morbidity, which highlights the contemporary features of tobacco’s multifarious history and impact among specific communities of color and the potential tobacco-related action areas needing further attention to combat health inequities. (1,2)

This is a review of the tobacco use lifecycle among Blacks and Latinos. We identify three main stages in the tobacco use lifecycle: 1) tobacco use onset; 2) established use; and 3) cessation (Figure 1). For each stage, we highlight the prevailing patterns of tobacco use among Blacks and Latinos, and patterns of transition from one stage to another. Additionally, we emphasize select macro-level factors that affect individual-level patterns of tobacco use. Finally, our discussion of tobacco use patterns among Blacks and Latinos is situated within historical time (i.e., historical trends) and developmental age. This commentary is not meant to be a comprehensive review of the expansive literature on tobacco use among Blacks and Latinos. Rather, it is meant to summarize and highlight important factors and patterns to consider when combatting tobacco-related health disparities and addressing tobacco-related health outcomes among Blacks and Latinos. Furthermore, although we focus on Blacks and Latinos in this commentary, similar attention is needed to other racial/ethnic subgroups and minoritized communities (e.g., American Indians and Alaska Natives (AI/AN), Asian American subgroups like Koreans) who exhibit unique patterns of tobacco use behaviors and equally bear a disproportionally high burden of tobacco-related morbidities and mortalities.

Tobacco-Related Burden of Disease

In 2020, Blacks represented 12.4% (41.1 million) of the US population. (9) Since 2010, the Black-only population grew by 5.6%, whereas the combination of Blacks and some other race grew by 88.7%. The Latino population represented 18.7% (62.1 million) of the US population, which increased to 23% between 2010 and 2020 and has contributed 51.1% to the growth of the total US population in the last decade. (1,9) Blacks bear the brunt of most tobacco-related disease burden and mortality of all US racial/ethnic groups. (2) Where CVD and cancer are the leading causes of death in the US (1), the relative mortality risk for Blacks is 30% and 10% higher for CVD and cancer, respectively, than Whites. (10,11) Furthermore, Blacks are more likely to exhibit risk factors for CVD. For example, they are 40% more likely to have hypertension than Whites but are 10% less likely to have their hypertension under control. (1,10) Conversely, Latinos are 10% less likely to have hypertension and their mortality risk is lower than Whites for CVD and cancer (i.e., Whites are 50% more likely to die from heart disease and 40% more likely to die from cancer than their Latino counterparts). (11)

Tobacco Use Lifecycle

Tobacco use surveillance requires an understanding of the complex tobacco landscape that has evolved beyond cigarettes and traditional smokeless tobacco products (e.g. chew) over the past decade. Figure 1 represents a visualization of the tobacco use lifecycle, which falls along three major stages (represented linearly in this figure, although pathways are cyclical): 1) tobacco use onset; 2) established use; and 3) cessation, whereby within each major stage, several sub-stages and pathways exist1¹. A tobacco user can remain stable at any stage or transition from one major stage to another, or from one sub-stage to another. For example (Figure 1, Stage 1), someone who is susceptible to cigarette smoking can remain susceptible but never take up smoking, whereas another smoking-susceptible individual can transition to initiation and then established use (Stage 2). The pace of within-stage transitions (e.g., from experimentation to initiation, from single use to dual use) or across stages (e.g., from tobacco use onset to established use) is determined, moderated, and mediated by many individual- and macro-level factors acting concurrently or in accumulation.

Although we depict the tobacco use lifecycle as a seamless transition between three stages, we do not suggest one-way directionality or a certain order whereby a user enters and/or moves through these stages. For example, a tobacco user can move from the onset stage to the established use stage without ever moving to the cessation stage. Similarly, a tobacco user who has reached the cessation stage can revert to the established use of the same tobacco product or a different product (e.g., product switching, dual use). We believe non-users/non-susceptible individuals represent a repertoire of potential users where a portion of them will enter the tobacco use lifecycle. Once a non-user/non-susceptible individual enters the tobacco use lifecycle, he/she becomes entrapped in this lifecycle because of a higher risk of established use, product switching, or relapse after cessation, and prolonged health effects of tobacco use.

Each stage of the tobacco use lifecycle has certainly evolved over historical time and exhibits different characteristics by developmental age. For example, adolescents are highly influenced by family dynamics and peers more so than adults, and accordingly exhibit nicotine dependence as a middle-aged adult if they initiate tobacco use at a young age. (2) We capture the tobacco landscape as it stands now, but that is certainly subject to change in the near or distant future depending on several factors, such as the introduction of new tobacco products. Finally, the moderating impact of several SDOH is undeniable – from proximal, individual-level factors to distal, societal-level factors – as they directly or indirectly affect each stage of tobacco use and both individual, community, and population health outcomes.

Stage 1: Tobacco use onset

Susceptibility and experimentation are the gateways to tobacco use initiation. Susceptibility is defined as openness to the idea of smoking and this construct is now being used to gauge openness to use OTPs, in addition to cigarettes for which the construct was initially developed. Experimentation is measured as ‘tried’ cigarettes either ‘ever’ or ‘lifetime,’ and the construct often predicts progression to and maintenance of tobacco use. Both susceptibility and experimentation are usually measured among never-users. (12)

Adolescent (ages 11 to 18) smoking susceptibility is highest among Latinos (30.1%), followed by AI/ANs and Native Hawaiians/Pacific Islanders (NHPIs) (28.8%), Whites (23.8%), Blacks (22.3%), and Asian Americans (21.2%). (12) Compared to Whites, cigarette smoking susceptibility peaks around age 11 to 13 years among Blacks, whereas susceptibility among Latinos is consistently higher throughout their adolescence. (13) Historically, susceptibility to cigarette smoking has remained steady despite successful efforts at reducing smoking prevalence (13). Recent peaks, or higher than normal, in adolescent susceptibility have been observed starting in 2014, which may be concurrent with the rise of OTPs (13). Despite a scarcity of research into the causes of these recent spikes in cigarette susceptibility, potential factors to investigate include spillover effects from OTPs susceptibility and use, foretelling a potential rise in smoking prevalence in adolescence and young adulthood. Research is needed to understand trends in susceptibility to OTPs and their association with progression to initiation and established use of cigarettes and OTPs. Finally, longitudinal data are needed to quantify the proportion of non-users/non-susceptible on different pathways to establishing tobacco use (i.e., cigarette and/or OTPs). For example, of Black non-users, what percent becomes susceptible to tobacco use? Of those, what percent goes on to experiment with tobacco products and initiate any tobacco product? Research shows that most first-time tobacco users experiment with flavored products (including menthol), regardless of the tobacco product, like traditional cigarettes and e-cigarettes, hookah, or cigars - the three most common tobacco products among youth and young adults today. (2)

Adolescent initiation of cigarette use (ages 11–17) varies by race/ethnicity, whereby most youth try their first cigarette by the age of 13 with Latino and Black youth consistently initiating at different times of developmental age. (2) Latino youth have highest rates of smoking initiation than Whites, initiating at age 14 and tapering off into complete cessation or non-daily smoking progression into adulthood. Blacks initiate smoking at age 18 or later and are most like to progress to established smoking into adulthood. (2) As OTPs, such as e-cigarettes, become more popular and claim the spot of the most used tobacco product, additional research is needed to understand initiation of OTPs and whether initiation follows similar patterns like cigarette smoking (e.g., does susceptibility precede experimentation and initiation? Does initiation/use of OTPs later progress into cigarette smoking initiation and established use?). In addition, as Blacks are more likely to initiate cigarette smoking in late adolescence or young adulthood, they are also more likely to use marijuana (cannabis) before tobacco. (2,14) Studies are needed to understand the patterns of initiation of other substances as it relates to cigarettes and OTPs, especially with the growing cannabis legalization policies for adult recreational use throughout the US.

Susceptibility, experimentation, and initiation during adolescence are important research topics because they are indicators of future tobacco use behavior and nicotine dependence, as well as the etiology of disease development. Developmentally, youth are more at risk for nicotine dependence due to their higher sensitivity to nicotine than adults, even at lower levels of nicotine exposure, which negatively impacts their cognitive development with prolonged exposure to nicotine. (2) From a life course perspective, early tobacco onset is strongly associated with other illicit substance use and co-morbid health issues. It is noteworthy that susceptibility, experimentation, and initiation should be consistently studied among young adults and adults to understand these constructs at late developmental ages especially given the exposure, availability, and accessibility of new OTPs through digital platforms and applications (e.g., social media, delivery services).

Beyond age and race/ethnicity, other indicators that affect susceptibility, experimentation, and initiation include individual-level factors such as sex and gender, genetic predisposition (i.e., dopamine receptors, nicotine metabolism genes), psychological distress (e.g., anxiety, stress, depression), attitudes toward and beliefs around tobacco norms, and other substance use/abuse (e.g., alcohol), in addition to interpersonal, community, and societal determinants (e.g., sociocultural norms, neighborhood, access to tobacco retailers and marketing), factors that we will touch on later in this review.

Stage 2: Established Tobacco Use

As overall cigarette smoking declines nationally, youth prevalence is highest among AI/AN (10.3%), followed by NHPI (9.5%), non-Hispanic Whites (6.6%), Latinos (5.7%), Blacks (3.3%), and Asian Americans (2.0%). (15) Among middle-school youth, current cigarette use is highest among Latino youth (3.7%) followed by Whites (2.2%) and Blacks (1.7%), whereas among high-school youth, Latinos (8.8%) and Blacks (4.5%) fall behind Whites (10.8%). (15) Cigarette-use trends among young adults, ages 18 to 25 years, follow those of adolescents. Among youth and young adult smokers, menthol-flavored cigarettes are the most popular (with a 10% increase from 2004 to 2010, (National Survey on Drugs and Health, NSDUH), especially among females and Black smokers. In fact, flavored tobacco (e.g., menthol) is attractive to youth and transitioning adults in OTPs such as cigars, smokeless tobacco, hookah, and e-cigarettes (16). Menthol-flavored tobacco is highly correlated with both the ease of tobacco initiation and difficulty to quit. (1,2) Historically and until now, Blacks preferred menthol-flavored cigarettes and cigars and are less likely to report the use of non-combustible (e.g., e-cigarettes, smokeless tobacco) tobacco products compared to Whites.

Of 23% of current youth tobacco users, 20% use e-cigarettes, and 7.8% are dual or poly users (i.e., defined here as the use two or more tobacco products, although the definition of dual and poly use varies greatly in the literature – see our definition of dual and poly use under product types and product use patterns in the next paragraphs), such as e-cigarettes, cigarettes, cigars, smokeless tobacco (i.e., chew, snus), and/or hookah. (17) Compared to 23.1% of non-Hispanic White youth, 13.6% of Blacks and 18.7% of Latino youth are e-cigarette users. (17) The popularity of e-cigarettes has grown substantially among youth in recent years (15), along with an expansion of e-cigarette availability (18) and cannabis dispensaries (19) in predominantly Black and Latino neighborhoods. Conversely, surveillance data show a decline in ever cigar use among Black, Indigenous, and People of Color (BIPOC) youth, with Black youth use still leading prevalence rates. Cigar use remains consistent across racial/ethnic groups among high school youth, and Latino middle school youth have the highest rates of current cigar use, followed by Blacks. Transitioning into adulthood, Blacks have the highest prevalence for cigar use among all racial/ethnic groups.

Among adults, current smoking is consistently more prevalent among males (24.8%) than females (19.3%) across all racial/ethnic groups. (2) By race/ethnicity, smoking prevalence is highest among AI/AN (38.5%), with Whites and Blacks trailing in second and third (23.9% and 22.6%, respectively), and lowest among Latinos (15.2%) and Asian Americans (8.3%). (2) Further disaggregation of racial/ethnic groups is needed in longitudinal and nationally representative data to better understand tobacco use patterns and, subsequently, where targeted treatment and prevention efforts are needed most, especially that lived experiences (e.g., socio-cultural, geo-political, historical events) and community norms around tobacco are heterogeneous across groups.

With cigarette use, smokers are often classified into three user type groups: intermittent/non-daily, light smokers (i.e., those who smoke less than 5 cigarettes per day), and established or regular smokers (i.e., those who smoke 10 cigarettes or more per day). (1,2) Roughly half of racial or ethnic minority cigarette smokers are intermittent or light as opposed to regular established smokers. (2) According to the addiction paradigm, intermittent and light smokers do not follow the nicotine-dependent patterns, nor do they experience the traditional nicotine withdrawal symptoms during cessation attempts. (2) Recent data reveal an increase in light and intermittent/non-daily smoking among all racial/ethnic groups. This is particularly true for Latinos (vs. Whites who have a higher prevalence of daily smoking behavior, regardless of intensity). Severe tobacco-related illnesses are often reported among established, regular smokers – most of whom are White.

The introduction of OTPs has expanded the tobacco landscape with innumerable combinations of tobacco product types used. To capture this complexity while retaining basic characteristics of tobacco products based on the nicotine delivery method (and consequentially the health risks incurred), members of the authorship team introduced a model that classifies tobacco products into three product types: cigarettes, non-cigarette combustibles (e.g., cigars, hookah), and non-combustibles (e.g., smokeless, e-cigarettes). Based on these three product categories, five exclusive tobacco product use patterns (T-PUPs) exist: single use of any of the three product categories (e.g., exclusive cigarette use), dual use of any two product categories (e.g., dual use of cigarettes and non-cigarette combustibles), and poly use of all three product categories (i.e., use of cigarettes, non-cigarette combustibles, and non-combustibles) (20). Single, dual, and poly use remain high among Black and Latino youth aged 17 and younger. In 2012, the prevalence of single-use of non-cigarette combustibles, cigarette-only use, dual use (of any dual combination of cigarette, non-cigarette combustible, or noncombustible), and poly use among Blacks was 50.9%, 11.1%, 26.9%, and 4.8%, respectively (20). Among Latinos, these rates were 28.6% for single use of non-cigarette combustibles, 28.1% for dual use, and 21.4% for poly use. Recent data show that tobacco users can transition from one T-PUP to another (5). For example, an exclusive cigarette smoker can become a dual user once he/she starts vaping; a dual or poly user can become an exclusive cigarette smoker. While recent research offers guidance on the categorization of tobacco product use, consensus is needed on definitions of tobacco product use patterns to reflect the continuing rise in dual and poly use.

Nicotine dependence is determined by the volume, frequency, and duration of exposure. (1,2,4) Nicotine delivery (smoked or absorbed) differs by product type, which is then compounded by the volume and frequency of use over time. Regardless of the tobacco type, all tobacco products emit varying levels of nicotine, a highly addictive chemical compound that changes a person’s brain function, igniting craving sensations and leading to further nicotine dependence. Along with nicotine, thousands of toxic chemicals in tobacco products pose varying levels of health risks and produce carcinogenic effects. For example, although smokeless tobacco has the highest nicotine content, combustible products like cigarettes and cigars that ‘burn’ tobacco are the most harmful. (1,2,6) With new OTPs, research must define thresholds of tobacco use by which a user can be classified as light, intermittent, or daily. For example, how many puffs a day an e-cigarette user takes to be considered light vs. regular user? How would we define nicotine dependency with new and future OTPs? Will these thresholds differ by age, sex, and race/ethnicity? Furthermore, with new OTPs and the rise of dual and poly use, researchers must examine the health effects of these T-PUPS (especially long-term effects). Although initial research shows that e-cigarettes and non-combustible tobacco products may be less harmful, it is unknown if these products are effective tools for cessation, especially when used in combination (dual or poly) with other tobacco products over time. (1,2)

Stage 3: Cessation

An important protective factor against tobacco-related adverse health outcomes is quitting tobacco use. Evidence on quitting tobacco is abundant for cigarette smoking. Smoking cessation is beneficial anytime during a smoker’s lifetime but is especially beneficial around age 30. Smoking cessation among 25 to 34-year-old smokers increases their life expectancy by 10 years and levels their mortality risk to that of non-smokers. (1,2,21,22) Black (44.1%) and Latino (53.6%) ever-smokers have lower quit ratios compared to Whites (57.1%). (1) Compared to regular, moderate-heavy smokers (i.e., those who smoke ≥10 cigarettes/day), the rate of quit success of light or intermittent smokers is less understood, many of whom are Blacks and Latinos (2,14), individuals who do not have health insurance, those who are living at/below the federal poverty level (FPL) or report lower educational attainment, and those who are less likely to use nicotine cessation medications. (2,4,14)

Those who quit smoking may relapse, both transitional use smokers who quit in the past 6 to 12 months and former use smokers who quit for more than 12 months. Smoking cessation begins with the desire and attempt to quit with varying cessation methods. Compared to Whites, Blacks express greater interest in quitting smoking and make more quit attempts overall despite having lower rates of successful cessation. (23) With over 60% of current Black smokers ever making a quit attempt, only 3% successfully abstain after quitting (compared to 7% of Whites). (2,14) In 2015, interest in quitting, past-year quit attempts, and successful cessation (e.g., at least six months smoke-free) among current Blacks smokers were 72.8%, 63.4%, and 4.9%, respectively, compared to 67.5%, 53.3%, and 7.1% among Whites. (23) The rates for Latinos were similar to those of Whites at 67.4%, 56.2%, and 8.2%. Among those who attempt to quit, it takes a current smoker on average 30 attempts before achieving success in quitting smoking for 1 year or longer (former use), given that most established smokers begin smoking in adolescence and may try to quit at least 1 time per year. (25) Blacks are 1.11 times as likely as Whites to be current smokers than former smokers. (24) Conversely, Latinos are 0.57 times as likely as Whites to be current smokers than former smokers. As Blacks and Latinos age, cigarette smoking prevalence and attempts to quit remain higher than Whites due to lower successful cessation (e.g., ≥1 year) odds among Blacks and Latinos. (14) Blacks are less likely to achieve successful smoking cessation due to limited access to and use of effective, long-term strategies and motivations for quitting (e.g., social support, discrimination, trust, counseling, medication). (2,4,14) Similarly, Latino smokers express high motivation to quit, citing family as their strongest driver, and often report quitting attempts without medical intervention (e.g., nicotine replacement therapy (NRTs)). (2,4)

Differences emerge between racial/ethnic groups in the way they achieve cessation (i.e., cessation types). For example, Blacks and Latinos are less likely to receive quit counseling from health care providers or subscribe to tobacco treatment despite being lighter smokers than Whites. Among Blacks who participated in medical intervention, they used pharmacologic aids (e.g., NRTs) at much lower rates (34%) than Whites (50%). (2,4,14) In 2015, the most prevalent cessation methods among Black and Latino smokers who made quit attempts in the past 12 months were pharmaceutical aids alone (Blacks: 25.2%, Latinos: 16.6%) and a combination of behavioral interventions (e.g., counseling) and/or pharmaceutical aids (Blacks: 28.9%, Latinos: 19.2%). (23) Yet, Whites had the highest prevalence of using pharmaceutical aids (32.6%) and behavioral interventions and/or pharmaceutical aids (34.3%). Behavioral interventions alone were the least utilized method among White (6.9%), Black (7.6%), and Latino (5.1%) smokers.

In the attempt to quit, most smokers often try to quit cold turkey (i.e., completely cease tobacco consumption) or reduce their consumption or frequency (e.g., product reduction by cutting down to 1–2 cigarettes every (other) day). The availability of OTPs has also introduced other cessation methods, mainly product switching. For example, some attempt to switch from cigarettes to OTPs to transition to ‘less harmful’ products and reduce frequency of nicotine and/or toxic chemical exposure. In the 2014–2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), e-cigarettes were the most prevalent OTP switch (38.8% Whites, 23.1% Blacks, and 22.8% Latinos) among smokers who made quit attempts in the past 12 months. (4) Smokeless tobacco was least prevalent (5.5% Whites, 4.6% Blacks, and 4.7% Latinos). Compared to 2.5% of Whites, 4.0% of Blacks and 3.0% of Latinos switched to cigars or pipes. The use of OTPs for quitting smoking, coupled with public perception of e-cigarettes as containing less nicotine than traditional cigarettes, warrants a redefinition of cessation that encompasses the complexity of product switching as a cessation method. Similarly, the rise of OTPs requires a new definition of cessation from OTPs. Considering where tobacco products fall on the risk continuum, fully switching from cigarettes to OTPs is a step toward reducing tobacco-induced adverse health outcomes. Although this harm reduction approach has its proponents, others argue against it. These results should be taken with the following caveats in mind – evidence on long-term consequences of many OTPs remains unknown; any “beneficial” effects are contingent upon full product switching; and finally, several factors may raise the level of risk to that of cigarette smoking – such as the frequency of using the product. With the use of OTPs for cessation and the emergence of new products only within the last decade, additional research is needed to document OTP cessation rates among users who do not, or no longer, use combustible cigarettes. This is prudent as racial/ethnic minority youth and adults increasingly turn to non-combustible OTPs (e.g., e-cigarettes) as “safer alternatives.” (4)

A successful attempt at quitting tobacco (i.e., ≥ 1 year) is not the final step in the tobacco use lifecycle as the former user requires continuous, long-term adjustments and support to remain tobacco-free. Most smokers relapse within a week of a quit attempt. Tobacco relapse (i.e., using tobacco after ceasing tobacco use even after a few hours or days, which quickly reverts tobacco habits) entails participating in any type of tobacco use, regardless of whether it involves the initial tobacco delivery mechanism (e.g., cigarettes) or different tobacco product(s). (2,26) Using tobacco involves a direct uptake of nicotine for non-cessation purposes. Although cessation research is rarely focused on relapse, less is known about the specific differences by race and ethnicity. Some cessation research shows that Latinos have higher odds of relapse than their counterparts, which in part may be due to economic and socio-cultural inequities (e.g., health insurance, health literacy). (26) Accordingly, more research is needed on transitioning smokers (i.e., those who quit within the past 6 to 12 months) who are at a higher risk of relapse. Conversely, former smokers (i.e., those who quit for more than 12 months) are considered less likely to relapse, although the risk is never null.

Several factors directly impact quitting tobacco success, such as nicotine dependent behaviors (e.g., volume or quantity of product consumed per single use, the frequency of use per day, the duration of use over time), age of initiation, quitting attempts, social support, living environment, and access and utilization of medical intervention (e.g., health care provider advise, treatment regime, education) among others. For example, studies show an inverse association between social support and smoking, revealing that smokers who successfully quit have naturally occurring, preexisting social support (e.g., watching children, borrowing money, encouragement) from partners, family members, and friends in their cessation plan. (2) Furthermore, lower quitting success and higher relapse with or without pharmacotherapy or nicotine cessation medication vary by race/ethnicity and income, and are moderated by quit attempt frequency, nicotine dependence, and other individual or systemic indicators. The decades of research contributing to understanding smoking prevalence and cessation must now be expanded to define and combat the complexity of OTP cessation.

Tobacco-related Health Determinants

Smoking determinants that plague the Black and Latino communities are multifarious, complex, and historically implicated. Those determinants range from healthcare barriers and quality of care to smoking environments that elucidate higher incidence of cancer and cardiometabolic issues that lead to premature death. The Social-Ecological Model (27) and the National Institutes of Minority Health and Health Disparities framework (2) epitomize these determinants that are needed to equitably tackle tobacco health disparities at multiple micro- and macro-levels of influence. Below we highlight select factors that influence tobacco use among Blacks and Latinos at various levels (i.e., individual, interpersonal, community, and societal) across the life course. Noteworthy is that the factors highlighted below are not exhaustive. Furthermore, cross-level interactions that impact tobacco use behaviors are not discussed (e.g., the effect of the interaction between individual-level income and county-level poverty on tobacco use).

Individual-level factors.

Individual factors include genetic predispositions and psychological factors. Genetic factors (i.e., nicotinic and dopamine receptor genes, nicotine metabolic genotypes, DNA repair) that affect behavior across the tobacco continuum are not well understood among BIPOC groups, and even less so among light or intermittent smoking populations, like Blacks and Latinos. (1,2,4) These genetic variations impact CVD and cancer risk by influencing tobacco compound carcinogenicity and smoking behavior. However, biological determinants only account for a small variance in tobacco use, especially when translational studies are scarce among BIPOC and marginalized tobacco users. Current studies allude to clinical cessation interventions that parse different groups based on genetic factors that trigger or intensify tobacco behaviors and increase risk for CVD and cancer.

Psychosocial factors include psychological stress, perceived discrimination, fatalism, living circumstances, and coping styles (or the lack thereof), among others. It is noteworthy that mental illness and smoking cessation are related, where BIPOC with depressive systems are more likely to smoke and less likely to quit. Generally, racial/ethnic minorities experience more barriers to mental health, specifically perceived social stigma, delayed diagnoses, and underutilization of mental health treatment than Whites. (2) Identifying as BIPOC and/or being of low SES, independently, are linked to increased rates of trauma-inducing exposures (i.e., adverse childhood events, violence) (2), which exacerbates tobacco-health outcomes. Despite these facts, Blacks who smoke and engage in other unhealthy behaviors (e.g., alcohol consumption, diets high in processed foods) to cope with life stressors, are 0.81 times as likely as Whites to meet depression diagnostic criteria (28), suggesting Blacks are temporarily protected against certain mental health outcomes compared to non-Hispanic Whites at high stress levels. (28) Further research in this area is needed, however, particularly among specific vulnerable BIPOC and other vulnerable groups (e.g., institutionalized and justice-involved individuals) for whom thresholds for distress tolerability may be lower, engagement in unhealthy coping behaviors are higher, and likelihood of tobacco use are more prevalent. Past research also suggests that Blacks and Latinos are more likely to endorse fatalism (i.e., submissive belief that events occur by fate or are predestined) towards their physical health, further implicating health-seeking behaviors, such as for CVD maintenance, diabetes management, and cancer screenings. (29,30) Additional research should examine the potential role of fatalism in perpetuating tobacco use and in the management of tobacco-related health outcomes among BIPOC and other vulnerable populations.

Interpersonal- & community-level factors.

The built environment compounds the effects of psychosocial factors and health care disparities on tobacco use in communities of color. For our purposes, the built environment refers to environmental conditions and resources (or lack thereof) that influence the risk of tobacco use and exposure. These include housing type, neighborhood characteristics (i.e., neighborhood poverty level, access to nutritious foods and parks), and density and proximity of tobacco retailers. Public housing units, for instance, are a common source of secondhand smoke (SHS) exposure. (31) They are also home to approximately 40% of Blacks. (31) Black youth and non-smoking adults are more likely than any other racial/ethnic group to be exposed to tobacco smoke – firsthand and SHS (2,4), a known risk factor for smoking initiation among youth (32) and CVD in adulthood. (33,34) Low SES families living with a current user are less likely to enforce home smoking bans, increasing risk for initiation and persistent use. (2,4) Black youth with siblings who smoke are more susceptible to tobacco uptake themselves. (35) When trying to quit smoking, however, Blacks rely less on familial and peer support than do Latinos and non-Hispanic Whites. (36) Additionally, access to healthy foods and green space is low in high-poverty communities with predominantly Black and other racial/ethnic minority residents. (37) Relationships between limited access to such health-promoting outlets and tobacco use have been observed. (24) Tobacco retailers further amplify the role of the built environment. These are disproportionately concentrated in neighborhoods with majority-Black residents and school districts, which are often systemically disenfranchised (18,38,39).

Environmental stressors (i.e., neighborhood safety, racial discrimination, occupational strain) (28,40), exacerbate unhealthy, risky behaviors. Taken together, environmental stressors and unhealthy behaviors are associated with chronic physical morbidity and mortality among Blacks and Latinos later in life. (28) Perceived racial discrimination, for instance, is associated with high allostatic load and cumulative chronic stress among Blacks. (41) High allostatic load, in turn, is associated with tobacco use and increased risk of CVD and chronic health issues like obesity and hypertension. (37,41) For example, the odds of smoking among Black women who report a high burden of racial discrimination is 2.07 times higher than those who experience a low burden of discrimination (40), while the odds of developing chronic health conditions (e.g., hypertension, heart disease, lung disease) among Blacks who engage in unhealthy behaviors (e.g., smoking) are 1.3 times higher compared to Blacks who do not. (28)

Health disparities research should examine and invest in the role of protective factors against tobacco use among racial/ethnic minorities, which can prevent or delay tobacco use onset and be leveraged against initiation and use of emerging OTPs. For example, among Black youth, these protective factors include parental opposition, religiosity, body image, participation in high-intensity sports, and negative attitudes towards cigarette smoking (38). Other factors include household communication practices (e.g., parental monitoring, smoking-related communication, closeness, smoke-free home rules). However, protective factors in youth dissipate throughout the life course, evident by the fact that Black smokers establish regular smoking habits later in life. This alludes to the fact that protective factors are offset by environmental factors and cues, such as the tobacco industry’s targeted marketing (1,38), increased chronic stressors related to income, occupation, built-in environment, poor access to quality of care, and targeted treatment as major contributors to smoking behavior. (42) More research is also needed to identify protective factors among other racial/ethnic minorities, like Latino and immigrant populations, where these protective factors such as strong ethnic identity and cultural value systems dissolve with time lived in the US and with assimilation. The increasing use of OTPs and dual/poly use of tobacco products also warrants examining protective factors among Black and other BIPOCs to delay onset of OTPs use and improve cessation strategies across the life course.

Societal factors.

Societal determinants normalize tobacco exposure and perpetuate health disparities among Blacks, Latinos, and other BIPOC. Systemic racism is a societal/structural determinant that refers to the intended and unintended biases within institutions that create systemic disadvantages for certain racial/ethnic groups while privileging others (43). Systemic racism in tobacco-related health disparities include social and economic policies which ultimately shape communities’ social norms, built environment, and healthcare infrastructure. Since the 1940s, tobacco companies have utilized racially based tactics to target Black communities as their leading consumer base, which resulted in higher tobacco use and addiction among Blacks (2,18,34,38,44). These tactics include increasing tobacco retailer density (i.e., convenience stores, supermarkets, gas stations) and outdoor advertising in predominantly Black neighborhoods (17,18,38,39), pro-tobacco print media (i.e., newspapers and magazines) (18), strategic product placement in retail settings (39), and monetary incentives in the form of coupons (44,45) and point-of-sale brand and price promotions (18,38,39). Marketing materials, such as coupons and point-of-sale promotions, are associated with increased youth initiation of tobacco use and continued use among Black adults (18,38,39,44,45). Among the products disproportionately marketed towards Blacks by the tobacco industry are mentholated cigarettes (18,38,39), little cigars (39), flavored cigars (18), cigarillos (39), and e-cigarettes (34,39). To date, however, none have sustained as insidious a reputation of promoting nicotine addiction and sustaining tobacco-related health disparities as mentholated cigarettes, which have been aggressively racialized by tobacco companies as the tobacco flavor of choice among Blacks (18,38,46).

The over-concentration of tobacco retailers in BIPOC communities corresponds with the SES of these communities. Attributed to historical policies like redlining and disinvestments in communities of color, Blacks are more likely to live in low-SES neighborhoods relative to Whites, making them more susceptible to smoking, SHS exposure, tobacco-related disease burden, and an incursion of tobacco-related health care costs. (2,34) Spending on tobacco products is also highest among low-SES households, including Black households, often taking priority over basic living expenses. (34,47) A report from the US Bureau of Labor Statistics found that, in 2014, 1.5% of total household spending among low-income Blacks was on tobacco and smoking supplies compared to 0.3% among high-income Black households. (47) The intersectionality of SES and race, thus, represents another mechanism of systemic racism at the structural level, one that requires a reframing and prioritizing of tobacco as a risk factor for CVD and other adverse health risks among specific racial/ethnic subgroups.

When exploring tobacco use across the life course, parental educational attainment (PEA) and student educational attainment serve as a proxy for youth SES in longitudinal, cohort studies. (2) The impact of SES on youth cigarette use may be moderated by factors related to race/ethnicity, cultural, and built-in environmental factors, whereby a large proportion of Black and Latino youth have low PEA compared to Whites. SES, specifically living at/below FPL, is a strong indicator for smoking behavior. Research shows that those living at/below FPL have a smoking duration median of 40 years compared to those living 3 times above FPL who have a smoking duration median of 22 years. (48)

Health care access and quality of care by providers significantly impact the tobacco lifecycle among BIPOC smokers and those with lower SES. Lower quitting success and higher relapse differ by race/ethnicity and income. Although tobacco cessation efforts expanded with growing health care coverage across the US, systemic barriers persist in initiating medical coverage to benefit from medical access (i.e., pre-authorizations, co-pay, duration limits), awareness about cessation treatments and programs, and persistent outreach efforts that promote benefits among both smokers and health care providers. (49,50) For example, comprehensive coverage of cessation treatments remains low across states with Medicaid enrollees, with only 15 states covering all nine treatments (i.e., individual counseling, group counseling, and seven FDA-approved cessation medications) and only 16 states covering both individual and group counseling. (49) Among adult smokers with Medicaid or other state-issued health insurance, 18.0% are Black and 12.0% are Latino (50), highlighting the importance of removing access barriers to cessation treatments among BIPOC smokers. Blacks and Latinos are less likely to be asked about their smoking status and to be offered smoking cessation programs or aids by health professionals compared to Whites. Additionally, 60.2% of White smokers receive advice to quit smoking from health professionals compared to Black (55.7%) and Latino (42.2%) smokers. (23) For pharmaceutical aids, cost represents a barrier to access. Other barriers such as time and stigma affect Blacks’ and Latinos’ access to behavioral interventions like support groups.

Policies and regulations are other structural determinants of tobacco use. Recent policies have been adopted across the US that have the potential to reduce tobacco use and related health disparities among Blacks and other BIPOC communities. In July 2018, the US Housing and Urban Development Agency implemented a federal policy requiring public housing units to adopt a smoking ban. (51) The impact of this policy, as well as compliance and enforcement, however, is not yet fully understood. Successful long-term implementation requires effective interventions that benefit Blacks and other majority-low-income populations living in public housing. (51) Additionally, as of March 31, 2021, 336 US jurisdictions, 13 states, and 3 American Indian tribes have at least one restriction on the sale of flavored tobacco products. (52) Such bans, however, remain regionally inconsistent across jurisdictions since many exempt menthol and other products (i.e., e-cigarettes, hookah, cigars). (52) Inconsistencies in policies disadvantage Black users of mentholated tobacco as they are more likely to make quit attempts than non-menthol users but have 12% lower odds of quitting successfully. (53) Furthermore, most policies restricting sales of flavored tobacco products are not comprehensive. This allows consumers to modify their spending behaviors (i.e., online purchase from cross-border or transnational retailers) and to exploit loopholes by the tobacco industry (i.e., increases in price promotions for policy-exempt products). (54)

Despite advertising bans on cigarettes, the growing popularity of e-cigarettes among younger age groups and the proliferation of unregulated advertising on social media platforms keep youth vulnerable to exposure to advertisements for non-flavored and alternative tobacco products. (17,44) The recent passing of the 2019 federal “Tobacco 21” (T21) law, which increased the minimum age for purchasing tobacco products from 18 to 21, aims to reduce youth tobacco use and delay tobacco initiation. (55) However, a recent study on California’s 2016 T21 law reported non-compliance and poor enforcement such that retailers did not object to selling tobacco products to youth and failed to verify age. (56) Thus, the impact of federal policy restrictions on youth tobacco susceptibility and initiation remains largely unknown. (54) Moreover, such restrictions do not acknowledge the tobacco industry’s role in perpetuating systemic health inequalities among Blacks and other BIPOC populations (43), nor do they address the need for regulation of pro-tobacco social media content and other web-based activities targeting youth. (44) Among both youth and adults, price increases and smoke-free policies have been associated with decreased smoking and higher quit rates since mid-1990s (38). Tax and price increases, in particular, resulted in significant reductions in tobacco use among low-SES populations, while smoke-free laws are known to reduce CVD and improve respiratory health. (34)

Future Directions

In this final section, we highlight a few gaps in current tobacco control and prevention efforts and suggest future directions to overcome existing gaps (see Table 1). First, decades of tobacco-related health research and surveillance data are, unfortunately, heavily White/European-centric and lack racial/ethnic diversity, which raise concerns about equity and the effectiveness of current and future tobacco control efforts to prevent CVD and other adverse health outcomes. For example, tobacco genotypes and biologic biomarkers cut-off ranges are based on White-dominated samples. (2) To disentangle tobacco-use disparities, there is a need to not only understand the biological effects of nicotine but also to address the cultural and social dimensions of tobacco prevention and control across the tobacco use lifecycle. Furthermore, tobacco cessation programs and interventions should not only address proximal risk factors (e.g., individual-level factors), as it is no longer enough to reduce the burden of tobacco-related morbidity and mortality among racial/ethnic subgroups and low-SES groups. Funders and policy makers are highly encouraged to further invest in research that includes historical contexts and systemic factors to dismantle colorblind policies that manifest as poor individual and community health outcomes, specifically among disenfranchised populations over generations. Other marginalized groups in need of attention due to their increased risk to tobacco-related disease include pregnant BIPOC mothers and sexual and gender minorities who have significantly higher prevalence of tobacco use than heterosexual counterparts, specifically LGBTQIA+ youth. (6) Furthermore, mixed-race or multi-race (2 or more races) individuals should be a focus of tobacco control and prevention efforts. Literature on this group shows growing health disparities with high rates of current use of any tobacco product, specifically cigarettes, e-cigarettes, cigars and cigarillos. (22)

Table 1.

Future actions for structural and systemic factors to reduce tobacco-related health disparities at a systemic and structural-level.

Gaps in current tobacco control and prevention efforts	Suggestions for future directions	Examples
Data collection infrastructure	Consistency and comprehensiveness of data collection to allow disaggregate analyses by specific characteristics based on life course perspectives, longitudinal analyses, and inclusion of culturally relevant intergenerational and historical indicators	- Oversampling specific racial/ethnic minority subgroups who have higher tobacco prevalence when disaggregated (e.g., Asian American vs. Koreans only) - Standardizing questions about tobacco use
Tunnel vision with a focus on isolated tobacco-use stages	Comprehensiveness in the outlook at tobacco-use lifecycle where tobacco use occurs along a continuum with different entry points and feedback loops across stages	- Exploring issues related to tobacco use relapse and product switching using longitudinal data
Narrow view of tobacco landscape with focus on single tobacco products or tobacco product categories	Comprehensiveness in the outlook at tobacco landscape with concurrent susceptibilities and tobacco use alongside other substances	- Surveilling tobacco use and co-substances (e.g., alcohol, cannabis, or illicit drugs) –through the tobacco use lifecycle stages, cohort-longitudinally, and across the life course
Rigid developmental age brackets in examining tobacco use lifecycle	Fluidity across developmental age since stages of tobacco-use lifecycle occur at different times of developmental age	- Using age as a continuous variable rather than using pre-determined age brackets (e.g., 18–25 years old) to explore tobacco use, susceptibility, and preventive and risk factors
Traditional approaches to tobacco use surveillance and control	Expansion into digital platforms for tobacco surveillance, prevention, and treatment	- Tracking exposure to tobacco advertising and use of digital coupons, expanding use of mobile health applications and electronic health records for prevention and control efforts.

The COVID-19 pandemic exacerbated health disparities of essential and frontline BIPOC communities, many of whom have pre-existing co-morbidities (e.g., hypertension, CVD, obesity), live in multi-generational households that increases risk for COVID-19, and are accordingly at cumulative risk for poorer mental health, occupational burnout, and multi-substance use. Special attention to the impact of tobacco on immigrants and intergenerational populations is needed. Homogenous assumptions like the healthy immigrant effect and model minority myth create biases that racial/ethnic immigrants (e.g., Asian Americans) are generally healthy, participate in healthy behaviors, and manifest improved health outcomes, despite a wide within-group variance. These false stereotypes overlook subgroup differences in cultural norms, acculturation/assimilation rates, duration of stay, and heterogeneous patterns that significantly impact health outcomes over time. For example, residing longer in the US means adoption of Western habits, lifestyles, and norms, with a simultaneous deterioration of protective factors against poor health behaviors and outcomes. This is most relevant among generations of Latino youth and specific subgroups of Asian American ancestry, which is the fastest-growing ethnic group in the US.

Second, a cultural shift is emerging with the normalization of OTPs, especially e-cigarettes, among youth and young adults that now complicates years of progress against tobacco’s detrimental impact on the health of communities of color and population health at large. This calls for a comprehensive outlook at both tobacco-use stages and the changing tobacco landscape across developmental age.

Furthermore, it is important to note that tobacco use cannot be investigated in isolation of other substances. Recent trends among youth and young adults demonstrate increasing use of tobacco with other substances (alcohol and/or cannabis especially with the multi-purpose use of vaping devices for tobacco and cannabis), (57, 58–61) which complicates the tobacco control landscape and minority health disparities. Understanding tobacco-related health disparities, specifically among Blacks, Latinos, and other at-risk communities, requires health professionals and policymakers to account for other substances used in combination with tobacco, specifically alcohol and cannabis, when combating tobacco-related health disparities among BIPOC youth and adults, while considering evolving tobacco market strategies that plague communities over generations.

Finally, tobacco control and prevention efforts have yet to harness digital technologies for data collection (e.g., through ecological momentary assessments) and treatment/prevention (e.g., mhealth interventions). Noteworthy is that tobacco companies are utilizing digital technologies – from social media advertising to time- and geographic-sensitive price promotions delivered to users’ mobile phones.

Future approaches to accelerate reductions in tobacco-related inequities include: 1) adopting data surveillance methodologies that allow for sufficient recruitment and identification of subgroups that exist among Blacks and those of Latino/Hispanic ancestry, 2) developing an equitable tobacco surveillance data infrastructure that adequately collects health indicators and outcome information from racial/ethnic subgroups and marginalized communities to successfully dismantle colorblind policies, research, and funding that restricted successful cessation in these communities over generations 3) creating effective strategies that identify and support disadvantaged tobacco users to quit, 4) investing in the etiology of tobacco-related mortality, like lung cancer and CVD, among Blacks and Latino light/intermittent smokers, 5) encouraging interdisciplinary partnerships to improve tobacco prevention and expand tobacco control in communities of color, 6) continuing treatment and prevention efforts that span traditional and digital platforms that are culturally relevant to developmental age, sex, and/or racial and ethnic communities, 7) promoting and supporting policies that aim to achieve equity in early child development, such as enriching educational experiences, safe learning and living environments, 8) strengthening policies that encourage healthy and equitable working environments and occupational conditions, and 9) continuing proven population-based tobacco control policies—especially increasing the price of tobacco (while remaining cognizant of unintended consequences such as the increased economic burden on those who do not quit).

Abbreviation List

AI/AN

American Indian/Alaska Native

BIPOC

Black, Indigenous, and People of Color

CVD

Cardiovascular Disease

COVID-19

Coronavirus Disease 2019

ENDS

Electronic Nicotine Delivery Systems

FDA

Food and Drug Administration

FPL

Federal Poverty Level

LGBTQIA+

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual

NHPI

Native Hawaiian and Pacific Islander

NRT

Nicotine Replacement Therapy

NSDUH

National Survey on Drugs and Health

PEA

Parental Educational Attainment

SDOH

Social Determinants of Health

SES

Socioeconomic Status

SHS

Secondhand Smoke

T21

Tobacco 21

OTP

Other Tobacco Product

T-PUP

Tobacco Product Use Pattern

TUS-CPS

Tobacco Use Supplement to the Current Population Survey

US

United States